Rationale for Questions Used in the Tri-Hospital + Toronto Public Health Equity Data Collection Research Project

Questions, by Topic	Evidence for Disparities in Access to Health Services	Evidence for Disparities in Health Outcomes	Rationale for Wording and Options Provided
Language
1. What language would you feel most comfortable speaking in with your health care provider? Check one only.	A strong relationship has been found between poor access to primary care and having a first language other than English or French. In particular, women who do not speak English as a first language are less likely to receive preventive services, including breast exams, mammography and pap testing.^¹–³	Language is a key social determinant of health.^⁴,⁵ Recent immigrants with prolonged limited English language proficiency are more likely to experience a downward trend in self-reported health and higher rates of unmet health needs.^⁶ Ontarians who do not speak English are more likely to report poor health.^³ Limited English proficiency in Canada has been associated with reduced treatment comprehension and compliance, increased risk of adverse drug reactions, and increased likelihood of inadequate management for chronic disease.^⁷ Non-English-speaking patients are less likely to be satisfied with the care received when not speaking the same language as their provider.^⁷,⁸	The options listed under the questions on language were based on the top 29 languages spoken across Toronto, plus ASL. To be inclusive from an equity perspective, other languages were added representing some of the most common nonofficial mother tongues in Toronto. This was important because certain groups who are fluent in English (and therefore do not request translation services) make up a sizeable group in the GTA (ie, Tagalog in the Filipino community).
2. How would you rate your ability to speak and understand English? Check one only.
3. In what language would you prefer to read health care information? Check one only.
Immigration status
4a. Were you born in Canada?	Approximately 25% of immigrants reporting a decline in health (from the time of arrival) experienced barriers to accessing health services.^⁹ Many Canadian newcomers report discrimination on the basis of immigration status as a significant obstacle to accessing primary care.^¹⁰	New immigrants arrive to Canada with a better health status than Canadian-born persons but experience a reduction in physical and mental health within 2–5 years of settlement, measured not only by self-reported health status but also by physician visits.^–¹³ Among immigrant women, stressful resettlement experiences contribute to an increased risk of preterm labor and low-birth-weight infants,^¹⁴ and cervical cancer is more likely to be detected later than in the general population.^¹⁵,¹⁶	Questions about immigration status can be a source of fear for those residing in Canada without legal status.^¹⁷ The question was phrased purposefully to not require disclosure of immigration status. This may mitigate fear of reprisal while allowing the assessment of differential health access or health outcomes for those born outside Canada. Asking about time of arrival in Canada allows institutions to identify and potentially anticipate the health decline that many immigrants experience without adding complexity to the question.^⁹
4b. If no, what year did you arrive in Canada?
Age
5. In what year were you born?	Age clearly influences the use of health services, with older persons typically using more services.^¹⁸,¹⁹	Health and quality of life decline as we age, in part related to an increase in the number of chronic diseases.^²⁰,²¹	This question was phrased in a simple and direct fashion.
Race
6. Which of the following best describes your race? Check one only.	African-Canadians are underrepresented in voluntary mental health services (eg, outpatient psychiatry clinics and addiction services) but are overrepresented in involuntary services such as medicolegal units in psychiatric hospitals.^²² In a study comparing health disparities between Canada and the United States, Canadian women of color were less likely to receive a Pap test in the past 3 years compared with white women.^²³ The Canadian health system has numerous shortcomings for Aboriginal Canadians who often avoid using mainstream health care because of a lack trust and culturally inappropriate care. Many Aboriginal people therefore delay seeking care and often do not benefit from preventive services.^²⁴,²⁵	Racialized groups are more likely to have worse health status than white Canadians after controlling for sex, age, education, immigration status, and income.^²⁶,²⁷ Nonwhite persons in Canada are more likely to have a lower perceived quality of care and satisfaction with services received.^²³ Race is an independent predictor of in-hospital mortality and adverse outcomes for certain conditions.^²⁸ Compared with nonaboriginals, urban Aboriginal men and woman in Canada have a significantly shorter life expectancy and are more likely to die prematurely from preventable diseases (including cervical cancer, pneumonia, and influenza), as well as from smoking and alcohol-related causes.^²⁹,³⁰ Canadian aboriginals are more likely to receive a cancer diagnosis at a more advanced stage of disease.^³¹	The accuracy of ethnoracial data is enhanced by self-reporting^³² as well as the availability of options outside of fixed categories; this is particularly true for persons of multiracial/ethnic backgrounds.^³³ These are important considerations for health systems data collection; self-identification with a certain subgroup often corresponds with beliefs and patterns of health care utilization that are shared within that subgroup.^³⁴,³⁵ However, open-ended questions on “ethnicity” may fail to provide useful information because of response heterogeneity and the inability to collate data. The formulation of this question therefore necessitated a balance between accuracy and utility, and respondents were asked to choose between categories. This pilot question also specifically used the term race as opposed to ethnicity in an effort to avoid the infinite number of ethnic categorizations and enhance data utility.
