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Course:SOWK551/2021/Protective and Risk Factors Among Marginalized Youth with Adverse Childhood Experiences (ACEs): Implications for Health Care Social Work

2026-07-07T18:06:56Z

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Course:SOWK551/2021/Protective and Risk Factors Among Marginalized Youth with Adverse Childhood Experiences : Implications for Health Care Social Work

2026-07-07T18:06:56Z

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== Short Summary ==
This literature review synthesizes emerging evidence on protective and risk factors among youth with adverse childhood experiences (ACEs), with a particular focus on marginalized and Indigenous populations.

Authors: Tsz Chun (Toby) Wan and Mei Wa Chu

Date: December 08, 2025
== Introduction ==
Adverse childhood experiences (ACEs) are commonly defined as early-life exposures to abuse, neglect, and household dysfunction that have been consistently linked to elevated risks for lifelong mental, emotional, and physical health challenges (Larkin et al., 2014). Since the foundational ACE study by Felitti and colleagues (Felitti et al., 1998), the ACE framework has expanded to include broader forms of adversity such as discrimination, community violence, poverty, and systemic oppression, reflecting an evolving understanding of how social environments shape development. Across disciplines, research demonstrates that ACEs are cumulative and interacting stressors rather than isolated events, influencing cognitive, emotional, and relational functioning throughout the lifespan (Larkin et al., 2014). For youth, particularly those navigating intersecting forms of marginalization, ACEs can disrupt developmental pathways, shape coping patterns, and contribute to long-term disparities in mental health, chronic disease, and social outcomes.

Contemporary ACE scholarship highlights that adversity is multidimensional and embedded within family, community, and structural contexts. Afifi et al. (2020), using confirmatory factor analysis with parents and adolescents, demonstrate that ACEs represent multiple latent constructs rather than a single uniform category, underscoring how adversity patterns are shaped by broader social conditions. Importantly, ACE exposure predicts not only internalizing outcomes such as depression and anxiety but also involvement with systems of surveillance and criminalization. In a Canadian context, Testa et al. (2025) found that youth with higher ACE scores were significantly more likely to experience police contact, illustrating how early adversity interacts with systemic inequities and contributes to cascading disadvantage.

Emerging research also emphasizes the importance of examining ACEs alongside positive childhood experiences (PCEs). Hinojosa and Hinojosa (2024) demonstrate that supportive relationships, emotional safety, and consistent caregiving can buffer the negative impacts of adversity, highlighting that resilience is environmentally supported rather than individually possessed. This dual focus that recognizing both adversity and strength is increasingly central to trauma-informed and resilience-oriented social work frameworks.

However, exposure to ACEs is not evenly distributed across populations. Youth from marginalized communities, including Black, Asian, racialized, and Indigenous groups would experience disproportionately high ACE burdens shaped by racism, intergenerational trauma, and structural inequities. Discrimination itself is now recognized as a form of adversity due to its psychological and physiological impacts, and racialized youth frequently encounter compounded forms of harm that interact with developmental stress processes and health-care access barriers. For Indigenous youth specifically, colonial histories of forced displacement, family separation, and child welfare involvement would contribute to some of the highest ACE prevalence rates in Canada. These intersecting adversities highlight the need for culturally anchored, trauma-informed approaches that recognize how identity, culture, power, and historical context shape both exposure to and the effects of childhood adversity.

Given these complexities, healthcare social workers play a critical role in addressing ACE-related needs through trauma-informed assessment, strengths-based engagement, cultural safety, and structural advocacy. This literature review synthesizes scholarship published between 2018 and 2025 to examine both risk and protective factors associated with ACEs, with particular emphasis on the experiences of marginalized, racialized, and Indigenous youth. It further explores how culturally grounded, ACE-informed, and resilience-focused practices can be integrated into health-care social work to strengthen protective factors, enhance culturally meaningful supports, and improve health and well-being outcomes for diverse youth populations.

== Protective Factors and Resilience ==
Protective factors can substantially buffer the negative effects of ACEs by promoting emotional security, resilience, and adaptive functioning (Tironi et al., 2024). At the individual level, psychological capacities such as epistemic trust, reflective functioning, and mentalized affectivity help youth interpret relationships safely, regulate emotions, and engage effectively with caregivers and professionals. Healthcare social workers can support these capacities through relational consistency, reflective dialogue, and strengths-based engagement, fostering resilience even in contexts of high adversity.

Beyond individual traits, relational and community-based protective factors are critical. Liu et al. (2020) highlight that positive childhood experiences (PCEs), including supportive caregiving, emotional safety, and a sense of being valued that frequently coexist with high ACE exposure and strongly predict resilience. Troxel et al. (2025) introduce the concept of social safety, defined as feeling connected, protected, and accepted, which mitigates the physiological and psychological impacts of both ACEs and discrimination. Together, these studies suggest that protective factors operate across multiple ecological levels, including individual, relational, and social and that interventions focusing solely on the individual may overlook relational and structural supports.

Cultural and community-based resources further extend protection for racialized and Indigenous youth. Radford et al. (2022) emphasize that for Indigenous youth, cultural continuity, community cohesion, language revitalization, and culturally meaningful practices serve as critical safeguards against the cumulative effects of historical and contemporary trauma. While mainstream health systems often prioritize individual-level interventions, these findings suggest that culturally grounded approaches are essential for fostering resilience in youth facing structural and historical adversity. The evidence collectively underscores the need for trauma-informed, culturally attuned environments that cultivate trust, relational safety, and cultural grounding.

== Risk Factors and the Role of Discrimination ==
Although ACEs are harmful across populations, recent literature shows that their impacts are intensified by systemic inequities, racism, and social exclusion. Discrimination functions as both a chronic stressor and a traumatic exposure, compounding the effects of conventional ACEs. Bernard et al. (2022) demonstrate that racial discrimination significantly increases internalizing mental health problems among Black youth, while Kim et al. (2024) find that Asian adolescents experiencing both ACEs and discrimination report higher rates of depression and anxiety. Jensen et al. (2025) further highlight elevated suicidality rates among Black, Hispanic, and multiracial youth with high ACE exposure, illustrating how systemic inequities interact with early adversity to shape mental health outcomes.

Indigenous youth experience some of the highest ACE prevalence rates globally due to ongoing colonialism, forced displacement, intergenerational trauma, and systemic inequities (Radford et al., 2022; Toombs et al., 2022). They face unique adversities, including cultural disruption, community-level trauma, and institutional discrimination, which intensify risks for poor mental health and highlight the necessity of culturally anchored support systems. Broader structural factors—such as poverty, housing instability, food insecurity, and limited access to early intervention—further exacerbate ACE impacts. Within healthcare systems, the lack of trauma-informed, culturally safe practice can inadvertently retraumatize youth through rushed assessments, culturally incongruent care, or dismissive responses to disclosures of discrimination.

The literature indicates that while protective factors can buffer adversity, risk factors are amplified by systemic oppression, and their expression varies across populations. This underscores the importance of integrating culturally responsive, ACE-informed, and trauma-informed frameworks that acknowledge both individual experiences and structural inequities in health care social work.

== Adverse Childhood Experiences Among Indigenous Populations in Canada ==
Indigenous populations in Canada experience disproportionately high rates of adverse childhood experiences (ACEs), shaped by ongoing colonial structures, intergenerational trauma, and systemic inequities (Toombs et al., 2022; Radford et al., 2022). Conventional ACE frameworks often focus on individual or household-level adversities, such as abuse, neglect, and household dysfunction, but fail to capture the historical, collective, and structural adversities that Indigenous youth face. These include forced assimilation, residential schools, child welfare interventions, land dispossession, and systemic discrimination, which together contribute to elevated ACE prevalence and unique trajectories of risk (Toombs et al., 2022). Radford et al. (2022) emphasize that Indigenous youth confront adversities that extend beyond family environments, including community-level trauma, cultural disruption, and institutional discrimination, which interact with systemic inequities to amplify risk for poor mental health outcomes. Bernard et al. (2021) similarly propose a culturally informed ACE framework (C-ACE) to account for racism and discrimination as pervasive forms of adversity among racialized youth, highlighting the limitations of applying universal ACE models without cultural context. LaBrenz et al. (2020) further underscore that structural factors such as poverty, housing instability, and limited access to early intervention exacerbate ACE impacts, reinforcing the necessity of race- and culture-specific analysis for equitable health care.

Empirical research illustrates how unaddressed ACEs intersect with broader systems. For instance, Muir and Viljoen (2022) report that higher ACE exposure correlates with increased recidivism among Indigenous adolescents in probation systems, demonstrating the compounding effects of trauma and systemic discrimination. These findings highlight the need for interventions that account for structural determinants in addition to individual or familial risk factors. Despite these challenges, Indigenous communities possess profound protective factors that can buffer the impacts of ACEs. Toombs et al. (2022) identify cultural continuity, community cohesion, connection to land, language revitalization, and Indigenous knowledge systems as central pillars of resilience. Luther et al. (2025) find that Indigenous university students with high adversity demonstrate coping capacities rooted in cultural identity, community belonging, relational support, and meaning-making practices. These culturally anchored resources echo findings among other racialized populations, where identity affirmation, collective solidarity, and culturally grounded practices mitigate health disparities (Bernard et al., 2021; LaBrenz et al., 2020).

The literature underscores the importance of trauma-informed, culturally safe, and ACE-informed care in healthcare settings. Toombs et al. (2022) and Radford et al. (2022) stress that interventions must integrate Indigenous worldviews, community-defined healing practices, and structural advocacy to avoid replicating colonial harms. Bernard et al. (2021) and LaBrenz et al. (2020) caution that standard ACE frameworks risk pathologizing Indigenous youth if they fail to incorporate historical, cultural, and structural contexts. By centering cultural strengths, community knowledge, and systemic awareness, healthcare social workers can foster resilience, support Indigenous sovereignty, and promote healing pathways aligned with the needs and values of Indigenous communities.

== Application to Practice ==
Translating this evidence into practice requires health-care social workers to intervene in ways that are trauma-informed, culturally safe, and responsive to the intersecting impacts of adverse childhood experiences, racial discrimination, and social marginalization. Findings across recent ACE studies highlight that youth who face racism and structural exclusion, particularly Black, Asian, and Indigenous youth who often experience heightened internalizing symptoms, suicidality, and barriers to trust in service systems (Bernard et al., 2022; Kim et al., 2024; Jensen et al., 2025; Radford et al., 2022). At the same time, protective processes such as epistemic trust, reflective functioning, relational safety, and supportive cultural identity have been shown to buffer against these risks (Tironi et al., 2024; Liu et al., 2020; Troxel et al., 2025). These findings collectively reinforce that social workers must center relational attunement, cultural humility, and collaborative care planning when working with ethnic minority and Indigenous youth in hospital settings.

'''1. Culturally adapted, ACE-informed assessment'''

Social workers can integrate an ACE- and discrimination-informed lens directly into biopsychosocial assessments by attending to racialized stressors, intergenerational trauma, and systemic inequities without pathologizing youth or “essentializing” cultural identities. This involves asking questions about safety, belonging, and past experiences of discrimination in ways that promote dignity and choice. Evidence suggests that trauma-informed assessment must prioritize emotional safety and consent, especially for youth with histories of racial or structural trauma (Stokes et al., 2024). For Indigenous patients, collaboration with the hospital’s Indigenous Health Team supports culturally grounded assessment, builds trust, and ensures that care plans reflect historical and community contexts (Radford et al., 2022).

'''2. Collaborative safety planning that restores relational and cultural safety'''

Given the elevated suicidality associated with ACEs and racial discrimination among diverse youth (Jensen et al., 2025), safety planning must extend beyond risk checklists to incorporate the youth’s cultural strengths, caregiving networks, and community supports. Trauma-informed practices highlight that collaborative planning increases agency and reduces coercion (Stokes et al., 2024). Integrating cultural anchors, such as extended kin networks, community mentors, or culturally meaningful practices that could strengthen protective factors identified in the literature (Liu et al., 2020; Tironi et al., 2024). For Indigenous youth, joint planning with Indigenous Elders, Knowledge Keepers, or Indigenous liaison workers supports continuity between hospital care and community wellness approaches.

'''3. Relationship-centered intervention to strengthen trust, affect regulation, and meaning-making'''

Because epistemic trust, reflective functioning, and mentalized affectivity protect youth facing ACEs (Tironi et al., 2024), hospital social workers can introduce brief relational interventions that model attunement, validation, and co-regulation. Even short-term inpatient encounters could strengthen a youth’s capacity to make sense of emotions and build trust with service providers are key predictors of engagement in follow-up care. This includes warm handovers to outpatient teams, transparent communication, and ensuring youth have voice and control in decisions. Stokes et al. (2024) emphasize that relational safety is a core component of trauma-informed mental health interventions in inpatient settings.

'''4. ACE-informed and culturally safe discharge planning'''

Discharge transitions are critical points for youth with complex trauma histories. Social workers could develop discharge plans that explicitly address environmental stressors linked to ACEs, such as housing instability, racism at school, or caregiver strain while connecting youth to culturally appropriate supports. For Indigenous and ethnic minority youth, coordination with community-based cultural, spiritual, or identity-affirming programs can enhance post-discharge safety and continuity of care. Integrating Hospital Indigenous Health Team recommendations ensures plans reflect community values, uphold cultural self-determination, and acknowledge systemic barriers.

These strategies integrate research on protective factors (Tironi et al., 2024; Troxel et al., 2025), culturally informed assessment (Liu et al., 2020; Bernard et al., 2021), and trauma-informed organizational approaches (Stokes et al., 2024). Collectively, they provide practical, evidence-informed steps that healthcare social workers could implement in hospital settings, supporting youth resilience, culturally safe care, and long-term wellbeing.

== Conclusion ==
Adverse childhood experiences (ACEs) are complex, multi-level stressors that intersect with systemic inequities, racial discrimination, and intergenerational trauma, disproportionately affecting marginalized and Indigenous youth (Felitti et al., 1998; Larkin et al., 2014; Afifi et al., 2020; Testa et al., 2025). While all youth exposed to ACEs face developmental risks, structural and cultural contexts intensify adverse outcomes, highlighting the limitations of conventional ACE frameworks that fail to account for historical and collective trauma (Radford et al., 2022; Toombs et al., 2022; Bernard et al., 2021). Protective factors, including relational safety, supportive caregiving, social connectedness, and culturally grounded identity could buffer these risks and promote resilience (Tironi et al., 2024; Liu et al., 2020; Troxel et al., 2025).

For healthcare social workers, translating this evidence into practice involves trauma-informed, culturally safe, and strengths-based approaches. Strategies such as ACE- and discrimination-informed assessments, collaborative safety planning, relationship-centered interventions, and culturally responsive discharge planning can strengthen protective factors, foster trust, and support youth well-being. Engaging with Indigenous Health Teams and community resources ensures care is aligned with cultural, historical, and systemic realities, enhancing both safety and agency. Ultimately, ACE-informed social work must recognize adversity alongside resilience, situate individual experiences within broader contexts, and prioritize relational and community supports. By doing so, social workers can mitigate the impacts of ACEs and promote equitable, culturally grounded outcomes for diverse youth populations.

== References ==
Afifi, T. O., Salmon, S., Garcés, I., Struck, S., Fortier, J., Taillieu, T., Stewart-Tufescu, A., Asmundson, G. J. G., Sareen, J., & MacMillan, H. L. (2020). Confirmatory factor analysis of adverse childhood experiences (ACEs) among a community-based sample of parents and adolescents. ''BMC Pediatrics'', ''20''(1), 178. <nowiki>https://doi.org/10.1186/s12887-020-02063-3</nowiki>

Bernard, D. L., Calhoun, C. D., Banks, D. E., Halliday, C. A., Hughes-Halbert, C., & Danielson, C. K. (2021). Making the “C-ACE” for a culturally-informed adverse childhood experiences framework to understand the pervasive mental health impact of racism on black youth. ''Journal of Child & Adolescent Trauma, 14''(2), 233-247. <nowiki>https://doi.org/10.1007/s40653-020-00319-9</nowiki>

Bernard, D. L., Smith, Q., & Lanier, P. (2022). Racial discrimination and other adverse childhood experiences as risk factors for internalizing mental health concerns among Black youth. ''Journal of Traumatic Stress, 35''(2), 473–483.<nowiki>https://doi.org/10.1002/jts.22760</nowiki>

Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The adverse childhood experiences (ACE) study. ''American Journal of Preventive Medicine, 14''(4), 245-258. <nowiki>https://doi.org/10.1016/S0749-3797(98)00017-8</nowiki>

Hinojosa, M. S., & Hinojosa, R. (2024). Positive and adverse childhood experiences and mental health outcomes of children. ''Child Abuse & Neglect'', ''149'', 106603. <nowiki>https://doi.org/10.1016/j.chiabu.2023.106603</nowiki>

Jensen, L. W. C., Jones, M. S., Gibbs, B. G., & Jarvis, J. A. (2025). Adverse childhood experiences, race/ethnicity, and suicidality among Florida high school students. ''Youth & Society, 57''(2), 233–257. <nowiki>https://doi.org/10.1177/0044118X241312248</nowiki>

Kim, I., Jang, H., Kim, S. R., & Choi, J. (2024). Adverse childhood experiences, racial discrimination, and internalizing problems among Asian adolescents. ''Journal of Child & Adolescent Trauma, 17''(4), 1177–1188. <nowiki>https://doi.org/10.1007/s40653-024-00652-3</nowiki>

LaBrenz, C. A., O'Gara, J. L., Panisch, L. S., Baiden, P., & Larkin, H. (2020). Adverse childhood experiences and mental and physical health disparities: The moderating effect of race and implications for social work. ''Social Work in Health Care, 59''(8), 588-614. <nowiki>https://doi.org/10.1080/00981389.2020.1823547</nowiki>

Larkin, H., Felitti, V. J., & Anda, R. F. (2014). Social Work and Adverse Childhood Experiences Research: Implications for Practice and Health Policy. ''Social Work in Public Health'', ''29''(1), 1–16. <nowiki>https://doi.org/10.1080/19371918.2011.619433</nowiki>

Liu, S. R., Kia‐Keating, M., Nylund‐Gibson, K., & Barnett, M. L. (2020). Co‐occurring youth profiles of adverse childhood experiences and protective factors: Associations with health, resilience, and racial disparities. ''American Journal of Community Psychology, 65''(1–2), 173–186. <nowiki>https://doi.org/10.1002/ajcp.12387</nowiki>

Luther, A. W., Skinner, K., Anthony, K., & Mielke, J. G. (2025). Childhood adversity and coping among indigenous university students in canada: Considerations when examining adverse childhood experiences. ''Psychological Trauma,'' <nowiki>https://doi.org/10.1037/tra0001885</nowiki>

Muir, N. M., & Viljoen, J. L. (2022). Adverse childhood experiences and recidivism in indigenous and white female and male adolescents on probation. ''Child Abuse & Neglect, 126'', 105512. <nowiki>https://doi.org/10.1016/j.chiabu.2022.105512</nowiki>

Radford, A., Toombs, E., Zugic, K., Boles, K., Lund, J., & Mushquash, C. J. (2022). Examining adverse childhood experiences (ACEs) within Indigenous populations: A systematic review. ''Journal of Child & Adolescent Trauma, 15''(2), 401–421. <nowiki>https://doi.org/10.1007/s40653-021-00393-7</nowiki>

Stokes, Y., Lewis, K. B., Tricco, A. C., Hambrick, E., Jacob, J. D., Demery Varin, M., Gould, J., Aggarwal, D., Cloutier, P., Landriault, C., Greenham, S., Ward, M., Kennedy, A., Boggett, J., Sheppard, R., Murphy, D., Robb, M., Gandy, H., Lavergne, S., & Graham, I. D. (2024). Trauma-informed care interventions used in pediatric inpatient or residential treatment mental health settings and strategies to implement them: A scoping review. ''Trauma, Violence & Abuse, 25''(3), 1737-1755. <nowiki>https://doi.org/10.1177/15248380231193444</nowiki>

Testa, A., Jacobs, B., Thompson, J., Pang, N., Jackson, D. B., Nagata, J. M., & Ganson, K. T. (2025). Adverse Childhood Experiences and Police Contact in Canada. ''Journal of Interpersonal Violence'', ''40''(9–10), 2188–2204. <nowiki>https://doi.org/10.1177/08862605241270047</nowiki>

Tironi, M., Charpentier Mora, S., Liotti, M., Fiorini Bincoletto, A., Tanzilli, A., Cavanna, D., Lingiardi, V., Speranza, A. M., Giovanardi, G., & Bizzi, F. (2024). Adverse childhood experiences and psychological maladjustment in adolescence: The protective role of epistemic trust, mentalized affectivity, and reflective functioning. ''Journal of Clinical Psychology, 80''(11), 2228–2246. <nowiki>https://doi.org/10.1002/jclp.23733</nowiki>

Toombs, E., Lund, J., & Mushquash, C. J. (2022). Adverse childhood experiences (ACEs) are increasing in indigenous populations in canada: Now what? ''Canadian Psychology = Psychologie Canadienne, 63''(4), 576-588. <nowiki>https://doi.org/10.1037/cap0000331</nowiki>

Troxel, W. M., Seelam, R., Perez, L. G., Davis, J., & D’Amico, E. J. (2025). Social safety and health outcomes in emerging adults: Interactions of adverse childhood experiences and discrimination. ''Journal of Community Psychology, 53''(4), e70011. <nowiki>https://doi.org/10.1002/jcop.70011</nowiki>

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Course:SOWK551/2021/Dementia Caregivers: Caregiver Burden, avenues of caregiver support, and a path forward for caregiver support

2026-07-06T17:05:42Z

KellyAllison: pulled content from SOWK 551 (2025) project page

[[File:Pexels-jsme-mila-523821574-29354077.jpg|alt=Older adult woman being assisted with her medication by younger female caregiver|thumb|Photo by jsme-mila on Pexels ]]

== Short Summary ==
Literature review exploring the needs of caregivers of people with dementia.

== Introduction ==
Currently, within the province of BC, caregivers are withstanding 1-2 years waitlists to have their loved one (living with dementia) placed in long-term care (Office of the Seniors Advocate BC, 2025). During this waiting period, caregivers are left to “figure it out” and offered existing resources that are limited and may not necessarily meet the unique needs of the caregiver and their loved one (Office of the Seniors Advocate BC, 2025). The increasing prevalence of people living with dementia and subsequently requiring caregiving is growing at at exponential rate and is now classified one of the leading public health crisis of this generation, thus amplifying the need to adequate social infrastructure to support the needs of those living with dementia and those caring for them (Devenney, Nguyen, Tse, Kiernan, & Tan, 2025). It is imperative that efforts to better understand the projected impact of the increasing number of individuals living with dementia in order to implement changes in the healthcare system in order to accommodate the demand (Office of the Seniors Advocate BC, 2025).

== Caregiver Burden ==
Caregiver burden is a culmination of a series of the following symptoms where the root cause stems from caregiving: stress, emotional strain, care demands, and relationship challenges (Richardson et al., 2013). Caregivers of those living with dementia are likely to experience significantly higher levels of depression, anxiety, and stress compared to other caregiver groups (Liu et al., 2021). Heightened rates of emotional distress, social isolation, feelings of loneliness and guilt, and diminished sense of self have been consistently picked up on across academic studies (Seetharaman, Kervin, Khan, Cooke, & Baumbusch, 2025).

Dementia carers often experience complex psychological trauma stemming from their anticipatory grief experience as they witness their loved one change. They may also be subjected to complex psychological trauma while managing their loved ones behavioural symptoms of dementia and navigating systems that are not equipped to support their loved ones changing care needs, which can lead to experiences of vicarious distress(Meng, Lachapelle, Adekoya, & et al., 2025). Spouses who provide caregiving for a partner living with dementia have been shown across studies to be the most vulnerable to intense psychological symptoms as they navigate through their loved ones journey (Seetharaman et al., 2025). Additionally, carers of female gender (Jhang et al., 2025) have been shown across studies to be disproportionately represented in regards to experiences of acute caregiver burden. Social and cultural norms placed on female dementia carers have been shown to contribute towards excessive caregiver demand, feelings of guilt, and unseen/unspoken shame for experiencing emotional distress (Seetharaman et al., 2025). Behavioural and psychological symptoms of dementia, BPSD for short, can include experiences of elevated agitation, anxiety, confusion, disorientation, and sleep disturbances which can expose caregivers to increased caregiver burnout and complex psychological trauma (Richardson et al.,2013). Furthermore, Richardson et al (2013) detailed that BPSD systematically applies,“significant burden to patients, their families, and their caregivers.” Others such as Jhang, Chen, Wang, & et al. (2025) found that the severity of experiences of BPSD were a significant contributing factor towards acute caregiver burnout. In addition to psychological impacts of caregiver demand, dementia carers can often be noted to have elevator stress hormones and inflammatory indicators (Richardson et al., 2013). Elevated stress hormones and inflammatory markers have been found to be causatory factors in hypertension, metabolic disorders,heart disease, and more shockingly mortality (Richardson et al., 2013)

The toll of caregiving for those living with dementia can also come along with considerable financial implications for the patient and their caregivers who often have to limit their employment obligations and dive into their own savings to be able to access respite services or medical equipment needs for their loved ones (Oba, Kadoya, Okamoto, Matsuoka, Abe, Shibata, & Narumoto, 2021).

== Avenues of Caregiver Supports ==
Systematic gaps in health and social care infrastructure across North America have been well observed and shown to impact caregivers on an upward trend post covid, which have exposed caregivers to increased systems navigation barriers and service deficits (Seetharaman et al., 2025). The existing formal care systems have failed to keep up with aging population demands and increasing diverse needs of the baby boomer generation. Meng et al. (2025) note that caregivers often experience pressure from power imbalances between themselves and health are professionals that they seek needed support from. The health care system has become widely viewed by carers as unreliable and lacking integrity. The Office of the Seniors Advocate BC (2025) similarly reports strained services, inconsistent access to home support, and long waitlists for publicly funded careers key areas of concern.

Respite care has long been considered to be the go to avenue for caregiver support however, current deficits and failure to adapt respite services to changing diverse needs of the aging population have categorically reduced the effectiveness of its efforts(Vandepitte, Van Den Noortgate, Putman, Verhaeghe, Verdonck, & Annemans.,2016).Advances in respite programs could work towards better outcomes for caregivers however, it would require jurisdictions to expand on current models to provide offerings that match the changing diverse needs of the population. Continued non-actions towards this will result in un-emcompassable wait times and concerning outcomes for dementia carers(Seetharaman et al., 2025).

Organizations such as the Alzheimer's Society of BC, as well as various non-profit community organizations across the province of BC have developed various caregiver support groups which have shown positive contributions towards better outcomes for dementia caregivers. Many organizations such as the aforementioned, equip caregivers with essential knowledge required to effectively navigate the health care system and the changing needs of those they are caring for. Learnings and enhanced knowledge pertaining to dementia can empower caregivers and arm them with protective factors that may support them across their caregiving journey. Outcomes of a Canadian based dementia support services evaluation illuminated the effectiveness of dementia education in caregiver resiliency building and enhanced resource pathways (Tam, Martin, Jiang, Machado, & Robillard, Year).

== Application to Social Work Practice ==
Caregiver support derived from a trauma-informed modality that prioritizes caregivers feelings of psychological safety and works towards building trust via communication, transparency, and reliability are found to have positive outcomes for caregivers (Meng et al., 2025) This modality has proven its effectives across Meng et al’s (2025) findings which identified the value of caregiver support groups where by shared experiences caregivers were able to find commonality, collaboration, and enhanced feelings of empowerment. Trauma informed caregiver support approaches encourage empowerment, self determination and autonomy by providing a safe space for dementia carers to share their worries, concerns, challenges, and to identify and build upon their strengths. Social workers employing the above approach within therapeutic interventions for caregivers are contributing towards narrowing systemic gaps within the health and social care system by way of empowering and amplifying the voice of caregivers. In a qualitative study by Seethanaman et al. (2025) fluctuating and unpredictable needs of caregiver were noticed across the findings, further illuminating the value of trauma-informed social work interventions that build caregiver resilience. With dementia carers often experiences various intensities of mixed emotions throughout the caregiver journey, described by fleeting feelings of hope and instability triggered by shifts in relationship dynamics and changes in self identity it is imperative that caregivers are offered a safe spaces to unpack these experiences. Social workers withhold the necessary core competencies and knowledge around therapeutic approaches that may best foster these spaces for dementia carers.

== Conclusion ==
Across the literary resources explored in this review common patterns and themes were identified: expansive emotional-psychological-physical-social toll of caregiving is far too great and continues to be further strained by deficits within the formal health care and social support systems who are failing to provide adequate levels of support. Caregivers continue to fill the gaps of the failing healthcare system while their own well being deteriorates, which will result in further pressure on the healthcare system. While growth of the aging population (baby boomers) was not appropriately accounted for within government planning, we are now experiencing the beginning of a public health crisis that is expected to worsen if it is not identified and approached as a high priority.Proposed enhancements to caregiver support and dementia care could work towards sustainability within the healthcare and social system which would likely result in better outcomes for dementia caregivers and those living with dementia, however it would require significant efforts on the provincial and federal social planning level.

Evidence noted across the findings of this literature note that enhanced access to educational opportunities, increased diversity across respite programs, and trauma informed interventions embedded within caregiver support systems employed collectively could lay the framework for a working support system for dementia carers and their loved ones.

== References ==
Devenney, E. M., Nguyen, Q. A. N., Tse, N. Y., Kiernan, M. C., & Tan, R. H. (2025). A scoping review of the unique landscape and challenges associated with dementia in the Western Pacific region. The Lancet Regional Health – Western Pacific. <nowiki>https://www.thelancet.com/journals/lanwpc/article/PIIS2666-6065(24)00186-X/fulltext</nowiki>

Jhang, K. M., Chen, C. C., Wang, S. Y., & et al. (2025). Caregivers’ burden analytics: Combining variables from patients with dementia and their caregivers. BMC Geriatrics, 25, 620. <nowiki>https://doi.org/10.1186/s12877-025-06284-y</nowiki>

Liu, C., Badana, A. N. S., Burgdorf, J., Fabius, C. D., Roth, D. L., & Haley, W. E. (2020). Systematic review and meta-analysis of racial and ethnic differences in dementia caregivers’ well-being. The Gerontologist. <nowiki>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8276619/</nowiki>

Meng, C., Lachapelle, S., Adekoya, A., et al. (2025). Using a trauma-informed care approach to understand family caregivers’ experiences of accessing formal supports in dementia care. Journal of Family Nursing, 31(1), 3–15. <nowiki>https://doi.org/10.1177/10748407251314549</nowiki>

Oba, H., Kadoya, Y., Okamoto, H., Matsuoka, T., Abe, Y., Shibata, K., & Narumoto, J. (2021). The economic burden of dementia: Evidence from a survey of households of people with dementia and their caregivers. International Journal of Environmental Research and Public Health, 18(5), 2717. <nowiki>https://doi.org/10.3390/ijerph18052717</nowiki>

Office of the Seniors Advocate BC. (2025). From shortfall to crisis: Report. <nowiki>https://www.seniorsadvocatebc.ca/app/uploads/sites/4/2025/07/From-Shortfall-to-Crisis-Report.pdf</nowiki>

Richardson, T. J., Lee, S. J., Berg-Weger, M., & Grossberg, G. T. (2013). Caregiver health: Health of caregivers of Alzheimer’s and other dementia patients. Current Psychiatry Reports, 15, 367. <nowiki>https://doi.org/10.1007/s11920-013-0367-2</nowiki>

Seetharaman, K., Kervin, L., Khan, K., Cooke, H., & Baumbusch, J. (2025). Longitudinal reflections on family caregiving experiences: Insights from solicited diaries of caregivers of people living with dementia in British Columbia, Canada. SSM – Qualitative Research in Health, 100677. <nowiki>https://doi.org/10.1016/j.ssmqr.2025.100677</nowiki>

Tam, M. T., Martin, S., Jiang, Y. F., Machado, A., & Robillard, J. M. (Year). “Dementia doesn’t mean that life doesn’t have more wonderful things ahead”: A qualitative study evaluating a Canadian dementia support services program. Journal Name, Volume(Issue), page range. <nowiki>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11100986/</nowiki>

Vandepitte, S., Van Den Noortgate, N., Putman, K., Verhaeghe, S., Verdonck, C., & Annemans, L. (2016). Effectiveness of respite care in supporting informal caregivers of persons with dementia: A systematic review. International Journal of Geriatric Psychiatry, 31(12), 1277–1288. <nowiki>https://doi.org/10.1002/gps.4504</nowiki>{{Cc-by-nc-4.0}}

Course:SOWK551/2025/Dementia Caregivers: Caregiver Burden, avenues of caregiver support, and a path forward for caregiver support

2026-07-06T16:41:16Z

KellyAllison: inserted cc template logo

[[File:Pexels-jsme-mila-523821574-29354077.jpg|thumb|Female caregiver helping a female older adult with medicaiton.]]
1. Introduction

The intent of this literature review is to gather existing research and information that can help us better understand the question: What do caregivers need? Currently, within the province of BC, caregivers are withstanding 1-2 years waitlists to have their loved one (living with dementia) placed in long-term care (Office of the Seniors Advocate BC, 2025). During this waiting period, caregivers are left to “figure it out” and offered existing resources that are limited and may not necessarily meet the unique needs of the caregiver and their loved one (Office of the Seniors Advocate BC, 2025). The increasing prevalence of people living with dementia and subsequently requiring caregiving is growing at at exponential rate and is now classified one of the leading public health crisis of this generation, thus amplifying the need to adequate social infrastructure to support the needs of those living with dementia and those caring for them (Devenney, Nguyen, Tse, Kiernan, & Tan, 2025). It is imperative that efforts to better understand the projected impact of the increasing number of individuals living with dementia in order to implement changes in the healthcare system in order to accommodate the demand (Office of the Seniors Advocate BC, 2025).

2. Literature Review

Topic 1: Caregiver Burden

Caregiver burden is a culmination of a series of the following symptoms where the root cause stems from caregiving: stress, emotional strain, care demands, and relationship challenges (Richardson et al., 2013). Caregivers of those living with dementia are likely to experience significantly higher levels of depression, anxiety, and stress compared to other caregiver groups (Liu et al., 2021). Heightened rates of emotional distress, social isolation, feelings of loneliness and guilt, and diminished sense of self have been consistently picked up on across academic studies (Seetharaman, Kervin, Khan, Cooke, & Baumbusch, 2025).

Dementia carers often experience complex psychological trauma stemming from their anticipatory grief experience as they witness their loved one change. They may also be subjected to complex psychological trauma while managing their loved ones behavioural symptoms of dementia and navigating systems that are not equipped to support their loved ones changing care needs, which can lead to experiences of vicarious distress(Meng, Lachapelle, Adekoya, & et al., 2025). Spouses who provide caregiving for a partner living with dementia have been shown across studies to be the most vulnerable to intense psychological symptoms as they navigate through their loved ones journey (Seetharaman et al., 2025). Additionally, carers of female gender (Jhang et al., 2025) have been shown across studies to be disproportionately represented in regards to experiences of acute caregiver burden. Social and cultural norms placed on female dementia carers have been shown to contribute towards excessive caregiver demand, feelings of guilt, and unseen/unspoken shame for experiencing emotional distress (Seetharaman et al., 2025). Behavioural and psychological symptoms of dementia, BPSD for short, can include experiences of elevated agitation, anxiety, confusion, disorientation, and sleep disturbances which can expose caregivers to increased caregiver burnout and complex psychological trauma (Richardson et al.,2013). Furthermore, Richardson et al (2013) detailed that BPSD systematically applies,“significant burden to patients, their families, and their caregivers.” Others such as Jhang, Chen, Wang, & et al. (2025) found that the severity of experiences of BPSD were a significant contributing factor towards acute caregiver burnout. In addition to psychological impacts of caregiver demand, dementia carers can often be noted to have elevator stress hormones and inflammatory indicators (Richardson et al., 2013). Elevated stress hormones and inflammatory markers have been found to be causatory factors in hypertension, metabolic disorders,heart disease, and more shockingly mortality (Richardson et al., 2013)

The toll of caregiving for those living with dementia can also come along with considerable financial implications for the patient and their caregivers who often have to limit their employment obligations and dive into their own savings to be able to access respite services or medical equipment needs for their loved ones (Oba, Kadoya, Okamoto, Matsuoka, Abe, Shibata, & Narumoto, 2021).

Topic 2: Avenues of caregiver support

Systematic gaps in health and social care infrastructure across North America have been well observed and shown to impact caregivers on an upward trend post covid, which have exposed caregivers to increased systems navigation barriers and service deficits (Seetharaman et al., 2025). The existing formal care systems have failed to keep up with aging population demands and increasing diverse needs of the baby boomer generation. Meng et al. (2025) note that caregivers often experience pressure from power imbalances between themselves and health are professionals that they seek needed support from. The health care system has become widely viewed by carers as unreliable and lacking integrity. The Office of the Seniors Advocate BC (2025) similarly reports strained services, inconsistent access to home support, and long waitlists for publicly funded careers key areas of concern.

Respite care has long been considered to be the go to avenue for caregiver support however, current deficits and failure to adapt respite services to changing diverse needs of the aging population have categorically reduced the effectiveness of its efforts(Vandepitte, Van Den Noortgate, Putman, Verhaeghe, Verdonck, & Annemans.,2016).Advances in respite programs could work towards better outcomes for caregivers however, it would require jurisdictions to expand on current models to provide offerings that match the changing diverse needs of the population. Continued non-actions towards this will result in un-emcompassable wait times and concerning outcomes for dementia carers(Seetharaman et al., 2025).

Organizations such as the Alzheimer's Society of BC, as well as various non-profit community organizations across the province of BC have developed various caregiver support groups which have shown positive contributions towards better outcomes for dementia caregivers. Many organizations such as the aforementioned, equip caregivers with essential knowledge required to effectively navigate the health care system and the changing needs of those they are caring for. Learnings and enhanced knowledge pertaining to dementia can empower caregivers and arm them with protective factors that may support them across their caregiving journey. Outcomes of a Canadian based dementia support services evaluation illuminated the effectiveness of dementia education in caregiver resiliency building and enhanced resource pathways (Tam, Martin, Jiang, Machado, & Robillard, Year).

Application to Social Work:

Caregiver support derived from a trauma-informed modality that prioritizes caregivers feelings of psychological safety and works towards building trust via communication, transparency, and reliability are found to have positive outcomes for caregivers (Meng et al., 2025) This modality has proven its effectives across Meng et al’s (2025) findings which identified the value of caregiver support groups where by shared experiences caregivers were able to find commonality, collaboration, and enhanced feelings of empowerment. Trauma informed caregiver support approaches encourage empowerment, self determination and autonomy by providing a safe space for dementia carers to share their worries, concerns, challenges, and to identify and build upon their strengths. Social workers employing the above approach within therapeutic interventions for caregivers are contributing towards narrowing systemic gaps within the health and social care system by way of empowering and amplifying the voice of caregivers. In a qualitative study by Seethanaman et al. (2025) fluctuating and unpredictable needs of caregiver were noticed across the findings, further illuminating the value of trauma-informed social work interventions that build caregiver resilience. With dementia carers often experiences various intensities of mixed emotions throughout the caregiver journey, described by fleeting feelings of hope and instability triggered by shifts in relationship dynamics and changes in self identity it is imperative that caregivers are offered a safe spaces to unpack these experiences. Social workers withhold the necessary core competencies and knowledge around therapeutic approaches that may best foster these spaces for dementia carers.

Conclusion:

Across the literary resources explored in this review common patterns and themes were identified: expansive emotional-psychological-physical-social toll of caregiving is far too great and continues to be further strained by deficits within the formal health care and social support systems who are failing to provide adequate levels of support. Caregivers continue to fill the gaps of the failing healthcare system while their own well being deteriorates, which will result in further pressure on the healthcare system. While growth of the aging population (baby boomers) was not appropriately accounted for within government planning, we are now experiencing the beginning of a public health crisis that is expected to worsen if it is not identified and approached as a high priority.Proposed enhancements to caregiver support and dementia care could work towards sustainability within the healthcare and social system which would likely result in better outcomes for dementia caregivers and those living with dementia, however it would require significant efforts on the provincial and federal social planning level.

Evidence noted across the findings of this literature note that enhanced access to educational opportunities, increased diversity across respite programs, and trauma informed interventions embedded within caregiver support systems employed collectively could lay the framework for a working support system for dementia carers and their loved ones.

References

Devenney, E. M., Nguyen, Q. A. N., Tse, N. Y., Kiernan, M. C., & Tan, R. H. (2025). A scoping review of the unique landscape and challenges associated with dementia in the Western Pacific region. The Lancet Regional Health – Western Pacific. <nowiki>https://www.thelancet.com/journals/lanwpc/article/PIIS2666-6065(24)00186-X/fulltext</nowiki>

Jhang, K. M., Chen, C. C., Wang, S. Y., & et al. (2025). Caregivers’ burden analytics: Combining variables from patients with dementia and their caregivers. BMC Geriatrics, 25, 620. <nowiki>https://doi.org/10.1186/s12877-025-06284-y</nowiki>

Liu, C., Badana, A. N. S., Burgdorf, J., Fabius, C. D., Roth, D. L., & Haley, W. E. (2020). Systematic review and meta-analysis of racial and ethnic differences in dementia caregivers’ well-being. The Gerontologist. <nowiki>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8276619/</nowiki>

Meng, C., Lachapelle, S., Adekoya, A., et al. (2025). Using a trauma-informed care approach to understand family caregivers’ experiences of accessing formal supports in dementia care. Journal of Family Nursing, 31(1), 3–15. <nowiki>https://doi.org/10.1177/10748407251314549</nowiki>

Oba, H., Kadoya, Y., Okamoto, H., Matsuoka, T., Abe, Y., Shibata, K., & Narumoto, J. (2021). The economic burden of dementia: Evidence from a survey of households of people with dementia and their caregivers. International Journal of Environmental Research and Public Health, 18(5), 2717. <nowiki>https://doi.org/10.3390/ijerph18052717</nowiki>

Office of the Seniors Advocate BC. (2025). From shortfall to crisis: Report. <nowiki>https://www.seniorsadvocatebc.ca/app/uploads/sites/4/2025/07/From-Shortfall-to-Crisis-Report.pdf</nowiki>

Richardson, T. J., Lee, S. J., Berg-Weger, M., & Grossberg, G. T. (2013). Caregiver health: Health of caregivers of Alzheimer’s and other dementia patients. Current Psychiatry Reports, 15, 367. <nowiki>https://doi.org/10.1007/s11920-013-0367-2</nowiki>

Seetharaman, K., Kervin, L., Khan, K., Cooke, H., & Baumbusch, J. (2025). Longitudinal reflections on family caregiving experiences: Insights from solicited diaries of caregivers of people living with dementia in British Columbia, Canada. SSM – Qualitative Research in Health, 100677. <nowiki>https://doi.org/10.1016/j.ssmqr.2025.100677</nowiki>

Tam, M. T., Martin, S., Jiang, Y. F., Machado, A., & Robillard, J. M. (Year). “Dementia doesn’t mean that life doesn’t have more wonderful things ahead”: A qualitative study evaluating a Canadian dementia support services program. Journal Name, Volume(Issue), page range. <nowiki>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11100986/</nowiki>

Vandepitte, S., Van Den Noortgate, N., Putman, K., Verhaeghe, S., Verdonck, C., & Annemans, L. (2016). Effectiveness of respite care in supporting informal caregivers of persons with dementia: A systematic review. International Journal of Geriatric Psychiatry, 31(12), 1277–1288. <nowiki>https://doi.org/10.1002/gps.4504</nowiki>

{{Cc-by-nc-4.0}}

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2026-07-03T01:05:28Z

KellyAllison: Uploaded a work by Geralt from Pixabay with UploadWizard

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SOWK551/2021/Protective and risk factors among marginalized youth with adverse childhood experiences (ACEs): Implications for health care social work

2026-07-03T00:46:51Z

KellyAllison: Created page with " i want to delete"

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Course:SOWK551/2021/Healthcare Navigation for Racialized Immigrant Survivors of Family Violence

2026-07-03T00:22:12Z

KellyAllison:

[[File:Tumisu-violence-against-women-4209778.jpg|alt=Man's fist with woman cowering below|thumb|Photo by Tsumi on Pixabay]]

== Short Summary ==
Literature review exploring racialized immigrant survivors of family violence navigating the heathcare system.

== Introduction ==
Immigrant women, particularly those that are migrants, refugees or trans face persistent and deep inequities when interacting with the Canadian healthcare system. These challenges become more complex when they are experiencing family violence (also referred as intimate partner violence or IPV, and Gender Based Violence or GBV) and seeking support through the healthcare system. According to Women and Gender Equality Canada (WAGE), 44% of women aged 15 and older have who have been in an intimate relationship report experiencing some form of IPV, emphasizing an urgent need to reduce barriers towards offering appropriate safety and care-based interventions. For marginalized women, the intersection of immigration related stressors, precarious legal status, cultural norms and systemic discrimination compound the harm of violence and limits opportunities to receive timely and culturally responsive care. Improving healthcare access for immigrant women experiencing violence requires acknowledging the complex health impacts of IPV, addressing systemic and structural barriers, confronting provider biases and recognizing the role of both informal and formal support networks. In doing so, it would reframe the lack of access to appropriate care as a policy and systemic failure rather than an individual one and help us in building a coordinated, culturally responsive, violence and trauma informed healthcare system that meets diverse and intersecting needs of immigrant survivors.

== Health Impacts of Intimate Partner Violence ==
Intimate Partner Violence (IPV) produces interconnected physical, psychological and reproductive health consequences for immigrant women. Tastsoglou et al. (2025) note that violence often results in serious injuries, chronic reproductive issues and long-term mental health effects that are further intensified by the impact of trauma and migration. These interconnected outcomes demonstrate the limitations of our siloed models of care within the healthcare system where physical and emotional needs are treated independently despite being interconnected. While visible signs of abuse may be identified and addressed by healthcare providers, IPV related brain injuries, also known as traumatic brain injury (TBI) can go unnoticed and untreated. Toccalino et al. (2024) emphasize that TBI symptoms often overlap with mental health disorders and get misdiagnosed. By not being ablet to access imaging and other appropriate diagnostic tools, survivors are unable to receive confirmation of injury, leading to undiagnosed and inadequate treatment. Similarly, maternal health research demonstrates a higher level of vulnerability among migrant and refugee women. Khanlou et al. (2017) report that language barriers, limited familiarity with the healthcare system, and social isolation contribute to insufficient prenatal and postnatal support resulting in higher rates of postpartum depression, particularly among refugee women. These findings highlight the need for integrated, culturally responsive maternal care that takes migration related vulnerabilities along with the compounded impacts of IPV on overall health of an individual.

== Systemic and Structural Barriers ==
Systemic and structural barriers within the healthcare system further add onto the challenges that immigrant women face when navigating support for IPV. Across multiple studies, language barriers emerged as one of the most significant obstacles in accessing care (Tastsoglou et al., 2025; Kalich et al., 2015; Tsai & Ghahari, 2023). Due to limited access to appropriate translators and interpreters, feeling discomfort in having to discuss sensitive issues through a third party (a stranger or relative or their child), and low health literacy all reduce women’s ability to communicate their needs, understand treatment plans or seek help in a crisis such as when experiencing violence in the family. Communication challenges often result in multiple delays in receiving care, misinterpretations of symptoms, and feeling unsupported or misunderstood by the medical team.

Cultural norms and expectations also play a large role in an immigrant women’s experiences and cause delays in seeking timely support. Baloch et al. (2025) highlight the role of shame, stigma and concerns about dishonoring the family which leaves the woman to feel discouraged in disclosing the violence. These cultural pressures then interact with systemic gaps such as culturally inappropriate care or limited awareness of the healthcare provider about IPV resulting in an environment where immigrant women may feel unsafe or judged for attempting to access help.

Immigration based barriers such as having a precarious immigration status, having to be dependent on the abusive partner during the sponsorship process, or fearing deportation is another factor that prevents immigrant women from seeking formal assistance (Tastsoglou et al., 2025; Merken et al., 2023; Allen-Leap et al., 2022). While help seeking behaviour does depend on the individual, women may avoid healthcare all together because they fear disclosure of violence would result in deportation, or lead to child welfare involvement. For undocumented women, or those with limited eligibility for healthcare coverage such as on Interim Federal Health Program (IFHP), essential healthcare services including mental health services are either financially limited or unavailable altogether. Additionally, financial or logistical barriers which are often connected to the individual’s immigration status can restrict access to timely care. For instance, common challenges for newcomers includes transportation costs, childcare responsibilities, long wait times, and gaps in system navigation (Kalich et. al., 2015; Tsai & Ghahari, 2023). While there are government funded programs such as Crime Victim Assistance Program (CVAP) which provides limited financial support for individuals impacted by a violent crime, having to potentially pay out of pocket for medication, specialised services or ongoing counselling sessions can prevent women from seeking the help they need. These barriers are intensified for recent newcomers who would be facing a deep financial loss if they were to separate from an abusive partner. Immigrant women having to experience these structural constraints that highlight great difficulty in accessing care are not individual failings, rather are rooted in broader systemic inequities. For immigrant women experiencing IPV, these barriers play a large role in delaying or even preventing seeking help from healthcare or even social services spaces.

== Practitioner Level Barriers and Support Systems ==
Practitioner level barriers play a large role in shaping how immigrant women experience healthcare when seeking support for IPV. The interaction with a practitioner plays a large role in influencing how safe and believed the woman feels, and the extent to which they are able to then disclose the extent of violence they are facing. Healthcare providers may unintentionally reinforce harm through judgmental attitudes, minimization of the woman’s symptoms or experience, and through culturally insensitive responses (Baloch et al., 2025; Merken et al., 2023; Toccalino et al, 2024; Barrett & Pierre, 2011; Allen-Leap et al., 2022; Tsai, 2023). Baloch et al. (2025) further describes how women often feel blamed, dismissed, or misunderstood by practitioners leading them to avoid seeking care from them in the future. For instance, when a practitioner attaches reproductive or mental health concerns a client brings up to cultural assumptions rather than violent or abusive behavior, thus creating an additional barrier for a woman navigating a complex and traumatic situation. Furthermore, trans immigrant women face additional discrimination and exclusion when navigating various support systems, including healthcare. Merken et al. (2023) documents experiences of transphobia, misgendering, and inequitable treatment within shelters, when interacting with police and healthcare spaces. Therefore, while healthcare settings must work to create safer and more accessible environments for survivors, attention must also be given to the informal and formal supports immigrant women seek out when healthcare feels unsafe. These interventions provide critical support and offer models that healthcare providers can learn from or refer clients to, ensuring survivors receive appropriate and meaningful care.

Despite systemic challenges and barriers, immigrant women demonstrate determination, strength and agency in seeking support. Barrett (2011) points out that though most survivors use at least one formal or informal support, immigrant and racialized women are less likely to access formal services because of structural, cultural and practitioner level barriers. Furthermore, Allen-Leap et al. (2022), emphasize that trusting and empathetic relationships with healthcare providers can support clients in disclosing even when women are feeling a shame, fearing deportation or child welfare involvement. On the other hand, community-based organizations play an equally important role in clients feeling supported in a holistic manner. Raynayake et al. (2022) mention the crucial role of immigrant serving agencies acting as mediators, advocates, and system navigators in women understanding their rights, coordinating medical appointments, and accessing other essential services or funding. Moreover, these agencies support clients facing language, cultural barriers along with system navigation (Tsai & Ghahari, 2023; Kalich, 2015). However, these supports are often constrained by limited funding, high caseloads, and precarious organizational structures (Ratnayake et al., 2022). The ability of immigrant survivors of IPV to access timely and appropriate care highly depends not only on the client’s own strength but also on the ability of service providers to practice cultural humility and offer violence and trauma informed care.

== Application to Social Work ==
For social workers, supporting immigrant clients facing IPV within a healthcare setting have direct implications on their practice. As mentioned earlier by Tastsoglou (2025), the documented physical, psychological and reproductive consequences of violence, which are often worsened due to migration related stress and isolation, require social workers to bring in their trauma and violence informed approaches that emphasize client’s dignity, autonomy and right to safety. This further aligns with the social work code of ethics which calls on social workers to uphold individuals’ rights to self-determination and freedom from violence (CASW, 2024). As IPV related TBI is frequently misdiagnosed or undetected (Toccalino et al., 2024), social workers can bring this factor to the case consultations to ensure medical practitioners have performed an appropriate screening process to rule it out. Social workers can also remain attentive to any cognitive and emotional symptoms that survivors may struggle to articulate due to language or cultural barriers – sometimes it can be helpful to say the awkward thing out loud to ensure it has been addressed rather than have it go unnoticed. In doing so, a social worker would be acting in accordance to CASW (2024, Value 7) which requires providing accurate and culturally safe assessments to offer a competent service to clients.

Social workers also have a duty to address practitioner level barriers that clients may face, including judgement, minimization of client experience or culturally inappropriate responses, which often result in survivors feeling silenced (Baloch et al., 2025; Allen-Leap et al., 2022). While social workers may not be able to have direct conversations with medical practitioners to encourage them to change their harmful behavior, through offering non-judgmental, violence and trauma informed care which is rooted in respect and curiosity; clients can feel heard and validated about their experiences of violence. For system navigation support, social workers can help reduce barriers by ensuring access to interpreters, facilitating informed consent, explaining medical information, and coordinating appropriate culturally responsive referrals. In addition, social workers can offer clear information about client’s legal rights and help clarify any immigration related misinformation client may have received from the abusive party.

Finally, as the social work profession values collaboration and is rooted in building a client’s network, practitioners can collaborate with community-based organizations to help fill in any gaps the client’s needs. For example, immigrant serving agencies provide culturally grounded support, advocacy, translation and interpretation services along with one-on-one supportive counselling services or support groups in various languages. Social workers can strengthen a client’s social determinants of health while providing support that is often out of the scope of many health care settings.

== Conclusion ==
Ultimately, the experiences of immigrant women impacted by IPV and navigating healthcare reveal profound systemic challenges and gaps that social worker are uniquely positioned to help address. Through slowing down the conversation, creating space for the client to share her story and responding with respect and empathy, social workers can foster a collaborative environment that prioritizes safety, dignity and trust.

== Community Resources - Family Violence/Intimate Partner Violence (Canada Specific) ==
'''Advocacy, Education and Training:'''

* [https://bcsth.ca/ BCSTH] (BC Society of Transition Houses)
* [https://coercive-control.ca/ Coercive Control] (English and French Resources)
* [https://endingviolence.org/ EVA BC] (Ending Violence Association of BC)

'''Frontline Support and or Transition Housing:'''

* [https://www.bwss.org/ BWSS] (Battered Women's Support Service)
* [https://mosaicbc.org/our-services/violence-prevention-and-support/ MOSAIC] - (Settlement Agency, Violence Prevention and Support Program)
* [https://www.nisafoundation.ca/ NISA Foundation] (Transition Housing, Emotional Support etc)
* [https://www.options.bc.ca/program/transition-houses Options Community Services] (Transition Housing)
* [https://vlmfss.ca/ VLMFSS] (Multicultural Family Support Services)
* [https://ywcabc.org/programs/violence-prevention YWCA] (Transition Housing, Support Groups, Legal Support etc)

'''Legal Support:'''

* [https://www.irlc.ca/ Immigration and Refugee Legal Clinic]
* [https://www.womenslegalcentre.ca/ RISE Women's Legal Centre]
* [https://www.salcbc.org/ South Asian Legal Clinic]
* [https://mwcbc.ca/ Migrant Workers Center BC]

'''Other Trauma Informed, Women Centred Resources:'''

* [https://www.instagram.com/dfsvancouver/?hl=en Dress for Success] - (Employment Workshops, Clothing)

== References ==
Allen-Leap, M., Hooker, L., Wild, K., Wilson, I. M., Pokharel, B., & Taft, A. (2022). Seeking help from Primary Health-Care Providers in High-Income Countries: A scoping review of the experiences of migrant and refugee survivors of domestic violence. ''Trauma Violence & Abuse'', 24(5), 3715–3731. <nowiki>https://doi.org/10.1177/15248380221137664</nowiki>

Baloch, S., McLindon, E., Hameed, M., & Hegarty, K. (2025). South Asian women’s lived experiences of health care after disclosure of family violence: a qualitative meta-synthesis review. ''BMC Public Health'', 25(1), 445. <nowiki>https://doi.org/10.1186/s12889-025-21619-5</nowiki>

Barrett, B. J., & St Pierre, M. (2011). Variations in women’s help seeking in response to intimate partner violence: findings from a Canadian Population-Based study. ''Violence Against Women'', 17(1), 47–70. <nowiki>https://doi.org/10.1177/1077801210394273</nowiki>

CASW. (2024). Core social work values and guiding principles. <nowiki>https://www.caswacts.ca/files/attachements/CASW_Code_of_Ethics_2024_One_Pager.pdf</nowiki>

Government of Canada. (2025). ''Temporary health care coverage: What is covered''. Canada.ca. <nowiki>https://www.canada.ca/en/immigration-refugees-citizenship/services/refugees/help-within-canada/health-care/interim-federal-health-program/coverage-summary.html</nowiki>

Kalich, A., Heinemann, L., & Ghahari, S. (2015). A scoping review of immigrant experience of health care access barriers in Canada. ''Journal of Immigrant and Minority Health'', 18(3), 697–709. <nowiki>https://doi.org/10.1007/s10903-015-0237-6</nowiki>

Khanlou, N., Haque, N., Skinner, A., Mantini, A., & Landy, C. K. (2017). Scoping Review on Maternal Health among Immigrant and Refugee Women in Canada: Prenatal, Intrapartum, and Postnatal Care. ''Journal of Pregnancy'', 2017, 1–14. <nowiki>https://doi.org/10.1155/2017/8783294</nowiki>

Merken, S., Slakoff, D. C., Aujla, W., & Moton, L. (2023). Navigating Biases and Distrust of Systems: American and Canadian Intimate Partner Violence Service Providers’ Experiences with Trans and Immigrant Women Clients. ''Victims & Offenders'', 18(1), 141–168. <nowiki>https://doi.org/10.1080/15564886.2022.2136319</nowiki>

Ratnayake, A., Sayfi, S., Veronis, L., Torres, S., Baek, S., & Pottie, K. (2022). How are Non-Medical Settlement Service Organizations supporting access to healthcare and mental health services for immigrants: a scoping review. ''International Journal of Environmental Research and Public Health'', 19(6), 3616. <nowiki>https://doi.org/10.3390/ijerph19063616</nowiki>

Tastsoglou, E. (2025). Gender-Based Violence in a Migration Context: Health Impacts and Barriers to Healthcare Access and Help Seeking for Migrant and Refugee Women in Canada. ''Societies'', 15(3), 68. <nowiki>https://doi.org/10.3390/soc15030068</nowiki>

Toccalino, D., Haag, H., Nalder, E., Chan, V., Moore, A., Wickens, C. M., & Colantonio, A. (2024). “Using the right tools and addressing the right issue”: A qualitative exploration to support better care for intimate partner violence, brain injury, and mental health. <nowiki>https://doi.org/10.1371/journal.pone.0311852</nowiki>

Tsai, P., & Ghahari, S. (2023). Immigrants’ experience of health care access in Canada: a recent scoping review. ''Journal of Immigrant and Minority Health'', 25(3), 712–727.https://doi.org/10.1007/s10903-023-01461-w<nowiki/>{{Cc-by-nc-4.0}}

File:Tumisu-violence-against-women-4209778.jpg

2026-07-03T00:17:50Z

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Course:SOWK551/2021/Healthcare Navigation for Racialized Immigrant Survivors of Family Violence

2026-07-03T00:08:43Z

KellyAllison: pulled content from SOWK 551 (2025) project page

[[File:Placeholder_Image_1.jpg|alt=Adult writing in journal|thumb|Photo by Pexels on Pixabay]]

== Short Summary ==

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== Introduction ==
Immigrant women, particularly those that are migrants, refugees or trans face persistent and deep inequities when interacting with the Canadian healthcare system. These challenges become more complex when they are experiencing family violence (also referred as intimate partner violence or IPV, and Gender Based Violence or GBV) and seeking support through the healthcare system. According to Women and Gender Equality Canada (WAGE), 44% of women aged 15 and older have who have been in an intimate relationship report experiencing some form of IPV, emphasizing an urgent need to reduce barriers towards offering appropriate safety and care-based interventions. For marginalized women, the intersection of immigration related stressors, precarious legal status, cultural norms and systemic discrimination compound the harm of violence and limits opportunities to receive timely and culturally responsive care. Improving healthcare access for immigrant women experiencing violence requires acknowledging the complex health impacts of IPV, addressing systemic and structural barriers, confronting provider biases and recognizing the role of both informal and formal support networks. In doing so, it would reframe the lack of access to appropriate care as a policy and systemic failure rather than an individual one and help us in building a coordinated, culturally responsive, violence and trauma informed healthcare system that meets diverse and intersecting needs of immigrant survivors.

