Addressing Stigma: Towards a More Inclusive Health System

The Chief Public Health Officer's Report on the State of Public Health in Canada 2019

Message from the Chief Public Health Officer of Canada

By and large, we are a healthy nation. We can be proud of Canada's health and social systems that contribute to this status. From this position of strength, we have an even greater opportunity to lead the world in health status and to ensure all Canadians can achieve optimal health. This year, my annual report provides a snapshot of key public health trends and shines a light on one of the drivers of health inequities: stigma.

I am pleased to report on some important positive health trends this year like the lower incidence of certain chronic and other non-infectious diseases. Some social factors that lead to good health in Canada are also improving; more people are achieving post-secondary education, and poverty rates, especially childhood poverty, are decreasing.

I do continue to be concerned about worrying trends. With the dramatic rise in global measles cases this year, the risk of importation and domestic spread has increased. If we do not improve our vaccine coverage, we may lose our hard-earned measles elimination status. Sexually transmitted infections such as syphilis are also making a comeback with the additional challenge of antibiotic-resistant bacteria causing gonorrhoea. Youth vaping rates are increasing and we do not fully understand the related harms, from potential impacts on the respiratory system to the incidence of youth cigarette smoking. The opioid crisis continues, and claimed more than 12 deaths per day in 2018. The harms may have been much greater if a range of preventive, harm reduction, and treatment measures had not been implemented.

All of these trends are reversible. We know what to do but need to re-engineer how we implement proven public health measures in today's context. This includes getting trusted, evidence-based information to Canadians in the age of misinformation and disinformation.

Although public health policies and programs should benefit all, persistent health inequities prevent many from being able to achieve their full potential. Often these differences can only be explained by how people are treated. That is why I focused this annual report on stigma and health.

Stigma affects us all. We are all vulnerable to the slow and insidious practice of dehumanizing others and we are all responsible for recognizing and stopping it.

This is what we know. Stigma is associated with poorer physical and mental health outcomes. Stigma and discrimination towards persons with health conditions, such as mental illness, substance use disorders, and HIV, cannot be understood or treated separately from stigma related to other characteristics such as race, gender, sexual orientation, age, and income.

These many forms of stigma that intersect in complex ways, are very much present in our health system, driving those most in need from getting effective care and accessing services. It means that we, as health system leaders and practitioners, are contributing to negative health outcomes.

This report offers a way forward.

We can build on our Canadian multicultural and inclusive way of life, while at the same time openly recognize and name racism, homophobia, transphobia, and other stigmas related to social identities. We can stop using dehumanizing language, examine our own assumptions, and implement policies and education programs, while also measuring our progress towards stigma elimination across the health system. By understanding the common drivers, practices, and experiences of multiple stigmas, we may find more collaborative and effective interventions.

It is hard to face our vulnerabilities as individuals and organizations who set out to care for others but fall short on providing the safe, effective, and compassionate health system that puts people first. However, with a dose of humility and a deepened connection to people who experience stigma, we can deconstruct the "us versus them" narrative and develop the most inclusive health system in the world.

Dr. Theresa Tam

Chief Public Health Officer of Canada

Text box 1 We would like to respectfully acknowledge that the land on which we developed this report is in traditional First Nations, Inuit, and Métis territory, and we acknowledge their diverse histories and cultures. We strive for respectful partnerships with Indigenous peoples as we search for collective healing and true reconciliation. We would also like to acknowledge the territories in which we conducted discussion groups that contributed to this report: We acknowledge that the discussion group in Ottawa took place on the traditional unceded territory of the Algonquin people. We acknowledge that the discussion group in Toronto took place on the traditional territory of the Wendat, the Anishnaabeg, Haudenosaunee, Métis, and the Mississaugas of the New Credit First Nation. We acknowledge that the discussion group in Montréal took place on the traditional unceded territory of the Mohawk people. We acknowledge that the discussion group in Vancouver took place on the traditional unceded territory of the Coast Salish peoples, including the territories of the Musqueam, Squamish, Stó:lō, and Tsleil-Waututh Nations.

Quotation 1: "Greater attention needs to be paid to stigma as a social determinant of population healthFootnote 1."

Table of contents

About this report

Every year, the Chief Public Health Officer writes a report on the state of public health in Canada. These reports raise the profile of public health issues and stimulate dialogue. They can also lead to action in improving and protecting the health of Canadians.

This year's report first provides a summary of the overall health of Canadians, including how different populations experience poorer health. The rest of the report focuses on stigma, one of the reasons for these differences.

Health of Canadians

Chapter 1 draws on indicators from the Chief Public Health Officer's Health Status Dashboard (Appendix A), as well as other national data on the health of Canadians. Some health inequalities are highlighted by the use of key examples. The dashboard provides a breakdown of national indicators by sex where possible. In the past year, some new data have been released and indicator values have been updated. In other areas, the indicator values from last year remain the same.

Stigma and health

Chapter 2 presents a stigma and health model that highlights the pathways from stigma to poor health outcomes and how stigmas intersect. This new model illustrates how different stigma drivers and practices, including those in the health system, can lead to health inequities. Chapter 3 presents an action framework with a range of evidence-based actions that can be implemented simultaneously to reduce stigma across the health system. These chapters examine a range of health-related stigmas as well as stigmas associated with social identities.

The information presented in the stigma chapters was synthesized from an evidence review conducted in social and health science databases. When synthetizing the evidence, systematic reviews were prioritized and complemented by primary studies. The strongest evidence found through the review was prioritized. Where available, Canadian research has been highlighted. Emerging and promising practices were identified through the evidence review, environmental scan, and stakeholder engagement.

Throughout the stigma chapters, quotes have been included to reflect the lived experiences of stigma and broader input on solutions for developing an inclusive health system. These quotes were gathered during 5 discussion groups and 8 interviews with a range of people with expertise in stigma across Canada. Participants included health professionals, representatives from community-based organizations, service providers, policymakers, researchers, individuals with lived and living experience, and others working to improve the health of their communities. The areas of focus included stigma experienced by First Nations, Inuit, and Métis peoples, African, Caribbean, and Black Canadians, seniors, and LGBTQ2+ people, and across health issues such as mental illness, substance use, tuberculosis, HIV, and obesity.

More information about the themes from the discussion groups and interviews can be found in the What We Heard report.

Chapter 1. Describing the health of Canadians

Introduction

Canadians are among the healthiest people in the world. In general, we live long lives in good health. Nevertheless, there are some concerning public health trends and health inequities.

The content of this chapter is based on indicator data derived from the Chief Public Health Officer's Health Status Dashboard (Appendix A), as well as other national data sources and scientific literature exploring the health of Canadians. Dashboard changes compared to the previous version that was published as part of the Chief Public Health Officer's Report on the State of Public Health in Canada 2018: Preventing Problematic Substance Use in Youth,include indicator value updates and breakdowns per sex, where available. In the event that no new indicator results were available, last year's published results are used. It is important to note, however, that national-level data can mask the health status of some groups in Canada. This chapter offers some examples of these persistent health inequities.

Text box 2: Health inequalities and inequities in context Health inequalities reflect differences in health outcomes. When these differences are related to unfair conditions, they are called health inequities. When reporting on populations that experience a disproportionate burden of poor health outcomes, it is critical to understand the context of these data. For instance, First Nations, Inuit, and Métis peoples have had to overcome stigmatizing and catastrophic experiences throughout history, such as colonization, the loss of traditional lands and political institutions, and attempts at cultural assimilation. Poor health outcomes related to substance use and mental health are examples of the lasting impacts of intergenerational trauma (i.e., passing on the negative effects from one generation to the next) that have influenced the health of Indigenous peoples in Canada. Unique contexts also exist for other populations, which need to be contextualized within historical, political, social, and economic conditions. Not all of these situations may be referred to in this chapter due to data and space limitations. To further explore differences in health outcomes, please refer to the report Key Health Inequalities in Canada (PDF).

Health trend highlights

Life expectancy is changing

In 2017Footnote i, life expectancy at birth for women was 84 years, while for men it was 80 yearsFootnote 2. Life expectancy is affected by both the number of deaths in a population, as well as the age at which those deaths occur.

For years, life expectancy at birth has steadily increased in Canada for both sexes, but recent data suggest this may be starting to change. From 2016 to 2017, for the first time in 4 decades, there was no year-to-year increase in life expectancy at birth for either males or femalesFootnote 2.

Despite this, some encouraging trends in life expectancy have been observed. Over the course of the previous 3 decades, male life expectancy at birth has increasingly approached the life expectancy of females, so the gap between the sexes has decreasedFootnote 2. Life expectancy at birth has been positively influenced by fewer deaths or later deaths related to cancer or circulatory diseases from 2016 to 2017Footnote 2.

Life expectancy is changing across age groups. Older people benefitted from improved mortality rates in 2017, meaning that they are dying at a slower rate than in 2016. However, gains in life expectancy at birth, due to these improved mortality rates for older Canadians, are being largely offset by increased mortality rates among younger adults. This is especially true for males (Figure 1)Footnote 2.

Figure 1. Contribution of age-specific mortality rates to the changes in life expectancy at birth (by sex, 2016 to 2017, Canada) Source: Statistics Canada, Changes in life expectancy by selected causes of death, 2017. Figure 1: Text description The figure shows the absolute change in life expectancy at birth in years from 2016 to 2017, due to changes in age-specific mortality rates, for both males and females, in Canada. Contribution of age-specific mortality rates to the changes in life expectancy at birth (by sex, 2016 to 2017) Age group Males Females Less than 1 year 0.012 0.006 1 to 4 years -0.001 0.004 5 to 9 years -0.001 0.000 10 to 14 years 0.001 0.002 15 to 19 years 0.000 -0.002 20 to 24 years -0.012 -0.006 25 to 29 years -0.015 -0.001 30 to 34 years -0.021 -0.003 35 to 39 years -0.015 0.000 40 to 44 years -0.006 0.003 45 to 49 years 0.000 -0.001 50 to 54 years -0.001 0.003 55 to 59 years 0.009 0.005 60 to 64 years 0.011 0.006 65 to 69 years 0.013 0.004 70 to 74 years 0.016 0.007 75 to 79 years 0.024 0.006 80 to 84 years 0.020 0.017 85 to 89 years 0.007 0.019 90 years and older 0.000 -0.009

The increase in deaths in young adults has been primarily attributed to the increase in opioid-related overdose deaths, particularly among young and middle-aged men. Opioid-related deaths have had a serious impact on life expectancy for both sexes, but more so for males in British Columbia and Alberta, contributing to decreases in life expectancy in both provinces from 2016 to 2017Footnote 2.