Religion
7. What is your religious or spiritual affiliation? Check one only.	Few Canadian studies have explored faith-based disparities in access to health care. One study from Newfoundland found that Muslim women identified providers' lack of awareness and insensitivity to religious differences as a reason for unmet maternal care needs.^³⁶	The capacity of health care providers to understand and accommodate a patient's spiritual and religious paradigms can affect routine care^{²⁴,³⁶,³⁷} and end-of-life care and is increasingly important for patient satisfaction within the health care system.^{³⁸–⁴⁰}	Religion is a key social determinant of health.^⁴,⁵ The major religious denominations of people living in Ontario were included in the survey. To be inclusive from an equity perspective, other major world religions were included, such as Wicca, Zoroastrianism, and Jainism, as well as less common spiritual affiliations.
Disability
8. Do you have any of the following disabilities? Check all that apply.	People with disabilities often require greater health care attention because of comorbid conditions that occur with higher frequencies or differ from those faced by the general population; however, there is a trend of service underutilization within this group that is inversely correlated with disability severity.^{⁴¹–⁴³} Factors making this population particularly vulnerable to disparities in access (and outcomes) include functional and communication limitations as well as systemic barriers such as inadequate facilities and insufficient training for health care professionals.^⁴¹,⁴⁴	There is considerable evidence that certain intellectual disabilities are associated with higher rates of morbidity and shorter life expectancies compared with people without disabilities.^{⁴⁴–⁴⁶} The multiplicative effect of overlapping social determinants is shown strongly within this group. For example, Aboriginal people with epilepsy are less likely to see a neurologist but more likely to visit the emergency department or be hospitalized, whereas lower socioeconomic status is associated with poor medication compliance.^⁴⁷ Also, nonwhite people with Down syndrome have a higher mortality rate than white persons with Down syndrome.^⁴⁸ Psychotropic medications are prescribed with a high frequency for people with intellectual disabilities for behavioral or emotional problems; however, incorrect diagnoses often lead to misuse of these drugs, with significant adverse effects for cognition, mobility, and bone and metabolic health.^⁴⁴	All of the options provided under the question on disability were adopted from the OHRC definition of disability.^⁴⁹ OHRC definitions for each type of disability were linked to the question and could be referenced while completing the survey. Acknowledging that often multiple disabilities coexist, participants were prompted to select “all that apply.”