== Health Impacts of Intimate Partner Violence ==
Intimate Partner Violence (IPV) produces interconnected physical, psychological and reproductive health consequences for immigrant women. Tastsoglou et al. (2025) note that violence often results in serious injuries, chronic reproductive issues and long-term mental health effects that are further intensified by the impact of trauma and migration. These interconnected outcomes demonstrate the limitations of our siloed models of care within the healthcare system where physical and emotional needs are treated independently despite being interconnected. While visible signs of abuse may be identified and addressed by healthcare providers, IPV related brain injuries, also known as traumatic brain injury (TBI) can go unnoticed and untreated. Toccalino et al. (2024) emphasize that TBI symptoms often overlap with mental health disorders and get misdiagnosed. By not being ablet to access imaging and other appropriate diagnostic tools, survivors are unable to receive confirmation of injury, leading to undiagnosed and inadequate treatment. Similarly, maternal health research demonstrates a higher level of vulnerability among migrant and refugee women. Khanlou et al. (2017) report that language barriers, limited familiarity with the healthcare system, and social isolation contribute to insufficient prenatal and postnatal support resulting in higher rates of postpartum depression, particularly among refugee women. These findings highlight the need for integrated, culturally responsive maternal care that takes migration related vulnerabilities along with the compounded impacts of IPV on overall health of an individual.

== Systemic and Structural Barriers ==
Systemic and structural barriers within the healthcare system further add onto the challenges that immigrant women face when navigating support for IPV. Across multiple studies, language barriers emerged as one of the most significant obstacles in accessing care (Tastsoglou et al., 2025; Kalich et al., 2015; Tsai & Ghahari, 2023). Due to limited access to appropriate translators and interpreters, feeling discomfort in having to discuss sensitive issues through a third party (a stranger or relative or their child), and low health literacy all reduce women’s ability to communicate their needs, understand treatment plans or seek help in a crisis such as when experiencing violence in the family. Communication challenges often result in multiple delays in receiving care, misinterpretations of symptoms, and feeling unsupported or misunderstood by the medical team.

Cultural norms and expectations also play a large role in an immigrant women’s experiences and cause delays in seeking timely support. Baloch et al. (2025) highlight the role of shame, stigma and concerns about dishonoring the family which leaves the woman to feel discouraged in disclosing the violence. These cultural pressures then interact with systemic gaps such as culturally inappropriate care or limited awareness of the healthcare provider about IPV resulting in an environment where immigrant women may feel unsafe or judged for attempting to access help.

Immigration based barriers such as having a precarious immigration status, having to be dependent on the abusive partner during the sponsorship process, or fearing deportation is another factor that prevents immigrant women from seeking formal assistance (Tastsoglou et al., 2025; Merken et al., 2023; Allen-Leap et al., 2022). While help seeking behaviour does depend on the individual, women may avoid healthcare all together because they fear disclosure of violence would result in deportation, or lead to child welfare involvement. For undocumented women, or those with limited eligibility for healthcare coverage such as on Interim Federal Health Program (IFHP), essential healthcare services including mental health services are either financially limited or unavailable altogether. Additionally, financial or logistical barriers which are often connected to the individual’s immigration status can restrict access to timely care. For instance, common challenges for newcomers includes transportation costs, childcare responsibilities, long wait times, and gaps in system navigation (Kalich et. al., 2015; Tsai & Ghahari, 2023). While there are government funded programs such as Crime Victim Assistance Program (CVAP) which provides limited financial support for individuals impacted by a violent crime, having to potentially pay out of pocket for medication, specialised services or ongoing counselling sessions can prevent women from seeking the help they need. These barriers are intensified for recent newcomers who would be facing a deep financial loss if they were to separate from an abusive partner. Immigrant women having to experience these structural constraints that highlight great difficulty in accessing care are not individual failings, rather are rooted in broader systemic inequities. For immigrant women experiencing IPV, these barriers play a large role in delaying or even preventing seeking help from healthcare or even social services spaces.

== Practitioner Level Barriers and Support Systems ==
Practitioner level barriers play a large role in shaping how immigrant women experience healthcare when seeking support for IPV. The interaction with a practitioner plays a large role in influencing how safe and believed the woman feels, and the extent to which they are able to then disclose the extent of violence they are facing. Healthcare providers may unintentionally reinforce harm through judgmental attitudes, minimization of the woman’s symptoms or experience, and through culturally insensitive responses (Baloch et al., 2025; Merken et al., 2023; Toccalino et al, 2024; Barrett & Pierre, 2011; Allen-Leap et al., 2022; Tsai, 2023). Baloch et al. (2025) further describes how women often feel blamed, dismissed, or misunderstood by practitioners leading them to avoid seeking care from them in the future. For instance, when a practitioner attaches reproductive or mental health concerns a client brings up to cultural assumptions rather than violent or abusive behavior, thus creating an additional barrier for a woman navigating a complex and traumatic situation. Furthermore, trans immigrant women face additional discrimination and exclusion when navigating various support systems, including healthcare. Merken et al. (2023) documents experiences of transphobia, misgendering, and inequitable treatment within shelters, when interacting with police and healthcare spaces. Therefore, while healthcare settings must work to create safer and more accessible environments for survivors, attention must also be given to the informal and formal supports immigrant women seek out when healthcare feels unsafe. These interventions provide critical support and offer models that healthcare providers can learn from or refer clients to, ensuring survivors receive appropriate and meaningful care.

Despite systemic challenges and barriers, immigrant women demonstrate determination, strength and agency in seeking support. Barrett (2011) points out that though most survivors use at least one formal or informal support, immigrant and racialized women are less likely to access formal services because of structural, cultural and practitioner level barriers. Furthermore, Allen-Leap et al. (2022), emphasize that trusting and empathetic relationships with healthcare providers can support clients in disclosing even when women are feeling a shame, fearing deportation or child welfare involvement. On the other hand, community-based organizations play an equally important role in clients feeling supported in a holistic manner. Raynayake et al. (2022) mention the crucial role of immigrant serving agencies acting as mediators, advocates, and system navigators in women understanding their rights, coordinating medical appointments, and accessing other essential services or funding. Moreover, these agencies support clients facing language, cultural barriers along with system navigation (Tsai & Ghahari, 2023; Kalich, 2015). However, these supports are often constrained by limited funding, high caseloads, and precarious organizational structures (Ratnayake et al., 2022). The ability of immigrant survivors of IPV to access timely and appropriate care highly depends not only on the client’s own strength but also on the ability of service providers to practice cultural humility and offer violence and trauma informed care.

== Application to Social Work ==
For social workers, supporting immigrant clients facing IPV within a healthcare setting have direct implications on their practice. As mentioned earlier by Tastsoglou (2025), the documented physical, psychological and reproductive consequences of violence, which are often worsened due to migration related stress and isolation, require social workers to bring in their trauma and violence informed approaches that emphasize client’s dignity, autonomy and right to safety. This further aligns with the social work code of ethics which calls on social workers to uphold individuals’ rights to self-determination and freedom from violence (CASW, 2024). As IPV related TBI is frequently misdiagnosed or undetected (Toccalino et al., 2024), social workers can bring this factor to the case consultations to ensure medical practitioners have performed an appropriate screening process to rule it out. Social workers can also remain attentive to any cognitive and emotional symptoms that survivors may struggle to articulate due to language or cultural barriers – sometimes it can be helpful to say the awkward thing out loud to ensure it has been addressed rather than have it go unnoticed. In doing so, a social worker would be acting in accordance to CASW (2024, Value 7) which requires providing accurate and culturally safe assessments to offer a competent service to clients.

Social workers also have a duty to address practitioner level barriers that clients may face, including judgement, minimization of client experience or culturally inappropriate responses, which often result in survivors feeling silenced (Baloch et al., 2025; Allen-Leap et al., 2022). While social workers may not be able to have direct conversations with medical practitioners to encourage them to change their harmful behavior, through offering non-judgmental, violence and trauma informed care which is rooted in respect and curiosity; clients can feel heard and validated about their experiences of violence. For system navigation support, social workers can help reduce barriers by ensuring access to interpreters, facilitating informed consent, explaining medical information, and coordinating appropriate culturally responsive referrals. In addition, social workers can offer clear information about client’s legal rights and help clarify any immigration related misinformation client may have received from the abusive party.

Finally, as the social work profession values collaboration and is rooted in building a client’s network, practitioners can collaborate with community-based organizations to help fill in any gaps the client’s needs. For example, immigrant serving agencies provide culturally grounded support, advocacy, translation and interpretation services along with one-on-one supportive counselling services or support groups in various languages. Social workers can strengthen a client’s social determinants of health while providing support that is often out of the scope of many health care settings.

== Conclusion ==
Ultimately, the experiences of immigrant women impacted by IPV and navigating healthcare reveal profound systemic challenges and gaps that social worker are uniquely positioned to help address. Through slowing down the conversation, creating space for the client to share her story and responding with respect and empathy, social workers can foster a collaborative environment that prioritizes safety, dignity and trust.

== Community Resources - Family Violence/Intimate Partner Violence (Canada Specific) ==
'''Advocacy, Education and Training:'''

* [https://bcsth.ca/ BCSTH] (BC Society of Transition Houses)
* [https://coercive-control.ca/ Coercive Control] (English and French Resources)
* [https://endingviolence.org/ EVA BC] (Ending Violence Association of BC)

'''Frontline Support and or Transition Housing:'''

* [https://www.bwss.org/ BWSS] (Battered Women's Support Service)
* [https://mosaicbc.org/our-services/violence-prevention-and-support/ MOSAIC] - (Settlement Agency, Violence Prevention and Support Program)
* [https://www.nisafoundation.ca/ NISA Foundation] (Transition Housing, Emotional Support etc)
* [https://www.options.bc.ca/program/transition-houses Options Community Services] (Transition Housing)
* [https://vlmfss.ca/ VLMFSS] (Multicultural Family Support Services)
* [https://ywcabc.org/programs/violence-prevention YWCA] (Transition Housing, Support Groups, Legal Support etc)

'''Legal Support:'''

* [https://www.irlc.ca/ Immigration and Refugee Legal Clinic]
* [https://www.womenslegalcentre.ca/ RISE Women's Legal Centre]
* [https://www.salcbc.org/ South Asian Legal Clinic]
* [https://mwcbc.ca/ Migrant Workers Center BC]

'''Other Trauma Informed, Women Centred Resources:'''

* [https://www.instagram.com/dfsvancouver/?hl=en Dress for Success] - (Employment Workshops, Clothing)

== References ==
Allen-Leap, M., Hooker, L., Wild, K., Wilson, I. M., Pokharel, B., & Taft, A. (2022). Seeking help from Primary Health-Care Providers in High-Income Countries: A scoping review of the experiences of migrant and refugee survivors of domestic violence. ''Trauma Violence & Abuse'', 24(5), 3715–3731. <nowiki>https://doi.org/10.1177/15248380221137664</nowiki>

Baloch, S., McLindon, E., Hameed, M., & Hegarty, K. (2025). South Asian women’s lived experiences of health care after disclosure of family violence: a qualitative meta-synthesis review. ''BMC Public Health'', 25(1), 445. <nowiki>https://doi.org/10.1186/s12889-025-21619-5</nowiki>

Barrett, B. J., & St Pierre, M. (2011). Variations in women’s help seeking in response to intimate partner violence: findings from a Canadian Population-Based study. ''Violence Against Women'', 17(1), 47–70. <nowiki>https://doi.org/10.1177/1077801210394273</nowiki>

CASW. (2024). Core social work values and guiding principles. <nowiki>https://www.caswacts.ca/files/attachements/CASW_Code_of_Ethics_2024_One_Pager.pdf</nowiki>

Government of Canada. (2025). ''Temporary health care coverage: What is covered''. Canada.ca. <nowiki>https://www.canada.ca/en/immigration-refugees-citizenship/services/refugees/help-within-canada/health-care/interim-federal-health-program/coverage-summary.html</nowiki>

Kalich, A., Heinemann, L., & Ghahari, S. (2015). A scoping review of immigrant experience of health care access barriers in Canada. ''Journal of Immigrant and Minority Health'', 18(3), 697–709. <nowiki>https://doi.org/10.1007/s10903-015-0237-6</nowiki>

Khanlou, N., Haque, N., Skinner, A., Mantini, A., & Landy, C. K. (2017). Scoping Review on Maternal Health among Immigrant and Refugee Women in Canada: Prenatal, Intrapartum, and Postnatal Care. ''Journal of Pregnancy'', 2017, 1–14. <nowiki>https://doi.org/10.1155/2017/8783294</nowiki>

Merken, S., Slakoff, D. C., Aujla, W., & Moton, L. (2023). Navigating Biases and Distrust of Systems: American and Canadian Intimate Partner Violence Service Providers’ Experiences with Trans and Immigrant Women Clients. ''Victims & Offenders'', 18(1), 141–168. <nowiki>https://doi.org/10.1080/15564886.2022.2136319</nowiki>

Ratnayake, A., Sayfi, S., Veronis, L., Torres, S., Baek, S., & Pottie, K. (2022). How are Non-Medical Settlement Service Organizations supporting access to healthcare and mental health services for immigrants: a scoping review. ''International Journal of Environmental Research and Public Health'', 19(6), 3616. <nowiki>https://doi.org/10.3390/ijerph19063616</nowiki>

Tastsoglou, E. (2025). Gender-Based Violence in a Migration Context: Health Impacts and Barriers to Healthcare Access and Help Seeking for Migrant and Refugee Women in Canada. ''Societies'', 15(3), 68. <nowiki>https://doi.org/10.3390/soc15030068</nowiki>

Toccalino, D., Haag, H., Nalder, E., Chan, V., Moore, A., Wickens, C. M., & Colantonio, A. (2024). “Using the right tools and addressing the right issue”: A qualitative exploration to support better care for intimate partner violence, brain injury, and mental health. <nowiki>https://doi.org/10.1371/journal.pone.0311852</nowiki>

Tsai, P., & Ghahari, S. (2023). Immigrants’ experience of health care access in Canada: a recent scoping review. ''Journal of Immigrant and Minority Health'', 25(3), 712–727.https://doi.org/10.1007/s10903-023-01461-w<nowiki/>{{Cc-by-nc-4.0}}

Course:SOWK551/2021/Substance Use in an Aging Population

2026-07-02T23:38:27Z

KellyAllison:

[[File:Pexels-rdne-8139238.jpg|alt=Adult writing in journal|thumb|Photo by Pexels RDN stock project]]

== Short Summary ==
Literature exploring how to support individuals who use substances in end-of-life care.

''2025''

== Introduction ==
Palliative approaches in end-of-life care are increasingly gaining recognition for their utility in supporting people to access care in ways that reflect individual values and wishes at the end of life. The applicability of palliative approaches at the end of life is important within the health care system, with the proportion of Canadians aged 65 and older projected to account for 25% of the population by 2030 (National Institute on Ageing, 2021). With aging, individuals face changes in their health care needs, and this is increasingly complicated within the health care system supporting individuals who use substances in end-of-life care due to the complex barriers this population faces. People who use substances experience poor health outcomes and complex health challenges compared to those who do not use substances (Homayra et al., 2020). Despite this understanding, people who use substances often face fragmented care delivery and significant barriers to health care at the end of life (Homayra et al., 2020).

== Background ==
In order to better understand the barriers older adults who use substances face within the healthcare system, it is important to understand palliative care and end-of-life approaches, as well as the facilities themselves that work to support individuals at the end of life. Palliative care is an approach that prioritizes patients' quality of life when they are faced with serious, life-threatening illnesses and primarily focuses on symptom management and addressing physical, psychosocial, and spiritual care for the individual and their family (National Institute on Aging, 2021; Stajduhar & Mollison, 2018). Within this scope, end-of-life care is a term that is often used interchangeably with palliative care and utilizes similar approaches, with the specific distinction being care provision when the illness is terminal and death is expected in the near future (National Institute on Aging, 2021; Stajduhar & Mollison, 2018). End-of-life care and palliative care can be provided anywhere the client is living; however, it is well documented that older adults who use substances face barriers in accessing this care despite findings indicating people living with substance use disorders have increased risks of facing poorer health outcomes and life-threatening conditions (Government of British Columbia, 2025; Ebenau et al., 2019; Homayra et al., 2020).

Provision of end-of-life care often occurs within long-term care, hospice, or in patients' homes. Long-term care provides 24-hour professional health care “in a protective and supportive environment for individuals with complex care needs who can no longer be cared for in their own home or assisted living residence” (Government of British Columbia, 2025). Hospice care facilities offer similar 24-hour services; however, they uniquely focus on comfort care and quality of life optimization for individuals with a serious illness who are approaching the end of life (National Institute on Aging, 2021). Notably, people who use substances and face barriers to end-of-life care may be precariously housed, unhoused, or otherwise undetected by health care professionals to provide end-of-life support. Palliative and end-of-life approaches are inherently trauma-informed and focused on harm reduction as this approach is intended to position care around the needs of individuals in ways that are meaningful to them; however, people who use substances are often excluded from this care. People who use substances face unique challenges in receiving palliative care within the health care system due to intersecting experiences of oppression, resistance to accessing care due to previous experiences, and stigma within the health care system, limiting access to services such as hospice or long-term care.

== Social Determinants of Health ==
Social determinants of health uniquely impact individuals' access to care and influence their overall health outcomes. It is important to consider how a person’s age, gender, ethnicity, housing, income, education, and food security, among other factors, interact to determine individuals’ wellbeing and access to appropriate resources (Stajduhar & Mollison, 2018). Differential access based on these variables strongly influences unfair outcomes related to power, oppression, and health inequities experienced by certain individuals (World Health Organization, 2025). Additionally, consideration of the outcomes related to social determinants of health from an intersectional perspective is necessary to understand health outcomes and equitable access to palliative care approaches. Intersectional perspectives seek to understand how outcomes shaped by individuals’ social circumstances and identities create experiences of inclusion and exclusion (Walsh et al., 2025). Consideration of accessibility to end-of-life care for older adults who use substances is critical through these lenses to best understand how social and systemic structures interact to disproportionately lead to poorer health outcomes and health inequity.

Individuals diagnosed with a substance use disorder (SUD) have been closely linked with other structural forms of health inequities, such as experiences of economic disadvantage, limited formal education, and inadequate housing, which hold consequences related to higher rates of disease and poorer health outcomes compared to those who do not face similar health inequities (Higgs, 2022; Stajduhar & Mollison, 2018). Further, navigation of services to access basic needs such as shelter, food, and social insurance income becomes considerably difficult at the end of life (Stajduhar & Mollison, 2018). Fragmented support and lack of connection to community health care practitioners for these older adults to access palliative care at the end of life leave individuals isolated and without strong relationships to support their health care needs. Challenges with accessing care to support their intersecting identities of age and substance use, among other structural disadvantages individuals with a SUD face, make it difficult for them to focus on seeking out palliative end-of-life care support. As a result, individuals who are unhoused or precariously housed have understandably been found to prioritize focusing on immediate survival needs, such as food and shelter (Baines et al., 2025; McNeil, Guirguis-Younger & Dilley, 2012; Song et al., 2007), in lieu of seeking care for their serious illness. Older adults who use substances and are surviving within complex structures of oppression have been found to face increasingly poor physical and mental health outcomes, which impact their overall access to palliative care and facility-based admissions to support their complex care needs (Higgs, 2022).

== Harm Reduction Approaches ==
Many solutions for working with individuals with SUD at the end of life throughout the health care system appear to point towards abstinence as the standard by which care can best be provided. While this may work for some, many older adults who would benefit from palliative approaches at the end of life do not have goals of abstaining from substances, which does not negate the fact that they still require, and are deserving of care.

Harm reduction is an increasingly implemented policy and practice approach that is grounded in person-centered care from a social justice lens (Baines et al., 2025). Harm reduction policies are based on the acceptance that substance use is part of many individuals’ lives; rather than criminalizing substance use, harm reduction practices are based on the understanding that there are many ways to reduce individuals’ risk of harm, respect their human rights, and improve overall health outcomes (Baines et al., 2025; Kerman et al., 2021). Supporting individuals in accessing regulated supply and addressing social conditions of use are harm reduction approaches that work to minimize poor health outcomes and risks associated with unregulated substance use (Baines et al., 2025; National Harm Reduction Coalition, 2020; Jordan, 2023). Additionally, engaging in safer use, managed use, alternative use, or reduced use has centered this approach to support non-judgemental collaboration and prioritize autonomy in decision-making for people who use substances (Baines et al., 2025; National Harm Reduction Coalition, 2020; Jordan, 2023).

Vancouver Coastal Health (VCH) does not provide specific Harm Reduction policies on any of their LTC sites. However, May’s Place Hospice is in the Downtown Eastside and proudly practices a harm-reduction philosophy with dignity and respect (Li, 2024). With an aging population of people who use drugs, there is a clear need for long-term care homes to define and create policies on harm reduction.Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum.

== Stigma ==
Older adults with a SUD face many barriers to accessing end-of-life care, reflected by stigma from health care providers and past experiences influencing trust and willingness to engage with health care services at the end of life. Mistrust in the health care system can result in individuals opting not to disclose their substance use, which can contribute to incorrect symptom representations and inadequate pain management (Ebenau et al., 2019), carrying consequences related to poor quality of life and a lack of meaningful palliative approaches for individuals. Health care providers’ perceptions associated with substance use at the end of life have been linked to suboptimal palliative approaches to care focused on comfort and minimizing pain, as health care providers have stated fears of individuals abusing prescribed medications and label individuals as ‘drug seekers’ when requesting medication for pain management (Tayba et al., 2025).

In the long-term care context, older adults with a SUD encounter challenges with even being admitted despite their care needs requiring 24-hour care, and for those who are admitted, they often experience stigma and isolation within the home. Complex health outcomes necessitating long-term care earlier than others who have not faced the same extent of health inequities pose barriers in and of themselves. The role of age is a consideration for admission to long-term care, and research has found that this raises challenges on admission as staff share concerns that people who use substances would not be a good fit in these homes and that “mixing” populations would impact sociability with others in the home (Baines et al., 2025; Yang et al., 2023). Stigma and negative perceptions of older adults who use substances as being time-intensive, unpredictable, or challenging make cases for admission at the end of life more difficult; these perceptions were found to be exacerbated in long-term care homes that are understaffed (Yang et al., 2023). Additionally, older adults who use substances confront challenges in long-term care homes as many require abstinence over harm reduction approaches (Yang et al., 2023). This presents a major barrier for older adults at the end of life when their intention is not to abstain from substances, and their values misalign with those of the long-term care homes providing end-of-life care. As a result, long-term care admissions at the end of life may not be feasible despite a person being eligible due to high barriers requiring abstinence, or the risk of eviction due to reports of challenging behavioural characteristics (Baines et al., 2025).

== Application to Practice ==
Canada’s population is aging, and older adults who use substances will continue to require increased accessibility to strong palliative approaches to care at the end of life. Social workers play a vital role in the provision of health care accessibility for this population, and advocacy for better connection to this necessary care can be pivotal for older adults who use substances at the end of life.

Specialized training and education for social workers are an essential first step in this work to best understand the needs of this population on an individual level and the complex barriers to adequate health care that they experience, which impact their accessibility to end-of-life care. Providing education within health care to decrease stigma associated with substance use will be an important role when working on integrated care teams to ensure person-centered care is maintained and the health care team is utilizing harm reduction approaches to care. Facilities providing palliative and end-of-life care, such as long-term care, hospice, hospitals, and home supports offered from home, must all practice from a trauma-informed and harm reduction lens that is person-centered and cognizant of the dynamic barriers older adults who use substances face in accessing health care.

Developing policies to standardize more appropriate continuity of care would also be fundamental to ensure community, hospital, and bed-based facilities can provide consistent care and support, while also being prepared to best approach care for individuals with various levels of care needs. The benefits of this policy development would be multifaceted and impact individuals across the health care continuum to support end-of-life care. This would provide an opportunity for health care relationships to be initiated much earlier in an individual’s health trajectory once they have been diagnosed with a serious illness, and even before. Social workers can build trust earlier and support navigation of the complicated health system, with a strong role in harm reduction approaches and addressing social determinants of health to improve health outcomes. Social workers advocating for continuity of care is another harm reduction approach that is a necessary practice to ensure older adults receiving palliative care are well supported at every point within the health care system and to prioritize the older adults’ wishes at every step of care.

== References ==
Baines, D., Braedley, S., Daly, T., Hillier, S. and Cabahug, F. (2025) Low-barrier harm reduction and housing for older people in Vancouver’s opiate crisis: meeting people where they are, Critical and Radical Social Work, 13(1): 41–56, DOI: 10.1332/20498608Y2024D000000031

Ebenau, A., Dijkstra, B., ter Huurne, C., Hasselaar, J., Vissers, K., & Groot, M. (2019). Palliative care for people with substance use disorder and multiple problems: A qualitative study on experiences of patients and proxies. ''BMC Palliative Care'', ''18''(1). <nowiki>https://doi.org/10.1186/s12904-019-0443-4</nowiki>

Government of British Columbia. (2025). ''End-of-life care''. Province of British Columbia. <nowiki>https://www2.gov.bc.ca/gov/content/health/accessing-health-care/home-community-care/care-options-and-cost/end-of-life-care</nowiki>

Higgs, P. (2022). Ageing (dis)gracefully: People who inject drugs living with hepatitis C and the provision of end-of-life care. In ''Substance Use, End-of-Life Care and Multiple Deprivation'' (1st ed., pp. 105–117). essay, Routledge.

Homayra F, Pearce LA, Wang L, Panagiotoglou D, Sambo TF, Smith N, McKendry R, Wilson B, Joe R, Hawkins K, Barrios R, Mitton C, Nosyk B. Cohort profile: The provincial substance use disorder cohort in British Columbia, Canada. Int J Epidemiol. 2021 Jan 23;49(6):1776. doi: 10.1093/ije/dyaa150. PMID: 33097934; PMCID: PMC7825959.

Kerman, N., Polillo, A., Bardwell, G., Gran-Ruaz, S., Savage, C., Felteau, C. and Tsemberis, S. (2021) Harm reduction outcomes and practices in Housing First: a mixed-methods systematic review, Drug and Alcohol Dependence, 228: 109052. Doi: 10.1016/j.drugalcdep.2021.109052

McNeil, R., & Guirguis-Younger, M. (2011). Illicit drug use as a challenge to the delivery of end-of-life care services to homeless persons: Perceptions of Health and Social Services Professionals. ''Palliative Medicine'', ''26''(4), 350–359. <nowiki>https://doi.org/10.1177/0269216311402713</nowiki>

National Institute on Aging. (2021). What are palliative care and Hospice Care? . <nowiki>https://www.nia.nih.gov/health/hospice-and-palliative-care/what-are-palliative-care-and-hospice-care</nowiki>

Stajduhar & Mollison, 2018 Too Little, Too Late: How we fail vulnerable Canadians as they die and what to do about it. Final Project Report for the Equitable Access to Care Study in Victoria, British Columbia <nowiki>https://www.uvic.ca/research/groups/peol/assets/docs/too-little-too-late.pdf</nowiki>

Tayba L, Cuesta-Briand B, Auret K, Coleman M. Palliative care for people with substance use disorders: a qualitative study of the experiences of rural primary care providers. BMC Palliat Care. 2025 Jul 23;24(1):210. doi: 10.1186/s12904-025-01828-w. PMID: 40702457; PMCID: PMC12285175.

Walsh, J. J., Sussman, T., Bosma, H., Carter, R. Z., Cormier, É., & Canham, S. L. (2025). The intersections of palliative care and homelessness in social policy: A content analysis of Canadian policy documents. ''BMC Palliative Care'', ''24''(1). <nowiki>https://doi.org/10.1186/s12904-025-01866-4</nowiki>

World Health Organization. (2025). Social Determinants of Health. <nowiki>https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1</nowiki>

Yang, M., Beiting, K. J., & Levine, S. (2023). Barriers to care for nursing home residents with Substance Use Disorders: A qualitative study. Journal of Addiction Medicine, 17(2), 155–162. <nowiki>https://doi.org/10.1097/adm.0000000000001061</nowiki>

{{Cc-by-nc-4.0}}

Course:SOWK551/2021/Substance Use in an Aging Population

2026-07-02T23:37:44Z

KellyAllison:

Course:SOWK551/2021/Protective and Risk Factors Among Marginalized Youth with Adverse Childhood Experiences : Implications for Health Care Social Work

2026-07-02T23:29:22Z

KellyAllison:

Course:SOWK551/2021/Protective and Risk Factors Among Marginalized Youth with Adverse Childhood Experiences : Implications for Health Care Social Work

2026-07-02T23:26:50Z

KellyAllison:

Course:SOWK551/2021/Protective and Risk Factors Among Marginalized Youth with Adverse Childhood Experiences : Implications for Health Care Social Work

2026-07-02T23:24:08Z

KellyAllison:

Course:SOWK551/2021/Protective and Risk Factors Among Marginalized Youth with Adverse Childhood Experiences : Implications for Health Care Social Work

2026-07-02T23:21:28Z

KellyAllison: I pulled content from SOWWK 551 (2025) projects

[[File:Лечение Наркомании from Pixabay.jpg|alt=Adult writing in journal|thumb|Photo by Лечение Наркомании on Pixabay]]

== Short Summary ==
This literature review synthesizes emerging evidence on protective and risk factors among youth with adverse childhood experiences (ACEs), with a particular focus on marginalized and Indigenous populations.

Authors: Tsz Chun (Toby) Wan and Mei Wa Chu

Date: December 08, 2025
*

== Introduction ==
Adverse childhood experiences (ACEs) are commonly defined as early-life exposures to abuse, neglect, and household dysfunction that have been consistently linked to elevated risks for lifelong mental, emotional, and physical health challenges (Larkin et al., 2014). Since the foundational ACE study by Felitti and colleagues (Felitti et al., 1998), the ACE framework has expanded to include broader forms of adversity such as discrimination, community violence, poverty, and systemic oppression, reflecting an evolving understanding of how social environments shape development. Across disciplines, research demonstrates that ACEs are cumulative and interacting stressors rather than isolated events, influencing cognitive, emotional, and relational functioning throughout the lifespan (Larkin et al., 2014). For youth, particularly those navigating intersecting forms of marginalization, ACEs can disrupt developmental pathways, shape coping patterns, and contribute to long-term disparities in mental health, chronic disease, and social outcomes.

Contemporary ACE scholarship highlights that adversity is multidimensional and embedded within family, community, and structural contexts. Afifi et al. (2020), using confirmatory factor analysis with parents and adolescents, demonstrate that ACEs represent multiple latent constructs rather than a single uniform category, underscoring how adversity patterns are shaped by broader social conditions. Importantly, ACE exposure predicts not only internalizing outcomes such as depression and anxiety but also involvement with systems of surveillance and criminalization. In a Canadian context, Testa et al. (2025) found that youth with higher ACE scores were significantly more likely to experience police contact, illustrating how early adversity interacts with systemic inequities and contributes to cascading disadvantage.

Emerging research also emphasizes the importance of examining ACEs alongside positive childhood experiences (PCEs). Hinojosa and Hinojosa (2024) demonstrate that supportive relationships, emotional safety, and consistent caregiving can buffer the negative impacts of adversity, highlighting that resilience is environmentally supported rather than individually possessed. This dual focus that recognizing both adversity and strength is increasingly central to trauma-informed and resilience-oriented social work frameworks.

However, exposure to ACEs is not evenly distributed across populations. Youth from marginalized communities, including Black, Asian, racialized, and Indigenous groups would experience disproportionately high ACE burdens shaped by racism, intergenerational trauma, and structural inequities. Discrimination itself is now recognized as a form of adversity due to its psychological and physiological impacts, and racialized youth frequently encounter compounded forms of harm that interact with developmental stress processes and health-care access barriers. For Indigenous youth specifically, colonial histories of forced displacement, family separation, and child welfare involvement would contribute to some of the highest ACE prevalence rates in Canada. These intersecting adversities highlight the need for culturally anchored, trauma-informed approaches that recognize how identity, culture, power, and historical context shape both exposure to and the effects of childhood adversity.

Given these complexities, healthcare social workers play a critical role in addressing ACE-related needs through trauma-informed assessment, strengths-based engagement, cultural safety, and structural advocacy. This literature review synthesizes scholarship published between 2018 and 2025 to examine both risk and protective factors associated with ACEs, with particular emphasis on the experiences of marginalized, racialized, and Indigenous youth. It further explores how culturally grounded, ACE-informed, and resilience-focused practices can be integrated into health-care social work to strengthen protective factors, enhance culturally meaningful supports, and improve health and well-being outcomes for diverse youth populations.

== Protective Factors and Resilience ==
Protective factors can substantially buffer the negative effects of ACEs by promoting emotional security, resilience, and adaptive functioning (Tironi et al., 2024). At the individual level, psychological capacities such as epistemic trust, reflective functioning, and mentalized affectivity help youth interpret relationships safely, regulate emotions, and engage effectively with caregivers and professionals. Healthcare social workers can support these capacities through relational consistency, reflective dialogue, and strengths-based engagement, fostering resilience even in contexts of high adversity.

Beyond individual traits, relational and community-based protective factors are critical. Liu et al. (2020) highlight that positive childhood experiences (PCEs), including supportive caregiving, emotional safety, and a sense of being valued that frequently coexist with high ACE exposure and strongly predict resilience. Troxel et al. (2025) introduce the concept of social safety, defined as feeling connected, protected, and accepted, which mitigates the physiological and psychological impacts of both ACEs and discrimination. Together, these studies suggest that protective factors operate across multiple ecological levels, including individual, relational, and social and that interventions focusing solely on the individual may overlook relational and structural supports.

Cultural and community-based resources further extend protection for racialized and Indigenous youth. Radford et al. (2022) emphasize that for Indigenous youth, cultural continuity, community cohesion, language revitalization, and culturally meaningful practices serve as critical safeguards against the cumulative effects of historical and contemporary trauma. While mainstream health systems often prioritize individual-level interventions, these findings suggest that culturally grounded approaches are essential for fostering resilience in youth facing structural and historical adversity. The evidence collectively underscores the need for trauma-informed, culturally attuned environments that cultivate trust, relational safety, and cultural grounding.

== Risk Factors and the Role of Discrimination ==
Although ACEs are harmful across populations, recent literature shows that their impacts are intensified by systemic inequities, racism, and social exclusion. Discrimination functions as both a chronic stressor and a traumatic exposure, compounding the effects of conventional ACEs. Bernard et al. (2022) demonstrate that racial discrimination significantly increases internalizing mental health problems among Black youth, while Kim et al. (2024) find that Asian adolescents experiencing both ACEs and discrimination report higher rates of depression and anxiety. Jensen et al. (2025) further highlight elevated suicidality rates among Black, Hispanic, and multiracial youth with high ACE exposure, illustrating how systemic inequities interact with early adversity to shape mental health outcomes.

Indigenous youth experience some of the highest ACE prevalence rates globally due to ongoing colonialism, forced displacement, intergenerational trauma, and systemic inequities (Radford et al., 2022; Toombs et al., 2022). They face unique adversities, including cultural disruption, community-level trauma, and institutional discrimination, which intensify risks for poor mental health and highlight the necessity of culturally anchored support systems. Broader structural factors—such as poverty, housing instability, food insecurity, and limited access to early intervention—further exacerbate ACE impacts. Within healthcare systems, the lack of trauma-informed, culturally safe practice can inadvertently retraumatize youth through rushed assessments, culturally incongruent care, or dismissive responses to disclosures of discrimination.

The literature indicates that while protective factors can buffer adversity, risk factors are amplified by systemic oppression, and their expression varies across populations. This underscores the importance of integrating culturally responsive, ACE-informed, and trauma-informed frameworks that acknowledge both individual experiences and structural inequities in health care social work.

== Adverse Childhood Experiences Among Indigenous Populations in Canada ==
Indigenous populations in Canada experience disproportionately high rates of adverse childhood experiences (ACEs), shaped by ongoing colonial structures, intergenerational trauma, and systemic inequities (Toombs et al., 2022; Radford et al., 2022). Conventional ACE frameworks often focus on individual or household-level adversities, such as abuse, neglect, and household dysfunction, but fail to capture the historical, collective, and structural adversities that Indigenous youth face. These include forced assimilation, residential schools, child welfare interventions, land dispossession, and systemic discrimination, which together contribute to elevated ACE prevalence and unique trajectories of risk (Toombs et al., 2022). Radford et al. (2022) emphasize that Indigenous youth confront adversities that extend beyond family environments, including community-level trauma, cultural disruption, and institutional discrimination, which interact with systemic inequities to amplify risk for poor mental health outcomes. Bernard et al. (2021) similarly propose a culturally informed ACE framework (C-ACE) to account for racism and discrimination as pervasive forms of adversity among racialized youth, highlighting the limitations of applying universal ACE models without cultural context. LaBrenz et al. (2020) further underscore that structural factors such as poverty, housing instability, and limited access to early intervention exacerbate ACE impacts, reinforcing the necessity of race- and culture-specific analysis for equitable health care.

Empirical research illustrates how unaddressed ACEs intersect with broader systems. For instance, Muir and Viljoen (2022) report that higher ACE exposure correlates with increased recidivism among Indigenous adolescents in probation systems, demonstrating the compounding effects of trauma and systemic discrimination. These findings highlight the need for interventions that account for structural determinants in addition to individual or familial risk factors. Despite these challenges, Indigenous communities possess profound protective factors that can buffer the impacts of ACEs. Toombs et al. (2022) identify cultural continuity, community cohesion, connection to land, language revitalization, and Indigenous knowledge systems as central pillars of resilience. Luther et al. (2025) find that Indigenous university students with high adversity demonstrate coping capacities rooted in cultural identity, community belonging, relational support, and meaning-making practices. These culturally anchored resources echo findings among other racialized populations, where identity affirmation, collective solidarity, and culturally grounded practices mitigate health disparities (Bernard et al., 2021; LaBrenz et al., 2020).

The literature underscores the importance of trauma-informed, culturally safe, and ACE-informed care in healthcare settings. Toombs et al. (2022) and Radford et al. (2022) stress that interventions must integrate Indigenous worldviews, community-defined healing practices, and structural advocacy to avoid replicating colonial harms. Bernard et al. (2021) and LaBrenz et al. (2020) caution that standard ACE frameworks risk pathologizing Indigenous youth if they fail to incorporate historical, cultural, and structural contexts. By centering cultural strengths, community knowledge, and systemic awareness, healthcare social workers can foster resilience, support Indigenous sovereignty, and promote healing pathways aligned with the needs and values of Indigenous communities.

== Application to Practice ==
Translating this evidence into practice requires health-care social workers to intervene in ways that are trauma-informed, culturally safe, and responsive to the intersecting impacts of adverse childhood experiences, racial discrimination, and social marginalization. Findings across recent ACE studies highlight that youth who face racism and structural exclusion, particularly Black, Asian, and Indigenous youth who often experience heightened internalizing symptoms, suicidality, and barriers to trust in service systems (Bernard et al., 2022; Kim et al., 2024; Jensen et al., 2025; Radford et al., 2022). At the same time, protective processes such as epistemic trust, reflective functioning, relational safety, and supportive cultural identity have been shown to buffer against these risks (Tironi et al., 2024; Liu et al., 2020; Troxel et al., 2025). These findings collectively reinforce that social workers must center relational attunement, cultural humility, and collaborative care planning when working with ethnic minority and Indigenous youth in hospital settings.

'''1. Culturally adapted, ACE-informed assessment'''

Social workers can integrate an ACE- and discrimination-informed lens directly into biopsychosocial assessments by attending to racialized stressors, intergenerational trauma, and systemic inequities without pathologizing youth or “essentializing” cultural identities. This involves asking questions about safety, belonging, and past experiences of discrimination in ways that promote dignity and choice. Evidence suggests that trauma-informed assessment must prioritize emotional safety and consent, especially for youth with histories of racial or structural trauma (Stokes et al., 2024). For Indigenous patients, collaboration with the hospital’s Indigenous Health Team supports culturally grounded assessment, builds trust, and ensures that care plans reflect historical and community contexts (Radford et al., 2022).

'''2. Collaborative safety planning that restores relational and cultural safety'''

Given the elevated suicidality associated with ACEs and racial discrimination among diverse youth (Jensen et al., 2025), safety planning must extend beyond risk checklists to incorporate the youth’s cultural strengths, caregiving networks, and community supports. Trauma-informed practices highlight that collaborative planning increases agency and reduces coercion (Stokes et al., 2024). Integrating cultural anchors, such as extended kin networks, community mentors, or culturally meaningful practices that could strengthen protective factors identified in the literature (Liu et al., 2020; Tironi et al., 2024). For Indigenous youth, joint planning with Indigenous Elders, Knowledge Keepers, or Indigenous liaison workers supports continuity between hospital care and community wellness approaches.

'''3. Relationship-centered intervention to strengthen trust, affect regulation, and meaning-making'''

Because epistemic trust, reflective functioning, and mentalized affectivity protect youth facing ACEs (Tironi et al., 2024), hospital social workers can introduce brief relational interventions that model attunement, validation, and co-regulation. Even short-term inpatient encounters could strengthen a youth’s capacity to make sense of emotions and build trust with service providers are key predictors of engagement in follow-up care. This includes warm handovers to outpatient teams, transparent communication, and ensuring youth have voice and control in decisions. Stokes et al. (2024) emphasize that relational safety is a core component of trauma-informed mental health interventions in inpatient settings.

'''4. ACE-informed and culturally safe discharge planning'''

Discharge transitions are critical points for youth with complex trauma histories. Social workers could develop discharge plans that explicitly address environmental stressors linked to ACEs, such as housing instability, racism at school, or caregiver strain while connecting youth to culturally appropriate supports. For Indigenous and ethnic minority youth, coordination with community-based cultural, spiritual, or identity-affirming programs can enhance post-discharge safety and continuity of care. Integrating Hospital Indigenous Health Team recommendations ensures plans reflect community values, uphold cultural self-determination, and acknowledge systemic barriers.

These strategies integrate research on protective factors (Tironi et al., 2024; Troxel et al., 2025), culturally informed assessment (Liu et al., 2020; Bernard et al., 2021), and trauma-informed organizational approaches (Stokes et al., 2024). Collectively, they provide practical, evidence-informed steps that healthcare social workers could implement in hospital settings, supporting youth resilience, culturally safe care, and long-term wellbeing.

== Conclusion ==
Adverse childhood experiences (ACEs) are complex, multi-level stressors that intersect with systemic inequities, racial discrimination, and intergenerational trauma, disproportionately affecting marginalized and Indigenous youth (Felitti et al., 1998; Larkin et al., 2014; Afifi et al., 2020; Testa et al., 2025). While all youth exposed to ACEs face developmental risks, structural and cultural contexts intensify adverse outcomes, highlighting the limitations of conventional ACE frameworks that fail to account for historical and collective trauma (Radford et al., 2022; Toombs et al., 2022; Bernard et al., 2021). Protective factors, including relational safety, supportive caregiving, social connectedness, and culturally grounded identity could buffer these risks and promote resilience (Tironi et al., 2024; Liu et al., 2020; Troxel et al., 2025).

For healthcare social workers, translating this evidence into practice involves trauma-informed, culturally safe, and strengths-based approaches. Strategies such as ACE- and discrimination-informed assessments, collaborative safety planning, relationship-centered interventions, and culturally responsive discharge planning can strengthen protective factors, foster trust, and support youth well-being. Engaging with Indigenous Health Teams and community resources ensures care is aligned with cultural, historical, and systemic realities, enhancing both safety and agency. Ultimately, ACE-informed social work must recognize adversity alongside resilience, situate individual experiences within broader contexts, and prioritize relational and community supports. By doing so, social workers can mitigate the impacts of ACEs and promote equitable, culturally grounded outcomes for diverse youth populations.

== References ==
Afifi, T. O., Salmon, S., Garcés, I., Struck, S., Fortier, J., Taillieu, T., Stewart-Tufescu, A., Asmundson, G. J. G., Sareen, J., & MacMillan, H. L. (2020). Confirmatory factor analysis of adverse childhood experiences (ACEs) among a community-based sample of parents and adolescents. ''BMC Pediatrics'', ''20''(1), 178. <nowiki>https://doi.org/10.1186/s12887-020-02063-3</nowiki>

Bernard, D. L., Calhoun, C. D., Banks, D. E., Halliday, C. A., Hughes-Halbert, C., & Danielson, C. K. (2021). Making the “C-ACE” for a culturally-informed adverse childhood experiences framework to understand the pervasive mental health impact of racism on black youth. ''Journal of Child & Adolescent Trauma, 14''(2), 233-247. <nowiki>https://doi.org/10.1007/s40653-020-00319-9</nowiki>

Bernard, D. L., Smith, Q., & Lanier, P. (2022). Racial discrimination and other adverse childhood experiences as risk factors for internalizing mental health concerns among Black youth. ''Journal of Traumatic Stress, 35''(2), 473–483.<nowiki>https://doi.org/10.1002/jts.22760</nowiki>

Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The adverse childhood experiences (ACE) study. ''American Journal of Preventive Medicine, 14''(4), 245-258. <nowiki>https://doi.org/10.1016/S0749-3797(98)00017-8</nowiki>

Hinojosa, M. S., & Hinojosa, R. (2024). Positive and adverse childhood experiences and mental health outcomes of children. ''Child Abuse & Neglect'', ''149'', 106603. <nowiki>https://doi.org/10.1016/j.chiabu.2023.106603</nowiki>

Jensen, L. W. C., Jones, M. S., Gibbs, B. G., & Jarvis, J. A. (2025). Adverse childhood experiences, race/ethnicity, and suicidality among Florida high school students. ''Youth & Society, 57''(2), 233–257. <nowiki>https://doi.org/10.1177/0044118X241312248</nowiki>

Kim, I., Jang, H., Kim, S. R., & Choi, J. (2024). Adverse childhood experiences, racial discrimination, and internalizing problems among Asian adolescents. ''Journal of Child & Adolescent Trauma, 17''(4), 1177–1188. <nowiki>https://doi.org/10.1007/s40653-024-00652-3</nowiki>

LaBrenz, C. A., O'Gara, J. L., Panisch, L. S., Baiden, P., & Larkin, H. (2020). Adverse childhood experiences and mental and physical health disparities: The moderating effect of race and implications for social work. ''Social Work in Health Care, 59''(8), 588-614. <nowiki>https://doi.org/10.1080/00981389.2020.1823547</nowiki>

Larkin, H., Felitti, V. J., & Anda, R. F. (2014). Social Work and Adverse Childhood Experiences Research: Implications for Practice and Health Policy. ''Social Work in Public Health'', ''29''(1), 1–16. <nowiki>https://doi.org/10.1080/19371918.2011.619433</nowiki>

Liu, S. R., Kia‐Keating, M., Nylund‐Gibson, K., & Barnett, M. L. (2020). Co‐occurring youth profiles of adverse childhood experiences and protective factors: Associations with health, resilience, and racial disparities. ''American Journal of Community Psychology, 65''(1–2), 173–186. <nowiki>https://doi.org/10.1002/ajcp.12387</nowiki>

Luther, A. W., Skinner, K., Anthony, K., & Mielke, J. G. (2025). Childhood adversity and coping among indigenous university students in canada: Considerations when examining adverse childhood experiences. ''Psychological Trauma,'' <nowiki>https://doi.org/10.1037/tra0001885</nowiki>

Muir, N. M., & Viljoen, J. L. (2022). Adverse childhood experiences and recidivism in indigenous and white female and male adolescents on probation. ''Child Abuse & Neglect, 126'', 105512. <nowiki>https://doi.org/10.1016/j.chiabu.2022.105512</nowiki>

Radford, A., Toombs, E., Zugic, K., Boles, K., Lund, J., & Mushquash, C. J. (2022). Examining adverse childhood experiences (ACEs) within Indigenous populations: A systematic review. ''Journal of Child & Adolescent Trauma, 15''(2), 401–421. <nowiki>https://doi.org/10.1007/s40653-021-00393-7</nowiki>

Stokes, Y., Lewis, K. B., Tricco, A. C., Hambrick, E., Jacob, J. D., Demery Varin, M., Gould, J., Aggarwal, D., Cloutier, P., Landriault, C., Greenham, S., Ward, M., Kennedy, A., Boggett, J., Sheppard, R., Murphy, D., Robb, M., Gandy, H., Lavergne, S., & Graham, I. D. (2024). Trauma-informed care interventions used in pediatric inpatient or residential treatment mental health settings and strategies to implement them: A scoping review. ''Trauma, Violence & Abuse, 25''(3), 1737-1755. <nowiki>https://doi.org/10.1177/15248380231193444</nowiki>

Testa, A., Jacobs, B., Thompson, J., Pang, N., Jackson, D. B., Nagata, J. M., & Ganson, K. T. (2025). Adverse Childhood Experiences and Police Contact in Canada. ''Journal of Interpersonal Violence'', ''40''(9–10), 2188–2204. <nowiki>https://doi.org/10.1177/08862605241270047</nowiki>

Tironi, M., Charpentier Mora, S., Liotti, M., Fiorini Bincoletto, A., Tanzilli, A., Cavanna, D., Lingiardi, V., Speranza, A. M., Giovanardi, G., & Bizzi, F. (2024). Adverse childhood experiences and psychological maladjustment in adolescence: The protective role of epistemic trust, mentalized affectivity, and reflective functioning. ''Journal of Clinical Psychology, 80''(11), 2228–2246. <nowiki>https://doi.org/10.1002/jclp.23733</nowiki>

Toombs, E., Lund, J., & Mushquash, C. J. (2022). Adverse childhood experiences (ACEs) are increasing in indigenous populations in canada: Now what? ''Canadian Psychology = Psychologie Canadienne, 63''(4), 576-588. <nowiki>https://doi.org/10.1037/cap0000331</nowiki>

Troxel, W. M., Seelam, R., Perez, L. G., Davis, J., & D’Amico, E. J. (2025). Social safety and health outcomes in emerging adults: Interactions of adverse childhood experiences and discrimination. ''Journal of Community Psychology, 53''(4), e70011. <nowiki>https://doi.org/10.1002/jcop.70011</nowiki>

Protective and risk factors among marginalized youth with adverse childhood experiences (ACEs): Implications for health care social work © 2025 by Tsz Chun (Toby) Wan and Mei Wa Chu is licensed under CC BY-NC 4.0

Course:SOWK551/2021/Substance Use in an Aging Population

2026-07-02T23:04:05Z

KellyAllison: pulled content from SOWK 551 (2025) project page

Course:SOWK551/2025/Substance Use in an Aging Population

2026-07-02T22:35:47Z

KellyAllison:

[[File:Pexels-rdne-8139238.jpg|thumb|Pexel photo by RDNE stock project]]

== '''Background''' ==
Palliative approaches in end-of-life care are increasingly gaining recognition for their utility in supporting people to access care in ways that reflect individual values and wishes at the end of life. The applicability of palliative approaches at the end of life is important within the health care system, with the proportion of Canadians aged 65 and older projected to account for 25% of the population by 2030 (National Institute on Ageing, 2021). With aging, individuals face changes in their health care needs, and this is increasingly complicated within the health care system supporting individuals who use substances in end-of-life care due to the complex barriers this population faces. People who use substances experience poor health outcomes and complex health challenges compared to those who do not use substances (Homayra et al., 2020). Despite this understanding, people who use substances often face fragmented care delivery and significant barriers to health care at the end of life (Homayra et al., 2020).

In order to better understand the barriers older adults who use substances face within the healthcare system, it is important to understand palliative care and end-of-life approaches, as well as the facilities themselves that work to support individuals at the end of life. Palliative care is an approach that prioritizes patients' quality of life when they are faced with serious, life-threatening illnesses and primarily focuses on symptom management and addressing physical, psychosocial, and spiritual care for the individual and their family (National Institute on Aging, 2021; Stajduhar & Mollison, 2018). Within this scope, end-of-life care is a term that is often used interchangeably with palliative care and utilizes similar approaches, with the specific distinction being care provision when the illness is terminal and death is expected in the near future (National Institute on Aging, 2021; Stajduhar & Mollison, 2018). End-of-life care and palliative care can be provided anywhere the client is living; however, it is well documented that older adults who use substances face barriers in accessing this care despite findings indicating people living with substance use disorders have increased risks of facing poorer health outcomes and life-threatening conditions (Government of British Columbia, 2025; Ebenau et al., 2019; Homayra et al., 2020).

Provision of end-of-life care often occurs within long-term care, hospice, or in patients' homes. Long-term care provides 24-hour professional health care “in a protective and supportive environment for individuals with complex care needs who can no longer be cared for in their own home or assisted living residence” (Government of British Columbia, 2025). Hospice care facilities offer similar 24-hour services; however, they uniquely focus on comfort care and quality of life optimization for individuals with a serious illness who are approaching the end of life (National Institute on Aging, 2021). Notably, people who use substances and face barriers to end-of-life care may be precariously housed, unhoused, or otherwise undetected by health care professionals to provide end-of-life support. Palliative and end-of-life approaches are inherently trauma-informed and focused on harm reduction as this approach is intended to position care around the needs of individuals in ways that are meaningful to them; however, people who use substances are often excluded from this care. People who use substances face unique challenges in receiving palliative care within the health care system due to intersecting experiences of oppression, resistance to accessing care due to previous experiences, and stigma within the health care system, limiting access to services such as hospice or long-term care.

=== '''Social Determinants of Health''' ===
Social determinants of health uniquely impact individuals' access to care and influence their overall health outcomes. It is important to consider how a person’s age, gender, ethnicity, housing, income, education, and food security, among other factors, interact to determine individuals’ wellbeing and access to appropriate resources (Stajduhar & Mollison, 2018). Differential access based on these variables strongly influences unfair outcomes related to power, oppression, and health inequities experienced by certain individuals (World Health Organization, 2025). Additionally, consideration of the outcomes related to social determinants of health from an intersectional perspective is necessary to understand health outcomes and equitable access to palliative care approaches. Intersectional perspectives seek to understand how outcomes shaped by individuals’ social circumstances and identities create experiences of inclusion and exclusion (Walsh et al., 2025). Consideration of accessibility to end-of-life care for older adults who use substances is critical through these lenses to best understand how social and systemic structures interact to disproportionately lead to poorer health outcomes and health inequity.

Individuals diagnosed with a substance use disorder (SUD) have been closely linked with other structural forms of health inequities, such as experiences of economic disadvantage, limited formal education, and inadequate housing, which hold consequences related to higher rates of disease and poorer health outcomes compared to those who do not face similar health inequities (Higgs, 2022; Stajduhar & Mollison, 2018). Further, navigation of services to access basic needs such as shelter, food, and social insurance income becomes considerably difficult at the end of life (Stajduhar & Mollison, 2018). Fragmented support and lack of connection to community health care practitioners for these older adults to access palliative care at the end of life leave individuals isolated and without strong relationships to support their health care needs. Challenges with accessing care to support their intersecting identities of age and substance use, among other structural disadvantages individuals with a SUD face, make it difficult for them to focus on seeking out palliative end-of-life care support. As a result, individuals who are unhoused or precariously housed have understandably been found to prioritize focusing on immediate survival needs, such as food and shelter (Baines et al., 2025; McNeil, Guirguis-Younger & Dilley, 2012; Song et al., 2007), in lieu of seeking care for their serious illness. Older adults who use substances and are surviving within complex structures of oppression have been found to face increasingly poor physical and mental health outcomes, which impact their overall access to palliative care and facility-based admissions to support their complex care needs (Higgs, 2022).

'''Harm Reduction Approaches'''

Many solutions for working with individuals with SUD at the end of life throughout the health care system appear to point towards abstinence as the standard by which care can best be provided. While this may work for some, many older adults who would benefit from palliative approaches at the end of life do not have goals of abstaining from substances, which does not negate the fact that they still require, and are deserving of care.

Harm reduction is an increasingly implemented policy and practice approach that is grounded in person-centered care from a social justice lens (Baines et al., 2025). Harm reduction policies are based on the acceptance that substance use is part of many individuals’ lives; rather than criminalizing substance use, harm reduction practices are based on the understanding that there are many ways to reduce individuals’ risk of harm, respect their human rights, and improve overall health outcomes (Baines et al., 2025; Kerman et al., 2021). Supporting individuals in accessing regulated supply and addressing social conditions of use are harm reduction approaches that work to minimize poor health outcomes and risks associated with unregulated substance use (Baines et al., 2025; National Harm Reduction Coalition, 2020; Jordan, 2023). Additionally, engaging in safer use, managed use, alternative use, or reduced use has centered this approach to support non-judgemental collaboration and prioritize autonomy in decision-making for people who use substances (Baines et al., 2025; National Harm Reduction Coalition, 2020; Jordan, 2023).

Vancouver Coastal Health (VCH) does not provide specific Harm Reduction policies on any of their LTC sites. However, May’s Place Hospice is in the Downtown Eastside and proudly practices a harm-reduction philosophy with dignity and respect (Li, 2024). With an aging population of people who use drugs, there is a clear need for long-term care homes to define and create policies on harm reduction.

'''Stigma'''

Older adults with a SUD face many barriers to accessing end-of-life care, reflected by stigma from health care providers and past experiences influencing trust and willingness to engage with health care services at the end of life. Mistrust in the health care system can result in individuals opting not to disclose their substance use, which can contribute to incorrect symptom representations and inadequate pain management (Ebenau et al., 2019), carrying consequences related to poor quality of life and a lack of meaningful palliative approaches for individuals. Health care providers’ perceptions associated with substance use at the end of life have been linked to suboptimal palliative approaches to care focused on comfort and minimizing pain, as health care providers have stated fears of individuals abusing prescribed medications and label individuals as ‘drug seekers’ when requesting medication for pain management (Tayba et al., 2025).

