Finding Connections Assignment For this assignment, students will complete the following steps. Your written submission should be 12 point font and approximately 250 words in length. While you may use point form in the article summary, your analysis must be in sentence/paragraph form. No late assignments will be accepted without a medical note. Steps: 1. Social psychology is about how individuals think, feel and behave in social settings and, therefore, we are constantly making observations related to topics social psychology (e.g., role-playing, compliance, loneliness, socialization, group-think, etc,). For this assignment, you need to find an article that connects to a concept in social psychology (e.g., Huffington Post, Globe and Mail, New York Times, Macleans, The Atlantic, or a “popular press” magazine”) 1. Then, write a summary of the key points in the article; and analyze the relationship between the concepts in the article and social psychology. Prepare questions or an activity to engage the E440 CMAJ | MARCH 20, 2017 | VOLUME 189 | ISSUE 11 © 2017 Joule Inc. or its licensors R ecent attention to the role that social entrepreneurship could play in addressing acute health care challenges1 reminds us that addressing the socioenvironmental factors that influence the physical, mental, social and spiritual components of health and well-being2 requires similarly innovative and imagina- tive responses. Social enterprises are a potentially useful and economically viable strategy to this end. These are organiza- tions that engage in commercial trade for a social purpose — most often to address one or more aspects of social vulnerability  — rather than for the personal financial enrichment of owners or shareholders. Examples of Canadian social enter- prises include Manitoba Green Retrofit, a social enterprise that takes on small con- struction projects, environmental retrofits and treatments for bedbug infestation in Winnipeg’s low-income housing neigh- bourhoods, while at the same time pro- viding job skills training and employment to local residents that creates a sense of place and community belonging; Park- dale Green Thumb Enterprises in Toronto, a horticulture business that employs peo- ple living with serious mental illness to design green spaces and provide grounds- keeping services for nonprofit organiza- tions, low-income housing, hospitals, the private sector and community groups; and Inside Art, a cooperative run by inmates at Mountain Institution in British Columbia, a medium security prison. By engaging incarcerated individuals in cre- ating art and making business decisions about their cooperative business model, this social enterprise has helped persons excluded from society to contribute to correctional programming, learn new skills and build confidence. A WISE approach to health? Abundant “lay knowledge”3 exists that shows the influence that social enterprise can have on individual ...

1. Finding Connections Assignment
For this assignment, students will complete the following steps.
Your written submission should be 12 point font and
approximately 250 words in length. While you may use point
form in the article summary, your analysis must be in
sentence/paragraph form. No late assignments will be accepted
without a medical note.
Steps:
1. Social psychology is about how individuals think, feel and
behave in social settings and, therefore, we are constantly
making observations related to topics social psychology (e.g.,
role-playing, compliance, loneliness, socialization, group-think,
etc,). For this assignment, you need to find an article that
connects to a concept in social psychology (e.g., Huffington
Post, Globe and Mail, New York Times, Macleans, The
Atlantic, or a “popular press” magazine”)
1. Then, write a summary of the key points in the article; and
analyze the relationship between the concepts in the article and
social psychology. Prepare questions or an activity to engage
the
E440 CMAJ | MARCH 20, 2017 | VOLUME 189 | ISSUE 11
© 2017 Joule Inc. or its licensors
R ecent attention to the role that social entrepreneurship could
play in addressing acute health care
challenges1 reminds us that addressing the
socioenvironmental factors that influence
the physical, mental, social and spiritual
components of health and well-being2
requires similarly innovative and imagina-

2. tive responses. Social enterprises are a
potentially useful and economically viable
strategy to this end. These are organiza-
tions that engage in commercial trade for a
social purpose — most often to address one
or more aspects of social vulnerability —
rather than for the personal financial
enrichment of owners or shareholders.
Examples of Canadian social enter-
prises include Manitoba Green Retrofit, a
social enterprise that takes on small con-
struction projects, environmental retrofits
and treatments for bedbug infestation in
Winnipeg’s low-income housing neigh-
bourhoods, while at the same time pro-
viding job skills training and employment
to local residents that creates a sense of
place and community belonging; Park-
dale Green Thumb Enterprises in Toronto,
a horticulture business that employs peo-
ple living with serious mental illness to
design green spaces and provide grounds-
keeping services for nonprofit organiza-
tions, low-income housing, hospitals, the
private sector and community groups;
and Inside Art, a cooperative run by
inmates at Mountain Institution in British
Columbia, a medium security prison. By
engaging incarcerated individuals in cre-
ating art and making business decisions
about their cooperative business model,
this social enterprise has helped persons
excluded from society to contribute to
correctional programming, learn new
skills and build confidence.

3. A WISE approach to health?
Abundant “lay knowledge”3 exists that
shows the influence that social enterprise
can have on individual valorization, social
capital and civic engagement of society’s
most disenfranchised, giving credence to
the notion that social enterprise and social
entrepreneurship could potentially have an
influence on the social determinants of
health.4
A recent systematic review of social
enterprise–led activity on health and well-
being5 found evidence (albeit limited) of
positive impacts on mental health, self-
reliance/self-esteem and health behav-
iours, reductions in stigma and the build-
ing of social capital; all are important
determinants of health. Most of the studies
examined in that review focus on a particu-
lar type of social enterprise that aims to
create employment for vulnerable people
who are profoundly disadvantaged in
accessing the mainstream labour market.
This includes people who are chronically
unemployed, leaving long-term institu-
tional care, living with serious mental
health issues, chronic health conditions or
physical disabilities; in other words, fac-
tions of society that are most at risk for
poor health outcomes and most likely to

4. experience inequity in access to traditional
health services. The focus of such “Work
Integration Social Enterprises” (WISEs) is
to provide transitional or permanent
employment, and/or entrepreneurial
Action on the social determinants of health
through social enterprise
n Cite as: CMAJ 2017 March 20;189:E440-1. doi:
10.1503/cmaj.160864
A few of the workers at Parkdale Green Thumb Enterprises.
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5. e
Fu
nd
HUMANITIES | MEDICINE AND SOCIETY
H
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M
A
N
ITIES
CMAJ | MARCH 20, 2017 | VOLUME 189 | ISSUE 11
E441
opportunities in a supportive, empowering
and community-based environment.6
One particular at-risk group of long-
standing concern to both the health and
welfare sectors is youth with mental health
problems who live on the street. A tradi-
tional (pathogenic) approach to engaging
with this group might address common pre-
senting symptoms, such as injuries from
physical violence or abuse, physical and
emotional impacts of self-medication and
abuse of illicit substances. Programs such as
needle exchanges might seek to address

6. individual risk factors and/or wider harm
(including to society) from illegal or harmful
behaviours. Although we are not criticizing
such approaches, there is good evidence
that a holistic, social enterprise–led
approach to working with this population
can deliver positive results, and prevent
manifestation of such symptoms. For exam-
ple, Ferguson7 described a social enterprise
in which young people with mental illness
living on the streets of Los Angeles were
employed to design, manufacture and sell
clothing items popular with youth. Their
employment prospects and clinical out-
comes were improved through peer mentor-
ing, vocational training and training in small
business skills, and integrated with the pro-
vision of clinical and harm reduction
services.
Challenges showing impact
Despite many examples of good news, evi-
dence to support that social enterprises
such as WISEs do work (in particular, evi-
dence that meets the standards that public
health officials currently require) remains
scarce. Assessing the health and well-being
benefits of WISEs presents numerous chal-
lenges to researchers and to policy-makers.
We have seen that randomized controlled
trials — the gold standard in public health
evaluation — are often unsuitable for a vari-
ety of reasons, including the expense, small
sample sizes and ethical reasons relating to
the types of populations that social enter-

