Background
Methods
Setting of the study
Study design
Sampling
Data collection and characteristics of participants
Sector of employment | Role | Number of participants | Identification |
---|---|---|---|
Health sector (n=11) | Managerial position in a large-scale COVID-19 testing clinic | n=4 | Participants 02, 04, 05, 09 |
Support role for COVID-19 activities in a health centre (i.e., community organiser, communication specialist, healthcare evaluation specialist, research coordinator) | n=4 | Participants 08a, 10, 11, 16 | |
Public health position | n=3 | Participants 03, 12, 13 | |
Community and philanthropic sector (n=8) | Working with vulnerable populations in a community or philanthropic organisation (i.e., director, project coordinator, community organiser, outreach worker) | n=7 | Participants 01, 06, 14, 15, 17, 18, 19 |
Specific role for COVID-19 in a community or philanthropic organisation | n=1 | Participant 07 |
Theoretical bricolage
Data analysis
Reflexivity
Ethical considerations
Results
Different professional affiliations, different visions: Understanding and perception of SIH
We are always confronted with SIH. […] One of my mandates is ensuring that we meet the needs of the whole population. We know that our health centre is situated [in a low-income neighbourhood] and that our target population faces health and social deprivation. […] In the context of my current mandate, I always deal with SIH in making decisions. (Participant 09, health sector)
[I think the objectives of large-scale testing] only partly consider SIH, not fully… We’ve been in the field for months and […] if I come out of my “community sector bubble,” I don’t really see changes. […] I didn’t see initiatives put in place, except by the community sector […] I don’t think that large-scale testing decreases inequalities, because there are no specific services [for people with difficult living conditions]. (Participant 06, community sector)
You were asking me earlier if there was a common philosophy or perception of SIH… There is no doubt that with our colleagues in Montréal, we perceive SIH in a specific way, but at the level of the Ministry of Health more generally, or even of public health departments, it can really differ. (Participant 16, health sector)
The issue is that people who experience social inequalities are also those who are disproportionately impacted by the pandemic […] It’s extremely frustrating in Québec that we don’t have access to data on racialised populations, income, language… on all these elements that are important determinants for the pandemic, as we saw in Ontario and other countries. (Participant 08, health sector)
Between meeting the needs of the whole population and those of vulnerable subgroups: Overarching strategy to address SIH
State of emergency and lack of design
We really started from zero. […] I’m trying to think about what we had in terms of screening services [in our hospital], and nothing comes to mind. […] So, of course, it was a lot of “trial and error” in the end. (Participant 04, health sector)
Sometimes, before COVID, we discussed health crises, and I think it was an abstract concept. We thought that it was possible to plan in a crisis context… But in a real crisis, planning is very short term. (Participant 09, health sector)
I wonder if we would have been able to think about social inequalities, you know… At the same time as organising this clinic and… I don’t know. I’m under the impression that it’s maybe not a bad thing to work towards responding positively to emerging needs. (Participant 02)
Primacy of a population-wide strategy for the health sector
When we opened [our first testing centre], the message that we were putting forward was “come and get tested, we want you to get tested.” So, men, women, everyone… [Testing was available] for everyone. And then, we realised with our team […] that our service offer wasn’t working [for specific populations]. (Participant 02)
When you plan something for the masses… You can’t think of social inequalities in health. […] You’re creating a new service for the whole population, so you must create it – at the beginning, I mean at the very beginning only – by not thinking about that. But once the foundations are there, then you can start to think about, “OK, with what I have, am I able to reach everyone? What is the population I can’t reach? How can I adapt this universal service?” (Participant 09)
Heterogeneous planning and dependence on the health sector: Intersectoral collaboration
Shifting of the decision-making centre
We created partnerships for large-scale testing. At one point, we had [services planned for] the whole Island of Montréal, and then health centres took over. We were in partnerships with other health centres, because to tackle inequalities in accessing health services […] we should offer services where populations are located. So, the Ministry of Health decided – I think it was during the summer – that health centres would take over large-scale testing [to offer services to populations in their catchment area]. (Participant 05, health sector)
