Etowa et al.International Journal for Equity in Health
(2021) 20:255
https://doi.org/10.1186/s12939-021-01593-1
Open Access
RESEARCH
Difficulties accessing health care
services during the COVID-19 pandemic
in Canada: examining the intersectionality
between immigrant status and visible minority
status
Josephine Etowa1* , Yujiro Sano2, Ilene Hyman1,3, Charles Dabone1,4, Ikenna Mbagwu1,4, Bishwajit Ghose1,
Muna Osman5 and Hindia Mohamoud5
Abstract
Background: Difficulties accessing health care services can result in delaying in seeking and obtaining treatment.
Although these difficulties are disproportionately experienced among vulnerable groups, we know very little about
how the intersectionality of realities experienced by immigrants and visible minorities can impact their access to
health care services since the pandemic.
Methods: Using Statistics Canada’s Crowdsourcing Data: Impacts of COVID-19 on Canadians—Experiences of
Discrimination, we combine two variables (i.e., immigrant status and visible minority status) to create a new variable
called visible minority immigrant status. This multiplicative approach is commonly used in intersectionality research,
which allows us to explore disadvantages experienced by minorities with multiplicative identities.
Results: Main results show that, compared to white native-born, visible minority immigrants are less likely to report
difficulties accessing non-emergency surgical care (OR = 0.55, p < 0.001), non-emergency diagnostic test (OR = 0.74,
p < 0.01), dental care (OR = 0.71, p < 0.001), mental health care (OR = 0.77, p < 0.05), and making an appointment for
rehabilitative care (OR = 0.56, p < 0.001) but more likely to report difficulties accessing emergency services/urgent
care (OR = 1.46, p < 0.05).
Conclusion: We conclude that there is a dynamic interplay of factors operating at multiple levels to shape the
impact of COVID-19 related needs to be addressed through changes in social policies, which can tackle unique struggles faced by visible minority immigrants.
Keywords: COVID-19, Immigrants, Visible minorities, Health care, Canada
*Correspondence: jetowa@uottawa.ca
1
Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada
Full list of author information is available at the end of the article
Introduction
Since the beginning of the COVID-19 pandemic, health
care system resources are disproportionately demanded
by COVID-19 patients in Canada, often creating an
environment where it is difficult to meet the health care
needs of non-COVID-19 patients [1]. This is unfortunate, considering that easy and timely access to health
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Etowa et al. International Journal for Equity in Health
(2021) 20:255
care services is essential for maintaining health and wellbeing. Using the 2013 Canadian Community Health Survey, Clarke [2] reveals that about 30% of Canadians with
health care needs reported difficulties accessing health
care services such as ‘waiting too long for an appointment’ and ‘difficulty getting an appointment’. This finding
is concerning because Canadians with these experiences
may delay seeking and obtaining treatment, underuse
primary health care services, and be exposed to a greater
risk for the complications of delayed diagnoses [3].
Despite the emphasis on health equity of the Health Canada Act, research points to a disproportionate burden of
difficulties in accessing health care services among vulnerable populations in Canada, such as women, rural residents, Indigenous people, African, Caribbean, and Black
(ACB) people and people with health problems [2–6].
Research also shows that immigrant status is a critical factor in difficulties accessing health care services.
For example, compared to the native-born, recent immigrants (who have been in Canada for less than 5 years) are
more likely to have difficulties accessing immediate care
but established immigrants (5 years or more in Canada)
are less likely to face difficulties accessing routine care
[2]. Harrington et al. [6] also point out that both recent
and established immigrants are more likely to experience
difficulties accessing specialist care than the native-born.
Moreover, the odds of difficulties accessing specialized
services are higher for immigrants than the native-born;
however, a significant difference is not observed for
immediate care [2]. Immigrants also report higher rates
of difficulties accessing infant health care than the nativeborn [7]. These findings are worrying, particularly in the
context of the ‘healthy immigrant effect’, whereby immigrants are healthier than the native-born at the time of
their arrival in Canada; however, their health advantage
often disappears within 10 years [8].
Although these studies are useful, the role of visible
minority status is largely missing in the literature on difficulties accessing health care services. According to the
Employment Equity Act, visible minorities are defined
as ‘persons other than Aboriginal peoples who are nonCaucasian in race or non-White in colour’, including Chinese, South Asians, Blacks, Arabs/West Asians, Filipinos,
Japanese, Koreans, and others. Visible minorities account
for 22% of the total population and mostly include immigrants, their children, and grandchildren [9]. Visible
minorities often have more unique cultural, linguistic,
social, and economic characteristics than their non-visible minority counterparts. For example, Hou et al. [10]
find that the COVID-19 pandemic serves as a greater
barrier to meeting financial obligations or essential needs
for visible minorities than whites. Similarly, Chinese,
Korean, Southeast Asian, and Black people are twice
Page 2 of 11
or more likely to report perceived discrimination than
whites since the beginning of the pandemic [11]. Thus, it
is important to extend our analysis to reflect these visible
minorities’ experiences of difficulties accessing health
care services.
In the current study, we aim to incorporate both immigrant status and visible minority status in the analysis of
difficulties accessing health care services. While it is common for quantitative research to assess the independent
impact of immigrant status and visible minority status on
health and health care utilization, the literature suggests
that this approach overlooks the complexity of the intersectionality between immigrant status and visible minority status [12, 13]. The importance of this approach can
be further highlighted by the theory of intersectionality,
which seeks to examine how various socially and culturally constructed categories (such as immigrant status,
visible minority status, sexual orientation, and religious
identity) do not act independently but rather interact on
multiple levels, creating a system of oppression that contributes to inequalities in society [14].
Accordingly, it is possible that the intersectionality of
realities experienced by immigrants and visible minorities can impact their access to health care services since
the pandemic. Specifically, navigating through a new
health care system can be difficult for all immigrants,
particularly for visible minority immigrants, as many of
them migrate from less-developed regions where health
care systems are different than the one in Canada [15].
Overcoming this barrier may be persistently challenging
for visible minority immigrants when they concomitantly
face other barriers such as language problems, racial discrimination, and lack of cultural competence in health
care [16]. As health care systems have been exposed to
increasing demand for care of COVID-19 patients, visible
minority immigrants’ difficulties accessing health care
services may be more intensified by these experiences.
To this end, we compare difficulties accessing ten types of
health care services among non-visible minority nativeborn, visible minority native-born, non-visible minority
immigrants, and visible minority immigrants.
Method
We draw on data from Statistics Canada’s Crowdsourcing Data: Impacts of COVID-19 on Canadians—Experiences of Discrimination. Respondents were recruited
online through open advertisement between August 4
to 24, 2020, with self-selection as a sampling methodology. The survey covers two main topics: 1) experiences
of discrimination based on race, sex, gender identity or
expression, ethnicity, religion, sexual orientation, age,
disability, and language and 2) impacts of COVID-19
on experiences of discrimination and trust in various
Etowa et al. International Journal for Equity in Health
(2021) 20:255
institutions, the public, and neighbours. The target population includes all Canadians aged 15 and up living in one
of the ten provinces or three territories during the collection period. Crowdsourcing data did not use a probabilistic approach to collecting data. Therefore, unlike other
surveys conducted by Statistics Canada, a survey weight
cannot be calculated. Instead, benchmarking techniques
are applied to correct for unbalanced responses across
sociodemographic characteristics. More information
about this survey can be found in the Statistics Canada
report [11].
Dependent variables
The survey asked respondents if they experienced difficulties accessing the following services since the beginning of the COVID-19 pandemic: 1) non-emergency
surgery, 2) non-emergency diagnostic test, 3) appointment with a family doctor, 4) appointment with a medical
specialist, 5) appointment for rehabilitative care, 6) dental
care, 7) mental health care, 8) medical treatment, 9) natural medicine, and 10) emergency services/urgent care.
We use these ten variables as the dependent variables
to capture a comprehensive understanding of difficulties
accessing health care services. There are three potential
response categories for each service: a) yes, b) no, and c) I
do not need the service. To identify difficulties accessing
health care services, we exclude respondents who did not
need the service and code ‘yes’ as a higher category in the
variable (0 = no; 1 = yes).
Independent variable
Guided by the theory of intersectionality, the independent variable captures the combination of realities experienced by immigrants and visible minorities. In this case,
a traditional additive approach, which assumes privileges
and oppressions experienced by different groups can be
separated and treated independently, may not be suitable
[14]. Thus, instead of adding immigrant status and visible minority status separately as two independent variables, as shown in Table 1, we combine immigrant status
(0 = native-born; 1 = immigrant) and visible minority
status (0 = non-visible minority; 1 = visible minority) and generate a new variable called ‘visible minority
immigrant status’ (0 = non-visible minority native-born;
1 = visible minority native-born; 2 = non-visible minority
Page 3 of 11
immigrant; 3 = visible minority immigrant). This multiplicative approach is commonly used in intersectionality
research, which allows us to explore unique social locations held by some minorities with multiplicative identities [17].
Control variables
To account for potential confounding factors, we introduce factors informed by the Andersen and Newman
model of health service use [18]. According to this framework, people’s use of health care services is impacted by
three different blocks of factors, including predisposing,
enabling, and need factors. Predisposing factors capture
social structure, health system beliefs, and demographic
characteristics. Accordingly, we include experience of
discrimination (0 = no; 1 = yes), trust towards health care
system (0 = great deal of trust; 1 = fair amount of trust;
2 = moderate amount of trust; 3 = little trust; 4 = no trust
at all), education (0 = no university; 1 = university), sex
(0 = male; 1 = female), rural residence (0 = no; 1 = yes),
age (0 = 15–34; 1 = 35–44; 2 = 45+; 3 = unknown),
marital status (0 = married; 1 = not married), LGBTQ2
(0 = no; 1 = yes), Indigenous identity (0 = no; 1 = yes), and
living arrangement (0 = living alone; 1 = multiple person
household without children; 2 = multiple person household with children). Enabling factors reflect economic
and social resources that enable people to use health care
services. Unfortunately, the survey does not have an indicator of income that is often included as part of economic
resources. We include a sense of belonging to a community (0 = very strong; 1 = somewhat strong; 2 = somewhat
weak; 3 = very weak) as a type of social resources. Finally,
the most immediate cause of health service use may contain functional and health problems that lead to the need
for health care utilization. To account for this need factor, we add any difficulty or long-term condition (i.e., difficulty seeing, even when wearing glasses/contact lenses;
difficulty hearing, even when using hearing aid/cochlear
implant; difficulty walking, using stairs, using hands or
fingers/other physical act; difficulty learning, remembering, concentrating; emotional, psychological, mental
health conditions; or other health problem/long-term
condition) that has lasted or are expected to last for six or
more months (0 = no; 1 = yes).