7. prises traditionally work with. Although
some promising groundwork has been laid
to move this research agenda ahead in
recent years, some key issues remain. For
one, WISEs are highly idiosyncratic, often
based upon population-specific needs and
business-specific goals and visions. To
date, there is a lack of agreement on core
organizational, structural and process ele-
ments that define WISE, while respecting
the need for business diversity across a
range of business features such as the
products/services offered, hiring practices,
and level of involvement of the marginal-
ized population in business development
and operations. This variability, combined
with the multiple health determinants that
are affected by WISE participation, make
this a highly complex intervention that
must be carefully unpacked to better
understand the causal pathways, and how
the variables embedded in the social deter-
minants can (potentially) be identified and
measured in ways that are both valid and
conceptually meaningful.
Therefore, there is a clear need to
heighten theoretical understanding of how
WISEs affect health and health equity; iden-
tify WISE business implementation pro-
cesses and practices that contribute to pop-
ulation health and health equity; and
advance this emerging field of scientific
enquiry through identification of feasible
research designs to meaningfully explore

8. the impact of these enterprises on health
and health equity. Application of realist
evaluation principles8,9 may help guide sci-
entific inquiry in this regard: supporting
researchers to answer developmental-stage
questions concerning the contextual factors
that support positive outcomes, and the
theoretical processes leading to change.
Such a line of inquiry will help lay the
groundwork necessary for future rigorous
research on this highly complex form of
intervention. Furthermore, we need to influ-
ence and encourage policy-makers and
research funders to think imaginatively —
not only in terms of what actually consti-
tutes a public health intervention, but also
about how community-led activity could be
better supported and integrated with tradi-
tional health service approaches to form a
wider societal response to addressing the
social determinants of health.
The public health contributions of those
who work to address social vulnerabilities
in their local communities, but who oper-
ate outside of formal health systems,
deserve to be acknowledged and better
understood if we are to address longstand-
ing issues of public health concern.
Michael J. Roy PhD
Yunus Centre for Social Business and
Health, Glasgow Caledonian University,
Glasgow, UK
Rosemary Lysaght PhD, Terry M.

9. Krupa PhD
School of Rehabilitation Therapy, Queen’s
University, Kingston, Ont.
References
1. Lim YW, Chia A. Social entrepreneurship: improv-
ing global health. JAMA 2016;315:2393-4.
2. Gewurtz RE, Moll SE, Letts LJ, et al. What you do
every day matters: a new direction for health
promotion. Can J Public Health 2016; 107:e205-8.
3. Popay J, Williams G, Thomas C, et al. Theorising
inequalities in health: the place of lay knowledge.
Sociol Health Illn 1998;20:619-44.
4. Roy MJ, Donaldson C, Baker R, et al. Social enter-
prise: New pathways to health and well-being?
J Public Health Policy 2013;34:55-68.
5. Roy MJ, Donaldson C, Baker R, et al. The poten-
tial of social enterprise to enhance health and
well-being: a model and systematic review. Soc
Sci Med 2014;123:182-93.
6. Krupa TM, Lysaght R, Brown J, et al. Environ-
mental scan of social businesses. In: The aspiring
workforce — employment and income for people
with serious mental illness. Ottawa: Mental
Health Commission of Canada; 2013:46-70. Avail-
able: www.mentalhealthcommission.ca/English/
initiatives/11895/aspiring-workforce (accessed
2016 July 19).
7. Ferguson KM. Merging the fields of mental health

10. and social enterprise: lessons from abroad and
cumulative findings from research with homeless
youths. Community Ment Health J 2012;48:490-502.
8. Pawson R, Tilley N. Realistic evaluation. Thou-
sand Oaks (CA): Sage; 1997.
9. Fletcher A, Jamal F, Moore G, et al. Realist complex
intervention science: applying realist principles
across all phases of the Medical Research Council
framework for developing and evaluating complex
interventions. Evaluation (Lond) 2016; 22:286-303.
This article has been peer reviewed.
This work was supported by the Medical
Research Council, and the Economic and Social
Research Council (grant no. MR/L003287/1).
All editorial matter in CMAJ represents the opinions of the
authors and not necessarily those of the Can adian Medical
Association.
CMAJ Commentary
©2015 8872147 Canada Inc. or its licensors CMAJ, August 11,
2015, 187(11) E347
O
n Feb. 19, 2014, armed fighters entered
the Malakal Teaching Hospital run by
Médecins Sans Frontières in South

11. Sudan, robbed patients and their families of cash
and mobile phones, and shot those who had noth-
ing to give, killing 14 patients who were lying in
their hospital beds.1 In Syria, not only has the neu-
trality of medical personnel, hospitals and patients
been ignored, these individuals and facilities have
become strategic targets in a systematic campaign
of violence that, according to the United Nations,
has seen “… government forces and affiliated
militias interfere with and instrumentalise medical
care to further strategic and military aims.”2 These
acts of brutality are two examples of a global
problem for which there are few solutions: in
many parts of the world, health care is in danger.
Armed conflicts, internal disturbances and
other types of unrest create a generalized state of
insecurity that often makes maintaining a mini-
mally functional health system nearly impossi-
ble. Health facilities are destroyed, looted or
forced to close or become isolated from the pop-
ulations they serve.3 Patients may be attacked or
robbed, and health workers threatened or kid-
napped.4 Policies and laws may be enacted to
criminalize or restrict the provision of medical
care to those opposing the state.5 Ambulances
are frequently delayed or are targets of attacks
and hijackings, which limits the effectiveness of
referral systems.6
There have been growing calls to strengthen
the right to health in conflict, and for non-state
actors to be held accountable for attacks on
health workers through existing human rights
mechanisms.5 The Geneva Conventions, custom-
ary international humanitarian law and other

12. treaties include provisions that clearly identify
attacks on health workers and patients as a viola-
tion of international law. Regrettably, these are
routinely ignored or are not translated into
national legislation in the countries where these
acts occur.7 Meanwhile, several international
bodies have passed resolutions attempting to
strengthen these mechanisms, including the 2011
United Nations Security Council resolution
1998, which declared hospitals off limits for
armed groups and military activities and allows
public reporting of the parties who attack them.8
Civil society coalitions, such as the Safeguarding
Health in Conflict Coalition, have demanded
monitoring, reporting and accountability for such
attacks, while raising the issue politically and
within academic communities.
These interventions are necessary, but more
must be done. Attacks on health systems often
have a strategic advantage as a tactic of war, are
rarely prosecuted nationally and may even have
been committed by the government that would,
theoretically, be prosecuting them. Invoking the
jurisdiction of the International Criminal Court
in prosecuting these attacks may, therefore, be
appropriate in these circumstances.9
For humanitarian agencies operating in vio-
lent settings, the available interventions are
challenging: openly reporting attacks places
them at risk of reprisal; barricading or reinforc-
ing hospitals to become fortresses is inconsis-
tent with the need to be accessible and to be
viewed as a community, rather than a military,

13. asset; arming humanitarian agencies blurs the
boundaries between the militarization and neu-
trality of aid; and not operating in conflict zones
denies the world’s most vulnerable people of
basic health services.
Ensuring the security of health care in conflict settings:
an urgent global health concern
Jason W. Nickerson RRT PhD
Competing interests: Jason
Nickerson has worked as a
consultant for the United
Nations, nongovernmental
organizations and the
Canadian government in
various conflict settings.
This article has been peer
reviewed.
Correspondence to:
Jason Nickerson,
[email protected]
CMAJ 2015. DOI:10.1503
/cmaj.140410
• Attacks on health workers, health facilities and patients are a
common
threat to medical care in conflict zones.
• The Geneva Conventions, customary international
humanitarian law
and other treaties clearly identify attacks on health workers and
patients as a violation of international law.