[Working groups] don’t have the money. [Ad hoc] committees don’t have the money. Health centres can give us human resources and money. They go with what they can [offer] […] In terms of an action plan, we try to adapt our actions to the reality of health centres. (Participant 01, community sector)
Attempts at formalising an intersectoral approach to large-scale testing
From the first wave, we created what we called crisis units, in collaboration with city districts and community partners. These units brought together hospitals, districts, […] neighbourhood groups and key community partners to try and develop constant consultations to be able to intervene quickly and share information on upcoming large-scale testing clinics. (Participant 12, public health)
[The government] gives us information and, “figure it out with the information that we give you” and that’s it. […] [COVID-19] started in March, and I think it’s only in September that we received emergency funds. […] There’s a clear delay compared to services offered to the general population. (Participant 17, community sector)
And the exhaustion to always try to address these issues while it shouldn’t be the community sector’s responsibility. […] We shouldn’t be the people on the front lines… It should be hospitals, public health departments, the government, local authorities that come and really address [SIH]. (Participant 06, community sector)
Gradual joint efforts to reach vulnerable groups: Adaptation capacity of large-scale testing
Accessibility of large-scale testing
Another problem with planning was information on testing. […] This must be communicated very broadly to the population, through various means and in different languages, which wasn’t done at the beginning. We worked with a [community organisation] offering translation services […] which later contributed to translating material for other territories, allowing health centres to translate their material in various languages. (Participant 07, philanthropic sector)
We have done another series [of informative materials] that used pictograms, very few words and pictograms. […] We sometimes had templates that had too much text, so we went by trial-and-error… But it was something we thought about. (Participant 12, health sector)
We were asked to go and test people at home […] Our home-based services aimed at reaching people in long-term care facilities, private retirement homes, rehabilitation centres for people with intellectual disabilities, youth shelters […] This really allowed us to target a vulnerable clientele. (Participant 02, health sector)
We looked if it was possible to provide taxi fares for people who could not [get tested]. We had an agreement with [a taxi company] so that people at risk who couldn’t come could get transport. (Participant 05, health sector)
Acceptability of COVID-19 testing
Sometimes, there are occupational health teams present in the field in the case of outbreaks to inform people […] about their rights for the 14 days [of self-isolation]. […] There are also discussions with the Red Cross to provide care packages during self-isolation. […] There are discussions with foundations to see […] how we could find money to pay these people so they can isolate. It’s a public health mandate and many actions are taken towards this goal. (Participant 03, public health)
Obviously, patients experiencing homelessness needed a place to wait for their results, and needed a place to self-isolate, because most of the community organisations were not welcoming them anymore. So, we got that going. (Participant 02, health sector)
Some groups highlighted the issue of having a [health insurance card]. It was written on posters that you needed a health insurance card to get tested. So, there were many efforts to say, “We can’t put that on posters because people without an [authorised migrant] status, who don’t have the card, won’t want to get tested.” […] This can be an example of how we listened to what came from the field to adapt practices. (Participant 08, health sector)
Availability of services
We had regular clinics covering our territory, and we added mobile clinics too, to move closer to red zones with populations that we thought would not necessarily go [to regular clinics]. […] We worked in partnership with community organisations to promote and organise clinics. (Participant 12, public health)
Services were [initially] very focused on appointment booking. We believed, particularly in certain communities, that it was easier in terms of people’s working conditions or daily life to go to walk-in clinics. This offer is increasing with time… But we should have been more flexible from the beginning and create walk-in clinics to accommodate as many people as possible. (Participant 07, philanthropic sector)
We had to think about […] which operating hours could best tackle issues [of service availability]. […] We were suggesting that evenings were better, because a lot of people in the field were telling me they couldn’t go during the day. It took a long time for requests to be heard. […] Now it’s better in terms of location, operating hours, and advertising. (Participant 08, community sector)