When examining different groups in Canada, life expectancy is consistently lower among First Nations, Inuit, and Métis peoples. Other differences in life expectancies are consistent with what is known on the social determinants of health, like those living with lower income have a lower life expectancy than the general population. There are also populations for which we have very limited data. For example, life expectancy data for some populations, like other racial groups or LGBTQ2+ people, is not knownFootnote 3.

As seen in Figure 2, with respect to Indigenous peoples, Inuit were estimated to have the shorter life expectancy at birth, up to 14 years shorter for males, and up to 11 years shorter for females, compared to the overall Canadian populationFootnote 4. It is important to see these data in context; the lasting legacy of colonization and intergenerational trauma have led to systemic health inequities for First Nations, Inuit, and Métis peoplesFootnote 5.

Figure 2. Life expectancy at birth by Indigenous identity and sex (Canada, 2009 to 2011) Source: Pan-Canadian Health Inequalities Data Tool, 2017 Edition. Figure 2: Text description The figure shows the life expectancy estimates at birth by Indigenous identity and sex for the years 2009 to 2011 in Canada. The total Canadian population is used as the reference group. Life expectancy at birth for Indigenous males, 2009 to 2011 Males Years Total Canadian population 80 Métis 72 First Nations 68 Inuit 66 Life expectancy at birth for Indigenous females, 2009 to 2011 Females Years Total Canadian population 84 Métis 78 First Nations 74 Inuit 73

Chronic diseases continue to be the major disease burden

Chronic disease continues to be the biggest cause of disease burden in Canada. Close to half of Canadian adults over the age of 20 years report that they are living with at least 1 of 10 common chronic diseases or conditions (Figure 3)Footnote 7.

Figure 3. Prevalence rates of common chronic conditions Source: Public Health Agency of Canada. Canadian Chronic Disease Indicators, Quick Stats, 2018 Edition.

Note that although mood disorders are among the most common chronic conditions, they are described separately in a subsequent section.

The figure shows the prevalenceFootnote ii of the most common chronic conditionsFootnote iii, which are:

hypertension (age 20+): 26%

osteoarthritis (age 20+): 14%

osteoporosis (age 40+): 12%

asthma (age 1+): 12%

chronic obstructive pulmonary disease (age 35+): 10%

diabetes (age 1+): 9%

ischemic heart disease (age 20+): 9%

cancer (age 12+): 7%

dementia (age 65+): 7%

On a positive note, recent data suggest declining incidenceFootnote iv rates for a number of chronic diseases in Canada (Figure 4)Footnote 7. A report analyzing national data over the period of 1999 to 2012 from the Canadian Chronic Disease Surveillance System (CCDSS) identified decreasing overall incidence trends for diagnosed asthma, chronic obstructive pulmonary disease, hypertension, ischemic heart disease, and strokeFootnote 6. More recent data from CCDSS reiterates the continuation of these trends between 2003 and 2016 for all described chronic diseases and points to a declining incidence rate for diabetes starting in 2006Footnote 7, Footnote 8. The observed decrease in chronic disease incidence rates may be influenced by factors such as varying strategies used to diagnose, manage, and report chronic diseases across the country. Further investigations are needed to fully understand these observations.

Figure 4. Age-standardized chronic disease incidence estimates (2003 to 2016, Canada) Source: Canadian Chronic Disease Surveillance System data files (as of August 2019)Footnote 7. Figure 4: Text description The figure shows the declining age-standardized incidence rates per 100,000 population for various chronic diseases from 2003 to 2016 in Canada, such as: stroke

diabetes

asthma

chronic obstructive pulmonary disease

ischemic heart disease

hypertension Age-standardized chronic disease incidence estimates (2003 to 2016) Year Incidence rate per 100,000 population Hypertension Ischemic heart disease Chronic obstructive pulmonary disease Asthma Diabetes Stroke 2000 3,284 1,245 1,204 904 660 - 2001 3,249 1,153 1,120 823 672 - 2002 3,205 1,075 1,013 757 687 - 2003 3,146 1,016 1,008 724 668 385 2004 3,065 964 990 696 700 377 2005 3,041 919 947 699 728 366 2006 2,996 868 913 639 761 348 2007 2,842 826 926 583 717 337 2008 2,739 798 958 563 706 331 2009 2,684 763 994 562 743 326 2010 2,525 738 980 532 686 315 2011 2,399 712 920 500 662 308 2012 2,236 681 883 480 619 300 2013 2,210 658 846 473 627 295 2014 2,115 641 860 475 615 301 2015 2,048 632 828 461 614 300 2016 1,975 629 819 443 616 295

Canadian data also suggest a possible decline in the incidence rates of newly diagnosed cases of dementia, including Alzheimer's disease (Appendix A)Footnote 9, Footnote 10. A recent Lancet commission examined lifestyle factors which might influence an individual's risk of developing dementia. Evidence shows that healthy living and higher education levels may contribute to preventing or delaying dementiaFootnote 11. While the incidence rate may be decreasing in Canada, the burden of Alzheimer's disease and dementia is expected to continue to increase, due to factors such as a growing and aging population, and possibly improved survival. Accordingly, between 2005 and 2016, the age-standardized prevalence rate of dementia increased by 12%Footnote 7.

There are health inequalities across chronic diseases. For example, South Asian as well as African, Caribbean, and Black Canadian adults are more than twice as likely to live with diabetes than White adultsFootnote 3. Evidence suggests that dementia rates are rising more rapidly among First Nations populations compared to the general Canadian population, including earlier disease onsetFootnote 10, Footnote 12.

Poor mental health continues to impact Canadians

The good news is that 69% of Canadians aged 12 years and older reported their mental health status as very good or excellent in 2018. At the same time, the percentage of Canadians aged 12 years and older who indicated that they have been diagnosed by a health professional as having a mood disorder, such as depression, bipolar disorder, mania, or dysthymia (i.e., persistent depressive disorder) was 9% in 2018Footnote 13.

Mental health varies considerably among Canadians, with some sub-populations being much more likely to report low self-rated mental health. For example, for the period of 2010 to 2013, adults who identified as bisexual were close to 3 times more likely, and adults who identified as gay or lesbian, were approximately twice more likely, to report low self-rated mental health than adults who identified as heterosexual. These higher rates could be linked to internalized stress related to gender expectations and experienced discriminationFootnote 3.

In Canada, suicide rates remained stable from 2000 to 2017. On average, 11 Canadians die by suicide every dayFootnote 14. In 2017, the suicide rate among males was 3 times higher than the rate among females. Suicide rates were highest among middle-aged malesFootnote 14. Some Indigenous communities are disproportionally affected. Areas with a relatively high Inuit population had a 6.5 times higher suicide rate than areas with a low concentration of Indigenous peoplesFootnote 3. Suicide rates in areas primarily inhabited by First Nations and Métis peoples were also significantly higher (4 and 3 times, respectively) than in areas with a non-Indigenous peoples majorityFootnote 3. The impacts of intergenerational trauma can ultimately manifest in poor mental health and practices that may place individuals at risk for suicide. However, it is important to note that not all Indigenous communities experience high suicide rates. For example, over 60% of First Nations bands had a suicide rate of zeroFootnote 15. Protective factors can include opportunities to speak and learn one's traditional language, cultural identity, and connection to the landFootnote 16, Footnote 17.

Substance use

Substance use and its related harms remain a concerning public health issue and a national priority. Street drugs contaminated with highly toxic fentanyl and fentanyl analogues continue to drive the current epidemic of opioid-related deathsFootnote 18. In addition, reducing or preventing alcohol-related harm is a persistent challenge, alongside addressing emerging concerns such as tobacco use and nicotine vaping among youth.

High rates of opioid-related deaths continue

Nationally, more than 12 apparent opioid-related deaths occurred on average every day in 2018Footnote 18. In early 2019, 82% of accidental opioid-related deaths involved fentanyl or fentanyl analoguesFootnote 19. Regional variations continue to be observed and some provinces and territories (British Columbia and Alberta, in particular) have been impacted more than others. Data for 2018 show that overall, men accounted for 3 quarters of accidental apparent opioid-related deaths in CanadaFootnote 18. Likewise, in 2018, young and middle-aged adults accounted for the most accidental apparent opioid-related deaths overall, with 27% of deaths reported among those aged 30 to 39 years, followed by 22% in those aged 40 to 49 years, 21% aged 50 to 59 years, and 20% aged 20 to 29 yearsFootnote 18. Although complete national information on opioid-related harms in Indigenous peoples is lacking, available data suggest higher opioid use and associated harms, including higher rates of hospitalization, accidents, and death in some but not all Indigenous communities, compared to the general Canadian populationFootnote 258. In this context, it is important to note that First Nations, Inuit, and Métis peoples have experienced intergenerational trauma, abuse and systemic racism, which directly or indirectly contribute to elevated levels of substance use ratesFootnote 20, Footnote 21.

Vaping increases among youth

Vaping is the inhaling of a vapour created by an electronic cigarette (e-cigarette) or other vaping device. In 2017, the use of e-cigarettes as a cessation aid in the past 2 years was reported by 32% of current or former smokersFootnote 22. Among the 3% of Canadians aged 15 years and older who used a vaping product in the past 30 days in 2017, 65% were current smokers, 20% were former smokers, and 15% reported having never smoked cigarettesFootnote 22.