14. • However, the recommendations of such bodies are poorly
enforced in
many jurisdictions.
• Carefully collected data are needed to further our knowledge
of
attacks and to inform the development of countermeasures to
improve
programs in different settings and contexts.
Key points
CMAJ Podcasts: author interview at
soundcloud.com/cmajpodcasts/conflict-health
Commentary
E348 CMAJ, August 11, 2015, 187(11)
The use of military forces to protect civilians
and humanitarian agencies has garnered particu-
lar attention over the past decade through the
controversial concept of the “responsibility to
protect,” or R2P. This concept is controversial
for several reasons. Chief among them are the
lack of automatic or consistent protection from
foreign military forces, and the resistance by
many humanitarian agencies to support R2P on
the basis that it compromises their neutrality and
impartiality by providing legitimacy to the
objectives of one of the warring parties.10
A clear need exists to strengthen an under-

15. standing of the nature and causes of violent
events directed toward health care providers, and
the interventions that have been effective in miti-
gating them. The International Committee of the
Red Cross has taken the lead on this, conducting
a two-year, anonymized, 16-country study that
documented 1342 reports of 655 separate events
of violence or threats affecting health care.4 The
committee then convened stakeholder meetings
to identify best practices and potential solutions
for ensuring the continued provision of medical
care in conflict zones. In 2012, the World Health
Assembly passed a resolution (WHA65.20) call-
ing for the World Health Organization to
improve the systematic documentation of these
attacks and to generate an evidence base for
greater protection and advocacy.11
In addition to the systematic reporting of the
scope and incidence of violent attacks and
threats directed toward health workers, a more
nuanced understanding of the nature and causes
of these events is needed to better contextualize
their impact and the appropriate responses.
Operational research to systematically describe
the impact of violent events on patients, health
workers and health systems is needed to under-
stand more precisely what occurs and what inter-
ventions have been implemented to mitigate
these effects, both successfully and unsuccess-
fully, as well as their implications. Developing a
detailed understanding of what takes place at
checkpoints or during armed entries to hospitals,
for example, provides a needed context through
which interventions can be assessed. The synthe-
sis of these experiences is essential for weighing

16. the risks and benefits of interventions. Although
some interventions may be easily implemented,
such as placing plastic sheeting on windows to
absorb shrapnel from bomb blasts, other inter-
ventions such as decisions to stockpile medicines
have associated risks (e.g., looting).
More than merely documenting experiences,
what is needed is the development of a decision
aid based on pragmatic anecdotal, experiential and
often unpublished evidence to guide the main-
tenance of the essential functions of health systems
during violent events. This must be matched by
strong advocacy and engagement of civil society
organizations to ensure that those who commit
crimes against health workers and patients are held
to account. The medical community must pressure
governments to pursue international justice and
demand accountability for war crimes against
medical workers, in solidarity with colleagues and
patients whose safety is directly at risk.
References
1. Medical care under fire in South Sudan. Toronto: Médecins
Sans
Frontières Canada; 2014. Available: www.msf.ca/en/article/
medical-care-under-fire-south-sudan (accessed 2014 Mar. 24).
2. Assault on medical care in Syria [A/HRC/24/CRP.2].
Geneva:
United Nations Human Rights Council; 2013. Available:
www.ohchr.org/EN/HRBodies/HRC/RegularSessions/Session 24
/Documents/A-HRC-24-CRP-2.doc (accessed 2014 Mar. 17).

17. 3. Dewachi O, Skelton M, Nguyen V-K, et al. Changing
therapeu-
tic geographies of the Iraqi and Syrian wars. Lancet 2014;383:
449-57.
4. Health care in danger: a sixteen-country study. Geneva:
Interna-
tional Committee of the Red Cross; 2011. Available: www.icrc
.org
/eng/resources/documents/report/hcid-report-2011-08-10.htm
(ac-
cessed 2014 Mar. 24).
5. Report of the Special Rapporteur on the right of everyone to
the
enjoyment of the highest attainable standard of physical and
mental health. Geneva: United Nations Human Rights Office of
the High Commissioner for Human Rights; 2014.
6. Coupland R. Security of health care and global health. N
Engl J
Med 2013;368:1075-6.
7. Rubenstein LS, Bittle MD. Responsibility for protection of
med-
ical workers and facilities in armed conflict. Lancet 2010;375:
329-40.
8. Resolution 1998 (2011) [S/RES/1998(2011)]. Geneva:
United
Nations Security Council; 2011. Available: www.un.org/en/ga
/search/view_doc.asp?symbol=S/RES/1998(2011) (accessed
2014 Mar. 17).
9. Protection of health workers, patients and facilities in times
of

18. violence. Baltimore: Center for Public Health and Human
Rights, Johns Hopkins Bloomberg School of Public Health;
2013. Available: www.jhsph.edu/research/centers-and-institutes
/center-for-public-health-and-human-rights/_pdf/BellagioReport
-03192014.pdf (accessed 2014 Aug. 20).
10. Weissman F. Not in our name: why Médecins Sans
Frontières
does not support the “responsibility to protect.” Crim Justice
Ethics 2010;29:194-207.
11. WHO’s response, and role as the health cluster lead, in
meeting the
growing demands of health in humanitarian emergencies
[Resolu-
tion WHA65.20]. Sixty-fifth World Health Assembly; Geneva;
2012 May 21–26. Available: http://apps.who.int/gb/ebwha/pdf_
files/WHA65/A65_R20-en.pdf (accessed 2015 Apr. 21).
Affiliation: Bruyère Research Institute, Ottawa, Ont.
Open AccessResearch Article
Journal of Civil & Legal SciencesJou
rn
al
o
f C
ivil & Legal Sciences
ISSN: 2169-0170

19. Ponsford, J Civil Legal Sci 2016, 5:1
http://dx.doi.org/10.4172/2169-0170.1000170
Volume 5 • Issue 1 • 1000170J Civil Legal Sci
ISSN: 2169-0170 JCLS, an open access journal
Keywords: Canada’s Obligations; Discrimination against
women;
United Nations; Aboriginal women; Indigenous peoples;
Indigenous
theory; Canada; Canadian government; CEDAW; UNDRIP;
Violence
against women; Rurality; Rural communities; Human rights;
Sex work;
Equality
Introduction
Although Canadians are largely familiar with the ongoing
struggle
of Aboriginal peoples’ equality, and there exists so much
collective
community grieving, there is often little focus on the domestic
and international legal obligations that the Canadian
government
repeatedly neglects. International obligations include the United
Nations Declaration on the Rights of Indigenous Peoples [1],
ratified and
finally supported by Canada in 2010. The Convention on the
Elimination
of All Forms of Discrimination against Women (CEDAW) [2] is
also
important in helping to eradicate gender-based discrimination;
this
statute represents Canada’s international obligations to women

20. generally, but is particularly relevant to the discrimination
faced by
Aboriginal women. CEDAW will be of particular focus
throughout
the discussion. Specifically, Articles 6 and 14 will set the
framework
and context to how issues of both “prostitution” (sex work) and
rural
communities disproportionately impact Aboriginal women and
their
families. Next, other aspects of CEDAW will be examined,
including
Article 18, which requires regular progress report submissions
by
state parties to the Secretary-General of the United Nations.
Finally,
Canada’s compliance with Articles 6, 14 and 2 will be examined
in
detail, including an examination of the reply list of issues and
questions
from the Committee on the Elimination of Discrimination
against
Women (the “Committee”) pursuant to Article 20.
Detailed, critical analyses of Canada’s obligations under
CEDAW,
through examination of selective Articles of the Convention,
will help
form a central conclusion: the federal government of Canada
has failed
to implement a national action plan to address the systemic
problems
of violence, discrimination, murder, and disappearance of
Aboriginal
women and girls [3]. Government omissions include: inadequate
police training, inconsistent data collection of the number of