Table 1 Categorization of visible minority immigrant status
Immigrant status
Native-born
Visible minority status
Immigrant
Non-visible minority
Native-born non-visible minority
Non-visible minority immigrant
Visible minority
Visible minority native-born
Visible minority immigrant
Etowa et al. International Journal for Equity in Health
(2021) 20:255
Table 2 Characteristics of the respondents who needed at least
one type of health care service
Percentage
Health care services accessibility
Page 4 of 11
Table 2 (continued)
Percentage
Very weak
8 (7, 8)
Any health problem/long-term conditions
No issues in any service
38 (37, 38)
No
49 (48, 50)
Issues with one service
22 (22, 23)
Yes
51 (50, 52)
Issues with multiple services
40 (39, 41)
Total
28,800
Visible minority immigrant status
Point estimates and 95% confidence intervals (in parentheses)
Non-visible minority native-born
71 (70, 71)
Visible minority native-born
8 (8, 9)
Non-visible minority immigrants
7 (7, 8)
Visible minority immigrants
14 (13, 14)
Experience of discrimination
No
70 (70, 71)
Yes
30 (29, 30)
Trust towards health care system
Great deal of trust
24 (23, 24)
Fair amount of trust
40 (39, 41)
Moderate amount trust
23 (22, 24)
Little amount of trust
10 (9, 10)
No trust at all
3 (3, 4)
Level of education
No university
36 (35, 36)
University
64 (64, 65)
Sex
Male
47 (47, 48)
Female
53 (52, 53)
Rural residence
No
91 (91, 92)
Yes
9 (8, 9)
Age of respondents
15–34
25 (24, 26)
35–44
13 (13, 14)
45+
54 (53, 55)
Unknown
8 (7, 8)
Marital status
Married
63 (62, 64)
Not married
37 (36, 38)
LGBTQ2
No
86 (85, 86)
Yes
14 (14, 15)
Indigenous identity
No
97 (97, 97)
Yes
3 (3, 3)
Living arrangement
Living alone
17 (17, 18)
Multiple persons, no children
54 (53, 54)
Multiple persons, with children
29 (29, 30)
Sense of belonging to the community
Very strong
28 (27, 29)
Somewhat strong
41 (40, 41)
Somewhat weak
24 (23, 24)
Statistical analysis
Although originally collected from 36,674 respondents,
as we exclude the respondents who did not need the
health care service from the analysis, the sample size
differs for each type of health care. The sample size for
each type of health care is shown in Table 3. We do not
present the characteristics of analytical sample for each
heath care service in this paper; however, these estimates are available based on request. Consequently, we
show the characteristics of the respondents who needed
at least one type of health care service (see Table 2). We
then describe the bivariate results between the dependent and independent variables, describing relevant percentages and odds ratios (see Table 3). We also employ
multivariate analysis for the outcomes significantly associated with the independent variable at the bivariate level
(i.e., non-emergency surgery, non-emergency diagnostic test, appointment for rehabilitative care, dental care,
mental health care, and emergency services/urgent care)
by accounting for theoretically relevant variables (i.e.,
predisposing, enabling, and need factors) to estimate
odds ratios, describing the net impact of the independent
variable on the dependent variable (see Table 4). Finally,
as a subsequent analysis, we explore whether the reasons
for difficulties accessing health care services differ based
on visible minority immigrant status with relevant percentages and odds ratios (see Table 5). In particular, we
examine whether we observe significant disparities with
the reasons for difficulties accessing health care services
such as 1) getting a referral, 2) getting an appointment,
3) contacting physicians/nurses for information, 4) waiting between booking and visit, 5) waited too long to get
service, 6) not available at time required, 7) refused for
symptoms of COVID-19, 8) transportation problems, 9)
language problems, 10) cost, and 11) other reasons. Consistent with previous research [6, 19], we rely on bivariate
statistics for this part of analysis. As all dependent variables are binary in the nature, we use logistic regression
analysis for multivariate analysis. In all analyses, p < 0.05
is set as a cut-off for statistical significance. All analyses
are conducted using Stata 13.1 (StataCorp, College Station, TX).
Etowa et al. International Journal for Equity in Health
(2021) 20:255
Page 5 of 11
Table 3 Difficulties accessing each type of health care service by visible minority immigrant status
Overall
Non-emergency surgery (n = 5352)
Percentage
35 (34, 37)
Odds ratio
Non-emergency diagnostic test (n = 11,046)
Percentage
39 (38, 40)
Odds ratio
Appointment with family doctor (n = 21,954)
Percentage
37 (36, 38)
Odds ratio
NVMNB
VMNB
NVMI
VMI
37 (36, 39)
37 (30, 45)
35 (30, 42)
24 (20, 29)
1.00
0.97 (0.70, 1.37)
0.92 (0.69, 1.21)
0.54 (0.41, 0.70)***
40 (39, 41)
37 (32, 43)
39 (35, 44)
36 (32, 39)
1.00
0.88 (0.69, 1.12)
0.97 (0.81, 1.17)
0.83 (0.70, 0.98)*
37 (36, 38)
38 (34, 41)
35 (32, 38)
38 (35, 41)
1.00
1.04 (0.88, 1.24)
0.95 (0.82, 1.09)
1.06 (0.94, 1.20)
46 (45, 48)
45 (40, 50)
43 (39, 47)
44 (41, 48)
1.00
0.96 (0.78, 1.18)
0.88 (0.75, 1.04)
0.91 (0.79, 1.06)
45 (44, 47)
48 (42, 54)
46 (41, 51)
33 (30, 37)
1.00
1.11 (0.87, 1.41)
1.04 (0.84, 1.28)
0.60 (0.50, 0.73)***
50 (48, 51)
45 (41, 49)
46 (43, 50)
44 (41, 47)
1.00
0.82 (0.69, 0.97)*
0.88 (0.77, 1.01)
0.79 (0.69, 0.89)***
42 (40, 43)
45 (40, 51)
37 (32, 42)
35 (31, 39)
1.00
1.16 (0.92, 1.45)
0.83 (0.65, 1.04)
0.76 (0.62, 0.92)**
20 (19, 22)
20 (14, 27)
20 (15, 26)
18 (15, 23)
1.00
0.97 (0.62, 1.50)
0.97 (0.68, 1.40)
0.89 (0.66, 1.20)
24 (22, 25)
25 (19, 32)
26 (21, 33)
21 (17, 26)
1.00
1.08 (0.76, 1.55)
1.15 (0.83, 1.59)
0.87 (0.66, 1.15)
18 (17, 20)
21 (15, 28)
14 (10, 19)
24 (20, 28)
1.00
1.18 (0.80, 1.75)
0.73 (0.51, 1.04)
1.42 (1.11, 1.82)**
Appointment with medical specialist (n = 13,875)
Percentage
46 (45, 47)
Odds ratio
Appointment for rehabilitative care (n = 10,127)
Percentage
44 (43, 45)
Odds ratio
Dental care (n = 20,055)
Percentage
48 (47, 49)
Odds ratio
Mental health care (n = 9681)
Percentage
41 (39, 42)
Odds ratio
Medical treatment (n = 4438)
Percentage
20 (18, 21)
Odds ratio
Natural medicine (n = 4820)
Percentage
23 (22, 25)
Odds ratio
Emergency services/urgent care (n = 6369)
Percentage
Odds ratio
19 (18, 20)
*p < 0.05, **p < 0.01, ***p < 0.001; NVMNB non-visible minority native-born, VMNB visible minority native-born, NVMI non-visible minority immigrants, VMI visible
minority immigrants; odds ratio obtained from logistic regression; point estimates and 95% confidence intervals (in parentheses)
Results
Table 2 describes the characteristics of the respondents
who needed at least one type of health care service. It
is interesting that more than three fifths of respondents (62%) report that they face difficulties in accessing
at least one type of health care service. We also find the
largest visible minority immigrant group is non-visible
native-born (71%), followed by visible minority immigrants (14%), visible minority native-born (8%), and
non-visible immigrants (7%). Approximately one-third
of respondents (30%) report that they have experienced
discrimination. In addition, the majority of respondents
are university-educated (64%) and married (63%). Importantly, approximately half of the respondents (51%) report
that they have at least one health problem or long-term
condition.