Gender
9. What is your gender? Check one only.	Studies focusing on trans and intersex populations have identified stigma and discrimination as limiting access and quality of care.^{⁵⁰–⁵³} Approximately half (52%) of trans people surveyed reported negative experiences in the emergency department on the basis of their gender, whereas 21% reported avoiding care in the emergency department because of fear of a negative encounter.^⁵²	Research focusing on differences in care between the male and female sexes has uncovered inexplicable disparities across all levels of health care after controlling for potentially disease-mitigating factors.^{³,⁵⁴,⁵⁵} For instance, women with coronary syndromes are less likely to be admitted to acute care and receive revascularization procedures compared with men and more likely to die after a critical illness in hospital.^⁵⁶	There is a need to separate sex from gender in health research to understand and measure the impacts of gender relations, identity, and sex-linked biology.^⁵³ Whereas sex refers to one's biological status, assigned at birth, gender is tied to a person's sense of self. Thus gender identity can be male, female, both, or neither; it differs from sex and is distinct from sexual orientation. Within the survey, “trans” was used an abbreviation and umbrella term to include transgender, transsexual, gender nonconforming, and gender questioning. “Intersexuality” was meant to include those with physical and/or chromosomal variations where features often considered either male or female are combined into one body.^⁵⁷ Gender has been identified by the PHAC as a key social determinant of health.^⁵⁸
Lesbian, gay and bisexual persons
10. What is your sexual orientation? Check one only.	LGB Canadians consistently report more negative experiences within the health system.^{⁵⁹,⁶⁰} When encounters are not overtly discriminatory, LGB patients are treated “just like everybody else,” with inattention to the unique health needs of this population.^⁶¹,⁶² Many LGB persons do not divulge sexual orientation for fear of provider bias,^⁶³ and experiences of stigma leads to future avoidance or delay of care seeking.^{⁵⁹,⁶⁴} Lesbians are less likely to see a family physician for a Pap test than heterosexual women.^⁶⁴	Canadian LGB youth are at higher risk of suffering from mental illness (including suicidal ideation, suicide attempts, and depression), physical and sexual abuse, homelessness, and exposure to human immunodeficiency virus.^⁶⁵	Categories selected for this question were formulated based on consensus among the steering committee, which consisted of multiple health equity experts and researchers. Once again, the options provided for this question were designed as a balance between inclusivity (creating categories that people can identify with) and the need for utility in measurement and analysis.
Income
11. What was your total family income before taxes last year? Check one only.	Low-income persons have lower access to specialist^{⁶⁶–⁷⁰} and primary care compared with high-income persons.^⁷¹	Poverty in Canada is strongly correlated with the chronicity and severity of disease, with poorer treatment outcomes.^³,⁷² Canadians with a very low income experience as much as 9.8 years' difference in their life expectancy compared with the wealthy.^⁷³ Low-income Canadians are >2 times as likely to die of conditions for which effective preventive measures and/or treatment options exist, including diabetes, cervical cancer, and suicide.^⁷⁴	Income has been identified by the PHAC as a key social determinant of health (“income and social status”).^⁷⁵ Income brackets were developed in $10,000 increments so that they would be narrow enough to capture the LICOs but broad enough that participants would feel comfortable selecting a category. Asking about the number of dependents supported by the income allows for a more accurate assessment of poverty and its effect on health as LICO vary by family size (ie, LICO in 2009 was $18,421 for an individual but $34,829 for a family of 4).^⁷⁶
12. How many people does this income support?
Housing status
13. What type of housing do you live in? Check one only.	People who are homeless often feel unwelcomed within the health system and cite discriminatory treatment as a reason for avoidance.^⁷⁷	Canada's homeless suffer from higher levels of disease are more likely to die prematurely.^{⁷⁸,⁷⁹} Persons without a fixed address are more likely report poor health status and experience difficulty securing appropriate care.^{⁸⁰–⁸²}	Categories selected for this question were formulated based on consensus among the steering committee, based on an understanding of options available in Toronto. Steering committee members had extensive experience working with patients who were homeless or underhoused.

ASL, American Sign Language; GTA, Greater Toronto Area; LGB, lesbian, gay, and bisexual; LICO, low-income cutoff; OHRC, Ontario Human Rights Commission; PHAC, Public Health Agency of Canada.
↵1. Woloshin S, Schwartz LM, Katz SJ, Welch HG. Is language a barrier to the use of preventive services? J Gen Intern Med 1997;12:472–7.
↵2. Choudhry UK, Srivastava R, Fitch MI. Breast cancer detection practices of South Asian women: knowledge, attitudes, and beliefs. Oncol Nurs Forum 1998;25:1693–701.