21. missing
and murdered women, and lack of jurisdictional coordination,
among other shortsightedness. These omissions and oversights
mean
Canada has not fulfilled its international human rights
obligations to
investigate the hundreds of missing Aboriginal women. The
Canadian
government has steadfastly refused to investigate, identify, and
address
the problem, and has willfully contributed to the tragedy
through
politically “convenient,” partisan-centered decision-making.
The
neglect this community has faced has had, and without
immediate
action will continue to have, long-lasting and harmful social,
environmental, health, and financial costs, as well as negative
cultural
and social ramifications for Aboriginal women, their
communities, and
all Canadians.
Historical Overview: Discriminatory Treatment against
Aboriginal Peoples and Aboriginal Women
An opinion editorial written by Liberal Member of Parliament
Carolyn Bennett illustrates a grim picture: in 2012, the federal
government’s Department of Aboriginal Affairs and Northern
Development spent $106 million on litigation, more than any
other
department and double the amount spent by the Canada Revenue
Agency [4]. This statistic is shocking when considering the very
pertinent concerns surrounding the status of Aboriginal women
and

22. Canada’s obligations under CEDAW. The vast funding allocated
*Corresponding author: Matthew P Ponsford, LLM (Master of
Laws) Candidate,
McGill University, Canada, Tel: 514-398-8411; E-mail:
[email protected]
Received December 31, 2015; Accepted January 20, 2016;
Published January
27, 2016
Citation: Ponsford MP (2016) A Critical Examination of
Canada’s Obligations
Under the Convention on the Elimination of all Forms of
Discrimination against
Women and the Government’s Actions and Omissions in
Relation to the
Investigation of the Hundreds of Missing Aboriginal Women. J
Civil Legal Sci 5:
170. doi:10.4172/2169-0170.1000170
Copyright: © 2016 Ponsford MP. This is an open-access article
distributed under
the terms of the Creative Commons Attribution License, which
permits unrestricted
use, distribution, and reproduction in any medium, provided the
original author and
source are credited.
A Critical Examination of Canada’s Obligations Under the
Convention on
the Elimination of all Forms of Discrimination against Women
and the
Government’s Actions and Omissions in Relation to the
Investigation of
the Hundreds of Missing Aboriginal Women
Matthew P Ponsford*

23. JD, BSc, LLM (Master of Laws) Candidate, McGill University,
Canada
Abstract
Standing on Canada’s Parliament Hill, meters from the historic
Centennial Flame, Canadians witnessed another
year of commemoration, representing the many missing and
murdered Aboriginal women across Canada. Stories of
loss and hope, grief and frustration, filled with song and dance
and spoken word, left many standing in a mesmerizing
stare; they were moved by powerful words, but remained
speechless. The event was one of the annual Sisters in
Spirit Vigils to honor lost sisters, wives, daughters, and aunts,
among friends, families, activists, and supporters, who
have fought in their communities for so long. Families and
leaders have lobbied governments for decades, facing the
reality of the Canadian government’s inaction and omissions
relating to the investigation of hundreds of missing and
murdered Aboriginal women. Families and leaders are faced
with the dissatisfactory inaction that has persisted too
long at the cost of so many. And despite countless setbacks and
hardships endured, Aboriginal voices and allies calling
for action remain strong.
http://dx.doi.org/10.4172/2169-0170.1000170
Citation: Ponsford MP (2016) A Critical Examination of
Canada’s Obligations Under the Convention on the Elimination
of all Forms of Discrimination
against Women and the Government’s Actions and Omissions in
Relation to the Investigation of the Hundreds of Missing
Aboriginal Women.
J Civil Legal Sci 5: 170. doi:10.4172/2169-0170.1000170

24. Page 2 of 7
Volume 5 • Issue 1 • 1000170J Civil Legal Sci
ISSN: 2169-0170 JCLS, an open access journal
toward Aboriginal litigation demonstrates what is perceived to
be
the government’s strong opposition to full equality for all
Canadian
citizens.
Aboriginal women in Canada have historically suffered
widespread
gender-based discrimination and oppression. Finding Dawn, a
documentary written, directed, and narrated by Métis filmmaker
Christine Welsh, sheds light on the hundreds of Aboriginal
women
who have gone missing or who have been murdered in Canada
over
the last twenty years [5]. The film highlights the complex
historical,
social, political, and economic factors that have contributed to
the
abuse, neglect, and ill treatment associated with Aboriginal
women
in Canada. Repeatedly, interviews and stories in the film
emphasize
the desperate need for change. From the “Highway of Tears” on
Highway 16 in northern British Columbia, the Women’s
Memorial
Walk in Vancouver, “skid row” in Vancouver’s Downtown
Eastside,
and unsolved murders in Saskatoon, the mistreatment of
Aboriginal
women proves to be vast and appalling.

25. Dawn Crey, the central character featured in the film, was
placed in
foster care as a young child following her father’s tragic death.
She later
entered into a life of drugs and prostitution in Vancouver’s
Downtown
Eastside. Approximately half of the missing women in this area
are
Aboriginal and they share a common struggle: living in poverty.
These
women do not have adequate access to education or
employment,
even though equal access is guaranteed under Articles 10 and 11
of
CEDAW. In fact, the 2006 Census illustrates Aboriginal women
are
less likely than non-Aboriginal Canadians to be part of the paid
work
force. Aboriginal women 15 years of age or older had an
employment
rate of 51.1% compared to 57.7% of non-Aboriginal women who
were
employed [6], and unemployment rates for Aboriginal women
are
often double that of non-Aboriginal women.
It is disgraceful that the Canadian government has failed to take
accountability to ensure Aboriginal women are valued and
respected.
Jim Silver, author of “Building a Path to a Better Future,” states
that
Aboriginals are “lacking in self-confidence, self-esteem and a
sense of
self—worth-the result of having internalized the colonial
ideology—
and are in need of healing [7].” Dealing with these

26. disadvantages and
unfair burdens has huge costs, as evident by Aboriginal suicide
rates
that are three to six times higher than the national average [8].
In
particular, the suicide rate for First Nations women is 35 per
100,000
compared to 5 per 100,000 for non-Aboriginal women. M ental
health
challenges and depression have other far-reaching
consequences. In
the film, Janice Acoose, a Saskatchewan Professor,
acknowledges that it
was the social environment she lived in that was responsible for
sending
her to Regina’s “skid row” on South Railway Street. She stated
that the
city “was a place of hope” and offered her something different
than the
reserve. It is the lack of social programs that is at the root of
much of
the inequality that exists for Aboriginal women like Crey and
Acoose; it
is the vicious cycle of neglect and mistreatment that has
resulted in the
marginalization and social exclusion of Aboriginal women.
The often-demoralizing social status of Aboriginal women is
another important aspect of the mistreatment and violence
directed
toward them. Aboriginal women are treated in an inferior
manner and
with less self-worth compared to non-Aboriginal Canadians.
Ernie,
Crey’s brother, is featured in the film and has been an
outspoken activist.

27. He believes that the investigation into his sister’s disappearance
would
have been better financed and coordinated if the victim, his
sister,
were non-Aboriginal. This pattern of differential treatment is
evident
through anecdotal records and has been widely documented,
including
a 2009 comparative study [9].
To understand the discrimination faced by Aboriginal women
today, it is important to acknowledge that discrimination against
Aboriginal people has occurred on numerous occasions in
Canada,
often under the incontestable view of the Canadian government.
For
example, in the nineteenth century, the Canadian government
took
part in “aggressive cultural assimilation,” resulting in the
removal
of about 150,000 Aboriginal, Inuit and Métis children from their
communities. This tragedy is known widely as the Indian
Residential
Schools [10]. Although some former students have received
minor
compensation, the government cannot compensate the victims
for
isolating these children from their families, traditions, and
culture.
Prime Minister Stephen Harper, of the Conservative Party of
Canada,
released an official, historic government apology on June 11,
2008, but
little action has been taken since.
Following the apology made on behalf of the Government, the

