Introduction
Despite recent advances in treatments for HIV and HCV, prevention of these blood-borne infections remains a significant public health issue in Canada and globally (Tucker et al.
2013). Further, these preventable blood-borne viruses create significant social and financial burdens, not only for the infected individuals, but also for prevention services. This is particularly challenging for populations of at-risk youth (e.g., street involved, injection drug using, MSM, those under the age of 30). In 2011, the Public Health Agency of Canada (PHAC) estimated that 71,300 Canadians were living with HIV, an increase from 64,000 in 2008 (CATIE,
2015; PHAC
2014a). Of these, female youth aged 15–29 years account for 26% of all reported HIV cases in Canada, while male youth account for 24% of reported cases (PHAC
2014a). As of 2012, the national HCV infection rate was estimated at 245,987, with 332,414 individuals testing positive for HCV antibody (PHAC
2014b). Male youth aged 15–24 are diagnosed at a rate of 32.1 per 100,000 individuals, while female youth are diagnosed at 43.3 per 100,000 individuals (PHAC
2014b). As indicated by these data, young people in Canada remain a population group at risk of contracting HIV and/or HCV.
It is important to note that a complex array of various determinants of health at both the individual and broader structural level create challenges in the prevention of HIV/HCV. As suggested by Raphael (
2008), the social determinants of health such as poverty, social exclusion, housing, food insecurity, among others, impact on youth’s likelihood of contracting HIV/HCV. Specifically, youth face challenges in accessing youth-friendly information and services on negotiating safer sexual intercourse and safe injection drug use (IDU). In addition, youth experience gender-based stereotype in prevention programs, which has been identified as significant contributors to social marginalization and stigmatization among those seeking access to HIV/HCV prevention services (Gahagan et al.
2011; Shoveller et al.
2009). Given these challenges, our study explored the current state of primary and secondary HIV/HCV prevention initiatives targeting youth 15–24 years of age in the Atlantic region of Canada, using population health, determinants of health, and gender-based conceptual perspectives (McLeroy et al.
1998; PHAC
2010). Atlantic Canada was targeted for this research and is comprised of four provinces: New Brunswick, Newfoundland and Labrador, Nova Scotia, and Prince Edward Island. It is noteworthy that, relative to the rest of Canada, people living in the Atlantic region experience significantly higher burdens of chronic disease, higher levels of poverty, homelessness and food insecurity (Knezevic et al.
2014; Murray et al.
2013; PHAC
2009). They also have geographic barriers such as limited access to specialized healthcare, limited resources, and a significant proportion of rural regions (Murray et al.
2013). Youth in Atlantic Canada and elsewhere in the world are particularly vulnerable to these conditions, as many face risk of HIV/HCV infections due to social stigma related to youth sexuality, barriers to access services, limited education pertaining to risks of exposure, and lack of youth-oriented prevention initiatives (Gahagan et al.
2011). It is, therefore, imperative that the impact of these social, economic, and political contexts be examined and addressed, particularly in relation to the prevention of HIV/HCV infections to inform provincial, national, and international health related policies and programs targeting youth and at-risk populations.
The complexities of preventing blood-borne infections among youth are well known. In fact, many international health organizations have recommended the use of a multi-level, collaborative approach to patient-centered care for this population to address these complexities (Chircop et al.
2014; Frankish et al.
2007; World Health Organization
2014). This approach is consistent with the World Health Organization’s (WHO) vision for healthcare, which advocates for intersectoral action for health. WHO defines the intersectoral concept as a “relationship between part or parts of the health sector with parts of another sector which has been formed to take action on an issue to achieve health outcomes… that is more effective, efficient or sustainable than could be achieved by the health sector acting alone” (WHO
1997, p.3). Intersectoral collaborations are a dynamic process of interaction that occurs during information exchange, policy development, and program-planning activities related to prevention (Fuster et al.
2011; Harris et al.
2012). These collaborations also allow service providers to share their expertise and resources to identify and address the key determinants influencing the health status of youth. This approach has not been adopted by many Canadian provinces. Further, the health system is functioning in a fractured way according to O’Reilly (
2014). This is reflected in the Romanow report (
2002), which suggests that minimal efforts are being made to solidify the complex intersections between all micro- to macro-level factors influencing, for example, access to healthcare (O’Reilly
2014). While functioning in this fractured way, different sectors may be unaware of their duplicated efforts and the potential impact this may have on healthcare costs (Dick and Ferguson
2015).
Within intersectoral collaboration is the urgent need for greater conceptual and practical clarity on key concepts such as sex and gender. These concepts are often seen as pivotal to the discourse on disease prevention, from epidemiological surveillance data reporting to research opportunities (Gahagan
2016; Gahagan et al.
2011; Shoveller et al.
2009). Given that sex and gender, however, carry distinctive, yet often conflated, characteristics, these are important factors to consider in HIV/HCV prevention in that it relates to the physiological differences between males and females, including susceptibility and disease progression. Unlike sex, gender is a relational concept that intersects with other social determinants, such as the influence of age, literacy levels, access to and uptake of preventative services for HIV/HCV. Gender as a key determinant can, for example, influence patient care across sectors, which includes prevention initiatives, treatment delivery, and access (Shoveller et al.
2009). Gender roles, including expectations about how young men and women should socially behave and relate their sexuality in particular context, also become influential factors in how, and indeed if, youth will access services (Gahagan et al.