In the long-term care context, older adults with a SUD encounter challenges with even being admitted despite their care needs requiring 24-hour care, and for those who are admitted, they often experience stigma and isolation within the home. Complex health outcomes necessitating long-term care earlier than others who have not faced the same extent of health inequities pose barriers in and of themselves. The role of age is a consideration for admission to long-term care, and research has found that this raises challenges on admission as staff share concerns that people who use substances would not be a good fit in these homes and that “mixing” populations would impact sociability with others in the home (Baines et al., 2025; Yang et al., 2023). Stigma and negative perceptions of older adults who use substances as being time-intensive, unpredictable, or challenging make cases for admission at the end of life more difficult; these perceptions were found to be exacerbated in long-term care homes that are understaffed (Yang et al., 2023). Additionally, older adults who use substances confront challenges in long-term care homes as many require abstinence over harm reduction approaches (Yang et al., 2023). This presents a major barrier for older adults at the end of life when their intention is not to abstain from substances, and their values misalign with those of the long-term care homes providing end-of-life care. As a result, long-term care admissions at the end of life may not be feasible despite a person being eligible due to high barriers requiring abstinence, or the risk of eviction due to reports of challenging behavioural characteristics (Baines et al., 2025).

'''Application to Practice'''

Canada’s population is aging, and older adults who use substances will continue to require increased accessibility to strong palliative approaches to care at the end of life. Social workers play a vital role in the provision of health care accessibility for this population, and advocacy for better connection to this necessary care can be pivotal for older adults who use substances at the end of life.

Specialized training and education for social workers are an essential first step in this work to best understand the needs of this population on an individual level and the complex barriers to adequate health care that they experience, which impact their accessibility to end-of-life care. Providing education within health care to decrease stigma associated with substance use will be an important role when working on integrated care teams to ensure person-centered care is maintained and the health care team is utilizing harm reduction approaches to care. Facilities providing palliative and end-of-life care, such as long-term care, hospice, hospitals, and home supports offered from home, must all practice from a trauma-informed and harm reduction lens that is person-centered and cognizant of the dynamic barriers older adults who use substances face in accessing health care.

Developing policies to standardize more appropriate continuity of care would also be fundamental to ensure community, hospital, and bed-based facilities can provide consistent care and support, while also being prepared to best approach care for individuals with various levels of care needs. The benefits of this policy development would be multifaceted and impact individuals across the health care continuum to support end-of-life care. This would provide an opportunity for health care relationships to be initiated much earlier in an individual’s health trajectory once they have been diagnosed with a serious illness, and even before. Social workers can build trust earlier and support navigation of the complicated health system, with a strong role in harm reduction approaches and addressing social determinants of health to improve health outcomes. Social workers advocating for continuity of care is another harm reduction approach that is a necessary practice to ensure older adults receiving palliative care are well supported at every point within the health care system and to prioritize the older adults’ wishes at every step of care.

'''References'''

Baines, D., Braedley, S., Daly, T., Hillier, S. and Cabahug, F. (2025) Low-barrier harm reduction and housing for older people in Vancouver’s opiate crisis: meeting people where they are, Critical and Radical Social Work, 13(1): 41–56, DOI: 10.1332/20498608Y2024D000000031

Ebenau, A., Dijkstra, B., ter Huurne, C., Hasselaar, J., Vissers, K., & Groot, M. (2019). Palliative care for people with substance use disorder and multiple problems: A qualitative study on experiences of patients and proxies. ''BMC Palliative Care'', ''18''(1). <nowiki>https://doi.org/10.1186/s12904-019-0443-4</nowiki>

Government of British Columbia. (2025). ''End-of-life care''. Province of British Columbia. <nowiki>https://www2.gov.bc.ca/gov/content/health/accessing-health-care/home-community-care/care-options-and-cost/end-of-life-care</nowiki>

Higgs, P. (2022). Ageing (dis)gracefully: People who inject drugs living with hepatitis C and the provision of end-of-life care. In ''Substance Use, End-of-Life Care and Multiple Deprivation'' (1st ed., pp. 105–117). essay, Routledge.

Homayra F, Pearce LA, Wang L, Panagiotoglou D, Sambo TF, Smith N, McKendry R, Wilson B, Joe R, Hawkins K, Barrios R, Mitton C, Nosyk B. Cohort profile: The provincial substance use disorder cohort in British Columbia, Canada. Int J Epidemiol. 2021 Jan 23;49(6):1776. doi: 10.1093/ije/dyaa150. PMID: 33097934; PMCID: PMC7825959.

Kerman, N., Polillo, A., Bardwell, G., Gran-Ruaz, S., Savage, C., Felteau, C. and Tsemberis, S. (2021) Harm reduction outcomes and practices in Housing First: a mixed-methods systematic review, Drug and Alcohol Dependence, 228: 109052. Doi: 10.1016/j.drugalcdep.2021.109052

McNeil, R., & Guirguis-Younger, M. (2011). Illicit drug use as a challenge to the delivery of end-of-life care services to homeless persons: Perceptions of Health and Social Services Professionals. ''Palliative Medicine'', ''26''(4), 350–359. <nowiki>https://doi.org/10.1177/0269216311402713</nowiki>

National Institute on Aging. (2021). What are palliative care and Hospice Care? . <nowiki>https://www.nia.nih.gov/health/hospice-and-palliative-care/what-are-palliative-care-and-hospice-care</nowiki>

Stajduhar & Mollison, 2018 Too Little, Too Late: How we fail vulnerable Canadians as they die and what to do about it. Final Project Report for the Equitable Access to Care Study in Victoria, British Columbia <nowiki>https://www.uvic.ca/research/groups/peol/assets/docs/too-little-too-late.pdf</nowiki>

Tayba L, Cuesta-Briand B, Auret K, Coleman M. Palliative care for people with substance use disorders: a qualitative study of the experiences of rural primary care providers. BMC Palliat Care. 2025 Jul 23;24(1):210. doi: 10.1186/s12904-025-01828-w. PMID: 40702457; PMCID: PMC12285175.

Walsh, J. J., Sussman, T., Bosma, H., Carter, R. Z., Cormier, É., & Canham, S. L. (2025). The intersections of palliative care and homelessness in social policy: A content analysis of Canadian policy documents. ''BMC Palliative Care'', ''24''(1). <nowiki>https://doi.org/10.1186/s12904-025-01866-4</nowiki>

World Health Organization. (2025). Social Determinants of Health. <nowiki>https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1</nowiki>

Yang, M., Beiting, K. J., & Levine, S. (2023). Barriers to care for nursing home residents with Substance Use Disorders: A qualitative study. Journal of Addiction Medicine, 17(2), 155–162. <nowiki>https://doi.org/10.1097/adm.0000000000001061</nowiki>

Course:SOWK551/2025/Substance Use in an Aging Population

2026-06-30T23:59:41Z

KellyAllison: I inserted a photo

[[File:Pexels-rdne-8139238.jpg|thumb|Pexel photo by RDNE stock project]]
'''Background'''

Palliative approaches in end-of-life care are increasingly gaining recognition for their utility in supporting people to access care in ways that reflect individual values and wishes at the end of life. The applicability of palliative approaches at the end of life is important within the health care system, with the proportion of Canadians aged 65 and older projected to account for 25% of the population by 2030 (National Institute on Ageing, 2021). With aging, individuals face changes in their health care needs, and this is increasingly complicated within the health care system supporting individuals who use substances in end-of-life care due to the complex barriers this population faces. People who use substances experience poor health outcomes and complex health challenges compared to those who do not use substances (Homayra et al., 2020). Despite this understanding, people who use substances often face fragmented care delivery and significant barriers to health care at the end of life (Homayra et al., 2020).

In order to better understand the barriers older adults who use substances face within the healthcare system, it is important to understand palliative care and end-of-life approaches, as well as the facilities themselves that work to support individuals at the end of life. Palliative care is an approach that prioritizes patients' quality of life when they are faced with serious, life-threatening illnesses and primarily focuses on symptom management and addressing physical, psychosocial, and spiritual care for the individual and their family (National Institute on Aging, 2021; Stajduhar & Mollison, 2018). Within this scope, end-of-life care is a term that is often used interchangeably with palliative care and utilizes similar approaches, with the specific distinction being care provision when the illness is terminal and death is expected in the near future (National Institute on Aging, 2021; Stajduhar & Mollison, 2018). End-of-life care and palliative care can be provided anywhere the client is living; however, it is well documented that older adults who use substances face barriers in accessing this care despite findings indicating people living with substance use disorders have increased risks of facing poorer health outcomes and life-threatening conditions (Government of British Columbia, 2025; Ebenau et al., 2019; Homayra et al., 2020).

Provision of end-of-life care often occurs within long-term care, hospice, or in patients' homes. Long-term care provides 24-hour professional health care “in a protective and supportive environment for individuals with complex care needs who can no longer be cared for in their own home or assisted living residence” (Government of British Columbia, 2025). Hospice care facilities offer similar 24-hour services; however, they uniquely focus on comfort care and quality of life optimization for individuals with a serious illness who are approaching the end of life (National Institute on Aging, 2021). Notably, people who use substances and face barriers to end-of-life care may be precariously housed, unhoused, or otherwise undetected by health care professionals to provide end-of-life support. Palliative and end-of-life approaches are inherently trauma-informed and focused on harm reduction as this approach is intended to position care around the needs of individuals in ways that are meaningful to them; however, people who use substances are often excluded from this care. People who use substances face unique challenges in receiving palliative care within the health care system due to intersecting experiences of oppression, resistance to accessing care due to previous experiences, and stigma within the health care system, limiting access to services such as hospice or long-term care.

'''Social Determinants of Health'''

Social determinants of health uniquely impact individuals' access to care and influence their overall health outcomes. It is important to consider how a person’s age, gender, ethnicity, housing, income, education, and food security, among other factors, interact to determine individuals’ wellbeing and access to appropriate resources (Stajduhar & Mollison, 2018). Differential access based on these variables strongly influences unfair outcomes related to power, oppression, and health inequities experienced by certain individuals (World Health Organization, 2025). Additionally, consideration of the outcomes related to social determinants of health from an intersectional perspective is necessary to understand health outcomes and equitable access to palliative care approaches. Intersectional perspectives seek to understand how outcomes shaped by individuals’ social circumstances and identities create experiences of inclusion and exclusion (Walsh et al., 2025). Consideration of accessibility to end-of-life care for older adults who use substances is critical through these lenses to best understand how social and systemic structures interact to disproportionately lead to poorer health outcomes and health inequity.

Individuals diagnosed with a substance use disorder (SUD) have been closely linked with other structural forms of health inequities, such as experiences of economic disadvantage, limited formal education, and inadequate housing, which hold consequences related to higher rates of disease and poorer health outcomes compared to those who do not face similar health inequities (Higgs, 2022; Stajduhar & Mollison, 2018). Further, navigation of services to access basic needs such as shelter, food, and social insurance income becomes considerably difficult at the end of life (Stajduhar & Mollison, 2018). Fragmented support and lack of connection to community health care practitioners for these older adults to access palliative care at the end of life leave individuals isolated and without strong relationships to support their health care needs. Challenges with accessing care to support their intersecting identities of age and substance use, among other structural disadvantages individuals with a SUD face, make it difficult for them to focus on seeking out palliative end-of-life care support. As a result, individuals who are unhoused or precariously housed have understandably been found to prioritize focusing on immediate survival needs, such as food and shelter (Baines et al., 2025; McNeil, Guirguis-Younger & Dilley, 2012; Song et al., 2007), in lieu of seeking care for their serious illness. Older adults who use substances and are surviving within complex structures of oppression have been found to face increasingly poor physical and mental health outcomes, which impact their overall access to palliative care and facility-based admissions to support their complex care needs (Higgs, 2022).

'''Harm Reduction Approaches'''

Many solutions for working with individuals with SUD at the end of life throughout the health care system appear to point towards abstinence as the standard by which care can best be provided. While this may work for some, many older adults who would benefit from palliative approaches at the end of life do not have goals of abstaining from substances, which does not negate the fact that they still require, and are deserving of care.

Harm reduction is an increasingly implemented policy and practice approach that is grounded in person-centered care from a social justice lens (Baines et al., 2025). Harm reduction policies are based on the acceptance that substance use is part of many individuals’ lives; rather than criminalizing substance use, harm reduction practices are based on the understanding that there are many ways to reduce individuals’ risk of harm, respect their human rights, and improve overall health outcomes (Baines et al., 2025; Kerman et al., 2021). Supporting individuals in accessing regulated supply and addressing social conditions of use are harm reduction approaches that work to minimize poor health outcomes and risks associated with unregulated substance use (Baines et al., 2025; National Harm Reduction Coalition, 2020; Jordan, 2023). Additionally, engaging in safer use, managed use, alternative use, or reduced use has centered this approach to support non-judgemental collaboration and prioritize autonomy in decision-making for people who use substances (Baines et al., 2025; National Harm Reduction Coalition, 2020; Jordan, 2023).

Vancouver Coastal Health (VCH) does not provide specific Harm Reduction policies on any of their LTC sites. However, May’s Place Hospice is in the Downtown Eastside and proudly practices a harm-reduction philosophy with dignity and respect (Li, 2024). With an aging population of people who use drugs, there is a clear need for long-term care homes to define and create policies on harm reduction.

'''Stigma'''

Older adults with a SUD face many barriers to accessing end-of-life care, reflected by stigma from health care providers and past experiences influencing trust and willingness to engage with health care services at the end of life. Mistrust in the health care system can result in individuals opting not to disclose their substance use, which can contribute to incorrect symptom representations and inadequate pain management (Ebenau et al., 2019), carrying consequences related to poor quality of life and a lack of meaningful palliative approaches for individuals. Health care providers’ perceptions associated with substance use at the end of life have been linked to suboptimal palliative approaches to care focused on comfort and minimizing pain, as health care providers have stated fears of individuals abusing prescribed medications and label individuals as ‘drug seekers’ when requesting medication for pain management (Tayba et al., 2025).

In the long-term care context, older adults with a SUD encounter challenges with even being admitted despite their care needs requiring 24-hour care, and for those who are admitted, they often experience stigma and isolation within the home. Complex health outcomes necessitating long-term care earlier than others who have not faced the same extent of health inequities pose barriers in and of themselves. The role of age is a consideration for admission to long-term care, and research has found that this raises challenges on admission as staff share concerns that people who use substances would not be a good fit in these homes and that “mixing” populations would impact sociability with others in the home (Baines et al., 2025; Yang et al., 2023). Stigma and negative perceptions of older adults who use substances as being time-intensive, unpredictable, or challenging make cases for admission at the end of life more difficult; these perceptions were found to be exacerbated in long-term care homes that are understaffed (Yang et al., 2023). Additionally, older adults who use substances confront challenges in long-term care homes as many require abstinence over harm reduction approaches (Yang et al., 2023). This presents a major barrier for older adults at the end of life when their intention is not to abstain from substances, and their values misalign with those of the long-term care homes providing end-of-life care. As a result, long-term care admissions at the end of life may not be feasible despite a person being eligible due to high barriers requiring abstinence, or the risk of eviction due to reports of challenging behavioural characteristics (Baines et al., 2025).

'''Application to Practice'''

Canada’s population is aging, and older adults who use substances will continue to require increased accessibility to strong palliative approaches to care at the end of life. Social workers play a vital role in the provision of health care accessibility for this population, and advocacy for better connection to this necessary care can be pivotal for older adults who use substances at the end of life.

Specialized training and education for social workers are an essential first step in this work to best understand the needs of this population on an individual level and the complex barriers to adequate health care that they experience, which impact their accessibility to end-of-life care. Providing education within health care to decrease stigma associated with substance use will be an important role when working on integrated care teams to ensure person-centered care is maintained and the health care team is utilizing harm reduction approaches to care. Facilities providing palliative and end-of-life care, such as long-term care, hospice, hospitals, and home supports offered from home, must all practice from a trauma-informed and harm reduction lens that is person-centered and cognizant of the dynamic barriers older adults who use substances face in accessing health care.

Developing policies to standardize more appropriate continuity of care would also be fundamental to ensure community, hospital, and bed-based facilities can provide consistent care and support, while also being prepared to best approach care for individuals with various levels of care needs. The benefits of this policy development would be multifaceted and impact individuals across the health care continuum to support end-of-life care. This would provide an opportunity for health care relationships to be initiated much earlier in an individual’s health trajectory once they have been diagnosed with a serious illness, and even before. Social workers can build trust earlier and support navigation of the complicated health system, with a strong role in harm reduction approaches and addressing social determinants of health to improve health outcomes. Social workers advocating for continuity of care is another harm reduction approach that is a necessary practice to ensure older adults receiving palliative care are well supported at every point within the health care system and to prioritize the older adults’ wishes at every step of care.

'''References'''

Baines, D., Braedley, S., Daly, T., Hillier, S. and Cabahug, F. (2025) Low-barrier harm reduction and housing for older people in Vancouver’s opiate crisis: meeting people where they are, Critical and Radical Social Work, 13(1): 41–56, DOI: 10.1332/20498608Y2024D000000031

Ebenau, A., Dijkstra, B., ter Huurne, C., Hasselaar, J., Vissers, K., & Groot, M. (2019). Palliative care for people with substance use disorder and multiple problems: A qualitative study on experiences of patients and proxies. ''BMC Palliative Care'', ''18''(1). <nowiki>https://doi.org/10.1186/s12904-019-0443-4</nowiki>

Government of British Columbia. (2025). ''End-of-life care''. Province of British Columbia. <nowiki>https://www2.gov.bc.ca/gov/content/health/accessing-health-care/home-community-care/care-options-and-cost/end-of-life-care</nowiki>

Higgs, P. (2022). Ageing (dis)gracefully: People who inject drugs living with hepatitis C and the provision of end-of-life care. In ''Substance Use, End-of-Life Care and Multiple Deprivation'' (1st ed., pp. 105–117). essay, Routledge.

Homayra F, Pearce LA, Wang L, Panagiotoglou D, Sambo TF, Smith N, McKendry R, Wilson B, Joe R, Hawkins K, Barrios R, Mitton C, Nosyk B. Cohort profile: The provincial substance use disorder cohort in British Columbia, Canada. Int J Epidemiol. 2021 Jan 23;49(6):1776. doi: 10.1093/ije/dyaa150. PMID: 33097934; PMCID: PMC7825959.

Kerman, N., Polillo, A., Bardwell, G., Gran-Ruaz, S., Savage, C., Felteau, C. and Tsemberis, S. (2021) Harm reduction outcomes and practices in Housing First: a mixed-methods systematic review, Drug and Alcohol Dependence, 228: 109052. Doi: 10.1016/j.drugalcdep.2021.109052

McNeil, R., & Guirguis-Younger, M. (2011). Illicit drug use as a challenge to the delivery of end-of-life care services to homeless persons: Perceptions of Health and Social Services Professionals. ''Palliative Medicine'', ''26''(4), 350–359. <nowiki>https://doi.org/10.1177/0269216311402713</nowiki>

National Institute on Aging. (2021). What are palliative care and Hospice Care? . <nowiki>https://www.nia.nih.gov/health/hospice-and-palliative-care/what-are-palliative-care-and-hospice-care</nowiki>

Stajduhar & Mollison, 2018 Too Little, Too Late: How we fail vulnerable Canadians as they die and what to do about it. Final Project Report for the Equitable Access to Care Study in Victoria, British Columbia <nowiki>https://www.uvic.ca/research/groups/peol/assets/docs/too-little-too-late.pdf</nowiki>

Tayba L, Cuesta-Briand B, Auret K, Coleman M. Palliative care for people with substance use disorders: a qualitative study of the experiences of rural primary care providers. BMC Palliat Care. 2025 Jul 23;24(1):210. doi: 10.1186/s12904-025-01828-w. PMID: 40702457; PMCID: PMC12285175.

Walsh, J. J., Sussman, T., Bosma, H., Carter, R. Z., Cormier, É., & Canham, S. L. (2025). The intersections of palliative care and homelessness in social policy: A content analysis of Canadian policy documents. ''BMC Palliative Care'', ''24''(1). <nowiki>https://doi.org/10.1186/s12904-025-01866-4</nowiki>

World Health Organization. (2025). Social Determinants of Health. <nowiki>https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1</nowiki>

Yang, M., Beiting, K. J., & Levine, S. (2023). Barriers to care for nursing home residents with Substance Use Disorders: A qualitative study. Journal of Addiction Medicine, 17(2), 155–162. <nowiki>https://doi.org/10.1097/adm.0000000000001061</nowiki>

File:Pexels-rdne-8139238.jpg

2026-06-30T23:58:26Z

KellyAllison: Uploaded a work by RDNE Stock Project from Pexels with UploadWizard

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Course:SOWK551/2025/Protective and risk factors among marginalized youth with adverse childhood experiences (ACEs): Implications for health care social work

2026-06-30T23:52:55Z

KellyAllison: inserted a photo

[[File:Лечение Наркомании from Pixabay.jpg|thumb|Image by Лечение Наркомании from Pixabay]]

== Short Summary (Thesis Statement) ==
This project uses an open education literature review to synthesize emerging evidence on protective and risk factors among youth with adverse childhood experiences (ACEs), with a particular focus on marginalized and Indigenous populations. It argues that trauma-informed, ACE-informed, and culturally grounded practices offer the most ethically responsive and clinically effective framework for health-care social work, enabling practitioners to promote healing, resilience, and justice for youth whose experiences are shaped by both personal adversity and structural forms of oppression.

Authors: Tsz Chun (Toby) Wan and Mei Wa Chu

Date: December 08, 2025

== Introduction ==
Adverse childhood experiences (ACEs) are commonly defined as early-life exposures to abuse, neglect, and household dysfunction that have been consistently linked to elevated risks for lifelong mental, emotional, and physical health challenges (Larkin et al., 2014). Since the foundational ACE study by Felitti and colleagues (Felitti et al., 1998), the ACE framework has expanded to include broader forms of adversity such as discrimination, community violence, poverty, and systemic oppression, reflecting an evolving understanding of how social environments shape development. Across disciplines, research demonstrates that ACEs are cumulative and interacting stressors rather than isolated events, influencing cognitive, emotional, and relational functioning throughout the lifespan (Larkin et al., 2014). For youth, particularly those navigating intersecting forms of marginalization, ACEs can disrupt developmental pathways, shape coping patterns, and contribute to long-term disparities in mental health, chronic disease, and social outcomes.

Contemporary ACE scholarship highlights that adversity is multidimensional and embedded within family, community, and structural contexts. Afifi et al. (2020), using confirmatory factor analysis with parents and adolescents, demonstrate that ACEs represent multiple latent constructs rather than a single uniform category, underscoring how adversity patterns are shaped by broader social conditions. Importantly, ACE exposure predicts not only internalizing outcomes such as depression and anxiety but also involvement with systems of surveillance and criminalization. In a Canadian context, Testa et al. (2025) found that youth with higher ACE scores were significantly more likely to experience police contact, illustrating how early adversity interacts with systemic inequities and contributes to cascading disadvantage.

Emerging research also emphasizes the importance of examining ACEs alongside positive childhood experiences (PCEs). Hinojosa and Hinojosa (2024) demonstrate that supportive relationships, emotional safety, and consistent caregiving can buffer the negative impacts of adversity, highlighting that resilience is environmentally supported rather than individually possessed. This dual focus that recognizing both adversity and strength is increasingly central to trauma-informed and resilience-oriented social work frameworks.

However, exposure to ACEs is not evenly distributed across populations. Youth from marginalized communities, including Black, Asian, racialized, and Indigenous groups would experience disproportionately high ACE burdens shaped by racism, intergenerational trauma, and structural inequities. Discrimination itself is now recognized as a form of adversity due to its psychological and physiological impacts, and racialized youth frequently encounter compounded forms of harm that interact with developmental stress processes and health-care access barriers. For Indigenous youth specifically, colonial histories of forced displacement, family separation, and child welfare involvement would contribute to some of the highest ACE prevalence rates in Canada. These intersecting adversities highlight the need for culturally anchored, trauma-informed approaches that recognize how identity, culture, power, and historical context shape both exposure to and the effects of childhood adversity.

Given these complexities, healthcare social workers play a critical role in addressing ACE-related needs through trauma-informed assessment, strengths-based engagement, cultural safety, and structural advocacy. This literature review synthesizes scholarship published between 2018 and 2025 to examine both risk and protective factors associated with ACEs, with particular emphasis on the experiences of marginalized, racialized, and Indigenous youth. It further explores how culturally grounded, ACE-informed, and resilience-focused practices can be integrated into health-care social work to strengthen protective factors, enhance culturally meaningful supports, and improve health and well-being outcomes for diverse youth populations.

== Literature Review ==
'''Protective Factors and Resilience'''

Protective factors can substantially buffer the negative effects of ACEs by promoting emotional security, resilience, and adaptive functioning (Tironi et al., 2024). At the individual level, psychological capacities such as epistemic trust, reflective functioning, and mentalized affectivity help youth interpret relationships safely, regulate emotions, and engage effectively with caregivers and professionals. Healthcare social workers can support these capacities through relational consistency, reflective dialogue, and strengths-based engagement, fostering resilience even in contexts of high adversity.

Beyond individual traits, relational and community-based protective factors are critical. Liu et al. (2020) highlight that positive childhood experiences (PCEs), including supportive caregiving, emotional safety, and a sense of being valued that frequently coexist with high ACE exposure and strongly predict resilience. Troxel et al. (2025) introduce the concept of social safety, defined as feeling connected, protected, and accepted, which mitigates the physiological and psychological impacts of both ACEs and discrimination. Together, these studies suggest that protective factors operate across multiple ecological levels, including individual, relational, and social and that interventions focusing solely on the individual may overlook relational and structural supports.

Cultural and community-based resources further extend protection for racialized and Indigenous youth. Radford et al. (2022) emphasize that for Indigenous youth, cultural continuity, community cohesion, language revitalization, and culturally meaningful practices serve as critical safeguards against the cumulative effects of historical and contemporary trauma. While mainstream health systems often prioritize individual-level interventions, these findings suggest that culturally grounded approaches are essential for fostering resilience in youth facing structural and historical adversity. The evidence collectively underscores the need for trauma-informed, culturally attuned environments that cultivate trust, relational safety, and cultural grounding.

'''Risk Factors and the Role of Discrimination'''

Although ACEs are harmful across populations, recent literature shows that their impacts are intensified by systemic inequities, racism, and social exclusion. Discrimination functions as both a chronic stressor and a traumatic exposure, compounding the effects of conventional ACEs. Bernard et al. (2022) demonstrate that racial discrimination significantly increases internalizing mental health problems among Black youth, while Kim et al. (2024) find that Asian adolescents experiencing both ACEs and discrimination report higher rates of depression and anxiety. Jensen et al. (2025) further highlight elevated suicidality rates among Black, Hispanic, and multiracial youth with high ACE exposure, illustrating how systemic inequities interact with early adversity to shape mental health outcomes.

Indigenous youth experience some of the highest ACE prevalence rates globally due to ongoing colonialism, forced displacement, intergenerational trauma, and systemic inequities (Radford et al., 2022; Toombs et al., 2022). They face unique adversities, including cultural disruption, community-level trauma, and institutional discrimination, which intensify risks for poor mental health and highlight the necessity of culturally anchored support systems. Broader structural factors—such as poverty, housing instability, food insecurity, and limited access to early intervention—further exacerbate ACE impacts. Within healthcare systems, the lack of trauma-informed, culturally safe practice can inadvertently retraumatize youth through rushed assessments, culturally incongruent care, or dismissive responses to disclosures of discrimination.

The literature indicates that while protective factors can buffer adversity, risk factors are amplified by systemic oppression, and their expression varies across populations. This underscores the importance of integrating culturally responsive, ACE-informed, and trauma-informed frameworks that acknowledge both individual experiences and structural inequities in health care social work.

'''Adverse Childhood Experiences Among Indigenous Populations in Canada'''

Indigenous populations in Canada experience disproportionately high rates of adverse childhood experiences (ACEs), shaped by ongoing colonial structures, intergenerational trauma, and systemic inequities (Toombs et al., 2022; Radford et al., 2022). Conventional ACE frameworks often focus on individual or household-level adversities, such as abuse, neglect, and household dysfunction, but fail to capture the historical, collective, and structural adversities that Indigenous youth face. These include forced assimilation, residential schools, child welfare interventions, land dispossession, and systemic discrimination, which together contribute to elevated ACE prevalence and unique trajectories of risk (Toombs et al., 2022). Radford et al. (2022) emphasize that Indigenous youth confront adversities that extend beyond family environments, including community-level trauma, cultural disruption, and institutional discrimination, which interact with systemic inequities to amplify risk for poor mental health outcomes. Bernard et al. (2021) similarly propose a culturally informed ACE framework (C-ACE) to account for racism and discrimination as pervasive forms of adversity among racialized youth, highlighting the limitations of applying universal ACE models without cultural context. LaBrenz et al. (2020) further underscore that structural factors such as poverty, housing instability, and limited access to early intervention exacerbate ACE impacts, reinforcing the necessity of race- and culture-specific analysis for equitable health care.

Empirical research illustrates how unaddressed ACEs intersect with broader systems. For instance, Muir and Viljoen (2022) report that higher ACE exposure correlates with increased recidivism among Indigenous adolescents in probation systems, demonstrating the compounding effects of trauma and systemic discrimination. These findings highlight the need for interventions that account for structural determinants in addition to individual or familial risk factors.Despite these challenges, Indigenous communities possess profound protective factors that can buffer the impacts of ACEs. Toombs et al. (2022) identify cultural continuity, community cohesion, connection to land, language revitalization, and Indigenous knowledge systems as central pillars of resilience. Luther et al. (2025) find that Indigenous university students with high adversity demonstrate coping capacities rooted in cultural identity, community belonging, relational support, and meaning-making practices. These culturally anchored resources echo findings among other racialized populations, where identity affirmation, collective solidarity, and culturally grounded practices mitigate health disparities (Bernard et al., 2021; LaBrenz et al., 2020).

The literature underscores the importance of trauma-informed, culturally safe, and ACE-informed care in healthcare settings. Toombs et al. (2022) and Radford et al. (2022) stress that interventions must integrate Indigenous worldviews, community-defined healing practices, and structural advocacy to avoid replicating colonial harms. Bernard et al. (2021) and LaBrenz et al. (2020) caution that standard ACE frameworks risk pathologizing Indigenous youth if they fail to incorporate historical, cultural, and structural contexts. By centering cultural strengths, community knowledge, and systemic awareness, healthcare social workers can foster resilience, support Indigenous sovereignty, and promote healing pathways aligned with the needs and values of Indigenous communities.

== Application to Social Work Practice ==
Translating this evidence into practice requires health-care social workers to intervene in ways that are trauma-informed, culturally safe, and responsive to the intersecting impacts of adverse childhood experiences, racial discrimination, and social marginalization. Findings across recent ACE studies highlight that youth who face racism and structural exclusion, particularly Black, Asian, and Indigenous youth who often experience heightened internalizing symptoms, suicidality, and barriers to trust in service systems (Bernard et al., 2022; Kim et al., 2024; Jensen et al., 2025; Radford et al., 2022). At the same time, protective processes such as epistemic trust, reflective functioning, relational safety, and supportive cultural identity have been shown to buffer against these risks (Tironi et al., 2024; Liu et al., 2020; Troxel et al., 2025). These findings collectively reinforce that social workers must center relational attunement, cultural humility, and collaborative care planning when working with ethnic minority and Indigenous youth in hospital settings.

'''1. Culturally adapted, ACE-informed assessment'''

Social workers can integrate an ACE- and discrimination-informed lens directly into biopsychosocial assessments by attending to racialized stressors, intergenerational trauma, and systemic inequities without pathologizing youth or “essentializing” cultural identities. This involves asking questions about safety, belonging, and past experiences of discrimination in ways that promote dignity and choice. Evidence suggests that trauma-informed assessment must prioritize emotional safety and consent, especially for youth with histories of racial or structural trauma (Stokes et al., 2024). For Indigenous patients, collaboration with the hospital’s Indigenous Health Team supports culturally grounded assessment, builds trust, and ensures that care plans reflect historical and community contexts (Radford et al., 2022).

'''2. Collaborative safety planning that restores relational and cultural safety'''

Given the elevated suicidality associated with ACEs and racial discrimination among diverse youth (Jensen et al., 2025), safety planning must extend beyond risk checklists to incorporate the youth’s cultural strengths, caregiving networks, and community supports. Trauma-informed practices highlight that collaborative planning increases agency and reduces coercion (Stokes et al., 2024). Integrating cultural anchors, such as extended kin networks, community mentors, or culturally meaningful practices that could strengthen protective factors identified in the literature (Liu et al., 2020; Tironi et al., 2024). For Indigenous youth, joint planning with Indigenous Elders, Knowledge Keepers, or Indigenous liaison workers supports continuity between hospital care and community wellness approaches.

'''3. Relationship-centered intervention to strengthen trust, affect regulation, and meaning-making'''

Because epistemic trust, reflective functioning, and mentalized affectivity protect youth facing ACEs (Tironi et al., 2024), hospital social workers can introduce brief relational interventions that model attunement, validation, and co-regulation. Even short-term inpatient encounters could strengthen a youth’s capacity to make sense of emotions and build trust with service providers are key predictors of engagement in follow-up care. This includes warm handovers to outpatient teams, transparent communication, and ensuring youth have voice and control in decisions. Stokes et al. (2024) emphasize that relational safety is a core component of trauma-informed mental health interventions in inpatient settings.

'''4. ACE-informed and culturally safe discharge planning'''

Discharge transitions are critical points for youth with complex trauma histories. Social workers could develop discharge plans that explicitly address environmental stressors linked to ACEs, such as housing instability, racism at school, or caregiver strain while connecting youth to culturally appropriate supports. For Indigenous and ethnic minority youth, coordination with community-based cultural, spiritual, or identity-affirming programs can enhance post-discharge safety and continuity of care. Integrating Hospital Indigenous Health Team recommendations ensures plans reflect community values, uphold cultural self-determination, and acknowledge systemic barriers.

These strategies integrate research on protective factors (Tironi et al., 2024; Troxel et al., 2025), culturally informed assessment (Liu et al., 2020; Bernard et al., 2021), and trauma-informed organizational approaches (Stokes et al., 2024). Collectively, they provide practical, evidence-informed steps that healthcare social workers could implement in hospital settings, supporting youth resilience, culturally safe care, and long-term wellbeing.

== Conclusion ==
Adverse childhood experiences (ACEs) are complex, multi-level stressors that intersect with systemic inequities, racial discrimination, and intergenerational trauma, disproportionately affecting marginalized and Indigenous youth (Felitti et al., 1998; Larkin et al., 2014; Afifi et al., 2020; Testa et al., 2025). While all youth exposed to ACEs face developmental risks, structural and cultural contexts intensify adverse outcomes, highlighting the limitations of conventional ACE frameworks that fail to account for historical and collective trauma (Radford et al., 2022; Toombs et al., 2022; Bernard et al., 2021). Protective factors, including relational safety, supportive caregiving, social connectedness, and culturally grounded identity could buffer these risks and promote resilience (Tironi et al., 2024; Liu et al., 2020; Troxel et al., 2025).

For healthcare social workers, translating this evidence into practice involves trauma-informed, culturally safe, and strengths-based approaches. Strategies such as ACE- and discrimination-informed assessments, collaborative safety planning, relationship-centered interventions, and culturally responsive discharge planning can strengthen protective factors, foster trust, and support youth well-being. Engaging with Indigenous Health Teams and community resources ensures care is aligned with cultural, historical, and systemic realities, enhancing both safety and agency. Ultimately, ACE-informed social work must recognize adversity alongside resilience, situate individual experiences within broader contexts, and prioritize relational and community supports. By doing so, social workers can mitigate the impacts of ACEs and promote equitable, culturally grounded outcomes for diverse youth populations.

== References ==
Afifi, T. O., Salmon, S., Garcés, I., Struck, S., Fortier, J., Taillieu, T., Stewart-Tufescu, A., Asmundson, G. J. G., Sareen, J., & MacMillan, H. L. (2020). Confirmatory factor analysis of adverse childhood experiences (ACEs) among a community-based sample of parents and adolescents. ''BMC Pediatrics'', ''20''(1), 178. <nowiki>https://doi.org/10.1186/s12887-020-02063-3</nowiki>

Bernard, D. L., Calhoun, C. D., Banks, D. E., Halliday, C. A., Hughes-Halbert, C., & Danielson, C. K. (2021). Making the “C-ACE” for a culturally-informed adverse childhood experiences framework to understand the pervasive mental health impact of racism on black youth. ''Journal of Child & Adolescent Trauma, 14''(2), 233-247. <nowiki>https://doi.org/10.1007/s40653-020-00319-9</nowiki>

Bernard, D. L., Smith, Q., & Lanier, P. (2022). Racial discrimination and other adverse childhood experiences as risk factors for internalizing mental health concerns among Black youth. ''Journal of Traumatic Stress, 35''(2), 473–483.<nowiki>https://doi.org/10.1002/jts.22760</nowiki>

Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The adverse childhood experiences (ACE) study. ''American Journal of Preventive Medicine, 14''(4), 245-258. <nowiki>https://doi.org/10.1016/S0749-3797(98)00017-8</nowiki>

Hinojosa, M. S., & Hinojosa, R. (2024). Positive and adverse childhood experiences and mental health outcomes of children. ''Child Abuse & Neglect'', ''149'', 106603. <nowiki>https://doi.org/10.1016/j.chiabu.2023.106603</nowiki>

Jensen, L. W. C., Jones, M. S., Gibbs, B. G., & Jarvis, J. A. (2025). Adverse childhood experiences, race/ethnicity, and suicidality among Florida high school students. ''Youth & Society, 57''(2), 233–257. <nowiki>https://doi.org/10.1177/0044118X241312248</nowiki>

Kim, I., Jang, H., Kim, S. R., & Choi, J. (2024). Adverse childhood experiences, racial discrimination, and internalizing problems among Asian adolescents. ''Journal of Child & Adolescent Trauma, 17''(4), 1177–1188. <nowiki>https://doi.org/10.1007/s40653-024-00652-3</nowiki>

LaBrenz, C. A., O'Gara, J. L., Panisch, L. S., Baiden, P., & Larkin, H. (2020). Adverse childhood experiences and mental and physical health disparities: The moderating effect of race and implications for social work. ''Social Work in Health Care, 59''(8), 588-614. <nowiki>https://doi.org/10.1080/00981389.2020.1823547</nowiki>

Larkin, H., Felitti, V. J., & Anda, R. F. (2014). Social Work and Adverse Childhood Experiences Research: Implications for Practice and Health Policy. ''Social Work in Public Health'', ''29''(1), 1–16. <nowiki>https://doi.org/10.1080/19371918.2011.619433</nowiki>

Liu, S. R., Kia‐Keating, M., Nylund‐Gibson, K., & Barnett, M. L. (2020). Co‐occurring youth profiles of adverse childhood experiences and protective factors: Associations with health, resilience, and racial disparities. ''American Journal of Community Psychology, 65''(1–2), 173–186. <nowiki>https://doi.org/10.1002/ajcp.12387</nowiki>

Luther, A. W., Skinner, K., Anthony, K., & Mielke, J. G. (2025). Childhood adversity and coping among indigenous university students in canada: Considerations when examining adverse childhood experiences. ''Psychological Trauma,'' <nowiki>https://doi.org/10.1037/tra0001885</nowiki>

Muir, N. M., & Viljoen, J. L. (2022). Adverse childhood experiences and recidivism in indigenous and white female and male adolescents on probation. ''Child Abuse & Neglect, 126'', 105512. <nowiki>https://doi.org/10.1016/j.chiabu.2022.105512</nowiki>

Radford, A., Toombs, E., Zugic, K., Boles, K., Lund, J., & Mushquash, C. J. (2022). Examining adverse childhood experiences (ACEs) within Indigenous populations: A systematic review. ''Journal of Child & Adolescent Trauma, 15''(2), 401–421. <nowiki>https://doi.org/10.1007/s40653-021-00393-7</nowiki>

Stokes, Y., Lewis, K. B., Tricco, A. C., Hambrick, E., Jacob, J. D., Demery Varin, M., Gould, J., Aggarwal, D., Cloutier, P., Landriault, C., Greenham, S., Ward, M., Kennedy, A., Boggett, J., Sheppard, R., Murphy, D., Robb, M., Gandy, H., Lavergne, S., & Graham, I. D. (2024). Trauma-informed care interventions used in pediatric inpatient or residential treatment mental health settings and strategies to implement them: A scoping review. ''Trauma, Violence & Abuse, 25''(3), 1737-1755. <nowiki>https://doi.org/10.1177/15248380231193444</nowiki>

Testa, A., Jacobs, B., Thompson, J., Pang, N., Jackson, D. B., Nagata, J. M., & Ganson, K. T. (2025). Adverse Childhood Experiences and Police Contact in Canada. ''Journal of Interpersonal Violence'', ''40''(9–10), 2188–2204. <nowiki>https://doi.org/10.1177/08862605241270047</nowiki>

Tironi, M., Charpentier Mora, S., Liotti, M., Fiorini Bincoletto, A., Tanzilli, A., Cavanna, D., Lingiardi, V., Speranza, A. M., Giovanardi, G., & Bizzi, F. (2024). Adverse childhood experiences and psychological maladjustment in adolescence: The protective role of epistemic trust, mentalized affectivity, and reflective functioning. ''Journal of Clinical Psychology, 80''(11), 2228–2246. <nowiki>https://doi.org/10.1002/jclp.23733</nowiki>

Toombs, E., Lund, J., & Mushquash, C. J. (2022). Adverse childhood experiences (ACEs) are increasing in indigenous populations in canada: Now what? ''Canadian Psychology = Psychologie Canadienne, 63''(4), 576-588. <nowiki>https://doi.org/10.1037/cap0000331</nowiki>

Troxel, W. M., Seelam, R., Perez, L. G., Davis, J., & D’Amico, E. J. (2025). Social safety and health outcomes in emerging adults: Interactions of adverse childhood experiences and discrimination. ''Journal of Community Psychology, 53''(4), e70011. <nowiki>https://doi.org/10.1002/jcop.70011</nowiki>

[[Course:SOWK551/2025/Protective and risk factors among marginalized youth with adverse childhood experiences (ACEs): Implications for health care social work|Protective and risk factors among marginalized youth with adverse childhood experiences (ACEs): Implications for health care social work]] © 2025 by Tsz Chun (Toby) Wan and Mei Wa Chu is licensed under CC BY-NC 4.0

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Course:SOWK551/2025/Healthcare Navigation for Racialized Immigrant Survivors of Family Violence

2026-06-30T23:44:37Z

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== Introduction ==
Immigrant women, particularly those that are migrants, refugees or trans face persistent and deep inequities when interacting with the Canadian healthcare system. These challenges become more complex when they are experiencing family violence (also referred as intimate partner violence or IPV, and Gender Based Violence or GBV) and seeking support through the healthcare system. According to Women and Gender Equality Canada (WAGE), 44% of women aged 15 and older have who have been in an intimate relationship report experiencing some form of IPV, emphasizing an urgent need to reduce barriers towards offering appropriate safety and care-based interventions. For marginalized women, the intersection of immigration related stressors, precarious legal status, cultural norms and systemic discrimination compound the harm of violence and limits opportunities to receive timely and culturally responsive care. Improving healthcare access for immigrant women experiencing violence requires acknowledging the complex health impacts of IPV, addressing systemic and structural barriers, confronting provider biases and recognizing the role of both informal and formal support networks. In doing so, it would reframe the lack of access to appropriate care as a policy and systemic failure rather than an individual one and help us in building a coordinated, culturally responsive, violence and trauma informed healthcare system that meets diverse and intersecting needs of immigrant survivors.

== Literature Review ==

==== '''Health Impacts of Intimate Partner Violence''' ====
Intimate Partner Violence (IPV) produces interconnected physical, psychological and reproductive health consequences for immigrant women. Tastsoglou et al. (2025) note that violence often results in serious injuries, chronic reproductive issues and long-term mental health effects that are further intensified by the impact of trauma and migration. These interconnected outcomes demonstrate the limitations of our siloed models of care within the healthcare system where physical and emotional needs are treated independently despite being interconnected. While visible signs of abuse may be identified and addressed by healthcare providers, IPV related brain injuries, also known as traumatic brain injury (TBI) can go unnoticed and untreated. Toccalino et al. (2024) emphasize that TBI symptoms often overlap with mental health disorders and get misdiagnosed. By not being ablet to access imaging and other appropriate diagnostic tools, survivors are unable to receive confirmation of injury, leading to undiagnosed and inadequate treatment. Similarly, maternal health research demonstrates a higher level of vulnerability among migrant and refugee women. Khanlou et al. (2017) report that language barriers, limited familiarity with the healthcare system, and social isolation contribute to insufficient prenatal and postnatal support resulting in higher rates of postpartum depression, particularly among refugee women. These findings highlight the need for integrated, culturally responsive maternal care that takes migration related vulnerabilities along with the compounded impacts of IPV on overall health of an individual.

==== '''Systemic and Structural Barriers''' ====
Systemic and structural barriers within the healthcare system further add onto the challenges that immigrant women face when navigating support for IPV. Across multiple studies, language barriers emerged as one of the most significant obstacles in accessing care (Tastsoglou et al., 2025; Kalich et al., 2015; Tsai & Ghahari, 2023). Due to limited access to appropriate translators and interpreters, feeling discomfort in having to discuss sensitive issues through a third party (a stranger or relative or their child), and low health literacy all reduce women’s ability to communicate their needs, understand treatment plans or seek help in a crisis such as when experiencing violence in the family. Communication challenges often result in multiple delays in receiving care, misinterpretations of symptoms, and feeling unsupported or misunderstood by the medical team.

Cultural norms and expectations also play a large role in an immigrant women’s experiences and cause delays in seeking timely support. Baloch et al. (2025) highlight the role of shame, stigma and concerns about dishonoring the family which leaves the woman to feel discouraged in disclosing the violence. These cultural pressures then interact with systemic gaps such as culturally inappropriate care or limited awareness of the healthcare provider about IPV resulting in an environment where immigrant women may feel unsafe or judged for attempting to access help.

Immigration based barriers such as having a precarious immigration status, having to be dependent on the abusive partner during the sponsorship process, or fearing deportation is another factor that prevents immigrant women from seeking formal assistance (Tastsoglou et al., 2025; Merken et al., 2023; Allen-Leap et al., 2022). While help seeking behaviour does depend on the individual, women may avoid healthcare all together because they fear disclosure of violence would result in deportation, or lead to child welfare involvement. For undocumented women, or those with limited eligibility for healthcare coverage such as on Interim Federal Health Program (IFHP), essential healthcare services including mental health services are either financially limited or unavailable altogether. Additionally, financial or logistical barriers which are often connected to the individual’s immigration status can restrict access to timely care. For instance, common challenges for newcomers includes transportation costs, childcare responsibilities, long wait times, and gaps in system navigation (Kalich et. al., 2015; Tsai & Ghahari, 2023). While there are government funded programs such as Crime Victim Assistance Program (CVAP) which provides limited financial support for individuals impacted by a violent crime, having to potentially pay out of pocket for medication, specialised services or ongoing counselling sessions can prevent women from seeking the help they need. These barriers are intensified for recent newcomers who would be facing a deep financial loss if they were to separate from an abusive partner. Immigrant women having to experience these structural constraints that highlight great difficulty in accessing care are not individual failings, rather are rooted in broader systemic inequities. For immigrant women experiencing IPV, these barriers play a large role in delaying or even preventing seeking help from healthcare or even social services spaces.

==== '''Practitioner Level Barriers and Support Systems''' ====
Practitioner level barriers play a large role in shaping how immigrant women experience healthcare when seeking support for IPV. The interaction with a practitioner plays a large role in influencing how safe and believed the woman feels, and the extent to which they are able to then disclose the extent of violence they are facing. Healthcare providers may unintentionally reinforce harm through judgmental attitudes, minimization of the woman’s symptoms or experience, and through culturally insensitive responses (Baloch et al., 2025; Merken et al., 2023; Toccalino et al, 2024; Barrett & Pierre, 2011; Allen-Leap et al., 2022; Tsai, 2023). Baloch et al. (2025) further describes how women often feel blamed, dismissed, or misunderstood by practitioners leading them to avoid seeking care from them in the future. For instance, when a practitioner attaches reproductive or mental health concerns a client brings up to cultural assumptions rather than violent or abusive behavior, thus creating an additional barrier for a woman navigating a complex and traumatic situation. Furthermore, trans immigrant women face additional discrimination and exclusion when navigating various support systems, including healthcare. Merken et al. (2023) documents experiences of transphobia, misgendering, and inequitable treatment within shelters, when interacting with police and healthcare spaces. Therefore, while healthcare settings must work to create safer and more accessible environments for survivors, attention must also be given to the informal and formal supports immigrant women seek out when healthcare feels unsafe. These interventions provide critical support and offer models that healthcare providers can learn from or refer clients to, ensuring survivors receive appropriate and meaningful care.

Despite systemic challenges and barriers, immigrant women demonstrate determination, strength and agency in seeking support. Barrett (2011) points out that though most survivors use at least one formal or informal support, immigrant and racialized women are less likely to access formal services because of structural, cultural and practitioner level barriers. Furthermore, Allen-Leap et al. (2022), emphasize that trusting and empathetic relationships with healthcare providers can support clients in disclosing even when women are feeling a shame, fearing deportation or child welfare involvement. On the other hand, community-based organizations play an equally important role in clients feeling supported in a holistic manner. Raynayake et al. (2022) mention the crucial role of immigrant serving agencies acting as mediators, advocates, and system navigators in women understanding their rights, coordinating medical appointments, and accessing other essential services or funding. Moreover, these agencies support clients facing language, cultural barriers along with system navigation (Tsai & Ghahari, 2023; Kalich, 2015). However, these supports are often constrained by limited funding, high caseloads, and precarious organizational structures (Ratnayake et al., 2022). The ability of immigrant survivors of IPV to access timely and appropriate care highly depends not only on the client’s own strength but also on the ability of service providers to practice cultural humility and offer violence and trauma informed care.

== Application to Social Work ==

For social workers, supporting immigrant clients facing IPV within a healthcare setting have direct implications on their practice. As mentioned earlier by Tastsoglou (2025), the documented physical, psychological and reproductive consequences of violence, which are often worsened due to migration related stress and isolation, require social workers to bring in their trauma and violence informed approaches that emphasize client’s dignity, autonomy and right to safety. This further aligns with the social work code of ethics which calls on social workers to uphold individuals’ rights to self-determination and freedom from violence (CASW, 2024). As IPV related TBI is frequently misdiagnosed or undetected (Toccalino et al., 2024), social workers can bring this factor to the case consultations to ensure medical practitioners have performed an appropriate screening process to rule it out. Social workers can also remain attentive to any cognitive and emotional symptoms that survivors may struggle to articulate due to language or cultural barriers – sometimes it can be helpful to say the awkward thing out loud to ensure it has been addressed rather than have it go unnoticed. In doing so, a social worker would be acting in accordance to CASW (2024, Value 7) which requires providing accurate and culturally safe assessments to offer a competent service to clients.

Social workers also have a duty to address practitioner level barriers that clients may face, including judgement, minimization of client experience or culturally inappropriate responses, which often result in survivors feeling silenced (Baloch et al., 2025; Allen-Leap et al., 2022). While social workers may not be able to have direct conversations with medical practitioners to encourage them to change their harmful behavior, through offering non-judgmental, violence and trauma informed care which is rooted in respect and curiosity; clients can feel heard and validated about their experiences of violence. For system navigation support, social workers can help reduce barriers by ensuring access to interpreters, facilitating informed consent, explaining medical information, and coordinating appropriate culturally responsive referrals. In addition, social workers can offer clear information about client’s legal rights and help clarify any immigration related misinformation client may have received from the abusive party.

Finally, as the social work profession values collaboration and is rooted in building a client’s network, practitioners can collaborate with community-based organizations to help fill in any gaps the client’s needs. For example, immigrant serving agencies provide culturally grounded support, advocacy, translation and interpretation services along with one-on-one supportive counselling services or support groups in various languages. Social workers can strengthen a client’s social determinants of health while providing support that is often out of the scope of many health care settings.

== Concluding Thoughts ==
Ultimately, the experiences of immigrant women impacted by IPV and navigating healthcare reveal profound systemic challenges and gaps that social worker are uniquely positioned to help address. Through slowing down the conversation, creating space for the client to share her story and responding with respect and empathy, social workers can foster a collaborative environment that prioritizes safety, dignity and trust.

== Community Resources - Family Violence/Intimate Partner Violence (Canada Specific) ==

'''Advocacy, Education and Training:'''

* [https://bcsth.ca BCSTH] (BC Society of Transition Houses)
* [https://coercive-control.ca Coercive Control] (English and French Resources)
* [https://endingviolence.org EVA BC] (Ending Violence Association of BC)

'''Frontline Support and or Transition Housing:'''

* [https://www.bwss.org BWSS] (Battered Women's Support Service)
* [https://mosaicbc.org/our-services/violence-prevention-and-support/ MOSAIC] - (Settlement Agency, Violence Prevention and Support Program)
* [https://www.nisafoundation.ca NISA Foundation] (Transition Housing, Emotional Support etc)
* [https://www.options.bc.ca/program/transition-houses Options Community Services] (Transition Housing)
* [https://vlmfss.ca VLMFSS] (Multicultural Family Support Services)
* [https://ywcavan.org/programs/violence-prevention YWCA] (Transition Housing, Support Groups, Legal Support etc)

'''Legal Support:'''

* [https://www.irlc.ca Immigration and Refugee Legal Clinic]
* [https://www.womenslegalcentre.ca RISE Women's Legal Centre]
* [https://www.salcbc.org/ South Asian Legal Clinic]
* [https://mwcbc.ca/ Migrant Workers Center BC]
'''Other Trauma Informed, Women Centred Resources:'''

* [https://dfsvancouver.ca Dress for Success] - (Employment Workshops, Clothing)

== References ==
Allen-Leap, M., Hooker, L., Wild, K., Wilson, I. M., Pokharel, B., & Taft, A. (2022). Seeking help from Primary Health-Care Providers in High-Income Countries: A scoping review of the experiences of migrant and refugee survivors of domestic violence. ''Trauma Violence & Abuse'', 24(5), 3715–3731. https://doi.org/10.1177/15248380221137664

Baloch, S., McLindon, E., Hameed, M., & Hegarty, K. (2025). South Asian women’s lived experiences of health care after disclosure of family violence: a qualitative meta-synthesis review. ''BMC Public Health'', 25(1), 445. https://doi.org/10.1186/s12889-025-21619-5

Barrett, B. J., & St Pierre, M. (2011). Variations in women’s help seeking in response to intimate partner violence: findings from a Canadian Population-Based study. ''Violence Against Women'', 17(1), 47–70. https://doi.org/10.1177/1077801210394273

CASW. (2024). Core social work values and guiding principles. [https://www.casw-acts.ca/files/attachements/CASW_Code_of_Ethics_2024_One_Pager.pd https://www.caswacts.ca/files/attachements/CASW_Code_of_Ethics_2024_One_Pager.pd]f

Government of Canada. (2025). ''Temporary health care coverage: What is covered''. Canada.ca. https://www.canada.ca/en/immigration-refugees-citizenship/services/refugees/help-within-canada/health-care/interim-federal-health-program/coverage-summary.html

Kalich, A., Heinemann, L., & Ghahari, S. (2015). A scoping review of immigrant experience of health care access barriers in Canada. ''Journal of Immigrant and Minority Health'', 18(3), 697–709. https://doi.org/10.1007/s10903-015-0237-6

Khanlou, N., Haque, N., Skinner, A., Mantini, A., & Landy, C. K. (2017). Scoping Review on Maternal Health among Immigrant and Refugee Women in Canada: Prenatal, Intrapartum, and Postnatal Care. ''Journal of Pregnancy'', 2017, 1–14. https://doi.org/10.1155/2017/8783294

Merken, S., Slakoff, D. C., Aujla, W., & Moton, L. (2023). Navigating Biases and Distrust of Systems: American and Canadian Intimate Partner Violence Service Providers’ Experiences with Trans and Immigrant Women Clients. ''Victims & Offenders'', 18(1), 141–168. https://doi.org/10.1080/15564886.2022.2136319

Ratnayake, A., Sayfi, S., Veronis, L., Torres, S., Baek, S., & Pottie, K. (2022). How are Non-Medical Settlement Service Organizations supporting access to healthcare and mental health services for immigrants: a scoping review. ''International Journal of Environmental Research and Public Health'', 19(6), 3616. https://doi.org/10.3390/ijerph19063616

Tastsoglou, E. (2025). Gender-Based Violence in a Migration Context: Health Impacts and Barriers to Healthcare Access and Help Seeking for Migrant and Refugee Women in Canada. ''Societies'', 15(3), 68. https://doi.org/10.3390/soc15030068

Toccalino, D., Haag, H., Nalder, E., Chan, V., Moore, A., Wickens, C. M., & Colantonio, A. (2024). “Using the right tools and addressing the right issue”: A qualitative exploration to support better care for intimate partner violence, brain injury, and mental health. https://doi.org/10.1371/journal.pone.0311852

Tsai, P., & Ghahari, S. (2023). Immigrants’ experience of health care access in Canada: a recent scoping review. ''Journal of Immigrant and Minority Health'', 25(3), 712–727. https://doi.org/10.1007/s10903-023-01461-w
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Course:SOWK551/2025/Dementia Caregivers: Caregiver Burden, avenues of caregiver support, and a path forward for caregiver support

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Course:SOWK551/2021/Sample Project: Fostering Resiliency in Healthcare

2026-06-30T23:11:33Z

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Course:SOWK551/2021/Fostering Resiliency in Healthcare

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== '''SHORT SUMMARY''' ==
Literature review of strategies for fostering resiliency in front-line healthcare workers.

''Author: Unspecified''

''Date: December 6, 2022''
== '''INTRO''' ==
At first, I wanted to review literatures on resiliency specifically based on social work in healthcare in Canada; however, there was very little literature that speaks directly to my initial research query. I ended up having to look at literature that speaks to fostering resilience in healthcare from around the world within the last 10 years. The key topics from the literature I chose to discuss are embracing positive as well as negative emotions, practicing being rooted in the present, relationship building, social support, growing healthy lifestyle habits, and highlighting as well as supporting moral resilience.

Since the first covid-19 outbreak in 2019, there is an increased need to find ways to foster resilience for front line workers in healthcare settings. There has been a fair amount of new literature written that provides valuable tips that promote ‘integrative resilience’ in healthcare practice approaches. For this reason, I was able to search for related literature in a narrower time frame of 5-10 years. While most of the literature speaks to nursing and allied healthcare workers, the moral distress has weighed heavy on healthcare social workers as well. According to Wald (2020), during a public health crisis, healthcare workers experience “significant health risk and concomitant stress, fear, decreased sense of control, and uncertainty. Deleterious impact on both physical and mental health can result, including for healthcare professionals and health professions trainees” (p. 744).