The increased use of vaping products by youth represents an emerging and serious health trend. Vaping can increase the risk of nicotine addiction and could alter brain development in youthFootnote 23. The long-term effect of exposure to a range of harmful chemicals such as formaldehyde, acrolein, metals, and other contaminants through vaping remains unknown. Emerging evidence points to increased risk of respiratory disease in vaping device users, highlighting the need for further studiesFootnote 24, Footnote 25. In 2017, approximately 15% of Canadians aged 15 years and older had ever tried a vaping product, with the greatest likelihood among youth aged 15 to 19 years (23%) and young adults aged 20 to 24 years (29%)Footnote 22. A recent meta-analysis indicates that adolescents and young adults who had ever used e-cigarettes had close to 4 times higher odds of initiating cigarette smoking than those who had never used e-cigarettesFootnote 26. Accordingly, from 2017 to 2018, the percentage of Canadian youth aged 16 to 19 years who reported vaping in the last month increased substantially by 74%Footnote 27. More research is required to better understand the association between vaping and smoking behaviour in Canada, and the related health impacts.

Cannabis use rises in adults 25+

In 2017, the prevalence of past-year cannabis use was 15%, a 3% increase compared to 2015Footnote 22. Frequent cannabis use did not change between 2015 and 2017, with approximately 3% of Canadians aged 15 years and older reporting daily or almost daily cannabis use in the previous 3 months. It is important to note that most of the available data on cannabis consumption pre-dates cannabis legalization in Canada in 2018Footnote 28. Consequently, cannabis use reporting was strengthened with the implementation of the Cannabis Stats Hub in 2018, which now monitors cannabis use every 3 monthsFootnote 29.

Cannabis use varies by age. In 2017, past-year use of cannabis was highest among youth aged 15 to 19 years (19%) and young adults aged 20 to 24 years (33%) compared to adults aged 25 years and older (13%). Compared to 2017, past-year cannabis use among adults aged 25 years and older increased from 10% in 2015, though there were no changes reported for other age groupsFootnote 22. National and regional studies identified differences in cannabis use by race in youth, with Indigenous youth being the most likely group reporting lifetime and recent cannabis useFootnote 30, Footnote 31.

By the end of 2018, the cannabis sources accessed by users largely depended on their reasons for using it. Eighty-six percent of medical users with documentation acquired cannabis from legally authorized retailers or licensed online producers, in contrast to 26% of non-medical usersFootnote 32. Forty-two percent of non-medical users declared obtaining cannabis from illegal sources and 54% from friends or familyFootnote 32.

One important contributor for harms related to cannabis use is the increased risk of motor vehicle collisions when driving under the influence of cannabisFootnote 33. Among cannabis users with a valid driver's licence, 14% admitted to driving within 2 hours of using cannabis. This practice was nearly twice as common in males compared to femalesFootnote 34.

Heavy drinking rates remain harmfully high

Alcohol continues to be the most used psychoactive substance amongst adults and youth. In 2017, 78% of the population over 15 years of age reported drinking alcohol in the last yearFootnote 22. In 2017, past-year alcohol use among youth aged 15 to 19 years was 57%Footnote 22. These figures were all unchanged from 2015.

Heavy drinking rates remained stable from 2017 to 2018, with 19% of Canadians aged 12 years and older reporting heavy drinking in 2018Footnote 13. Heavy drinking means having 5 or more standard drinks for men or 4 or more standard drinks for women, on one occasion, at least once a month in the past yearFootnote 35.

The rate of alcohol-related hospitalizations has increased faster for women than for men. More than 25,000 women had alcohol-related hospitalizations, representing a 3% increase from 2015-16 to 2016-17. In contrast, the increase for men was 0.6%Footnote 36. Differences in heavy drinking behaviour exist across populations. For instance, close to 22% of White adults reported heavy drinking between 2010 and 2012, which is greater than the 7% of heavy drinking among African, Caribbean, and Black, Asian, and Arab adults. Bisexual women and lesbians were almost twice as likely to declare high alcohol consumption as heterosexual womenFootnote 3.

Sexually transmitted and blood-borne infections are on the rise

Concerning increases for some sexually transmitted and blood-borne infections (STBBI) have been observed in Canada. From 2007 to 2016, the reported rates for chlamydia, gonorrhea, and syphilis increased by 49%, 81% and 178%, respectively (Figure 5)Footnote 37. Moreover, 6 cases of congenital syphilis were reported in Canada in 2015, reversing the previous downward trend observed from 2011 to 2014Footnote 38. This result is disquieting as it coincides with a rise in syphilis cases in women of childbearing age. There are numerous factors that may contribute to some extent to the observed trends, other than a true rise in incidence, such as improved diagnostic tools, contact tracing, and case detectionFootnote 39.

Figure 5. Percentage change in reported rates of selected STBBI in Canada (2007 to 2016) Source: Adapted from Accelerating our Response: Government of Canada Five-year Action Plan on Sexually Transmitted and Blood-borne InfectionsFootnote 37. Figure 5: Text description The figure represents the year-to-year percent change in the observed infection rates of sexually transmitted and blood-borne infections (STBBI) from 2007 to 2016 in Canada. Percentage change in reported rates of selected STBBI (2007 to 2016) Year Percent change (compared to 2007) Acute hep B Chlamydia Gonorrhea Hep C HIV Syphilis 2007 0% 0% 0% 0% 0% 0% 2008 -6% 11% 5% -2% 7% 10% 2009 -24% 15% -8% -9% -4% 24% 2010 -37% 24% -7% -15% -8% 31% 2011 -33% 31% -3% -20% -10% 34% 2012 -46% 35% 4% -20% -19% 55% 2013 -46% 33% 12% -20% -21% 66% 2014 -46% 37% 27% -19% -21% 77% 2015 -54% 45% 53% -17% -21% 134% 2016 -45% 49% 81% -15% -12% 178% Infection rate per 100,000 population (2016) 0.53 334.3 65.4 31.1 6.4 10.6

Percentages represent the percent change relative to the reference year of 2007. The values in brackets represent the 2016 infection rates per 100,000 population.

While the number of newly diagnosed HIV infections remained relatively stable in Canada, 14% of people living with HIV were estimated to be unaware of their status in 2016Footnote 40. Similarly, as of 2016, national Hepatitis C infection rates remained stable over the course of previous yearsFootnote 41. An estimated 44% of Canadians living with Hepatitis C are thought to be unaware of their statusFootnote 42.

Some communities are disproportionally affected. For example, gay, bisexual and other men who have sex with men accounted for more than 50% of new HIV infections in 2016, although they represented approximately 3% of the male population in Canada. Indigenous peoples accounted for 11% of new HIV infections in 2016, but represented only 5% of the general populationFootnote 40.

Certain sub-populations are at high risk for Hepatitis C infections, such as people who inject drugs and people who are incarceratedFootnote 42.

Current vaccination rates are not reaching national targets

For many decades, vaccines have helped prevent and control the spread of serious infectious diseases in Canada and abroad. However, effective vaccine protection at the population level requires establishing and maintaining high vaccination rates across the country. Since 2011, little progress has been made towards reaching national childhood vaccination targets for several vaccine preventable diseases, such as measles and polio (Appendix A)Footnote 43.

In the case of measles, for example, the disease was declared eliminated from Canada in 1998. This was shortly after introducing a routine second dose of the measles vaccine to the childhood immunization schedule, prior to school entryFootnote 44. In spite of this success, the national estimated measles vaccine coverage rate among 2-year-olds was only 90% in 2017, which is below the minimum 95% vaccination coverage needed at the population level to maintain measles eliminationFootnote 45. Over the past 2 decades, measles cases and outbreaks have occurred intermittently in Canada, ranging from a few secondary cases to over 680 cases per outbreak (Figure 6)Footnote 46, Footnote 47, Footnote 48, Footnote 49, Footnote 50. They have been linked to individuals who acquired measles during international travel.

Figure 6. Annual number of confirmed measles cases (1998 to 2019, Canada) Footnote v Figure 6: Text description The figure shows the annual number of confirmed measles cases from 1998 to 2019 in Canada. Labels adjacent to the line graph peaks and shoulders depict the number of confirmed measles cases for the particular year. Annual number of confirmed measles cases (1998 to 2019) Year Number of cases 1998 17 1999 32 2000 207 2001 38 2002 9 2003 17 2004 9 2005 8 2006 13 2007 101 2008 61 2009 14 2010 98 2011 752 2012 10 2013 83 2014 418 2015 196 2016 11 2017 45 2018 29 2019 107

Antimicrobial resistance and unnecessary antibiotic use is an emerging threat

Antimicrobial resistance (AMR) describes the capability of disease-causing microorganisms to withstand antimicrobial treatments such as antibiotics, thereby limiting available treatment options. AMR has been identified by the World Health Organization as 1 of the 10 most significant threats to global health. Globalization, travel, and medical tourism mean that Canada shares this threatFootnote 51, Footnote 52. If left unchecked, it is estimated that AMR could cause 10 million deaths a year worldwide by 2050Footnote 53.

Concerning national AMR trends were observed for several infectious diseases. For example, rates of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) infections increased by 62% between 2012 and 2017; Neisseria gonorrhoeae infections resistant to azithromycin increased by 50% from 2015 to 2016Footnote 52. While infection rates of some of the most resistant organisms, for example, carbapenem-resistant Enterobactericeae (CRE), have been stable, a very worrisome trend can be found in the five-fold increase, between 2014 and 2017, in the number of people who are carriers of these bacteriaFootnote 54. However, some progress has been made in Canada to reduce AMR, primarily in hospital settings. For example, healthcare-associated Clostridioides difficile and healthcare-associated MRSA infections decreased respectively by 36% and 6% from 2012 to 2017Footnote 54.

Threats from AMR are not restricted to those coming from bacterial infections. For example, multidrug-resistant fungal infections caused by Candida auris are also a concern. Initially reported in Japan in 2009, the first imported case described in Canada was in 2017Footnote 55. As of July 2019, there have been 20 cases of C. auris reported in CanadaFootnote 8.

