Planning and Delivery of Health Services-An Article Review on Urban Aboriginal Mobility in Canada : Examining the Association With Healthcare Utilization

An article from Social Science and Medicine, written by Snyder and Wilson (2012), examined the use of healthcare services by urban Aboriginal populations in Canada. Using the Behavioural Model of Health Services Use (BMHSU), predisposing, enabling, and need factors were organized and used for data analysis. Specifically, a comparison was made between conventional (physicians and nurses) and traditional (traditional healers) health service utilization in Toronto and Winnipeg. In addition to the geographical and educational factors, the results of the research recognized mobility as a significant predisposing complement to healthcare utilization.


Introduction
Snyder and Wilson open the article by briefing the readers on the history of Indigenous population of Canada, referred to as Aboriginals.They suggest various "push and pull factors" including socioeconomic status (SES), education, and unmet healthcare needs that influence the Aboriginal population to migrate to urban environments (Snyder & Wilson, 2012).These factors of migration strongly align with Evelyn Peters' research (2005) on urban Aboriginal communities in Canada, and set a foundation upon which the authors attempt to explain the utilization of health services amongst the Aboriginal population.This introduction, well supported by the data from Statistics Canada's 2006 Aboriginal Peoples Survey (APS) and other research papers, is bound to capture the readers' attention.

Materials and Methods
The effect of mobility on healthcare utilization amongst the Aboriginal population is an under-researched topic.Thus, Snyder and Wilson used an existing conceptual framework that best fits their study -the Behavioural Model of Health Services Use (BMHSU; Andersen & Newman, 1973).This model, which has been modified and expanded, is still applicable and widely used in the field of public health; one such use was noticed in a recent study on Canadians with dementia (Forbes, Morgan, & Janzen, 2006).This model organizes variables such as residential mobility, employment, and self-rated health status into three categories that determine the use of health services: (i) predisposing, (ii) enabling, and (iii) need factors (Andersen & Newman, 1973).Using the data from Statistics Canada's 2006 APS, Snyder and Wilson have astutely applied this model, using binary logistic regression analysis, to correlate the three factors to physician, nurse, and traditional healer use.In their research, Winnipeg and Toronto are the two Canadian Census Metropolitan Areas (CMAs) that were compared due to the contrasting differences in their Aboriginal population size, geographical location, and Aboriginal-led services offered (Snyder & Wilson, 2012).By using a similar approach, research conducted by Peters (2006) and Snyder and Wilson (2015) both provide support for this viewpoint.

Results and Discussion
Due to categorical differentiation by the BMHSU, the readers will discover that the authors' findings are easier to comprehend.The results for both CMAs and the assessed factors are within a 95% confidence interval, making the data precise.The results conclude that education, income, and employment are significant predictors of the use of health services; however, this is true for the whole Canadian population, and not exclusive to Aboriginal people (Steele, Dewa, & Lee, 2007).
In addition, two significant predisposing factors concluded from the study are age and residential mobility.Research by Wilson, Rosenberg, and Abonyi (2011) explains that the older Aboriginal population is predominantly affected, as they experience geographic isolation and loss of traditional approaches to healing due to their colonial past.This strengthens the article's findings by indicating that "traditional healing represents an unmet healthcare need" for the Aboriginal population in Toronto and may require a person to travel outside the city in search of traditional healthcare services (Snyder & Wilson, 2012).For further support, the results illustrate that only a small fraction of newcomers have access to traditional healer use in Toronto when compared to Winnipeg.
The Second Report on the Health of Canadians (1999) mentions that despite reductions in substance use and improvements in education, many Aboriginal communities still experience higher infant mortality rates, suicide rates, chronic diseases, and risk for unintentional injuries than the Canadian population as a whole.While all 12 key determinants of health (Public Health Agency of Canada, 2011) apply to the aforementioned issues, culture seems to be particularly dominant since the article specifically takes Aboriginal population into consideration.Some underlying premises could be marginalization (Skinner & Masuda, 2013) and perception of conditions by the Aboriginal people (Senese & Wilson, 2013).While Snyder and Wilson (2012) are not as specific regarding each determinant, they provide the readers with a wide range of possibilities for low healthcare utilization.
Hence, when reading this article, one should keep in mind that changes in healthcare access is dependent on more than just mobility factors.If conventional traditional uses are valued differently amongst Aboriginal people living in Winnipeg and Toronto, this may simply be due to differences in cultural values placed on those services (Wilson et al., 2011).This is further characterized by the classification of three distinct Aboriginal groups: First Nations, Métis, and Inuit.While Snyder and Wilson (2012) mention this distinction in the beginning, they generalize them into one group in their findings.Also, the 2006 APS only accounts for First Nations living off reserves; whereas, similar or decreased health access may be affecting those living on reserves.Likewise, Toronto and Winnipeg, which do provide insight into two differing urban settings, are not representative of all urban Aboriginal populations as described by the title of the article.On the contrary, Snyder and Wilson (2015) have successfully maintained this distinction throughout their research.

Conclusion
Overall, Snyder and Wilson have written a compelling article that raises the issue of planning and delivery of healthcare services in Canada.Particularly, it enlightens the readers by analyzing and discussing the complex relationship between Aboriginal peoples' mobility and healthcare utilization.While the article is not specific regarding the outlined causes, it exposes the readers to many determinants of health, provides sufficient evidence for mobility being a significant predisposing factor, and provides an impetus for more thought and research.Recent healthcare research by Snyder and Wilson (2015) has contributed by further employing the aforementioned concepts to analyze this public health issue.