Table 3 shows the findings from bivariate analysis that
examines whether the difficulties accessing health care
services differ based on visible minority immigrant status. We find that compared to non-visible native-born
(37%), visible minority immigrants (24%) are less likely
to report difficulties accessing non-emergency surgery
(OR = 0.54, p < 0.001). Similarly, compared to non-visible
minority native-born (40%), visible minority immigrants
(36%) are less likely to report difficulties accessing nonemergency diagnostic test (OR = 0.83, p < 0.05). Also, the
percentage of visible minority immigrants (33%) reporting difficulties making an appointment for rehabilitative care is also smaller than that of non-visible minority
native-born (45%) (OR = 0.60, p < 0.001). In terms of dental care, compared to non-visible minority native-born
(50%), visible minority immigrants (44%) are also less
Etowa et al. International Journal for Equity in Health
(2021) 20:255
Page 6 of 11
Table 4 Multivariate analysis of difficulties accessing health care services
NES
NEDT
ARC
DC
MHC
ESUC
OR (95% CI)
OR (95% CI)
OR (95% CI)
OR (95% CI)
OR (95% CI)
OR (95% CI)
Visible minority immigrant status
NVMNB
1.00
1.00
1.00
1.00
1.00
1.00
VMNB
0.96 (0.66, 1.40)
0.74 (0.57, 0.96)*
0.99 (0.77, 1.28)
0.69 (0.58, 0.83)***
0.98 (0.75, 1.27)
1.12 (0.74, 1.69)
NVMI
0.99 (0.74, 1.32)
1.02 (0.84, 1.24)
1.05 (0.85, 1.30)
0.92 (0.80, 1.06)
1.03 (0.80, 1.32)
0.87 (0.60, 1.25)
VMI
0.55 (0.40, 0.75)***
0.74 (0.61, 0.89)***
0.56 (0.46, 0.68)***
0.71 (0.62, 0.82)***
0.77 (0.62, 0.96)*
1.46 (1.07, 1.98)*
Experience of discrimination
No
1.00
1.00
1.00
1.00
1.00
1.00
Yes
1.42 (1.18, 1.71)***
1.50 (1.33, 1.70)***
1.39 (1.22, 1.58)***
1.41 (1.28, 1.56)***
1.87 (1.63, 2.15)***
1.72 (1.41, 2.09)***
Trust towards health care
Great deal of trust
1.00
1.00
1.00
1.00
1.00
1.00
Fair amount of trust
1.12 (0.89, 1.41)
1.36 (1.17, 1.58)***
1.15 (0.98, 1.35)
1.06 (0.95, 1.18)
1.01 (0.83, 1.23)
1.20 (0.89, 1.63)
Moderate amount trust
1.39 (1.08, 1.80)*
1.76 (1.49, 2.07)***
1.21 (1.02, 1.45)*
1.23 (1.09, 1.38)**
1.15 (0.94, 1.42)
2.29 (1.68, 3.10)***
Little amount of trust
1.95 (1.45, 2.63)***
2.93 (2.38, 3.60)***
1.67 (1.34, 2.07)***
1.50 (1.29, 1.76)***
1.90 (1.50, 2.42)***
3.76 (2.67, 5.29)***
No trust at all
2.73 (1.83, 4.08)***
4.86 (3.61, 6.54)***
1.72 (1.26, 2.34)***
1.64 (1.28, 2.10)***
2.33 (1.69, 3.23)***
7.07 (4.76, 9.51)***
Level of education
No university
1.00
1.00
1.00
1.00
1.00
1.00
University
1.01 (0.85, 1.20)
1.18 (1.05, 1.33)**
1.13 (0.99, 1.28)
1.12 (1.02, 1.22)*
0.85 (0.74, 0.98)*
1.05 (0.86, 1.28)
Sex
Male
1.00
1.00
1.00
1.00
1.00
1.00
Female
1.18 (0.99, 1.39)
1.27 (1.13, 1.43)***
1.45 (1.28, 1.65)***
1.08 (0.99, 1.17)
1.25 (1.08, 1.46)**
1.16 (0.94, 1.42)
Rural residence
No
1.00
1.00
1.00
1.00
1.00
1.00
Yes
1.13 (0.88, 1.44)
1.11 (0.92, 1.32)
1.25 (1.03, 1.52)**
1.23 (1.08, 1.41)**
1.30 (1.04, 1.61)*
1.04 (0.78, 1.38)
Age of respondents
15–34
1.00
1.00
1.00
1.00
1.00
1.00
35–44
0.98 (0.75, 1.27)
1.02 (0.85, 1.23)
1.40 (1.18, 1.67)***
0.98 (0.86, 1.11)
0.73 (0.61, 0.87)***
0.85 (0.64, 1.12)
45+
1.18 (0.94, 1.50)
1.05 (0.89, 1.23)
1.35 (1.15, 1.58)***
0.95 (0.84, 1.06)
0.74 (0.64, 0.87)***
1.03 (0.80, 1.33)
Unknown
1.06 (0.66, 1.70)
1.03 (0.75, 1.40)
1.86 (1.35, 2.56)***
1.13 (0.92, 1.39)
1.24 (0.91, 1.68)
1.24 (0.79, 1.94)
Marital status
Married
1.00
1.00
1.00
1.00
1.00
1.00
Not married
0.94 (0.75, 1.16)
0.96 (0.82, 1.12)
0.96 (0.81, 1.13)
0.97 (0.86, 1.09)
1.18 (1.01, 1.39)*
0.98 (0.77, 1.24)
LGBTQ2
No
1.00
1.00
1.00
1.00
1.00
1.00
Yes
0.93 (0.72, 1.21)
1.09 (0.91, 1.31)
1.11 (0.92, 1.33)
1.17 (1.02, 1.33)*
1.33 (1.12, 1.57)**
1.10 (0.83, 1.45)
Indigenous identity
No
1.00
1.00
1.00
1.00
1.00
1.00
Yes
1.05 (0.73, 1.51)
1.02 (0.77, 1.35)
0.92 (0.67, 1.26)
0.96 (0.77, 1.19)
1.12 (0.86, 1.47)
1.81 (1.26, 2.59)**
Living arrangement
Living alone
1.00
1.00
1.00
1.00
1.00
1.00
Multiple persons, no children
1.02 (0.77, 1.34)
1.21 (0.99, 1.48)
1.00 (0.82, 1.22)
1.19 (1.03, 1.37)*
1.13 (0.92, 1.38)
1.08 (0.78, 1.49)
1.15 (0.86, 1.53)
1.17 (0.95, 1.44)
1.17 (0.94, 1.44)
1.20 (1.03, 1.39)*
1.49 (1.20, 1.84)***
1.33 (0.96, 1.86)
Multiple persons, with
children
Sense of belonging
Very strong
1.00
1.00
1.00
1.00
1.00
1.00
Somewhat strong
1.43 (1.19, 1.73)***
1.18 (1.03, 1.34)*
1.24 (1.09, 1.43)**
1.11 (1.01, 1.22)*
1.12 (0.95, 1.33)
1.06 (0.84, 1.33)
Somewhat weak
1.45 (1.15, 1.83)**
1.31 (1.12, 1.53)***
1.57 (1.32, 1.85)***
1.27 (1.13, 1.43)***
1.40 (1.16, 1.69)***
1.14 (0.88, 1.49)
Very weak
1.64 (1.20, 2.25)**
1.46 (1.16, 1.84)***
1.43 (1.13, 1.80)**
1.33 (1.12, 1.58)**
1.76 (1.39, 2.23)***
1.19 (0.85, 1.67)
Any health problem
No
1.00
1.00
1.00
1.00
1.00
1.00
Yes
3.23 (2.70, 3.86)***
2.21 (1.96, 2.48)***
2.18 (1.94, 2.46)***
1.54 (1.42, 1.67)***
2.85 (2.42, 3.35)***
2.03 (1.64, 2.50)***
652.66***
437.49***
400.77***
598.60***
391.62***
Wald X2 371.83***
Etowa et al. International Journal for Equity in Health
(2021) 20:255
Page 7 of 11
Table 4 (continued)
NES non-emergency surgery, NEDT non-emergency diagnostic test, DC dental care, MHC mental health care, ESUC emergency service/urgent care; *p < 0.05, **p < 0.01,
***p < 0.001; point estimates and 95% confidence intervals (in parentheses)
Table 5 Reasons for difficulties accessing health care services by visible minority immigrant status
Percentage
Overall
NVMNB
VMNB
NVMI
VMI
Getting a referral
Percentage
18 (18, 19)
Odds ratio
18 (17, 19)
21 (18, 25)
18 (15, 21)
21 (18, 24)
1.00
1.24 (0.98, 1.57)
0.99 (0.81, 1.23)
1.22 (1.02, 1.46)*
Getting an appointment
Percentage
69 (68, 70)
Odds ratio
69 (68, 70)
67 (63, 72)
67 (64, 71)
68 (65, 71)
1.00
0.92 (0.75, 1.13)
0.91 (0.77, 1.08)
0.93 (0.80, 1.09)
Contacting physicians/nurses for information
Percentage
29 (28, 29)
Odds ratio
27 (26, 28)
31 (27, 36)
29 (25, 32)
33 (30, 37)
1.00
1.21 (0.99, 1.48)
1.07 (0.90, 1.28)
1.33 (1.15, 1.55)***
Waiting between booking and visit
Percentage
32 (31, 33)
Odds ratio
30 (29, 31)
34 (30, 39)
31 (27, 34)
40 (37, 43)
1.00
1.20 (0.98, 1.48)
1.03 (0.87, 1.22)
1.55 (1.34, 1.80)***
Waited too long to get service
Percentage
16 (15, 16)
Odds ratio
14 (14, 15)
17 (14, 21)
13 (11, 16)
22 (19, 25)
1.00
1.21 (0.93, 1.56)
0.90 (0.72, 1.14)
1.69 (1.41, 2.03)***
Not available at time required
Percentage
46 (45, 47)
Odds ratio
47 (46, 48)
49 (44, 53)
41 (38, 45)
43 (40, 47)
1.00
1.06 (0.88, 1.29)
0.79 (0.67, 0.92)**
0.85 (0.74, 0.98)*
Refused for symptoms of COVID-19
Percentage
3 (2, 3)
Odds ratio
3 (2, 3)
3 (2, 7)
2 (1, 3)
3 (2, 4)
1.00
1.58 (0.89, 2.80)
0.63 (0.38, 1.06)
1.06 (0.68, 1.67)
Transportation problems
Percentage
7 (6, 8)
Odds ratio
6 (6, 7)
8 (6, 10)
5 (4, 7)
11 (9, 14)
1.00
1.24 (0.89, 1.72)
0.83 (0.59, 1.15)
1.81 (1.36, 2.40)***
Language problems
Percentage
1 (1, 2)
Odds ratio
1 (1, 2)
1 (1, 3)
1 (1, 2)
3 (2, 5)
1.00
1.01 (0.41, 2.50)
0.66 (0.31, 1.43)
2.68 (1.67, 4.30)***
Cost
Percentage
10 (9, 10)
Odds ratio
9 (8, 10)
12 (10, 16)
6 (5, 9)
13 (10, 15)
1.00
1.44 (1.07, 1.95)*
0.68 (0.50, 0.93)*
1.43 (1.13, 1.81)**
Other
Percentage
16 (15, 17)
Odds ratio
Total
16,302
16 (15, 17)
16 (13, 20)
15 (13, 18)
14 (12, 16)
1.00
0.98 (0.75, 1.28)
0.92 (0.74, 1.15)
0.83 (0.68, 1.02)
13,027
825
1160
1290
*p < 0.05, **p < 0.01, ***p < 0.001; NVMNB non-visible minority native-born, VMNB visible minority native-born, NVMI non-visible minority immigrants, VMI visible
minority immigrants
likely to report difficulties accessing services (OR = 0.79,
p < 0.001). We observe a similar trend for mental health
care, indicating that, compared to non-visible minority
native-born (42%), visible minority immigrants (35%) are
less likely to report difficulties accessing services. In contrary to these findings, visible minority immigrants (24%)
are more likely to report difficulties accessing emergency
services/urgent care than non-visible minority nativeborn (18%) (OR = 1.42, p < 0.01).
For the significant bivariate associations observed
in Table 3, we further account for predisposing, enabling, and need factors. Table 4 shows these multivariate results, which are largely consistent with
bivariate results. Specifically, compared to non-visible
Etowa et al. International Journal for Equity in Health
(2021) 20:255
native-born, visible minority immigrants are less likely
to report difficulties accessing non-emergency surgery (OR = 0.55, p < 0.001), non-emergency diagnostic test (OR = 0.74, p < 0.001), dental care (OR = 0.71,
p < 0.001), and mental health care (OR = 0.77, p < 0.05).
Visible minority immigrants are less likely to face difficulties making an appointment for rehabilitative care
than non-visible minority native-born (OR = 0.56,
p < 0.001). Visible minority native-born are also less
likely to report difficulties accessing dental care than
their non-visible minority counterparts (OR = 0.69,
p < 0.001). In addition, we find that visible minority
immigrants are still more likely to report difficulties
accessing emergency services/urgent care than nonvisible minority native-born; however, this difference
is partially explained by theoretically relevant variables, particularly their experience of discrimination
(OR = 1.46, p < 0.05).