↵3. Bierman AS, Johns A, Hyndman B, Mitchell C, Degani N, Shack AR, Creatore MI, Lofters AK, Urquia ML, Ahmad F, Khanlou N, Parlette V, eds. Chapter 12: Social determinants of health and populations at risk. In: Bierman AS, ed. Project for an Ontario Women's health Evidence-based Report: Volume 2. Toronto; 2012.
↵4. Raphael D. Social determinants of health: Canadian perspectives. 2nd ed. Toronto: Canadian Scholars' Press; 2008.
↵5. Commission on the Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva: World Health Organisation; 2008.
↵6. Wu Z, Penning MJ, Schimmele CM. Immigrant status and unmet health care needs. Can J Public Health 2005;96:369–73.
↵7. Bowen S. Language barriers in access to health care. Ottawa: Health Canada; 2001.
↵8. Dastjerdi M, Olson K, Ogilvie L. A study of Iranian immigrants' experiences of accessing Canadian health care services: a grounded theory. Int J Equity Health 2012;11:55.
↵9. Fuller-Thomson E, Noack AM, George U. Health decline among recent immigrants to Canada: findings from a nationally-representative longitudinal survey. Can J Public Health 2011;102:273–80.
↵10. Pollock G, Newbold B, Lafreniere G, Edge S. Perceptions of discrimination in health services experienced by immigrant minorities in Ontario. 2012.
↵11. Wang L, Hu W. Immigrant health, place effect and regional disparities in Canada. Soc Sci Med 2013;98:8–17.
↵12. Beiser M, Goodwill AM, Albanese P, McShane K, Nowakowski M. Predictors of immigrant children's mental health in Canada: selection, settlement contingencies, culture, or all of the above? Soc Psychiatry Psychiatr Epidemiol 2014;49:743–56.
↵13. Pottie K, Batista R, Mayhew M, Mota L, Grant K. Improving delivery of primary care for vulnerable migrants: Delphi consensus to prioritize innovative practice strategies. Can Fam Physician 2014;60:e32–40.
↵14. Patrick TE, Bryan Y. Research strategies for optimizing pregnancy outcomes in minority populations. Am J Obstet Gynecol 2005;192(5 Suppl):S64–70.
↵15. National Cancer Institute of Canada. Cancer statistics 2005. Available from: http://www.cancer.ca/∼/media/cancer.ca/CW/cancer%20information/cancer%20101/Canadian%20cancer%20statistics/Canadian-Cancer-Statistics-2005-EN.pdf. Updated 2005. Accessed September 3, 2014.
↵16. Oelke ND, Vollman AR. “Inside and outside”: Sikh women's perspectives on cervical cancer screening. Can J Nurs Res 2007;39:174–89.
↵17. Magalhaes L, Carrasco C, Gastaldo D. Undocumented migrants in Canada: a scope literature review on health, access to services, and working conditions. J Immigr Minor Health 2010;12:132–51.
↵18. Stukel TA, Fisher ES, Alter DA, et al. Association of hospital spending intensity with mortality and readmission rates in Ontario hospitals. JAMA 2012;307:1037–45.
↵19. Austin PC, van Walraven C, Wodchis WP, Newman A, Anderson GM. Using the Johns Hopkins aggregated diagnosis groups (ADGs) to predict mortality in a general adult population cohort in Ontario, Canada. Med Care 2011;49:932–9.
↵20. Hogan DB, Amuah JE, Strain LA, et al. High rates of hospital admission among older residents in assisted living facilities: opportunities for intervention and impact on acute care. Open Med 2014;8:e33–45.
↵21. Sibley LM, Glazier RH. Evaluation of the equity of age-sex adjusted primary care capitation payments in Ontario, Canada. Health Policy 2012;104:186–92.