28. Truth and Reconciliation Commission of Canada [11] was
launched
following the largest class-action lawsuit in Canadian history—
the
Indian Residential Schools Settlement Agreement. The
Assembly of First
Nations agreed to the establishment of the Truth and
Reconciliation
Commission that began with a five-year, $60 million budget.
However,
work on the final report remained, and so the mandate was
extended
by one year, until June 30, 2015 [12]. The Honorable Bernard
Valcourt,
Minister of Aboriginal Affairs and Northern Development,
stated:
“Our government remains committed to achieving a fair and
lasting
resolution to the legacy of Indian Residential Schools, which
lies at
the heart of reconciliation and the renewal of the relationship
between
Aboriginal people and all Canadians.”
Revelations into the inexcusable discrimination faced by
Aboriginal peoples continues. Recently, government documents
uncovered by Ian Mosby of the University of Guelph exposed
the
shocking practice of widespread nutritional experiments
conducted
by Canadian government bureaucrats during the 1940s,
following the
Second World War. The deplorable execution of these
experiments
was occurring during a period of “scientific uncertainty around
nutrition [13].” At least 1,300 Aboriginals were involved,

29. including
many children. A spokesperson for the Minister of Aboriginal
Affairs
and Northern Development stated the news was “abhorrent and
completely unacceptable.” Following the shocking revelations,
First
Nations leaders demanded an apology for the nutritional
experiments
[14]. Shawn Atleo, National Chief of the Assembly of First
Nations,
demanded the government take responsibility and acknowledged
ongoing food security problems that disproportionately impact
Aboriginal children. It is hoped that other government
documentation
will be made publicly available.
The disgraceful pattern of Aboriginal children and women being
treated as “less than” and “second class” is an all too common
pattern
seen in many social contexts throughout Canadian history. In
Finding
Dawn, Fay Blaney, an advocate for native rights nationally and
internationally, states that she believes an attitudinal shift needs
to
take place; her comments included the idea that Aboriginals
have been
perceived as “nothing and only good for prostitution.” She
preaches
that Aboriginal women deserve respect and need to reclaim
some of
their traditions, land, and culture. It is evident that improved
public
health and social policy, directed specifically at Aboriginal
women, is
desperately needed. With these improvements, Aboriginal
women will

30. be better able to improve their way of life and to restore their
human
dignity; but these improvements cannot happen without the
Canadian
government’s full realization and implementation of its
international
human rights obligations.
http://dx.doi.org/10.4172/2169-0170.1000170
Citation: Ponsford MP (2016) A Critical Examination of
Canada’s Obligations Under the Convention on the Elimination
of all Forms of Discrimination
against Women and the Government’s Actions and Omissions in
Relation to the Investigation of the Hundreds of Missing
Aboriginal Women.
J Civil Legal Sci 5: 170. doi:10.4172/2169-0170.1000170
Page 3 of 7
Volume 5 • Issue 1 • 1000170J Civil Legal Sci
ISSN: 2169-0170 JCLS, an open access journal
Introduction to the Convention on the Elimination of
All Forms of Discrimination against Women
The Convention on the Elimination of All Forms of
Discrimination
against Women was adopted by the United Nations General
Assembly
on December 18, 1979, open for signature on March 1, 1980,
and
entered into force on September 3, 1981, faster than any other
human rights convention [15]. As of December 2013, there were
99

31. signatories and 187 parties to CEDAW [16]. Canada signed
CEDAW
on July 17, 1980 and ratified the Convention on December 10,
1981.
The Convention consists of a preamble, six parts, and thirty
articles.
Issues addressed within CEDAW include: equal representation
of
women in government and international organizations (Article
7), the
elimination of discrimination against women based on marriage
and
family relations (Article 16), policy pursuits by state parties to
ensure
women’s equality (Article 2), and equal rights to education for
women
(Article 10).
CEDAW advocates for equal rights of men and women by
building on the impermissible grounds of discrimination based
on sex
enshrined in the Universal Declaration of Human Rights
(Article 2)
[17], the International Covenant on Civil and Political Rights
(Articles
2, 4, 24, 26) [18], and the International Covenant on Economic,
Social
and Cultural Rights (Article 2) [19]. Discriminatory grounds
based on
sex are also present in the Canadian Charter of Rights and
Freedoms
(Sections 15(1)(2), 27) [20].
Articles 6 and 14 of the Convention on the Elimination
of All Forms of Discrimination against Women

32. It is important to recognize that beyond gender-based
discrimination, in Canada, further discrimination is experienced
by women of Aboriginal status. Specifically, Articles 6 and 14
will
inform the discussion. These Articles receive limited attention
in the
context of the involvement of Aboriginal women in the sex
industry,
a decision often rooted in historical poverty and wider problems
faced
by Aboriginal women in rural communities. Article 6 states:
“States
Parties shall take all appropriate measures, including
legislation, to
suppress all forms of traffic in women and exploitation of
prostitution
of women.” In Canada, the exploitation of “prostitution” of
women
is particularly troubling given that Aboriginal women report
much
higher rates of violence and abuse when working in the sex
industry
compared to non-Aboriginal women [21]. Article 14(1) states:
States Parties shall take into account the particular problems
faced
by rural women and the significant roles which rural women
play in
the economic survival of their families, including their work in
the
non-monetized sectors of the economy, and shall take all
appropriate
measures to ensure the application of the provisions of the
present
Convention to women in rural areas.

33. Missing and murdered Aboriginal women are not always part
of rural communities in Canada, but for many rural Aboriginal
women, the challenges they face compared to those living in
urban
environments are substantial. Challenges include reduced access
to
education and employment compared to non-Aboriginal women.
40% of Aboriginal women did not graduate high school in 1996,
and although that number dropped to 27% in 2006, the rate of
non-
Aboriginal high school dropouts for women was 22% and 12%
in
1996 and 2006 respectively [22]. That means, as of 2006, 88%
of non-
Aboriginal women graduated high school compared to only 73%
for
Aboriginal women. The comprehensive report from the
Canadian
Centre for Policy Alternatives also demonstrated that although
rural
reserves comprise only 9% of non-Aboriginal workers, those
individuals
earn 88% more than Aboriginal peoples. The authors
unequivocally
conclude: “the data clearly shows that non-Aboriginal
Canadians make
more than their Aboriginal counterparts whether working on
reserve,
off reserve, or in urban, rural, or remote communities.”
The impact of rurality on Aboriginal women’s lives continues to
be important. Recently, on October 7, 2013, the Committee on
the
Elimination of Discrimination against Women (the
“Committee”),

34. created through Article 17, held a general discussion on rural
women
in Geneva [23]. The report aimed to “provide appropriate and
authoritative guidance to States Parties on the measures to be
adopted
to ensure full compliance with their obligations to protect,
respect
and fulfill the rights of rural women.” NGOs were invited to
provide
submissions before the discussion. Human Rights Watch (HRW)
submitted highlights of their work related to rural women and
girls,
noting: “we have documented, for example, police abuse of
indigenous
and rural women and girls in northern British Columbia, Canada
[24].”
The presence of Canada in this submission, among other
countries,
emphasizes the attention this issue is garnering internationally.
HRW’s
submission alluded to their comprehensive report entitled
“Those Who
Take Us Away,” published in February 2013, underlining the
failure of
law enforcement and police personnel, particularly the
dysfunctional
relationship between the Royal Canadian Mounted Police
(RCMP) and
the families of Aboriginal women and girls in northern, rural
British
Columbia [25].
Intersecting Marginalization: Rurality, Sex Work, and
Aboriginal Women’s Equality
There is greater disparity in income levels of Aboriginal women

35. in rural communities compared to aboriginal men. In situations
of
significant and often dire levels of systemic poverty, the
intersecting
marginalization of Aboriginal women and sex work begins to
surface.
A comprehensive report published in 2010 and entitled
“Challenges:
Ottawa-Area Sex Workers Speak Out” is the basis for a case
study
related to Aboriginal women and sex work. The report stems
from
a community-based research initiative focused on the labor site
challenges, safety, security, and well-being of sex workers, and
interactions between sex workers and police and law
enforcement. The
report also focuses on the social stigma and intersecting
marginalization
of sex workers, including the “well-documented oppression and
disadvantage experienced by Aboriginal people, homosexual
men and
women, transgender people and drug users.”
Intersections of class, socioeconomic status, gender, ableism,
and
economic resource distribution are explored, formulating
discussions
of the “question of choice [to engage in sex work].” The
report’s
findings are based on interview exchanges with 37 Ottawa-
based
sex workers, including four Aboriginal women and one
Aboriginal
transgender woman. The sample used for Aboriginal women sex
workers is relatively low, but the consensus among the five
participants