As an additional analysis, we further explore whether
the reasons for difficulties accessing health care services differ based on visible minority immigrant status. Overall, visible minority immigrants are more
likely to report a range of reasons than non-visible
minority native-born. For example, compared to nonvisible minority immigrants (33%), visible minority
immigrants (21%) are more likely to identify ‘getting
a referral’ as difficult (OR = 1.22, p < 0.05). Similarly,
visible minority immigrants (33%) are more likely
to report ‘contacting physicians/nurses for information and advice’ as difficult than non-visible minority
native-born (27%) (OR = 1.33, p < 0.001). Visible minority immigrants are also more likely to report ‘waiting
between booking and visit’ as difficult than non-visible
minority native-born (30%) (OR = 1.55, p < 0.001). In
addition, compared to non-visible minority nativeborn (13%), visible minority immigrants (21%) are more
likely to report ‘waited too long to get service’ as difficult (OR = 1.69, p < 0.001). Visible minority immigrants
(8%) are more likely to report transportation problems
than non-visible minority native-born (6%) (OR = 1.81,
p < 0.001). Consistently, visible minority immigrants
(3%) are also more likely to report language problems
than non-visible minority native-born (1%) (OR = 2.68,
p < 0.001). We also find that, compared to non-visible
minority native-born (9%), visible minority native-born
(12%; OR = 1.44, p < 0.05) and visible minority immigrants (11%; OR = 1.43, p < 0.001) are both more likely
to report cost problems. Finally, non-visible minority
(41%; OR = 79, p < 0.01) and visible minority immigrants (43%; OR = 0.85, p < 0.05) are less likely to report
‘not available at time required’ as difficult than non-visible minority native-born (46%).
Page 8 of 11
Discussion and conclusions
Difficulties accessing health care services can cause
potential undesirable outcomes, such as delays in seeking
and obtaining treatment and limited access to primary
health care [3]. Although the Canada Health Act emphasizes universality and equity in the delivery of health
care services, the research shows that difficulties accessing health care services are disproportionally burdened
among vulnerable groups such as women, rural residents,
Indigenous people, ACB people, and people with existing
health problems [2, 3, 5, 6]. The current study advances
the literature in two important ways. For one, guided by
the theory of intersectionality, we extend our analysis to
include the unique social locations linked to immigrant
status and visible minority status in the context of difficulties accessing health care services. For another, it
is equally important to extend our analysis to reflect
the situation of the COVID-19 pandemic, considering
that demand for health care system resources has been
skewed by COVID-19 patients [1]. This situation may be
increasing difficulties in accessing health care services
among vulnerable populations such as visible minority
immigrants. To this end, we compare difficulties accessing health care services among non-visible native-born,
visible minority native-born, non-visible immigrants, and
visible minority immigrants.
Depending on the types of health care services, we find
that difficulties accessing health care services are commonly reported during the pandemic in Canada. Specifically, at least more than one-third of respondents face
difficulties accessing dental care (48%), non-emergency
surgical care (35%), non-emergency diagnostic test (39%),
making an appointment with rehabilitative care (44%),
medical specialist (46%), family doctor (37%), and seeking mental health care (41%). These figures are much
higher than relevant statistics documented before the
pandemic. For example, Harrington et al. [6] find that
22% of respondents in Ontario experience difficulties
accessing specialist care for diagnosis and consultation.
Similarly, research reveals that 16% report difficulties
accessing non-emergency surgical care between 2005
and 2014 [5]. These findings potentially indicate that the
COVID-19 pandemic is impacting Canadians’ access to
specialist and routine care.
In addition, we find that compared to non-visible
minority native-born, visible minority immigrants are
less likely to report difficulties accessing non-emergency
surgical care, non-emergency diagnostic test, dental care,
mental health care, and making an appointment for rehabilitative care. These findings are very surprising because
the literature indicates that access to health care among
immigrants is most compromised in the use of preventive care, mental health care, and specialist care [5, 6,
Etowa et al. International Journal for Equity in Health
(2021) 20:255
20]. However, other scholars report comparable findings to our findings. For example, Setia et al. [15] show
that female immigrants are less likely to report unmet
care needs than their native-born counterparts. Similarly, Wu et al. [19] establish that the odds of reporting
unmet care needs are lower for immigrants than the
native-born, regardless of immigrants’ length of stay in
Canada. It is also found that recent immigrants are less
likely to report difficulties accessing preventive care
services such as annual examinations [3]. There are at
least two explanations for these findings. First, difficulties accessing health care services may be constructed
based on people’s past experiences. It is possible that visible minority immigrants are perceiving fewer difficulties in Canadian health care settings, considering many
of them come to Canada from less developed countries
where there may be insurmountable barriers to accessing health care resources. In this context, visible minority
immigrants may perceive that their access to health care
services equals or surpasses that in their home countries.
Second, as explained by Sanmartin and Ross [3], some
visible minority immigrants may not have adequate levels of health literacy, which are necessary to identify the
lack of appropriate health care. Specifically, some visible
minority immigrants may still be in the process of learning to navigate the health care system sufficiently to get
to the most suitable health care for themselves [21]. This
potential bias may be underestimating their difficulties
accessing health care services. As research shows that
immigrants tend to underuse preventive health care services before the pandemic [22], it is possible that access
to health care services has become even more complex
with constant changes in health and safety protocols during the pandemic [23].
As opposed to these findings, we observe that visible
minority immigrants are more likely to report difficulties accessing emergency services and urgent care since
the beginning of the pandemic than non-visible minority native-born. Importantly, research shows that visible
minority immigrants are more likely to lack a regular
doctor than their white counterparts, regardless of their
length of residence in Canada, although this difference
is not observed among the native-born [24]. In addition, it is shown that recent immigrants who have been
in Canada for fewer than 10 years are less likely to have
family doctor than the native-born [25]. Similarly, Mian
and Pong [26] observe that the chance of visiting emergency department is particularly high among recent
immigrants in Canada. Although these findings indicate
that emergency services and urgent care may be the only
viable health care option for many visible minority immigrants, our results suggest that they seem to be exposed
to unique barriers to access to these services since the
Page 9 of 11
beginning of the pandemic. For example, visible minority immigrants’ higher odds of reporting difficulties
accessing emergency services and urgent care is partially
explained by their experience of discrimination, implying
that discrimination serves as a critical barrier to immediate care among visible minority immigrants. Considering
that discrimination against visible minorities has been
intensified during the pandemic [11], visible minority
immigrants may be facing difficulties in accessing immediate care, leaving some of them with no option at all to
address their health care needs.
We also observe the different patterns on the reasons
for difficulties accessing health care services by visible
minority immigrant status. For example, visible minority immigrants are more likely to report ‘getting a referral’ as difficult in comparison with non-visible minority
native-born. Although access to speciality care often
requires referrals from primary care providers in Canada, this process has been recognized as being complex
among vulnerable populations [6]. Accordingly, getting
a referral may be difficult among visible minority immigrants who often lack comprehensive knowledge about
Canada’s health care system [16]. In addition, visible
minority immigrants are more likely to report ‘waiting
between booking and visit’ as their reason for difficulties
accessing health care services. This result may imply that,
wait time, which is often cited as one of the major structural barriers, is disproportionately affecting vulnerable
populations such as visible minority immigrants during
the pandemic. Visible minority immigrants are also more
likely to report ‘contacting physicians/nurses to get information or advice’ and ‘language problems’ as barriers to
health care services. These findings may be supported by
research, arguing that health care services often lack culturally and linguistically competent care in Canada [27].
These barriers may be more intensified during the pandemic where in-person consultations have been largely
replaced by virtual ones in many health care settings [28].
In addition, visible minority immigrants are more likely
to report cost and transportation as problems than nonvisible minority native-born. Despite the universal health
care system, cost may still serve as a major barrier if they
use uncovered health care services such as prescribing
drugs and psychotherapy [6]. Similarly, as mentioned by
Ahmed et al. [29], the cost associated with travel to and
from health care facilities is often a concern among economically vulnerable groups including immigrants. Considering that visible minority immigrants are exposed to
many unique reasons for difficulties, it may not be too
surprising that they hesitate to use health care services in
Canada, potentially leading to our observation that they
are more likely to ‘wait too long to get service’ in comparison with non-visible minority native-born.
Etowa et al. International Journal for Equity in Health
(2021) 20:255
Based on these findings, we have several suggestions
for policymakers with health equity in mind. Policymakers should move beyond a binary understanding of the
social categorization of immigrant status (i.e., immigrants and the native-born), considering our findings
that visible minority immigrants may be facing unique
vulnerabilities and difficulties when it comes to accessing health care services during the COVID-19 pandemic.
Specifically, multilevel actions are necessary to address
the unique barriers that visible minority immigrants may
be facing in accessing health care services in Canada. For
example, at the structural level, it is important for policymakers to develop public policies that require organizations to collect disaggregated race-based data to inform
programming. At the institutional level, evidence-based
guidelines should be created to guide the implementation
and promotion of culturally and linguistically competent
care. These policy actions may reduce the level of barriers faced by racialized people and immigrants including
language problems and racial discrimination experienced
in health care settings. Moreover, community health education targeted visible minority immigrants may be helpful with opportunities to learn about Canada’s health care
system comprehensively, which may enable them to learn
about referral system and wait time. In addition, reflecting on the universal and equity principles embodied in
the Health Canada Act, it is recommended that policy
programs are implemented to reduce financial barriers
derived from direct and indirect cost from health care
access faced by structurally exposed groups including visible minority immigrants. These policy efforts possibly
reduce difficulties accessing health care services among
immigrants and visible minority immigrants, including
our observation on visible minority immigrants’ difficulties accessing emergency services and urgent care.
Although our findings may be beneficial for policymakers, our study is not without limitations. For example,
Statistics Canada’s Crowdsourcing Data series are useful
for monitoring Canadians’ social and economic experiences during the pandemic. However, the data collection did not employ a probabilistic sampling technique.
Therefore, our results are not generalizable to the Canadian population. Moreover, the data are cross-sectional
in nature, limiting our results to statistical associations.
Thus, caution is needed when interpreting the results. It
is equally important to mention that access to health care
services is socially desirable. In this sense, due to social
desirability bias, difficulties in accessing health care services may be exposed to underreporting or overreporting. In addition, while we explore the intersectionality
between immigrant status and visible minority status, it
would have been useful to examine the heterogeneity of
immigrants by length of residence in Canada (e.g., recent
Page 10 of 11
immigrants and established immigrants vs. native-born)
and admission class (e.g., economic class, family class,
and refugees). However, we are not able to employ this
approach due to data limitations. Importantly, we are not
able to control for any financial and economic status due
to a lack of relevant information in the data, which could
have been critical in further explaining the difference in
difficulties accessing health care services based on visible
minority immigrant status. We would also like to mention that there is a potential sampling bias that may have
underrepresented visible minorities and immigrants in
the sample. It is important to take into consideration that
barriers to participation such as limited time and financial resources and language problems may be particularly
relevant among vulnerable groups. This bias may have
selected healthier visible minority immigrants who experience fewer unmet needs and barriers to many types of
health care services. Finally, although we find that visible
minority immigrants are less likely to report difficulties
accessing a range of health care services, these results
may be biased due to lack of adequate health literacy that
helps evaluate the quality of health care services. As suggested by Etowa et al. [30], it is especially important to
strengthen the collection and use of disaggregated data to
understand the risk and burden of COVID-19 and to further unpack the underlying processes that contribute to
the difficulties faced by immigrants and visible minorities
in Canada in accessing health care services.