Antibiotics are used widely in both human and veterinary medicine as well as in the agricultural industry. The prevalence of AMR is strongly associated with antibiotic use, and lowering antibiotic use can reduce the development of AMRFootnote 56. In Canada, 92% of all antibiotics dedicated to human health care are prescribed in the community, primarily by general practitioners (65%), followed by dentists, nurses, and pharmacists (22%), as well as other specialists (13%)Footnote 57.

Greater efforts are required to reduce the unnecessary use of antibioticsFootnote 58. In many cases, antibiotics are prescribed for indications where they are ineffective, such as for viral infectionsFootnote 56, Footnote 59. Not only does this accelerate the development of AMR, it puts the patient at risk of side effects without offering them benefit. In some studies, it is estimated that 30-50% of all antibiotic prescriptions in outpatient settings are inappropriateFootnote 60, Footnote 61.

Climate change is impacting health and well-being

Our climate is changing. Canada is warming at about double the global rate, and northern Canada has already warmed to almost 3 times the global rateFootnote 62, Footnote 63, Footnote 64. Canada's Top Climate Change Risks report (2019) has identified health and well-being as one of the key areas of climate change risk facing Canada, while pointing out that such risks can be meaningfully reduced through adaptation measures that lessen vulnerability and/or exposureFootnote 65.

Climate change is having an impact on health and well-being both directly and indirectly. Extreme weather events such as flooding, wildland fires, and heatwaves can result in death, injury, and illness. For example, more than 90 people in Quebec died as a result of the July 2018 heatwaveFootnote 66. Changes in precipitation and temperature have also influenced the spread of climate-driven infectious diseases.

Social determinants of health such as housing, working conditions, and food security will be affected by climate change. Extreme weather events not only increase the risk of direct negative health impacts, but also pose challenges to health systems and health care facilities with consequences for patient care, safety, and healthcare costsFootnote 64.

The impacts of climate change on health and well-being will also vary by region. In northern Canada, the consequences of climate change are significant and widespread. For example, loss of sea ice is associated with food insecurity and mental health impacts for populations that rely on ice to access hunting grounds and traditional sites, and to bring food and supplies from the SouthFootnote 64. In Rigolet, Nunatsiavut community members have reported feelings of displacement due to the disruption of hunting, fishing, foraging, trapping, and travelling from climate change impactsFootnote 67.

Text box 3: Climate-driven infectious diseases Changes in precipitation and temperature can increase the spread of climate-driven infectious diseases, specifically, zoonoses (i.e., diseases that can spread between animals and people), vector-, food- and water-borne diseases: Changing climate has facilitated the spread of the tick responsible for Lyme disease, contributing in part to an increase in cases from 144 in 2009 to 2025 in 2017 Footnote 68 , Footnote 69 . Other tick-borne diseases have also started to emerge in Canada including, for example, anaplasmosis and Powassan virus Footnote 68 .

, . Other tick-borne diseases have also started to emerge in Canada including, for example, anaplasmosis and Powassan virus . 4 out of the 5 bacteria that account for over 90% of foodborne illness in Canada are influenced by climate change Footnote 70 .

. Over the last 20 years, the incidence rates of endemic mosquito-borne diseases, such as West Nile virus and Californian serogroup virus, have increased in Canada Footnote 71.

Highlights of other factors impacting health

The health of individuals and populations is determined by a number of personal, social, economic, and environmental factors. These factors influence someone's place and position of power in society, and the access they have to the building blocks of good health. Examining key trends in the determinants of health is important to our understanding of public health and health inequities.

Strong sense of community belonging

Community belonging has a particularly important role in shaping mental health and a number of indicators related to community connectedness are included in the Public Health Agency of Canada's Positive Mental Health Surveillance FrameworkFootnote 72. In 2018, 68% of the population aged 12 years and older reported a somewhat strong or very strong sense of belonging to the local communityFootnote 13. Some Indigenous peoples rate their sense of community belonging much higher than the national average. For example, close to 81% of First Nations peoples declared a somewhat strong or very strong sense of belonging to their local community in 2015-2016Footnote 73. A strong sense of community belonging can be an asset for fostering resilience and mitigating the impact of societal inequities.

Higher education attainment and less poverty

Income and education are 2 key social determinants of health exerting an influence on many important health measures, such as overall life expectancy. In the period from 2009 to 2011, Canadians living in the lowest-income neighbourhoods had a life expectancy at birth that was approximately 4 years lower than those living in the highest income neighbourhoods. Similarly, Canadians living in areas with the highest proportion of people having less than a high school education had close to 3 years lower life expectancy at birth compared to those living in areas with the highest proportion of university graduatesFootnote 4.

This year, important and encouraging trends are being reported for income and education.

The proportion of Canadians aged 25 to 54 yearsFootnote vi without a certificate, diploma or degree has decreased by 51%, from 14% in 2003 to 7% in 2018Footnote 74. This trend may be influenced by a generational shift in the likelihood of completing postsecondary education.

There have also been considerable decreases in the proportion of Canadians living below Canada's Official Poverty Line, which is a measure of low income (based on the Market Basket MeasureFootnote vii). In 2017, 10% of Canadians were living below the poverty line compared to 16% in 2006Footnote 75. This represents a decrease of 39%. The change was even more pronounced among children living below the poverty line, with a decrease of 53% from 19% in 2006 to 9% in 2017Footnote 75. Despite this encouraging trend, childhood poverty remains a concern in some populations. For example, in 2015, high childhood poverty rates were reported for Indigenous children, ranging from an average of 47% for First Nations children to 25% and 22% for Inuit and Métis children, respectively. Moreover, data on non-Indigenous children indicate that recent immigrant and non-Caucasian children had poverty rates of 35% and 22% respectively, compared to 12% for all children in the remaining groupFootnote 76.

Chapter 2. Stigma is a public health issue

Some Canadians experience worse social and health outcomes than others. The evidence tells us this is, in part, due to how we treat each other. When we stigmatize people, we affect their chances for a long and healthy life.

Stigma affects health through stress and other physical pathways. Many people are exposed to multiple stigmas, preventing them from attaining the resources they need to achieve optimal health such as education, employment, housing, and health services.

These stigma chapters will focus on the health system, which includes health care, public health, and other allied health services. Stigma in the health system can be particularly harmful, as people are prevented from accessing the health information services and resources they need, creating mistrust and further exclusion.

The experience of stigma

Here we introduce you to Charles and Cynthia, fictional people who experience multiple and intersecting stigmas. They face stigma in society and the health system, which affects their well-being and health. We revisit Charles and Cynthia in the next chapter, to see how things could have worked out differentlyFootnote viii.

Charles Charles recently moved to a mid-sized town in Ontario. He feels people staring at him and has even seen people crossing to the other side of the street when he walks by. He wonders whether this is because he is Black. Charles has been with his partner David for most of his adult life. During the AIDS epidemic of the 1980's, he contracted HIV. Thanks to current treatments, the virus is undetectable in his body. However, recently he has been experiencing some symptoms that he thinks may have something to do with cardiovascular disease, just like his parents had. He knows that he needs to go see his new doctor and get this checked out, but he is hesitant because he had been treated with disrespect before by healthcare providers. Charles attends an appointment with his new doctor to discuss his symptoms; however, she seems dismissive of his concerns. She instead asks Charles several questions about his HIV status and whether he is practising safe sex. At the end of the appointment, she only suggests that Charles change his diet, and she does not refer him for any further testing. Charles leaves feeling frustrated and ignored. He does not seek further care as he is worried that he will not be taken seriously again. Several months later, Charles suffers a heart attack and is rushed to the hospital. While recovering, Charles feels the hospital staff are apprehensive to touch him and he notices that they put on gloves to perform routine tests, such as taking his blood pressure, which they do not do with other patients. Charles overhears 2 nurses whispering about his HIV status. Charles feels unsettled about the care he received and is worried about his future health.

Cynthia Cynthia is a Cree woman living in Saskatchewan with her 2 young children and is pregnant with her third baby. She is connected with members of her First Nations community and has been receiving health care in a First Nations health centre. She has just learned that she will need to be admitted to a large hospital to receive treatment for complications related to her pregnancy. She is afraid of going into the hospital because during her first pregnancy, her non-Indigenous doctor kept asking her questions about drug and alcohol use and insinuating that she may not be capable of providing for her child. She has delayed going to the hospital because she does not want to face those kinds of questions or risk losing her children. The stress of worrying is causing her to not sleep or eat properly. Due to her previous negative experiences, Cynthia avoids going to the hospital for treatment. Cynthia experiences severe complications during the seventh month of her pregnancy, and is rushed to the hospital, where she has an emergency C-section. Her baby is born with an extremely low birth weight and will need to stay in the neo-natal intensive care unit for at least 1 month. As she is recovering, the doctors and nurses repeatedly ask Cynthia why she did not get treatment to avoid these complications. Cynthia feels that they are implying she is a bad mother, and they are blaming her for the outcome of the pregnancy. Cynthia feels alone and is worried about the next steps for herself and her new baby. She is unsure how she can visit her new baby at the hospital without adequate childcare for her other children. Despite voicing her concerns, the hospital staff tell Cynthia these are "normal" emotions after having a baby, and they do not refer her to a hospital social worker or provide her with additional resources for support. Cynthia leaves the hospital feeling helpless and stressed, which adds to her existing eating and sleeping problems.

Interview quote 1: "There are so, so many ways stigma stops people from reaching their full potential. And we as a society are poorer for that."

The pathways of stigma to health outcomes

Stigma begins with the labeling of differences and negative stereotyping of people, creating a separation between "us" and "them." Those who are stigmatized are devalued and subjected to discrimination, which is unjust treatment. This can lead to disadvantage and inequitable social and health outcomesFootnote ix. Stigma happens in institutions (e.g., healthcare organizations), at a population level (e.g., norms and values), through interpersonal relationships (e.g., mistreatment), and internally (e.g., self-worth and value).

Stigma can be seen as both a cause and effect; it continues to justify the devaluing of people through stereotypes and exclusionFootnote 77. Unless this cycle is actively stopped, the separation into "us" and "them" is reinforced by unequal power dynamics in society. People and institutions with resources and power, including health organizations, shape laws and social norms that can influence what is considered to be "normal" and "acceptable." In the health system, this power dynamic also exists between healthcare providers and patients.