36. is noteworthy. For example, four of five Aboriginal sex workers
(80%)
described experiences of violence and abuse compared to 15 of
32
(47%) of non-Aboriginal sex workers.
Intersecting Marginalization: Poverty, Sex Work, and
Aboriginal Women’s Equality
A disproportionate number of Aboriginal women are involved in
sex
work and bear the burden of poverty, including women in
Vancouver’s
notorious Downtown Eastside. It is important when critically
analyzing
Canada’s obligations under CEDAW to examine how poverty,
the
http://dx.doi.org/10.4172/2169-0170.1000170
Citation: Ponsford MP (2016) A Critical Examination of
Canada’s Obligations Under the Convention on the Elimination
of all Forms of Discrimination
against Women and the Government’s Actions and Omissions in
Relation to the Investigation of the Hundreds of Missing
Aboriginal Women.
J Civil Legal Sci 5: 170. doi:10.4172/2169-0170.1000170
Page 4 of 7
Volume 5 • Issue 1 • 1000170J Civil Legal Sci
ISSN: 2169-0170 JCLS, an open access journal
social status of Aboriginal women, and their involvement in sex
work,

37. intersect and profoundly contribute to government inaction
related to
the investigation of the hundreds of missing Aboriginal women.
Culturally relevant social support services are especially
important
for Aboriginal women like Alice, a street-based sex worker who
powerfully articulates the implications of her intersecting
struggle:
It is especially true because I am Aboriginal. We’re a minority
who
has very big issues. I am a residential school survivor and it’s
such a
huge barrier. And I often see a difference, like, sometimes I tell
myself
“If I was a White woman, this would not be happening to me.”
As an
Aboriginal woman, I am automatically nothing but trash, you
know, I
don’t like being considered that way. I feel that from the
community as
whole, it’s racism, and then the judgment of being a sex worker.
I am a
minority and I get treated differently [emphasis added].
Security and Safety: Aboriginal Women and Sex Work
In Canada, the mistreatment of Aboriginal women like Alice
who engage in sex work is exacerbated by an ongoing
constitutional
challenge of Canada’s prostitution laws, where in October 2009
three
Ontario sex workers of Sex Professionals of Canada, applicants
Amy
Lebovitch, Terri-Jean Bedford, and Valerie Scott, argued that

38. current
prostitution laws threaten their Section 7 Charter rights to life,
liberty
and security of the person, and freedom of expression rights
under
Section 2. On September 28, 2010, Justice Susan Himel of the
Ontario
Superior Court of Justice struck down Sections 210, 212(1)(j)
and
213(1)(c) [26], a decision which was later appealed by the
Canadian
government to the Court of Appeal for Ontario [27]. On March
26,
2012, the appellate court’s decision was issued, demonstrating
the
Crown’s successful limitation of Section 7 freedom of
expression rights
for communicating for the purposes of prostitution. After leave
to
appeal was granted, the Supreme Court of Canada heard
arguments
on June 13, 2013. The Supreme Court has since released a
decision,
Bedford v Canada (AG), 2013 SCC 72. The verdict will have
far-reaching
implications for Aboriginal women’s security and safety.
Unfortunately, Aboriginal women are over-policed like other
Aboriginal peoples in Canada, including three out of the five
Aboriginal
sex workers included in the study who were criminally charged
for
soliciting; four of these individuals also experienced physical
violence
and “police abuse of power.” It is clear that the Criminal Code
[28]

39. provisions reviewed by the Supreme Court of Canada will have
significant impacts on the intersection between Aboriginal
women sex
workers and the criminal justice system, as well as Canada’s
obligations
under Article 2(C)(D)(E) to “ensure the protection of women
against
any act of discrimination.”
Violations of Article 2(C)(D)(E) of the Convention on
the Elimination of All Forms of Discrimination against
Women
Although the Supreme Court of Canada heard an appeal
regarding
the safety implications of sex work in Canada related to current
Criminal Code provisions, Article 2(C)(D)(E) obliges state
parties,
of which Canada is a signatory, to “condemn discrimination
against
women in all its forms,” which extends to the inclusion of
Aboriginal
women sex workers in addition to Aboriginal women more
broadly. In
Canada, “johns” (a sex worker’s client) and police and law
enforcement
personnel subject Aboriginal women to sexual and physical
exploitation
at much higher rates compared to non-Aboriginal women.
Sexual and
physical mistreatment is unacceptable no matter the
circumstance
or gender, but is particularly prevalent when examining
Aboriginal
women’s safety and security. The Canadian government must

40. investigate the abuse and murders of Aboriginal women
regardless of
current “prostitution” laws or political ideologies. Particularly,
Article
2(C)(D)(E) requires state parties:
(c) To establish legal protection of the rights of women on an
equal
basis with men and to ensure through competent national
tribunals and
other public institutions the effective protection of women
against any
act of discrimination;
(d) To refrain from engaging in any act or practice of
discrimination
against women and to ensure that public authorities and
institutions
shall act in conformity with this obligation;
(e) To take all appropriate measures to eliminate discrimination
against women by any person, organization or enterprise
[emphasis
added];
The Canadian government’s irresponsible approach to ensuring
Aboriginal women’s safety and security is clear; the federal
government
has refused to establish a national inquiry into missing and
murdered
Aboriginal women, many of whom have gone missing or been
murdered due to involvement in sex work, or targeted because
of their
perceived or self-identified ethnicity.
National Inquiry into Missing and Murdered Aboriginal

41. Women
For decades, innumerable civil society organizations,
nongovernmental organizations, municipal, provincial and
federal
politicians, community leaders, First Nations organizations
(including
the Assembly of First Nations), United Nations experts, and
countless
others, have called for a national inquiry into the hundreds of
missing
and murdered Aboriginal women in Canada. Discrimination and
violence against Indigenous women has been well documented.
The
record and personal stories of these missing and murdered
women,
Canada’s “stolen sisters,” are indisputable. Organizations such
as
Amnesty International Canada [29] have researched and
published
extensively about governmental obligations to adopt measures
“to
guard against private individuals committing acts which result
in
human rights abuses.” Accountability by state parties includes
the
need to ensure adequate police training, consistent data
collection
of the number of missing and murdered Aboriginal women, and
jurisdictional coordination, internationally mandated practices
of
which Canada is a signatory.
The Canadian public, international human rights experts and
bodies, as well as provincial and territorial leaders, all support a
comprehensive review of violence against Aboriginal women

42. across
the country. In fact, ahead of the Council of the Federation
meeting
in July 2013, every provincial and territorial leader among
Canada’s
ten provinces and three territories publicly supported an inquiry
on
missing and murdered Aboriginal women [30]. The Native
Women’s
Association of Canada has been calling for an inquiry for the
past
thirteen years. In part, these leaders believe national-level
coordination
is required in order to compare and contrast jurisdictional
similarities
or distinctions. There is a plethora of research and evidence to
support
this approach, not the least of which is Canada’s obligations
under
Article 2(C) of CEDAW to establish legal protections through
national
tribunals.
Provincially, an Order in Council established the Missing
Women
Commission of Inquiry in British Columbia on September 27,
2010
[31]. The Terms of Reference states the Inquiry’s mandate is to:
http://dx.doi.org/10.4172/2169-0170.1000170
Citation: Ponsford MP (2016) A Critical Examination of
Canada’s Obligations Under the Convention on the Elimination
of all Forms of Discrimination
against Women and the Government’s Actions and Omissions in

43. Relation to the Investigation of the Hundreds of Missing
Aboriginal Women.
J Civil Legal Sci 5: 170. doi:10.4172/2169-0170.1000170
Page 5 of 7
Volume 5 • Issue 1 • 1000170J Civil Legal Sci
ISSN: 2169-0170 JCLS, an open access journal
(a) Inquire into and make findings of fact respecting the
conduct
of the investigations conducted between January 23, 1997 and
February
5, 2002, by police forces in British Columbia respecting women
reported
missing from the Downtown Eastside of the city of Vancouver;
(b) Inquire into and make findings of fact respecting the
decision
of the Criminal Justice Branch on January 27, 1998, to enter a
stay of
proceedings on charges against Robert William Pickton of
attempted
murder, assault with a weapon, forcible confinement and
aggravated
assault;
(c) Recommend changes considered necessary respecting the
initiation and conduct of investigations in British Columbia of
missing
women and suspected multiple homicides; and
(d) Recommend changes considered necessary respecting
homicide investigations in British Columbia by more than one
investigating organization, including the co-ordination of those
investigations.