Acknowledgments
We are grateful to Michel Frojmovic for providing insightful comments on an
earlier draft of this manuscript.
Authors’ contributions
JE, YS, and IH conceived the study. JE, YS, IH, CD, IM, and BG analysed data
and wrote the first draft of the manuscripts. MO and HM edited and rewrote
the discussion. The final version of manuscript was read and approved by all
authors.
Funding
There is no funding for this study.
Availability of data and materials
Data are publicly available from https://search1.odesi.ca/#/.
Declarations
Ethics approval and consent to participate
No ethics approval required as this was secondary data analysis of publicly
available data.
Consent for publication
Not Applicable.
Competing interests
There are no competing interests.
Author details
1
Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada.
2
Department of Sociology, Nipissing University, North Bay, ON, Canada. 3 Dalla
Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
Etowa et al. International Journal for Equity in Health
4
5
(2021) 20:255
Page 11 of 11
Canadians of African Descent Health Organization, Ottawa, ON, Canada.
Ottawa Local Immigrant Partnership, Ottawa, ON, Canada.
Received: 21 June 2021 Accepted: 17 November 2021
22.
23.
References
1. Ammi M. Collateral damage: the unmet health-care needs of nonCOVID-19 patients. Conversation. 2020. https://theconversation.com/
collateral-damage-the-unmet-health-care-needs-of-non-covid-19-patie
nts-145934. Accessed 2 June 2021.
2. Clarke J. Difficulty accessing health care services in Canada. Ottawa:
Statistics Canada; 2016. Catalogue No. 82-624-X
3. Sanmartin C, Ross N. Experiencing difficulties accessing first-contact
health services in Canada. Healthc Policy. 2006;1(2):103–19.
4. Etowa J, Kohoun B, Etowa EB, Kiros G, Mbagwu I, Muray M, et al. “Leaving
no one behind”: COVID-19 Response in Black Canadian Communities.
Witness CJCND. 2020;2(2):124–30.
5. Sommer JL, Noh E, Jacobsohn E, Christodoulou C, El-Gabalawy R. An
examination of difficulties accessing surgical care in Canada from 20052014: results from the Canadian community health survey. PLoS One.
2020;15(10):e0240083.
6. Harrington DW, Wilson K, Rosenberg M, Bell S. Access granted! Barriers
endure: determinants of difficulties accessing specialist care when
required in Ontario, Canada. BMC Health Serv Res. 2013;13:146.
7. Brandon AD, Costanian C, El Sayed MF, Tamim H. Factors associated with
difficulty accessing health care for infants in Canada: mothers’ reports
from the cross-sectional maternity experiences survey. BMC Pediatr.
2016;16:192.
8. Vang ZM, Sigouin J, Flenon A, Gagnon A. Are immigrants healthier than
native-born Canadians? A systematic review of the healthy immigrant
effect in Canada. Ethn Health. 2017;22(3):209–41.
9. Statistics Canada. Immigration and ethnocultural diversity: key results
from the 2016 census. Ottawa: Statistics Canada; 2017. Catalogue No.
11-001-X
10. Hou F, Frank K, Schimmele C. Economic impact of COVID-19 among
visible minority groups. Ottawa: Statistics Canada; 2020. Catalogue No.
45280001
11. Statistics Canada. Experiences of discrimination during the COVID-19
pandemic. Ottawa: Statistics Canada; 2020. Catalogue No. 11-001-X
12. Khan MM, Kobayashi K, Vang ZM, Lee SM. Are visible minorities “invisible”
in Canadian health data and research? A scoping review. Int J Migr Health
Soc Care. 2017;13(1):126–43.
13. Kobayashi KM, Prus S, Lin Z. Ethnic differences in self-rated and functional
health: does immigrant status matter? Ethn Health. 2008;13(2):129–47.
14. Bowleg L. The problem with the phrase women and minorities: intersectionality—an important theoretical framework for public health. Am J
Public Health. 2012;102(7):1267–73.
15. Setia MS, Quesnel-Vallee A, Abrahamowicz M, Tousignant P, Lynch J.
Access to health-care in Canadian immigrants: a longitudinal study of
the National Population Health Survey. Health Soc Care Community.
2011;19(1):70–9.
16. Zanchetta MS, Poureslami IM. Health literacy within the reality of immigrants’ culture and language. Can J Public Health. 2006;97(SUPPLEMENT
2):S26–30.
17. Bauer GR. Incorporating intersectionality theory into population health
research methodology: challenges and the potential to advance health
equity. Soc Sci Med. 2014;110:10–7.
18. Andersen R, Newman JF. Societal and individual determinants of medical
care utilization in the United States. Milbank Mem Fund Q Health Soc.
1973;51(1):95–124.
19. Wu Z, Penning MJ, Schimmele CM. Immigrant status and unmet health
care needs. Can J Public Health. 2005;96(5):369–73.
20. Hyman I, Wray R. Health inequalities and Racialized groups: a review of
the evidence. Toronto: Toronto Public Health; 2013.
21. Etowa J, Tharao W, Husbands W, Mbuagwu L, Nelson, L Hyman I, Baidoobonso S. Community Perspectives on Addressing and Responding to
HIV/AIDS among African, Caribbean, and Black (ACB) People in Ontario.
24.
25.
26.
27.
28.
29.
30.
Paper presented at: The 30th Annual Canadian Conference on HIV/AIDS
Research; 2021 May 5-7; Virtual Conference.
Lebrun LA, Dubay LC. Access to primary and preventive care among
foreign-born adults in Canada and the United States. Health Serv Res.
2010;45(6p1):1693–719.
Etowa J, Hyman I. Unpacking the health and social consequences of
COVID-19 through a race, migration and gender lens. Can J Public Health.
2021;112(1):8–11.
Siddiqi AA, Wang S, Quinn K, Nguyen QC, Christy AD. Racial disparities in
access to care under conditions of universal coverage. Am J Prev Med.
2016;50(2):220–5.
Hay C, Pacey M, Bains N, Ardal S. Understanding the unattached population in Ontario: evidence from the primary care access survey (PCAS).
Healthc Policy. 2010;6(2):33–47.
Mian O, Pong R. Does better access to FPs decrease the likelihood of
emergency department use? Results from the primary care access survey.
Can Fam Physician. 2012;58(11):e658–66.
McCalman J, Jongen C, Bainbridge R. Organisational systems’ approaches
to improving cultural competence in healthcare: a systematic scoping
review of the literature. Int J Equity Health. 2017;16:78.
Ortega G, Rodriguez JA, Maurer LR, Witt EE, Perez N, Reich A, et al. Telemedicine, COVID-19, and disparities: policy implications. Health Policy
Technol. 2020;9(3):368–71.
Ahmed S, Shommu NS, Rumana N, Barron GR, Wicklum S, Turin TC. Barriers to access of primary healthcare by immigrant populations in Canada:
a literature review. J Immigr Minor Health. 2016;18(6):1522–40.
Etowa J, Hyman I, Dabone C, Mbagwu I, Ghose B, Osman M, Mohamoud H. Strengthening the Collection and Use of Disaggregated Data
to Understand and Monitor the Risk and Burden of COVID‑19 Among
Racialized Populations. Canadian Studies in Population. 2021. https://doi.
org/10.1007/s42650-021-00050-2.
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Ahmed et al. Tropical Diseases, Travel Medicine and Vaccines
https://doi.org/10.1186/s40794-021-00138-2
(2021) 7:15
RESEARCH
Open Access
Racial equity in the fight against COVID-19:
a qualitative study examining the
importance of collecting race-based data in
the Canadian context
Ranie Ahmed1,2* , Omer Jamal1,2, Waleed Ishak3, Kiran Nabi1,2 and Nida Mustafa1
Abstract
Background: A failure to ensure racial equity in response to the COVID-19 pandemic has caused Black
communities in Canada to disproportionately be impacted. The aim of the current study was to determine the
needs and concerns of Black communities in the Greater Toronto Area (GTA) and to highlight the importance of
collecting race-based COVID-19 data early on to address these needs.
Methods: Six qualitative interviews were conducted with local community health centre leaders who serve a high
population of racialized communities within the GTA. Content analysis was used to extract the main themes and
concerns raised during the interviews.
Results: The findings from this study provide further evidence of the disproportionate impact COVID-19 has had on
Black and other racialized communities. Difficulty self-isolating due to overcrowded housing, food insecurity, and
less social support for seniors were concerns identified by community health leaders. Also, enhanced financial
support for front-line workers, such as Personal Support Workers (PSWs), was an important concern raised. In order
to lessen the impact of the pandemic on these communities, leaders noted the need for greater accessibility of
testing centres in these areas and a greater investment in tailored health promotion approaches.
Conclusions: Overall, our findings point to the importance of collecting race-based data to ensure an equitable
response to the pandemic. The current “one size fits all” response is not effective for all individuals, especially Black
communities. Not all populations have access to the same resources, nor do they live in the same conditions
(Kantamneni, J Vocal Behav 119:103439, 2020). A deeper consideration of the social determinants of health are
needed when implementing COVID-19 policies and responses. Also, a lack of attention to Black communities only
continues to perpetuate the under-acknowledged issue of anti-Black racism prevalent in Canada.
Keywords: Racial equity, COVID-19, Black community, Social determinants of health, Racialized communities
* Correspondence: ranie.ahmed@mail.utoronto.ca
1
Department of Health and Society, University of Toronto, 1265 Military Trail,
Toronto, ON M1C 1A4, Canada
2
Department of Biological Sciences, University of Toronto, 1265 Military Trail,
Toronto, ON M1C 1A4, Canada
Full list of author information is available at the end of the article
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The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the
data made available in this article, unless otherwise stated in a credit line to the data.
Ahmed et al. Tropical Diseases, Travel Medicine and Vaccines
(2021) 7:15
Background
COVID-19 is an infectious disease caused by the SARSCoV-2 virus, targeting the respiratory and gastrointestinal tract of humans [1]. It is spread through respiratory
droplets and airborne transmission, and manifests both
asymptomatically and symptomatically within individuals
[2]. Good hygiene, including hand sanitization, the use
of facial masks/coverings and social distancing, are key
protective measures identified by public health organizations, agencies and leaders across the globe.
Although the virus does not discriminate in terms of
who it infects, research has shown that marginalized
communities are at greater risks due to an inequitable
distribution of resources, such as lack of government
funding, housing, social support, and food insecurity [3].