Stigma can target different identities, characteristics, behaviours, practices, or health conditionsFootnote 78. For example, stigma can be based on race, gender and gender identity, sexual orientation, language, age, substance use, ability, and social class. Stigma related to health conditions can include obesity, substance use disorders, mental illness, dementia, tuberculosis, and HIV infection. When stigmas intersect, they can exacerbate negative health outcomes.

Stigma includes discrimination, as "enacted" stigmaFootnote 1, Footnote 79. While there is little data measuring stigma in Canada, discrimination is more commonly measured. The following section summarizes available self-reported discrimination data for some key populations. It is important to note that there is still limited data in this area and that experiences of discrimination may be underreported.

Text box 4 Stigma can benefit those in power in several waysFootnote 80: By keeping people "in," that is, by enforcing preferred social norms and values By keeping people "down," which maintains one's group advantage in society By keeping people "away," in order to avoid disease or a perceived threat

Discrimination in Canada

Over 1 in 4 Canadians have reported experiencing at least one form of discrimination in their lifetimeFootnote 81. Many Canadians experience discrimination based on race, religion, ethnic origin, gender, or sexual orientation. The most common type of discrimination reported by Canadians is racial discriminationFootnote 81. African, Caribbean, and Black Canadians are the most likely to report discrimination in Canada, followed by Indigenous peoplesFootnote 82. Alarmingly, hate crimes, one of the most extreme forms of discrimination, have been on the rise in Canada, primarily against people who are part of Arab, Muslim, Jewish, and Black communitiesFootnote 83.

New analyses of the 2013 Canadian Community Health Survey Rapid Response Discrimination Module, the only national discrimination survey in Canada, support these findings. Lesbian, gay, bisexual (LGB) participants (note that transgender identities were not included in the survey), African, Caribbean, and Black Canadians and Indigenous peoples in Canada were more likely to report being unfairly treated than the general population. More specifically, LGB community members were almost 3 times more likely, and African, Caribbean, and Black Canadians and Indigenous peoples were twice as likely, to report having faced discrimination than their general population counterpartsFootnote 8.

In a national Canadian survey, the majority of youth who identified as transgender (ages 19 to 25 years) reported having experienced discrimination in the last year based on their gender identity (70%), sex (63%), physical appearance (60%) or sexual orientation (59%)Footnote 84.

In 2012, 20% of Canadians with a mental health illness reported being affected by negative opinions or unfair treatment due to their poor mental healthFootnote 85. In 2014, 10% of Canadians with mental health disabilitiesFootnote x reported violent victimization in the 12 months prior to the survey, which was more than double the general populationFootnote 86.

In an online Canadian survey in 2016, 49% of people currently in recovery from addiction reported experiencing stigma or discrimination during their active addictionFootnote 87.

Discussion group quote 1: "I think there are actually two groups that are impacted by stigma, those groups who are negatively impacted… [and] another group that we don't think about very often, and that's the group that benefits from stigma, and benefits from the perpetuation of those mainstream ideologies that continue to maintain that settlers, people with European background, as being better."

Why a new stigma model is needed

The following Stigma Pathways to Health Outcomes Model (Stigma Model) provides a new way to think about stigma and how it undermines health for individuals and contributes to population health inequities (Figure 7)Footnote xi. It builds on recent efforts to understand the full impact and significance of stigma on health, including the experience of multiple and intersecting stigmas that many people experienceFootnote 1, Footnote 98, Footnote 99, Footnote 100.

Although stigma has been studied in social and health sciences for decades, the research is generally focused on isolated health conditions or social identitiesFootnote 1. This Stigma Model can be used to understand individual stigmas while also considering how different stigmas inevitably intersect to create worse outcomes for some people. The Stigma Model also offers the opportunity to understand the impact of stigma on different health outcomes simultaneously.

Figure 7. Stigma Pathways to Health Outcomes Model Figure 7: Text description This figure depicts the Stigma Pathways to Health Outcomes Model. The model works from left to right, describing the following components that flow into one another: drivers of stigma

types of stigmas

stigma practices

stigma experiences

outcomes for affected populations These components also influence each other. Drivers of stigma can include: stereotypes

fear of contagion

colonizing norms

unequal power dynamics

lack of awareness Drivers lead to different types of stigmas that include those targeting: racialized identity

sexual orientation

gender identity

age

health issues, such as: mental illness HIV substance use tuberculosis

These can also be intersecting stigmas. Stigma practices include: discriminatory policies, norms and behaviours

stereotyping and demeaning language and portrayals

social avoidance and exclusion by others

hate crimes and assaults Stigma experiences include: enacted stigma (which is the experience of unfair treatment)

internalization of negative stereotypes and beliefs

anticipated stigma

secondary stigma experienced by family, friends or caregivers Outcomes for affected populations include: reduced access to, and quality of, protective resources and health services

chronic stress

poor coping responses and behaviours

higher risk for assault and injury Ultimately, these lead to poorer mental and physical health and increased social and health inequities. Key areas for intervention would target: stigma drivers

stigma practices

stigma experiences

outcomes for affected populations These interventions would happen at the individual, interpersonal, institutional or population level.

Importantly, the Stigma Model can be used by policy leaders, researchers, practitioners, and service providers to identify drivers of stigma and stigma practices in the health system that cut across areas of stigma. Interventions to address these broader issues are explored in Chapter 3 and through the proposed Action Framework for Building an Inclusive Health System.

The Stigma Model works from left to right, but the components also influence one another. Applying the model to a particular stigma offers a way to understand how certain drivers lead to the "marking" and labelling of targeted groups. Once marked, people are then vulnerable to a variety of stigmatizing practices and discriminatory actions from other people, institutions, and society in general. Experiencing stigma can then lead to adverse health outcomes for individuals and increased inequities for populationsFootnote 98.

Text box 6: Stigmas intersect differently to affect health Different types of stigma can intersect and work interactively to affect healthFootnote 101. Researchers use the term "intersectionality" to understand the complex connections, outcomes, and opportunities that can arise when people are subjected to multiple forms of stigmaFootnote 102. For example, the discrimination experienced by a racialized gay man living with HIV could produce poorer health outcomes because of the stigmas that arise from being racialized, identifying as gay, and living with HIV. Poorer outcomes might also result for an Indigenous, two-spirited person living with a mental illness. The reality is that many Canadians live with multiple stigmas. A key benefit of an intersectional approach is that it embeds an understanding of this complexity in our understanding of stigma's impact on health, and can therefore lead to a more complete and impactful response in addressing health consequences.

Practical application of the stigma model

To illustrate how the model can be used to explore stigma pathways in detail and identify both cross-cutting and unique issues for different stigmas, 7 examples are presented below (Table 1):

Racism as experienced by First Nations, Inuit, and Métis peoples Racism as experienced by African, Caribbean, and Black Canadians Stigmas as experienced by LGBTQ2+ people (sexual stigma and gender identity stigma) Mental illness stigma Substance use stigma HIV stigma Obesity stigma

Although the content for these examples has been drawn from the evidence, this is not a full examination of all possible pathways or the varied experiences within stigmas. Rather, the examples offer some areas for intervention across the health system. The Stigma Model can be used to further explore these stigmas as well as examine additional stigmas related to racial identities, religion, age, disability, and other characteristics or behaviours.

A detailed list of references for each stigma topic in Table 1 will be available on the 2019 CPHO annual report web page.

Table 1: Examples of how the Stigma Pathways to Health Outcomes Model can be applied to different stigmas Drivers of stigma Intersecting stigmas Stigma practices Experiences of stigma Outcomes and impacts for affected populations Racialized identities: First Nations, Inuit, and Métis peoples (racism) Unequal racial power dynamics created by colonization and reinforced by ongoing colonialism; forced removal from traditional lands and creation of reservation system; the residential school system; historical and current rates of disproportionate apprehension by child welfare agencies (e.g., Sixties Scoop); race-based stereotypes Other social identity stigmas (e.g., sexual stigma, gender identity stigma, ageism) and health-related stigmas (e.g., mental illness stigma, substance use stigma, HIV stigma) Abolishing or not recognizing traditional language and culture; social avoidance and exclusion by others; hate crimes and assaults; negative media portrayals; demeaning language (e.g., racial slurs); discrimination in employment, education, criminal justice, and housing sectors creating health vulnerabilities

Health system: Discriminatory interpersonal behaviour of health professionals; Eurocentric health professional training (e.g., rejection of traditional knowledge, medicine, and healing practices) Enacted stigma (the experience of unfair treatment); internalized stigma (e.g., shame and embarrassment for LGBTQ2+ people, people who use substances, and people living with HIV, mental illness or obesity); anticipated stigma; secondary stigma for family, friends, and/or caregivers Overcrowded or inadequate housing; barriers to accessing post-secondary education; reduced economic resources due to employment barriers; increased risk of food insecurity; disconnection from family, community and culture; exposure to violence, particularly against Indigenous women and girls; reduced seeking or avoidance of healthcare services and poorer quality of services received Chronic stress leading to health harming coping strategies (e.g., smoking, alcohol and substance use) Health outcomes: Increased risk of adverse physical health (e.g., lower life expectancy, tuberculosis) and mental health outcomes (e.g., intergenerational trauma, post-traumatic stress disorder, suicide and suicide attempts) Racialized identities: African, Caribbean, and Black Canadians (racism) Unequal racial power dynamics from slavery and colonization; forced removal from traditional lands; social, educational, residential, and occupational segregation; race-based stereotypes Other social identity stigmas (e.g., sexual stigma, gender identity stigma, ageism) and health-related stigmas (e.g., mental illness stigma, substance use stigma, HIV stigma) Social avoidance and exclusion by others; hate crimes and assaults; negative media portrayals; demeaning language (e.g., racial slurs); discrimination in employment, education, criminal justice, and housing sectors creating health vulnerabilities