44. Although numerous reports from the Commission have been
released, a national inquiry would ensure jurisdictional
coordination,
effective analyses of ineffective and discriminatory police
practices, and
a more accurate sense of the scale of the problem. As of
October 2015,
there were nearly 1,200 documented cases of missing and
murdered
Aboriginal women and girls, according to the Royal Canadian
Mounted
Police. Provincial and territorial leaders do not, cannot, and
must
not claim sole responsibility; instead, they must aim to work
with
the federal government and Aboriginal communities to address
the
problem collaboratively, while recognizing solutions may be
adapted
to the particular needs of various communities across Canada.
Canada’s Periodic Report to the Secretary-General of
the United Nations
Article 18 of CEDAW requires Canada and other state parties to
submit a report outlining the progress made toward the
principles of
CEDAW. Article 18 states:
A. States Parties undertake to submit to the Secretary-General
of
the United Nations, for consideration by the Committee, a
report on
the legislative, judicial, administrative or other measures which
they

45. have adopted to give effect to the provisions of the present
Convention
and on the progress made in this respect:
(a) Within one year after the entry into force for the State
concerned;
(b) Thereafter at least every four years and further whenever the
Committee so requests.
B. Reports may indicate factors and difficulties affecting the
degree
of fulfillment of obligations under the present Convention.
Canada’s eighth reporting cycle to the UN Secretary-General
was
due December 1, 2014; reporting cycles six and seven were
combined,
submitted and published on August 17, 2007 [32]. This 186-
page
report, covering the period from April 1999 to March 2006, will
form
the discussion [33]. Although prostitution is not a criminal
offence
in Canada, the report fails to mention the measures taken to
protect
vulnerable and marginalized Aboriginal women who engage in
sex
work, particularly in rural communities.
The discussion of Article 6 focuses on trafficking and
exploitation of
women and girls generally; this appears to be the correct
interpretation
of the statute. However, although the suppression of
“trafficking” of

46. women into Canada appears to be in alignment with the
legislation and
policies adopted by the Canadian government, the term
“exploitation”
is narrowly applied. The application of the term includes
prohibitions
against the sexual exploitation of children. The Canadian
government
has not recognized the disproportionate number of Aboriginal
women
who may “choose” to engage in sex work but are nonetheless
subjected
to exploitative behavior. This includes the basic premise that
Aboriginal
women may be exploited by both Aboriginal and non-Aboriginal
men
through unfair, sexually exploitative, violent, abusive, and
sometimes
homicidal encounters, at the hands of “johns,” or others, who
exploit
them. Although Canada’s periodic report acknowledges eight
times
higher spousal homicide rates for Aboriginal women compared
to non-
Aboriginal women, Canada’s political stance surrounding
prostitution
laws may have diluted the attention these marginalized women
may
otherwise have received.
UN Periodic Review and Canada’s Compliance with
Articles 6 and 14 of CEDAW
In March 2008, the Committee on the Elimination of
Discrimination against Women met and replied to Canada’s

47. combined
sixth and seventh periodic submission, as per Article 20, issuing
a list of
considerations [34]. The Committee highlighted the need for
additional
information pertaining to Aboriginal women and their
communities,
noting patriarchal attitudes permeating Canadian society:
Stereotypes and education
Please inform the committee whether activities to promote
Aboriginal women which are funded by the Government …
include
awareness-raising programmes aimed at sensitizing Aboriginal
communities about women’s human rights and combating
patriarchal
attitudes, practices and stereotyping roles [emphasis added].
The Committee continued to inquire about public education
programmes used in Newfoundland and Labrador to combat
stereotypes, asking if similar culturally sensitive programming
would
be implemented in other provinces and territories; this relates to
the
need for jurisdictional collaboration and the sharing of best
practices
inter-provincially and inter-territorially in a systematic fashion,
a
request many politicians have expressed. The Committee does
not
comment explicitly on exploitation of prostitution, instead
focusing
on trafficking of women, but their discussion of patriarchal
attitudes
is important and will help Canada address widespread gender

48. and
stereotype-based discrimination that places Aboriginal women
at
increased danger.
The overrepresentation of Aboriginal women in the prison
system,
and the high level of violence and abuse directed toward them,
was also
highlighted. The Committee requested sex-disaggregated data of
the
gender impact of anti-poverty measures for minority groups,
including
Aboriginal women. This is important because the levels of
poverty
Aboriginal women face often impacts their involvement in sex
work to
support themselves and their families, and sex work places
women at
an increased risk of abuse and disappearance. Unfortunately,
Canada’s
reply to the list of these issues was inaccessible through the
United
Nations database; however, the Committee’s reply is significant
because
over half of the submission deals specifically with Aboriginal
women’s
equality, including their representation in governance and
legislative
processes by means of election to public office. Again, it is a
testament
to the attention Aboriginal women’s issues in Canada is
amassing
internationally because of government inaction and omissions.
Article 14, relating to challenges faced by rural women,

49. specifically
Aboriginal women, was not directly discussed in the
Committee’s six-
http://dx.doi.org/10.4172/2169-0170.1000170
Citation: Ponsford MP (2016) A Critical Examination of
Canada’s Obligations Under the Convention on the Elimination
of all Forms of Discrimination
against Women and the Government’s Actions and Omissions in
Relation to the Investigation of the Hundreds of Missing
Aboriginal Women.
J Civil Legal Sci 5: 170. doi:10.4172/2169-0170.1000170
Page 6 of 7
Volume 5 • Issue 1 • 1000170J Civil Legal Sci
ISSN: 2169-0170 JCLS, an open access journal
page reply. It would have been helpful for the Committee to
address
Aboriginal women’s roles in the “non-monetized sectors of the
economy,” as Article 14 stipulates, although there was brief
mention
of the affordability of childcare and benefit levels for parental
leave, to
encourage men to equally contribute to family life and
responsibilities.
It is interesting to note that Canada’s submission mentioned
rural
challenges facing minorities, including Aboriginal women, more
than
the Committee’s reply, which may suggest compliance of this
provision.
Canada mentioned the Domestic Violence Action Plan,

50. pertaining to
Article 3 of CEDAW, and recognized the increased risk of
domestic
violence directed toward Aboriginal rural women who have
limited
access to support services, shelters, and crisis centres due to
geography
and culture. However, the government seems to engage in short-
term
commitments to discussions pertaining to Aboriginal women,
such
as the March 2006 policy forum on Aboriginal Women and
Violence,
rather than implementing a long-term, streamlined, coordinated
national tribunal, in compliance with Article 2 of the
Convention.
Intersecting CEDAW Provisions Impacting Aboriginal
Women’s Equality
Issues of sex work and rurality facing Aboriginal women
formed
the basis of the analyzing framework of CEDAW throughout the
discussion; however, there was minimal discussion directly
related to
Articles 6 and 14 in Canada’s periodic submission to the
Committee and
the Committee’s reply. This may be explained by intersecting
CEDAW
provisions with other Articles within the statute. For example,
systemic
issues of poverty affecting Aboriginal women (Article 11),
access to
childcare and maternity services (Article 5), gender equitable
parenting
(Article 11), among other issues previously addressed,