↵22. Annoual PC, Bibeau G, Marshall C, Sterlin C. Developing a new service model for Canadians of African descent: enslavement, colonization, racism, identity and mental health. Toronto: Centres for Addiction and Mental Health; 2007. Available from: http://www.camhx.ca/Publications/Resources_for_Professionals/EACRIMH/eacrimh_report1107.pdf. Accessed March 19, 2015.
↵23. Lasser KE, Himmelstein DU, Woolhandler S. Access to care, health status, and health disparities in the united states and Canada: results of a cross-national population-based survey. Am J Public Health 2006;96:1300–7.
↵24. Access to health services as a social determinant of First Nations, Inuit and Métis health. Prince George, British Columbia, CA: National Collaborating Centre for Aboriginal Health; 2011.
↵25. Empathy, dignity, and respect: creating cultural safety for aboriginal people in urban health care. Toronto: Health Council of Canada; 2012.
↵26. Veenstra G. Racialized identity and health in Canada: results from a nationally representative survey. Soc Sci Med 2009;69:538–42.
↵27. Hyman I. Racism as a determinant of immigrant health. Policy brief to Public Health Agency of Canada. March 20, 2009. Available from: http://canada.metropolis.net/pdfs/racism_policy_brief_e.pdf. Accessed March 19, 2015.
↵28. McNabb-Baltar J, Trinh QD, Barkun AN. Disparities in outcomes following admission for cholangitis. PLoS One 2013;8:e59487.
↵29. Tjepkema M, Wilkins R, Senécal S, Guimond E, Penney C. Mortality of Métis and registered Indian adults in Canada: an 11-year follow-up study. Health Rep 2009;20:31–51.
↵30. Tjepkema M, Wilkins R, Senécal S, Guimond E, Penney C. Mortality of urban aboriginal adults in Canada, 1991–2001. Chronic Dis Can 2010;31:4–21.
↵31. Morrisseau K. Aboriginal cancer control progress report. Available from: http://www.cancercare.mb.ca/resource/File/Aboriginal_CancerControlProgressReport_07–08.pdf. Accessed September 3, 2014.
↵32. Hasnain-Wynia R, Pierce D, Haque A, Hedges Greising C, Prince V, Reiter J. Health research and educational trust disparities toolkit. Available from: http://www.hretdisparities.org/. Accessed September 3, 2014.
↵33. Hasnain-Wynia R, Baker DW. Obtaining data on patient race, ethnicity, and primary language in health care organizations: current challenges and proposed solutions. Health Serv Res 2006;41(4 Pt 1):1501–18.
↵34. Hasnain-Wynia R, Van Dyke K, Youdelman M, et al. Barriers to collecting patient race, ethnicity, and primary language data in physician practices: an exploratory study. J Natl Med Assoc 2010;102:769–75.
↵35. Wynia MK, Ivey SL, Hasnain-Wynia R. Collection of data on patients' race and ethnic group by physician practices. N Engl J Med 2010;362:846–50.
↵36. Reitmanova S, Gustafson DL. “They can't understand it”: maternity health and care needs of immigrant Muslim women in St. John's, Newfoundland. Matern Child Health J 2008;12:101–11.
↵37. Lee R, Rodin G, Devins G, Weiss MG. Illness experience, meaning and help-seeking among Chinese immigrants in Canada with chronic fatigue and weakness. Anthropol Med 2001;8:89–107.
↵38. Balboni TA, Vanderwerker LC, Block SD, et al. Religiousness and spiritual support among advanced cancer patients and associations with end-of-life treatment preferences and quality of life. J Clin Oncol 2007;25:555–60.
↵39. Ehman JW, Ott BB, Short TH, Ciampa RC, Hansen-Flaschen J. Do patients want physicians to inquire about their spiritual or religious beliefs if they become gravely ill? Arch Intern Med 1999;159:1803–6.
↵40. Koenig H. Spirituality in patient care. Philadelphia: Templeton Foundation Press; 2007.
↵41. Alborz A, McNally R, Glendinning C. Access to health care for people with learning disabilities in the UK: mapping the issues and reviewing the evidence. J Health Serv Res Policy 2005;10:173–82.