The covid-19 pandemic has taken a significant toll on all healthcare workers due to increased demands of caring for patients with serious illness, the moral distress associated with having to make tough decisions involving patient care, and the potential risk to workers as well as their families. According to the American Psychological Association (2010) resilience is defined as “the process of adapting well in the face of adversity, trauma, tragedy, threats, or significant sources of stress— such as family and relationship problems, serious health problems or workplace and financial stressors. It means "bouncing back" from difficult experiences” (p. 1). This means that resilience to stress is complex and complicated.

One’s ability to bounce back from hardship and trauma depend on genetic factors as some are more naturally resilient possibly due to having better temperament than others or having learned better coping mechanisms from whomever helped to raise them. However, the good news is anyone can learn ways to foster resilience if they choose to learn how. Wald (2020) asserts the use of an ‘integrative resilience’ approach includes the “individual, learning environment, and organizational/systemic factors can ideally buffer negative impact, address ‘pre-traumatic’ and traumatic stress, elucidate strengths, and ideally reduce vulnerability to prolonged psychological distress” (p. 745). Some principles of wellbeing for coping

== '''EMBRACING POSITIVE AND NEGATIVE EMOTIONS''' ==
When it comes to ‘integrative resilience’ Wald (2020) emphasizes the importance of not only embracing positive emotions or experiences, but negative emotions and experiences as well. It is common knowledge that positive emotions are ideal or more socially acceptable when we think of optimal mental health and wellbeing. However, it is also good practice to take a holistic view to emotions, thoughts, and feelings to nurture resilience as they are a natural part of the human experience. According to Wald (2020) it is perfectly normal to feel emotions “such as sadness, worry, anxiety, fear, irritability, and anger within significant life disruption and uncertainty” (p. 745). More, Virk (2020) conveys that unexpressed “emotions are often stored in our body in the form of muscle tension, tightness, and other body sensations” (para. 9).

Berinato (2020) encourages folks to be consistent in naming negative emotions because while it may not seem to help at first, it is important to be repetitious in naming emotions which is often grief or loss when it comes to experiencing a health crisis. There is something powerful about naming negative emotions because naming negative emotions are just as natural as naming positive emotions. Unfortunately, western society normalizes positive emotions and tends to stigmatize the expression of negative emotions. According to Berinato (2020), naming emotions is necessary for one to be able to move through the identified emotion to allow the emotion to flow through one’s body rather internalizing the emotion, which can be empowering and can free us from being fixed in a state of victimhood.

== '''PRACTICING BEING ROOTED IN THE PRESENT''' ==
Wald (2020) further encourages frontline healthcare workers to practice being present in the here and now, to breathe, to ground oneself as well as letting go of the things we cannot control. Frontline workers can learn strategies that would be helpful not only to themselves but also to patients. These strategies can help facilitate to prevent or reduce stress and anxiety. They can also help one to shift from catastrophic thought patterns of expecting the worst to happen to a place of tolerance of feelings of uncertainty.

According to Wald (2020) the use of meditation and mindfulness is another helpful technique to foster resilience. Mindful awareness helps one to be calm, to feel reenergized, to bring clarity, to manage stress, to ground oneself, and to reduce moral distress as well as to release emotional grief. Being in the present helps one to move away from the overwhelm of ruminative or intrusive thoughts. Mindfulness strategies and being rooted in the present can also help with sleep disturbances and can improve concentration.

Holzel et al. (2011) advises that if mindfulness is felt deep within the body through breathing exercises and acceptance of what cannot be controlled can significantly improve one’s focus as well as concentration. More, Holzel et al. (2011) also indicates that when one practices mindfulness techniques for a long period of time it can have “long-term positive consequences on attention, body awareness, emotion regulation, and perspectives on the self” (p.2). Virk (2020) asserts the importance of “mindful body movements like stretching, yoga, and focused breathing, we can get in touch with how we’re feeling and ground ourselves in the present experience” (para. 9).

== '''RELATIONSHIP BUILDING AND SOCIAL SUPPORT''' ==
To foster resilience the literature conveys the importance of social support where frontline healthcare workers connect purposefully and intentionally with others. Wald (2020) asserts that when it starts to feel like dooms day connecting with others is essential when it comes to stress resilience, which is “positively associated with active problem-focused coping, sense of control and predictability in life, self-esteem, motivation, optimism, enhanced immune function, dampened neuroendocrine and cardiovascular responses to stress” (p.747). The literature encourages one to connect with teammates to debrief and identify challenges with one another allowing the sharing of ideas or thoughts that helps one to cope with challenges. According to Wald (2020) focusing on challenges with teammates can reduce symptoms of post-traumatic stress disorder (PTSD), depression, and boosts resiliency.

Abu-Sharkia et al. (2020) upholds that when frontline healthcare workers are repeatedly exposed to mental and physical suffering, it can significantly affect them negatively, including “secondary traumatization, and positive consequences like posttraumatic growth” (p. 283). According to Abu-Sharkia et al. (2020) posttraumatic growth is connected personal growth which is defined as “positive changes that may occur as a result of psychological struggle” (p. 283). Even during the challenging times of a health crises requiring the population to adhere to physical distancing regulation, Wald (2020) says it is still important to encourage social connection as it helps front line healthcare workers not feel alone during times of adversity.

Social connection can be achieved in many ways. According to Wald (2020) this can be accomplished by checking in with colleagues and connecting to medical education groups for frontline workers by means of social media platforms. Kwok et al. (2016) asserts the importance of recognizing the power of frontline health workers having a collective sense of community during difficult times to cultivate “social well-being [and health], quality of life, sense of place and belonging, and civic engagement” (p. 198). Wald (2020) adds the need to respect that frontline “professionals will have narratives specific to those experiences; trainees at various levels will have their narratives as well” (p. 747). When necessary, it is essential that frontline workers come together to debrief and hold space to share the challenging experiences they are facing in supporting patients.

== '''GROWING HEALTHY LIFESTYLE HABITS''' ==
Another way to foster resilience in frontline healthcare workers is to adopt healthy lifestyle habits. According to Wald (2020) the adoption of healthy lifestyle habits involves practicing relaxation, exercise, rest, healthy food choices, humour, and holistic wellness. Holistic wellness invites frontline health workers to look after their spiritual, emotional, physical, and social health.

According to Southwick and Charney (2012) improving physical health includes boosting one’s “quality of diet, amount of exercise, capacity to relax, and quantity and [sic] quality of sleep is important in determining how the body and brain respond to stress” (p. 81). Southwick and Charney (2012) assert a strong connection when it comes to fostering resilience through aerobic exercise and its ability to improve depression, brain function and cognition. According to Southwick and Charney (2012) “aerobic exercise is believed to induce the expression of genes associated with neuroplasticity and neurogenesis, as well as to regulate the HPA-axis response to stress” (p. 81). Cherry (2022) asserts neuroplasticity is “the brain's ability to change and adapt due to experience” (para. 1) which refers to the brain’s capacity to reorganize, change, and grow neural systems.

Some studies also indicate that exercise is just as effective antidepressants in treating as well as preventatively for general depression. Wald (2020) asserts that the physical activity can be “meditation in motion” as walking not only provides physical exercise and mindfulness at the same time, but also allows individuals to connect to nature by taking a simple walk outside (p. 748). Nature is well known to reduce stress and improve wellbeing as well as facilitate healing for folks. The knowledge keepers or Elders I connect often remind me to connect to the land to recalibrate balance and this has been easier to do since getting a puppy who also need to get out and release some energy, it works well for both of us.

== '''HIGHLIGHTING AND SUPPORTING MORAL RESILIENCE''' ==
According to Wald (2020) part of fostering resilience includes bringing attention to moral resilience as it is important for frontline healthcare workers to know that experienced moral distress or grief comes from moral dilemmas, which can significantly reduce their sense of agency. During times of adversity, Wald (2020) asserts the need to support frontline healthcare workers and their ability to navigate moral distress, support their sense of integrity and strengthen moral resilience. According to Holtz et al. (2018) moral distress when there are conflicting views or values between healthcare providers, patients, and patients’ families on the best plan of action for healthcare delivery.

Although moral distress has primarily been studied in frontline nurses, it is now apparent that moral distress affects the entire interprofessional team. Holtz (2018) highlights that while moral distress has shown to be intensified during the Covid-19 pandemic as lifelong learners it is crucial to be open to navigating the muddy waters of adversity. Frontline work is important, and it is critical the work is done in a good and honourable way where workers can continue to try to strengthen their moral resilience.

According to Wald (2020) this can be achieved by validating “ethical uncertainties and complexities, feelings of powerlessness (should these be present), discussing any perceived threats to one’s sense of integrity” (p. 750). A great deal of distress can come along with the inability to give the level of care one should hope to provide especially when systems get in the way of achieving this as this can feel quite conflicting with one’s moral compass. Wald (2020) asserts support should be tailored to “individual needs including clarifying realistic expectations of trainees, colleagues, institutional leadership, and self within a crisis environment” (p. 750). It is important to be able to identify when were out of our scope of practice and encouraged to set boundaries by strong leadership.

== '''APPLICATION TO SOCIAL WORK PRACTICE''' ==
The key topics from the literature I chose to discuss are embracing positive as well as negative emotions, practicing being rooted in the present, relationship building, social support, growing healthy lifestyle habits, and highlighting as well as supporting moral resilience. Social workers should be open embracing positive and negative emotions not only to become comfortable with talking through all feelings, but to allow the negative emotions to leave out bodies to decrease any chances of sickness or tension from building up inside their bodies. Social workers can practice being rooted in the present by practicing mindfulness like breathing exercises or deep relaxation techniques that help reduce stress, increase focus, revitalize us, and accept what we cannot change.

When it comes to relationship building and social support, it is crucial to have an outlet to talk about the challenges we faced in our day or week by debriefing with out team. It is also important that the people we debrief have a good understanding that debriefing needs to be a space free of judgment and non-hierarchical. When it comes to growing healthy lifestyle habits, it is important for social workers to tend to all areas of health also know as holistic health and wellness. It is also vital to be able to identify experienced moral distress to validate as well as foster resilience. Due the high likelihood of experiencing moral distress in the world of social work, I feel it is so important for social workers to see a counsellor especially when they are working in a setting that does not have strong culture of debriefing or coming together.

== '''REFERENCES''' ==
Abu‐Sharkia S., Taubman‐Ben‐Ari O., Mofareh A. (2020). Secondary traumatization and personal growth of healthcare teams in maternity and neonatal wards: the role of differentiation of self and social support. ''Nurse Health Sci.'' DOI:10.1111/nhs.12710

American Psychological Association. (2010). The Road to Resilience. ''APA Washington'', ''DC''. <nowiki>https://uncw.edu/studentaffairs/committees/pdc/documents/the%20road%20to%20resilience.pdf</nowiki>

Berinato, S. (2020). That discomfort you’re feeling is grief. ''Harvard Business Review.'' <nowiki>https://hbr.org/2020/03/that-discomfort-youre-feeling-is-grief</nowiki>

Cherry, K. (2022). What is neuroplasticity? ''Very well mind''. <nowiki>https://www.verywellmind.com/what-is-brain-plasticity-2794886</nowiki>

Holtz, H., Heinze, K., Rushton C. (2018). Interprofessional' definitions of moral resilience. ''J Clinical Nurse''. 27(3–4): e488–e494.

Holzel, B. K., Lazar, S. W., Gard, T., Schuman-Olivier, Z., Vago, D. R., and Ott, U. (2011). How does mindfulness meditation work? Proposing mechanisms of action from a conceptual and neural perspective. ''Perspective Psychology. Sci.'' 6, 537–559. Doi: 10.1177/1745691611419671

Kwok, A., Doyle, E., Becker, J., Johnston, D, Paton, D. (2016). What is ‘social resilience’? Perspectives of disaster researchers, emergency management practitioners, and policymakers in New Zealand''. Int J Disaster Risk Reduction''. 19:197–211.

Southwick, S., Charney, D. (2012). The science of resilience: implications for the prevention and treatment of depression. ''Science.'' 338(6103):79–82.

Virk, L. (2020). Social distancing not emotional distancing. ''Closler'', April 13. <nowiki>http://closler.org/lifelong-learning-in-clinical-excellence/social-distancing-not-emotional-distancing</nowiki>

Wald, H. (2020). Optimizing resilience and wellbeing for healthcare

professions trainees and healthcare professionals during public health crises – Practical tips for an ‘integrative resilience’ approach, ''Medical Teacher'', 42:7, 744-755, DOI: 10.1080/0142159X.2020.1768230<references responsive="0" />
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Course:SOWK551/2021/Gay men with Chemsex in Healthcare

2023-05-28T21:10:36Z

KellyAllison:

[[File:Image from Pexels.jpg|alt=Adult writing in journal|thumb|Photo by Pexels on Pixabay]]

== Short Summary ==
Literature review of how healthcare workers can better support gay men involved inChemsex in their healthcare experiences.

''Author: Valerie Siu''

''Date: April 2, 2023''

== Introduction ==
The practice of combining substances and alcohol use with sexual activities is known as Chemsex or Party and Play (PNP), and it is used to sustain, enhance, disinhibit or facilitate the sexual experience (Bourne et al., 2015). In a 2018 publication in the International Journal of Drug Policy, the occurrence of chemsex among Canadian men who have sex with men (MSM) was estimated at 5.5%. Meanwhile, a 2020 study in the Journal of Homosexuality revealed that 40% of MSM in Canada had reportedly used drugs while engaging in sexual activity. As a result, the activity has become an increasingly pressing issue for healthcare professionals, especially within the gay male community.

This paper aims to explore research on "How can healthcare social workers provide support for gay men involved in chemsex in their healthcare service? "Through a review of current literature, this resource will provide recommendations for social work practice in healthcare and contribute to the conversation on substance use and sexual health in the LGBTQ+ community.

== Literature Review: What is Chemsex ==
HM Government (2017) defined Chemsex as "the use of specific drugs in sexual contexts by gay men, bisexual, MSM and trans people and to sustain, enhance, disinhibit or facilitate the experience before or planned sexual activity”. The activity typically involved using specific substances, such as Methamphetamine, Mephedrone, gamma-hydroxybutyrate (GHB) and crystal methamphetamine (meth). According to a study by Bourne et al. (2015), Methamphetamine, crystal meth and Mephedrone are stimulants that increase physical energy, enhance sexual performance and induce euphoria. GHB is a depressant to relax and causes loss of consciousness. It is also commonly used as a date rape substance. These substances could bring significant impacts on both physical and mental health. In particular, the stimulants could increase heart rate and blood pressure and damage the liver, kidneys and lungs (Isaiah et al., 2006). In addition, the depressant had a significant effect in small doses, while a high dose may cause loss of consciousness, coma or even death (Degenhardt et al., 2019).

== Physical and Mental health risks in Chemsex ==
Although using substances involved in Chemsex mentioned above would physically severely impact the body, the risk of HIV and other sexually transmitted infections (STIs) would also increase the likelihood of engaging in unprotected sex while under the influence of substances. In addition, STIs could cause many harmful effects on the body, including inflammation, pain and organ damage (Burchell et al., 2015).

In addition to physical health risks, Chemsex is associated with various mental health issues, such as anxiety, depression and social isolation. Furthermore, Bourne et al. (2015) stated that Chemsex also led to feelings of shame, guilt and low self-esteem. As such, it would exacerbate existing mental health problems or lead to new mental health concerns.

Some substances, such as GHB, could lead to amnesia or "blackout"; the unconsciousness could increase the risk of sexual assault or other forms of violence (Csete et al., 2016). In particular, those involved in marginalized employment or sex work might be susceptible to coercion and exploitation, especially when participating in Chemsex.

== Factors contribute to Chemsex ==
Chemsex is a complex phenomenon influenced by various factors, and research has identified individual, social, cultural and systemic factors.

Individual factors, such as trauma, anxiety, depression and low self-esteem, are potential factors linked to the use of substances during sex (Sewell et al., 2019). For example, Tan et al. (2021) suggested that some gay men see Chemsex as a utility in allowing them to achieve positive emotional states, sexual enhancements and feelings of connectedness and intimacy in their study of exploring the role of trauma in underpinning Chemsex in Singapore. They also reported using substances to cope with the trauma of past experiences such as sexual abuse, unwanted and unprotected sex, domestic violence and discrimination.

Social and cultural factors, such as peer pressure, social isolation and misunderstanding LGBTQ+ community, were also significant contributors to Chemsex (Gaudette et al., 2023; Bourne et al., 2015). Bourne et al. (2015) stated that Chemsex could be a way for gay men to cope with societal discrimination and homophobia. Hence, the trend of dating apps or online dating platforms was also identified as a contributing factor as they provided easy access to partners, substances or related Chemsex information, according to a report from the University of Amsterdam (2018). They found out that MSM who use dating apps were more likely to engage in Chemsex than those who did not use online dating platforms. The normalization of the LGBTQ+ community also worked as an active contributor to using substances during sex (McBride et al., 2019).

Systematic factors such as criminalization and stigma associated with substance use and sex work could also contribute to the prevalence of Chemsex. Bauer et al. (2015) stated that the criminalization of substance use and sex work had led to a lack of harm reduction resources and services for gay men engaged in Chemsex. The intolerance from society and bias on particular behaviour also hindered this population and contributed to their substance use.

== Impact of Chemsex on relationships ==
The use of substances during sex could have a profound impact on relationships, particularly intimate partnerships.

Increased sexual risk behaviour is one significant impact, such as engaging in unprotective sex with multiple partners, which can lead to STIs and HIV transmission (Bourne et al., 2015). Furthermore, this behaviour might cause tension and mistrust between partners, especially if one partner is unaware or uncomfortable with the other's participation in Chemsex. Additionally, the physical and emotional effects of substances could impair judgement and consciousness, leading to a potentially dangerous situation and causing further damage to the relationship (Hegazi et al., 2017).

Another impact on a relationship was the potential for addiction and substance dependence. Bourne et al. (2015) stated that addiction could lead to secrecy and dishonesty in relationships and would prioritize substance use over the relationship itself. They noted that Chemsex could focus on sex as a primary activity in the relationship rather than emotional intimacy and connection. The shift could result in a lack of communication and emotional distance between partners, damaging their bond.

== Barriers to accessing healthcare services ==
Milhet and colleagues (2019) conducted in-depth interviews with 33 gay men and other MSM engaged in Chemsex aged 31-39 in this qualitative study. The results showed that one of the difficulties was the lack of language to express the bodily pleasures of Chemsex. Even if they did, they mentioned it would not be understood by a non-practicer (Pennant et al., 2009).

Another barrier to accessing healthcare services for MSM was the lack of culturally competent care. LGBTQ+ individuals often face discrimination, stigma and prejudice when accessing healthcare services; Grant et al., 2011 stated the lack of trust and avoidance of care would restrict them from seeking help or disclosing their difficulties. As such, this population would have higher rates of substance use, mental health issues and STIs.

Furthermore, the criminalization of substance use and sex work could also create barriers to accessing healthcare services due to the fear of legal consequences, such as arrest and incarceration, which would deter individuals from seeking medical care (Csete et al., 2016). The reluctance to care leads to a lack of testing and treatment for STIs, mental health issues and substance-related harm. Criminalization also limited the availability of harm reduction services such as safe injection sites and clean needles (Bauer et al., 2015). For example, in the Mental Health Act, physicians' duty of report or police involvement in healthcare services would become a barrier for MSM to disclose and access services with dignity.

In addition, negative hospitalizations or experiences would impede MSM from seeking services. Dodge et al. (2008) suggested that MSM may experience trauma related to their interactions with healthcare providers as their prejudgment and attitudes would create an unsafe and unwelcome environment. Hence, healthcare may also hold stigmatizing attitudes toward MSM or those engaged in sex work, which can result in a lack of empathy and inadequate care (Hegazi et al., 2017). Fulcher and colleagues conducted a qualitative research in semi-structure interviews with 33 MSM to identify their needs and preferences regarding treatment and services in British Columbia, Canada. Participants expressed a desire for support and assistance with their substance use but shared that the services were lack of connection with healthcare professionals. This study also pointed out that healthcare professionals used a "one size fits all" approach but did not adequately meet their needs, while Chemsex was a complex issue requiring a multi-faceted approach. It showed a lack of understanding, knowledge, early assumptions, and judgements that would lead to misdiagnosis or inappropriate treatment (Bauer et al., 2015) and further harm. It contributed to a cycle of trauma in avoiding healthcare services (Hegazi et al., 2017).

== The implication of practice: What can be suggested to enhance the services ==
While Canada strives to promote gender-sensitive and respectful healthcare environments, there is still room for improvement in addressing the needs of marginalized groups. By synthesizing information from multiple sources, various practice implications are recommended to be implemented to serve this population better.

'''''Awareness of ethical considerations''''': Ethical considerations are critical in healthcare, particularly in providing equitable and respectful services to marginalized groups. One important consideration is the need for healthcare providers to be non-judgemental and free from discrimination based on sexual orientation or gender identity. This includes using appropriate pronouns and avoiding assumptions about an individual's sexual orientation or gender identity. It is also suggested to prioritize informed consent to ensure individuals fully understand the potential risks and benefits of any interventions, including those related to Chemsex (Canadian Medical Association, 2020).

'''''Training for healthcare providers''''': Physicians, therapists, social workers or other practitioners involved in healthcare service should all have adequate training to create a safe, welcoming and supportive space for MSM without coming with fear of stigma and discrimination. The training involves trauma-informed practice, addressing trauma and concerns, cultural awareness and knowledge about harm reduction strategies and resources available in their settings. Social workers are expected to collaborate with other healthcare professionals to develop holistic care plans that address multiple needs. Social workers are believed to have a crucial role in supporting MSM, in developing approaches that account for the fine line between stigma and care. A study by Gaudette and colleagues (2023) found that social workers trained in harm reduction strategies were better equipped to support MSM. This showed that providing and advocating culturally sensitive care can help reduce the harm associated with Chemsex and promote clients' health and wellbeing.

'''''Educate with harm reduction approach''''': Besides assisting in accessing resources, healthcare social workers have a crucial role in educating MSM engaged in Chemsex using a harm reduction approach, aiming to reduce the transmission risk of HIV and other STIs (Fulcher et al., 2022). For example, they can provide counselling on safer sex practices and emphasize the importance of regular STI testing to promote their clients' health and wellbeing. Furthermore, social workers can advocate for providing safe sex supplies and testing kits in their offices or specific wards to promote safer and healthier sex practices.

'''''Building partnerships with community organizations''''': Healthcare social workers can gain valuable insights into the unique needs and challenges faced by MSM engaged in chemsex. As harm reduction programs play a crucial role in promoting the health and welling-being of this population, healthcare social workers can ensure clients are provided with holistic and culturally competent care in partnering with a community organization. Efficiency is crucial to healthcare services, particularly in a hospital care setting. However, the constraint of time can pose a significant obstacle in meeting the needs of patients, as discussed in a recent study by Fulcher et al. (2022). As such, partnering with community services can help bridge the gap between healthcare services and community-based resources to promote a more seamless and coordinated approach to care.

'''''Promoting policy changes''''': Healthcare social workers can work toward creating policies, including increased access to affordable healthcare and mental health services or policies that address discrimination and stigma toward this population. Social workers can work with policymakers to promote harm reduction approaches such as safe injection sites, specialized wards or free access to safe kit supplies. Plus, healthcare social workers can also work towards increasing funding for research on the health and social impacts of Chemsex on gay men. This can help us to understand this population better and advocate for the inclusion of gay men engaged in Chemsex in research studies and clinical trials to promote the dissemination of research findings to inform a better inclusion policy.

== Limitation ==
This study focuses on the experience and impacts of gay men involved in Chemsex and addresses their barriers to healthcare service. However, it only focused on gay men but did not cover other LGBTQ+ groups who may also be engaged in Chemsex. In addition, although there were serval studies that found gay men and bisexual men were more likely to report using drugs during sex compared to lesbian and bisexual women (Bourne et al., 2015; Dodge et al., 2008), it is essential to note that these studies are not necessarily representative of all LGBTQ+ individuals, and more research is needed to fully understand the patterns of substance use during sex in this population.

== Conclusion ==
Chemsex, including its definition and the physical and mental health risks it poses, as well as its impact on relationships and the factors contributing to its prevalence in the gay community, was explored in this paper. The study also analyzed the obstacles faced in accessing healthcare services and proposed practical recommendations for improving them. Finally, it emphasized the critical role of healthcare social workers in creating a safe and respectful environment for this population. However, further research is necessary to reduce the risks associated with the LGBTQ+ community.

== References ==
<references responsive="0" />
Bauer, G. R., Scheim, A. I., Pyne, J., Travers, R., & Hammond, R. (2015). Intervenable factors associated with suicide risk in transgender persons: A respondent driven sampling study in ontario, canada. BMC Public Health, 15(1), 525-525.

Bourne, A., Reid, D., Hickson, F., Torres-Rueda, S., & Weatherburn, P. (2015). Illicit drug use insexual settings (‘chemsex’) and HIV/STI transmission risk behaviour among gay men in south london: Findings from a qualitative study. Sexually Transmitted Infections, 91(8), 564-568.

Bourne, A., Reid, D., Hickson, F., Torres-Rueda, S., Steinberg, P., & Weatherburn, P. (2015). “Chemsex” and harm reduction need among gay men in south london. The International Journal of Drug Policy, 26(12), 1171-1176.

Burchell, A. N., Allen, V. G., Gardner, S. L., Moravan, V., Tan, D. H. S., Grewal, R., Raboud, J., Bayoumi, A. M., Kaul, R., Mazzulli, T., McGee, F., Rourke, S. B., OHTN Cohort Study Team, & on behalf of the OHTN Cohort Study Team. (2015). High incidence of diagnosis with syphilis co-infection among men who have sex with men in an HIV cohort in ontario, canada. BMC Infectious Diseases, 15(1), 356-356.

Canadian Medical Association. (2020). CMA code of ethics and professionalism.

Chemsex Forum Organisation Comittee 3rd European Chemsex Forum Paris. 2019.

Csete, J., PhD, Kamarulzaman, A., Prof, Kazatchkine, M., Prof, Altice, F., Prof, Balicki, M., MD, Buxton, J., Prof, Cepeda, J., PhD, Comfort, M., PhD, Goosby, E., Prof, Goulão, J., MD, Hart, C., Prof, Kerr, T., Prof, Lajous, A. M., Prof, Lewis, S., Prof, Martin, N., DPhil, Mejía, D., Prof, Camacho, A., Prof, Mathieson, D., MA, Obot, I., Prof, . . . Beyrer, C., Prof. (2016). Public health and international drug policy. The Lancet (British Edition), 387(10026), 1427-1480.Daley, A., Solomon, S., Newman, P. A., & Mishna, F. (2007). Traversing the margins: Intersectionalities in the bullying of lesbian, gay, bisexual and transgender youth. Journal of Gay & Lesbian Social Services, 19(3-4), 9-29.

Degenhardt, L., Prof, Charlson, F., PhD, Stanaway, J., PhD, Larney, S., PhD, Alexander, L. T., BA, Hickman, M., Prof, Cowie, B., PhD, Hall, W. D., Prof, Strang, J., Prof, Whiteford, H., Prof, & Vos, T., Prof. (2016). Estimating the burden of disease attributable to injecting drug use as a risk factor for HIV, hepatitis C, and hepatitis B: Findings from the global burden of disease study 2013. The Lancet Infectious Diseases, 16(12), 1385-1398.

Dodge, B., Jeffries, W. L., & Sandfort, T. G. M. (2008). Beyond the down low: Sexual risk, protection, and disclosure among at-risk black men who have sex with both men and women (MSMW). Archives of Sexual Behavior, 37(5), 683-696.

Fulcher, K., Berlin, G., Taylor, K., Wells, A., Nguyen, T., Moore, D., Hull, M., & Lachowsky, N. J. (2022). Understanding the service needs and preferences of men who have sex with men who use crystal methamphetamine in british columbia, canada: A qualitative study. International Journal of Mental Health and Addiction,

Grant, J., Keisling, M., Harrison, J., Mottet, L., Herman, J., Tanis, J., National Center for Transgender Equality, & The National LGBTQ Task Force. (2011). Injustice at every turn: A report of the national transgender discrimination survey

Gaudette, Y., Flores-Aranda, J., & Heisbourg, E. (2023). Needs and experiences of people practising chemsex with support services: Toward chemsex-affirmative interventions. Journal of Men's Health, 18(12), 57-67.

Hegazi, A., Lee, M., Whittaker, W., Green, S., Simms, R., Cutts, R., Nagington, M., Nathan, B., & Pakianathan, M. (2017). Chemsex and the city: Sexualised substance use in gay bisexual and other men who have sex with men attending sexual health clinics. International Journal of STD & AIDS, 28(4), 362-366.

Isaiah Green, A., & Halkitis, P. N. (2006). Crystal methamphetamine and sexual sociality in an urban gay subculture: An elective affinity. Culture, Health & Sexuality, 8(4), 317-333.

International journal of drug policy issues 11 research articles in february 2018 edition; journal. (2018, ). Targeted News Service (TNS)

Kattari, S. K., Walls, N. E., & Speer, S. R. (2017). Differences in experiences of discrimination in accessing social services among Transgender/Gender nonconforming individuals by (dis)ability. Journal of Social Work in Disability & Rehabilitation, 16(2), 116.

McBride, K. R., Reece, M., Sanders, S. A., & Dodge, B. (2019). Exploring the complex realities of chemsex: a narrative review. Substance Use & Misuse, 54(2), 259-269.

Moreno-Gámez, L., Hernández-Huerta, D., & Lahera, G. (2022). Chemsex and psychosis: A systematic review. Behavioral Sciences, 12(12), 516.

Milhet, M., Shah, J., Madesclaire, T., & Gaissad, L. (2019). Chemsex experiences: Narratives of pleasure. Drugs and Alcohol Today, 19(1), 11-22.

Pachankis, J. E., Hatzenbuehler, M. L., Rendina, H. J., Safren, S. A., & Parsons, J. T. (2015). LGB affirmative cognitive-behavioral therapy for young adult gay and bisexual men: A randomized controlled trial of a transdiagnostic minority stress approach. Journal of Consulting and Clinical Psychology, 83(5), 875-889.

Pennant, M. E., Bayliss, S. E., & Meads, C. A. (2009). Improving lesbian, gay and bisexual healthcare: a systematic review of qualitative literature from the UK. Diversity and Equality in Health and Care, 6(3).

Pufall, E., Kall, M., Shahmanesh, M., Nardone, A., Gilson, R., Delpech, V., Ward, H., Hart, G., Anderson, J., Azad, Y., Elford, J., Sullivan, A., Mercer, C., McOwan, A., Peck, J., Cassell, J., Musonda, J., Bruton, J., Positive Voices study group, & The Positive Voices study group. (2018). Sexualized drug use (‘chemsex’) and high‐risk sexual behaviours in HIV‐positive men who have sex with men. HIV Medicine, 19(4), 261-270.

Reports from University of Amsterdam Describe Recent Advances in HIV/AIDS (Chemsex Among Men Who Have Sex With Men: a Sexualized Drug Use Survey Among Clients of the Sexually Transmitted Infection Outpatient Clinic and Users of a Gay Dating App ...). (2018, May 21). AIDS Weekly, 126

Strategy, D. (2017). Drug strategy. HM Government.

Sewell, J., Cambiano, V., Speakman, A., Lampe, F. C., Phillips, A., Stuart, D., Gilson, R., Asboe, D., Nwokolo, N., Clarke, A., & Rodger, A. J. (2019). Changes in chemsex and sexual behaviour over time, among a cohort of MSM in london and brighton: Findings from the AURAH2 study. The International Journal of Drug Policy, 68, 54-61.

Tan, R. K. J., Phua, K., Tan, A., Gan, D. C. J., Ho, L. P. P., Ong, E. J., & See, M. Y. (2021). Exploring the role of trauma in underpinning sexualised drug use (‘chemsex’) among gay, bisexual and other men who have sex with men in singapore. The International Journal of Drug Policy, 97, 103333-103333.

{{Cc-by-nc-4.0}}

Course:SOWK551/2021/Gay men with Chemsex in Healthcare

2023-05-26T16:29:37Z

KellyAllison:

[[File:Image from Pexels.jpg|alt=Adult writing in journal|thumb|Photo by Pexels on Pixabay]]

== Short Summary ==
Literature review of how healthcare workers can better support gay men involved with Chemsex in their healthcare experiences

''Author: Valerie Siu''

''Date: April 2, 2023''

== Introduction ==
The practice of combining substances and alcohol use with sexual activities is known as Chemsex or Party and Play (PNP), and it is used to sustain, enhance, disinhibit or facilitate the experience (Bourne et al., 2015). In a 2018 publication in the International Journal of Drug Policy, the occurrence of chemsex among Canadian men who have sex with men (MSM) was estimated at 5.5%. Meanwhile, a 2020 study in the Journal of Homosexuality revealed that 40% of MSM in Canada had reportedly used drugs while engaging in sexual activity. As a result, the activity has become an increasingly pressing issue for healthcare professionals, especially within the gay male community.

This paper aims to explore research on "How can healthcare social workers provide support for gay men with chemsex in healthcare service? "Through a review of current literature, this resource will provide recommendations for social work practice in healthcare and contribute to the conversation on substance use and sexual health in the LGBTQ+ community.

== Literature Review: What is Chemsex ==
HM Government (2017) defined Chemsex as "the use of specific drugs in sexual contexts by gay men, bisexual, MSM and trans people and to sustain, enhance, disinhibit or facilitate the experience before or planned sexual activity”. The activity typically involved using specific substances, such as Methamphetamine, Mephedrone, gamma-hydroxybutyrate (GHB) and crystal methamphetamine (meth). According to a study by Bourne et al. (2015), Methamphetamine, crystal meth and Mephedrone are stimulants that increase physical energy, enhance sexual performance and induce euphoria. GHB is a depressant to relax and causes loss of consciousness. It is also commonly used as a date rape substance. These substances could bring significant impacts on both physical and mental health. In particular, the stimulants could increase heart rate and blood pressure and damage the liver, kidneys and lungs (Isaiah et al., 2006). In addition, the depressant had a significant effect in small doses, while a high dose may cause loss of consciousness, coma or even death (Degenhardt et al., 2019).

== Physical and Mental health risks in Chemsex ==
Although using substances involved in Chemsex mentioned above would physically severely impact the body, the risk of HIV and other sexually transmitted infections (STIs) would also increase the likelihood of engaging in unprotected sex while under the influence of substances. In addition, STIs could cause many harmful effects on the body, including inflammation, pain and organ damage (Burchell et al., 2015).

In addition to physical health risks, Chemsex is associated with various mental health issues, such as anxiety, depression and social isolation. Furthermore, Bourne et al. (2015) stated that Chemsex also led to feelings of shame, guilt and low self-esteem. As such, it would exacerbate existing mental health problems or lead to new mental health concerns.

Some substances, such as GHB, could lead to amnesia or "blackout"; the unconsciousness could increase the risk of sexual assault or other forms of violence (Csete et al., 2016). In particular, those involved in marginalized employment or sex work might be susceptible to coercion and exploitation, especially when participating in Chemsex.

== Factors contribute to Chemsex ==
Chemsex is a complex phenomenon influenced by various factors, and research has identified individual, social, cultural and systemic factors.

Individual factors, such as trauma, anxiety, depression and low self-esteem, are potential factors linked to the use of substances during sex (Sewell et al., 2019). For example, Tan et al. (2021) suggested that some gay men see Chemsex as a utility in allowing them to achieve positive emotional states, sexual enhancements and feelings of connectedness and intimacy in their study of exploring the role of trauma in underpinning Chemsex in Singapore. They also reported using substances to cope with the trauma of past experiences such as sexual abuse, unwanted and unprotected sex, domestic violence and discrimination.

Social and cultural factors, such as peer pressure, social isolation and misunderstanding LGBTQ+ community, were also significant contributors to Chemsex (Gaudette et al., 2023; Bourne et al., 2015). Bourne et al. (2015) stated that Chemsex could be a way for gay men to cope with societal discrimination and homophobia. Hence, the trend of dating apps or online dating platforms was also identified as a contributing factor as they provided easy access to partners, substances or related Chemsex information, according to a report from the University of Amsterdam (2018). They found out that MSM who use dating apps were more likely to engage in Chemsex than those who did not use online dating platforms. The normalization of the LGBTQ+ community also worked as an active contributor to using substances during sex (McBride et al., 2019).

Systematic factors such as criminalization and stigma associated with substance use and sex work could also contribute to the prevalence of Chemsex. Bauer et al. (2015) stated that the criminalization of substance use and sex work had led to a lack of harm reduction resources and services for gay men engaged in Chemsex. The intolerance from society and bias on particular behaviour also hindered this population and contributed to their substance use.

== Impact of Chemsex on relationships ==
The use of substances during sex could have a profound impact on relationships, particularly intimate partnerships.

Increased sexual risk behaviour is one significant impact, such as engaging in unprotective sex with multiple partners, which can lead to STIs and HIV transmission (Bourne et al., 2015). Furthermore, this behaviour might cause tension and mistrust between partners, especially if one partner is unaware or uncomfortable with the other's participation in Chemsex. Additionally, the physical and emotional effects of substances could impair judgement and consciousness, leading to a potentially dangerous situation and causing further damage to the relationship (Hegazi et al., 2017).

Another impact on a relationship was the potential for addiction and substance dependence. Bourne et al. (2015) stated that addiction could lead to secrecy and dishonesty in relationships and would prioritize substance use over the relationship itself. They noted that Chemsex could focus on sex as a primary activity in the relationship rather than emotional intimacy and connection. The shift could result in a lack of communication and emotional distance between partners, damaging their bond.

== Barriers to accessing healthcare services ==
Milhet and colleagues (2019) conducted in-depth interviews with 33 gay men and other MSM engaged in Chemsex aged in the qualitative study. The results showed that one of the difficulties was the lack of language to express the bodily pressures of Chemsex. Even if they did, they mentioned it would not be understood by a non-practicer (Pennant et al., 2009).

Another barrier to accessing healthcare services for MSM was the lack of culturally competent. LGBTQ+ individuals often face discrimination, stigma and prejudice when accessing healthcare services; Grant et al., 2011 stated the lack of trust and avoidance of care would restrict them from seeking help or disclosing their difficulties. As such, this population would have higher rates of substance use, mental health issues and STIs.

Furthermore, the criminalization of substance user and sex work could also create barriers to accessing healthcare services due to the fear of legal consequences, such as arrest and incarceration, which would deter individuals from seeking medical care (Csete et al., 2016). The reluctance to care leads to a lack of testing and treatment for STIs, mental health issues and substance-related harm. Criminalization also limited the availability of harm reduction services such as safe injection sites and clean needles (Bauer et al., 2015). For example, in the Mental Health Act, physicians' duty of report or police involvement in healthcare services would become a barrier for MSM to disclose and access services with dignity.

In addition, negative hospitalizations or experiences would impede MSM from seeking services. Dodge et al. (2008) suggested that MSM may experience trauma related to their interactions with healthcare providers as their prejudgment and attitudes would create an unsafe and unwelcome environment. Hence, healthcare may also hold stigmatizing attitudes toward MSM or those engaged in sex work, which can result in a lack of empathy and inadequate care (Hegazi et al., 2017). Fulcher and colleagues conducted a qualitative research in seme-structure interviews with 33 MSM to identify their needs and preferences regarding treatment and services in British Columbia, Canada. Participants expressed a desire for support and assistance with their substance use but shared that the services were lack of connection with healthcare professionals. This study also pointed out that healthcare professionals used a "one size fits all" approach but did not adequately meet their needs, while Chemsex was a complex issue requiring a multi-faceted approach. It showed a lack of understanding, knowledge, early assumptions, and judgements that would lead to misdiagnosis or inappropriate treatment (Bauer et al., 2015) and further harm. It contributed to a cycle of trauma in avoiding healthcare services (Hegazi et al., 2017).

== The implication of practice: What can be suggested to enhance the services ==
While Canada strives to promote gender-sensitive and respectful healthcare environments, there is still room for improvement in addressing the needs of marginalized groups. By synthesizing information from multiple sources, various practice implications are recommended to be implemented to serve this population better.

'''''Awareness of ethical considerations''''': Ethical considerations are critical in healthcare, particularly in providing equitable and respectful services to marginalized groups. One important consideration is the need for healthcare providers to be non-judgemental and free from discrimination based on sexual orientation or gender identity. This included using appropriate pronouns and avoiding assumptions about an individual's sexual orientation or gender identity. It is also suggested to prioritize informed consent to ensure individuals fully understand the potential risks and benefits of any interventions, including those related to Chemsex (Canadian Medical Association, 2020).

'''''Training for healthcare providers''''': Physicians, therapists, social workers or other practitioners involved in healthcare service should all have adequate training to create a safe, welcoming and supportive space for MSM without coming with fear of stigma and discrimination. The training involved trauma-informed practice, addressing trauma and concerns, cultural awareness and knowledge about harm reduction strategies and resources available in their settings. Social workers are expected to collaborate with other healthcare professionals to develop holistic care plans that address multiple needs. Social workers are believed to have a crucial role in supporting MSM, in developing approaches that account for the fine line between stigma and care. A study by Gaudette and colleagues (2023) found that social workers trained in harm reduction strategies were better equipped to support MSM. This showed that providing and advocating culturally sensitive care can help reduce the harm associated with Chemsex and promote clients' health and wellbeing.

'''''Educate with harm reduction approach''''': Besides assisting in accessing resources, healthcare social workers have a crucial role in educating MSM engaged in Chemsex using a harm reduction approach, aiming to reduce the transmission risk of HIV and other STIs (Fulcher et al., 2022). For example, they can provide counselling on safer sex practices and emphasize the importance of regular STI testing to promote their clients' health and wellbeing. Furthermore, social workers can advocate for providing safe sex supplies and testing kits in their offices or specific wards to promote safer and healthier sex practices.

'''''Building partnerships with community organizations''''': Healthcare social workers can gain valuable insights into the unique needs and challenges faced by MSM engaged in chemsex. As harm reduction programs play a crucial role in promoting the health and welling-being of this population, healthcare social workers can ensure clients are provided with holistic and culturally competent care in partnering with a community organization. Efficiency is crucial to healthcare services, particularly in a hospital care setting. However, the constraint of time can pose a significant obstacle in meeting the needs of patients, as discussed in a recent study by Fulcher et al. (2022). As such, partnering with community services can help bridge the gap between healthcare services and community-based resources to promote a more seamless and coordinated approach to care.

'''''Promoting policy changes''''': Healthcare social workers can work toward creating policies, including increased access to affordable healthcare and mental health services or policies that address discrimination and stigma toward this population. Social workers can work with policymakers to promote harm reduction approaches such as safe injection sites, specialized wards or free access to safe kit supplies. Plus, healthcare social workers can also work towards increasing funding for research on the health and social impacts of Chemsex with gay men. This can help to understand this population better and advocate for the inclusion of gay men engaged in Chemsex in research studies and clinical trials to promote the dissemination of research findings to inform a better inclusion policy.

== Limitation ==
This study focuses on the experience and impacts of gay men in Chemsex and addresses their barriers to healthcare service. However, it only focused on gay men but did not cover other LGBTQ+ groups who may also be engaged in Chemsex. In addition, although there were serval studies that found gay men and bisexual men were more likely to report using drugs during sex compared to lesbian and bisexual women (Bourne et al., 2015; Dodge et al., 2008), it is essential to note that these studies are not necessarily representative of all LGBTQ+ individuals, and more research is needed to fully understand the patterns of substance use during sex in this population.

== Conclusion ==
The subject of Chemsex, including its definition and the physical and mental health risks it poses, as well as its impact on relationships and the factors contributing to its prevalence in the gay community, was explored in this paper. The study also analyzed the obstacles faced in accessing healthcare services and proposed practical recommendations for improving them. Finally, it emphasized the critical role of healthcare social workers in creating a safe and respectful environment for this population. However, further research is necessary to reduce the risks associated with the LGBTQ+ community.

== References ==
<references responsive="0" />
Bauer, G. R., Scheim, A. I., Pyne, J., Travers, R., & Hammond, R. (2015). Intervenable factors associated with suicide risk in transgender persons: A respondent driven sampling study in ontario, canada. BMC Public Health, 15(1), 525-525.

Bourne, A., Reid, D., Hickson, F., Torres-Rueda, S., & Weatherburn, P. (2015). Illicit drug use insexual settings (‘chemsex’) and HIV/STI transmission risk behaviour among gay men in south london: Findings from a qualitative study. Sexually Transmitted Infections, 91(8), 564-568.

Bourne, A., Reid, D., Hickson, F., Torres-Rueda, S., Steinberg, P., & Weatherburn, P. (2015). “Chemsex” and harm reduction need among gay men in south london. The International Journal of Drug Policy, 26(12), 1171-1176.

Burchell, A. N., Allen, V. G., Gardner, S. L., Moravan, V., Tan, D. H. S., Grewal, R., Raboud, J., Bayoumi, A. M., Kaul, R., Mazzulli, T., McGee, F., Rourke, S. B., OHTN Cohort Study Team, & on behalf of the OHTN Cohort Study Team. (2015). High incidence of diagnosis with syphilis co-infection among men who have sex with men in an HIV cohort in ontario, canada. BMC Infectious Diseases, 15(1), 356-356.

Canadian Medical Association. (2020). CMA code of ethics and professionalism.

Chemsex Forum Organisation Comittee 3rd European Chemsex Forum Paris. 2019.

Csete, J., PhD, Kamarulzaman, A., Prof, Kazatchkine, M., Prof, Altice, F., Prof, Balicki, M., MD, Buxton, J., Prof, Cepeda, J., PhD, Comfort, M., PhD, Goosby, E., Prof, Goulão, J., MD, Hart, C., Prof, Kerr, T., Prof, Lajous, A. M., Prof, Lewis, S., Prof, Martin, N., DPhil, Mejía, D., Prof, Camacho, A., Prof, Mathieson, D., MA, Obot, I., Prof, . . . Beyrer, C., Prof. (2016). Public health and international drug policy. The Lancet (British Edition), 387(10026), 1427-1480.Daley, A., Solomon, S., Newman, P. A., & Mishna, F. (2007). Traversing the margins: Intersectionalities in the bullying of lesbian, gay, bisexual and transgender youth. Journal of Gay & Lesbian Social Services, 19(3-4), 9-29.

Degenhardt, L., Prof, Charlson, F., PhD, Stanaway, J., PhD, Larney, S., PhD, Alexander, L. T., BA, Hickman, M., Prof, Cowie, B., PhD, Hall, W. D., Prof, Strang, J., Prof, Whiteford, H., Prof, & Vos, T., Prof. (2016). Estimating the burden of disease attributable to injecting drug use as a risk factor for HIV, hepatitis C, and hepatitis B: Findings from the global burden of disease study 2013. The Lancet Infectious Diseases, 16(12), 1385-1398.

Dodge, B., Jeffries, W. L., & Sandfort, T. G. M. (2008). Beyond the down low: Sexual risk, protection, and disclosure among at-risk black men who have sex with both men and women (MSMW). Archives of Sexual Behavior, 37(5), 683-696.

Fulcher, K., Berlin, G., Taylor, K., Wells, A., Nguyen, T., Moore, D., Hull, M., & Lachowsky, N. J. (2022). Understanding the service needs and preferences of men who have sex with men who use crystal methamphetamine in british columbia, canada: A qualitative study. International Journal of Mental Health and Addiction,

Grant, J., Keisling, M., Harrison, J., Mottet, L., Herman, J., Tanis, J., National Center for Transgender Equality, & The National LGBTQ Task Force. (2011). Injustice at every turn: A report of the national transgender discrimination survey

Gaudette, Y., Flores-Aranda, J., & Heisbourg, E. (2023). Needs and experiences of people practising chemsex with support services: Toward chemsex-affirmative interventions. Journal of Men's Health, 18(12), 57-67.

Hegazi, A., Lee, M., Whittaker, W., Green, S., Simms, R., Cutts, R., Nagington, M., Nathan, B., & Pakianathan, M. (2017). Chemsex and the city: Sexualised substance use in gay bisexual and other men who have sex with men attending sexual health clinics. International Journal of STD & AIDS, 28(4), 362-366.

Isaiah Green, A., & Halkitis, P. N. (2006). Crystal methamphetamine and sexual sociality in an urban gay subculture: An elective affinity. Culture, Health & Sexuality, 8(4), 317-333.

International journal of drug policy issues 11 research articles in february 2018 edition; journal. (2018, ). Targeted News Service (TNS)

Kattari, S. K., Walls, N. E., & Speer, S. R. (2017). Differences in experiences of discrimination in accessing social services among Transgender/Gender nonconforming individuals by (dis)ability. Journal of Social Work in Disability & Rehabilitation, 16(2), 116.

McBride, K. R., Reece, M., Sanders, S. A., & Dodge, B. (2019). Exploring the complex realities of chemsex: a narrative review. Substance Use & Misuse, 54(2), 259-269.

Moreno-Gámez, L., Hernández-Huerta, D., & Lahera, G. (2022). Chemsex and psychosis: A systematic review. Behavioral Sciences, 12(12), 516.

Milhet, M., Shah, J., Madesclaire, T., & Gaissad, L. (2019). Chemsex experiences: Narratives of pleasure. Drugs and Alcohol Today, 19(1), 11-22.

Pachankis, J. E., Hatzenbuehler, M. L., Rendina, H. J., Safren, S. A., & Parsons, J. T. (2015). LGB affirmative cognitive-behavioral therapy for young adult gay and bisexual men: A randomized controlled trial of a transdiagnostic minority stress approach. Journal of Consulting and Clinical Psychology, 83(5), 875-889.

Pennant, M. E., Bayliss, S. E., & Meads, C. A. (2009). Improving lesbian, gay and bisexual healthcare: a systematic review of qualitative literature from the UK. Diversity and Equality in Health and Care, 6(3).

Pufall, E., Kall, M., Shahmanesh, M., Nardone, A., Gilson, R., Delpech, V., Ward, H., Hart, G., Anderson, J., Azad, Y., Elford, J., Sullivan, A., Mercer, C., McOwan, A., Peck, J., Cassell, J., Musonda, J., Bruton, J., Positive Voices study group, & The Positive Voices study group. (2018). Sexualized drug use (‘chemsex’) and high‐risk sexual behaviours in HIV‐positive men who have sex with men. HIV Medicine, 19(4), 261-270.

Reports from University of Amsterdam Describe Recent Advances in HIV/AIDS (Chemsex Among Men Who Have Sex With Men: a Sexualized Drug Use Survey Among Clients of the Sexually Transmitted Infection Outpatient Clinic and Users of a Gay Dating App ...). (2018, May 21). AIDS Weekly, 126

Strategy, D. (2017). Drug strategy. HM Government.

Sewell, J., Cambiano, V., Speakman, A., Lampe, F. C., Phillips, A., Stuart, D., Gilson, R., Asboe, D., Nwokolo, N., Clarke, A., & Rodger, A. J. (2019). Changes in chemsex and sexual behaviour over time, among a cohort of MSM in london and brighton: Findings from the AURAH2 study. The International Journal of Drug Policy, 68, 54-61.

Tan, R. K. J., Phua, K., Tan, A., Gan, D. C. J., Ho, L. P. P., Ong, E. J., & See, M. Y. (2021). Exploring the role of trauma in underpinning sexualised drug use (‘chemsex’) among gay, bisexual and other men who have sex with men in singapore. The International Journal of Drug Policy, 97, 103333-103333.

{{Cc-by-nc-4.0}}

Course:SOWK551/2021/Gay men with Chemsex in Healthcare

2023-05-26T03:35:14Z

KellyAllison:

[[File:Image from Pexels.jpg|alt=Adult writing in journal|thumb|Photo by Pexels on Pixabay]]

== Short Summary ==
Literature review of how healthcare workers can better support gay men involved with Chemsex in their healthcare experiences

'''Please do not remove this section.'''

''Author: Valerie Siu''

''Date: April 2, 2023''

== Introduction ==
The practice of combining substances and alcohol use with sexual activities is known as Chemsex or Party and Play (PNP), and it is used to sustain, enhance, disinhibit or facilitate the experience (Bourne et al., 2015). In a 2018 publication in the International Journal of Drug Policy, the occurrence of chemsex among Canadian men who have sex with men (MSM) was estimated at 5.5%. Meanwhile, a 2020 study in the Journal of Homosexuality revealed that 40% of MSM in Canada had reportedly used drugs while engaging in sexual activity. As a result, the activity has become an increasingly pressing issue for healthcare professionals, especially within the gay male community.

This paper aims to explore research on "How can healthcare social workers provide support for gay men with chemsex in healthcare service? "Through a review of current literature, this resource will provide recommendations for social work practice in healthcare and contribute to the conversation on substance use and sexual health in the LGBTQ+ community.

== Literature Review: What is Chemsex ==
HM Government (2017) defined Chemsex as "the use of specific drugs in sexual contexts by gay men, bisexual, MSM and trans people and to sustain, enhance, disinhibit or facilitate the experience before or planned sexual activity”. The activity typically involved using specific substances, such as Methamphetamine, Mephedrone, gamma-hydroxybutyrate (GHB) and crystal methamphetamine (meth). According to a study by Bourne et al. (2015), Methamphetamine, crystal meth and Mephedrone are stimulants that increase physical energy, enhance sexual performance and induce euphoria. GHB is a depressant to relax and causes loss of consciousness. It is also commonly used as a date rape substance. These substances could bring significant impacts on both physical and mental health. In particular, the stimulants could increase heart rate and blood pressure and damage the liver, kidneys and lungs (Isaiah et al., 2006). In addition, the depressant had a significant effect in small doses, while a high dose may cause loss of consciousness, coma or even death (Degenhardt et al., 2019).

== Physical and Mental health risks in Chemsex ==
Although using substances involved in Chemsex mentioned above would physically severely impact the body, the risk of HIV and other sexually transmitted infections (STIs) would also increase the likelihood of engaging in unprotected sex while under the influence of substances. In addition, STIs could cause many harmful effects on the body, including inflammation, pain and organ damage (Burchell et al., 2015).

In addition to physical health risks, Chemsex is associated with various mental health issues, such as anxiety, depression and social isolation. Furthermore, Bourne et al. (2015) stated that Chemsex also led to feelings of shame, guilt and low self-esteem. As such, it would exacerbate existing mental health problems or lead to new mental health concerns.

Some substances, such as GHB, could lead to amnesia or "blackout"; the unconsciousness could increase the risk of sexual assault or other forms of violence (Csete et al., 2016). In particular, those involved in marginalized employment or sex work might be susceptible to coercion and exploitation, especially when participating in Chemsex.

== Factors contribute to Chemsex ==
Chemsex is a complex phenomenon influenced by various factors, and research has identified individual, social, cultural and systemic factors.

Individual factors, such as trauma, anxiety, depression and low self-esteem, are potential factors linked to the use of substances during sex (Sewell et al., 2019). For example, Tan et al. (2021) suggested that some gay men see Chemsex as a utility in allowing them to achieve positive emotional states, sexual enhancements and feelings of connectedness and intimacy in their study of exploring the role of trauma in underpinning Chemsex in Singapore. They also reported using substances to cope with the trauma of past experiences such as sexual abuse, unwanted and unprotected sex, domestic violence and discrimination.

Social and cultural factors, such as peer pressure, social isolation and misunderstanding LGBTQ+ community, were also significant contributors to Chemsex (Gaudette et al., 2023; Bourne et al., 2015). Bourne et al. (2015) stated that Chemsex could be a way for gay men to cope with societal discrimination and homophobia. Hence, the trend of dating apps or online dating platforms was also identified as a contributing factor as they provided easy access to partners, substances or related Chemsex information, according to a report from the University of Amsterdam (2018). They found out that MSM who use dating apps were more likely to engage in Chemsex than those who did not use online dating platforms. The normalization of the LGBTQ+ community also worked as an active contributor to using substances during sex (McBride et al., 2019).

Systematic factors such as criminalization and stigma associated with substance use and sex work could also contribute to the prevalence of Chemsex. Bauer et al. (2015) stated that the criminalization of substance use and sex work had led to a lack of harm reduction resources and services for gay men engaged in Chemsex. The intolerance from society and bias on particular behaviour also hindered this population and contributed to their substance use.

== Impact of Chemsex on relationships ==
The use of substances during sex could have a profound impact on relationships, particularly intimate partnerships.

Increased sexual risk behaviour is one significant impact, such as engaging in unprotective sex with multiple partners, which can lead to STIs and HIV transmission (Bourne et al., 2015). Furthermore, this behaviour might cause tension and mistrust between partners, especially if one partner is unaware or uncomfortable with the other's participation in Chemsex. Additionally, the physical and emotional effects of substances could impair judgement and consciousness, leading to a potentially dangerous situation and causing further damage to the relationship (Hegazi et al., 2017).

Another impact on a relationship was the potential for addiction and substance dependence. Bourne et al. (2015) stated that addiction could lead to secrecy and dishonesty in relationships and would prioritize substance use over the relationship itself. They noted that Chemsex could focus on sex as a primary activity in the relationship rather than emotional intimacy and connection. The shift could result in a lack of communication and emotional distance between partners, damaging their bond.

== Barriers to accessing healthcare services ==
Milhet and colleagues (2019) conducted in-depth interviews with 33 gay men and other MSM engaged in Chemsex aged in the qualitative study. The results showed that one of the difficulties was the lack of language to express the bodily pressures of Chemsex. Even if they did, they mentioned it would not be understood by a non-practicer (Pennant et al., 2009).

Another barrier to accessing healthcare services for MSM was the lack of culturally competent. LGBTQ+ individuals often face discrimination, stigma and prejudice when accessing healthcare services; Grant et al., 2011 stated the lack of trust and avoidance of care would restrict them from seeking help or disclosing their difficulties. As such, this population would have higher rates of substance use, mental health issues and STIs.

Furthermore, the criminalization of substance user and sex work could also create barriers to accessing healthcare services due to the fear of legal consequences, such as arrest and incarceration, which would deter individuals from seeking medical care (Csete et al., 2016). The reluctance to care leads to a lack of testing and treatment for STIs, mental health issues and substance-related harm. Criminalization also limited the availability of harm reduction services such as safe injection sites and clean needles (Bauer et al., 2015). For example, in the Mental Health Act, physicians' duty of report or police involvement in healthcare services would become a barrier for MSM to disclose and access services with dignity.

In addition, negative hospitalizations or experiences would impede MSM from seeking services. Dodge et al. (2008) suggested that MSM may experience trauma related to their interactions with healthcare providers as their prejudgment and attitudes would create an unsafe and unwelcome environment. Hence, healthcare may also hold stigmatizing attitudes toward MSM or those engaged in sex work, which can result in a lack of empathy and inadequate care (Hegazi et al., 2017). Fulcher and colleagues conducted a qualitative research in seme-structure interviews with 33 MSM to identify their needs and preferences regarding treatment and services in British Columbia, Canada. Participants expressed a desire for support and assistance with their substance use but shared that the services were lack of connection with healthcare professionals. This study also pointed out that healthcare professionals used a "one size fits all" approach but did not adequately meet their needs, while Chemsex was a complex issue requiring a multi-faceted approach. It showed a lack of understanding, knowledge, early assumptions, and judgements that would lead to misdiagnosis or inappropriate treatment (Bauer et al., 2015) and further harm. It contributed to a cycle of trauma in avoiding healthcare services (Hegazi et al., 2017).