Many marginalized populations are not able to adopt adequate preventative measures due to these conditions,
which further increases their susceptibility to contract
the virus [3]. In Canada, research shows that Black communities, in particular, are more likely to become sick
and be hospitalized with COVID-19 compared to other
ethnic groups [4]. For example, from May 20 to July 16
(2020), it was found that Black individuals made up 21%
of the COVID-19 cases in Toronto (one of the most
populated cities in the country), despite only making up
9% of the population [4]. These communities are also
disproportionately affected by certain chronic conditions, such as HIV, diabetes, food insecurity, lowincome, and unstable housing in Canada [5]. The effects
of COVID-19 have, therefore, further exacerbated these
already present health disparities.
Race-based data is the collection of population health
outcomes stratified by racial groups [6]. Although some
provinces in Canada, including Ontario, have started
collecting this data, measures should have been taken
earlier to ensure vulnerable communities are protected
during this time. It has been suggested that the province
should have gathered neighborhood based COVID-19
data in the early stages of the pandemic, or even prior,
to identify communities that would be most impacted
[6]. This data could have guided and informed equitable
response efforts, such as providing additional funding
and safety resources (e.g. face masks, sanitizers) to those
communities. Also, the government could have taken
preventive measures such as establishing priority food
drives, pop-up testing clinics, and resource donation
drives (e.g. hand sanitizers, masks, personal protective
equipment, etc.) in the locations that have the highest
prevalence of cases, which are marginalized
communities.
Race-specific data collected early on could have guided
a more equitable response to the pandemic as we would
have clearly seen the intersection of race, income, location of residence, education, occupation/employment
Page 2 of 6
and resource availability. If collected earlier, these variables could have helped public health officials understand the challenges, barriers and living conditions of
different racial and marginalized populations and the
impact the pandemic could have on these communities.
In times of crisis, the inequitable experiences of marginalized populations need to be identified and addressed at
the beginning, as these groups disproportionately bear a
greater burden of suffering [7]. Hence, the goal of this
project was to demonstrate the importance of collecting
race-based COVID-19 data to ensure an equitable response to the current pandemic, in the Canadian
context.
Materials and methods
Qualitative study design
Qualitative research is a process that involves collecting
and analyzing non-numerical data to achieve an improved understanding of a specific concept, opinion, or
experience [8]. It provides researchers with personal accounts and experiences on various topics, and a deeper
understanding of a problem to help generate new ideas
for research. Unlike quantitative research, which uses
statistics and numerical data, qualitative research allows
researchers to further understand population health outcomes based on conversations, narratives, and discussions with those who have lived experiences of an issue,
or those who work closely with members within a
community.
In order to understand the issue of racial equity in this
matter, we decided to take a qualitative approach. This
issue cannot be examined through health statistics because the lived experiences of the target populations
through community-based research is required. This
provides a powerful means to examine concerns and
challenges which cannot be quantified through quantitative measures, and so our project utilized this approach.
Data collection method
After obtaining ethical approval from a University’s Research Ethics Board, six qualitative interviews were conducted with five executive directors of community
health centre leaders across the GTA and one University
professor, between July 2020 to August 2020. Interviews
were conducted through zoom, an online communication platform, due to COVID-19 policies and guidelines.
Each interview was between 45 min to 1 h. Community leaders were asked about issues and concerns within
their communities in regards to the pandemic; for example, “what resources are currently needed that the
community does not have access to?”, “how important is
it that our leaders understand that a one-size fits all approach is not an effective solution this pandemic?”. Also,
community leaders were asked for their thoughts on the
Ahmed et al. Tropical Diseases, Travel Medicine and Vaccines
(2021) 7:15
importance and need for collecting race-based data in
the GTA. It was important to interview these community health leaders as they deal directly, communicate
and interact with members of the Black community. Individuals of the Black community often rely on these
health centres for aid and advice regarding their personal health. Since the communities are tightly knit, the
lived experiences of its members are truly understood by
the community health leaders who are involved in voicing the community’s concerns to the government.
Hence, in our study we aimed to target these community
leaders as they were able to provide us with valuable
insight into the lived experience of the members within
their community.
Once interviews were complete, they were transcribed
verbatim, followed by the extraction of main themes
through the use of Content Analysis [9]. This systematic
method identifies important and emerging thematic
findings that relate to the overall research focus/
question.
Page 3 of 6
These concerns provide clarity on the negative effects
of COVID-19 on Black communities, and the impact of
this on the communities’ physical and mental health.
Mobile testing
Mobile testing became available in non-racialized GTA
neighborhoods (which were socially less burdened)
weeks before regions that were most affected by
COVID-19. In particular, those communities with inadequate housing and poor access to healthcare were delayed in receiving such resources. Communities with
greater populations of racialized individuals suffered the
most during the pandemic because there was no prior
knowledge of the needs of these communities or what
health concerns were already present. Community
leaders suggested that differences in resource allocation
between certain communities’ points to systemic discrimination, neglect, and a lack of prioritization of racialized communities which are in need the most.
Working conditions
Results
The findings below identify the main concerns which
arose among Black communities during the pandemic.
In particular, community leaders discussed the importance of mobile testing and the role of working conditions in spreading the virus among marginalized groups.
They also identified the role of anti-Black racism in the
pandemic response and the importance of equitable
health policies. Future lessons/approaches the government should take to implement equitable public health
measures that are tailored to the lived experiences of
Black communities, were also highlighted.
Common concerns of the community
A common concern emerging from the interviews was a
reluctance among individuals from Black communities
to get tested for the virus due to misunderstandings of
how painful the test would be. Also, there was a fear of
increased contact with individuals who have tested positive at the testing centre. This made individuals from
these communities less likely to get tested for the virus.
In addition, individuals were hesitant to get tested due
to the possibility of a positive test, leading them to worry
about taking time off work. This would mean they would
need to find other sources of income to support their
families (i.e. to pay rent, buy groceries).
Many members of these communities also lost jobs
and were not eligible for the Canadian Emergency Response Benefit (CERB). This led to other concerns such
as the affordability of food and personal protective
equipment (PPE). As many members from these communities have a lower socio-economic status, the loss of
employment further exacerbated income inequality.
A disproportionate number of Black female personal
support workers (PSW) were employed in nursing
homes which were most affected during the pandemic.
This increased their chances of contracting the virus
themselves, as well as becoming carriers for their family
members.
Also, community leaders indicated a correlation between low-income jobs and the risk of contracting
COVID-19, in these communities specifically. As one
leader highlighted, “a lot of racialized and marginalized
communities live in low-income conditions, where their
employment situation is precarious to an extent where
they aren’t able to access financial assistance” (Executive
Director, Community Health Centre in Scarborough,
Toronto). Thus, to make ends meet, some Black individuals have to work multiple jobs to receive adequate
income.
Psychological effects
The psychological effects of COVID-19 are expected to
have a significant impact on populations across the
country, especially those of marginalized communities
who face a greater burden. For example, many individuals from these regions must work throughout the pandemic as they do not have the option of staying home.
Often times, these individuals are living with vulnerable
family members (e.g. seniors; those with chronic conditions), and therefore, have to send them to other family
member’s houses to reduce the spread of COVID-19.
This adds to the isolation, loneliness, and depression
these communities face. The psychological effects are
cumulating; therefore, resources need to be tailored and
made accessible in these communities. One community
Ahmed et al. Tropical Diseases, Travel Medicine and Vaccines
(2021) 7:15
leader noted that, “there are accessibility issues to mental health support in these communities already” (Executive Director, Community Health Centre in
Scarborough, Toronto). Thus, efforts need to be made to
increase access to mental health services in Black
communities.
Anti-black racism
Community leaders highlighted that earlier measures
should have been implemented to avoid the high percentage of COVID-19 cases among Black people and
other people of colour. Racial inequities faced by communities in the healthcare system continues to be a
long-standing concern even prior to the current pandemic. Health officials, therefore, need to acknowledge
and prioritize the health of minority populations through
the implementation of tangible policies that will produce
meaningful change.
Policies
It was also noted that health officials need to review policies and create new ways to respond to COVID-19,
which target anti-Black racism, specifically. Similar to
the importance of collecting race-based data, it is important for policies to reflect the lived experiences of racialized populations in a real, structural, and meaningful
way. Community leaders identified that many institutions already have such policies in place; however, these
policies do not always translate into practice.
Lessons/future approaches
The provincial delay to collect race-based data is an important lesson to keep in mind, according to community
leaders. Black and other racialized communities are impacted by COVID-19 and (other chronic conditions) significantly more than other populations. The inequitable
disparities that already exist in these communities (in
terms of housing, income, food security), perpetuate
these problems even further.
As one leader notes, “the common denominator is
anti-Black racism and a system that is generating all of
these problems. With the COVID-19 pandemic and
what has transpired after the Black Lives Matter (BLM)
movement [and recent attention given to the BLM in
2020], we as a society have been given a good opportunity to think differently about race and health, and to
bring about change” (Executive Director, Community
Health Centre in Scarborough, Toronto). Public health
officials, governments, and the overall population, can,
and should shift the needle towards equity and fairness
in health, and overall quality of life.
An important point raised by those in the study was
the importance of considering how different communities will access health services when the virus vaccine is
Page 4 of 6
ready to distribute, in order to ensure effective usage.
Making vaccinations available where community members are most comfortable visiting will be important to
consider. Public health officials also need to raise awareness within these communities and promote community
engagement to overcome misinformation and myths
about vaccinations. In addition, Black communities particularly have a difficult time trusting the health system,
since health services, including clinical trials and vaccines, have previously been used to further racialize,
marginalize, and kill members of the Black community.
Therefore, community leaders encourage and support an
equitable deployment plan for vaccination.
Also, community leaders mentioned that they would
like to see relationship and community building within
Black communities to encourage the use of testing and
mobile testing units. This will ensure trust is built and
members of the community feel comfortable taking the
vaccination. Normally, vaccinations are given through
institutions and hospitals; however, this may not be accessible to all Black community members. Therefore,
there needs to be a shift in planning to ensure a more
equitable approach to intervention and prevention.
Discussion
The Canadian federal, provincial, and municipal government’s general response to the pandemic has been commendable, as we saw a flattening of COVID-19 cases
early on. Unfortunately, there still remains gaps in the
lack of community-specific responses that are racially
and socially equitable. Not all individuals should be
treated the same way, as people do not have the same
opportunities, privileges, and access to health care [3].