↵42. Sullivan WF, Berg JM, Bradley E, et al. Primary care of adults with developmental disabilities: Canadian consensus guidelines. Can Fam Physician 2011;57:541–53, e154–68.
↵43. Wei W, Findley PA, Sambamoorthi U. Disability and receipt of clinical preventive services among women. Womens Health Issues 2006;16:286–96.
↵44. Ouellette-Kuntz H, Garcin N, Lewis ME, Minnes P, Martin C, Holden JJ. Addressing health disparities through promoting equity for individuals with intellectual disability. Can J Public Health 2005;96(Suppl 2):S8–22.
↵45. Bittles AH, Petterson BA, Sullivan SG, Hussain R, Glasson EJ, Montgomery PD. The influence of intellectual disability on life expectancy. J Gerontol A Biol Sci Med Sci 2002;57:M470–2.
↵46. Balogh R, Ouellette-Kuntz H, Hunter D. Regional variation in dental procedures among people with an intellectual disability, Ontario, 1995–2001. J Can Dent Assoc 2008;70:681–8.
↵47. Burneo JG, Jette N, Theodore W, et al. Disparities in epilepsy: report of a systematic review by the North American Commission of the International League Against Epilepsy. Epilepsia 2009;50:2285–95.
↵48. Yang Q, Rasmussen SA, Friedman JM. Mortality associated with Down's syndrome in the USA from 1983 to 1997: a population-based study. Lancet 2002;359:1019–25.
↵49. Disability and human rights (brochure). Toronto: Ontario Human Rights Commission; 2014. Available from: http://www.ohrc.on.ca/en/disability-and-human-rights-brochure. Accessed September 4, 2014.
↵50. Lesbian health: current assessment and directions for the future. Washington, DC: Institute of Medicine; 1999.
↵51. Kaufman R. Introduction to transgender identity and health. In: Mukadon H, Mayer K, Potter J, Goldhammer H, eds. The Fenway guide to lesbian, gay, bisexual, and transgender health. Philadelphia: American College of Physicians; 2007.
↵52. Bauer GR, Scheim AI, Deutsch MB, Massarella C. Reported emergency department avoidance, use, and experiences of transgender persons in Ontario, Canada: results from a respondent-driven sampling survey. Ann Emerg Med 2014;63:713–20.e1.
↵53. Scheim AI, Bauer GR. Sex and gender diversity among transgender persons in Ontario, Canada: results from a respondent-driven sampling survey. J Sex Res 2015;52:1–14.
↵54. Fowler RA, Sabur N, Li P, et al. Sex-and age-based differences in the delivery and outcomes of critical care. CMAJ 2007;177:1513–9.
↵55. Birnie DH, Sambell C, Johansen H, et al. Use of implantable cardioverter defibrillators in Canadian and US survivors of out-of-hospital cardiac arrest. CMAJ 2007;177:41–6.
↵56. Kaul P, Chang WC, Westerhout CM, Graham MM, Armstrong PW. Differences in admission rates and outcomes between men and women presenting to emergency departments with coronary syndromes. CMAJ 2007;177:1193–9.
↵57. Holmes M. Intersex: a perilous difference. Selinsgrove, PA: Susquehanna University Press; 2008.
↵58. Public Health Agency of Canada. Population health approach - what determines health? Web site. Available from: http://www.phac-aspc.gc.ca/ph-sp/determinants/index-eng.php. Updated 2001. Accessed March 4, 2009.
↵59. Bergeron S, Senn CY. Health care utilization in a sample of Canadian lesbian women: predictors of risk and resilience. Women Health 2003;37:19–35.
↵60. Tjepkema M. Health care use among gay, lesbian and bisexual Canadians. Health Rep 2008;19:53–64.
↵61. Brotman S, Ryan B, Jalbert Y, Rowe B. The impact of coming out on health and health care access: rhe experiences of gay, lesbian, bisexual and two-spirit people. J Health Soc Policy 2002;15:1–29.