Health system: Discriminatory interpersonal behaviour of health professionals; Eurocentric health professional training Enacted stigma (the experience of unfair treatment); internalized stigma (e.g., shame and embarrassment for LGBTQ2+ people, people who use substances, and people living with HIV, mental illness or obesity); anticipated stigma; secondary stigma for family, friends, and/or caregivers Barriers to accessing post-secondary education; overcrowded or inadequate housing; reduced economic resources due to employment barriers; increased risk of food insecurity; exposure to violence; reduced seeking or avoidance of healthcare services and poorer quality of services received Chronic stress leading to health harming coping strategies (e.g. smoking, alcohol and substance use) Health outcomes: Increased risk of adverse physical health (e.g., hypertension, diabetes) and mental health outcomes (e.g., intergenerational trauma, depression and anxiety) LGBTQ2+ (sexual stigma and gender identity stigma) Heteronormativity (expected sexual orientation is heterosexual); historical criminalization of same-sex relationships and sexual practices; societal expectation that gender identity matches biological sex at birth; gender bias that values men over women; historical medical diagnosis of alternative sexual orientation or gender identity as disordered; stereotypes based on sexual orientation Other social identity stigmas (e.g., racism, sexual stigma, gender identity stigma, ageism) and health-related stigmas (e.g., mental illness stigma, substance use stigma, HIV stigma) Assumptions of an individual's sexual orientation or gender identity; rejection and exclusion from family, peers, and/or community; lack of alternative gender identities on identification documents; hate crimes and assaults; negative media portrayals; demeaning language

Health system: Discriminatory interpersonal behaviour of health professionals (e.g., incorrect use of gender pronouns); insufficient training of health professionals pertaining to LGBTQ2+ health; inappropriate practices such as conversion therapy; insufficient tailored health information, resources, and services Enacted stigma (the experience of unfair treatment); internalized stigma (e.g., shame and embarrassment for LGBTQ2+ people, people who use substances, and people living with HIV, mental illness or obesity); anticipated stigma; secondary stigma for family, friends, and/or caregivers Decreased social participation; concealment or denial of identity; increased risk of homelessness; reduced employment and income opportunities; exposure to violence; reduced seeking or avoidance of healthcare services and poorer quality of services received Chronic stress leading to health harming coping strategies (e.g., self-harm, disordered eating, smoking, alcohol and substance use) Health outcomes: Increased risk of adverse physical health (e.g., sexually transmitted and blood-borne infections) and mental health outcomes (e.g., depression, anxiety and suicide ideation and attempts) Mental illness stigma Beliefs that mental illness is caused by "bad genes," behavioural problems, or social skills deficits; divergent perceptions and understanding about the meaning of [mental] health; beliefs that people with mental illness are dangerous; negative perceptions about prognosis of recovery Social identity stigmas (e.g., racism, sexual stigma, gender identity stigma, ageism) and other health-related stigmas (e.g., substance use stigma, HIV stigma, obesity stigma) Low investment in research and education; negative media portrayals; demeaning language; violence and assault; distrust and avoidance of people living with mental illness; failure to accommodate employees with mental illness

Health system: Limited training of health professionals to meet the needs of people with mental illness; using labels instead of person-first language (e.g., "schizophrenic" instead of "person living with schizophrenia"); low investment in mental health services Enacted stigma (the experience of unfair treatment); internalized stigma (e.g., shame and embarrassment for LGBTQ2+ people, people who use substances, and people living with HIV, mental illness or obesity); anticipated stigma; secondary stigma for family, friends, and/or caregivers Decreased social participation; concealment of illness; limited access to and loss of work or advancement opportunities; decreased use of health and social services and poorer quality of services received Health harming coping strategies (e.g., denial, self-isolation, substance use) Health outcomes: Increased risks of poorer physical health, quality of life, and psychological outcomes (e.g., lower self-efficacy, self-esteem, and hopeless); decreased patient safety when stigma prevents health professionals from seeking care for their own mental health problems Substance use stigma Footnote a Belief that substance use is a reflection of poor willpower or moral failure, and that people are to blame for their condition; belief that people who use substances are dangerous and reckless; belief that substance use is not a real illness and people "could choose to stop" Social identity stigmas (e.g., racism, sexual stigma, gender identity stigma, ageism) and other health-related stigmas (e.g., mental illness stigma, HIV stigma) Negative media portrayals; social avoidance and exclusion by others; discrimination in housing (e.g., denial of applications, eviction), failure to accommodate employees with substance use disorders

Health system: Use of demeaning or inappropriate language; reduced empathy from professionals and less motivation to meet the needs of people who use substances; lack of training in harm reduction Enacted stigma (the experience of unfair treatment); internalized stigma (e.g., shame and embarrassment for LGBTQ2+ people, people who use substances, and people living with HIV, mental illness or obesity); anticipated stigma; secondary stigma for family, friends, and/or caregivers Decreased use of health and social services and poorer quality of services received; concealment of substance use disorder; loss of work and limited access to leadership positions; increased risk of homelessness Health harming coping strategies (e.g., isolation, social withdrawal and avoidance, further substance use) and behaviours (e.g., needle sharing) Health outcomes: Increased risks of poorer physical health, quality of life and psychological outcomes (e.g., lower self-efficacy, self-esteem, and hopelessness); limited uptake of opioid agonist therapy; poorer outcomes for substance use disorder treatment HIV stigma Fear of infection or contagion; misinformation about transmission of HIV; incorrect assumptions about prognosis and treatment Social identity stigmas (e.g., racism, ageism) and other health-related stigmas (e.g., mental illness stigma, substance use stigma) Criminalization of non-disclosure; forced disclosure; social distancing and avoidance; negative media portrayals

Health system: Taking unnecessary precautions when interacting with people living with HIV; compartmentalized care (focus on HIV and not seeing the whole person); restrictions on blood and organ donations from gay, bisexual, and other men who have sex with men Enacted stigma (the experience of unfair treatment); internalized stigma (e.g., shame and embarrassment for LGBTQ2+ people, people who use substances, and people living with HIV, mental illness or obesity); anticipated stigma; secondary stigma for family, friends, and/or caregivers Delayed or decreased use of health and social services and poorer quality of services received; concealment of HIV status; self isolation; limited access to employment Health harming coping strategies (e.g., social withdrawal, substance use, denial, non-adherence to medications) Health outcomes: Increased risks of poorer physical health, quality of life, and psychological outcomes (e.g., depression, loneliness, suicidal ideation); lower self-rated health Obesity stigma Belief that individuals are to blame for their weight due to lifestyle choices; stereotypes related to the behaviour or character of people living with obesity Social identity stigmas (e.g., racism, sexual stigma, gender identity stigma, ageism) and other health-related stigmas (e.g., mental illness stigma, substance use stigma, HIV stigma) Physical avoidance and exclusion by others; bullying; exclusion from the workforce; negative media portrayals

Health system: Refusal of care, or low quality of care from service providers; healthcare environment not adapted to larger bodies; lack of empathy from health professionals; use of demeaning language Enacted stigma (the experience of unfair treatment); internalized stigma (e.g., shame and embarrassment for LGBTQ2+ people, people who use substances, and people living with HIV, mental illness or obesity); anticipated stigma; secondary stigma for family, friends, and/or caregivers Reduced seeking of care and use of health and social services and poorer quality of services received; decreased social participation; socioeconomic consequences (lower personal income) Health harming coping strategies (e.g., disordered eating) Health outcomes: Higher acute and chronic stress and related physiological responses; maintenance of excess weight, poorer mental and physical health outcomes (e.g., anxiety, depression, decreased motivation for physical activity) Footnote a The extent to which substance use is stigmatized varies by the particular substance and context of use. Much of the literature on substance use stigma focuses on substance use-related health conditions (e.g., substance use disorders) or use of substances in ways that might be harmful (e.g., drinking alcohol during pregnancy), though other contexts of substance use are also subject to stigma. Return to footnote a referrer

Text box 7 Implicit bias refers to attitudes and stereotypes that occur unconsciously and inform our thinking, beliefs, and behaviours about social groups. Implicit bias occurs involuntarily and beneath the level of conscious awarenessFootnote 103.

Understanding stigma drivers and practices in the health system

Understanding how stigma manifests in everyday practices in the health system can inform the development of system-wide interventions. Below is a description of interrelated key drivers and practices that foster and sustain stigma in the health system.

The language we use

Language is a powerful tool that reflects and perpetuates biases in society. Words communicate assumptions, values, judgements, and stereotypes that create and reinforce negative portrayals of devalued groups. The way language is used in media, popular culture, health promotion initiatives, education, research, and policy shapes how people understand the world.

Using outdated or incorrect language in the health system, such as an inaccurate pronoun or the negative labelling of a particular group, perpetuates stigma and can influence healthcare providers' perceptions of patientsFootnote 104, Footnote 105. For example, labelling people who use drugs as "addicts" or "junkies" marks them as less worthy of care and promotes fearFootnote 106. In another example, describing the illness ahead of the person (e.g., using "schizophrenic" instead of "person living with schizophrenia") contributes to dismissive or demeaning behaviours by healthcare providers during treatmentFootnote 107. These types of labels also do not allow for other identities a person may have and suggest that everyone within that group has the same wants, needs, and challenges.

Implicit and conscious biases

Stigmatizing practices by health professionals may be a result of implicit or conscious biasFootnote 21, Footnote 105, Footnote 108. Conscious bias occurs when an individual believes and reproduces negative stereotypes and myths about particular groups or individuals, resulting in discriminatory language or practicesFootnote 105,Footnote 108. For example, a health professional may use demeaning, offensive, or incorrect language in reference to a patient's identity or condition, even after the patient has previously stated their preferred terminologyFootnote 105.

Implicit bias occurs when professionals are unaware that their actions or language is stigmatizingFootnote 21, Footnote 105. Commonly held beliefs, stereotypes, and assumptions that pervade society make bias difficult to recognize. For example, many Canadians believe there are only 2 genders, and this assumption is widely reflected in everyday practices such as washroom signage, clothing labels, and healthcare intake forms. Assumptions are generally based on misperceptions or misinformation about certain groups, and may influence how a professional examines, treats, and assesses a patient. For example, patients with chronic pain may be denied medication on the assumption that they may be displaying "drug seeking" behaviourFootnote 109, Footnote 110. Lack of training on appropriate care for health conditions or traditional cultural approaches to healing may contribute to the implicit bias of health professionalsFootnote 21, Footnote 105, Footnote 111, Footnote 112, Footnote 113. Although the avoidance of learning appropriate care is an example of conscious bias.