Collecting race-based data prior to the pandemic, would
have made this more evident. In that case, more
community-specific responses could have been implemented, which could have led to a significant reduction
in the virus cases we see today. However, since there is
not enough detailed race-based data available that clearly
shows the impact of the pandemic on Black communities across the GTA, the current issues remain. For example, current COVID-19 policies and responses are not
tailored to meet the needs and concerns of Black communities, as noted earlier in our findings. The Canadian
government’s neglect toward these communities not
only prevents an equitable response, but worsens the
health of these communities. Moving forward, there
should be specific plans and strategies put in place for
Black communities, as well as other minority groups
such as Indigenous peoples and those living in lowincome communities, which ensure better health outcomes for all.
In June 2020, the City of Toronto declared anti-Black
racism a public health crisis [10]. The question remains
Ahmed et al. Tropical Diseases, Travel Medicine and Vaccines
(2021) 7:15
on what our governmental systems and structures will
do to translate this declaration into the pandemic response. Public health officials need to prepare and implement an equitable response, especially knowing that
80% of COVID-19 cases are among Black people and
those of colour [4]. The large proportion of Black community members who have contracted the virus further
shows the systemic racism which contributes to the
current inequity. If race-based data was collected early
on, the high percentages could have been avoided with
greater resources allocated to the communities which
need them the most. The anti-Black racism experienced
by Black individuals also adds to the growing distrust
from the community towards the health care system.
This will need to be rectified by building trust between
Black communities and the healthcare system through
the establishment of meaningful partnerships. This can
be done by creating policies that acknowledge and create
culturally sensitive systems, as well as targeted resources,
including mental health support. Furthermore, efforts
should be made to recognize the generational trauma
Black communities have faced at the hands of the
healthcare system.
The collection of race-based data across the country
is, therefore, extremely necessary to ensure this response
is equitable. Currently, public health officials have begun
collecting this data, however, they need to be better prepared to desegregate the data to identify which regions
are most disproportionately impacted. If action is taken
now, there is promise for equitable changes within our
health and social systems.
Limitations
This study has potential limitations. Firstly, the sample
size for the interviews was limited. Due to the timeline
of the study and COVID-19 restrictions, directly reaching Black community members during this time was not
feasible. We were, therefore, not able to directly interview Black community members who are not professionals due to restrictions that were in place during our
project (i.e. 4 month timeline). Recruitment of these individuals would have taken significantly longer, especially due to the second-wave of the pandemic.
However, we decided to optimize our findings by reaching out to the community health centre leaders who represent these marginalized populations. We strongly
believe that by interviewing the community health centre
leaders within pre-dominantly Black communities, we
were able to capture broad needs and concerns of members within these communities. This is because the
leaders are constantly involved and engaged with the
community and their needs, and have a strong understanding of their lived experiences. Secondly, we were
unable to target a larger demographic in this study, as
Page 5 of 6
only the Black communities of the GTA were included.
Future studies should consider exploring this issue beyond the GTA, to avoid selection bias.
Conclusion
The COVID-19 pandemic has and continues to disproportionately impact Black communities, which highlights
the importance of collecting race-based data to ensure
an equitable response. The collection of this data will inform health officials on the needs of vulnerable communities, followed by effective resource allocation.
Collecting race-based data is one step towards addressing the health inequities faced by Black communities in
Canada.
Abbreviations
GTA: Greater Toronto Area; COVID- 19: Coronavirus disease 2019;
PSWs: Personal Support Workers; SARS-CoV-2: Severe acute respiratory
syndrome, coronavirus 2; BME: Black and minority ethnic communities;
CERB: Canadian Emergency Response Benefit; PPE: Personal protective
equipment
Acknowledgements
Not Applicable.
Authors’ contributions
RA, OJ, KN, and WI were all involved in data collection, analysis, conception,
design, and write-up of the first draft. NM was the senior supervisor of the
project. All authors critically revised the manuscript and serve as guarantors
of the work.
Funding
This research was supported by the University of Toronto’s COVID-19 Student
Engagement Award (2020).
Declarations
Ethics approval and consent to participate
The research was approved by the University of Toronto’s Research Ethics
Board. Written consent was obtained from all study participants.
Consent for publication
Not Applicable.
Competing interests
The authors declare that they have no competing interests.
Author details
Department of Health and Society, University of Toronto, 1265 Military Trail,
Toronto, ON M1C 1A4, Canada. 2Department of Biological Sciences,
University of Toronto, 1265 Military Trail, Toronto, ON M1C 1A4, Canada.
3
Department of Human Biology, University of Toronto, 100 St. George St,
Toronto, ON M5S 3G3, Canada.
1
Received: 20 January 2021 Accepted: 6 May 2021
References
1. Li T. Diagnosis and clinical management of severe acute respiratory
syndrome Coronavirus 2 (SARS-CoV-2) infection: An operational
recommendation of Peking Union Medical College Hospital (V2.0). Emerg
Microbes Infect. 2020;9(1):582–5. https://doi.org/10.1080/22221751.2020.173
5265.
2. Helmy YA, Fawzy M, Elaswad A, Sobieh A, Kenney SP, Shehata AA. The
COVID-19 pandemic: a comprehensive review of taxonomy, genetics,
epidemiology, diagnosis, treatment, and control. J Clin Med. 2020;9(4):1225.
https://doi.org/10.3390/jcm9041225.
Ahmed et al. Tropical Diseases, Travel Medicine and Vaccines
3.
(2021) 7:15
Kantamneni N. The impact of the COVID-19 pandemic on marginalized
populations in the United States: a research agenda. J Vocat Behav. 2020;
119:103439. https://doi.org/10.1016/j.jvb.2020.103439.
4. Cheung J. Black people and other people of colour make up 83% of
reported COVID-19 cases in Toronto. CBC. 2020; https://www.cbc.ca/news/
canada/toronto/toronto-covid-19-data-1.5669091. Accessed 20 Aug 2020.
5. Gardezi F, Calzavara L, Husbands W, Tharao W, Lawson E, Myers T, et al.
Experiences of and responses to HIV among African and Carribean
communities in Toronto. AIDS Care. 2008;20(6):718–25. https://doi.org/10.1
080/09540120701693966.
6. Rizvic S. Why race-based data matters in health care: Institute for Canadian
Citizenship: Institut pour la citoyenneté canadienne. 2020. https://www.
inclusion.ca/article/why-race-based-data-matters-in-health-care/. Accessed
06 Dec 2020.
7. Garg S, Kim L, Whitaker M, et al. Hospitalization rates and characteristics of
patients hospitalized with laboratory-confirmed Coronavirus Disease 2019
— COVID-NET, 14 States, March 1–30, 2020. MMWR Morb Mortal Wkly Rep.
2020;69:458–64. https://doi.org/10.15585/mmwr.mm6915e3.
8. Aspers P, Corte U. What is qualitative in qualitative research. Qual Sociol.
2019;42(2):139–60. https://doi.org/10.1007/s11133-019-9413-7.
9. Flick U. Mapping the Field. In the SAGE handbook qualitative data analysis.
Los Angeles: SAGE; 2014. p. 3–19.
10. Boisvert N. Toronto Board of Health declares anti-black racism a public
health crisis. CBC News. 2020; https://www.cbc.ca/news/canada/toronto/boa
rd-of-health-anti-black-racism-1.5603383. Accessed 25 Nov 2020.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Page 6 of 6
1066813
research-article2021
ORG0010.1177/13505084211066813OrganizationVieta and Heras
Special Issue: Solidarity
Organizational solidarity in
practice in Bolivia and Argentina:
Building coalitions of resistance
and creativity
Organization
2022, Vol. 29(2) 271–294
© The Author(s) 2021
Article reuse guidelines:
sagepub.com/journals-permissions
https://doi.org/10.1177/13505084211066813
DOI: 10.1177/13505084211066813
journals.sagepub.com/home/org
Marcelo Vieta
University of Toronto, Canada
Ana Inés Heras
Universidad Nacional de San Martín, Argentina
Abstract
This article considers organizational solidarity in practice—modes of organizing rooted in solidarity,
relationality, coalition-building, and difference. It does so by studying two Latin American
illustrative cases: Bolivia’s campesino-indígena movements coalescing traditional practices and
urban-neighborhood experiences in order to self-organize socio-political spaces; and Argentina’s
worker-led empresas recuperadas por sus trabajadores (worker-recuperated enterprises), where
workers have been drawing on working-class self-activity to convert companies to cooperatives
and self-manage spaces of production. Via a diverse economies approach, the article begins to
inventory, describe, and provisionally theorize the recuperations, rearticulations, and creative
proposals for organizing social, cultural, and economic life being forged by these diverse groups.
The article ultimately unravels four broad commonalities threading and shaping each case: the
neoliberal political economic context, collective memory, horizontal organizing, and coalitional
possibilities. Though emerging in different national conjunctures and histories, what these two
cases bring to the surface are the resistive and creative dimensions of each organizing experience.
They are rooted in deeply relational coalitions linked via solidarity in difference, while drawing on
collective memories of the past to recreate and reenvision the present and the future beyond the
legacies of colonial histories and capitalist-centered actualities.
Keywords
Argentina, Bolivia, campesino-Indigenous organizing, communal system, organizational solidarity,
self-management/autogestión, solidarity in difference, worker-recuperated companies/empresas
recuperadas
Corresponding author:
Marcelo Vieta, Ontario Institute for Studies in Education, University of Toronto, 252 Bloor Street W., Toronto, ON
M5S 1V6, Canada.
Email: marcelo.vieta@utoronto.ca
272
Organization 29(2)
Introduction
The region known as Latin America has been plagued for centuries with colonialist legacies
encompassing patriarchal ideologies, racism, classism, and economic exploitation, to the point that
many Indigenous and working-class peoples have been decimated by genocide or have been forced
to merge into Westernized versions of themselves. This has been a centuries-long struggle,
addressed by myriad social and political movements. At the end of the 20th and the beginning of
the 21st centuries, different peoples and movements in the region continued to coalesce to actively
resist and begin to invent new paths beyond this situation, reflected in struggles to self-determine
and affirm the cultural and social traditions of Indigenous groups, secure the rights of women and
LGBTQ+ communities, overcome racialized injustices, and ensure the livelihoods of campesino
and urban workers, all considered other from Western epistemological lenses.
In this article, we home in on solidarity and coalitional forms of organizing in the place known
as Latin America. Articulated poignantly by Arturo Escobar:
Latin America today is the clearest case of a struggle between neoliberal globalization (the project of the
right), alternative modernizations (the leftist project at the level of the state), and the creation of post/noncapitalist and post/non-liberal worlds. This latter project relies primarily on the political mobilization of
relational worlds by communities and social movements. (Escobar, 2018: 64)
We adopt the term “Latin America” reflexively, as place holder and shorthand for a lived, performed, but also imagined region. Our standpoint embraces a non-essentialist sensitivity and
acknowledges that there exists in the region shared historical and contemporary experiences across
difference that have been deeply impacted by and that creatively push back against (neo)colonialist
and neoliberal legacies. Following Quijano (2010), Escobar (2010, 2018), Rivera Cusicanqui
(2015), Gutiérrez Aguilar (2008), Grandia (2009, 2020), and the compilation coordinated by several other critical thinkers in Adamovsky et al. (2011), we recognize that the region’s marginalized
and oppressed have faced common challenges while innovating or recreating new socio-economic,
cultural, and political realities from below. These groups have formed, over time, several different
coalitions that have challenged (neo)colonialism and, today, neoliberalism, in their different
expressions.