↵62. Mayer KH, Bradford JB, Makadon HJ, Stall R, Goldhammer H, Landers S. Sexual and gender minority health: what we know and what needs to be done. Am J Public Health 2008;98:989–95.
↵63. Eliason M, Schope R. Does “don't ask don't tell” apply to health care? Lesbian, gay, and bisexual people's disclosure to health care providers. J Gay Lesbian Med Assoc 2001;5:125–34.
↵64. Tjepkema M. Health care use among gay, lesbian and bisexual Canadians. Health Rep 2008;19:53–64.
↵65. Ylioja T, Craig SL. Exclusionary health policy: responding to the risk of poor health among sexual minority youth in Canada. Soc Work Public Health 2014;29:81–6.
↵66. van Doorslaer E, Masseria C, Koolman X; OECD Health Equity Research Group. Inequalities in access to medical care by income in developed countries. CMAJ 2006;174:177–83.
↵67. Alter D, Naylor C, Austin P, Tu J. Effects of socieoeconomic status on acccess to invasive cardiac procedures and on mortality after acute myocardial infarction. N Engl J Med 1999;341:1359–67.
↵68. Alter D, Naylor C, Austin P, Chan B, Tu J. Geography and service supply do not explain socioeconomic gradients in angiography use after acute myocardial infarction. CMAJ 2003;168:261–4.
↵69. Dunlop S, Coyte PC, McIsaac W. Socio-economic status and the utilisation of physicians' services: results from the Canadian National Population Health Survey. Soc Sci Med 2000;51:123–33.
↵70. Roos NP, Mustard CA. Variation in health and health care use by socioeconomic status in Winnipeg, Canada: does the system work well? yes and no. Milbank Q 1997;75:89–111.
↵71. Olah ME, Gaisano G, Hwang SW. The effect of socioeconomic status on access to primary care: an audit study. CMAJ 2013;185:E263–9.
↵72. Auger N, Raynault M, Lessard R, Choiniere R. Income and health in Canada. In: Raphael D, ed. Social determinants of health: Canadian perspectives. Toronto: Canadian Scholars Press; 2004:39–52.
↵73. Stratton J, Mowat DL, Wilkins R, Tjepkema M. Income disparities in life expectancy in the City of Toronto and region of Peel, Ontario. Chronic Dis Inj Can 2012;32:208–15.
↵74. Tjepkema M, Wilkins R, Long A. Socio-economic inequalities in cause-specific mortality: a 16-year follow-up study. Can J Public Health 2013;104:e472–8.
↵75. Public Health Agency of Canada. Population health approach–what is the population health approach? Updated January 15, 2013. Available from: http://www.phac-aspc.gc.ca/ph-sp/approach-approche/appr-eng.php. Accessed March 31, 2016.
↵76. Statistics Canada. Low Income Lines, 2009-2010. Ottawa, 2011. Available from: http://www.statcan.gc.ca/pub/75f0002m/75f0002m2011002-eng.pdf. Accessed April 15, 2016.
↵77. Wen CK, Hudak PL, Hwang SW. Homeless people's perceptions of welcomeness and unwelcomeness in healthcare encounters. J Gen Intern Med 2007;22:1011–7.
↵78. Cheung AM, Hwang SW. Risk of death among homeless women: a cohort study and review of the literature. CMAJ 2004;170:1243–7.
↵79. Frankish CJ, Hwang SW, Quantz D. Homelessness and health in Canada: research lessons and priorities. Can J Public Health 2005;96(Suppl 2):S23–9.
↵80. Hwang S. Homelessness and health. CMAJ 2005;164:229–33.
↵81. Levitt AJ, Culhane DP, DeGenova J, O'Quinn P, Bainbridge J. Health and social characteristics of homeless adults in Manhattan who were chronically or not chronically unsheltered. Psychiatr Serv 2009;60:978–81.
↵82. Zakrison T, Hamel P, Hwang S. Homeless people's trust and interactions with police and paramedics. J Urban Health 2004;81:596–605.