Discussion group quote 2: "So in order to address that root cause of stigma, we absolutely need everybody to hold that mirror up and ask themselves that really important question, of how am I implicated in these systems and structures that discriminate, that stereotype, that hurt people. How can I be an agent of change, what can I do to arrest and disrupt those practices and policies that are so harmful to many of us?"

Text box 8: The death of Brian Sinclair In 2009, Brian Sinclair, a 45-year old Indigenous man, died of preventable and treatable sepsis in an emergency room (ER). He was referred to the ER by a community physician for a bladder infection. Once he arrived, he did not get properly triaged and was told to wait in the waiting room. There he stayed for 34 hours before someone else let ER staff know that Brian did not seem to be breathing. The Winnipeg Regional Health Authority publicly apologized to his family for the preventable tragedy and has accepted all recommendations from a judicial inquest into this death. Recommendations include improving cultural safety for all staff at regional health authorities and recruitment of Elders for improved care in health centres. Indigenous leaders have asked the judicial inquest to seriously consider the ways in which Brian Sinclair's race, disability, and class led to his deathFootnote 21.

Discussion group quote 3: "We need to acknowledge that it [slavery] happened in Canada - if you don't ever acknowledge it, you leave us out there wondering if it even happened. You need to validate our reality."

Lack of respect and understanding of people's lives

Colonization and subsequent colonialism have been defining factors for Indigenous peoples and racialized populations. Colonialism has driven unjust attempts to erase cultural identity and practices, and has contributed to loss of language, exclusion from social and health institutions, and continued spatial segregationFootnote 21, Footnote 108, Footnote 113, Footnote 114. The influence of colonialism is reflected in medical curricula that often do not incorporate or reflect the experiences of Indigenous peoples and other racialized populations, including diverse ways of knowing and understanding health and well-beingFootnote 21, Footnote 112, Footnote 113, Footnote 116, Footnote 117. The exclusion of these perspectives and ways of knowing shapes health professionals' practices and leads to culturally inappropriate treatment or care, which leads to further exclusion from health settingsFootnote 105.

Relatedly, healthcare providers are traditionally trained to focus on individual agency and lifestyle factors, without acknowledging the other factors that impact a person's life (e.g., the social determinants of health)Footnote 118. Patients have reported a lack of empathy and compassion from healthcare providers, as they feel they are blamed for their circumstances while the systemic barriers that have contributed to these are ignoredFootnote 110, Footnote 119, Footnote 120, Footnote 121.

Discussion group quote 4: "You need education throughout your career. Not one day on cultural sensitivity, or mental health sensitivity."

Fear of danger and of contagion

Fear is a significant driver of stigmas relating to infectious diseasesFootnote 122, Footnote 123. Quarantine-related policies, mandatory immigration screening, and notifiable disease frameworks can have unintended stigmatizing effectsFootnote 124, Footnote 125. For example, people with tuberculosis may be stigmatized due to their perceived incurable and contagious stateFootnote 126. In a low-disease incidence country like Canada, specific population groups such as migrants can be portrayed as a public health threat and blamed for being carriers of infectious diseases such as HIVFootnote 127, Footnote 128. Fear can also drive stigmatization of other health conditions, such as mental illness, where affected people may be seen as dangerous, unpredictable, or aggressiveFootnote 129.

Discussion group quote 5: "People often struggle with the idea that people can be different than them."

Stigmatizing organizational cultures

Organizational cultures influence whether stigmatizing practices are acceptable and how health providers interact with patientsFootnote 107, Footnote 130, Footnote 131, Footnote 132, Footnote 133. The above drivers and practices can become embedded in the culture of health organizations and reinforced by clinical and non-clinical staff (e.g., administrative, management and support staff). This can manifest in stigmatizing language, making assumptions, breaching confidentiality, using unnecessary precautions, and even, in some cases, denying care or access to treatmentFootnote 21, Footnote 105, Footnote 111, Footnote 112, Footnote 134. For example, transgender women have been denied access to women-only services for appearing too masculineFootnote 135 and "flagging" files to distinguish particular medical records may also promote stigmatizationFootnote 112. Burnout and compassion fatigue of providers can further contribute to these practicesFootnote 107.

Service providers may convey power and distance through the utilization of unnecessary protection, their way of delivering diagnoses, and their reactions to diagnosesFootnote 107, Footnote 128, Footnote 136. This may also be seen through the imposing of rules and policies that shape treatment and recovery opportunities for individuals seeking help for conditions such as mental health problems, substance use disorders, and HIV infectionFootnote 106, Footnote 137, Footnote 138. These practices include refusing mental health care to people who use drugs or restricting treatment for recurrent drug use, and denying access to treatment because of particular sexual practices or gender nonconformityFootnote 106, Footnote 131, Footnote 135, Footnote 138, Footnote 139, Footnote 140.

Stigma in organizational cultures may also have an impact on the health and well-being of staff. Healthcare providers may be reluctant to acknowledge or disclose their own stigmatized conditions, such as mental illness, in workplaces where stigma is persistent. This may result in self-treatment and a lack of peer supportFootnote 107.

Discussion group quote 6: "When you challenge [cultural norms] in your practice, you can get boxed in… For example, when I talk about race, religion, gender, there is a defense mechanism that kicks in."

How stigma leads to adverse health outcomes

The following more fully unpacks how the experience of stigma leads to poorer outcomes and impacts overall health. Emerging research indicates that stigma affects health in 3 key waysFootnote xii:

It reduces access to and quality of protective resources and health services It increases the risk of chronic stress and poor coping responses It puts stigmatized people at higher risk of assault and injury

Figure 8. How stigma affects an individual's health Source: Adapted from Paradies et al. 2013Footnote 141. Figure 8: Text description The figure shows possible health outcomes of stigma on an individual level. The figure depicts an individual experiencing stigma (enacted, internalized and anticipated) with arrows pointing to 3 key ways in which stigma affects health: it reduces access to and quality of protective resources it increases the risk of chronic stress it increases the risk of violence and assault Reduced access to protective resources can lead to: poorer living conditions and socioeconomic status

decreased access to and quality of health services Chronic stress can lead to: psychological symptoms

negative coping behaviours

physiological stress responses These key components can lead to: mental health outcomes, such as: anxiety depression suicide self-harm

physical health outcomes, such as: cardiovascular disease decreased birth weights increased blood pressure physical injury sexually transmitted and blood-borne infections



While this is not a comprehensive list of all possible outcomes or mechanisms, it does summarize many of the proposed associationsFootnote 149.

1. Stigma reduces access to and quality of protective resources and health services

Stigma can be a barrier to accessing essential resources and opportunities in life, such as housing, jobs, education, interpersonal relationships, and health care. These barriers may be the result of direct and active exclusion through discrimination by gatekeepers (e.g., landlords, employers, teachers, and healthcare professionals) or may arise internally from one's anticipation of facing stigma and mistreatment based on previous exposure to negative environments or discriminatory practicesFootnote 21, Footnote 105, Footnote 108, Footnote 110, Footnote 111, Footnote 120, Footnote 142. When people are excluded from these opportunities in life, they are exposed to more health risk factors and fewer protective factorsFootnote 108, Footnote 142, Footnote 143, Footnote 144, Footnote 145. Importantly, once accessed, the services may be culturally inappropriate or of poorer qualityFootnote 116, Footnote 143.

Discussion group quote 7: "We're kind of scared, when I say "we're" I'm speaking as a Black woman, we fear not being understood, and most times... I find it more manageable for me to just handle it on my own, or to maybe seek out a friend or family. Where really, I should feel comfortable to go and seek help in these facilities."

2. Stigma causes chronic stress and poor coping responses and behaviours

Stigma is a major source of psychological stress, whether it is enacted, internalized, or anticipated. Because of their stigmatized status, people from stigmatized groups may experience shame, low self-worth, and blame, and are at increased risk of exposure to stressful and unfair conditions and situationsFootnote 105, Footnote 111, Footnote 146. Excessive and ongoing stress can affect the body in a negative way throughout the life course and can be particularly damaging for developing childrenFootnote 147, Footnote 148. This repeated activation of stress responses can lead to an impaired immune system and interfere with the body's repair processes. It can also elevate blood pressure, heart rate, and stress hormones, which may have an effect on health over timeFootnote 149, Footnote 150, Footnote 151.

Discussion group quote 8: "Well I think for people it [stigma] sort of affects their self-worth, their self-confidence, even though they might be skilled, or very educated, or informed, that it creates the self-doubt in them."

3. Stigma can expose people to violence and assault

Certain groups of people are feared or seen as less worthy of respect or dignity because of stigma. In combination with other social inequities, groups that are stigmatized are targets for explicit hatred and violence, including physical assault or abuse, sexual assault, bullying, harassment, and hate crimes. Verbal, physical and sexual violence against individuals or groups can occur at home, in school, in the workplace, in the community, or onlineFootnote 105, Footnote 114, Footnote 152, Footnote 153, Footnote 154.

The effort required to deal with stigma reduces a person's psychological resources and resilience. It creates challenges in managing emotions and the ability to self-regulate, and an increased likelihood of having poor sleep habits, using substances, risky sexual behaviour and unhealthy eatingFootnote 142, Footnote 155, Footnote 156, Footnote 157, Footnote 158. These can place stigmatized people at even higher risk of acquiring further stigmatizing conditions (e.g., HIV infection, obesity). Although the outcomes may be harmful, these behaviours can be coping strategies and a way to survive challenging or even traumatizing events and experiencesFootnote 141. Through this lens, these responses can be understood as normal or expected responses to unjust and traumatic situations.

Discussion group quote 9: (Living while Black) "There isn't a moment when we are not calculating what does this mean, how will this be seen, how are they going to react, how am I going to react - it takes a lot of energy."