== The implication of practice: What can be suggested to enhance the services ==
While Canada strives to promote gender-sensitive and respectful healthcare environments, there is still room for improvement in addressing the needs of marginalized groups. By synthesizing information from multiple sources, various practice implications are recommended to be implemented to serve this population better.

'''''Awareness of ethical considerations''''': Ethical considerations are critical in healthcare, particularly in providing equitable and respectful services to marginalized groups. One important consideration is the need for healthcare providers to be non-judgemental and free from discrimination based on sexual orientation or gender identity. This included using appropriate pronouns and avoiding assumptions about an individual's sexual orientation or gender identity. It is also suggested to prioritize informed consent to ensure individuals fully understand the potential risks and benefits of any interventions, including those related to Chemsex (Canadian Medical Association, 2020).

'''''Training for healthcare providers''''': Physicians, therapists, social workers or other practitioners involved in healthcare service should all have adequate training to create a safe, welcoming and supportive space for MSM without coming with fear of stigma and discrimination. The training involved trauma-informed practice, addressing trauma and concerns, cultural awareness and knowledge about harm reduction strategies and resources available in their settings. Social workers are expected to collaborate with other healthcare professionals to develop holistic care plans that address multiple needs. Social workers are believed to have a crucial role in supporting MSM, in developing approaches that account for the fine line between stigma and care. A study by Gaudette and colleagues (2023) found that social workers trained in harm reduction strategies were better equipped to support MSM. This showed that providing and advocating culturally sensitive care can help reduce the harm associated with Chemsex and promote clients' health and wellbeing.

'''''Educate with harm reduction approach''''': Besides assisting in accessing resources, healthcare social workers have a crucial role in educating MSM engaged in Chemsex using a harm reduction approach, aiming to reduce the transmission risk of HIV and other STIs (Fulcher et al., 2022). For example, they can provide counselling on safer sex practices and emphasize the importance of regular STI testing to promote their clients' health and wellbeing. Furthermore, social workers can advocate for providing safe sex supplies and testing kits in their offices or specific wards to promote safer and healthier sex practices.

'''''Building partnerships with community organizations''''': Healthcare social workers can gain valuable insights into the unique needs and challenges faced by MSM engaged in chemsex. As harm reduction programs play a crucial role in promoting the health and welling-being of this population, healthcare social workers can ensure clients are provided with holistic and culturally competent care in partnering with a community organization. Efficiency is crucial to healthcare services, particularly in a hospital care setting. However, the constraint of time can pose a significant obstacle in meeting the needs of patients, as discussed in a recent study by Fulcher et al. (2022). As such, partnering with community services can help bridge the gap between healthcare services and community-based resources to promote a more seamless and coordinated approach to care.

'''''Promoting policy changes''''': Healthcare social workers can work toward creating policies, including increased access to affordable healthcare and mental health services or policies that address discrimination and stigma toward this population. Social workers can work with policymakers to promote harm reduction approaches such as safe injection sites, specialized wards or free access to safe kit supplies. Plus, healthcare social workers can also work towards increasing funding for research on the health and social impacts of Chemsex with gay men. This can help to understand this population better and advocate for the inclusion of gay men engaged in Chemsex in research studies and clinical trials to promote the dissemination of research findings to inform a better inclusion policy.

== Limitation ==
This study focuses on the experience and impacts of gay men in Chemsex and addresses their barriers to healthcare service. However, it only focused on gay men but did not cover other LGBTQ+ groups who may also be engaged in Chemsex. In addition, although there were serval studies that found gay men and bisexual men were more likely to report using drugs during sex compared to lesbian and bisexual women (Bourne et al., 2015; Dodge et al., 2008), it is essential to note that these studies are not necessarily representative of all LGBTQ+ individuals, and more research is needed to fully understand the patterns of substance use during sex in this population.

== Conclusion ==
The subject of Chemsex, including its definition and the physical and mental health risks it poses, as well as its impact on relationships and the factors contributing to its prevalence in the gay community, was explored in this paper. The study also analyzed the obstacles faced in accessing healthcare services and proposed practical recommendations for improving them. Finally, it emphasized the critical role of healthcare social workers in creating a safe and respectful environment for this population. However, further research is necessary to reduce the risks associated with the LGBTQ+ community.

== References ==
<references responsive="0" />
Bauer, G. R., Scheim, A. I., Pyne, J., Travers, R., & Hammond, R. (2015). Intervenable factors associated with suicide risk in transgender persons: A respondent driven sampling study in ontario, canada. BMC Public Health, 15(1), 525-525.

Bourne, A., Reid, D., Hickson, F., Torres-Rueda, S., & Weatherburn, P. (2015). Illicit drug use insexual settings (‘chemsex’) and HIV/STI transmission risk behaviour among gay men in south london: Findings from a qualitative study. Sexually Transmitted Infections, 91(8), 564-568.

Bourne, A., Reid, D., Hickson, F., Torres-Rueda, S., Steinberg, P., & Weatherburn, P. (2015). “Chemsex” and harm reduction need among gay men in south london. The International Journal of Drug Policy, 26(12), 1171-1176.

Burchell, A. N., Allen, V. G., Gardner, S. L., Moravan, V., Tan, D. H. S., Grewal, R., Raboud, J., Bayoumi, A. M., Kaul, R., Mazzulli, T., McGee, F., Rourke, S. B., OHTN Cohort Study Team, & on behalf of the OHTN Cohort Study Team. (2015). High incidence of diagnosis with syphilis co-infection among men who have sex with men in an HIV cohort in ontario, canada. BMC Infectious Diseases, 15(1), 356-356.

Canadian Medical Association. (2020). CMA code of ethics and professionalism.

Chemsex Forum Organisation Comittee 3rd European Chemsex Forum Paris. 2019.

Csete, J., PhD, Kamarulzaman, A., Prof, Kazatchkine, M., Prof, Altice, F., Prof, Balicki, M., MD, Buxton, J., Prof, Cepeda, J., PhD, Comfort, M., PhD, Goosby, E., Prof, Goulão, J., MD, Hart, C., Prof, Kerr, T., Prof, Lajous, A. M., Prof, Lewis, S., Prof, Martin, N., DPhil, Mejía, D., Prof, Camacho, A., Prof, Mathieson, D., MA, Obot, I., Prof, . . . Beyrer, C., Prof. (2016). Public health and international drug policy. The Lancet (British Edition), 387(10026), 1427-1480.Daley, A., Solomon, S., Newman, P. A., & Mishna, F. (2007). Traversing the margins: Intersectionalities in the bullying of lesbian, gay, bisexual and transgender youth. Journal of Gay & Lesbian Social Services, 19(3-4), 9-29.

Degenhardt, L., Prof, Charlson, F., PhD, Stanaway, J., PhD, Larney, S., PhD, Alexander, L. T., BA, Hickman, M., Prof, Cowie, B., PhD, Hall, W. D., Prof, Strang, J., Prof, Whiteford, H., Prof, & Vos, T., Prof. (2016). Estimating the burden of disease attributable to injecting drug use as a risk factor for HIV, hepatitis C, and hepatitis B: Findings from the global burden of disease study 2013. The Lancet Infectious Diseases, 16(12), 1385-1398.

Dodge, B., Jeffries, W. L., & Sandfort, T. G. M. (2008). Beyond the down low: Sexual risk, protection, and disclosure among at-risk black men who have sex with both men and women (MSMW). Archives of Sexual Behavior, 37(5), 683-696.

Fulcher, K., Berlin, G., Taylor, K., Wells, A., Nguyen, T., Moore, D., Hull, M., & Lachowsky, N. J. (2022). Understanding the service needs and preferences of men who have sex with men who use crystal methamphetamine in british columbia, canada: A qualitative study. International Journal of Mental Health and Addiction,

Grant, J., Keisling, M., Harrison, J., Mottet, L., Herman, J., Tanis, J., National Center for Transgender Equality, & The National LGBTQ Task Force. (2011). Injustice at every turn: A report of the national transgender discrimination survey

Gaudette, Y., Flores-Aranda, J., & Heisbourg, E. (2023). Needs and experiences of people practising chemsex with support services: Toward chemsex-affirmative interventions. Journal of Men's Health, 18(12), 57-67.

Hegazi, A., Lee, M., Whittaker, W., Green, S., Simms, R., Cutts, R., Nagington, M., Nathan, B., & Pakianathan, M. (2017). Chemsex and the city: Sexualised substance use in gay bisexual and other men who have sex with men attending sexual health clinics. International Journal of STD & AIDS, 28(4), 362-366.

Isaiah Green, A., & Halkitis, P. N. (2006). Crystal methamphetamine and sexual sociality in an urban gay subculture: An elective affinity. Culture, Health & Sexuality, 8(4), 317-333.

International journal of drug policy issues 11 research articles in february 2018 edition; journal. (2018, ). Targeted News Service (TNS)

Kattari, S. K., Walls, N. E., & Speer, S. R. (2017). Differences in experiences of discrimination in accessing social services among Transgender/Gender nonconforming individuals by (dis)ability. Journal of Social Work in Disability & Rehabilitation, 16(2), 116.

McBride, K. R., Reece, M., Sanders, S. A., & Dodge, B. (2019). Exploring the complex realities of chemsex: a narrative review. Substance Use & Misuse, 54(2), 259-269.

Moreno-Gámez, L., Hernández-Huerta, D., & Lahera, G. (2022). Chemsex and psychosis: A systematic review. Behavioral Sciences, 12(12), 516.

Milhet, M., Shah, J., Madesclaire, T., & Gaissad, L. (2019). Chemsex experiences: Narratives of pleasure. Drugs and Alcohol Today, 19(1), 11-22.

Pachankis, J. E., Hatzenbuehler, M. L., Rendina, H. J., Safren, S. A., & Parsons, J. T. (2015). LGB affirmative cognitive-behavioral therapy for young adult gay and bisexual men: A randomized controlled trial of a transdiagnostic minority stress approach. Journal of Consulting and Clinical Psychology, 83(5), 875-889.

Pennant, M. E., Bayliss, S. E., & Meads, C. A. (2009). Improving lesbian, gay and bisexual healthcare: a systematic review of qualitative literature from the UK. Diversity and Equality in Health and Care, 6(3).

Pufall, E., Kall, M., Shahmanesh, M., Nardone, A., Gilson, R., Delpech, V., Ward, H., Hart, G., Anderson, J., Azad, Y., Elford, J., Sullivan, A., Mercer, C., McOwan, A., Peck, J., Cassell, J., Musonda, J., Bruton, J., Positive Voices study group, & The Positive Voices study group. (2018). Sexualized drug use (‘chemsex’) and high‐risk sexual behaviours in HIV‐positive men who have sex with men. HIV Medicine, 19(4), 261-270.

Reports from University of Amsterdam Describe Recent Advances in HIV/AIDS (Chemsex Among Men Who Have Sex With Men: a Sexualized Drug Use Survey Among Clients of the Sexually Transmitted Infection Outpatient Clinic and Users of a Gay Dating App ...). (2018, May 21). AIDS Weekly, 126

Strategy, D. (2017). Drug strategy. HM Government.

Sewell, J., Cambiano, V., Speakman, A., Lampe, F. C., Phillips, A., Stuart, D., Gilson, R., Asboe, D., Nwokolo, N., Clarke, A., & Rodger, A. J. (2019). Changes in chemsex and sexual behaviour over time, among a cohort of MSM in london and brighton: Findings from the AURAH2 study. The International Journal of Drug Policy, 68, 54-61.

Tan, R. K. J., Phua, K., Tan, A., Gan, D. C. J., Ho, L. P. P., Ong, E. J., & See, M. Y. (2021). Exploring the role of trauma in underpinning sexualised drug use (‘chemsex’) among gay, bisexual and other men who have sex with men in singapore. The International Journal of Drug Policy, 97, 103333-103333.

{{Cc-by-nc-4.0}}

Course:SOWK551/2021/Gay men with Chemsex in Healthcare

2023-05-26T03:30:30Z

KellyAllison:

[[File:Image from Pexels.jpg|alt=Adult writing in journal|thumb|Photo by Pexels on Pixabay]]

== Short Summary ==
Literature review of how healthcare workers can better support gay men iinvolved with Chemsex in their healthcare experiences

'''Please do not remove this section.'''

''Author: Valerie Siu''

''Date: April 2, 2023''

== Introduction ==
The practice of combining substances and alcohol use with sexual activities is known as Chemsex or Party and Play (PNP), and it is used to sustain, enhance, disinhibit or facilitate the experience (Bourne et al., 2015). In a 2018 publication in the International Journal of Drug Policy, the occurrence of chemsex among Canadian men who have sex with men (MSM) was estimated at 5.5%. Meanwhile, a 2020 study in the Journal of Homosexuality revealed that 40% of MSM in Canada had reportedly used drugs while engaging in sexual activity. As a result, the activity has become an increasingly pressing issue for healthcare professionals, especially within the gay male community.

This paper aims to explore research on "How can healthcare social workers provide support for gay men with chemsex in healthcare service? "Through a review of current literature, this resource will provide recommendations for social work practice in healthcare and contribute to the conversation on substance use and sexual health in the LGBTQ+ community.

== Literature Review: What is Chemsex ==
HM Government (2017) defined Chemsex as "the use of specific drugs in sexual contexts by gay men, bisexual, MSM and trans people and to sustain, enhance, disinhibit or facilitate the experience before or planned sexual activity”. The activity typically involved using specific substances, such as Methamphetamine, Mephedrone, gamma-hydroxybutyrate (GHB) and crystal methamphetamine (meth). According to a study by Bourne et al. (2015), Methamphetamine, crystal meth and Mephedrone are stimulants that increase physical energy, enhance sexual performance and induce euphoria. GHB is a depressant to relax and causes loss of consciousness. It is also commonly used as a date rape substance. These substances could bring significant impacts on both physical and mental health. In particular, the stimulants could increase heart rate and blood pressure and damage the liver, kidneys and lungs (Isaiah et al., 2006). In addition, the depressant had a significant effect in small doses, while a high dose may cause loss of consciousness, coma or even death (Degenhardt et al., 2019).

== Physical and Mental health risks in Chemsex ==
Although using substances involved in Chemsex mentioned above would physically severely impact the body, the risk of HIV and other sexually transmitted infections (STIs) would also increase the likelihood of engaging in unprotected sex while under the influence of substances. In addition, STIs could cause many harmful effects on the body, including inflammation, pain and organ damage (Burchell et al., 2015).

In addition to physical health risks, Chemsex is associated with various mental health issues, such as anxiety, depression and social isolation. Furthermore, Bourne et al. (2015) stated that Chemsex also led to feelings of shame, guilt and low self-esteem. As such, it would exacerbate existing mental health problems or lead to new mental health concerns.

Some substances, such as GHB, could lead to amnesia or "blackout"; the unconsciousness could increase the risk of sexual assault or other forms of violence (Csete et al., 2016). In particular, those involved in marginalized employment or sex work might be susceptible to coercion and exploitation, especially when participating in Chemsex.

== Factors contribute to Chemsex ==
Chemsex is a complex phenomenon influenced by various factors, and research has identified individual, social, cultural and systemic factors.

Individual factors, such as trauma, anxiety, depression and low self-esteem, are potential factors linked to the use of substances during sex (Sewell et al., 2019). For example, Tan et al. (2021) suggested that some gay men see Chemsex as a utility in allowing them to achieve positive emotional states, sexual enhancements and feelings of connectedness and intimacy in their study of exploring the role of trauma in underpinning Chemsex in Singapore. They also reported using substances to cope with the trauma of past experiences such as sexual abuse, unwanted and unprotected sex, domestic violence and discrimination.

Social and cultural factors, such as peer pressure, social isolation and misunderstanding LGBTQ+ community, were also significant contributors to Chemsex (Gaudette et al., 2023; Bourne et al., 2015). Bourne et al. (2015) stated that Chemsex could be a way for gay men to cope with societal discrimination and homophobia. Hence, the trend of dating apps or online dating platforms was also identified as a contributing factor as they provided easy access to partners, substances or related Chemsex information, according to a report from the University of Amsterdam (2018). They found out that MSM who use dating apps were more likely to engage in Chemsex than those who did not use online dating platforms. The normalization of the LGBTQ+ community also worked as an active contributor to using substances during sex (McBride et al., 2019).

Systematic factors such as criminalization and stigma associated with substance use and sex work could also contribute to the prevalence of Chemsex. Bauer et al. (2015) stated that the criminalization of substance use and sex work had led to a lack of harm reduction resources and services for gay men engaged in Chemsex. The intolerance from society and bias on particular behaviour also hindered this population and contributed to their substance use.

== Impact of Chemsex on relationships ==
The use of substances during sex could have a profound impact on relationships, particularly intimate partnerships.

Increased sexual risk behaviour is one significant impact, such as engaging in unprotective sex with multiple partners, which can lead to STIs and HIV transmission (Bourne et al., 2015). Furthermore, this behaviour might cause tension and mistrust between partners, especially if one partner is unaware or uncomfortable with the other's participation in Chemsex. Additionally, the physical and emotional effects of substances could impair judgement and consciousness, leading to a potentially dangerous situation and causing further damage to the relationship (Hegazi et al., 2017).

Another impact on a relationship was the potential for addiction and substance dependence. Bourne et al. (2015) stated that addiction could lead to secrecy and dishonesty in relationships and would prioritize substance use over the relationship itself. They noted that Chemsex could focus on sex as a primary activity in the relationship rather than emotional intimacy and connection. The shift could result in a lack of communication and emotional distance between partners, damaging their bond.

== Barriers to accessing healthcare services ==
Milhet and colleagues (2019) conducted in-depth interviews with 33 gay men and other MSM engaged in Chemsex aged in the qualitative study. The results showed that one of the difficulties was the lack of language to express the bodily pressures of Chemsex. Even if they did, they mentioned it would not be understood by a non-practicer (Pennant et al., 2009).

Another barrier to accessing healthcare services for MSM was the lack of culturally competent. LGBTQ+ individuals often face discrimination, stigma and prejudice when accessing healthcare services; Grant et al., 2011 stated the lack of trust and avoidance of care would restrict them from seeking help or disclosing their difficulties. As such, this population would have higher rates of substance use, mental health issues and STIs.

Furthermore, the criminalization of substance user and sex work could also create barriers to accessing healthcare services due to the fear of legal consequences, such as arrest and incarceration, which would deter individuals from seeking medical care (Csete et al., 2016). The reluctance to care leads to a lack of testing and treatment for STIs, mental health issues and substance-related harm. Criminalization also limited the availability of harm reduction services such as safe injection sites and clean needles (Bauer et al., 2015). For example, in the Mental Health Act, physicians' duty of report or police involvement in healthcare services would become a barrier for MSM to disclose and access services with dignity.

In addition, negative hospitalizations or experiences would impede MSM from seeking services. Dodge et al. (2008) suggested that MSM may experience trauma related to their interactions with healthcare providers as their prejudgment and attitudes would create an unsafe and unwelcome environment. Hence, healthcare may also hold stigmatizing attitudes toward MSM or those engaged in sex work, which can result in a lack of empathy and inadequate care (Hegazi et al., 2017). Fulcher and colleagues conducted a qualitative research in seme-structure interviews with 33 MSM to identify their needs and preferences regarding treatment and services in British Columbia, Canada. Participants expressed a desire for support and assistance with their substance use but shared that the services were lack of connection with healthcare professionals. This study also pointed out that healthcare professionals used a "one size fits all" approach but did not adequately meet their needs, while Chemsex was a complex issue requiring a multi-faceted approach. It showed a lack of understanding, knowledge, early assumptions, and judgements that would lead to misdiagnosis or inappropriate treatment (Bauer et al., 2015) and further harm. It contributed to a cycle of trauma in avoiding healthcare services (Hegazi et al., 2017).

== The implication of practice: What can be suggested to enhance the services ==
While Canada strives to promote gender-sensitive and respectful healthcare environments, there is still room for improvement in addressing the needs of marginalized groups. By synthesizing information from multiple sources, various practice implications are recommended to be implemented to serve this population better.

'''''Awareness of ethical considerations''''': Ethical considerations are critical in healthcare, particularly in providing equitable and respectful services to marginalized groups. One important consideration is the need for healthcare providers to be non-judgemental and free from discrimination based on sexual orientation or gender identity. This included using appropriate pronouns and avoiding assumptions about an individual's sexual orientation or gender identity. It is also suggested to prioritize informed consent to ensure individuals fully understand the potential risks and benefits of any interventions, including those related to Chemsex (Canadian Medical Association, 2020).

'''''Training for healthcare providers''''': Physicians, therapists, social workers or other practitioners involved in healthcare service should all have adequate training to create a safe, welcoming and supportive space for MSM without coming with fear of stigma and discrimination. The training involved trauma-informed practice, addressing trauma and concerns, cultural awareness and knowledge about harm reduction strategies and resources available in their settings. Social workers are expected to collaborate with other healthcare professionals to develop holistic care plans that address multiple needs. Social workers are believed to have a crucial role in supporting MSM, in developing approaches that account for the fine line between stigma and care. A study by Gaudette and colleagues (2023) found that social workers trained in harm reduction strategies were better equipped to support MSM. This showed that providing and advocating culturally sensitive care can help reduce the harm associated with Chemsex and promote clients' health and wellbeing.

'''''Educate with harm reduction approach''''': Besides assisting in accessing resources, healthcare social workers have a crucial role in educating MSM engaged in Chemsex using a harm reduction approach, aiming to reduce the transmission risk of HIV and other STIs (Fulcher et al., 2022). For example, they can provide counselling on safer sex practices and emphasize the importance of regular STI testing to promote their clients' health and wellbeing. Furthermore, social workers can advocate for providing safe sex supplies and testing kits in their offices or specific wards to promote safer and healthier sex practices.

'''''Building partnerships with community organizations''''': Healthcare social workers can gain valuable insights into the unique needs and challenges faced by MSM engaged in chemsex. As harm reduction programs play a crucial role in promoting the health and welling-being of this population, healthcare social workers can ensure clients are provided with holistic and culturally competent care in partnering with a community organization. Efficiency is crucial to healthcare services, particularly in a hospital care setting. However, the constraint of time can pose a significant obstacle in meeting the needs of patients, as discussed in a recent study by Fulcher et al. (2022). As such, partnering with community services can help bridge the gap between healthcare services and community-based resources to promote a more seamless and coordinated approach to care.

'''''Promoting policy changes''''': Healthcare social workers can work toward creating policies, including increased access to affordable healthcare and mental health services or policies that address discrimination and stigma toward this population. Social workers can work with policymakers to promote harm reduction approaches such as safe injection sites, specialized wards or free access to safe kit supplies. Plus, healthcare social workers can also work towards increasing funding for research on the health and social impacts of Chemsex with gay men. This can help to understand this population better and advocate for the inclusion of gay men engaged in Chemsex in research studies and clinical trials to promote the dissemination of research findings to inform a better inclusion policy.

== Limitation ==
This study focuses on the experience and impacts of gay men in Chemsex and addresses their barriers to healthcare service. However, it only focused on gay men but did not cover other LGBTQ+ groups who may also be engaged in Chemsex. In addition, although there were serval studies that found gay men and bisexual men were more likely to report using drugs during sex compared to lesbian and bisexual women (Bourne et al., 2015; Dodge et al., 2008), it is essential to note that these studies are not necessarily representative of all LGBTQ+ individuals, and more research is needed to fully understand the patterns of substance use during sex in this population.

== Conclusion ==
The subject of Chemsex, including its definition and the physical and mental health risks it poses, as well as its impact on relationships and the factors contributing to its prevalence in the gay community, was explored in this paper. The study also analyzed the obstacles faced in accessing healthcare services and proposed practical recommendations for improving them. Finally, it emphasized the critical role of healthcare social workers in creating a safe and respectful environment for this population. However, further research is necessary to reduce the risks associated with the LGBTQ+ community.

== References ==
<references responsive="0" />
Bauer, G. R., Scheim, A. I., Pyne, J., Travers, R., & Hammond, R. (2015). Intervenable factors associated with suicide risk in transgender persons: A respondent driven sampling study in ontario, canada. BMC Public Health, 15(1), 525-525.

Bourne, A., Reid, D., Hickson, F., Torres-Rueda, S., & Weatherburn, P. (2015). Illicit drug use insexual settings (‘chemsex’) and HIV/STI transmission risk behaviour among gay men in south london: Findings from a qualitative study. Sexually Transmitted Infections, 91(8), 564-568.

Bourne, A., Reid, D., Hickson, F., Torres-Rueda, S., Steinberg, P., & Weatherburn, P. (2015). “Chemsex” and harm reduction need among gay men in south london. The International Journal of Drug Policy, 26(12), 1171-1176.

Burchell, A. N., Allen, V. G., Gardner, S. L., Moravan, V., Tan, D. H. S., Grewal, R., Raboud, J., Bayoumi, A. M., Kaul, R., Mazzulli, T., McGee, F., Rourke, S. B., OHTN Cohort Study Team, & on behalf of the OHTN Cohort Study Team. (2015). High incidence of diagnosis with syphilis co-infection among men who have sex with men in an HIV cohort in ontario, canada. BMC Infectious Diseases, 15(1), 356-356.

Canadian Medical Association. (2020). CMA code of ethics and professionalism.

Chemsex Forum Organisation Comittee 3rd European Chemsex Forum Paris. 2019.

Csete, J., PhD, Kamarulzaman, A., Prof, Kazatchkine, M., Prof, Altice, F., Prof, Balicki, M., MD, Buxton, J., Prof, Cepeda, J., PhD, Comfort, M., PhD, Goosby, E., Prof, Goulão, J., MD, Hart, C., Prof, Kerr, T., Prof, Lajous, A. M., Prof, Lewis, S., Prof, Martin, N., DPhil, Mejía, D., Prof, Camacho, A., Prof, Mathieson, D., MA, Obot, I., Prof, . . . Beyrer, C., Prof. (2016). Public health and international drug policy. The Lancet (British Edition), 387(10026), 1427-1480.Daley, A., Solomon, S., Newman, P. A., & Mishna, F. (2007). Traversing the margins: Intersectionalities in the bullying of lesbian, gay, bisexual and transgender youth. Journal of Gay & Lesbian Social Services, 19(3-4), 9-29.

Degenhardt, L., Prof, Charlson, F., PhD, Stanaway, J., PhD, Larney, S., PhD, Alexander, L. T., BA, Hickman, M., Prof, Cowie, B., PhD, Hall, W. D., Prof, Strang, J., Prof, Whiteford, H., Prof, & Vos, T., Prof. (2016). Estimating the burden of disease attributable to injecting drug use as a risk factor for HIV, hepatitis C, and hepatitis B: Findings from the global burden of disease study 2013. The Lancet Infectious Diseases, 16(12), 1385-1398.

Dodge, B., Jeffries, W. L., & Sandfort, T. G. M. (2008). Beyond the down low: Sexual risk, protection, and disclosure among at-risk black men who have sex with both men and women (MSMW). Archives of Sexual Behavior, 37(5), 683-696.

Fulcher, K., Berlin, G., Taylor, K., Wells, A., Nguyen, T., Moore, D., Hull, M., & Lachowsky, N. J. (2022). Understanding the service needs and preferences of men who have sex with men who use crystal methamphetamine in british columbia, canada: A qualitative study. International Journal of Mental Health and Addiction,

Grant, J., Keisling, M., Harrison, J., Mottet, L., Herman, J., Tanis, J., National Center for Transgender Equality, & The National LGBTQ Task Force. (2011). Injustice at every turn: A report of the national transgender discrimination survey

Gaudette, Y., Flores-Aranda, J., & Heisbourg, E. (2023). Needs and experiences of people practising chemsex with support services: Toward chemsex-affirmative interventions. Journal of Men's Health, 18(12), 57-67.

Hegazi, A., Lee, M., Whittaker, W., Green, S., Simms, R., Cutts, R., Nagington, M., Nathan, B., & Pakianathan, M. (2017). Chemsex and the city: Sexualised substance use in gay bisexual and other men who have sex with men attending sexual health clinics. International Journal of STD & AIDS, 28(4), 362-366.

Isaiah Green, A., & Halkitis, P. N. (2006). Crystal methamphetamine and sexual sociality in an urban gay subculture: An elective affinity. Culture, Health & Sexuality, 8(4), 317-333.

International journal of drug policy issues 11 research articles in february 2018 edition; journal. (2018, ). Targeted News Service (TNS)

Kattari, S. K., Walls, N. E., & Speer, S. R. (2017). Differences in experiences of discrimination in accessing social services among Transgender/Gender nonconforming individuals by (dis)ability. Journal of Social Work in Disability & Rehabilitation, 16(2), 116.

McBride, K. R., Reece, M., Sanders, S. A., & Dodge, B. (2019). Exploring the complex realities of chemsex: a narrative review. Substance Use & Misuse, 54(2), 259-269.

Moreno-Gámez, L., Hernández-Huerta, D., & Lahera, G. (2022). Chemsex and psychosis: A systematic review. Behavioral Sciences, 12(12), 516.

Milhet, M., Shah, J., Madesclaire, T., & Gaissad, L. (2019). Chemsex experiences: Narratives of pleasure. Drugs and Alcohol Today, 19(1), 11-22.

Pachankis, J. E., Hatzenbuehler, M. L., Rendina, H. J., Safren, S. A., & Parsons, J. T. (2015). LGB affirmative cognitive-behavioral therapy for young adult gay and bisexual men: A randomized controlled trial of a transdiagnostic minority stress approach. Journal of Consulting and Clinical Psychology, 83(5), 875-889.

Pennant, M. E., Bayliss, S. E., & Meads, C. A. (2009). Improving lesbian, gay and bisexual healthcare: a systematic review of qualitative literature from the UK. Diversity and Equality in Health and Care, 6(3).

Pufall, E., Kall, M., Shahmanesh, M., Nardone, A., Gilson, R., Delpech, V., Ward, H., Hart, G., Anderson, J., Azad, Y., Elford, J., Sullivan, A., Mercer, C., McOwan, A., Peck, J., Cassell, J., Musonda, J., Bruton, J., Positive Voices study group, & The Positive Voices study group. (2018). Sexualized drug use (‘chemsex’) and high‐risk sexual behaviours in HIV‐positive men who have sex with men. HIV Medicine, 19(4), 261-270.

Reports from University of Amsterdam Describe Recent Advances in HIV/AIDS (Chemsex Among Men Who Have Sex With Men: a Sexualized Drug Use Survey Among Clients of the Sexually Transmitted Infection Outpatient Clinic and Users of a Gay Dating App ...). (2018, May 21). AIDS Weekly, 126

Strategy, D. (2017). Drug strategy. HM Government.

Sewell, J., Cambiano, V., Speakman, A., Lampe, F. C., Phillips, A., Stuart, D., Gilson, R., Asboe, D., Nwokolo, N., Clarke, A., & Rodger, A. J. (2019). Changes in chemsex and sexual behaviour over time, among a cohort of MSM in london and brighton: Findings from the AURAH2 study. The International Journal of Drug Policy, 68, 54-61.

Tan, R. K. J., Phua, K., Tan, A., Gan, D. C. J., Ho, L. P. P., Ong, E. J., & See, M. Y. (2021). Exploring the role of trauma in underpinning sexualised drug use (‘chemsex’) among gay, bisexual and other men who have sex with men in singapore. The International Journal of Drug Policy, 97, 103333-103333.

{{Cc-by-nc-4.0}}

Course:SOWK551/2021/Peer Support in Mental Health

2023-01-13T00:09:46Z

KellyAllison:

[[File:Clay-banks-LjqARJaJotc-unsplash.jpg|alt=Adult writing in journal|thumb|Photo by Clay Banks on Unsplash ]]

== Short Summary ==
Literature review of the benefits and challenges with peer support in mental health settings.

''Author: Anonymous''

''Date: 2022-Dec-11''

== Introduction ==
Peer support is growing in popularity and is increasingly utilized in many mental health settings (Tseris, 2020). It may continue to expand as the government of British Columbia recognizes that peer support in health care and social services is of critical importance (2021). Social workers will likely be in a position of power when working with peer support workers and therefore it is important for social workers to understand peer support. This literature review aims to explore within the mental health field the role of peer support workers, peer support values and their overlap with social work, the benefits and challenges of peer support work, and the role of social workers with peer support.

== Peer Support Definition ==
In the mental health field, there is no standard definition of peer support and its role has evolved. Historically, peer support has been in the form of peer groups where mutual support was provided (Chinman et al., 2014). This version of peer support came out of the ex-patient movement in the 1970s due to negative experiences in the mental health system and goes against the medical model (Cusick, 2021). In recent years, peer support has shifted to an emphasis on assisting the consumer instead of it being a mutually beneficial relationship (Fortuna, Solomon, & Rivera, 2022). Additionally, professionalization is becoming increasingly important in peer support (Chinman et al., 2014). In 2019, the government of BC provided one million dollars to support the development of the Provincial Peer Support Worker Training Curriculum and standards of practice (Government of BC, 2021). This training is free and can be accessed at peerconnectbc.ca.

Many studies define who is considered a peer support worker (PSW) differently. Wang, Chen, & Deng define a peer as an individual who has successfully lived with a serious mental illness and is now supporting others with a mental illness (2021). Braiser et al.’s definition includes the additional need for the use of professional skills and training in the direct support of others (2022). Chinman defines PSWs as employees either in traditional mainstream positions who self-identify as having a serious mental illness or in unique positions designed specifically for peers (2014). There is a difference between the two as peer support workers in unique positions fill a gap in the system that peers in traditional mainstream positions are unable to address (Cusick, 2021). Other terms for PSW include peer worker, peer consultant, consumer consultant, service user-run, and service user-led (Tseris, 2020; Chinman et al., 2014)

The role of PSWs within an organization also has no set standard. One form of peer support is peers as employees (Fortuna, Solomon, & Rivera, 2022). This form of peer support work often occurs within traditional mental health care. Chinman et al. found that the most common job task of peer support employees in their meta-analysis was providing mutual aid and sharing personal experiences (2014). However, there are many other expectations of peers in this role. Peers may be expected to be involved in group facilitation or co-facilitation (Moll et al., 2009). Peer support services also typically include education and supporting the development of problem-solving and coping skills to self-manage the consumer’s mental health, supporting the activities of the rest of the healthcare team, and traditional activities such as case management (Chinman et al., 2014).

Another form of peer support is peer-run services (Fortuna, Solomon, & Rivera, 2022). This often occurs in larger non-peer organizations. The services include peer respite, non-clinical support phone lines, and drop-in centers. An additional form of peer support is relationships that voluntarily, informally, and naturally occur between consumers who are using the same service (Bouchard, Montreuil, & Gros, 2010). This form of support could occur in a voluntary group format (Fortuna, Solomon, & Rivera, 2022). Informal peer support has been found to be beneficial as it may include supportive actions such as providing information and advice, sharing material goods, helping with activities, and offering emotional support which has then led to improved mental health and quality of life (Bouchard, Montreuil, & Gros, 2010).

A new form of peer support is digital peer support (Fortuna et al., 2022). This form of support has gained popularity since covid-19 (Fortuna, Solomon, & Rivera, 2022). This is a newly emerging form of peer support and there is a lack of supporting data for its efficacy due to its novelty (Fortuna et al., 2022).

== Connections to social work values ==
There are many commonalities between social work and peer support values. Both peer support work and social work value social justice (Penney, 2018). Other values in common are a strength-based approach, respect, empowerment, collaboration, valuing of lived experience, equity, and self-determination (Loumpa, 2012; Cusick, 2021; Tseris, 2020). Peer support work recognizes that trauma has played a central role in many consumers’ experiences in the mental health system (Penney, 2018). Many social workers also use a trauma-informed lens with their clients. Finally, Social Work values align with recovery theory, and recovery theory advocates for PSWs involvement as part of the recovery process (Loumpa, 2012). It is important to recognize the mutual values between social work practice and peer support as they identify a common ground between the professions. Additionally, as previous initiatives involving peer support have caused harm to peers it is important to adopt values that hold social workers accountable (BCcampus, n.d.).

== Benefits of Peer Support ==
There are many identified benefits for consumers to having PSWs working on mental health teams. These benefits include the knowledge they hold, their ability to contribute to change mechanisms, their support of the consumer-health team relationship, and their support in reducing the consumer’s need for mental health services.

The knowledge base that PSWs provide is one that many non-PSWs employees are lacking as PSWs have knowledge of the social context, experiences, and needs of service users (Tseris, 2020). This is a benefit as this knowledge base is a largely underutilized resource and harnessing it may improve service experiences for consumers (Tseris, 2020).

Another benefit that PSWs contribute is their ability to impact the consumer's change mechanisms by building trusting relationships with them through common lived experiences, role-modeling recovery and living well, and engaging service users in both mental health services and the community (Gillard, 2020). Braiser et al. also found that PSWs have skills in relationship-building, empathy, de-escalation, and listening (2022). The findings of multiple studies provide evidence to support that consumers are experiencing positive change as they found that consumers have a decrease in loneliness and stigma and an increase in well-being, hope, and empathy due to PSWs (Repper & Carter, 2011; Wang, Chen, & Deng, 2021). Furthermore, they found that consumers are empowered through their interactions with PSWs (Repper & Carter, 2011; Chinman et al., 2014).

Additionally, PSWs build a bridge between the staff and the clients due to their ability to engage with those highly unlikely to engage in services (Tseris, 2020). Chinman also found that PSWs promote engagement with care and relationships with care providers (2014). This is a benefit as engaging in services and with their care team may aid in the consumer's recovery.

Finally, PSWs may help the consumer decrease their need for mental health services. Studies on PSWs have shown they help with medication adherence, reducing inpatient service use, reducing admissions rates to hospitals, and increasing community tenure (Wang, Chen, & Deng, 2021; Chinman et al., 2014; Repper & Carter, 2011). Looking beyond the benefits to consumers with regard to decreasing service needs, Muschler found that the benefits of PSWs to the healthcare organization outweigh their financial costs (2022).

== Challenges to Peer Support ==
There are many challenges that PSWs face in the mental health field. These range from lack of clarity of their role, lack of respect for their role and expertise, inadequate hours provided by the employer, power differentials, and maintaining boundaries.

The lack of clarity around the role was a challenge raised by multiple articles (Tseris, 2020; Moll et al., 2009). Each organization may have different expectations for PSWs and without clarification from the employer, PSWs may not be aware of the expectations of their position (Cusick, 2021). Moll et al. highlighted how tension between PSW and non-PSW can occur due to this lack of clarity especially if there are overlapping job duties between PSW and non-PSW staff (2009). Additionally, Tseris found that non-PSW staff lacked an understanding of how to effectively utilize PSWs due to this and that in turn, PSWs felt undervalued by non-PSWs (2020). However, Hiller-Venegas et al. found that in their study of PSWs supporting youth aged 16-24 having an unstructured peer support program allowed PSWs to provide a wide range of services to their clients (2022).

Another challenge for PSWs is a lack of respect from non-PSW staff members. Braiser et al. found that PSWs must be recognized as experts and full members of the team (2022). Tseris also found that PSWs need to be supported by the actions and attitudes of non-PSW staff and organizational structures (2020). If PSW are not supported, Repper and Carter suggest that PSWs risk being socialized into the usual ways of an organization, especially if their role is undervalued (2011). This may undermine the potential benefits of peer support (Repper and Carter, 2011). Cusick also acknowledged the risk of PSW adapting to the practices of a clinical model and stated that it is critical that PSWs remain peers and work against the hierarchical nature of the medical model (2021).

Inadequate hours were another challenge for PSWs (Tseris, 2020). Moll et al. found that inadequate hours provided a challenge to integrate with the full-time staff which was identified by both managers and PSWs (2009). Braiser identified that PSWs need long-term financial support from the organization (Braiser et al., 2022). Limited hours may limit the financial support PSWs are receiving.

An additional identified challenge is power differentials between PSW and non-PSW staff (Tseris, 2020; Repper & Carter, 2011). This may occur as PSWs inhabit a social location between consumers and other staff members (Moll et al., 2009). Due to this social location, consumers may view PSWs as staff which hurts trust and non-PSW staff may see them as consumers which may lead to PSWs being stigmatized and discriminated against (Moll et al., 2009). However, this social location may also be beneficial as Fortuna, Solomon, & Rivera found that PSWs may alter non-PSW staff’s detrimental views of consumers by providing a direct example of someone who is successfully functioning (2022).

PSWs maintaining boundaries with consumers was another identified challenge (Moll et al., 2009; Repper & Carter, 2011). This is because PSWs are expected to share personal experiences and knowing how much and when to share is required to maintain boundaries (Moll et al., 2009). Additionally, a lack of clear role expectations may leave PSWs unable to know where the boundaries of their role lay (Cusick, 2021).

These are only some of the identified challenges that PSWs face in their employment. For example, there is a lack of research on the role of cultural competency in PSWs’ work (Chinman et al., 2014). Therefore, there may be challenges that PSW are facing which do not appear in the current literature on this topic.

== Social Work Role ==
Social workers have a role in promoting peer support practices and workers. Three areas this review will highlight are peer engagement and consultation, promoting informal peer support, and supporting PSWs in their workplace. For additional education, the government of BC has created a resource for facilitators working with PSWs which was made by peers (2021). It can be located at <nowiki>https://peerconnectbc.ca/</nowiki>.

Social workers may be in positions where they utilize peer engagement and consultation. BCcampus has a list of recommendations for when working with peers in this capacity (n.d.). The recommendations include following the provincial peer payment guidelines, challenging power structures as consultation may be tokenizing, accommodating the needs and wants of PSWs, only including PSWs if the project is willing to adapt to peer feedback, seeking diversity in the PSWs included, and prioritizing the process over the outcomes (BCcampus, n.d.). Tseris also highlights that for ethical practice social workers need to be open to listening to PSWs and willing to change their practices based on PSW feedback (2020). As social workers need to be aware of these considerations so that they are engaging with peer support in an ethical manner.

Social workers can also promote informal peer support by creating a supportive environment and facilitating peer relationships in their workplaces (Bouchard, Montreuil, & Gros, 2010). Loumpa suggests that when SWers facilitate groups for peer support they can provide space for group members to hold the position of expert by ensuring conversation and exchange of peer support is happening (2012).

Finally, Social Workers have a role in advocating for PSWs. This is because PSWs may not be able to voice their views due to fears about job security (Tseris, 2020). Social workers can advocate for PSWs to not be taken advantage of by organizational assumptions and for the improvement of PSWs’ job conditions (Tseris, 2020). In partnership with PSWs social workers may consider engaging in macro reform and policy work relating to social justice for people involved in the mental health system (Tseris, 2020).

== Conclusion ==
As social workers in the mental health field are increasingly likely to work with peer support workers it is important that they understand their role, how they benefit consumers, and the challenges they may face. Social work and peer support have many common values and are likely to work simultaneously together with consumers. Social workers have a role in promoting peer support and assisting their PSW colleagues.

== References ==
<references responsive="0" />
BCcampus. (n.d.). 10 Recommendations for Peer Engagement & Consultation. <nowiki>https://peerconnectbc.ca/wp-content/uploads/10-Recommendations-Peer-Engagement.pdf</nowiki>

Bouchard, L., Montreuil, M., & Gros, C. (2010). Peer support among inpatients in an adult mental health setting. ''Issues in mental health nursing'', ''31''(9), 589–598. <nowiki>https://doi.org/10.3109/01612841003793049</nowiki>

Brasier, C., Roennfeldt, H., Hamilton, B., Martel, A., Hill, N., Stratford, A., Buchanan-Hagen, S., Byrne, L., Castle, D., Cocks, N., Davidson, L., & Brophy, L. (2022). Peer support work for people experiencing mental distress attending the emergency department: Exploring the potential. ''Emergency medicine Australasia : EMA'', ''34''(1), 78–84. <nowiki>https://doi.org/10.1111/1742-6723.13848</nowiki>

Chinman, M., George, P., Dougherty, R. H., Daniels, A. S., Ghose, S. S., Swift, A., & Delphin-Rittmon, M. E. (2014). Peer support services for individuals with serious mental illnesses: assessing the evidence. Psychiatric services (Washington, D.C.), 65(4), 429–441. <nowiki>https://doi.org/10.1176/appi.ps.201300244</nowiki>

Cusick, J. (2021). The B.C. Peer Support Training Curriculum Guide. B.C. Ministry of Mental Health and Addictions. <nowiki>https://peerconnectbc.ca/wp-content/uploads/Curriculum-Guide_Final.pdf</nowiki>

Fortuna, K. L., Myers, A. L., Ferron, J., Kadakia, A., Bianco, C., Bruce, M. L., & Bartels, S. J. (2022). Assessing a digital peer support self-management intervention for adults with serious mental illness: feasibility, acceptability, and preliminary effectiveness. ''Journal of mental health (Abingdon, England)'', 1–9. Advance online publication. <nowiki>https://doi.org/10.1080/09638237.2021.2022619</nowiki>

Fortuna, K.L., Solomon, P. & Rivera, J. (2022). An Update of Peer Support/Peer Provided Services Underlying Processes, Benefits, and Critical Ingredients. ''Psychiatr Q 93'', 571–586. <nowiki>https://doi.org/10.1007/s11126-022-09971-w</nowiki>

Gillard, S., Gibson, S. L., Holley, J., & Lucock, M. (2015). Developing a change model for peer worker interventions in mental health services: a qualitative research study. Epidemiology and psychiatric sciences, 24(5), 435–445. <nowiki>https://doi.org/10.1017/S2045796014000407</nowiki>

Government of British Columbia. (2021). Training resources to improve the quality of mental health and substance use services. <nowiki>https://news.gov.bc.ca/releases/2021MMHA0037-001380</nowiki>

Hiller-Venegas, S., Gilmer, T. P., Jones, N., Munson, M. R., & Ojeda, V. D. (2022). Clients' Perspectives Regarding Peer Support Providers' Roles and Support for Client Access to and Use of Publicly Funded Mental Health Programs Serving Transition-Age Youth in Two Southern California Counties. The journal of behavioral health services & research, 49(3), 364–384. <nowiki>https://doi.org/10.1007/s11414-022-09792-6</nowiki>

Loumpa V. (2012). Promoting recovery through peer support: possibilities for social work practice. ''Social work in health care'', ''51''(1), 53–65. <nowiki>https://doi.org/10.1080/00981389.2011.622667</nowiki>

Moll, S., Holmes, J., Geronimo, J., & Sherman, D. (2009). Work transitions for peer support providers in traditional mental health programs: unique challenges and opportunities. ''Work (Reading, Mass.)'', ''33''(4), 449–458. <nowiki>https://doi.org/10.3233/WOR-2009-0893</nowiki>

Mutschler, C., Bellamy, C., Davidson, L., Lichtenstein, S., & Kidd, S. (2022). Implementation of peer support in mental health services: A systematic review of the literature. Psychological Services, 19(2), 360–374. <nowiki>https://doi.org/10.1037/ser0000531</nowiki>

Penney, D. (2018). Defining “ Peer Support ” : Implications for Policy , Practice , and Research.

Repper, J., & Carter, T. (2011). A review of the literature on peer support in mental health services. ''Journal of mental health (Abingdon, England)'', ''20''(4), 392–411. <nowiki>https://doi.org/10.3109/09638237.2011.583947</nowiki>

Tseris E. (2020). The Expansion of the Peer Adviser Workforce: Opportunities and Challenges for Social Work, ''Australian Social Work, 73(''2), 162-174, DOI: 10.1080/0312407X.2019.1675734

Wang, Y., Chen, Y., & Deng, H. (2022). Effectiveness of Family- and Individual-Led Peer Support for People With Serious Mental Illness: A Meta-Analysis. ''Journal of psychosocial nursing and mental health services'', ''60''(2), 20–26. <nowiki>https://doi.org/10.3928/02793695-20210818-01</nowiki>{{Cc-by-nc-4.0}}

Course:SOWK551/2021/Peer Support in Mental Health

2023-01-13T00:08:26Z

KellyAllison:

[[File:Clay-banks-LjqARJaJotc-unsplash.jpg|alt=Adult writing in journal|thumb|Photo by Clay Banks on Unsplash ]]

== Short Summary ==
Literature review of the benefits and challenges of peer support in mental health settings and the social work role in promoting peer support.

''Author: Anonymous''

''Date: 2022-Dec-11''

== Introduction ==
Peer support is growing in popularity and is increasingly utilized in many mental health settings (Tseris, 2020). It may continue to expand as the government of British Columbia recognizes that peer support in health care and social services is of critical importance (2021). Social workers will likely be in a position of power when working with peer support workers and therefore it is important for social workers to understand peer support. This literature review aims to explore within the mental health field the role of peer support workers, peer support values and their overlap with social work, the benefits and challenges of peer support work, and the role of social workers with peer support.

== Peer Support Definition ==
In the mental health field, there is no standard definition of peer support and its role has evolved. Historically, peer support has been in the form of peer groups where mutual support was provided (Chinman et al., 2014). This version of peer support came out of the ex-patient movement in the 1970s due to negative experiences in the mental health system and goes against the medical model (Cusick, 2021). In recent years, peer support has shifted to an emphasis on assisting the consumer instead of it being a mutually beneficial relationship (Fortuna, Solomon, & Rivera, 2022). Additionally, professionalization is becoming increasingly important in peer support (Chinman et al., 2014). In 2019, the government of BC provided one million dollars to support the development of the Provincial Peer Support Worker Training Curriculum and standards of practice (Government of BC, 2021). This training is free and can be accessed at peerconnectbc.ca.

Many studies define who is considered a peer support worker (PSW) differently. Wang, Chen, & Deng define a peer as an individual who has successfully lived with a serious mental illness and is now supporting others with a mental illness (2021). Braiser et al.’s definition includes the additional need for the use of professional skills and training in the direct support of others (2022). Chinman defines PSWs as employees either in traditional mainstream positions who self-identify as having a serious mental illness or in unique positions designed specifically for peers (2014). There is a difference between the two as peer support workers in unique positions fill a gap in the system that peers in traditional mainstream positions are unable to address (Cusick, 2021). Other terms for PSW include peer worker, peer consultant, consumer consultant, service user-run, and service user-led (Tseris, 2020; Chinman et al., 2014)

The role of PSWs within an organization also has no set standard. One form of peer support is peers as employees (Fortuna, Solomon, & Rivera, 2022). This form of peer support work often occurs within traditional mental health care. Chinman et al. found that the most common job task of peer support employees in their meta-analysis was providing mutual aid and sharing personal experiences (2014). However, there are many other expectations of peers in this role. Peers may be expected to be involved in group facilitation or co-facilitation (Moll et al., 2009). Peer support services also typically include education and supporting the development of problem-solving and coping skills to self-manage the consumer’s mental health, supporting the activities of the rest of the healthcare team, and traditional activities such as case management (Chinman et al., 2014).

Another form of peer support is peer-run services (Fortuna, Solomon, & Rivera, 2022). This often occurs in larger non-peer organizations. The services include peer respite, non-clinical support phone lines, and drop-in centers. An additional form of peer support is relationships that voluntarily, informally, and naturally occur between consumers who are using the same service (Bouchard, Montreuil, & Gros, 2010). This form of support could occur in a voluntary group format (Fortuna, Solomon, & Rivera, 2022). Informal peer support has been found to be beneficial as it may include supportive actions such as providing information and advice, sharing material goods, helping with activities, and offering emotional support which has then led to improved mental health and quality of life (Bouchard, Montreuil, & Gros, 2010).

A new form of peer support is digital peer support (Fortuna et al., 2022). This form of support has gained popularity since covid-19 (Fortuna, Solomon, & Rivera, 2022). This is a newly emerging form of peer support and there is a lack of supporting data for its efficacy due to its novelty (Fortuna et al., 2022).

== Connections to social work values ==
There are many commonalities between social work and peer support values. Both peer support work and social work value social justice (Penney, 2018). Other values in common are a strength-based approach, respect, empowerment, collaboration, valuing of lived experience, equity, and self-determination (Loumpa, 2012; Cusick, 2021; Tseris, 2020). Peer support work recognizes that trauma has played a central role in many consumers’ experiences in the mental health system (Penney, 2018). Many social workers also use a trauma-informed lens with their clients. Finally, Social Work values align with recovery theory, and recovery theory advocates for PSWs involvement as part of the recovery process (Loumpa, 2012). It is important to recognize the mutual values between social work practice and peer support as they identify a common ground between the professions. Additionally, as previous initiatives involving peer support have caused harm to peers it is important to adopt values that hold social workers accountable (BCcampus, n.d.).

== Benefits of Peer Support ==
There are many identified benefits for consumers to having PSWs working on mental health teams. These benefits include the knowledge they hold, their ability to contribute to change mechanisms, their support of the consumer-health team relationship, and their support in reducing the consumer’s need for mental health services.

The knowledge base that PSWs provide is one that many non-PSWs employees are lacking as PSWs have knowledge of the social context, experiences, and needs of service users (Tseris, 2020). This is a benefit as this knowledge base is a largely underutilized resource and harnessing it may improve service experiences for consumers (Tseris, 2020).

Another benefit that PSWs contribute is their ability to impact the consumer's change mechanisms by building trusting relationships with them through common lived experiences, role-modeling recovery and living well, and engaging service users in both mental health services and the community (Gillard, 2020). Braiser et al. also found that PSWs have skills in relationship-building, empathy, de-escalation, and listening (2022). The findings of multiple studies provide evidence to support that consumers are experiencing positive change as they found that consumers have a decrease in loneliness and stigma and an increase in well-being, hope, and empathy due to PSWs (Repper & Carter, 2011; Wang, Chen, & Deng, 2021). Furthermore, they found that consumers are empowered through their interactions with PSWs (Repper & Carter, 2011; Chinman et al., 2014).

Additionally, PSWs build a bridge between the staff and the clients due to their ability to engage with those highly unlikely to engage in services (Tseris, 2020). Chinman also found that PSWs promote engagement with care and relationships with care providers (2014). This is a benefit as engaging in services and with their care team may aid in the consumer's recovery.

Finally, PSWs may help the consumer decrease their need for mental health services. Studies on PSWs have shown they help with medication adherence, reducing inpatient service use, reducing admissions rates to hospitals, and increasing community tenure (Wang, Chen, & Deng, 2021; Chinman et al., 2014; Repper & Carter, 2011). Looking beyond the benefits to consumers with regard to decreasing service needs, Muschler found that the benefits of PSWs to the healthcare organization outweigh their financial costs (2022).

== Challenges to Peer Support ==
There are many challenges that PSWs face in the mental health field. These range from lack of clarity of their role, lack of respect for their role and expertise, inadequate hours provided by the employer, power differentials, and maintaining boundaries.

The lack of clarity around the role was a challenge raised by multiple articles (Tseris, 2020; Moll et al., 2009). Each organization may have different expectations for PSWs and without clarification from the employer, PSWs may not be aware of the expectations of their position (Cusick, 2021). Moll et al. highlighted how tension between PSW and non-PSW can occur due to this lack of clarity especially if there are overlapping job duties between PSW and non-PSW staff (2009). Additionally, Tseris found that non-PSW staff lacked an understanding of how to effectively utilize PSWs due to this and that in turn, PSWs felt undervalued by non-PSWs (2020). However, Hiller-Venegas et al. found that in their study of PSWs supporting youth aged 16-24 having an unstructured peer support program allowed PSWs to provide a wide range of services to their clients (2022).

Another challenge for PSWs is a lack of respect from non-PSW staff members. Braiser et al. found that PSWs must be recognized as experts and full members of the team (2022). Tseris also found that PSWs need to be supported by the actions and attitudes of non-PSW staff and organizational structures (2020). If PSW are not supported, Repper and Carter suggest that PSWs risk being socialized into the usual ways of an organization, especially if their role is undervalued (2011). This may undermine the potential benefits of peer support (Repper and Carter, 2011). Cusick also acknowledged the risk of PSW adapting to the practices of a clinical model and stated that it is critical that PSWs remain peers and work against the hierarchical nature of the medical model (2021).

Inadequate hours were another challenge for PSWs (Tseris, 2020). Moll et al. found that inadequate hours provided a challenge to integrate with the full-time staff which was identified by both managers and PSWs (2009). Braiser identified that PSWs need long-term financial support from the organization (Braiser et al., 2022). Limited hours may limit the financial support PSWs are receiving.

An additional identified challenge is power differentials between PSW and non-PSW staff (Tseris, 2020; Repper & Carter, 2011). This may occur as PSWs inhabit a social location between consumers and other staff members (Moll et al., 2009). Due to this social location, consumers may view PSWs as staff which hurts trust and non-PSW staff may see them as consumers which may lead to PSWs being stigmatized and discriminated against (Moll et al., 2009). However, this social location may also be beneficial as Fortuna, Solomon, & Rivera found that PSWs may alter non-PSW staff’s detrimental views of consumers by providing a direct example of someone who is successfully functioning (2022).

PSWs maintaining boundaries with consumers was another identified challenge (Moll et al., 2009; Repper & Carter, 2011). This is because PSWs are expected to share personal experiences and knowing how much and when to share is required to maintain boundaries (Moll et al., 2009). Additionally, a lack of clear role expectations may leave PSWs unable to know where the boundaries of their role lay (Cusick, 2021).

These are only some of the identified challenges that PSWs face in their employment. For example, there is a lack of research on the role of cultural competency in PSWs’ work (Chinman et al., 2014). Therefore, there may be challenges that PSW are facing which do not appear in the current literature on this topic.

== Social Work Role ==
Social workers have a role in promoting peer support practices and workers. Three areas this review will highlight are peer engagement and consultation, promoting informal peer support, and supporting PSWs in their workplace. For additional education, the government of BC has created a resource for facilitators working with PSWs which was made by peers (2021). It can be located at <nowiki>https://peerconnectbc.ca/</nowiki>.

Social workers may be in positions where they utilize peer engagement and consultation. BCcampus has a list of recommendations for when working with peers in this capacity (n.d.). The recommendations include following the provincial peer payment guidelines, challenging power structures as consultation may be tokenizing, accommodating the needs and wants of PSWs, only including PSWs if the project is willing to adapt to peer feedback, seeking diversity in the PSWs included, and prioritizing the process over the outcomes (BCcampus, n.d.). Tseris also highlights that for ethical practice social workers need to be open to listening to PSWs and willing to change their practices based on PSW feedback (2020). As social workers need to be aware of these considerations so that they are engaging with peer support in an ethical manner.

Social workers can also promote informal peer support by creating a supportive environment and facilitating peer relationships in their workplaces (Bouchard, Montreuil, & Gros, 2010). Loumpa suggests that when SWers facilitate groups for peer support they can provide space for group members to hold the position of expert by ensuring conversation and exchange of peer support is happening (2012).

Finally, Social Workers have a role in advocating for PSWs. This is because PSWs may not be able to voice their views due to fears about job security (Tseris, 2020). Social workers can advocate for PSWs to not be taken advantage of by organizational assumptions and for the improvement of PSWs’ job conditions (Tseris, 2020). In partnership with PSWs social workers may consider engaging in macro reform and policy work relating to social justice for people involved in the mental health system (Tseris, 2020).

== Conclusion ==
As social workers in the mental health field are increasingly likely to work with peer support workers it is important that they understand their role, how they benefit consumers, and the challenges they may face. Social work and peer support have many common values and are likely to work simultaneously together with consumers. Social workers have a role in promoting peer support and assisting their PSW colleagues.