2011; Johnson and Repta
2012). When interacting with others (e.g., health service providers), young men and women often struggle internally with their self-perceived masculinity or femininity (Johnson and Repta
2012). Gender-based differences can create vulnerabilities and inequities, such as social marginalization and stigmatization, while defining or re-defining roles and responsibilities ascribed by an underlying understanding of what is acceptable in a given society (Gahagan et al.
2011). Therefore, neglecting to acknowledge the impact of a key determinant, such as gender, may mean missing critical barriers to access that influence the risk of contracting an infectious disease. The current paper focuses on the study findings related to the five overarching themes, with a particular focus on intersectoral collaborations and gender-based approaches as a means to enhance HIV/HCV prevention efforts aimed at at-risk youth globally.
Methods
The current exploratory study focused on the scope and accessibility of existing youth-oriented HIV/HCV prevention initiatives based on population health, determinants of health and gender-based perspectives in Atlantic Canada. The study also identified gaps and weaknesses in the present prevention policies and programs. The research was conducted in collaboration with community-based organizations, an interprofessional research team and a youth advisory committee made up of representatives from each province. These groups served an integral role in providing insight into youth-focused HIV/HCV programs. The groups also helped to disseminate recruitment materials as well as research findings through their respective networks. This study was divided into three phases. During the first phase, the research team completed a scoping review of policy documents on youth-oriented prevention of HIV/HCV and published the findings (Hare et al.
2015). To triangulate the data, the findings from the initial scoping review were used to inform phase two and three, which included the development of the interview guide and the subsequent focus group guide.
In phase two, 47 key informants from all sectors were interviewed using semi-structured, in-depth interviews to explore their perceptions of themes related to primary and secondary prevention of HIV, gender, sex, diversity, and equity. Participants were recruited using a purposive sampling strategy by sectors and background. Potential participants contacted the research assistants to arrange one-on-one interviews. Individuals were invited to participate in an interview if they were a youth, government, healthcare policy decision maker, health service provider, or educator for a youth-focused HIV/HCV service organization (Table
1). The inclusion criteria required participants to have knowledge of HIV and/or HCV prevention policy or programming issues for youth, to have lived and worked in Atlantic Canada, and being sixteen years of age or older. Once the participant read, accepted and signed the consent, interviews were audio-recorded and conducted by phone or in person, and then transcribed verbatim using Nvivo9. Coding was done iteratively in collaboration with other provincial members using a pre-developed codebook. The team coded the same transcripts and then compared initial findings to help ensure inter-coder reliability. Braun and Clark’s (
2006) approach to thematic analysis was used to explore how gender as a social determinant of health, as well as issues of equity pertaining to gender identity, were reflected in HIV/HCV prevention. The analysis also helped identify promising practices in each province and gaps in youth-related HIV/HCV prevention across sectors. This phase allowed the team to reflect critically on boundaries surrounding HIV/HCV initiatives and enabled them to identify innovative approaches.
Table 1
Summary of the number of interviewed key informants per province and per sector
Education | 2 | 5 | 4 | 1 | 12 | 26 |
Justice | 1 | 0 | 0 | 1 | 2 | 4 |
Health | 8 | 5 | 4 | 2 | 19 | 40 |
Community | 4 | 4 | 3 | 0 | 11 | 24 |
Unreported | 0 | 0 | 3 | 0 | 3 | 6 |
Total | 15 | 14 | 14 | 4 | 47 | – |
The final phase of the study included four focus group discussions with 21 key informants from community-based organizations, government, health institutions, and youth sectors. The purpose of the focus group discussions was to explore potential solutions or strategies to address the barriers as indicated in the in-depth interview data and solicit feedback on how best to advance HIV/HCV prevention policies and programs among youth. A purposive sampling method was also used for recruitment with a balanced mix of representatives from community-based organizations, government health departments, service providers, and clients. Following the consent procedure, focus group discussions were audio-recorded, transcribed, and managed with Nvivo9. The focus group codebook was derived from, and expanded upon, the in-depth interview data to reflect emergent themes identified during phase two. Lessons learned, and best practices were also factored into the focus group analysis, to identify gaps and barriers, as well as identify practical opportunities to collaborate and to look for ways to maximize existing resources. Following the analysis of the in-depth interviews and focus groups, key themes emerged in relation to the prevention landscape.
Conclusion
In conclusion, participants in this study strongly urged the bridging of silos across sectors, in an effort to prevent duplication of HIV/HCV prevention policies and programs while streamlining integrated initiatives. Our analysis revealed that for many stakeholders, their sector of practice, their core mandate, and the region in which they work influenced their ability to work in collaboration with others. In many cases, public health agencies and organizations, such as ASOs, were very efficient in tapping into national awareness campaigns by working in collaboration in building youth-friendly integrated HIV/HCV prevention messaging. This approach was seen as critical to unpacking barriers, such as gender-based stereotypes, resource constraints, and limited access, while enhancing the understanding of youth-focused approaches, such as safe spaces for prevention, e-health campaigns, and non-judgmental educational and innovative testing initiatives. Although used strategically in certain sectors and regions, not all programs mandated intersectoral collaboration and gender-based approaches, which hindered efforts to strengthen current HIV/HCV prevention for youth. Therefore, to facilitate a successful scaling up of collective approaches, stakeholders and target populations will need to forge strategic partnerships to better meet the prevention needs of youth. Moving forward, strategic efforts should be aimed at normalizing and facilitating intersectoral collaboration, including gender-based analyses of innovative HIV/HCV testing approaches to help de-stigmatize prevention efforts aimed at at-risk youth.