Discussion group quote 10: "Often I find people don't hear, listen to or see me"

Through these 3 avenues, stigma can lead to adverse mental and physical health outcomes

Measuring the health impacts specifically due to stigma is methodologically difficult; however, research indicates that poor mental health is often associated with many types of stigma. Adverse outcomes include anxiety, depression and depressive symptoms, post-traumatic stress disorder (PTSD), suicidal ideation and behaviours, self-harm, and low self-esteem and self-worthFootnote 98, Footnote 143. Poor cardiovascular health has also been linked to discrimination and chronic stress, and is a major cause of morbidity and mortalityFootnote 143, Footnote 159. For example, recent research has focused on examining how systemic racism can have an impact on hypertension, cardiovascular health, and diabetesFootnote 160, Footnote 161. In other research, experiencing stigma and discrimination while pregnant has been associated with pre-term birth, low birth weight, and higher rates of infant mortalityFootnote 162, Footnote 163. Discrimination has also been associated with increased rates of diabetes, cancer, tuberculosis, increased Body Mass Index and obesity, and increased risk of sexually transmitted and blood-borne infectionsFootnote 111, Footnote 122, Footnote 143, Footnote 159.

Discussion group quote 11: "When you kind of zoom out a little bit and realize that our social structures create situations in which people are silenced and can't get the resources they need to reach their full potential, then we see all kinds of poorer health outcomes."

Resisting the impacts of stigma

Building resilience

Many people living with stigma resist devaluation and discrimination and build strength, resilience, and strategies to ward off stressorsFootnote 164, Footnote 165. These strategies can include invalidating the negative beliefs associated with stigma, attributing prejudices to ignorance and not to themselves, and drawing upon their identities (such as LGBTQ2+) or social roles for protectionFootnote 164, Footnote 165.

Others may disclose their stigmatized status and educate others on their health condition. Disclosure can lead to having more informal and formal supportFootnote 166, Footnote 167. Although disclosure can be empowering, not everyone may feel comfortable or safe to do so. Resilience can mean choosing not to disclose in order to feel safeFootnote 168. In recent years, many people from stigmatized groups have come forward and publicly disclosed experiences of stigma and discrimination (for example, women who experienced violence and sexual assault).

When groups mobilize, there can be psychological and social benefits, such as social support, that buffer them from some negative health consequencesFootnote 164. For example, Black Canadian women are less likely to self-report poor mental health compared to White Canadian womenFootnote 169, Footnote 170. Research from the US demonstrates that African Americans may develop resiliency strategies, such as strong family and community ties, to cope with and challenge racism and discriminationFootnote 171. These strategies and strengths may act as buffers and help prevent mental health issuesFootnote 170, Footnote 171. Although this has not yet been researched in a Canadian setting, similar dynamics may be at playFootnote 169, Footnote 170.

Text box 9: Community connection Community culture and connection can play a protective role in supporting individuals who face stigma and discrimination. Among Indigenous peoples in Canada, cultural continuity has been associated with lower youth suicide ratesFootnote 172. Cultural continuity is measured in different ways, and can include factors such as self-government, community-level Indigenous language knowledge, and control over education, community, social or health services. As emphasized in the First Nations Mental Wellness Continuum Framework, culture - including values, sacred knowledge, language and cultural practices - is the foundation of health and wellnessFootnote 16.

Discussion group quote 12: "…we have to get back to finding our kindness, and our humanness, and recognizing that if we were all the same it would be a very boring place to be and that the difference is what makes us strong and what keeps us going."

Collectively changing the health system

Populations subjected to stigma and oppression for generations have responded by engaging in collective responses and self-determination, and displaying profound group resilience. For example, despite a history of cultural genocide, assimilation, intergenerational trauma, and colonial policies, Indigenous peoples have survived and preserved their cultures and ways of beingFootnote 21. Learning about and incorporating traditional Indigenous health practices can build resilience and a sense of ownership over one's healthFootnote 21, Footnote 173, Footnote 174. First Nations, Inuit and Métis peoples in Canada have engaged in collective resistance to health system stigma by advocating for Indigenous education programs, promoting public education against negative stereotyping, and developing Indigenous-run governing health bodies and holistic approaches to health that respect and build on traditional ways of knowingFootnote 21.

Discussion group quote 13: "Being Indigenous doesn't make you more prone to HIV. Living without hope does."

People living with HIV mobilized early in the AIDS epidemic to form a powerful social movement that helped to mitigate the stigma associated with HIV and AIDS and change the health system response by improving the patient-provider relationship, challenging stereotypes, and ensuring the meaningful participation of people living with HIV in research and health practicesFootnote 175, Footnote 176.

The call for meaningful representation has been echoed across other movements and communities, such as the disability movement that initiated the slogan "Nothing about us without us" as an act of resistance to the under-representation of people living with disabilities in research and in the mediaFootnote 177. Similarly, Indigenous peoples have emphasized the importance of telling their own stories about Indigenous health and well-being, and leading the way forward through Indigenous-directed health and community servicesFootnote 21.

Discussion group quote 14: "Members of communities who are affected by stigma should be involved. [They] should be leading the conversation."

The mental health movement in Canada contributed to normalizing mental health, the deinstitutionalization of mental health services and the shift towards having mental health and social supports available in the community, which can all reduce stigmatizationFootnote 178, Footnote 179. More recently, there has been a shift in approaches within the substance use movement in Canada. Utilizing a strengths-based and resilience approach instead of a risk-based perspective has led to increased availability and accessibility of harm reduction services and initiatives for reducing substance-related harms, such as supervised consumption sites, naloxone distribution and training, educational initiatives related to lower-risk substance use, and drug contamination testingFootnote 180.

Discussion group quote 15: "What has happened to us, is not who we are! If you look at who we are, there in lies the solution."

Chapter 3. Building an inclusive health system

The Stigma Pathways to Health Outcomes Model (Stigma Model) offers a comprehensive approach to understanding stigma and the real and measurable impact it has on physical and mental health outcomes. The Stigma Model also demonstrates that stigma is not simply an interaction between people but a process influenced by larger social, cultural, political, and economic forces.

Responding to stigma in the health system requires an equally comprehensive approach, through system-wide interventions in education, training, practice, and policy. This chapter presents a new Action Framework for Building an Inclusive Health System (Action Framework), developed for this report. Whereas the Stigma Model helps to understand the nature and extent of the problem of stigma, the Action Framework explores where and how it can be addressed.

The experience of stigma revisited

Let's revisit Charles and Cynthia, who we met in Chapter 2. Previously, we examined the ways in which Charles and Cynthia experienced stigma in the health system and how this negatively impacted their overall health. Now, let's see how their experiences could have been different if they had been treated in inclusive environments that met their needs.

Charles Charles, a Black, gay man who is living with HIV, recently moved to a mid-sized town in Ontario and believes he may have signs of heart disease. Charles books an appointment with his new doctor regarding his symptoms. At the appointment, his doctor takes the time to review his social and family history. As a routine part of getting to know each patient, his new doctor always asks patients for their preferred name and pronoun. When Charles sees how much his new doctor prioritizes patient trust, he feels comfortable sharing that he is gay. She knows that Charles is at higher risk of heart troubles because of his age and family history, and also due to social determinants such as his racialized identity status. Charles' doctor determines that the best course of action is to refer him to a specialist at the hospital for further testing. Charles feels heard and respected by his doctor and appreciates her thoroughness. Charles is nervous about the tests with the specialist but when he arrives, he is treated with respect and dignity by the hospital staff. He also notices that the specialist and some of the other health professionals look like him. The specialist focuses on Charles' presenting symptoms and does not ask questions about his HIV status or sexual orientation when it is inappropriate to do so. Even when doing more diagnostic testing, the specialist and other health professionals do not take unnecessary precautions. The results of the tests show that Charles has early stage heart disease; however, because the disease was detected early, Charles' prognosis is good. Charles will continue to have follow-up appointments periodically with the specialist to monitor his health. Charles feels comfortable attending these appointments due to the excellent care he has received and the trust he has in his doctors.

Cynthia Cynthia is a Cree woman living in Saskatchewan with her 2 young children. She is pregnant with her third child and has recently learned of complications with her pregnancy. Cynthia has been receiving care at a First Nations health centre in her community but needs specialist care at a large hospital. A nurse from the health centre refers her to the hospital's new Indigenous Health Program, where an Elder is available to provide guidance and cultural and spiritual support to Cynthia before, during, and after her treatments. When it is time for her treatment, Cynthia's doctor introduces herself. She asks Cynthia about her experience and her priorities before thoroughly explaining the treatment, timelines, and next steps. Cynthia's doctor talks to Cynthia, and encourages Cynthia to ask questions so they can make decisions together. The doctor began the appointment with this approach because the hospital recently implemented an institutional policy requiring and supporting all health professionals to learn and implement a cultural safety model of practice. Cynthia feels respected and the introduction eases her anxiety about the appointment. The Elder collaborates with Cynthia's healthcare team to facilitate communication and cultural understanding to create and maintain a culturally safe care plan. Cynthia continues to meet with the Elder during future treatments who also connects her to an appropriate, funded childcare facility where she can take her 2 children while she attends her ongoing appointments. Cynthia feels well supported by the Elder and her healthcare team at the hospital who successfully manage her pregnancy complications while providing culturally relevant care. Cynthia carries her baby to term and gives birth to a healthy baby.

An Action Framework for Building an Inclusive Health System

The complex and reinforcing processes that fuel stigma drivers and practices require system-wide responses. Using a public health lens, it is important to prioritize broad interventions that can have the most benefit to the greatest number of people. Population- and institution-level interventions to address stigma drivers and to prevent stigma practices are most aligned with this approachFootnote 181. To mitigate individual-level harms, it is also necessary to implement interventions to better support individuals who have experienced stigma.

While actions have been organized according to various levels, complementary and synergistic interventions will need to be implemented across all levels to achieve the most impact. Though much of the research in this field has explored the impact of one intervention at one level, researchers 