== References ==
<references responsive="0" />
BCcampus. (n.d.). 10 Recommendations for Peer Engagement & Consultation. <nowiki>https://peerconnectbc.ca/wp-content/uploads/10-Recommendations-Peer-Engagement.pdf</nowiki>

Bouchard, L., Montreuil, M., & Gros, C. (2010). Peer support among inpatients in an adult mental health setting. ''Issues in mental health nursing'', ''31''(9), 589–598. <nowiki>https://doi.org/10.3109/01612841003793049</nowiki>

Brasier, C., Roennfeldt, H., Hamilton, B., Martel, A., Hill, N., Stratford, A., Buchanan-Hagen, S., Byrne, L., Castle, D., Cocks, N., Davidson, L., & Brophy, L. (2022). Peer support work for people experiencing mental distress attending the emergency department: Exploring the potential. ''Emergency medicine Australasia : EMA'', ''34''(1), 78–84. <nowiki>https://doi.org/10.1111/1742-6723.13848</nowiki>

Chinman, M., George, P., Dougherty, R. H., Daniels, A. S., Ghose, S. S., Swift, A., & Delphin-Rittmon, M. E. (2014). Peer support services for individuals with serious mental illnesses: assessing the evidence. Psychiatric services (Washington, D.C.), 65(4), 429–441. <nowiki>https://doi.org/10.1176/appi.ps.201300244</nowiki>

Cusick, J. (2021). The B.C. Peer Support Training Curriculum Guide. B.C. Ministry of Mental Health and Addictions. <nowiki>https://peerconnectbc.ca/wp-content/uploads/Curriculum-Guide_Final.pdf</nowiki>

Fortuna, K. L., Myers, A. L., Ferron, J., Kadakia, A., Bianco, C., Bruce, M. L., & Bartels, S. J. (2022). Assessing a digital peer support self-management intervention for adults with serious mental illness: feasibility, acceptability, and preliminary effectiveness. ''Journal of mental health (Abingdon, England)'', 1–9. Advance online publication. <nowiki>https://doi.org/10.1080/09638237.2021.2022619</nowiki>

Fortuna, K.L., Solomon, P. & Rivera, J. (2022). An Update of Peer Support/Peer Provided Services Underlying Processes, Benefits, and Critical Ingredients. ''Psychiatr Q 93'', 571–586. <nowiki>https://doi.org/10.1007/s11126-022-09971-w</nowiki>

Gillard, S., Gibson, S. L., Holley, J., & Lucock, M. (2015). Developing a change model for peer worker interventions in mental health services: a qualitative research study. Epidemiology and psychiatric sciences, 24(5), 435–445. <nowiki>https://doi.org/10.1017/S2045796014000407</nowiki>

Government of British Columbia. (2021). Training resources to improve the quality of mental health and substance use services. <nowiki>https://news.gov.bc.ca/releases/2021MMHA0037-001380</nowiki>

Hiller-Venegas, S., Gilmer, T. P., Jones, N., Munson, M. R., & Ojeda, V. D. (2022). Clients' Perspectives Regarding Peer Support Providers' Roles and Support for Client Access to and Use of Publicly Funded Mental Health Programs Serving Transition-Age Youth in Two Southern California Counties. The journal of behavioral health services & research, 49(3), 364–384. <nowiki>https://doi.org/10.1007/s11414-022-09792-6</nowiki>

Loumpa V. (2012). Promoting recovery through peer support: possibilities for social work practice. ''Social work in health care'', ''51''(1), 53–65. <nowiki>https://doi.org/10.1080/00981389.2011.622667</nowiki>

Moll, S., Holmes, J., Geronimo, J., & Sherman, D. (2009). Work transitions for peer support providers in traditional mental health programs: unique challenges and opportunities. ''Work (Reading, Mass.)'', ''33''(4), 449–458. <nowiki>https://doi.org/10.3233/WOR-2009-0893</nowiki>

Mutschler, C., Bellamy, C., Davidson, L., Lichtenstein, S., & Kidd, S. (2022). Implementation of peer support in mental health services: A systematic review of the literature. Psychological Services, 19(2), 360–374. <nowiki>https://doi.org/10.1037/ser0000531</nowiki>

Penney, D. (2018). Defining “ Peer Support ” : Implications for Policy , Practice , and Research.

Repper, J., & Carter, T. (2011). A review of the literature on peer support in mental health services. ''Journal of mental health (Abingdon, England)'', ''20''(4), 392–411. <nowiki>https://doi.org/10.3109/09638237.2011.583947</nowiki>

Tseris E. (2020). The Expansion of the Peer Adviser Workforce: Opportunities and Challenges for Social Work, ''Australian Social Work, 73(''2), 162-174, DOI: 10.1080/0312407X.2019.1675734

Wang, Y., Chen, Y., & Deng, H. (2022). Effectiveness of Family- and Individual-Led Peer Support for People With Serious Mental Illness: A Meta-Analysis. ''Journal of psychosocial nursing and mental health services'', ''60''(2), 20–26. <nowiki>https://doi.org/10.3928/02793695-20210818-01</nowiki>{{Cc-by-nc-4.0}}

Course:SOWK551/2021/A Review of the Social Work Role in the Process of MAiD within Healthcare

2023-01-12T23:02:39Z

KellyAllison:

[[File:Hospice-1761276 1920.jpg|alt=Dying Man holding hands with another person|thumb|Photo by Use at your Ease on Pixabay]]

== Short Summary ==
Literature review of the social work role in the process of MAiD within healthcare.

''Author: Anonymous''

''Date: 12/08/2022''

== Introduction ==
Medical Assistance in Dying (MAiD) has been evolving at a rapid rate in Canada over the last 6 years and when we reflect upon the future of this legislation, there appears to be no slowing down in sight. Medical Assistance in Dying occurs when a medication is intentionally administered by a doctor or nurse practitioner that at the request of an individual, brings about their death (Government of British Columbia, 2022). The federal government of Canada passed legislation to amend the criminal code and introduced MAiD into practice on June 17th, 2016 under Bill C-7. Five years later, the original legislation was modified and on March 17th, 2021 Bill C-14 was implemented (Government of British Columbia, 2022). The major change to eligibility criteria between Bill C-7 and Bill C-14 is that a “two track system was created”, one for folks with a naturally foreseeable death and one for those with a “grievous and irremediable condition” but whose natural death may not be reasonably foreseeable (Pesut et al., 2021). The objective of MAiD legislation is to provide an end-of-life care option that respects a patient’s autonomy while subsequently relieving their suffering (Sulmasy et al., 2017). Discussions surrounding MAiD are important to the healthcare profession because it has had a major effect on both the conversations and outcomes of patients seeking end-of-life and palliative care.

At the end of 2020, the number of individuals receiving MAiD had grown by 34.2% from 2019 and MAiD accounted for 2.5% of all deaths in Canada totalling 21,589 people receiving it in the year (Pesut et al., 2021). As MAiD legislation becomes more relevant in the day to day lives of Canadians, it also becomes increasingly prevalent within healthcare and subsequently in the role and involvement of the interprofessional healthcare team. Because of this, this paper aims to provide an analytical review of the social work role in the process of MAiD within healthcare. In doing this, this paper will synthesize the literature to provide a review of the role of social work in death and dying, the legal and ethical considerations related to MAiD, and the relevance of the social determinants of health. Additionally, an analysis of how this literature review might be applied to social work practice in healthcare will be discussed.

== Overview ==
This literature review consists of 17 scholarly articles published between 2005 to 2022. The peer-reviewed articles were found using google scholar and the UBC library search engine. To gather the most relevant articles about my literature review, the following keywords were used: “MAiD within Canada”, “legal and ethical considerations” “social work”, “healthcare”, and “social determinants of health”. These keywords were used both alone and in various combinations. The findings were examined from a Canadian context and therefore focus on the Canadian legislation and experiences of Canadian healthcare providers. Upon analysis of the latest literature, the following three themes were identified: (1) Social Work Practice in Death and Dying, (2) Legal and Ethical Obligations related to MAiD, and (3) the Relevance of the Social Determinants of Health. The purpose of this literature review is to inform healthcare social workers on how to improve their role in the process of Medical Assistance in Dying.

== Social Work Practice in Death and Dying ==
All social workers will interact with death and dying at some point in their professional journeys. Gwyther et al. (2008) suggests that social workers hold a unique position in which they are notably “qualified and positioned” to provide services in end-of-life care. In agreeance is Hobart (2008) who notes that social workers “have the training and expertise” to identify psychosocial factors related to death and dying that help to effectively speak with the family members of a person who may be nearing or thinking about death. Because of this, social workers are expected to have the necessary knowledge to provide general information about the process of MAiD and liaise with the rest of the team to determine the next steps. Amurao (2020) suggests that when social workers lack an understanding of MAiD, they may experience higher levels of work-related stress and personal anxiety. It can be concluded that having a high level of confidence for social workers in the process of MAiD will not only benefit the patient and the interdisciplinary team, but it will also influence how social workers feels about the rest of their practice.

Christ and Sormanti (2008) share findings from their study that argue social workers feel as though graduate-level studies do not provide a substantial level of understanding on how to work with patients who are dying or grieving. It was shown that only 54% of social workers rated their interventions related to death and dying with patients and families as “good” or “excellent”. In addition, research conducted by Alkema, Linton, and Davies (2008) notes that social workers often face multifaceted challenges when working with death and dying such as their personal grief and the grief of patients. Similarly, a study conducted on “vague end-of-life policies” showed social workers often feel unprepared for ethical considerations that arise amidst end-of-life care (Amurao, 2020). To prevent this, Westefeld (2013) argues that human service workers should be provided with additional training on how to work with patients and families who are requesting MAiD. However, Gaston (2018) states that knowledge about the factors that influence a social worker’s preparedness in end-of-life care has yet to be studied in much of the available literature. Regardless of literature support, the role of social work in death and dying and subsequently the involvement with patients and families in the process of MAiD can be both rewarding and difficult, however many times it will be both.

== Legal and Ethical Obligations related to MAiD ==
The Medical Assistance in Dying legislation has been under ethical and legal critique since it was first introduced in 2016 and the rapid expansion to MAiD has resulted in a noteworthy debate within palliative care settings (Pesut et al., 2021). Some Canadians view MAiD as a “commendable act of compassion, while others consider it an act of severe violence”. The most prevalent argument used in favour of MAiD is a person’s right to autonomy. Within a western culture and medical ethics, autonomy is looked at as one of the most fundamental principles of healthcare, and the impact of autonomy is one of the key arguments in favour of MAiD (Allan & Allan., 2020; Westefeld et al., 2013). The social work profession is rooted in a framework of social justice whereby fairness, equality, and respect for all people is at the forefront of the practice. As a result of this framework, social workers advocate for people’s rights to self-determination and their ability to make informed and voluntary decisions (CASW, 2022). Interestingly, Wright and Shaw (2019) discuss that in medical decisions, a patient’s autonomy is normally used to allow folks the right to refuse treatment options rather than to allow requests for specific treatment options.

The legislation of MAiD may affect social workers at all levels of practice however, due to its medical nature, social workers within healthcare are often the ones that encounter it most frequently. As per Amurao (2020), social workers are part of the interdisciplinary team and therefore abide by the ethics and values that guide holistic and person-centered care. As Gaston (2018) states, social workers working in end-of-life care are expected to become experts in both the bioethical issues and legal considerations of MAiD. Using biopsychosocial assessments to determine a person’s needs, social workers may be the first person to hear of a patient expressing their desire for MAiD (Amurao, 2020). Although the criminal code exempts criminal prosecution for healthcare providers involved in the provision of information for MAiD, as per the Newfoundland and Labrador Association of Social Workers (2016), “it remains a criminal offence to counsel a person to die by suicide as outlined in the Criminal Code, subsection 241(1)”. Concerns about initiating MAiD conversations remain an ethical consideration for many healthcare providers out of fear of accidentally influencing a patient’s decision, sending the wrong message, or negatively impacting a working relationship (Ho et al., 2021). On the other hand, some medical professionals have argued that many patients react positively when healthcare workers initiate end-of-life conversations (Hot et al., 2021). Due to the complex ethical and legal considerations that are ongoing with MAiD legislation, social workers should maintain their competence through ongoing education of polices and issues related to end-of-life care and MAiD.

== The Social Determinants of Health ==
As the MAiD legislation continues to develop and the population that accesses it continues to expand, concerns have been raised about what psychosocial factors may drive people to an initial request for MAiD. As members of the interdisciplinary team, social workers are often the first ones to complete biopsychosocial assessments to assess what a patient believes they need for an “optimal quality of life” (Amurao, 2020). It has been researched that the individuals who are choosing MAiD are commonly well-educated and of higher socio-economic status and therefore, are more often able to advocate for themselves to have access to end-of-life care (Downer et al., 2020). In agreeance with this, Westefeld et al. (2013), states that those in favour of medical assistance in dying are primarily “white and able-bodied” individuals. Due to their social determinants of health, these individuals are more likely to have a consistent medical practitioner. The healthcare system in Canada relies upon the relationships between family doctors and patients (Wright & Shaw, 2019). However, as argued by Wright and Shaw (2019), accessing appropriate treatment, and having end of life discussions “present as a unique barrier” for marginalized individuals often due to “inconsistent or non-existent relationships with physicians” (Wright & Shaw, 2019). Marginalized individuals frequently face structural and systemic barriers when interacting with the healthcare system due to “poverty, homelessness, racism, ageism, substance use, and mental health diagnoses” (Wright & Shaw, 2019).

The influence of social determinants on a person’s health is viewed by many scholars as a driving factor behind many MAiD requests in Canada. Many studies have articulated that patient’s often seek MAiD not because of chronic pain or terminal diagnoses but because of poor quality of life and loss of autonomy (Amurao, 2020). Other studies have stated that a lack of self-worth, limited support services, and a reduced social network may influence a patient’s wish for MAiD (Ho et al., 2021). Tran et al. (2021) state that the cost of medical “non-necessities” such as “prescription medications, home care, long-term care, and services offered by nonphysician providers (eg, optometrists, physiotherapists)” can create large health disparities for patients of low economic status. As such, a patient’s request for MAiD may be “a reactive phenomenon intertwined with physical, psychosocial, and existential suffering” related to a broken social safety net rather than a true desire to die (Ho et al., 2021). In agreeance with this understanding is Wiebe et al. (2022), who argues that it is often easier for folks to access MAiD than to get the necessary supportive care that they require to treat their symptoms or psychosocial problems. On the contrary, a study completed by Ho et al. (2021), found that MAiD assessors rarely met with patients where unmet needs and limited resources were the main factors contributing to their request for MAiD. However, findings from a study completed by Brown et al. (2020), showed that more often, patients were requesting MAiD in Canada due to non-physical symptoms such as “quality of life, and desire for dignity and control over death” rather than “physical symptoms like dyspnea or pain”. A Canadian annual report on MAiD indicated that in 2020, 18.6% of patients noted that feelings of isolation or loneliness were a factor in their suffering (Health Canada, 2021). Based on the findings, there appear to be discrepancies about whether the influence of psychosocial factors such as a person’s housing or income is a true driving factor to access MAiD. However, it can be recognized that non-physical symptoms such as loneliness, and quality of life are pertinent to a person’s final decision about accessing MAiD which are key findings relevant to social work practice.

== Application to Practice ==
MAiD legislation is changing at a rapid rate despite it being relatively new in Canada. This topic is relevant to practice as social workers working in healthcare will more than likely be involved in a care discussion regarding MAiD at some point in their practice and should feel equipped to have difficult conversations with patients and families. By reviewing the social work role in MAiD, the legal and ethical considerations, and the influence of the social determinants of health, this literature review has demonstrated that there is a growing need for healthcare provider competence surrounding MAiD. Due to the sensitive nature and novelty of assisted dying in Canada, there is a lack of literature regarding the topic. Therefore, this paper has provided a literature review to understand how the social work role fits within MAiD in healthcare. This is relevant to practice as it can serve as an educational tool and can guide social workers to a greater understanding of their role.

== Conclusion ==
It can be concluded that the legislation and process of MAiD is a complex issue that continues to elicit difficult discourse between the public and health care providers. As such, this is an important topic for social workers to be aware of, specifically those working within healthcare. Through analyzing the latest research and synthesizing the literature, this paper has discussed key themes relevant to the social work role related to death and dying, the legal and ethical considerations that may arise, and the relevance of the social determinants of health in accessing MAiD. The goal of this research is to highlight important insights regarding the practical challenges experienced in health systems as they continue to develop policies that create best practice for the delivery of MAiD care. The findings from this paper suggest that literature specific to the social work role in the process of MAiD within healthcare is limited and further data should be obtained to better understand why the social work role is important and how it can be modified to best fit the needs of patients and their families.

== References ==
<references responsive="0" />
Alkema, K., Linton, J., & Davies., R. (2008). A study of the relationship between self-care,

compassion satisfaction, compassion fatigue, and burnout among hospice professionals. ''Social Work End Life Palliative Care''. 4(2):101-19. doi: 10.1080/15524250802353934.

Amurao, A. (2020). Medical assistance in dying (maid). ''Canadian Social Work Review'', ''36''(2),

143–164. <nowiki>https://doi.org/10.7202/1068553ar</nowiki>

CASW. (2020). CASWE code of ethics and scope of practice. <nowiki>https://www.casw-</nowiki>

acts.ca/en/Code-of-Ethics%20and%20Scope%20of%20Practice

Christ, G., & Sormanti, M. (2008) Advancing social work practice in end-of-life care. ''Social''

''Work in Health Care'', 30:2, 81-99, doi: 10.1300/ J010v30n02_05

Downar, J., Fowler, R., Halko, R., Huyer, D., Hill, D., & Gibson, L. (2020). Early experience

with medical assistance in dying in Ontario, Canada: A cohort study. ''Canadian Medical Association Journal: journal de l'Association medicale canadienne'', ''192''(8), E173–E181. <nowiki>https://doi.org/10.1503/cmaj.200016</nowiki>

Gaston, N. R., Randall, J. M., & Kiesel, L. R. (2018). Physician-assisted suicide and midwest

social workers: where do they stand? ''Journal of social work in end-of-life & palliative care''. 14(1), 73–92. <nowiki>https://doiorg.proxy.ufv.ca:2443/10.1080/15524256.2018.1433097</nowiki>

Government of British Columbia. (2021). Medical assistance in dying.

<nowiki>https://www2.gov.bc.ca/gov/content/health/accessing-health-care/home-community-care/care-options-and-cost/end-of-life-care/medical-assistance-in-dying</nowiki>

Gwyther, L., Altilio, T., Blacker, S., Christ, G., Csikai, E., Hooyman, N., Kramer, B., Linton, J.,

Raymer, M., & Howe, J. (2005) Social work competencies in palliative and end-of-life care. ''J Soc Work End Life Palliat Care''. 1(1):87-120. doi: 10.1300/J457v01n01_06.

Ho, A., Norman, J., Joolaee, S., Serota, K., Twells, L., & William, L. (2021). How does medical

assistance in dying affect end-of-life care planning discussions? Experiences of canadian multidisciplinary palliative care providers. ''Palliative Care and Social Practice''. doi:10.1177/26323524211045996

Hobart, K. (2008). Death and dying and the social work role. ''Journal of Gerontological Social''

''Work''. 36:3-4, 181-192, doi: 10.1300/J083v36n03_14

Health Canada. (2021). Second annual report on medical assistance in dying in

Canada 2020. <nowiki>https://www.canada.ca/en/health-canada/services/medical-assistance-dying/annual-report-2020.html</nowiki>

Newfoundland & Labrador Association of Social Workers (2016). Medical assistance in dying:

What social workers need to know. <nowiki>https://nlcsw.ca/sites/default/files/inline-files/Medical%20Assistance%20in%20Dying%20%28final%29.pdf</nowiki>

Pesut, B., Thorne, S., Wright, D., Schiller, C., Huggins, M., Puurveen, G., & Chambaere, K.

(2021). Navigating medical assistance in dying from Bill C-14 to Bill C-7: a qualitative study. ''BMC Health Serv Res'' '''21''', 1195. <nowiki>https://doi.org/10.1186/s12913-021-07222-5</nowiki>

Sulmasy, L., & Mueller, P. (2017). Ethics and the legalization of physician-assisted suicide: An

american college of physician’s position paper. ''Annals of Internal Medicine''. 167(8), 576–578. <nowiki>https://doiorg.proxy.ufv.ca:2443/10.7326/M17-0938</nowiki>

Tran, M., Honarmand, K., Sibbald, R., Priestap, F., Oczkowski, S., & Ball, I. (2021).

Socioeconomic status and medical assistance in dying: A regional descriptive study. ''Journal of Palliative Care''. 2022;37(3):359-365. doi:10.1177/08258597211053088

Westefeld, J., Casper, D., Lewis, A., Manlick, C., Rasmussen, W., Richards, A., & Sieck,

B. (2013) Physician-assisted death and its relationship to the human services professions. ''Journal of Loss and Trauma''. 18:6, 539-555, doi: 10.1080/15325024.2012.719345

Wright, A., & Shaw, J. The spectrum of end-of-life care: an argument for access to medical

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{{Cc-by-nc-4.0}}

Course:SOWK551/2021/A Review of the Social Work Role in the Process of MAiD within Healthcare

2023-01-12T22:57:22Z

KellyAllison:

<nowiki><a rel="license" href="http://creativecommons.org/licenses/by-nc/4.0/"><img alt="Creative Commons License" style="border-width:0" src="https://i.creativecommons.org/l/by-nc/4.0/88x31.png" /></nowiki><nowiki></a></nowiki><nowiki> </nowiki>This work is licensed under a <nowiki><a rel="license" href="http://creativecommons.org/licenses/by-nc/4.0/">Creative Commons Attribution-NonCommercial 4.0 International License</a></nowiki>.
[[File:Placeholder_Image_1.jpg|alt=Adult writing in journal|thumb|Photo by Pexels on Pixabay]]

== Short Summary ==
Literature review of the social work role in the process of MAiD within healthcare.

''Author: Anonymous''

''Date: 12/08/2022''

== Introduction ==
Medical Assistance in Dying (MAiD) has been evolving at a rapid rate in Canada over the last 6 years and when we reflect upon the future of this legislation, there appears to be no slowing down in sight. Medical Assistance in Dying occurs when a medication is intentionally administered by a doctor or nurse practitioner that at the request of an individual, brings about their death (Government of British Columbia, 2022). The federal government of Canada passed legislation to amend the criminal code and introduced MAiD into practice on June 17th, 2016 under Bill C-7. Five years later, the original legislation was modified and on March 17th, 2021 Bill C-14 was implemented (Government of British Columbia, 2022). The major change to eligibility criteria between Bill C-7 and Bill C-14 is that a “two track system was created”, one for folks with a naturally foreseeable death and one for those with a “grievous and irremediable condition” but whose natural death may not be reasonably foreseeable (Pesut et al., 2021). The objective of MAiD legislation is to provide an end-of-life care option that respects a patient’s autonomy while subsequently relieving their suffering (Sulmasy et al., 2017). Discussions surrounding MAiD are important to the healthcare profession because it has had a major effect on both the conversations and outcomes of patients seeking end-of-life and palliative care.

At the end of 2020, the number of individuals receiving MAiD had grown by 34.2% from 2019 and MAiD accounted for 2.5% of all deaths in Canada totalling 21,589 people receiving it in the year (Pesut et al., 2021). As MAiD legislation becomes more relevant in the day to day lives of Canadians, it also becomes increasingly prevalent within healthcare and subsequently in the role and involvement of the interprofessional healthcare team. Because of this, this paper aims to provide an analytical review of the social work role in the process of MAiD within healthcare. In doing this, this paper will synthesize the literature to provide a review of the role of social work in death and dying, the legal and ethical considerations related to MAiD, and the relevance of the social determinants of health. Additionally, an analysis of how this literature review might be applied to social work practice in healthcare will be discussed.

== Overview ==
This literature review consists of 17 scholarly articles published between 2005 to 2022. The peer-reviewed articles were found using google scholar and the UBC library search engine. To gather the most relevant articles about my literature review, the following keywords were used: “MAiD within Canada”, “legal and ethical considerations” “social work”, “healthcare”, and “social determinants of health”. These keywords were used both alone and in various combinations. The findings were examined from a Canadian context and therefore focus on the Canadian legislation and experiences of Canadian healthcare providers. Upon analysis of the latest literature, the following three themes were identified: (1) Social Work Practice in Death and Dying, (2) Legal and Ethical Obligations related to MAiD, and (3) the Relevance of the Social Determinants of Health. The purpose of this literature review is to inform healthcare social workers on how to improve their role in the process of Medical Assistance in Dying.

== Social Work Practice in Death and Dying ==
All social workers will interact with death and dying at some point in their professional journeys. Gwyther et al. (2008) suggests that social workers hold a unique position in which they are notably “qualified and positioned” to provide services in end-of-life care. In agreeance is Hobart (2008) who notes that social workers “have the training and expertise” to identify psychosocial factors related to death and dying that help to effectively speak with the family members of a person who may be nearing or thinking about death. Because of this, social workers are expected to have the necessary knowledge to provide general information about the process of MAiD and liaise with the rest of the team to determine the next steps. Amurao (2020) suggests that when social workers lack an understanding of MAiD, they may experience higher levels of work-related stress and personal anxiety. It can be concluded that having a high level of confidence for social workers in the process of MAiD will not only benefit the patient and the interdisciplinary team, but it will also influence how social workers feels about the rest of their practice.

Christ and Sormanti (2008) share findings from their study that argue social workers feel as though graduate-level studies do not provide a substantial level of understanding on how to work with patients who are dying or grieving. It was shown that only 54% of social workers rated their interventions related to death and dying with patients and families as “good” or “excellent”. In addition, research conducted by Alkema, Linton, and Davies (2008) notes that social workers often face multifaceted challenges when working with death and dying such as their personal grief and the grief of patients. Similarly, a study conducted on “vague end-of-life policies” showed social workers often feel unprepared for ethical considerations that arise amidst end-of-life care (Amurao, 2020). To prevent this, Westefeld (2013) argues that human service workers should be provided with additional training on how to work with patients and families who are requesting MAiD. However, Gaston (2018) states that knowledge about the factors that influence a social worker’s preparedness in end-of-life care has yet to be studied in much of the available literature. Regardless of literature support, the role of social work in death and dying and subsequently the involvement with patients and families in the process of MAiD can be both rewarding and difficult, however many times it will be both.

== Legal and Ethical Obligations related to MAiD ==
The Medical Assistance in Dying legislation has been under ethical and legal critique since it was first introduced in 2016 and the rapid expansion to MAiD has resulted in a noteworthy debate within palliative care settings (Pesut et al., 2021). Some Canadians view MAiD as a “commendable act of compassion, while others consider it an act of severe violence”. The most prevalent argument used in favour of MAiD is a person’s right to autonomy. Within a western culture and medical ethics, autonomy is looked at as one of the most fundamental principles of healthcare, and the impact of autonomy is one of the key arguments in favour of MAiD (Allan & Allan., 2020; Westefeld et al., 2013). The social work profession is rooted in a framework of social justice whereby fairness, equality, and respect for all people is at the forefront of the practice. As a result of this framework, social workers advocate for people’s rights to self-determination and their ability to make informed and voluntary decisions (CASW, 2022). Interestingly, Wright and Shaw (2019) discuss that in medical decisions, a patient’s autonomy is normally used to allow folks the right to refuse treatment options rather than to allow requests for specific treatment options.

The legislation of MAiD may affect social workers at all levels of practice however, due to its medical nature, social workers within healthcare are often the ones that encounter it most frequently. As per Amurao (2020), social workers are part of the interdisciplinary team and therefore abide by the ethics and values that guide holistic and person-centered care. As Gaston (2018) states, social workers working in end-of-life care are expected to become experts in both the bioethical issues and legal considerations of MAiD. Using biopsychosocial assessments to determine a person’s needs, social workers may be the first person to hear of a patient expressing their desire for MAiD (Amurao, 2020). Although the criminal code exempts criminal prosecution for healthcare providers involved in the provision of information for MAiD, as per the Newfoundland and Labrador Association of Social Workers (2016), “it remains a criminal offence to counsel a person to die by suicide as outlined in the Criminal Code, subsection 241(1)”. Concerns about initiating MAiD conversations remain an ethical consideration for many healthcare providers out of fear of accidentally influencing a patient’s decision, sending the wrong message, or negatively impacting a working relationship (Ho et al., 2021). On the other hand, some medical professionals have argued that many patients react positively when healthcare workers initiate end-of-life conversations (Hot et al., 2021). Due to the complex ethical and legal considerations that are ongoing with MAiD legislation, social workers should maintain their competence through ongoing education of polices and issues related to end-of-life care and MAiD.

== The Social Determinants of Health ==
As the MAiD legislation continues to develop and the population that accesses it continues to expand, concerns have been raised about what psychosocial factors may drive people to an initial request for MAiD. As members of the interdisciplinary team, social workers are often the first ones to complete biopsychosocial assessments to assess what a patient believes they need for an “optimal quality of life” (Amurao, 2020). It has been researched that the individuals who are choosing MAiD are commonly well-educated and of higher socio-economic status and therefore, are more often able to advocate for themselves to have access to end-of-life care (Downer et al., 2020). In agreeance with this, Westefeld et al. (2013), states that those in favour of medical assistance in dying are primarily “white and able-bodied” individuals. Due to their social determinants of health, these individuals are more likely to have a consistent medical practitioner. The healthcare system in Canada relies upon the relationships between family doctors and patients (Wright & Shaw, 2019). However, as argued by Wright and Shaw (2019), accessing appropriate treatment, and having end of life discussions “present as a unique barrier” for marginalized individuals often due to “inconsistent or non-existent relationships with physicians” (Wright & Shaw, 2019). Marginalized individuals frequently face structural and systemic barriers when interacting with the healthcare system due to “poverty, homelessness, racism, ageism, substance use, and mental health diagnoses” (Wright & Shaw, 2019).

The influence of social determinants on a person’s health is viewed by many scholars as a driving factor behind many MAiD requests in Canada. Many studies have articulated that patient’s often seek MAiD not because of chronic pain or terminal diagnoses but because of poor quality of life and loss of autonomy (Amurao, 2020). Other studies have stated that a lack of self-worth, limited support services, and a reduced social network may influence a patient’s wish for MAiD (Ho et al., 2021). Tran et al. (2021) state that the cost of medical “non-necessities” such as “prescription medications, home care, long-term care, and services offered by nonphysician providers (eg, optometrists, physiotherapists)” can create large health disparities for patients of low economic status. As such, a patient’s request for MAiD may be “a reactive phenomenon intertwined with physical, psychosocial, and existential suffering” related to a broken social safety net rather than a true desire to die (Ho et al., 2021). In agreeance with this understanding is Wiebe et al. (2022), who argues that it is often easier for folks to access MAiD than to get the necessary supportive care that they require to treat their symptoms or psychosocial problems. On the contrary, a study completed by Ho et al. (2021), found that MAiD assessors rarely met with patients where unmet needs and limited resources were the main factors contributing to their request for MAiD. However, findings from a study completed by Brown et al. (2020), showed that more often, patients were requesting MAiD in Canada due to non-physical symptoms such as “quality of life, and desire for dignity and control over death” rather than “physical symptoms like dyspnea or pain”. A Canadian annual report on MAiD indicated that in 2020, 18.6% of patients noted that feelings of isolation or loneliness were a factor in their suffering (Health Canada, 2021). Based on the findings, there appear to be discrepancies about whether the influence of psychosocial factors such as a person’s housing or income is a true driving factor to access MAiD. However, it can be recognized that non-physical symptoms such as loneliness, and quality of life are pertinent to a person’s final decision about accessing MAiD which are key findings relevant to social work practice.

== Application to Practice ==
MAiD legislation is changing at a rapid rate despite it being relatively new in Canada. This topic is relevant to practice as social workers working in healthcare will more than likely be involved in a care discussion regarding MAiD at some point in their practice and should feel equipped to have difficult conversations with patients and families. By reviewing the social work role in MAiD, the legal and ethical considerations, and the influence of the social determinants of health, this literature review has demonstrated that there is a growing need for healthcare provider competence surrounding MAiD. Due to the sensitive nature and novelty of assisted dying in Canada, there is a lack of literature regarding the topic. Therefore, this paper has provided a literature review to understand how the social work role fits within MAiD in healthcare. This is relevant to practice as it can serve as an educational tool and can guide social workers to a greater understanding of their role.

== Conclusion ==
It can be concluded that the legislation and process of MAiD is a complex issue that continues to elicit difficult discourse between the public and health care providers. As such, this is an important topic for social workers to be aware of, specifically those working within healthcare. Through analyzing the latest research and synthesizing the literature, this paper has discussed key themes relevant to the social work role related to death and dying, the legal and ethical considerations that may arise, and the relevance of the social determinants of health in accessing MAiD. The goal of this research is to highlight important insights regarding the practical challenges experienced in health systems as they continue to develop policies that create best practice for the delivery of MAiD care. The findings from this paper suggest that literature specific to the social work role in the process of MAiD within healthcare is limited and further data should be obtained to better understand why the social work role is important and how it can be modified to best fit the needs of patients and their families.

== References ==
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Alkema, K., Linton, J., & Davies., R. (2008). A study of the relationship between self-care,

compassion satisfaction, compassion fatigue, and burnout among hospice professionals. ''Social Work End Life Palliative Care''. 4(2):101-19. doi: 10.1080/15524250802353934.

Amurao, A. (2020). Medical assistance in dying (maid). ''Canadian Social Work Review'', ''36''(2),

143–164. <nowiki>https://doi.org/10.7202/1068553ar</nowiki>

CASW. (2020). CASWE code of ethics and scope of practice. <nowiki>https://www.casw-</nowiki>

acts.ca/en/Code-of-Ethics%20and%20Scope%20of%20Practice

Christ, G., & Sormanti, M. (2008) Advancing social work practice in end-of-life care. ''Social''

''Work in Health Care'', 30:2, 81-99, doi: 10.1300/ J010v30n02_05

Downar, J., Fowler, R., Halko, R., Huyer, D., Hill, D., & Gibson, L. (2020). Early experience

with medical assistance in dying in Ontario, Canada: A cohort study. ''Canadian Medical Association Journal: journal de l'Association medicale canadienne'', ''192''(8), E173–E181. <nowiki>https://doi.org/10.1503/cmaj.200016</nowiki>

Gaston, N. R., Randall, J. M., & Kiesel, L. R. (2018). Physician-assisted suicide and midwest

social workers: where do they stand? ''Journal of social work in end-of-life & palliative care''. 14(1), 73–92. <nowiki>https://doiorg.proxy.ufv.ca:2443/10.1080/15524256.2018.1433097</nowiki>

Government of British Columbia. (2021). Medical assistance in dying.

<nowiki>https://www2.gov.bc.ca/gov/content/health/accessing-health-care/home-community-care/care-options-and-cost/end-of-life-care/medical-assistance-in-dying</nowiki>

Gwyther, L., Altilio, T., Blacker, S., Christ, G., Csikai, E., Hooyman, N., Kramer, B., Linton, J.,

Raymer, M., & Howe, J. (2005) Social work competencies in palliative and end-of-life care. ''J Soc Work End Life Palliat Care''. 1(1):87-120. doi: 10.1300/J457v01n01_06.

Ho, A., Norman, J., Joolaee, S., Serota, K., Twells, L., & William, L. (2021). How does medical

assistance in dying affect end-of-life care planning discussions? Experiences of canadian multidisciplinary palliative care providers. ''Palliative Care and Social Practice''. doi:10.1177/26323524211045996

Hobart, K. (2008). Death and dying and the social work role. ''Journal of Gerontological Social''

''Work''. 36:3-4, 181-192, doi: 10.1300/J083v36n03_14

Health Canada. (2021). Second annual report on medical assistance in dying in

Canada 2020. <nowiki>https://www.canada.ca/en/health-canada/services/medical-assistance-dying/annual-report-2020.html</nowiki>

Newfoundland & Labrador Association of Social Workers (2016). Medical assistance in dying:

What social workers need to know. <nowiki>https://nlcsw.ca/sites/default/files/inline-files/Medical%20Assistance%20in%20Dying%20%28final%29.pdf</nowiki>

Pesut, B., Thorne, S., Wright, D., Schiller, C., Huggins, M., Puurveen, G., & Chambaere, K.

(2021). Navigating medical assistance in dying from Bill C-14 to Bill C-7: a qualitative study. ''BMC Health Serv Res'' '''21''', 1195. <nowiki>https://doi.org/10.1186/s12913-021-07222-5</nowiki>

Sulmasy, L., & Mueller, P. (2017). Ethics and the legalization of physician-assisted suicide: An

american college of physician’s position paper. ''Annals of Internal Medicine''. 167(8), 576–578. <nowiki>https://doiorg.proxy.ufv.ca:2443/10.7326/M17-0938</nowiki>

Tran, M., Honarmand, K., Sibbald, R., Priestap, F., Oczkowski, S., & Ball, I. (2021).

Socioeconomic status and medical assistance in dying: A regional descriptive study. ''Journal of Palliative Care''. 2022;37(3):359-365. doi:10.1177/08258597211053088

Westefeld, J., Casper, D., Lewis, A., Manlick, C., Rasmussen, W., Richards, A., & Sieck,

B. (2013) Physician-assisted death and its relationship to the human services professions. ''Journal of Loss and Trauma''. 18:6, 539-555, doi: 10.1080/15325024.2012.719345

Wright, A., & Shaw, J. The spectrum of end-of-life care: an argument for access to medical

assistance in dying for vulnerable populations. ''Med Health Care and Philos'' 22, 211–219 (2019). <nowiki>https://doi.org/10.1007/s11019-018-9860-z</nowiki>

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Course:SOWK551/2021/ HIV/AIDS, Women, and Social Work Practice

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KellyAllison:

[[File:Ehimetalor-akhere-unuabona-Hf4QOGcnBnA-unsplash.jpg|thumb|Photo by Ehimatalor Ekhere Ubuobona on Unsplash]]

== Short Summary ==
Literature review informing healthcare social workers on how they can improve the quality of care to Women living with HIV.

''Author: anonymous''

''Date: December 8, 2022''

== Introduction ==
Although it has been about 40 years since HIV/AIDS was initially diagnosed in Canada many healthcare professionals still hold incorrect beliefs and misconceptions about the illness (Act, 2021). Presently, these preconceived notions lead to stigmatization, discrimination, and alienation of HIV-positive (HIV+) people, particularly among marginalized groups and women. Due to these negative societal pressures, HIV+ individuals continually face oppressive systematic barriers which generate extraordinary strain within the healthcare system, that is ill-equipped in meeting their needs. To put the public health issue into perspective “women represent 50% of the 33.3 million people living with HIV globally” (Carter et al., 2013, p.1). As a result, social workers often become part of the interdisciplinary team to lend guidance, education, and support to navigating these complex structures. An overview of the struggles and implications which are unique to women living with HIV (“WLWH”) is needed to navigate the bureaucratic medical system. Nevertheless, parameters and theoretical perspectives become influential in forming a social worker’s practice when working with WLWH. Present and future social work interventions and theoretical frameworks will be addressed which can be utilized in addressing the potentially fragmented service delivery of healthcare to WLWH.

'''Keywords:''' HIV-positive women, services for women, healthcare, social determinants of health, healthcare, and social work.

== Overview ==
The review of seventeen research publications occurred between 2000 to 2022. This literature review was conducted by using electronic online databases by searching the UBC library and google scholar to find peer-reviewed articles and grey literature. The search included the following keywords “HIV-positive women”, “services for women”, “healthcare”, “social determinants of health”, “healthcare”, and “social work”. The search terms were used alone and in various combinations. A considerable number of studies involved interviews with WLWH. A critique in the literature is that there is insufficient research completed on WLWH in Canada. As a result, the scope of the findings was examined globally to identify relevant literature. A thematic analysis was completed and resulted in three themes: (1) barriers to healthcare, (2) theoretical framework, and (3) practice recommendations. This literature review will inform healthcare social workers on how they can improve the quality of care to WLWH.

== Barriers to Healthcare ==
There are many overarching issues associated with WLWH and healthcare barriers. Carr and Gramling (2004) discussed how WLWH may experience stigma, discrimination, sexism, racism, homophobia, and transphobia while interacting with the healthcare system. Consequently, WLWH regularly encounter negative experience when seeking assistance through the healthcare system. WLWH may express concern about accessing healthcare due to violence from their perpetrator. This may further isolate WLWH, and due to their reduced coping abilities they may be further prevented from accessing healthcare (Lichtenstein, 2006). WLWH could experience substance use, mental health, and isolation which further exacerbates their need for adequate and interdisciplinary care (Gahagan & Loppie, 2001). Funding is often overlooked and prevents WLWH from accessing HIV care services (Moneyham et al., 2010). Often WLWH will have negative experiences with healthcare providers which may discourage them from receiving routine medical care (Churcher, 2013). A lack of services focusing on WLWH limits their ability to access women-specific services to address their unique needs (Csete, 2005). It is increasingly complicated for a WLWH to address her own healthcare needs when there are multiple other responsibilities such as being a mother, homemaker, paid worker, and caregiver (Stein et al., 2000; Schuster et al., 2000). These conflicting responsibilities pose a unique challenge for women when they attempt to try to address their own healthcare needs. WLWH experience a multitude of barriers to healthcare and the findings above are not an exhaustive list. These findings do not encompass all the recommendations identified in the research and additional research can be useful to further articulate additional barriers. The barriers discussed above must be dismantled and addressed in healthcare services to prevent unjust access to care.

== Theoretical Framework ==
In accordance with the Canadian Association of Social Workers (CASW), social workers need to utilize theoretical frameworks in exercising professional judgments (CASW, 2020). The curative medical model often pathologizes WLWH. To shift from this ideology practitioners will need to be more cognizant to look beyond this extent thus incorporating a more holistic and inclusive approach to one’s bio-psychosocial diverse needs. By utilizing a theoretical framework such as the social determinants of health it will help medical professionals to evaluate the intersection of social and structural factors that threaten WLWH’s health (Benoit et al., 2009). This framework acknowledges the intersections of a WLWH’s identity and their experience of social, economic, and political realities and the role that these intersections have in shaping their health outcome and experiences with healthcare services (Hankivsky & Christoffersen, 2008). The social determinants of health offer a more integrated approach when working within a multi-disciplinary medical team. The model further provides digestible language to encourage the use of open communication to discuss further ways to improve opportunities of equity, accountability, efficiency, and responsiveness of the delivery of healthcare for WLWH.

== Practice Recommendations ==
It is of utmost importance to include the voices of WLWH to influence recommendations so that healthcare services can be tailored to be women-specific which will respond to the intersectional needs of WLWH. WLWH are the experts of their own experiences and should influence what resources and services should look like for themselves which would likely address their healthcare needs more holistically and effectively. In turn, this would involve WLWH in the planning, delivery, and evaluation of services. While working with WLWH it is critical to work from a women-centered approach. The women-centered approach would include service providers providing opportunities that promote self-determination which would enhance their equity and quality of care (Vancouver/Richmond Health Board, 2001). It is further encouraged to ensure tailored programming for women (Grella, 2008). There is a need to listen to the experiences of women and provide meaningful access to care through social and supportive services (Vancouver/Richmond Health Board, 2001). Offering practical support like on-site childcare or childcare subsidies would alleviate any child-rearing stressors.

Researchers encourage healthcare providers to facilitate access to culturally sensitive information wherever possible and facilitate meaningful communication (Wisdom et al., 2008; 2009). This could look like culturally appropriate brochures in a women’s language or a peer support group to facilitate access to information. Additional recommendations for social work and healthcare practice include the need to consider the family as the unit of intervention (Schuster et al., 2000). Women consider their family in the context of decision making and therefore family and family context should be acknowledged and included. Additionally, it is crucial to involve a multidisciplinary integration and coordination of services (Vancouver/Richmond Health Board, 2001). For example, WLWH have unique experiences, and services are required to have an integrated approach to meet their unique needs to improve health outcomes. In Canada, BC Women’s Hospital has an Oak Tree Clinic which provides specialized and interprofessional care to women, children, and their families living with HIV. This program is a positive model that can be incorporated across other regions and enhanced by incorporating the practice recommendations mentioned.

WLWH have multiple social determinants of health that may need to be addressed along with their medical care like drug therapies and specialist appointments with various healthcare providers. WLWH have unique needs and a women-centered approach would include meeting the women where they are at (Shannon et al., 2005). All social workers and healthcare professionals should be encouraged to engage in gender, culture, and HIV training (Vancouver/Richmond Health Board, 2001). This would help professionals deconstruct any biases, judgments, and stereotypes which would evolve into more inclusive and women-centered care. WLWH have felt unsafe and discriminated against while interacting with the healthcare system. Therefore, there is a need to create a sense of safety, respect, and acceptance while working with WLWH (Carter et al., 2013''').''' Lastly, the role of engaging in HIV/AIDS research will help shed light on implications for practice with the hope of improving the quality of healthcare for patients experiencing HIV/AIDS.

== Conclusion ==
Literary resources attribute largely to repressive societal factors and social ideals. What becomes necessary for social workers is to be aware of the historical and political context of any crisis. There needs to be more establishment in developing empowerment, self-determination, and autonomy, so that WLWH can make independent decisions that impact the services they as women receive from the healthcare system. To achieve this, one must recognize power imbalances, so assumptions and institutional practices are challenged. Institutions are sometimes disempowering in preventing the health and well-being of individuals. As social workers, we must understand and navigate the complexities within the healthcare system. By understanding WLWH, their barriers to healthcare, the social determinants of health, and practice recommendations, social workers can adapt to change and implement strategies and resources to influence new interventions to meet the increasingly diverse and growing population of WLWH. As one tries to revise the century-old ideologies of the healthcare system, we must strive to address the social determinants of health for WLWH and work towards finding balance, equal opportunity for treatment and care, and provide resources to address the specific bio-psychosocial needs of WLWH.

== References ==
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Act. (2021). ''History''. AIDS Committee of Toronto. Retrieved November 18, 2022, from <nowiki>https://www.actoronto.org/about-act/our-organization/history</nowiki>

Benoit, C., Shumka, L., Vallance, K., Hallgrimsdottir, H., Phillips, R., Kobayashi, K., Hankivsky, O., Reid, C., Brief, E. (2009). Explaining the health gap experienced by girls and women in Canada: A social determinants of health perspective. ''Sociological Research Online, 14''(5), 1-13. <nowiki>https://doi.org/10.5153/sro.2024</nowiki>.

Canadian Association of Social Work (CASW). (2020). ''CASW Scope of Practice Statement''. Retrieved November 19, 2022, from <nowiki>https://www.casw-acts.ca/files/attachements/Scope_of_Practice_Statement_2020_1.pdf</nowiki>

Carr, R. L., Gramling, L.F. (2004). Stigma: A healthcare barrier for women with HIV/AIDS. ''The Journal of the Association of Nurses in AIDS care, 15''(5), 30.

Carter, A.J., Bourgeois, S., O’Brien, N., Abelsohn, K., Tharao, W., Greene, S., Margolese, S., Kaida, A., Sanchez, M., Palmer, A.K., Cescon, A., Pokomandy, A., Loutfy, M.R., & CHIWOS Research Team. (2013). Women-specific HIV/AIDS services: Identifying and defining the components of holistic service delivery for women living with HIV/AIDS. ''Journal of the International AIDS Society, 16''(1), 17433-n/a. <nowiki>https://doi.org/10.7448/IAS.16.1.17433</nowiki>

Csete, J. (2005). ''‘Vectors, Vessels and Victims’:'' ''HIV/AIDS and women’s human rights in Canada.'' Canadian HIV/AIDS Legal Network.

Churcher, S. (2013). Stigma related to HIV and AIDS as a barrier to accessing healthcare in Thailand. A review of recent literature. ''WHO South-East Asia Journal of Public Health, 2''(1), 12-22. <nowiki>https://doi.org/10.4103/2224-3151.115829</nowiki>

Gahagan, J.C., & Loppie, C.J. (2001). Counting pills or counting on pills? What HIV+ women have to say about antiretroviral therapy. ''Canadian Woman studies, 21''(2), 118.

Grella, C.E. (2008). From generic to gender-responsive treatment: Changes in social policies, treatment services, and outcomes of women in substance abuse treatment: California substance abuse research consortium (SARC) meetings 2007. ''Journal of psychoactive Drugs'', 327-343.

Hankivsky, O. & Christoffersen, A. (2008) Intersectionality and the determinants of health: A Canadian perspective. ''Critical Public Health'', 18(3): 271-283.

Lichtenstein, B. (2006). Domestic violence in barriers to healthcare for HIV-positive women. ''AIDS Patient Care and STDs, 20''(2), 122.

Moneyham, L., McLeod, J., Boehme, A., Wright, L., Mugavero, M., Seal, P., Norton, W.E., & Kempf, M. (2010). Perceived barriers to HIV care among HIV-infected women in the deep south. ''The Journal of the Association of Nurses in AIDS Care, 21''(6), 467-477. <nowiki>https://doi.org/10.1016/j.jana.2010.03.00</nowiki>.

Stein, M., Crystal, S., Cunningham, W., Ananthanarayanan, A., Andersen, R., Turner, B., Zierler, S., Morton, S., Katz, M., Bozzette, S., Shapiro, M., & Schuster, M. (2000). ''Delays in seeking HIV Care due to competing caregiver responsibilities. American Journal of Public Health (1971), 90''(7), 1138-1140. <nowiki>https://doi.org/10.2105/AJPH.90.7.1138</nowiki>

Schuster, M., Kanouse, D., Morton, S., Bozzette, S., Miu, A., Scott, G., & Shapiro, M. (2000). HIV-infected parents and their children in the United States. ''American Journal of Public Health (1971), 90''(7), 1074-1081. <nowiki>https://doi.org/10.2105/AJPH.90.7.1074</nowiki>.

Shannon, K., Bright, V., Duddy, J., & Tyndall, M.W. (2005). Access and utilization of HIV treatment and services among women sex workers in Vancouver’s downtown eastside. ''Journal of Urban Health, 82''(3), 488-497. <nowiki>https://doi.org/10.1093/jurban/jti076</nowiki>.

Vancouver/Richmond Health Board. (2001). ''A Framework for women centred health'': Vancouver/ Richmond Health Board.

Wisdom, J.P., Hoffman, K., Rechberger, E., Seim, K., Owens, B. (2008;2009;). Women-focused treatment agencies and process improvement: Strategies to increase client engagement. ''Women & Therapy, 32''(1), 69-87. <nowiki>https://doi.org/10.1080/02703140802384693</nowiki>.

{{Cc-by-nc-4.0}}

Course:SOWK551/2021/ HIV/AIDS, Women, and Social Work Practice

2023-01-12T21:53:42Z

KellyAllison:

[[File:Ehimetalor-akhere-unuabona-Hf4QOGcnBnA-unsplash.jpg|thumb|Photo by Ehimatalor Ekhere Ubuobona on Unsplash]]

== Short Summary ==
This literature review will inform healthcare social workers on how they can improve the quality of care to Women living with HIV.

''Author: anonymous''

''Date: December 8, 2022''

== Introduction ==
Although it has been about 40 years since HIV/AIDS was initially diagnosed in Canada many healthcare professionals still hold incorrect beliefs and misconceptions about the illness (Act, 2021). Presently, these preconceived notions lead to stigmatization, discrimination, and alienation of HIV-positive (HIV+) people, particularly among marginalized groups and women. Due to these negative societal pressures, HIV+ individuals continually face oppressive systematic barriers which generate extraordinary strain within the healthcare system, that is ill-equipped in meeting their needs. To put the public health issue into perspective “women represent 50% of the 33.3 million people living with HIV globally” (Carter et al., 2013, p.1). As a result, social workers often become part of the interdisciplinary team to lend guidance, education, and support to navigating these complex structures. An overview of the struggles and implications which are unique to women living with HIV (“WLWH”) is needed to navigate the bureaucratic medical system. Nevertheless, parameters and theoretical perspectives become influential in forming a social worker’s practice when working with WLWH. Present and future social work interventions and theoretical frameworks will be addressed which can be utilized in addressing the potentially fragmented service delivery of healthcare to WLWH.

'''Keywords:''' HIV-positive women, services for women, healthcare, social determinants of health, healthcare, and social work.

== Overview ==
The review of seventeen research publications occurred between 2000 to 2022. This literature review was conducted by using electronic online databases by searching the UBC library and google scholar to find peer-reviewed articles and grey literature. The search included the following keywords “HIV-positive women”, “services for women”, “healthcare”, “social determinants of health”, “healthcare”, and “social work”. The search terms were used alone and in various combinations. A considerable number of studies involved interviews with WLWH. A critique in the literature is that there is insufficient research completed on WLWH in Canada. As a result, the scope of the findings was examined globally to identify relevant literature. A thematic analysis was completed and resulted in three themes: (1) barriers to healthcare, (2) theoretical framework, and (3) practice recommendations. This literature review will inform healthcare social workers on how they can improve the quality of care to WLWH.

== Barriers to Healthcare ==
There are many overarching issues associated with WLWH and healthcare barriers. Carr and Gramling (2004) discussed how WLWH may experience stigma, discrimination, sexism, racism, homophobia, and transphobia while interacting with the healthcare system. Consequently, WLWH regularly encounter negative experience when seeking assistance through the healthcare system. WLWH may express concern about accessing healthcare due to violence from their perpetrator. This may further isolate WLWH, and due to their reduced coping abilities they may be further prevented from accessing healthcare (Lichtenstein, 2006). WLWH could experience substance use, mental health, and isolation which further exacerbates their need for adequate and interdisciplinary care (Gahagan & Loppie, 2001). Funding is often overlooked and prevents WLWH from accessing HIV care services (Moneyham et al., 2010). Often WLWH will have negative experiences with healthcare providers which may discourage them from receiving routine medical care (Churcher, 2013). A lack of services focusing on WLWH limits their ability to access women-specific services to address their unique needs (Csete, 2005). It is increasingly complicated for a WLWH to address her own healthcare needs when there are multiple other responsibilities such as being a mother, homemaker, paid worker, and caregiver (Stein et al., 2000; Schuster et al., 2000). These conflicting responsibilities pose a unique challenge for women when they attempt to try to address their own healthcare needs. WLWH experience a multitude of barriers to healthcare and the findings above are not an exhaustive list. These findings do not encompass all the recommendations identified in the research and additional research can be useful to further articulate additional barriers. The barriers discussed above must be dismantled and addressed in healthcare services to prevent unjust access to care.

== Theoretical Framework ==
In accordance with the Canadian Association of Social Workers (CASW), social workers need to utilize theoretical frameworks in exercising professional judgments (CASW, 2020). The curative medical model often pathologizes WLWH. To shift from this ideology practitioners will need to be more cognizant to look beyond this extent thus incorporating a more holistic and inclusive approach to one’s bio-psychosocial diverse needs. By utilizing a theoretical framework such as the social determinants of health it will help medical professionals to evaluate the intersection of social and structural factors that threaten WLWH’s health (Benoit et al., 2009). This framework acknowledges the intersections of a WLWH’s identity and their experience of social, economic, and political realities and the role that these intersections have in shaping their health outcome and experiences with healthcare services (Hankivsky & Christoffersen, 2008). The social determinants of health offer a more integrated approach when working within a multi-disciplinary medical team. The model further provides digestible language to encourage the use of open communication to discuss further ways to improve opportunities of equity, accountability, efficiency, and responsiveness of the delivery of healthcare for WLWH.

== Practice Recommendations ==
It is of utmost importance to include the voices of WLWH to influence recommendations so that healthcare services can be tailored to be women-specific which will respond to the intersectional needs of WLWH. WLWH are the experts of their own experiences and should influence what resources and services should look like for themselves which would likely address their healthcare needs more holistically and effectively. In turn, this would involve WLWH in the planning, delivery, and evaluation of services. While working with WLWH it is critical to work from a women-centered approach. The women-centered approach would include service providers providing opportunities that promote self-determination which would enhance their equity and quality of care (Vancouver/Richmond Health Board, 2001). It is further encouraged to ensure tailored programming for women (Grella, 2008). There is a need to listen to the experiences of women and provide meaningful access to care through social and supportive services (Vancouver/Richmond Health Board, 2001). Offering practical support like on-site childcare or childcare subsidies would alleviate any child-rearing stressors.

Researchers encourage healthcare providers to facilitate access to culturally sensitive information wherever possible and facilitate meaningful communication (Wisdom et al., 2008; 2009). This could look like culturally appropriate brochures in a women’s language or a peer support group to facilitate access to information. Additional recommendations for social work and healthcare practice include the need to consider the family as the unit of intervention (Schuster et al., 2000). Women consider their family in the context of decision making and therefore family and family context should be acknowledged and included. Additionally, it is crucial to involve a multidisciplinary integration and coordination of services (Vancouver/Richmond Health Board, 2001). For example, WLWH have unique experiences, and services are required to have an integrated approach to meet their unique needs to improve health outcomes. In Canada, BC Women’s Hospital has an Oak Tree Clinic which provides specialized and interprofessional care to women, children, and their families living with HIV. This program is a positive model that can be incorporated across other regions and enhanced by incorporating the practice recommendations mentioned.

WLWH have multiple social determinants of health that may need to be addressed along with their medical care like drug therapies and specialist appointments with various healthcare providers. WLWH have unique needs and a women-centered approach would include meeting the women where they are at (Shannon et al., 2005). All social workers and healthcare professionals should be encouraged to engage in gender, culture, and HIV training (Vancouver/Richmond Health Board, 2001). This would help professionals deconstruct any biases, judgments, and stereotypes which would evolve into more inclusive and women-centered care. WLWH have felt unsafe and discriminated against while interacting with the healthcare system. Therefore, there is a need to create a sense of safety, respect, and acceptance while working with WLWH (Carter et al., 2013''').''' Lastly, the role of engaging in HIV/AIDS research will help shed light on implications for practice with the hope of improving the quality of healthcare for patients experiencing HIV/AIDS.

== Conclusion ==
Literary resources attribute largely to repressive societal factors and social ideals. What becomes necessary for social workers is to be aware of the historical and political context of any crisis. There needs to be more establishment in developing empowerment, self-determination, and autonomy, so that WLWH can make independent decisions that impact the services they as women receive from the healthcare system. To achieve this, one must recognize power imbalances, so assumptions and institutional practices are challenged. Institutions are sometimes disempowering in preventing the health and well-being of individuals. As social workers, we must understand and navigate the complexities within the healthcare system. By understanding WLWH, their barriers to healthcare, the social determinants of health, and practice recommendations, social workers can adapt to change and implement strategies and resources to influence new interventions to meet the increasingly diverse and growing population of WLWH. As one tries to revise the century-old ideologies of the healthcare system, we must strive to address the social determinants of health for WLWH and work towards finding balance, equal opportunity for treatment and care, and provide resources to address the specific bio-psychosocial needs of WLWH.

== References ==
<references responsive="0" />
Act. (2021). ''History''. AIDS Committee of Toronto. Retrieved November 18, 2022, from <nowiki>https://www.actoronto.org/about-act/our-organization/history</nowiki>

Benoit, C., Shumka, L., Vallance, K., Hallgrimsdottir, H., Phillips, R., Kobayashi, K., Hankivsky, O., Reid, C., Brief, E. (2009). Explaining the health gap experienced by girls and women in Canada: A social determinants of health perspective. ''Sociological Research Online, 14''(5), 1-13. <nowiki>https://doi.org/10.5153/sro.2024</nowiki>.