In this article we engage with two broad coalitions in Latin America practicing forms of organizing in difference(s) through solidarity: Indigenous and communal self-organizing of socio-political
spaces in Bolivia, building coalitions with campesino and urban groups; and the working-class practices of the empresas recuperadas por sus trabajadores (ERTs, worker-recuperated enterprises) in
Argentina, where workers have been taking over and self-managing spaces of production—factories,
shops, and other workplaces—as worker cooperatives. Both coalitions begin to resist hegemonic
impositions and creatively invent realities and ways of organizing the political and the productive
beyond the legacies of colonial histories and capitalist-centered actualities.
Organizational solidarity in practice is what we term these forms of organizing, highlighted by our two illustrative cases, that actively and creatively engage in social, political,
and economic solidarity in difference by embracing collective decision making, communal
ownership, and horizontal formations. Sharing commonalities but in different contexts in the
region, the two coalitions operate in diverse national settings while being constituted by
groups that have been marginalized or exploited by the status quo system propped up by neocolonial and neoliberal enclosure. Our entry points into these forms of organizing are practices
of solidarity and coalition-building. In the following pages we delve into how their protagonists construct both a politics of demand in emancipative struggles and a politics of
Vieta and Heras
273
self-determination in liberational expressions of social, political, and cultural creativity
beyond capitalocentric logics (Gibson-Graham, 2006; Zibechi, 2007).
We do not claim that these two Bolivian and Argentine cases are representative of all organizational solidarity practices and coalitions across Latin America. We aim to, more modestly, begin to
inventory and document some of these promising practices and experiences from two regional
coalitions in different national conjunctures. For this article, they offer vivid examples of the complex and varied ways that organizational solidarity in practice actualizes today. In doing so, via
documentary and empirical evidence, we highlight threads that make visible coalitional lines of
thought and practice mostly overlooked by Eurocentric organizational studies (Altieri and Faria,
2019; Mandiola, 2010; Wanderley and Barros, 2019). We aspire to understand what counts as
organizing in solidarity and what lessons can be learned from concrete contemporary practices in
a region rich with examples of this kind of solidarity-based coalition building.
We draw on the critical methodology inspired by the diverse economies work of Gibson-Graham
(2006) and associates (Gibson-Graham and Dombroski, 2020), which seeks to read economic,
social, and cultural practices and organizing beyond binaries by centrally considering difference.
Gibson-Graham (2020) insist that radical research projects proceed by queering dominant terms—
inverting, reinventing, and re-appropriating concepts by proposing a practice of “de-aligning” (p.
481). They performatively seek to unravel the effects of domination and hegemonic practices by
highlighting how certain constructs are defined at the expense of others, and by unpacking the alliances needed to make those definitions act and work. A necessary step for unpacking and “queering” dominant or common-sense notions and making visible other ways of doing and knowing is
what Gibson-Graham call conducting an inventory of practices and ways of doing economic,
social, and cultural life within and beyond capitalocentrism. This inventory is constructed by performing thick description, with the ultimate goal of developing weak theory, a theory that is emergent, tentative, non-essentialist, and constantly engaged in inductive interpretation, or what Santos
(2014) terms “rearguard theory” (p. 11).
In recent years, a similar approach of conceptual “dislocation” and “decentering” has been
called on for Latin American organizational studies by post-colonial theorists such as Mandiola
(2010: 165), Dussel (Dussel and Ibarra-Colado, 2006), Ibarra-Colado (2006), and others (for
instance Rodriguez et al., 2019). A queering or dislocative approach is central to decolonizing
“management and organization knowledge” (Wanderley and Barros, 2019: 79), which is ensconced
in the Anglo-European center and adopted uncritically by orthodox organizational researchers,
designers, and management gurus and practitioners in the global North and South, including in
Latin America (Ibarra-Colado, 2006). Here, the orthodox/colonizing notion of “[o]rganization is
associated with the new scientific paradigm” privileging “efficiency, the technological feasibility
associated with economic utility and the management of an enormous world system in continuous
expansion,” leading to the “simplification and ‘rationalization’ of the world of life” (Dussel and
Ibarra-Colado, 2006: 497–498).
However, as our synergistic reading of Gibson-Graham, Mandiola, Dussel and Ibarra-Colado,
and others reveals, a decentred, queered, and decolonized notion of organization can be conceived,
documented over several decades now as peripheral and non-capitalist spaces of coalition-building
by, for example, Rivera Cusicanqui (1984) and more recently by Florez-Florez (2007). These ways
of organizing “go beyond formal reason in its adaptation of means and ends” including, given the
centrality of community to human life, in ways that bring to light both alternative/other-than-capitalist socio-economic doing and the irrationality of the “rationalization” of the labor process under
capitalism (Dussel and Ibarra-Colado, 2006: 499; see also Altieri and Faria, 2019).
We thus advocate that an approach of thick description and weak theorizing allows one to construct arguments and definitions by assessing the diverse and pluriverse ways in which humans and
274
Organization 29(2)
non-humans build and organize conditions for living well, from the so-called “margins” of capitalistic systems. Again, these are already happening rather than solely future-oriented. It also allows
us to re-center the concepts of organization and organizing with grassroots protagonists and communities, rather than from blanket universalist and Eurocentric assumptions. For these reasons, our
writing is also aimed at contributing to a mode of conceptualizing that moves beyond neoclassical,
Eurocentric, instrumentalist, masculinist, and self-interested epistemologies.
In short, visibilizing organizing practices that may remain marginalized or hidden by orthodox
economics and hegemonic social sciences and ideologies becomes especially important for diverse
economies research (Gibson-Graham, 2020) and for casting light on and inventorying modes of
organizing in non-capitalocentric ways and in solidarity with others, while recognizing differences
within a pluriversal reality (Escobar, 2018; Rodriguez et al., 2019). Our two illustrative cases of
organizational solidarity in practice—Bolivia’s campesino-indígena self-organizing of socio-political spaces and Argentina’s ERTs’ self-managing of spaces of production—embrace this critical
perspective.
Why “Latin America”?
In a similar fashion to our decentering of the concept of organization, we also view the notion of
Latin America critically, but have decided to continue to use it as methodological placeholder and
shorthand. We thus first review the contested concept of Latin America to clarify this decision. We
also do so to begin to better grasp the possible commonalities and differences with organizational
solidarity in practice in the region.
América Latina was used by white and mestizo elites when most of the region’s nation-states
were established in the 19th and early 20th centuries. In using the term, they stressed similarities
across countries of the region and sought to indicate the fact that their new nations were in a complex relation to Europe, and later to the United States. These elite ruling groups simultaneously
sought to highlight their ties to these centers of power, yet also differentiate themselves from these
geopolitical centers that intended to dominate the region’s emergent nation-states. These elites also
used other terms, such as América Hispana, Hispanomérica, Hispano y Luso América, or
Iberoamérica. For them, each of their countries were regarded as existing within a region, and they
saw themselves as conducting politics, culture, and society in common ways. Several of these elite
groups emphasized the use of Spanish as their native tongue, but also associated with the use of
French, Portuguese, Dutch, or English, depending on the time and regional specificities of colonization, to signal their belonging to a broader spectrum of governing elites linked to Europe and
reaffirming in that way a neocolonial position. Overall, it was important for ruling elites to stress
commonalities and consolidate their local powerbase by negating local diversity. Their political
actions sought to dominate different groups considered others, such as Indigenous peoples,
African-descendant populations, and the growing working class (Stavenhagen, 2009). In each
country of the region the ruling elite constructed this position over time, which, according to historical research, reached its ideological apex in the 18th century (Castro Gómez, 2005): anyone
who did not speak a European language or was not a white or mestizo/creole elite was considered
“less than,” “outdated,” “not civilized,” and “barbarian,” ultimately regarded as cheap labor
deployed by inferior human beings.
At the same time, these positions were also continually challenged by those considered “others.” Such is the case with the notion of Nuestra América that was advanced by Cuban philosopher
and poet Martí (1891), or the concept of negritud put forward by Martinican born Césaire (2006
[1950]) and Fanon (2009 [1952]), or the Kuna notion of Abya Yala (Estermann, 2014). In this
regard, and drawing on the inheritance of the Caribbean thinkers cited above, the term América
Vieta and Heras
275
Negra emerged over time to become important for reaffirming the traditions and perspectives of
Afro-American populations in this geographical part of the world. In a similar way, but also
embracing other cultural groups, the term América Profunda, as expounded by Argentine anthropologist Kusch (2000 [1962]), was proposed more than half a century later. Other terms, such as
the Mapuche Wallmapu and the Quechua Suyus, are also used by Indigenous groups to assert their
ancestral ways of knowing their lands and, in contemporary usage, also to contest the Eurocentric
and colonial inheritance underscoring the term América Latina. The use of these varied concepts—
among many others—highlights the diversity of peoples and the Indigenous roots of this part of the
world that bring to the fore their ways of knowing and being on the lands they inhabit. From these
perspectives, what counts as a political or cultural unit, the ways in which they become perceived
units or not, and what language(s) and knowledge traditions are legitimized for purposes of mutual
understanding and cultural self-affirmation, are all open questions.
This reclamation of the term América Latina took hold in the late 1950s and throughout the
1960s when, in several countries of the region, Indigenous peoples, campesinos, the working class,
women, students, myriad progressive groups, urban political parties, theology of liberation advocates, and numerous community groups coalesced under the banner in shared struggles against
imperialist–capitalist impositions from the region’s state governments and from centers of power
in the global North. For these groups in struggle, América Latina was reappropriated into a shared
concept used to articulate the diverse coalitions formed contra North–Anglo–American domination and the imposition of English, Anglo-Protestantism, and, eventually, extreme exploitive and
extractive international capitalism (Varsavsky, 1969).
The discussion presented in this section makes visible several terms, used at different points in
time and by different groups or writers. We are thus aware that the use of “Latin America” may
perform differential semantic actions according to who uses the term, how it is used and accompanied by which other term(s), and when and for what purposes one uses it or another term altogether
(Bohoslavsky, 2011; CLACSO 2017 [1969]; Stavenhagen, 2009; Torres Martínez, 2016). To summarize then, on the one hand, the genealogy we just presented problematizes the use of América
Latina increasingly over time. On the other hand, and complicating matters, the term continues to
be used by Indigenous, Afro-American, campesino, and working-class peoples, as we pointed out,
as well as by progressive left activists in the countries of the region, considering this term to re...
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