Canadian Association of Social Work (CASW). (2020). ''CASW Scope of Practice Statement''. Retrieved November 19, 2022, from <nowiki>https://www.casw-acts.ca/files/attachements/Scope_of_Practice_Statement_2020_1.pdf</nowiki>

Carr, R. L., Gramling, L.F. (2004). Stigma: A healthcare barrier for women with HIV/AIDS. ''The Journal of the Association of Nurses in AIDS care, 15''(5), 30.

Carter, A.J., Bourgeois, S., O’Brien, N., Abelsohn, K., Tharao, W., Greene, S., Margolese, S., Kaida, A., Sanchez, M., Palmer, A.K., Cescon, A., Pokomandy, A., Loutfy, M.R., & CHIWOS Research Team. (2013). Women-specific HIV/AIDS services: Identifying and defining the components of holistic service delivery for women living with HIV/AIDS. ''Journal of the International AIDS Society, 16''(1), 17433-n/a. <nowiki>https://doi.org/10.7448/IAS.16.1.17433</nowiki>

Csete, J. (2005). ''‘Vectors, Vessels and Victims’:'' ''HIV/AIDS and women’s human rights in Canada.'' Canadian HIV/AIDS Legal Network.

Churcher, S. (2013). Stigma related to HIV and AIDS as a barrier to accessing healthcare in Thailand. A review of recent literature. ''WHO South-East Asia Journal of Public Health, 2''(1), 12-22. <nowiki>https://doi.org/10.4103/2224-3151.115829</nowiki>

Gahagan, J.C., & Loppie, C.J. (2001). Counting pills or counting on pills? What HIV+ women have to say about antiretroviral therapy. ''Canadian Woman studies, 21''(2), 118.

Grella, C.E. (2008). From generic to gender-responsive treatment: Changes in social policies, treatment services, and outcomes of women in substance abuse treatment: California substance abuse research consortium (SARC) meetings 2007. ''Journal of psychoactive Drugs'', 327-343.

Hankivsky, O. & Christoffersen, A. (2008) Intersectionality and the determinants of health: A Canadian perspective. ''Critical Public Health'', 18(3): 271-283.

Lichtenstein, B. (2006). Domestic violence in barriers to healthcare for HIV-positive women. ''AIDS Patient Care and STDs, 20''(2), 122.

Moneyham, L., McLeod, J., Boehme, A., Wright, L., Mugavero, M., Seal, P., Norton, W.E., & Kempf, M. (2010). Perceived barriers to HIV care among HIV-infected women in the deep south. ''The Journal of the Association of Nurses in AIDS Care, 21''(6), 467-477. <nowiki>https://doi.org/10.1016/j.jana.2010.03.00</nowiki>.

Stein, M., Crystal, S., Cunningham, W., Ananthanarayanan, A., Andersen, R., Turner, B., Zierler, S., Morton, S., Katz, M., Bozzette, S., Shapiro, M., & Schuster, M. (2000). ''Delays in seeking HIV Care due to competing caregiver responsibilities. American Journal of Public Health (1971), 90''(7), 1138-1140. <nowiki>https://doi.org/10.2105/AJPH.90.7.1138</nowiki>

Schuster, M., Kanouse, D., Morton, S., Bozzette, S., Miu, A., Scott, G., & Shapiro, M. (2000). HIV-infected parents and their children in the United States. ''American Journal of Public Health (1971), 90''(7), 1074-1081. <nowiki>https://doi.org/10.2105/AJPH.90.7.1074</nowiki>.

Shannon, K., Bright, V., Duddy, J., & Tyndall, M.W. (2005). Access and utilization of HIV treatment and services among women sex workers in Vancouver’s downtown eastside. ''Journal of Urban Health, 82''(3), 488-497. <nowiki>https://doi.org/10.1093/jurban/jti076</nowiki>.

Vancouver/Richmond Health Board. (2001). ''A Framework for women centred health'': Vancouver/ Richmond Health Board.

Wisdom, J.P., Hoffman, K., Rechberger, E., Seim, K., Owens, B. (2008;2009;). Women-focused treatment agencies and process improvement: Strategies to increase client engagement. ''Women & Therapy, 32''(1), 69-87. <nowiki>https://doi.org/10.1080/02703140802384693</nowiki>.

{{Cc-by-nc-4.0}}

Course:SOWK551/2021/Use of Horticultural Therapy on Mental Health in Healthcare

2023-01-12T20:15:34Z

KellyAllison:

[[File:Benjamin-combs-wuU SSxDeS0-unsplash (1).jpg|thumb|Two people working in a garden]]
== Short Summary ==
Literature review on using horticultural therapy on patients suffering from mental illness in healthcare setting and social work practice.

''Author: Davis T.''

''Date: December 9, 2022''

== Introduction ==
Mental health is one of the outstanding healthcare issues in the world (World Health Organization (WHO), 2022). Per Bland et al. (2021), mental health is a specialist social work practice, and general social workers in various fields of practice have been employed in working with individuals’ mental health concerns as a part of psychosocial interventions. Mental health service providers adopted various evidence-based clinical practice models in their work. Horticulture Therapy has been long used as a therapeutic activity for people suffering from mental illnesses (Siu et al., 2020). This literature review aims at providing an overview of the effectiveness of the application of Horticultural Therapy on Mental illness Patients in healthcare and its relevance to social work practice.

== Definition of Horticultural Therapy ==
Horticultural therapy (HT) is a clinical practice model that uses plants, horticultural activities, and the garden landscape to promote holistic well-being for service users to achieve clinically outlined goals (Canadian Horticultural Therapy Association (CHTA), 2022; Cipriani et al., 2017; Kam & Siu, 2010). The goals are measurable, and the outcome of HT is expected to bring a sense of accomplishment. In practicing HT, participants are generally invited to take care of plants during therapy and counselling sessions; they are guided to experience the growth process of the plants in healing gardens; and therapists should make use of the multi-sensory characteristics of plants during the program (Siu et al., 2020).

HT is often considered interchangeable with ‘therapeutic horticulture’ (Cipriani et al., 2017), which is the process to improve participants’ health and wellness through plants and related activities (CHTA, 2022). Compared to HT, goals and defined outcomes of therapeutic horticulture are not necessarily considered nor clinically documented (CHTA, 2022). The general public can practice therapeutic horticulture on their own without the presence of HT practitioners. ''.''

== Effectiveness on Mental Health ==
In accordance with WHO (2022), an estimated 970 million people were living with a mental illness worldwide, which accounted of 13% of the global population in 2019. There was an anticipated 27% rise in the global prevalence of mental disorders after the COVID-19 pandemic (Santomauro et al., 2021; WHO, 2022).

Canadian Institute for Health Information (2019) and Smetanin et al. (2011) revealed that 20% of Canadians experienced a mental illness in their lives; about 38% of Canadians reported that their symptoms started before the age of 15, and half of Canadians have experienced or developed a mental illness when they reached 40 years old. About 17% of British Columbians, approximately 800, 000 people, were experiencing a mental illness or substance use issue (Canadian Mental Health Association Mental, 2022).

HT has been long used extensively as a non-pharmacological intervention for people with mental illnesses, such as schizophrenia and depression, and promoting mental health in rehabilitative, vocational, and community settings (Clatworthy et al., 2013; Tu, 2022). Participants would engage in goal-orientated HT in the form of active gardening and the passive appreciation of nature alongside counseling. HT is proven to be effective in working with patients with mental illness in terms of generating emotional benefits to patients, such as reducing psychiatric symptoms and stress, and increasing the sense of tranquility, mood stabilization and enjoyment (Han et al., 2018); reducing fatigue and restore attention and cognitive ability (Berman et al., 2008); increasing self-efficacy, self-esteem, and quality of life (Siu et al., 2020); as well as improving decision-making and delivering a sense of perceived control and empowerment (Kenmochi et al., 2019; Tu, 2022). Moreover, group HT provides an opportunity for patients to have group cohesiveness and a sense of belonging (Siu et al., 2020).

HT benefits mental health due to its ability to restore attention, and promote social cohesion and connectedness (Chen et al., 2013; Ng et al., 2021; Tu, 2022). According to the attention restoration theory, HT program activities involve being in touch with plants and nature to focus on here-and-now, distract participants from negative emotions and reduce feelings of depression and anxiety (Kenmochi et al., 2019). The horticultural activity in a natural environment generates a feeling of distancing from hustle daily lives or the urban environment, which is critical in promoting mental health and reducing mental fatigue (Tu, 2022). Patients can engage in purposeful activities and develop a sense of accomplishment and productivity, as well as develop sustainable vocational skills and productivity in horticulture (Siu et al., 2020).

== Healing Garden ==
Healing garden or therapeutic garden, interchangeably, is imperative in delivering HT. It a nature-oriented space aimed at providing therapeutic or rehabilitative potential benefits and maximum influence on health to participants (Söderback et al., 2004). It acts as a place of sanctuary to meet one’s desire for contact with nature, in particular in the metropolis and developed urban cities (Söderback et al., 2004). Healing gardens should a prevalence of green material throughout seasons, encourage exercise, minimize intrusions and ambiguity (Marcus & Barnes, 1999). In addition to a plentiful variety of plant materials that attract birds and butterflies, healing gardens also consist of leaves that move with breeze, and pools have fish. Healing gardens should be open to all and give a sense of familiarity. It should be tranquil and peaceful so that its voices, such as birdsong and water-splash, can be heard, and facilitate non-discrimination with high accessibility. (Söderback et al., 2004).

== Horticultural Therapy in Healthcare ==
HT is considered an alternative treatment option in rehabilitation for patients suffering from chronic mental disorders. Evidence has shown that HT significant benefits multiple populations of hospitalized patients including paediatric, geriatric, and psychiatric patients (Knotos et al., 2021). The diverse structure of HT benefits patients in terms of mental well-being, stress and coping, self-esteem, cognitive function, and interpersonal relationships (Siu, Kam & Mok, 2020).

In Canada, gardens are commonly found in hospitals for therapeutic practice. There are gardens in hospitals throughout Metro Vancouver designed for patients, friends, relatives, and staff such as Banfield Pavilion in Vancouver General Hospital, the garden in Royal Columbia Hospital, and the rooftop garden in St Paul’s Hospital … etc. Healing gardens can improve the quality of a hospital’s physical environment which provides positive patient medical outcomes and care quality. For instance, long-stay and paediatric hospitals are suggested to have gardens access to grounds, parks, and playgrounds the US (Söderback et al., 2004).

HT can also be used for influencing health and well-being by viewing photographs, slides, and videos of outdoor nature and garden scenes (Söderback et al., 2004). These are beneficial to patients with low mobility or bedridden patients. In terms of promoting patients’ health, well-being, and quality of life, in addition to the positive outcomes on one’s emotional skills, HT is often used by occupational therapy professionals in hospitals to address the performance needs of clients in areas of occupation such as activities of daily living (Cipriani et al., 2017).

== Critiques & Application to Social Work Practice ==
Mental health assessment is a common topic in HT studies. Existing studies have explored the outcome of HT on mental health with reported positive results (Kenmochi et al., 2019; Zhu et al., 2016). Nevertheless, there are critiques of the results, that the studies are inconsistent due to the different tools used in assessing mental health (Kam & Siu, 2010; Nicholas et al., 2019). The results have also been disturbed by factors including report quality, suitable control group randomization, study participants, and blinding methods. The randomized controlled trials of HT research were indicated to lack strength of evidence and gave rise to non-significant results in some existing studies (Nicholas et al., 2019).

There is inadequate evidence of the prospective advantages of HT for hospitalized patients. Despite the increasing prevalence of HT and therapeutic horticulture implementation in healthcare, most literature has merely focused on the advantages of therapeutic horticulture and social horticulture through exploratory analyses (Cipriani et al., 2017). The validity was reduced by the small sample size and incomplete narrative of actual HT interventions (Clatworthy et al., 2017).

Though HT is a recognized profession, service providers does not have to be trained horticultural therapists to implement HT. Practitioners from diverse settings including hospitals, hospices, rehabilitation facilities, botanical gardens, and private practice could provide HT to participants (Cipriani et al., 2017). Alongside recreational therapists, physical therapists and occupational therapists, social workers are also an example of common practitioners who can utilize HT within their scope of practice (Horticultural Therapy Institute, 2022). However, most of the existing literature about HT is written by recreational therapy professionals, occupational therapy professionals, or nursing professionals. There lacks literature on the social work perspectives.

Since mental health is one of the major service scopes of social work practice (Bland et al., 2021), it is imperative for social work practitioners to understand the available resources and work in the multi-disciplinary team, or equip with effective clinical practice models for rendering therapeutic intervention and assessment. HT is suitable for social work as it aligns with the social work values of a client-centered approach and person-in-environment perspectives. Healing gardens also associate with social workers’ mission of social justice and anti-oppressive practice in terms of addressing cultural sensitivity and high accessibility. Moreover, HT also acts as an intervention addressing patients’ needs in the social determinant of health perspective.

In addition to implementing HT in clinical practice or using it as a resource for system navigation, social workers can conduct high-quality social research on HT for exploring the related issues and concerns with social work perspective and promoting social justice, for instance, social workers can utilize the intersectionality lens and anti-oppressive practice in conducting critical research with providing strong evidence.

== Recommendation ==
HT was shown to be a safe and feasible non-pharmacological intervention in healthcare. Lin et al (2021) recommend that HT should be promoted in nursing homes, communities, hospitals, and even families. Healthcare professionals are recommended to apply HT to different populations, especially there are increased loneliness in the population, such as older adults due to the post-pandemic influence. Developing HT intervention could bring a positive influence on the physical and psychological well-being of the society. Furthermore, HT is important in public mental health. Literature suggested that HT should be considered valuable for cultivating mental health by healthcare service providers and to be integrated into medical, healthcare, and community settings to promote mental health (Tu, 2022).

There are regulatory bodies for horticultural therapist professionals in North America, Conversely, HT was not widely used as mainstream medicine practitioners considered that there needs to be more substantial in favor of the beneficial effects of HT based on evidence-based medicine (Tu 2022). For future research, there could be more robust and larger sample sizes for higher levels of evidence and minimizing error. More studies should focus on HT interventions and healing gardens with clinically designed goals instead of simply focusing on horticulture-based interventions such as therapeutic horticulture and social horticulture (Cipriani et al., 2017). Future studies could also observe the changes in participants’ interest in plants, and their horticultural knowledge and skills so as to have holistic evidence for determining the long-lasting effect of HT (Siu et al., 2020).

Eventually, Cipriani et al. (2017) suggested that more studies should be carried out by various healthcare professionals, for instance, social workers and physical therapists. Therefore, outcomes of interest to the related profession can be comprised in subsequent studies.

== Conclusion ==
In conclusion, this paper reviewed recent literature and has found significant effectiveness of horticulture therapy on mental health. Social workers are recommended to apply HT in their clinical practice and to conduct high-quality research in this model.

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Siu, A. M. H., Kam, M., & Mok, I. (2020). Horticultural therapy program for people with mental illness: A mixed-method evaluation. ''International Journal of Environmental Research and Public Health'', ''17''(3), 711. [[/doi.org/10.3390/ijerph17030711|https://doi.org/10.3390/ijerph17030711]]

Smetanin, P., Stiff, D., Briante, C., Adair, C.E., Ahmad, S. & Khan, M. (2011). The Life and Economic Impact of Major Mental Illnesses in Canada: 2011 to 2041. ''RiskAnalytica, on behalf of the Mental Health Commission of Canada 2011.''

Söderback, I., Söderström, M., & Schälander, E. (2004). Horticultural therapy: The ‘healing garden’and gardening in rehabilitation measures at Danderyd Hospital Rehabilitation Clinic, Sweden. ''Pediatric Rehabilitation'', ''7''(4), 245–260. <nowiki>https://doi.org/10.1080/13638490410001711416</nowiki>

Tu, H. M. (2022). Effect of horticultural therapy on Mental Health: A meta‐analysis of Randomized Controlled Trials. ''Journal of Psychiatric and Mental Health Nursing'', ''29''(4), 603–615. <nowiki>https://doi.org/10.1111/jpm.12818</nowiki>

World Health Organization. (2022). ''World mental health report: transforming mental health for all.'' <nowiki>ISBN 978-92-4-004933-8</nowiki>

Zhu, S., Wan, H., Lu, Z., Wu, H., Zhang, Q., Qian, X., & Ye, C. (2016). Treatment Effect of Antipsychotics in Combination with Horticultural Therapy on Patients with Schizophrenia: A Randomized, Double-blind, Placebo-controlled Study. ''Shanghai archives of psychiatry'', ''28''(4), 195–203. <nowiki>https://doi.org/10.11919/j.issn.1002-0829.216034</nowiki>
<references responsive="0" />
{{Cc-by-nc-4.0}}

Course:SOWK551/2021/Use of Horticultural Therapy on Mental Health in Healthcare

2023-01-12T20:14:21Z

KellyAllison:

[[File:Benjamin-combs-wuU SSxDeS0-unsplash (1).jpg|thumb|Two people working in a garden]]
== Short Summary ==
A literature review on using horticultural therapy on patients suffering from mental illness in healthcare setting and social work practice.

''Author: Davis T.''

''Date: December 9, 2022''

== Introduction ==
Mental health is one of the outstanding healthcare issues in the world (World Health Organization (WHO), 2022). Per Bland et al. (2021), mental health is a specialist social work practice, and general social workers in various fields of practice have been employed in working with individuals’ mental health concerns as a part of psychosocial interventions. Mental health service providers adopted various evidence-based clinical practice models in their work. Horticulture Therapy has been long used as a therapeutic activity for people suffering from mental illnesses (Siu et al., 2020). This literature review aims at providing an overview of the effectiveness of the application of Horticultural Therapy on Mental illness Patients in healthcare and its relevance to social work practice.

== Definition of Horticultural Therapy ==
Horticultural therapy (HT) is a clinical practice model that uses plants, horticultural activities, and the garden landscape to promote holistic well-being for service users to achieve clinically outlined goals (Canadian Horticultural Therapy Association (CHTA), 2022; Cipriani et al., 2017; Kam & Siu, 2010). The goals are measurable, and the outcome of HT is expected to bring a sense of accomplishment. In practicing HT, participants are generally invited to take care of plants during therapy and counselling sessions; they are guided to experience the growth process of the plants in healing gardens; and therapists should make use of the multi-sensory characteristics of plants during the program (Siu et al., 2020).

HT is often considered interchangeable with ‘therapeutic horticulture’ (Cipriani et al., 2017), which is the process to improve participants’ health and wellness through plants and related activities (CHTA, 2022). Compared to HT, goals and defined outcomes of therapeutic horticulture are not necessarily considered nor clinically documented (CHTA, 2022). The general public can practice therapeutic horticulture on their own without the presence of HT practitioners. ''.''

== Effectiveness on Mental Health ==
In accordance with WHO (2022), an estimated 970 million people were living with a mental illness worldwide, which accounted of 13% of the global population in 2019. There was an anticipated 27% rise in the global prevalence of mental disorders after the COVID-19 pandemic (Santomauro et al., 2021; WHO, 2022).

Canadian Institute for Health Information (2019) and Smetanin et al. (2011) revealed that 20% of Canadians experienced a mental illness in their lives; about 38% of Canadians reported that their symptoms started before the age of 15, and half of Canadians have experienced or developed a mental illness when they reached 40 years old. About 17% of British Columbians, approximately 800, 000 people, were experiencing a mental illness or substance use issue (Canadian Mental Health Association Mental, 2022).

HT has been long used extensively as a non-pharmacological intervention for people with mental illnesses, such as schizophrenia and depression, and promoting mental health in rehabilitative, vocational, and community settings (Clatworthy et al., 2013; Tu, 2022). Participants would engage in goal-orientated HT in the form of active gardening and the passive appreciation of nature alongside counseling. HT is proven to be effective in working with patients with mental illness in terms of generating emotional benefits to patients, such as reducing psychiatric symptoms and stress, and increasing the sense of tranquility, mood stabilization and enjoyment (Han et al., 2018); reducing fatigue and restore attention and cognitive ability (Berman et al., 2008); increasing self-efficacy, self-esteem, and quality of life (Siu et al., 2020); as well as improving decision-making and delivering a sense of perceived control and empowerment (Kenmochi et al., 2019; Tu, 2022). Moreover, group HT provides an opportunity for patients to have group cohesiveness and a sense of belonging (Siu et al., 2020).

HT benefits mental health due to its ability to restore attention, and promote social cohesion and connectedness (Chen et al., 2013; Ng et al., 2021; Tu, 2022). According to the attention restoration theory, HT program activities involve being in touch with plants and nature to focus on here-and-now, distract participants from negative emotions and reduce feelings of depression and anxiety (Kenmochi et al., 2019). The horticultural activity in a natural environment generates a feeling of distancing from hustle daily lives or the urban environment, which is critical in promoting mental health and reducing mental fatigue (Tu, 2022). Patients can engage in purposeful activities and develop a sense of accomplishment and productivity, as well as develop sustainable vocational skills and productivity in horticulture (Siu et al., 2020).

== Healing Garden ==
Healing garden or therapeutic garden, interchangeably, is imperative in delivering HT. It a nature-oriented space aimed at providing therapeutic or rehabilitative potential benefits and maximum influence on health to participants (Söderback et al., 2004). It acts as a place of sanctuary to meet one’s desire for contact with nature, in particular in the metropolis and developed urban cities (Söderback et al., 2004). Healing gardens should a prevalence of green material throughout seasons, encourage exercise, minimize intrusions and ambiguity (Marcus & Barnes, 1999). In addition to a plentiful variety of plant materials that attract birds and butterflies, healing gardens also consist of leaves that move with breeze, and pools have fish. Healing gardens should be open to all and give a sense of familiarity. It should be tranquil and peaceful so that its voices, such as birdsong and water-splash, can be heard, and facilitate non-discrimination with high accessibility. (Söderback et al., 2004).

== Horticultural Therapy in Healthcare ==
HT is considered an alternative treatment option in rehabilitation for patients suffering from chronic mental disorders. Evidence has shown that HT significant benefits multiple populations of hospitalized patients including paediatric, geriatric, and psychiatric patients (Knotos et al., 2021). The diverse structure of HT benefits patients in terms of mental well-being, stress and coping, self-esteem, cognitive function, and interpersonal relationships (Siu, Kam & Mok, 2020).

In Canada, gardens are commonly found in hospitals for therapeutic practice. There are gardens in hospitals throughout Metro Vancouver designed for patients, friends, relatives, and staff such as Banfield Pavilion in Vancouver General Hospital, the garden in Royal Columbia Hospital, and the rooftop garden in St Paul’s Hospital … etc. Healing gardens can improve the quality of a hospital’s physical environment which provides positive patient medical outcomes and care quality. For instance, long-stay and paediatric hospitals are suggested to have gardens access to grounds, parks, and playgrounds the US (Söderback et al., 2004).

HT can also be used for influencing health and well-being by viewing photographs, slides, and videos of outdoor nature and garden scenes (Söderback et al., 2004). These are beneficial to patients with low mobility or bedridden patients. In terms of promoting patients’ health, well-being, and quality of life, in addition to the positive outcomes on one’s emotional skills, HT is often used by occupational therapy professionals in hospitals to address the performance needs of clients in areas of occupation such as activities of daily living (Cipriani et al., 2017).

== Critiques & Application to Social Work Practice ==
Mental health assessment is a common topic in HT studies. Existing studies have explored the outcome of HT on mental health with reported positive results (Kenmochi et al., 2019; Zhu et al., 2016). Nevertheless, there are critiques of the results, that the studies are inconsistent due to the different tools used in assessing mental health (Kam & Siu, 2010; Nicholas et al., 2019). The results have also been disturbed by factors including report quality, suitable control group randomization, study participants, and blinding methods. The randomized controlled trials of HT research were indicated to lack strength of evidence and gave rise to non-significant results in some existing studies (Nicholas et al., 2019).

There is inadequate evidence of the prospective advantages of HT for hospitalized patients. Despite the increasing prevalence of HT and therapeutic horticulture implementation in healthcare, most literature has merely focused on the advantages of therapeutic horticulture and social horticulture through exploratory analyses (Cipriani et al., 2017). The validity was reduced by the small sample size and incomplete narrative of actual HT interventions (Clatworthy et al., 2017).

Though HT is a recognized profession, service providers does not have to be trained horticultural therapists to implement HT. Practitioners from diverse settings including hospitals, hospices, rehabilitation facilities, botanical gardens, and private practice could provide HT to participants (Cipriani et al., 2017). Alongside recreational therapists, physical therapists and occupational therapists, social workers are also an example of common practitioners who can utilize HT within their scope of practice (Horticultural Therapy Institute, 2022). However, most of the existing literature about HT is written by recreational therapy professionals, occupational therapy professionals, or nursing professionals. There lacks literature on the social work perspectives.

Since mental health is one of the major service scopes of social work practice (Bland et al., 2021), it is imperative for social work practitioners to understand the available resources and work in the multi-disciplinary team, or equip with effective clinical practice models for rendering therapeutic intervention and assessment. HT is suitable for social work as it aligns with the social work values of a client-centered approach and person-in-environment perspectives. Healing gardens also associate with social workers’ mission of social justice and anti-oppressive practice in terms of addressing cultural sensitivity and high accessibility. Moreover, HT also acts as an intervention addressing patients’ needs in the social determinant of health perspective.

In addition to implementing HT in clinical practice or using it as a resource for system navigation, social workers can conduct high-quality social research on HT for exploring the related issues and concerns with social work perspective and promoting social justice, for instance, social workers can utilize the intersectionality lens and anti-oppressive practice in conducting critical research with providing strong evidence.

== Recommendation ==
HT was shown to be a safe and feasible non-pharmacological intervention in healthcare. Lin et al (2021) recommend that HT should be promoted in nursing homes, communities, hospitals, and even families. Healthcare professionals are recommended to apply HT to different populations, especially there are increased loneliness in the population, such as older adults due to the post-pandemic influence. Developing HT intervention could bring a positive influence on the physical and psychological well-being of the society. Furthermore, HT is important in public mental health. Literature suggested that HT should be considered valuable for cultivating mental health by healthcare service providers and to be integrated into medical, healthcare, and community settings to promote mental health (Tu, 2022).

There are regulatory bodies for horticultural therapist professionals in North America, Conversely, HT was not widely used as mainstream medicine practitioners considered that there needs to be more substantial in favor of the beneficial effects of HT based on evidence-based medicine (Tu 2022). For future research, there could be more robust and larger sample sizes for higher levels of evidence and minimizing error. More studies should focus on HT interventions and healing gardens with clinically designed goals instead of simply focusing on horticulture-based interventions such as therapeutic horticulture and social horticulture (Cipriani et al., 2017). Future studies could also observe the changes in participants’ interest in plants, and their horticultural knowledge and skills so as to have holistic evidence for determining the long-lasting effect of HT (Siu et al., 2020).

Eventually, Cipriani et al. (2017) suggested that more studies should be carried out by various healthcare professionals, for instance, social workers and physical therapists. Therefore, outcomes of interest to the related profession can be comprised in subsequent studies.

== Conclusion ==
In conclusion, this paper reviewed recent literature and has found significant effectiveness of horticulture therapy on mental health. Social workers are recommended to apply HT in their clinical practice and to conduct high-quality research in this model.

== References ==
Berman, M. G., Jonides, J., & Kaplan, S. (2008). The cognitive benefits of interacting with nature. ''Psychological Science'', ''19''(12), 1207–1212. <nowiki>https://doi.org/10.1111/j.1467-9280.2008.02225.x</nowiki>

Bland, R., Drake, G., & Drayton, J. (2021). A starting point Understanding social work in mental health. In ''Social Work Practice in Mental Health: An introduction'' (3rd ed.). essay, Routledge.

Canadian Horticultural Therapy Association . (2022). ''What is Horticultural Therapy?'' . Canadian Horticultural Therapy Association . Retrieved December 9, 2022, from <nowiki>https://www.chta.ca/</nowiki>

Canadian Mental Health Association Mental. (2022). ''Canadian Mental Health Association Mental Health for all.'' Facts and Figures. Retrieved December 9, 2022, from <nowiki>https://cmha.bc.ca/impact/facts-and-figures/</nowiki>

Chen, H.-M., Tu, H.-M., & Ho, C.-I. (2013). Understanding biophilia leisure as facilitating well-being and the environment: An examination of participants’ attitudes toward horticultural activity. ''Leisure Sciences'', ''35''(4), 301–319. <nowiki>https://doi.org/10.1080/01490400.2013.797323</nowiki>

Cipriani, J., Benz, A., Holmgren, A., Kinter, D., McGarry, J., & Rufino, G. (2017). A systematic review of the effects of horticultural therapy on persons with mental health conditions. ''Occupational Therapy in Mental Health'', ''33''(1), 47–69. <nowiki>https://doi.org/10.1080/0164212x.2016.1231602</nowiki>

Clatworthy, J., Hinds, J., & M. Camic, P. (2013). Gardening as a mental health intervention: A Review. ''Mental Health Review Journal'', ''18''(4), 214–225. <nowiki>https://doi.org/10.1108/mhrj-02-2013-0007</nowiki>

Han, A.-R., Park, S.-A., & Ahn, B.-E. (2018). Reduced stress and improved physical functional ability in elderly with mental health problems following a horticultural therapy program. ''Complementary Therapies in Medicine'', ''38'', 19–23. <nowiki>https://doi.org/10.1016/j.ctim.2018.03.011</nowiki>

Horticultural Therapy Institute. (2022). ''Horticultural therapy careers.'' Horticultural Therapy Institute: Linking people and plants. Retrieved Retrieved December 9, 2022, from <nowiki>http://www.htinstitute.org</nowiki>.

Kam, M. C. Y., & Siu, A. M. H. (2010). Evaluation of a horticultural activity programme for persons with psychiatric illness. ''Hong Kong Journal of Occupational Therapy'', ''20''(2), 80–86. <nowiki>https://doi.org/10.1016/s1569-18611170007-9</nowiki>

Kenmochi, T., Kenmochi, A., & Hoshiyama, M. (2019). Effects of horti- cultural therapy on symptoms and future perspective of patients with schizophrenia in the chronic stage. ''Journal of Therapeutic Horticulture'', ''29''(1).

Kontos, K., Koutsou, S., Sismanidi, A., Theodoropoulou, N., Nikolopoulou, V., Filippiadou, M., & Papazisis, G. (2021). The effects of horticultural therapy on the functionality of psychotic patients employed in the green unit of the Psychiatric Hospital of Thessaloniki Greece. ''European Psychiatry'', ''64''(S1). <nowiki>https://doi.org/10.1192/j.eurpsy.2021.1354</nowiki>

Lin, Y., Lin, R., Liu, W., & Wu, W. (2021). Effectiveness of horticultural therapy on physical functioning and psychological health outcomes for older adults: A systematic review and meta‐analysis. ''Journal of Clinical Nursing'', ''31''(15-16), 2087–2099. <nowiki>https://doi.org/10.1111/jocn.16095</nowiki>

Marcus, C. C., & Barnes, M. (1999). ''Healing gardens: Therapeutic benefits and design recommendations''. J. Wiley.

Ng, T. K., Gan, D. R. Y., Mahendran, R., Kua, E. H., & Ho, R. C.-M. (2021). Social connectedness as a mediator for horticultural therapy's biological effect on community-dwelling older adults: Secondary analyses of a randomized controlled trial. ''Social Science & Medicine'', ''284'', 114191. <nowiki>https://doi.org/10.1016/j.socscimed.2021.114191</nowiki>

Nicholas, S. O., Giang, A. T., & Yap, P. L. K. (2019). The effectiveness of horticultural therapy on older adults: A systematic review. ''Journal of the American Medical Directors Association'', ''20''(10). [[/doi.org/10.1016/j.jamda.2019.06.021|https://doi.org/10.1016/j.jamda.2019.06.021]]

NursingBird. (2022, March 7). ''Social Work in Mental Health in Canada.'' Retrieved December 9, 2022, from [[/nursingbird.com/social-work-in-mental-health-in-canada/|https://nursingbird.com/social-work-in-mental-health-in-canada/]]

Santomauro, D. F., Mantilla Herrera, A. M., Shadid, J., Zheng, P., Ashbaugh, C., Pigott, D. M., Abbafati, C., Adolph, C., Amlag, J. O., Aravkin, A. Y., Bang-Jensen, B. L., Bertolacci, G. J., Bloom, S. S., Castellano, R., Castro, E., Chakrabarti, S., Chattopadhyay, J., Cogen, R. M., Collins, J. K., … Ferrari, A. J. (2021). Global prevalence and burden of depressive and anxiety disorders in 204 countries and territories in 2020 due to the COVID-19 pandemic. ''The Lancet'', ''398''(10312), 1700–1712. <nowiki>https://doi.org/10.1016/s0140-6736(21)02143-7</nowiki>

Siu, A. M. H., Kam, M., & Mok, I. (2020). Horticultural therapy program for people with mental illness: A mixed-method evaluation. ''International Journal of Environmental Research and Public Health'', ''17''(3), 711. <nowiki>https://doi.org/10.3390/ijerph17030711</nowiki>

Siu, A. M. H., Kam, M., & Mok, I. (2020). Horticultural therapy program for people with mental illness: A mixed-method evaluation. ''International Journal of Environmental Research and Public Health'', ''17''(3), 711. [[/doi.org/10.3390/ijerph17030711|https://doi.org/10.3390/ijerph17030711]]

Smetanin, P., Stiff, D., Briante, C., Adair, C.E., Ahmad, S. & Khan, M. (2011). The Life and Economic Impact of Major Mental Illnesses in Canada: 2011 to 2041. ''RiskAnalytica, on behalf of the Mental Health Commission of Canada 2011.''

Söderback, I., Söderström, M., & Schälander, E. (2004). Horticultural therapy: The ‘healing garden’and gardening in rehabilitation measures at Danderyd Hospital Rehabilitation Clinic, Sweden. ''Pediatric Rehabilitation'', ''7''(4), 245–260. <nowiki>https://doi.org/10.1080/13638490410001711416</nowiki>

Tu, H. M. (2022). Effect of horticultural therapy on Mental Health: A meta‐analysis of Randomized Controlled Trials. ''Journal of Psychiatric and Mental Health Nursing'', ''29''(4), 603–615. <nowiki>https://doi.org/10.1111/jpm.12818</nowiki>

World Health Organization. (2022). ''World mental health report: transforming mental health for all.'' <nowiki>ISBN 978-92-4-004933-8</nowiki>

Zhu, S., Wan, H., Lu, Z., Wu, H., Zhang, Q., Qian, X., & Ye, C. (2016). Treatment Effect of Antipsychotics in Combination with Horticultural Therapy on Patients with Schizophrenia: A Randomized, Double-blind, Placebo-controlled Study. ''Shanghai archives of psychiatry'', ''28''(4), 195–203. <nowiki>https://doi.org/10.11919/j.issn.1002-0829.216034</nowiki>
<references responsive="0" />
{{Cc-by-nc-4.0}}

File:Benjamin-combs-wuU SSxDeS0-unsplash (1).jpg

2023-01-12T20:13:01Z

KellyAllison: Uploaded a work by Benjamin Coombs from https://unsplash.com/photos/wuU_SSxDeS0 with UploadWizard

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Course:SOWK551/2021/Understanding Protective Factors to Transgender Youth Suicidality

2023-01-12T19:59:11Z

KellyAllison:

[[File:Transgender Pride flag.svg|alt=Transgender Flag|thumb|Photo by SVG file based on Monica Helms Design on Wikipedia]]

== Short Summary ==
Literature on the protective factors to transgender youth suicidality, current gaps in research, and implications for social work practice in healthcare.

''Author: SOWK 551 Student''

''Date: December 10, 2022''

== Introduction ==
Transgender folks (an umbrella term for people whose gender identify differs from their sex assigned at birth) often face unique stressors compared to their cisgender counterparts, including increased experiences of sexism, heterosexism, and transphobia, which result in poorer mental health outcomes. Research has consistently found transgender identity to be associated with heightened risk for suicidal ideation and higher suicide attempt rates than either the general population or lesbian, gay, or bisexual populations (Hunt et al., 2020). This risk is especially high for youth, and “many transgender youths report discrimination, bullying, and violence as a result of their gender identity” (Veale, 2017, p. 44). In a 2019 Canadian survey, almost two-thirds of trans youth had considered attempting suicide within the past year, and over 20% made an attempt (Taylor et al., 2020). Given an increase in awareness of the unique and complex challenges related to transgender youth and suicidality, there has been a growing body of research dedicated to better understanding what protective factors exist that are associated with decreased rates of suicidality and the promotion of the mental wellbeing for this population. Upon review of recent literature, the primary themes identified that will be touched in this paper include: 1) peer and parental support, 2) positive school support, and 3) use of chosen name and pronouns. Along with a mention on current gaps in the literature, a discussion of some of the implications for social workers in healthcare as it relates to this issue will be provided.

To capture current and relevant literature, only information published within the past ten years in a North American context has been included. To gather such information, the following search terms were used: “trans(gender)”, “youth”, “suicide”, and “protective factors”. The scholarly and peer-reviewed journal articles chosen for this review were found through the University of British Columbia Library search engine and Google Scholar.

== Protective Factors ==

=== Peer & Parental Support ===
Adequate social support is vital to the mental wellbeing of trans youth. Research suggests that support from young people’s peers and family members is not only associated with greater life satisfaction and fewer depressive symptoms, but can ultimately be lifesaving (Hunt et al., 2020). Having long-term, caring relationships with both family and friend groups provides trans youth with a source of resiliency when navigating challenging events in their lives. Parental support specifically can play a crucial role in offsetting the “mental health impact of societal harassment and discrimination their children receive” (Simons et al., 2013, p. 3). Parents or family members can contribute to their child’s wellbeing by advocating for them in ways which young people may find themselves powerless to do independently, such as championing for school policy reform (Gorse, 2020). In addition, Taylor et al. (2022) found that gender, role, and relationship differences can influence a youth’s willingness to seek support from parents, and that further research should address these dynamics as it relates to mothers, fathers, single, and two-parent families.

Imperative to note is that the need for support through a specific source/person (peer versus parental support) may differ given the young person’s ethnic, racial, and other intersecting identities. Ito et al. (2018) suggests that Asian trans youth may have increased internalized negative attitudes and are less likely to look to family for support whatsoever compared to other ethnic groups. Lawlace et al. (2022) found that support from a significant other (a person’s intimate partner) was particularly important for Black trans youth compared to their White and Latinx counterparts. Additionally, a strong connection with friends rather than family members was seen as significant for Latinx vs White or Black trans youth (Lawlace et al., 2022). In agreeance with this theme is Taylor et al. (2020), who found that Canadian trans youth reported their friends as being most helpful when in need of support.

=== Positive School Support ===
School is a place where youth spend a substantial amount of their time, yet the occurrence of school-based anti-transgender harassment, victimization, bullying, as well as the “corresponding mental health and behavioral health risks” is well documented (Austin et al., 2022, p. NP2071). Several studies propose that a trans youth’s sense of safety, belonging, and connectedness in school are all protective factors linked to a decrease in suicidal thoughts (Austin et al., 2022; Gorse, 2020; Taylor et al., 2020). Parodi et al. (2022) suggests one strategy to bolster student’s experience of school-connectedness is ensuring that sexual orientation and gender identity (SOGI) information and curriculum is provided to youth and educators alike. To further this, Austin et al. (2022) found that trans youth were half as likely to have attempted suicide if they felt they belonged at school and suggested that incorporating gender affirming and inclusive policies in schools “may be critical to staving off and/or mitigating the risk of suicidality among transgender young people” (p. NP2710). This includes taking a firm stance against interpersonal microaggressions through education and supporting gender diversity through environmental changes (e.g. inclusive washrooms or locker rooms) (Austin et al., 2022).

Apart from peer support, caring, supportive relationships with trusted adults within the school context appear to be a protective factor for trans youth and their mental wellbeing. Support from teachers, school counsellors, youth and/or social workers, and well as coaches can be provide helpful for trans youth in feeling connected to school as well as assist them in navigating other interpersonal relationship challenges with peers or family (Austin et al. 2022; Taylor et al., 2020). Moreover, Taliaferro et al. (2019) found that connection with non-familial adults in the school setting can support trans youth with increased feelings of safety in this environment.

=== Use of Chosen Name & Pronouns ===
Inclusive and gender-affirming language is a significant protective factor that positively impacts the mental wellbeing of trans youth. “Research has explored the way language often fails young trans people in their attempts to narrate the complexity of their gender, names, and identity” in a multitude of contexts, including the home and institutionalized settings (Sinclair-Palm & Chokly, 2022, p. 3). Respecting and using a young trans person’s name and pronouns is a matter of safety and dignity, and studies have found that transgender youth who are able to use their chosen name in various contexts, including home, school, healthcare, and work settings were associated with lower depressive symptoms, suicidal ideation, and suicidal behaviour (Russell et al., 2018; Sinclair-Palm & Chokly, 2022; Taylor et al., 2020). Going beyond the acknowledgement of chosen name and pronouns is the need for policies that promote the translation of this language to information systems and records (e.g. health records, personal ID cards) to further enhance a young person’s feelings of safety and belonging in society (Russell et al., 2018).

== Gaps in the Literature ==
Although research on this issue is quickly emerging, several limitations and shortcomings exist within the current body of literature. Much of literature does not adequately address the unique needs and experiences of trans youth specifically, and rather focuses on ‘LGBT’ or ‘sexual or gender minority’ populations in their entirety. Directing specific focus on subgroups will likely provide essential and revealing insight that honours the voices and lived experiences of transgender youth struggling with mental illness and suicidality.

Upon analysis of many of the articles included in this review, the samples of participants are predominantly White, which is a critique of LGBTQ2S+ research in general. Whilst some of the research conducted in the United States appears to be more inclusive of Black and Latinx trans youth voices, current findings “may not adequately reflect the lives and experiences of trans and/or non-binary youth who are Black, Indigenous, or from other cultural groups” in Canadian and Western contexts (Taylor et al., 2020). Opara et al. (2020) argues that “the intersection of multiple marginalized identities can increase an individual’s likelihood of experiencing discrimination and the resulting psychological consequences” (p. 617). Furthermore, few studies have solely examined the differences among trans youth of colour and have yet to fully explore how geographic (urban vs. rural), poverty, and/or socioeconomic factors correlate with mental health and suicidality (Opara et al., 2020). Thus, deeper exploration in this area may provide nuance to what is currently understood about protective factors to trans youth suicidality.

== Application to Practice ==
Foundational to the social work discipline is its strengths-based approach to practice that is rooted in social justice. Given this, social workers practicing in healthcare can play a pivotal role in supporting the psychosocial needs of trans youth clients and their families. Through comprehensive screening and assessment processes, social workers have the ability to “assess for and monitor levels of internalized stigma, exposure to microaggressions, and a lack of social support, in addition to general-population risk factors, so that they can intervene in these areas to reduce risk” related to suicidality in transgender youth (Lawlace et al., 2022, p. 7). Given that advocacy is central to the role of healthcare social workers, practitioners or mental health clinicians working with families of transgender youth are uniquely positioned to advocate for the importance of support from various sources, including parents, school staff, and other healthcare providers (Simons et al., 2013). Social workers can provide support to families in a variety of ways, including psychoeducation and other therapeutic interventions, as well as refer clients and/or their families to services that may better serve them in the community. Social workers may also advocate for increased support in the school environment and serve as a link between the young person’s healthcare team and formal support system at their school.

At the organizational and systemic levels of practice, social workers can play a role in advocating for and implementing policy change that seeks to develop and strengthen access to gender-affirming care within healthcare. Social workers provide an integral voice in the policy change process given their use of an intersectional, anti-oppressive lens and profound knowledge of the social determinants of health that directly applies to the multifaceted issues faced by trans youth and their loved ones. Perhaps unsurprisingly, much of the research outlined in this review was undertaken by social workers; therefore, social workers can utilize their skills in research to further advance their practice and invoke change in the organizations they work within as well as through larger institutions.

It should be mentioned that whilst social workers are indeed well positioned to support this population and enact positive change cross various settings and contexts, “opportunities must be developed and implemented to prepare practicing social workers on affirming practices with LGBTQ+ youth who are at risk for suicide” (Gorse, 2022, p. 25). Social workers often receive very minimal education and training through their graduate programs; thus, efforts must be made to better understand the unique needs, risks, and protective factors related to trans youth mental health (Gorse, 2022). Additionally, it is critical that this burden of education be on the social worker (or other healthcare provider) rather than the client or family as this population has historically been and continues to be severely underserved (Hunt, 2020).

== Conclusion ==
To conclude, transgender youth are folks who face unique stressors which can result in poor mental health outcomes and an increased risk for suicidality. This population has inherent strengths, and a better understanding of protective factors is key to promoting the health and wellbeing of trans youth now and into the future. Whilst other protective factors exist, current literature suggests that peer and parental support, positive school support, and the use of chosen names and pronouns are some of these key protective factors – and healthcare social workers are positively situated to contribute to the advancement of these aspects in trans youth’s lives. Ultimately, support for transgender youth needs to be weaved through and integrated across all systems, from the micro to macro. To support these efforts, continued research aimed at informing best practices for supporting transgender youth at risk of suicide is needed (Gorse, 2022). As alluded to earlier, research committed to exploring the needs and experiences of trans youth with multiple, intersecting identities is also highly sought after.

== References ==
<references responsive="0" />
Austin, A., Craig, S. L., D’Souza, S., & McInroy, L. B. (2022). Suicidality among transgender youth: Elucidating the role of interpersonal risk factors. ''Journal of Interpersonal Violence'', ''37''(5–6), NP2696–NP2718. <nowiki>https://doi.org/10.1177/0886260520915554</nowiki>

Gorse, M. (2022). Risk and protective factors to LGBTQ+ youth suicide: A review of the literature. ''Child and Adolescent Social Work Journal'', ''39''(1), 17–28. <nowiki>https://doi.org/10.1007/s10560-020-00710-3</nowiki>

Hunt, Q. A., Morrow, Q. J., & McGuire, J. K. (2020). Experiences of suicide in transgender youth: A qualitative, community-based study. ''Archives of Suicide Research'', ''24''(sup2), S340–S355. <nowiki>https://doi.org/10.1080/13811118.2019.1610677</nowiki>

Ito, B. (2018). Intersectionality: Why race matters in LGBTQ+ youth. ''Journal of the American Academy of Child & Adolescent Psychiatry'', ''57''(10), S63. <nowiki>https://doi.org/10.1016/j.jaac.2018.07.268</nowiki>

Lawlace, M., Newcomb, M. E., & Whitton, S. W. (2022). Minority stressors and suicidal ideation in sexual and gender minority youth assigned female at birth: Prospective associations and racial differences. ''Suicide and Life-Threatening Behavior'', ''n/a''(n/a). <nowiki>https://doi.org/10.1111/sltb.12912</nowiki>

Opara, I., Assan, M. A., Pierre, K., Gunn, J. F., Metzger, I., Hamilton, J., & Arugu, E. (2020). Suicide among black children: An integrated model of the interpersonal-psychological theory of suicide and intersectionality theory for researchers and clinicians. ''Journal of Black Studies'', ''51''(6), 611–631. <nowiki>https://doi.org/10.1177/0021934720935641</nowiki>

Parodi, K. B., Holt, M. K., Green, J. G., Katz-Wise, S. L., Shah, T. N., Kraus, A. D., & Xuan, Z. (2022). Associations between school-related factors and mental health among transgender and gender diverse youth. ''Journal of School Psychology'', ''90'', 135–149. <nowiki>https://doi.org/10.1016/j.jsp.2021.11.004</nowiki>

Russell, S. T., Pollitt, A. M., Li, G., & Grossman, A. H. (2018). Chosen name use is linked to reduced depressive symptoms, suicidal Ideation, and suicidal behavior among transgender youth. ''Journal of Adolescent Health'', ''63''(4), 503–505. <nowiki>https://doi.org/10.1016/j.jadohealth.2018.02.003</nowiki>

Simons, L., Schrager, S. M., Clark, L. F., Belzer, M., & Olson, J. (2013). Parental support and mental health among transgender adolescents. ''Journal of Adolescent Health'', ''53''(6), 791–793. <nowiki>https://doi.org/10.1016/j.jadohealth.2013.07.019</nowiki>

Sinclair-Palm, J., & Chokly, K. (2022). ‘It’s a giant faux pas’: Exploring young trans people’s beliefs about deadnaming and the term deadname. ''Journal of LGBT Youth'', ''0''(0), 1–20. <nowiki>https://doi.org/10.1080/19361653.2022.2076182</nowiki>

Taliaferro, L. A., McMorris, B. J., Rider, G. N., & Eisenberg, M. E. (2019). Risk and protective factors for self-harm in a population-based sample of transgender youth. ''Archives of Suicide Research'', ''23''(2), 203–221. <nowiki>https://doi.org/10.1080/13811118.2018.1430639</nowiki>

Taylor, A.B., Chan, A., Hall, S.L., Saewyc, E. M., & the Canadian Trans & Non-binary Youth Health Survey Research Group (2020). ''Being Safe, Being Me 2019: Results of the Canadian Trans and Non-binary Youth Health Survey''. Vancouver, Canada: Stigma and Resilience Among Vulnerable Youth Centre, University of British Columbia.

Veale, J. F., Watson, R. J., Peter, T., & Saewyc, E. M. (2017). Mental health disparities among Canadian transgender youth. ''Journal of Adolescent Health'', ''60''(1), 44–49. <nowiki>https://doi.org/10.1016/j.jadohealth.2016.09.014</nowiki>{{Cc-by-nc-4.0}}

Course:SOWK551/2021/Trauma-Informed Care Literature Review

2023-01-12T19:52:07Z

KellyAllison:

[[File:Kelly-sikkema-XX2WTbLr3r8-unsplash.jpg|thumb|Photo by Kelly Sikkema on Unsplash]]
== Short Summary ==
Literature review on utilizing trauma-informed care within adolescent mental health settings.
{{DISPLAYTITLE:Course:SOWK551/2021/Trauma-informed Care Literature Review}}

== Introduction ==
With the prevalence of mental health awareness, it is vital to understand the underlying causes and techniques used to support struggling individuals. This literature review’s specific focus will be on utilizing trauma-informed care within adolescent mental health settings. Supporting adolescents in their formative years is crucial, as untreated concerns can affect all aspects of health. The following search terms: trauma-informed ‘care OR practice OR application OR approach,’ adolescent, mental health, social work, and adverse childhood experiences were applied to the UBC library database for appropriate literature. The search was constricted only to include research that was published since the year 2000. Global research and all healthcare professions were included to procure a more comprehensive array of knowledge. This literature review discusses adverse childhood experiences (ACEs), trauma-informed care (TIC), how TIC can be applied when working with adolescents within a mental health setting, and theories that complement TIC.

== Adverse Childhood Experiences ==
Before TIC can be discussed thoroughly, understanding the causes of trauma within adolescents is crucial. ACEs are commonly related to trauma leading to mental health concerns. A consensus agreement from the literature reviewed defines ACEs as traumatic circumstances that occur over time or as single events within the adolescent or child’s environment (Brennan et al., 2018, as cited by Chizimba, 2021). Researchers have established connections between ACEs and negative health outcomes, demonstrating a plethora of detrimental physical, emotional, and behavioral impacts that ACEs have on an individual life (Murphy, 2016, as cited by Hatcher, 2022). This is also supported by findings displaying “a strong proportionate relationship between respondents’ ACE scores and subsequent lifelong medical and mental health pathology and early mortality rates” (Felitti & Anda, 2010, as cited by Bryson & Bosma, 2018, p.597, and Oral et al., 2021). It was also revealed that exposure to trauma during childhood is disproportionately high within mental health populations (Alvarez et al., 2011; Glad et al., 2017; Helpman et al., 2015; Rossiter et al., 2015, as cited by Knight, 2018). Research also connects the relationship between ACEs and children with behavioral and learning challenges (Oral et al., 2021).

With essential data on the effects of ACEs, early intervention is vital to improving child development. Goddard outlines that a “proactive, preventive approach[es] to childhood trauma includes a call to action to pediatric clinicians to recognize the tangible effects on brain development across the lifetime” (2021, p.146). With the awareness of how ACEs affect the developing mind, TIC can be used as a foundation to support individuals (Goddard, 2021). Thus, the foundation of TIC can be used as a scaffolding for supporting individuals with ACEs (Goddard, 2021). In summary, “scholars have suggested that TIC as a standard of practice in clinical settings can mitigate the health effects of ACEs during the lifetime of individuals, families, and communities” (Hatcher, 2022, p.3).

== Trauma-Informed Care ==
This literature review emphasizes the implementation of trauma-informed care within mental health settings. However, the use of TIC also encompasses trauma-informed services and applications. As noted within the introduction, trauma-informed practice (TIP) was also a keyword and search string that was applied; as such, a distinction between the two must be made. Other authors acknowledge that TIP and TIC are habitually used interchangeably; however, TIP is applied to clinical interventions, and TIC refers to the specific organizational context where services are provided to clients (Bassuk et al., 2017; Conover et al., 2015, as cited by Knight, 2018). Therefore, implementing TIP requires the foundation to be built by the organization, while TIC involves an entire paradigm shift. Brewerton (2019) echoes this by affirming that TIC requires individual, organizational, and systemic endorsement. Fundamentally, TIP directs attention to an individual by embedding an understanding of traumatic stress response “in all aspects of service delivery and plac[ing] priority on the individual’s safety, choice, and control” (Harris & Fallot, 2001, as cited by Bryson & Bosma, 2018, p.599).

The literature reveals many themes that lead to the success of TIC. One particular theme in the literature reveals the reduction in restraints and seclusion rooms when TIC is implemented. Notably, “a recent Canadian HSW realist systematic review of TIC implementation reveals a wide range of positive outcomes, including reductions in patient symptomatology, patient and staff injuries, episodes of seclusion and restraint, and staff morale” (Bryson et al., 2017, p.598). Azeem et al.’s research also demonstrates the reduction in the use of seclusion and restraints when specific TIC strategies are implemented (2011). The core strategies discussed by Azeem et al. were developed by the National Association of State Mental Health Program Directors and are: “leadership towards organizational change, use of data to inform practice, workforce development, use of restraint and seclusion reduction tools, improve consumer’s role in an inpatient setting, and vigorous debriefing techniques” (2011, p.12). In the United Kingdom, Chizimba (2021) also noted a reduction in restrictive interventions after the implementation of TIC.

A second theme was acknowledging prior ACEs and trauma history to prevent future physical and emotional re-traumatization (Mkandawire-Walhmu, 2018; Muskett, 2014; Wand et al., 2020). TIC considers that the system and service providers do not have a fulsome idea of the “trauma experiences of their clientele, which may lead to re-traumatization and failure to provide appropriate referrals” (Oral et al., 2016, p.231). Which Mkandawire-Valhmu (2018) believes can be alleviated by the conscious and intentional use of TIC. Fialkowski et al. (2022) also stress that service providers should avoid inquiring about overwhelming events too soon during the initial assessment, which can disrupt relationships and re-traumatize patients. The use of TIC acknowledges history and ACEs by individuals who need mental health services (Wand et al., 2020). Fialkowski et al. (2022) stressed the importance of building relationships and rapport to create a therapeutic relationship before discussing past trauma.

A third theme is the adjustment of environments and systems to utilize TIC best. Infrastructure that responds appropriately to traumatized individuals (2016). Muskett believes that clear leadership and responsibility in systemic changes lead to higher degrees of service users adopting TIC (2014). Oral et al. reinforce this belief by stating that the transformation of organizations towards TIC requires the creation of culturally sensitive infrastructure (2016). Brewerton also prompts the influence of western cultural beliefs regarding mental health which is crucial to historical trauma (2019). The physical environments also play a role in supporting TIC. Muskett shares that the trauma symptoms can arise from environments perceived as unsupportive and can create obstacles for best practice (2014). Oral et al. suggest that architecture and physical spaces must be inviting (2016). Furthermore, Muskett maintains that studies identified physical environments as a reasonable and positive step toward TIC strategies (2014). Boles amplifies this and states that TIC should extend to any points of contact with healthcare as minor actions can lead to potential trauma. (2017)

There are also limitations to requiring the change in settings and environments that utilize TIC. Practicing TIC requires organizational and systemic shifts, especially at an educational level. Ranjbar and Erb state that “the implementation of TIC requires additional training for most rehabilitation professionals because it has not been traditionally incorporated into their core studies” (2019, p.4). Goddard supports this claim by stating the value of an educational shift towards including ACEs and TIC as core concepts (Goddard, 2021). Fialkowski et al. (2022) continue this claim by stating that research needs to be completed on how to instruct both faculty and trainees on TIC methods with a way to assess their skills. Knight (2019) further builds upon this statement by asserting that “future efforts must not only be directed at helping field instructors adopt a trauma-informed orientation but also at advocating that their employing organizations do this same” (2019, p. 87).

== Trauma-informed Care Within Adolescent Mental Health ==
As mentioned previously, ACEs result in trauma which can lead to adolescents requiring support within a healthcare setting. Literature prompts the advantages of TIC within a mental health setting. “Traumatic stress is now understood to be at the root of many behavioral issues for which children are psychiatrically hospitalized or placed in residential facilities” (Hummer, Dollard, Robst, & Armstrong, 2010; Ko et al., 2008, as cited by Bryson & Bosma, 2018, p.597). This claim is supported by Fialkowski et al., (2022) who states that adolescents who face trauma are associated with lower mental and physical health outcomes as well as challenging behaviors in school, home, and work.Research by Keeshin et al. (2014) and Goddard (2021) stresses the value of TIC to adequately diagnose adolescents, as behavior can be misunderstood within a clinical setting. Azeem (2011) believes that TIC supports children within psychiatry units by setting the goal for hospitalization and medication rates to be standardized to match those of psychiatrically ill children to those who have not experienced trauma in other areas of healthcare. Keeshin et al. further state that taking ACEs into perspective when using TIC reduces psychiatric suffering and prevents future admissions to the hospital (2014).

== Trauma-informed Care and Other Theories ==
The application of TIC is flexible and versatile and can be applied within many different healthcare fields. Brewerton (2019) asserts that TIC can be implemented in any setting requiring individual assessments or treatments. However, as beneficial as TIC can be independent, it can be further strengthened by amalgamating it with other theories. One critical practice that is closely connected with TIC is the application of cultural safety (CS). Applying CS conveys that the service provider understands the history of trauma suffered by the individual and their strengths and resilience (Tujague & Ryan, 2021). CS aligns with TIC by considering how past trauma affects current health. Furthermore, Tujague and Ryan (2021) and Hatcher (2022) reinforce the importance of ongoing training and self-reflection on the service provider’s privilege, culture, and organization to seek further improvements. The knowledge of past trauma and critical reflection allows for the growth of entire systems. (Tujague & Ryan, 2021). The benefits of uniting TIC and CS are immeasurable when evaluating the number of racialized and Indigenous health service users there are in Canada.

A second fundamental theory that harmonizes well with TIC is strength-based theory. Boles contrasts TIC against conventional concepts of trauma-based care and highlights the influences of a strength-based theory (2017). Two authors stress the significance of assessments being a large proponent of utilizing strength-based theory (Ranjgar & Erb, 2021 and Want et al., 2020). These authors scrutinize the continuous need to assess and reassess service users that it is important to focus on forward-thinking language (Ranjgar & Erb, 2021 and Want et al., 2020). TIC considers the impacts of trauma and empowers individuals through grounding responses through personal strengths, skills, and attributes (Ranjbar & Erb, 2021 and Want et al., 2020). Boles continues by expressing that these actions can also support building coping strategies (2017).

== Conclusion ==
In conclusion, mental health continues to be a universal issue among individuals, especially adolescents. Determining and exercising the appropriate approaches can significantly improve the conditions within healthcare settings and individual vitality. Firstly, ACEs were examined for their correlation to mental health. The impacts of trauma within the early stages of life can have detrimental effects. Secondly, TIC was contrasted against synonymous language, and the differences were illustrated. Thirdly, TIC was defined, and the application of TIC within adolescent mental health was explored and how it can be applied. Lastly, the usage of TIC was integrated with other modalities to understand best how to support service users. Ultimately, “given social work’s complex understanding of trauma, intersectional identities, and mental health, social work is primed to continue to make contributions to the growing study and implementation of [trauma-informed services] in adult and child health settings” (Bryson & Bosma, 2018, p.598).

== References ==
<references responsive="0" />
Azeem, M. W., Aujla, A., Rammerth, M., Binsfeld, G., & Jones, R. B. (2011). Effectiveness of six core strategies based on trauma informed care in reducing seclusions and restraints at a child and adolescent psychiatric hospital. Journal of Child and Adolescent Psychiatric Nursing, 24(1), 11-15. <nowiki>https://doi.org/10.1111/j.1744-6171.2010.00262.x</nowiki>

Boles, J. (2017). Trauma-informed care: An intentional approach.(the children's corner: Perspectives on supportive care). Pediatric Nursing, 43(5), 250-255A.

Brewerton, T. D. (2019). An overview of trauma-informed care and practice for eating disorders. Journal of Aggression, Maltreatment & Trauma, 28(4), 445-462. <nowiki>https://doi.org/10.1080/10926771.2018.1532940</nowiki>

Bryson, S. A., & Bosma, H. (2018). Health social work in canada: Five trends worth noting. Social Work in Health Care, 57(8), 1-26. <nowiki>https://doi.org/10.1080/00981389.2018.1474161</nowiki>

Chizimba, B. (2021). Assessing the knowledge and skills gap for adverse childhood experiences (ACEs) and trauma-informed practice in children and young people’s services across the education, health, care and voluntary sector. Adoption & Fostering, 45(1), 105-111. <nowiki>https://doi.org/10.1177/0308575921995439</nowiki>

Fialkowski, A., Shaffer, K., Ball-Burack, M., Brooks, T. L., Trinh, N. T., Potter, J. E., & Peeler, K. R. (2022). Trauma-informed care for hospitalized adolescents. Current Pediatrics Reports (Philadelphia, PA), 10(2), 45-54. <nowiki>https://doi.org/10.1007/s40124-022-00262-3</nowiki>

Goddard, A. (2021). Adverse childhood experiences and trauma-informed care. Journal of Pediatric Health Care, 35(2), 145-155. <nowiki>https://doi.org/10.1016/j.pedhc.2020.09.001</nowiki>

Hatcher, B. (2022). Accelerating trauma-informed care practices in behavioral health settings to address patients’ adverse childhood experiences

Keeshin, B. R., Strawn, J. R., Luebbe, A. M., Saldaña, S. N., Wehry, A. M., DelBello, M. P., & Putnam, F. W. (2013;2014;). Hospitalized youth and child abuse: A systematic examination of psychiatric morbidity and clinical severity. Child Abuse & Neglect, 38(1), 76-83. <nowiki>https://doi.org/10.1016/j.chiabu.2013.08.013</nowiki>

Knight, C. (2019). Trauma informed practice and care: Implications for field instruction. Clinical Social Work Journal, 47(1), 79-89. <nowiki>https://doi.org/10.1007/s10615-018-0661-x</nowiki>

Mkandawire-Valhmu, L., & Taylor & Francis eBooks A-Z. (2018). Cultural safety, healthcare and vulnerable populations: A critical theoretical perspective (1st ed.). Routledge, Taylor and Francis Group. <nowiki>https://doi.org/10.4324/9781315708706</nowiki>

Muskett, C. (2014). Trauma-informed care in inpatient mental health settings: A review of the literature. International Journal of Mental Health Nursing, 23(1), 51-59. <nowiki>https://doi.org/10.1111/inm.12012</nowiki>

Oral, R., Ramirez, M., Coohey, C., Nakada, S., Walz, A., Kuntz, A., Benoit, J., & Peek-Asa, C. (2016;2015;). Adverse childhood experiences and trauma informed care: The future of healthcare. Pediatric Research, 79(1-2), 227-233. <nowiki>https://doi.org/10.1038/pr.2015.197</nowiki>

Ranjbar, N., & Erb, M. (2019). Adverse childhood experiences and trauma-informed care in rehabilitation clinical practice. Archives of Rehabilitation Research and Clinical Translation, 1(1-2), 100003-100003. <nowiki>https://doi.org/10.1016/j.arrct.2019.100003</nowiki>

Tujague, N. A., & Ryan, K. L. (2021). Ticking the box of ‘cultural safety’ is not enough: Why trauma-informed practice is critical to indigenous healing. Rural and Remote Health, 21(3), 6411-6411. <nowiki>https://doi.org/10.22605/RRH6411</nowiki>

Wand, T., Buchanan‐Hagen, S., Derrick, K., & Harris, M. (2020). Are current mental health assessment formats consistent with contemporary thinking and practice? International Journal of Mental Health Nursing, 29(2), 171-176. <nowiki>https://doi.org/10.1111/inm.12656</nowiki>

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Course:SOWK551/2021/The Impacts on Caregivers of Loved One’s With Dementia

2023-01-12T19:43:12Z

KellyAllison:

[[File:Esther-ann-glpYh1cWf0o-unsplash.jpg|thumb|Photo by Esther Ann on Unsplashed]]

== Short Summary ==
Literature review on the unique challenges that are involved with caregiving of a loved one with dementia.

''Date: December 7th 2022''

== Introduction ==
Dementia is an umbrella term for “any disorder where significant decline from one's previous level of cognition causes interference in occupational, domestic, or social functioning” (Gale, Acar & Daffner, 2018). There are two broad categories of dementia; neurodegenerative and non-neurodegenerative. Neurodegenerative dementia’s are irreversible and usually diagnosed in seniors over the age of 65, the most common neurodegenerative dementias are Alzheimers, dementia with Lewy Bodies, vascular and frontotemporal dementias (Gale, Acar & Daffner, 2018; Holmes & Amin, 2020). Non-neurodegenerative dementias are potentially reversible and can be caused by a variety of factors such as a severe B1 deficiency which can result in [[/www.sciencedirect.com/topics/medicine-and-dentistry/wernickes-encephalopathy|Wernicke encephalopathy]], exposure to toxic chemicals, pollutants or heavy metals can also cause dementia syndrome (Gale, Acar & Daffner, 2018). For the purpose of this literature review, I will be focusing on neurodegenerative dementias and the impact that these progressive and terminal diseases have on caregivers. These caregiving responsibilities often fall on family members or friends of the individuals with dementia and that’s who will be the focus of this literature review, the unpaid loved ones who provide frequent care. The Alzheimer’s Society of Canada (2022) has found that in 2020 there were 569,600 Canadians living with dementia and they predict that by 2030 that number will be 955,900. The Alzheimer’s Society of Canada also references that one in every five Canadians have cared for someone with dementia (Alzheimer’s Society of Canada, 2022). The unique challenges that are involved with caregiving for a loved one with dementia has gained more recognition in recent years, and therefore there is a great deal of research that has been done recently. The literature that was gathered for this literature review largely focuses on research that has been done in the last 10 years and seeing as dementia doesn’t discriminate across countries, ethnicities, income or otherwise, the literature was gathered from around the world. Recently the impacts of caregiving for a loved one with dementia has been recognized as having specific risks which can negatively impact the caregiver’s overall health and wellbeing, the main themes that the research suggests are a risk of anticipatory or complicated grief, ambiguous loss and social isolation.

== Grief ==
An understanding of grief requires “an awareness of the diverse forms and experience of loss and grief” and “recognising grief as a reaction to any kind of loss” (Goldsworthy, 2005). Grief can be especially complicated for the caregivers of loved ones with dementia. Seeing as neurodegenerative dementia’s are progressive and terminal diseases, the caregiver must adapt to different stages of the dementia with the knowledge that their loved one will continue to decline and eventually die from the illness. Neurodegenerative dementia’s can progress somewhat differently depending on the individual and the type of disease, however the average life expectancy after the symptom onset of these dementias are 8-12 years with exceptions of up to 20 years (Gale, Acar & Daffner, 2018; Pérez-González et al, 2021). This progressive and terminal diagnosis is understandably distressing to the patient and their loved ones. Anticipatory grief is a common experience for caregivers and can be defined as the emotional response to the impending death of a loved one, as well as the anticipation of the disease progressing and an expectation of loss in the quality of life (Chan et al, 2013; Pérez-González et al, 2021; Gavin et al, 2021). This type of grief can be extended to the expected serial losses of the caregiver, such as the loss of their companion, freedom and control (Chan et al, 2013). Due to the ongoing losses that the caregiver is experiencing, the process of grieving is often disrupted and prolonged, as a caregiver explained; “prolonged grieving is difficult, where you’re grieving for so long, but you haven’t really gotten the chance to really grieve” (Glass, 2016). After the loved one has died, caregivers can experience normal or complicated grief, complicated grief is when a caregiver has difficulty processing their grief and this grieving does not fade over time and impacts their day to day functioning. The death of a loved one with dementia can also bring up feelings of relief which can be surprising and distressing for the caregiver and the caregiver often grieves the loss of their role as a caregiver (Nathanson & Rogers 2021).

== Loss ==
Loss is closely tied to grief, as grief is the emotional response to a significant loss. Nathanson & Rogers (2021) highlight that “caregiving for people with dementia results in nearly double the amount of losses as caregiving for those with a disease other than dementia”. The stages of dementia are particularly challenging as dementia is a disease of the brain, one caregiver reported how they “slowly watch[ed] the deterioration and disintegration of someone once familiar” (Nathanson & Rogers 2021). Different dementias have different symptoms however, there are symptoms that are common across all neurodegenerative dementias such as neuropsychiatric symptoms, depression, apathy, changes in personality as well as agitation and aggression (Holmes & Amin, 2020). In addition, the person suffering from dementia often experiences memory and word finding difficulties which results in challenges with communication and decreased independence and mobility, which can make meaningful engagements difficult. The experience of witnessing this kind of a disease progression and losing pieces of your loved one is referred to as ‘ambiguous loss’ (Nathanson & Rogers 2021;Pérez-González et al, 2021). In other words, “these losses are called “ambiguous” because they are not always recognized or named, and, thus, they are not always allowed to progress through a natural grief cycle” (Nathanson & Rogers 2021). Another layer of ambiguous loss is that “the person is perceived as physically present but psychologically absent” (Pérez-González et al, 2021). Ambiguous losses can make grieving more difficult as the losses are not always clear or concrete and cultural grieving rituals often don’t include grieving for ambiguous loss which often leaves caregivers feeling like they don’t know how to grieve correctly (Nathanson & Rogers 2021).

== Social Isolation ==
Social isolation can be defined as “a state in which the individual lacks a sense of belonging socially, lacks engagement with others, has a minimal number of social contacts and they are deficient in fulfilling and quality relationships” (Lien-Gieschen, 1993). Caregivers of loved ones with dementia are at risk of social isolation and often become more isolated as the disease progresses (Davies et al, 2019; Kotwal et al, 2022; Lee et al, 2022). Lee et al (2022) categorized the disease progression into two categories that affect caregiver isolation: “symptom-related social isolation and disease progression-related social isolation”. Symptom-related social isolation includes caregiver distress over behavioural symptoms in public and concerns about stigma which result in the caregiver engaging in social activities less frequently. In addition, symptom-related social isolation can include family and friends engaging with the individual who has dementia less as the disease progresses. Disease progression-related social isolation refers to the increased amount of care that is required as the individual with dementia becomes more dependent on their caregiver, which results in the caregiver having less time to socialize (Davies et al, 2019; Lee et al, 2022). Financial strain can increase the risk of social isolation for caregivers as well. In addition, social isolation can be exacerbated when loved ones are caring for individuals with dementia as the individual with dementia is often the spouse or parent of the caregiver who may have been a major source of socialization and support for the caregiver. Socially isolated caregivers often report feelings of guilt in trying to balance meeting their own needs and their loved one’s needs (Lee et al, 2022) as well as high levels of stress and burden (Davies et al, 2019).

== Application to Practice ==
Grief, loss and social isolation can have a significant impact on a caregiver’s overall health and quality of life, recognizing this is a first step to supporting caregivers. Social workers are in a favourable position to support caregivers as social workers often work closely and build relationships with the caregivers of individuals with dementia. This is especially true as the disease progresses and the dementia patient has more interactions with the healthcare system. Viewing the caregiver's experience through a grief and loss lens can be a helpful way to frame what the caregiver is going through and highlights how grief and loss can be experienced with or without death. In addition, having an understanding of the specific types of grief and loss that are prevalent, namely anticipatory and complicated grief and ambiguous loss and providing the opportunity for education around these experiences can be validating for caregivers to put a name to how they are feeling. If caregivers are curious, it can also be beneficial to offer education around dementia and manage expectations of what the caregiver can expect surrounding disease progression in their loved one. Applying the social determinants of health (SDOH) theory when working with caregivers can also be helpful. The SDOH are non-medical factors that affect a person’s health, they include factors such as income, education, employment, food security, social inclusion and access to healthcare. The SDOH theory is supported by a qualitative study done by Oliveira et al (2020) who discovered that the “quality of life of older family carers can be enhanced by having more time away from caregiving, accessing health and social services that are dementia friendly and by having economic support”. In other words, social workers can support caregivers by assessing the caregivers SDOH with a specific focus on exploring respite or long term care options, dementia friendly healthcare and social supports and providing economic support when necessary and available. The stigma surrounding dementia increases the risk of social isolation in caregivers, this stigma or perceived stigma can also make it more difficult for caregivers to socialize with friends who do not have similar caregiving experiences (Oliveira et al, 2020; Lee et al, 2022). Providing opportunities for caregivers to socialize with other caregivers or more formal support such as volunteers with dementia caregiving experience can be a useful tool in combating social isolation (Oliveira et al, 2020; Lee et al, 2022). Lastly, these applications for social work practice can act as a guide for how to support caregivers but it is important to recognize that everyone’s caregiving experience will look different, it is essential to meet caregivers where they are at and listen to their specific needs.

== Conclusion ==
Neurodegenerative dementias can be extremely challenging for loved ones who take on caregiving responsibilities. These types of dementias are terminal illnesses which typically progress over the course of 8-10 years with increasing dependence on the caregiver. During this significant timeframe, caregivers watch their loved ones change and become progressively more unwell. For best practice, social workers who work with the caregivers of patients with dementia can educate themselves on the specific forms of grief, loss and isolation that these caregivers are at risk of. When social workers understand the needs of these caregivers, they can provide appropriate supports to increase their overall health and wellbeing.

== References ==
<references responsive="0" />
Alzheimer Society of Canada. (2022). Dementia numbers in Canada. Retrieved from <nowiki>https://alzheimer.ca/en/about-dementia/what-dementia/dementia-numbers-canada</nowiki>

Chan, D., Livingston, G., Jones, L., & Sampson, E. L. (2013). Grief reactions in dementia carers: A systematic review. International Journal of Geriatric Psychiatry, 28(1), 1-17. [[/doi.org/10.1002/gps.3795|https://doi.org/10.1002/gps.3795]]

Davies, N, Walker, N, Hopwood, J, Iliffe, S, Rait, G, Walters, K. A (2019).“separation of worlds”: The support and social networks of family carers of people with dementia at the end of life, and the possible role of the internet. Health Soc Care Community. 2019; 27: e223– e232. [[/doi.org/10.1111/hsc.12701|https://doi.org/10.1111/hsc.12701]]

Gale, S. A., Acar, D., & Daffner, K. R. (2018). Dementia. The American Journal of Medicine, 131(10), 1161-1169. [[/doi.org/10.1016/j.amjmed.2018.01.022|https://doi.org/10.1016/j.amjmed.2018.01.022]]

Gavin, N., Shan, M., Johns, S., Judge, K., & Fowler, N. (2021). The Relationship Between Family Caregivers’ Anticipatory Grief and Severity of Dementia. Innovation in Aging, 5(Suppl 1), 955–956. [[/doi.org/10.1093/geroni/igab046.3449|https://doi.org/10.1093/geroni/igab046.3449]]

Glass, A. (2016) Family Caregiving and the Site of Care: Four Narratives About End-of-Life Care for Individuals with Dementia, Journal of Social Work in End-of-Life & Palliative Care, 12:1-2, 23-46, DOI: [[/doi.org/10.1080/15524256.2016.1156605|10.1080/15524256.2016.1156605]]

Goldsworthy, K.K. (2005), Grief and loss theory in social work practice: All changes involve loss, just as all losses require change. Australian Social Work, 58: 167-178. [[/doi.org/10.1111/j.1447-0748.2005.00201.x|https://doi.org/10.1111/j.1447-0748.2005.00201.x]]

Holmes, C., Amin, J. (2020). Dementia. Medicine, 48 (11), 742-745. [[/doi.org/10.1016/j.mpmed.2020.08.014|https://doi.org/10.1016/j.mpmed.2020.08.014]]

Kotwal, A., Ritchie, C., Garrett, S., & Halim, M. (2022). Progressive isolation, loneliness, and support: The social experiences of persons with dementia and caregivers (RP421) Elsevier. doi:10.1016/j.jpainsymman.2022.04.062

Lee, J., Baik, S., Becker, T. D., & Cheon, J. H. (2022). Themes describing social isolation in family caregivers of people living with dementia: A scoping review. Dementia (London, England), 21(2), 701-721. [[/doi.org/10.1177/14713012211056288|https://doi.org/10.1177/14713012211056288]]

Lien-Gieschen T. (1993). Validation of social isolation related to maturational age: Elderly. Nursing Diagnosis, 4(1), 37–44. [[/doi.org/10.1111/j.1744-618X.1993.tb00082.x|https://doi.org/10.1111/j.1744-618X.1993.tb00082.x]]

Nathanson, A., & Rogers, M. (2021). When Ambiguous Loss Becomes Ambiguous Grief: Clinical Work with Bereaved Dementia Caregivers. Health & Social Work, 45(4), 268–275. [[/doi.org/10.1093/hsw/hlaa026|https://doi.org/10.1093/hsw/hlaa026]]

Oliveira, D., Sousa, L., & Aubeeluck, A. (2020). What would most help improve the quality of life of older family carers of people with dementia? A qualitative study of carers’ views. Dementia (London, England), 19(4), 939-950. [[/doi.org/10.1177/1471301218791906|https://doi.org/10.1177/1471301218791906]]

Pérez-González, A., Vilajoana-Celaya, J., & Guàrdia-Olmos, J. (2021). Alzheimer's Disease Caregiver Characteristics and Their Relationship with Anticipatory Grief. International journal of environmental research and public health, 18(16), 8838. [[/doi.org/10.3390/ijerph18168838|https://doi.org/10.3390/ijerph18168838]]{{Cc-by-nc-4.0}}

Course:SOWK551/2021/Strategies for Improving Inclusivity and Outcomes for Male Identified Patients in Eating Disorder Treatment Programs

2023-01-12T19:37:20Z

KellyAllison:

[[File:Allgo-an-app-for-plus-size-people-NozGHetpNoI-unsplash (1).jpg|thumb|Photo by Allgo an App for Plus Size People on Unsplash]]

= Short Summary =
Literature review synthesizes gender specific challenges, as well as clinically recommended adaptations for treating eating disorders in male identified populations.

== '''Introduction''' ==
Eating disorders are a set of maladaptive coping mechanisms and unfortunately, no demographic is immune. Despite this reality, eating disorders have traditionally been categorized as a uniquely female illness and as such, treatment literature, research samples, and assessment tools have largely been feminized. Within this societal context, male identified patients get lost among the stereotypes of eating disorders. As such, men end up presenting in health care with more severe symptoms, and are more frequently underdiagnosed and undertreated (Kinnaird et al., 2019). Furthermore, male identified patients face a range of gender specific challenges to seeking and receiving care for their eating disorder.

This literature review synthesizes gender specific challenges, as well as clinically recommended adaptations for treating eating disorders in male identified populations as found in recently published academic literature. The information collected here is intended to guide social workers to progress toward using best practices for care as defined by patients themselves. To keep the content current, only peer reviewed journals within the last 10 years have been included. With regards to male identified patients receiving treatment for eating disorders in health care settings, the following search terms were used to focus and refine the search: “experiences”, “challenges”, “treatment”, “adaptations”, and “inclusion”/ ”inclusivity”. A gender informed context of eating disorders will be presented, followed by treatment adaptations and implications for the social workers in health care settings.

As this paper aims to address the invisibility of men with eating disorders, it cannot go unstated that the context of this research takes place against the backdrop of a deeply patriarchal society that has classically ignored, denied, and invalidated the health concerns of women. This research also takes place in a traditionally binary society which has also long ignored, or victimized trans and non-binary patients within health care. Marginalized gender identities and structurally oppressed demographics must not be forgotten as health care advances. With these acknowledgments, I recognize that dignified and equitable access to health care must be guaranteed for all people, and health care will not be considered just or reputable until this is consistently delivered. For the sake of depth of the topic within the parameters of this assignment, solely the experiences of men/male identified populations will be discussed today.

== '''Gendered Context of Eating Disorders in Male Identified Patients''' ==
While it was believed that men made up 10% of people with eating disorders, male identified patients are now being recorded as an underreported 25-40% of the population (Strother et al., 2012). With the increase in diagnoses, comes the realization that men with eating disorders have been long misunderstood and underserved by health care (Collier, 2013a; Strother et al., 2012). Bunnell (2016) recognizes that in the same way that gender and body image ideals influence women, men too were being impacted. However, because men are impacted by the culture of masculinity, the disorder manifests uniquely, making it an invisible to those who only understand eating disorders as a female illness (Bunnell, 2016; Tchanturia et al., 2018; Strother et al., 2012).

Research reveals that men experience unique symptom presentation within eating disorders, and gender specific challenges associated with getting help (Bomben et al., 2022; Kinnaird et al., 2018). While eating disorders are generally characterized by a fixation on body image, self-worth, and subsistence rituals for all, men with eating disorders tend to focus less on thinness and weight loss, and focus more on muscularity, weight gain, and lean fitness (Bunnell, 2016; Collier, 2013b; Strother et al., 2012). Eating disorder behaviours in men also trend away from purging and more toward excessive exercise (Collier, 2013a). Because the focus on fitness and weight gain does not fit into societal stereotypes of eating disorders, this symptom presentation is less likely to trigger a diagnosis or signal the need for an intervention (Bunnell, 2016; Kinnaird et al., 2019). One of the loudest themes echoed in the literature is that men experience delayed recognition of their eating disorder, or have their symptoms denied altogether (Bomben et al., 2022; Richardson & Paslakis, 2021).

Statistics present a story of delayed onset, increased likelihood of being previously overweight, and greater psychiatric comorbidities in men with eating disorders (Kinnaird et al., 2019). Studies also show that while most men with eating disorders identify as heterosexual, there is a sharp increase of gay men being diagnosed with eating disorders (Collier, 2013a; Strother et al., 2012). While this is true statistically, Strother et al. (2012) clarify that not all gay subcultures stress body image, and as such, homosexuality is not a predictive factor for eating disorders. In the same vein is the recognition that while there are statistical trends in eating disorder presentation among men, not all men have a singular or unified experience of eating disorders. Treatment that considers their distinctiveness as well as their individuality is needed (Downs & Mycock, 2022).

Four essential assessment adaptations named when working with male populations are to examine: the nature of binge eating, muscle dysmorphia, body dissatisfaction, and disordered eating – as they relate to the culture of masculinity each individual is influenced by (Bunnell, 2016). Clinicians should also be prepared to inquire how men consume, experience, and respond to cultural messaging around masculinity (Bunnell, 2016). For men in particular, depression and shame could be hidden through emotional repression, and therefore substance use and prior sexual abuse history can be explored as potential concealed contributing factors (Strother et al., 2012).

== '''Challenges Faced When Seeking Help''' ==
Studies recognize that men with eating disorders face the added challenge of being conditioned by masculinity to hide and repress their feelings (Collier, 2013b). Because eating disorders are so inherently emotion based, emotional repression is not only a contributing factor for the illness, but also an obstacle to reaching out for help when it is needed (Collier, 2013b; Tchanturia et al., 2018). Further influenced by conventional masculinity, the feminization of services and information can lead to further internalized stigma, shame, and lack of access to relevant information about eating disorders (Bomben et al., 2022;Downs & Mycock, 2022; Richardson & Paslakis, 2021). When men do reach out for help, we heard from them that they were at risk of clinician judgments hindering timely or accurate diagnoses, treatment opportunities, and treatment outcomes (Richardson & Paslakis, 2021; Strother et al., 2012).

Within treatment programs, men reported feeling alienated in female dominated treatment programs, excluded in female dominated dialogue during group therapy, and not relating to feminized services or spaces where services are provided (Collier, 2013b; Kinnaird et al., 2019; Richardsom & Paslakis, 2021). Men also report being perceptibly impacted by gendered biases coming from practitioners who reinforce masculinity norms (Bunnell, 2016). Overall, outdated beliefs around who experiences eating disorders and what the illness looks like are preventing men from seeking help, and preventing clinicians from providing effective, and optimal treatment (Downs & Mycock, 2022).

General challenges that have been highlighted for men in treatment have been: overly high expectations of treatment programs to cure them, coupled with a negative view on therapy processes as a whole, ambivalence toward recovery, and difficulty letting go of the eating disorder advantages and coping with perceived negative outcomes of recovery (Richardson & Paslakis, 2021).

== '''Treatment Adaptations for Men with Eating Disorders''' ==
''' '''While adaptations for men remain underexplored, male patient perspectives on the issue are increasingly being sought (Kinnaird et al., 2019). Downs & Mycock (2022) suggest that because current treatment for eating disorders are only moderately effective at best, developing gender informed treatment is crucial for populations to have an optimal chance at recovery. There are two schools of thought regarding adapting treatment for male populations. On one hand, advocates suggest developing programming in a way that speaks directly to the male experience, societal influences, and medical needs (Downs & Mycock, 2022; Thapliyal et al., 2018). Research also reflects suggestions to a move away from a gender centred approach, stating that programming should equally accommodate the ways the disorder presents across a diverse range of cultural groups (Downs & Mycock, 2022).

Either way, research is revealing that most men clearly state that they don’t necessarily require new interventions, but prefer a person-centred approach that treats them as individuals and not as representatives of their gender or sexual orientation (Collier, 2013b; Kinnaird et al., 2019). Male patients are cited stating that they feel typical treatment frameworks would be suitable for them if modifications to the literature, environment, and dialogue in programs were made to acknowledge the cultural context of their experience (Kinnaird, 2019; Tchanturia, K. et al., 2018). We hear from men that even within treatment programs for male, they would like to be seen as individuals because there exists a vast range of how men experience eating disorders within masculine subcultures (Kinnaird et al., 2019).

All of the literature spoke to the urgency of dispelling myths, stereotypes, and refining discourse and education around eating disorders in society as a whole. Bomben et al. (2022), suggested that efforts be focused on portraying diversity in eating disorder identities across social media, health care, and education settings. Kinnaird et al. (2019), speak to the need to broaden eating disorder treatment materials to be more gender neutral and accessible. In program settings, men requested the physical environments, décor be made more gender neutral as well (Kinnaird et al., 2019). Essentially, a cultural shift needs to take place on the whole, and this shift needs to trickle down into the lived experience of diverse eating disorder patients.

== '''Application for Social Work in Health Care Settings''' ==
Clinicians have little experience with the unique male presentation of eating disorders (Collier, 2013b). Improved clinician training was a distinct group of suggestions that was reflected in multiple studies and a wealth of insight into potential clinician improvement has been documented (Bunnell, 2016; Downs & Mycock, 2022; Tchanturia et al., 2018).

First and foremost, clinicians need to develop ways of speaking that acknowledge differences in contributing factors, symptom presentation, and treatment styles for all individuals rather than focusing on gender/sex identities (Collier, 2013b; Richardson & Paslakis, 2021). In that vein, therapists/clinicians/health care providers can utilize an awareness of gender influences to improve their quality of care, without needing to segregate genders or create brand new intervention tools (Bunnell, 2016).

Clinician’s internal beliefs – explicit or implicit – about masculinity, will invariably impact the way they assess, engage, and treat male patients with eating disorders (Bunnell, 2016). Some of these views may manifest in working with male patients with eating disorders by expecting men to be less emotionally sophisticated by women, viewing men as less masculine for having an eating disorder, and praising men for eating disorder behaviours like excessive exercise and over-prioritizing fitness (Bunnell, 2016; Downs & Mycock, 2022). Bunnell (2016) stresses the significance of clinician’s responsibility to self-monitor for embodied gender biases, or stereotype affirming views that clients could experience through countertransference. Monitoring closely for gendered flavours of countertransference is essential to mitigate the subtle endorsement of acculturated beliefs during the treatment process (Bunnell, 2016). Bunnell (2016) suggests that health care providers can test for internal biases by identifying with intentional precision the ways they interact differently with each demographic of people with eating disorders.

== '''Conclusion''' ==
While targeted research is needed to better serve men with eating disorders, there is enough known to begin program re-design and clinician training. The insights gathered from this literature review can be used directly by social workers who work with patients with eating disorders to make their services more patient centered, gender informed, and effective for the affected populations. Gender informed care is necessary to optimally support male identified patients with eating disorders to transcend gender specific obstacles to recovery, while creating gender specific treatment interventions may not be necessary at this time. In other words, a person-centered approach has been highlighted profusely as the next step in the evolution of eating disorder approaches. As services evolve and move forward, male identified patients also need to be valued and consulted as stakeholders in the future of their care (Downs & Mycock, 2022; Richardson & Paslakis, 2021).

== '''References''' ==
Bomben, R., Robertson, N., & Allan, S. (2022). Barriers to help-seeking for eating disorders in men: A mixed-methods systematic review. ''Psychology of Men & Masculinities, 23''(2), 183-196. <nowiki>https://doi.org/10.1037/men0000382</nowiki>

Bunnell, D. W. (2016). ''Gender socialization, countertransference and the treatment of men with eating disorders''. Clinical Social Work Journal, 44(1), 99-104.

Collier, R. (2013a). ''Gender perceptions on eating disorders slow to change''. CMAJ 185 (3) E151-E152; DOI: <nowiki>https://doi.org/10.1503/cmaj.109-4360</nowiki>

Collier, R. (2013b). ''Treatment challenges for men with eating disorders''. CMAJ February 19, 2013 185 (3) E137-E138; DOI: <nowiki>https://doi.org/10.1503/cmaj.109-4363</nowiki>

Downs J, Mycock G (2022). ''Eating disorders in men: limited models of diagnosis and treatment are failing patients''. BMJ; 376-537. doi: 10.1136/bmj.o537. PMID: 35232721.

Kinnaird, E., Norton, C., Pimblett, C. (2019). “''There’s nothing there for guys”. Do men with eating disorders want treatment adaptations? A qualitative study''. Eating and Weight Disorders '''24''', 845–852. <nowiki>https://doi.org/10.1007/s40519-019-00770-0</nowiki>

Richardson, C., & Paslakis, G. (2021). ''Men’s experiences of eating disorder treatment: A qualitative systematic review of men‐only studies''. Journal of Psychiatric and Mental Health Nursing, 28(2), 237-250. <nowiki>https://doi.org/10.1111/jpm.12670</nowiki>

Strother, E., Lemberg, R., Stanford, S. C., & Turberville, D. (2012). ''Eating disorders in men: underdiagnosed, undertreated, and misunderstood''. Eating disorders, 20(5), 346-355.

Thapliyal, P., Hay, P., & Conti, J. (2018). ''Role of gender in the treatment experiences of people with an eating disorder: a metasynthesis''. ''Journal of eating disorders'', ''6'', 18. <nowiki>https://doi.org/10.1186/s40337-018-0207-1</nowiki>

Tchanturia, K., Kinnaird, E., Norton, C., (2018). ''Clinicians’ views on treatment adaptations for men with eating disorders: A qualitative study''. BMJ Open, 8(8), e021934-e021934. <nowiki>https://doi.org/10.1136/bmjopen-2018-021934</nowiki>

*

Course:SOWK551/2021/Strategies for Improving Inclusivity and Outcomes for Male Identified Patients in Eating Disorder Treatment Programs

2023-01-12T19:35:59Z

KellyAllison:

Course:SOWK551/2021/Strategies for Improving Inclusivity and Outcomes for Male Identified Patients in Eating Disorder Treatment Programs

2023-01-12T19:35:27Z

KellyAllison:

= Short Summary =
Literature review synthesizes gender specific challenges, as well as clinically recommended adaptations for treating eating disorders in male identified populations.[[File:Allgo-an-app-for-plus-size-people-NozGHetpNoI-unsplash (1).jpg|thumb|Photo by Allgo an App for Plus Size People on Unsplash]]

== '''Introduction''' ==
Eating disorders are a set of maladaptive coping mechanisms and unfortunately, no demographic is immune. Despite this reality, eating disorders have traditionally been categorized as a uniquely female illness and as such, treatment literature, research samples, and assessment tools have largely been feminized. Within this societal context, male identified patients get lost among the stereotypes of eating disorders. As such, men end up presenting in health care with more severe symptoms, and are more frequently underdiagnosed and undertreated (Kinnaird et al., 2019). Furthermore, male identified patients face a range of gender specific challenges to seeking and receiving care for their eating disorder.

This literature review synthesizes gender specific challenges, as well as clinically recommended adaptations for treating eating disorders in male identified populations as found in recently published academic literature. The information collected here is intended to guide social workers to progress toward using best practices for care as defined by patients themselves. To keep the content current, only peer reviewed journals within the last 10 years have been included. With regards to male identified patients receiving treatment for eating disorders in health care settings, the following search terms were used to focus and refine the search: “experiences”, “challenges”, “treatment”, “adaptations”, and “inclusion”/ ”inclusivity”. A gender informed context of eating disorders will be presented, followed by treatment adaptations and implications for the social workers in health care settings.

As this paper aims to address the invisibility of men with eating disorders, it cannot go unstated that the context of this research takes place against the backdrop of a deeply patriarchal society that has classically ignored, denied, and invalidated the health concerns of women. This research also takes place in a traditionally binary society which has also long ignored, or victimized trans and non-binary patients within health care. Marginalized gender identities and structurally oppressed demographics must not be forgotten as health care advances. With these acknowledgments, I recognize that dignified and equitable access to health care must be guaranteed for all people, and health care will not be considered just or reputable until this is consistently delivered. For the sake of depth of the topic within the parameters of this assignment, solely the experiences of men/male identified populations will be discussed today.

== '''Gendered Context of Eating Disorders in Male Identified Patients''' ==
While it was believed that men made up 10% of people with eating disorders, male identified patients are now being recorded as an underreported 25-40% of the population (Strother et al., 2012). With the increase in diagnoses, comes the realization that men with eating disorders have been long misunderstood and underserved by health care (Collier, 2013a; Strother et al., 2012). Bunnell (2016) recognizes that in the same way that gender and body image ideals influence women, men too were being impacted. However, because men are impacted by the culture of masculinity, the disorder manifests uniquely, making it an invisible to those who only understand eating disorders as a female illness (Bunnell, 2016; Tchanturia et al., 2018; Strother et al., 2012).

Research reveals that men experience unique symptom presentation within eating disorders, and gender specific challenges associated with getting help (Bomben et al., 2022; Kinnaird et al., 2018). While eating disorders are generally characterized by a fixation on body image, self-worth, and subsistence rituals for all, men with eating disorders tend to focus less on thinness and weight loss, and focus more on muscularity, weight gain, and lean fitness (Bunnell, 2016; Collier, 2013b; Strother et al., 2012). Eating disorder behaviours in men also trend away from purging and more toward excessive exercise (Collier, 2013a). Because the focus on fitness and weight gain does not fit into societal stereotypes of eating disorders, this symptom presentation is less likely to trigger a diagnosis or signal the need for an intervention (Bunnell, 2016; Kinnaird et al., 2019). One of the loudest themes echoed in the literature is that men experience delayed recognition of their eating disorder, or have their symptoms denied altogether (Bomben et al., 2022; Richardson & Paslakis, 2021).

Statistics present a story of delayed onset, increased likelihood of being previously overweight, and greater psychiatric comorbidities in men with eating disorders (Kinnaird et al., 2019). Studies also show that while most men with eating disorders identify as heterosexual, there is a sharp increase of gay men being diagnosed with eating disorders (Collier, 2013a; Strother et al., 2012). While this is true statistically, Strother et al. (2012) clarify that not all gay subcultures stress body image, and as such, homosexuality is not a predictive factor for eating disorders. In the same vein is the recognition that while there are statistical trends in eating disorder presentation among men, not all men have a singular or unified experience of eating disorders. Treatment that considers their distinctiveness as well as their individuality is needed (Downs & Mycock, 2022).

Four essential assessment adaptations named when working with male populations are to examine: the nature of binge eating, muscle dysmorphia, body dissatisfaction, and disordered eating – as they relate to the culture of masculinity each individual is influenced by (Bunnell, 2016). Clinicians should also be prepared to inquire how men consume, experience, and respond to cultural messaging around masculinity (Bunnell, 2016). For men in particular, depression and shame could be hidden through emotional repression, and therefore substance use and prior sexual abuse history can be explored as potential concealed contributing factors (Strother et al., 2012).

== '''Challenges Faced When Seeking Help''' ==
Studies recognize that men with eating disorders face the added challenge of being conditioned by masculinity to hide and repress their feelings (Collier, 2013b). Because eating disorders are so inherently emotion based, emotional repression is not only a contributing factor for the illness, but also an obstacle to reaching out for help when it is needed (Collier, 2013b; Tchanturia et al., 2018). Further influenced by conventional masculinity, the feminization of services and information can lead to further internalized stigma, shame, and lack of access to relevant information about eating disorders (Bomben et al., 2022;Downs & Mycock, 2022; Richardson & Paslakis, 2021). When men do reach out for help, we heard from them that they were at risk of clinician judgments hindering timely or accurate diagnoses, treatment opportunities, and treatment outcomes (Richardson & Paslakis, 2021; Strother et al., 2012).

Within treatment programs, men reported feeling alienated in female dominated treatment programs, excluded in female dominated dialogue during group therapy, and not relating to feminized services or spaces where services are provided (Collier, 2013b; Kinnaird et al., 2019; Richardsom & Paslakis, 2021). Men also report being perceptibly impacted by gendered biases coming from practitioners who reinforce masculinity norms (Bunnell, 2016). Overall, outdated beliefs around who experiences eating disorders and what the illness looks like are preventing men from seeking help, and preventing clinicians from providing effective, and optimal treatment (Downs & Mycock, 2022).

General challenges that have been highlighted for men in treatment have been: overly high expectations of treatment programs to cure them, coupled with a negative view on therapy processes as a whole, ambivalence toward recovery, and difficulty letting go of the eating disorder advantages and coping with perceived negative outcomes of recovery (Richardson & Paslakis, 2021).

== '''Treatment Adaptations for Men with Eating Disorders''' ==
''' '''While adaptations for men remain underexplored, male patient perspectives on the issue are increasingly being sought (Kinnaird et al., 2019). Downs & Mycock (2022) suggest that because current treatment for eating disorders are only moderately effective at best, developing gender informed treatment is crucial for populations to have an optimal chance at recovery. There are two schools of thought regarding adapting treatment for male populations. On one hand, advocates suggest developing programming in a way that speaks directly to the male experience, societal influences, and medical needs (Downs & Mycock, 2022; Thapliyal et al., 2018). Research also reflects suggestions to a move away from a gender centred approach, stating that programming should equally accommodate the ways the disorder presents across a diverse range of cultural groups (Downs & Mycock, 2022).

Either way, research is revealing that most men clearly state that they don’t necessarily require new interventions, but prefer a person-centred approach that treats them as individuals and not as representatives of their gender or sexual orientation (Collier, 2013b; Kinnaird et al., 2019). Male patients are cited stating that they feel typical treatment frameworks would be suitable for them if modifications to the literature, environment, and dialogue in programs were made to acknowledge the cultural context of their experience (Kinnaird, 2019; Tchanturia, K. et al., 2018). We hear from men that even within treatment programs for male, they would like to be seen as individuals because there exists a vast range of how men experience eating disorders within masculine subcultures (Kinnaird et al., 2019).

All of the literature spoke to the urgency of dispelling myths, stereotypes, and refining discourse and education around eating disorders in society as a whole. Bomben et al. (2022), suggested that efforts be focused on portraying diversity in eating disorder identities across social media, health care, and education settings. Kinnaird et al. (2019), speak to the need to broaden eating disorder treatment materials to be more gender neutral and accessible. In program settings, men requested the physical environments, décor be made more gender neutral as well (Kinnaird et al., 2019). Essentially, a cultural shift needs to take place on the whole, and this shift needs to trickle down into the lived experience of diverse eating disorder patients.

== '''Application for Social Work in Health Care Settings''' ==
Clinicians have little experience with the unique male presentation of eating disorders (Collier, 2013b). Improved clinician training was a distinct group of suggestions that was reflected in multiple studies and a wealth of insight into potential clinician improvement has been documented (Bunnell, 2016; Downs & Mycock, 2022; Tchanturia et al., 2018).

First and foremost, clinicians need to develop ways of speaking that acknowledge differences in contributing factors, symptom presentation, and treatment styles for all individuals rather than focusing on gender/sex identities (Collier, 2013b; Richardson & Paslakis, 2021). In that vein, therapists/clinicians/health care providers can utilize an awareness of gender influences to improve their quality of care, without needing to segregate genders or create brand new intervention tools (Bunnell, 2016).

Clinician’s internal beliefs – explicit or implicit – about masculinity, will invariably impact the way they assess, engage, and treat male patients with eating disorders (Bunnell, 2016). Some of these views may manifest in working with male patients with eating disorders by expecting men to be less emotionally sophisticated by women, viewing men as less masculine for having an eating disorder, and praising men for eating disorder behaviours like excessive exercise and over-prioritizing fitness (Bunnell, 2016; Downs & Mycock, 2022). Bunnell (2016) stresses the significance of clinician’s responsibility to self-monitor for embodied gender biases, or stereotype affirming views that clients could experience through countertransference. Monitoring closely for gendered flavours of countertransference is essential to mitigate the subtle endorsement of acculturated beliefs during the treatment process (Bunnell, 2016). Bunnell (2016) suggests that health care providers can test for internal biases by identifying with intentional precision the ways they interact differently with each demographic of people with eating disorders.

== '''Conclusion''' ==
While targeted research is needed to better serve men with eating disorders, there is enough known to begin program re-design and clinician training. The insights gathered from this literature review can be used directly by social workers who work with patients with eating disorders to make their services more patient centered, gender informed, and effective for the affected populations. Gender informed care is necessary to optimally support male identified patients with eating disorders to transcend gender specific obstacles to recovery, while creating gender specific treatment interventions may not be necessary at this time. In other words, a person-centered approach has been highlighted profusely as the next step in the evolution of eating disorder approaches. As services evolve and move forward, male identified patients also need to be valued and consulted as stakeholders in the future of their care (Downs & Mycock, 2022; Richardson & Paslakis, 2021).

== '''References''' ==
Bomben, R., Robertson, N., & Allan, S. (2022). Barriers to help-seeking for eating disorders in men: A mixed-methods systematic review. ''Psychology of Men & Masculinities, 23''(2), 183-196. <nowiki>https://doi.org/10.1037/men0000382</nowiki>

Bunnell, D. W. (2016). ''Gender socialization, countertransference and the treatment of men with eating disorders''. Clinical Social Work Journal, 44(1), 99-104.

Collier, R. (2013a). ''Gender perceptions on eating disorders slow to change''. CMAJ 185 (3) E151-E152; DOI: <nowiki>https://doi.org/10.1503/cmaj.109-4360</nowiki>

Collier, R. (2013b). ''Treatment challenges for men with eating disorders''. CMAJ February 19, 2013 185 (3) E137-E138; DOI: <nowiki>https://doi.org/10.1503/cmaj.109-4363</nowiki>

Downs J, Mycock G (2022). ''Eating disorders in men: limited models of diagnosis and treatment are failing patients''. BMJ; 376-537. doi: 10.1136/bmj.o537. PMID: 35232721.

Kinnaird, E., Norton, C., Pimblett, C. (2019). “''There’s nothing there for guys”. Do men with eating disorders want treatment adaptations? A qualitative study''. Eating and Weight Disorders '''24''', 845–852. <nowiki>https://doi.org/10.1007/s40519-019-00770-0</nowiki>

Richardson, C., & Paslakis, G. (2021). ''Men’s experiences of eating disorder treatment: A qualitative systematic review of men‐only studies''. Journal of Psychiatric and Mental Health Nursing, 28(2), 237-250. <nowiki>https://doi.org/10.1111/jpm.12670</nowiki>

Strother, E., Lemberg, R., Stanford, S. C., & Turberville, D. (2012). ''Eating disorders in men: underdiagnosed, undertreated, and misunderstood''. Eating disorders, 20(5), 346-355.

Thapliyal, P., Hay, P., & Conti, J. (2018). ''Role of gender in the treatment experiences of people with an eating disorder: a metasynthesis''. ''Journal of eating disorders'', ''6'', 18. <nowiki>https://doi.org/10.1186/s40337-018-0207-1</nowiki>

Tchanturia, K., Kinnaird, E., Norton, C., (2018). ''Clinicians’ views on treatment adaptations for men with eating disorders: A qualitative study''. BMJ Open, 8(8), e021934-e021934. <nowiki>https://doi.org/10.1136/bmjopen-2018-021934</nowiki>
[[File:Placeholder_Image_1.jpg|alt=Adult writing in journal|thumb|Photo by Pexels on Pixabay]]

*

Course:SOWK551/2021/Social Work in Primary Care

2023-01-12T19:29:51Z

KellyAllison:

[[File:National-cancer-institute-duNbFJRhaJQ-unsplash.jpg|thumb|Photo by the National Cancer Institute on Unsplash]]

= Short Summary =
Literature review of the role of social workers in primary health care with a focus on community health centers.

== Intro ==
Primary care has been playing an integral role in the health care system serving many communities, as the first point of contact, providing integrated, accessible, and comprehensive healthcare services by the interdisciplinary healthcare teams (AAFP, n.d.). Recognizing its effectiveness, Primary Care Networks (PCNs) and Community Health Centres (CHC) in which part of PCNs have emerged. In the United States, CHCs first emerged in the 1960’s as a response to the demand for equitable and accessible health care, and the model has expanded to serve 28 million people, playing a vital role as the social safety net (NASCHC, 2019 as cited in Longhurst, 2019). In BC, following the footsteps of the US and other providences such as Ontario, PCNs and CHC are expanding with the launch of primary care strategy in 2018 and the implementation plan to serve 41 communities (BC gov., 2019). With the expansion, the demand for social workers to join the integrated primary care teams is increasing but newly joined social workers struggle with the association of a medical model environment, assertation of their roles, and organizational barriers (Ashcroft et al., 2018). Indeed, the challenges associated with social workers in the predominant biomedical field to bring own values and navigate the interdisciplinary team dynamic while negotiating to establish their own scope of practice and identity as a health professional are well noted (Tucker & Webber, 2021; Morriss, 2017; O’Brien & Calderwood, 2010). The paper aims to provide an analytical review of research papers on the features and impact of overall primary care services, with an emphasis on CHC model and the role of social workers in primary care. As well, writer's commentary on application to social work practice is offered.

== '''Primary care models''' ==
In light of the increasing demand for comprehensive community health care services, primary care has been adopting different models to serve various marginalized populations such as the Integrated Health Hub model (Malachowski et al., 2018), Community Health Centre Model (Bhuiya, 2020), Model of Health and Well-being (Rayner et al., 2018) and Integrated Care model (Davis et al., 2015), Integrated Behavioral Health (Taylor et al, 2010). The IHH, as the first point of access for mental health services, provides various health care services such as case management, community wellness service, specialized psychiatric care, supportive housing and outreach (Malachowski et al., 2018). Recognizing the multiple barriers and complex care needs that people with mental health illnesses, the model evolved to meet the needs and provide wrap-around support by bridging the current gaps in health care and mental health care services. As well, Integrated Health Hub model refers to a primary care model that focuses on promoting the highest quality health and well-being for people and communities, health equity and social justice and community belonging, which has been gaining much attention in Ontario for its delivery of integrated and equitable primary care (Rayner et al., 2018). While these models adopted primary care clinics, under different names and focus of population or geographic area, operate, they share many fundamental guiding principles with CHCs which are the commitment to serve marginalized communities, to provide integrated and comprehensive care and to reduce barriers in accessing equitable health care.

== '''Community Health Centres model''' ==
In BC, primary care services are being reformed with many openings of the Primary Care Network, Urgent and Primary Care Centers and Community Health Centers with the endorsement of the Ministry of Health (BC Gov., 2019). In the Greater Vancouver area, there are REACH, RISE, Mid-Main and Atira Women’s resource society adopted the CHC model and opened their doors to serve their communities, and there are many underways (BCACHC, n.d.). According to the BC Association of CHC, CHCs are multi-sector health agencies that commit to delivering integrated, person-centred and culturally sensitive care (n.d.). The guiding principles of the model include: providing team-based care, integrated health and social care services, community-governed, social determinants of health focus and commitment to health equity and social justice (Bhuiya, 2020).

The CHC primary care clinics typically consist of a multidisciplinary team such as physicians, nurse practitioners, registered nurses, physiotherapists, registered counsellors, dietitians, social workers, community health workers and other administrative staff. The team-based model allows collaborative and fluid care for complex health needs clients and creates a supportive and equal relationship within the team and better health outcomes for clients such as shorter stay in hospitals, reduced visits to emergency departments and chronic disease management (Goldman et al., 2010; Jacobson, 2012; Katon et al., 2011 as cited in Rayner et al., 2018). The second principle, the integration of health and social care services refers to a diverse array of care such as medical care, mental health, harm reduction care such as Opioid Agonist Therapy, health promotion and outreach support. This approach allows for a one-stop-shop and holistic model of care (Chien, Walters & Chin, 2007; Rayner et al., 2020 as cited in Bhuiya, 2020; RISE, n.d.). Through the partnership with the health authority and community agencies, they strive for seamless and efficient care, thus reducing timeless efforts required by clients who struggle to navigate complicated systems.

CHCs stand out with their focus on addressing the social determinants of the health of their clients. The social determinants of health (SDH) are considered social factors influencing the health outcome consisting of income security, employment, education, housing, food security, gender identity and expression, and social network (Craig, Bejan & Muskat, 2013) as well as immigration status and language barriers. With the recognition of the (in)direct impact on the quality of life and physiological health of clients and communities, CHCs commit to identify and address SDH by allied health professionals such as social workers and community health workers. Through the intake process, frontline workers typically engage with clients to discuss their social factors and attempt to bridge the gaps. This is sometimes called social prescribing which involves empowerment, motivation, community connection and referral and health care system navigation for complex needs clients (Frostick and Bertotti, 2021).

CHCs’ community-oriented approach can be evident in their development. For instance, RISE CHC was established as a response to the Collingwood-Renfrew neighbours’ lowest rate of Family Practitioners per person and the community’s ongoing advocacy work (RISE, n.d.). As well, the community governed model also refers to that they elect community members of the board of directors or committees and have their saying in the delivery and overall structure of care to promote community engagement and a sense of ownership (Muldoon et al., 2010). They often either have a close partnership with local community agencies or are part of a non-profit agency. In Vancouver, the Collingwood neighbourhood house for RISE and Atria are examples of a non-profit agency operating CHC.

Lastly, CHC’s commitment to health equity and social justice is a crucial element of the guiding principles. This principle is demonstrated through their population of focus who experience marginalization and oppression due to their social identities such as gender identity, socio-economic status, ethnicity, and disability status (Glazier, Rayner & Kopp, 2015; Hudson, Boudreau & Graham as cited in Bhuiya, 2020). For instance, RISE has a population of focus that consists of Indigenous, isolated seniors, newcomers, LGBTQ2S, sex workers, those with inadequate housing, people experiencing racism, mental health conditions and problematic substance use, and to receive their primary care service clients are required to share their barriers to health care services (RISE, n.d.). Those who experience discrimination due to their gender identity may be reluctant to seek or receive health care services, leading to poor health outcomes (Giblon & Bauer, 2017), thus by providing gender-affirming and competent care CHCs actively aim to promote health equity amongst the affected population. As well, many CHCs recognize multiple barriers for complex needs clients in accessing care and thus incorporate home visits and mobile clinics for accessible and equitable care. Clients with mobility needs or mental health conditions are usually the targets of outreach offered by CHCs.

== '''The role of social workers in primary care setting''' ==
While the values and roles of social workers in the primary care setting are researched and recognized (Feryn, Corte & Rudi, 2022; Rehner, Brazeal & Doty, 2017; Tadic et al., 2020), there are also some barriers to social workers in primary care often face. There is a lack of awareness of the scope of social workers’ practice and reluctance in accepting social workers as part of the medical team from primary care providers (Keefe, Geron & Enguidanos, 2009). This view stems from the perception that social workers are secondary support rather than health professionals who can equally contribute to the care coordination plan. As well, the overlapping responsibilities with other allied professionals such as community health workers, line workers, mental health workers and triaging nurses is an added barrier that social workers often must navigate (Berrett-Abebe et al., 2020). Indeed, the work that social workers are involved in can be viewed as everyone’s scope of practice and therefore not valued (O’Brien & Calderwood, 2010). Thus, it’s crucial for social workers in the field to be able to articulate and demonstrate their role in order to be valued and appreciated as an equally contributing member of the interdisciplinary team, who can offer a unique social work value-driven approach and a concrete set of practice.

First of all, social workers have a skill set and knowledge in addressing social determinants of health. The psychosocial assessment task is usually delegated to social workers, which enables the workers to access psycho-social and environmental barriers related to health concerns, spiritual or religious beliefs that can be part of the treatment plan, individual’s views on health care services, motivation, social network and strengths (Rowe et al., 2017). With the information gathered, social workers can engage in various case-management responsibilities. This includes, but is not limited to: facilitating communication among the team members, between team and patients and/or caregivers (Fraser et al., 2018); connecting clients to financial assistance, other government benefits, and community resources for food security, housing, employment, and legal support; implementing the effective problem-solving skills; collaboration with other healthcare/community professionals; and navigation of social service systems. Because of the heavy emphasis on community connecting job, social workers are sometimes called community engagement specialists (Fraser et al., 2018). This wide range of responsibilities performed by social workers is what makes them stand out, although sometimes viewed as a factor for the confusion and unclarity around the role of social workers. Another contribution social workers offer is their advocacy work. With the understanding of psycho-social and structural factors impacting individuals, which social workers call ‘person in environment’ or systemic approach, social workers can advocate to address the pitfall. For instance, for those in need of a medical certificate for their disability benefit or employment insurance, social workers can advocate and facilitate the provision by communicating the need and impact of the certificate to their primary care support. As filling out a form can sometimes be viewed as a time-consuming task, physicians may be reluctant to commit the time and effort to complete one but relaying the importance and offering assistance to the team can make a positive difference in individuals’ well-being. Another example of advocacy work is around support for those with precarious status. Facilitating social and medical support for those without legal status can be challenging but advocating for the support on the ground of human rights and equitable health care could initiate bending a rule or policy by other specialists, identifying a loophole in the system and making allies with other community/health care agencies. When observed by other team members, social workers can change their perception and ambivalence of social worker involvement to appreciating the social work practice. As well, a systemic review demonstrates that the social work intervention in the primary care setting is effective in improving the overall health outcome for clients such as self-management of long-term conditions, reducing psychosocial morbidity and barriers to treatment and health maintenance (McGregor, Mercer & Harris, 2018).

In addition to case management and psychosocial assessment tasks, social workers are being more recognized for their behavioural interventions work or psychotherapeutic practice in some CHCs. Maxxine Wright CHC (n.d.) in Surrey has employed clinical social workers in this capacity while other social workers in CHCs typically focus on the earlier stated roles. They typically focus on the assessment and treatment of mental health and substance use issues clients have, using standardized assessment/diagnostic tools and brief interventions such as dialectical behaviour therapy, cognitive behavioural therapy, and motivational interviewing (Ell et al., 2008; Roy-Bryne et al., 2010; Safren et al., 2013 as cited in Fraser et al., 2018) as well as providing psychoeducation around mental health illness and utilizing person-centred skills such as empathy and active listening (Rowe et al., 2017) and connecting to and liaising with other mental health services. The integration of the behavioural health program offered by social workers is found to be especially effective in meeting patient population’s particular needs (Rehner et al., 2017; Davis, 2015).

== '''Application to practice: Anti-oppressive framework in CHC model''' ==
In addition to these roles primary care social workers take on, there are additional ones social workers can do for their marginalized clients. One of the guiding principles of CHCs, commitment to health equity and social justice can be expanded with the anti-oppressive approach (AOP). Limiting the population of focus to the marginalized clientele may not be socially just as it can reinforce the deficit view that the clientele is problematic and thus requires more comprehensive care and costly intervention. AOP is strongly grounded in the social justice and equity principle which emphasizes the impact of oppressive structures such as racism, sexism and ageism on people’s lives including health-related well-being (Thompson, 2016). Instead of situating a health issue in the context of the individual, AOP-driven social workers could pay attention to the bigger structural force and attempt to address it by employing self-awareness, power-sharing and education (Larson, 2008). This means starting from being aware of own professional privileges and social locations and understanding how own values and cultural factors influence the relationship with clients. As well, social workers should be aware of the dominant narrative of the top-down and Western value focus approach in health care and thus should actively challenge the bio-medical model. Instead of perpetuating the “power over” dynamic, social workers utilize the “power with” strategies such as listening and validating to their discriminatory experiences in engaging with their healthcare providers; helping them aware and naming their experience as the structural oppression to bring the community together; building relationship based on mutual respect and safe space. This power-sharing can be also employed in conversing with the team. When the care providers may be frustrated with the lack of involvement and commitment from clients, social workers can educate them on the impact of trauma and other structural factors and experience of discrimination that marginalized clients may have experienced. Instead of quickly discharging non-engaging clients, social workers can then rather bring different strategies to approach and encourage them. As well, CHC’s principle of community development can be enhanced with AOP-driven practice. By naming their experience as something universal and shared experience among the community, social workers can bring the community together and empower them to define their narrative and increase their capacity within them. This can mean creating a peer support group amongst new immigrants or the elderly to create a sense of belonging and social connection. What social workers can offer could allow them to take a lead in promoting community development and empowerment.

== Conclusion ==
So far, the paper provided an overview of the CHC model and the role of social workers as well as discussed the further development opportunities social workers can take on. While this is not an exhaustive list of social work approaches, the discussion could offer some concrete scope of social work practice that fellow social workers can list and share with their co-workers. Though social workers in a primary care setting are more recognized for playing a vital role, advancing to leadership roles within the setting perhaps enhances the delivery of CHC that more aligns with social justice values and perhaps policy change as well.

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