51. contribute to
the exploitation of sex workers and a heightened rural-urban
support
services divide. The correction and improvement of these issues
inextricably reinforces the principles contained in Articles 6
and 14.
Article 2: UN Periodic Review and Canada’s Failure to
Establish a National Inquiry
The remainder of the discussion will focus on Canada’s
compliance
with Article 2 of the Convention, namely Canada’s obligations
to
investigate the hundreds of missing and murdered Aboriginal
women.
It is shocking that the words “murder” and “murdered” appear a
mere
three times within the 186-page periodic report from Canada;
these
words occur only twice in the context of Aboriginal women
homicide.
The word “missing” as it relates to Aboriginal women is
mentioned
fourteen times. These numbers are symbolic because it
demonstrates
the lack of attention the Canadian government has for missing
and
murdered Aboriginal women.
In the report, the government references $5 million in funding
contributed to the Sisters in Spirit Initiative from 2005 to 2010,
a
campaign of the Native Women’s Association of Canada. In
part, the
funding supported quantifying the number of missing and

52. murdered
Aboriginal women, which has been challenging, but the
initiative should
be a government-mandated priority. Second, the report mentions
the
Government of Saskatchewan’s 2005 initiative to (1) increase
police
resources directed toward missing women investigations; (2)
evaluate
and redevelop police policies; and (3) strengthen partnerships
with
police, government, communities, and families of missing
persons. The
Missing Persons Task Force was regionally focused, and not a
national
tribunal as Article 2(C) implies. British Columbia’s Hate
Crimes Team
is also mentioned briefly, which simply named the Missing
Women
Taskforce, with no further elaboration or insight of what this
taskforce
entails. The $5 million funding, Saskatchewan case study and
“Missing
Women Taskforce” are the only insights the Canadian
government
provided to the Committee. There was absolutely no mention of
a
national inquiry, tribunal, or investigative body within the 186-
page
report.
It seems, without question, that Canada has not only failed to
take
action as required by international law, but has also failed to
even

53. acknowledge the alarming problem at the request of respected
United
Nations agencies. Although the principle of equality for both
men
and women is enshrined in the Canadian constitution, as
required by
Article 2(A), “the practical realization of this principle” has not
been
met. Legislative frameworks prohibiting discrimination against
women
do exist as per Article 2(B)(F)(G); albeit the existence of such
legislation
does not mean compliance with enacted principles.
Further, Canada is in clear violation of Article 2(C), refusing to
establish a national inquiry in the form of a tribunal. Canada
has failed
to conduct a nationwide investigation of systematic,
discriminatory
police practices against Aboriginal women as per Article 2(D),
“to
ensure that public authorities and institutions shall act in
conformity
with this obligation.” Finally, Canada has not taken “all
appropriate
measures” to ensure the eradication of discrimination against
women
by “any person, organization or enterprise” as per Article 2(E);
in fact,
it has taken very few, regional measures, selectively funding
Aboriginal
women’s rights initiatives generally, without directly addressing
the
tragedy of missing and murdered women.
Conclusion: Moving Forward Together—Struggles,

54. Hope and Cautious Optimism
The purpose of emphasizing Article 6 through the lens of a local
Ottawa-based sex workers advocacy group (POWER), and in
discussing
Article 14, was to direct attention to the stigmatic assumptions
underlying rural Aboriginal women and those who engage in sex
work,
which contributes to vast social judgment by both Canadians
and the
government. It is difficult to quantify the number of Aboriginal
women
who have gone missing or been murdered as a result of
involvement
in sex work or living on isolated rural reserves and
communities. The
commonality is that these issues contribute to the social
exclusion of
Aboriginal women, reinforce recurrent themes of power and
privilege,
and remind us of the intersections of class, poverty, ethnicity,
and
gender.
It was disconcerting to examine the Convention and recognize
the scale of Canada’s incompliance. Government inaction is not
only
disgraceful to missing Aboriginal women, but a troublingly,
brazen
disregard to women’s families, friends, and allies who have
repeatedly
sought justice for missing and murdered Aboriginal women. A
fundamental theme throughout Finding Dawn was hope. It is
now time
Canadians take a united, assertive stand, and voice to the
government

55. the dire need for change and responsible leadership. As the
struggle
continues, collaboration on Aboriginal women’s issues will
hopefully
improve the quality of life for daughters, sisters, aunts, friends,
and
mothers of missing and murdered Aboriginal women across
Canada.
We must honor Aboriginal women who have been tragically
murdered,
and vow to search for those still missing; in fact, international
law
obliges the Canadian government to undertake no less.
http://dx.doi.org/10.4172/2169-0170.1000170
Citation: Ponsford MP (2016) A Critical Examination of
Canada’s Obligations Under the Convention on the Elimination
of all Forms of Discrimination
against Women and the Government’s Actions and Omissions in
Relation to the Investigation of the Hundreds of Missing
Aboriginal Women.
J Civil Legal Sci 5: 170. doi:10.4172/2169-0170.1000170
Page 7 of 7
Volume 5 • Issue 1 • 1000170J Civil Legal Sci
ISSN: 2169-0170 JCLS, an open access journal
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Canada’s Obligations
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Discrimination against
Women and the Government’s Actions and Omissions in
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170. doi:10.4172/2169-0170.1000170
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http://dx.doi.org/10.4172/2169-0170.1000170
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http://dx.doi.org/10.4172/2169-
0170.1000170TitleCorresponding
authorAbstractKeywordsIntroduction Historical Overview:
Discriminatory Treatment against Aboriginal Peoples and
Aboriginal Women Introduction to the Convention on the
Elimination of All Forms of Discrimination against Women
Articles 6 and 14 of the Convention on the Elimination of All
Forms of Discrimination against Women Intersecting
Marginalization: Rurality, Sex Work, and Aboriginal Women’s
Equality Intersecting Marginalization: Poverty, Sex Work, and

63. Aboriginal Women’s Equality Security and Safety: Aboriginal
Women and Sex Work Violations of Article 2(C)(D)(E) of the
Convention on the Elimination of All Forms of
DiscriminationNational Inquiry into Missing and Murdered
Aboriginal Women Canada’s Periodic Report to the Secretary-
General of the United Nations UN Periodic Review and
Canada’s Compliance with Articles 6 and 14 of CEDAW
Stereotypes and education Intersecting CEDAW Provisions
Impacting Aboriginal Women’s Equality Article 2: UN Periodic
Review and Canada’s Failure to Establish a National Inquiry
References
Research CMAJ
E568 CMAJ, October 21, 2014, 186(15) © 2014 Canadian
Medical Association or its licensors
F
requent users of health care services rep-
resent a relatively small group of patients
who account for a disproportionately large
amount of health care utilization, including
emergency department visits,1,2 hospital admis-
sions and clinic visits. These patients are often of
low socioeconomic status,3,4 have multiple medi-
cal, psychiatric and social disorders5,6 and have a
high mortality.7 Frequent use of the health care
system contributes to longer wait times and
affects the quality of care.4,8
Disproportionate use of health care services by
a segment of the population has been identified as
a challenge in many countries, including Can-

64. ada.9–12 To encourage less resource-intensive care
for frequent users, many efforts have been imple-
mented. Some of these interventions, for example,
have been designed specifically to transition health
care utilization away from the hospital to other set-
tings, such as community-based clinics.13
Much of the literature has focused on frequent
users of emergency departments, with less focus
on their use of the health care system in general.
One systematic review identified a number of
studies that assessed the effect of various interven-
tions, including care coordination.14 The authors
concluded that case management and multidisci-
plinary teams were likely effective interventions to
reduce emergency department visits.
Emergency department visits typically represent
only a fraction of the cost burden on the health care
system. There is a need to understand the impact of
interventions aimed at reducing overall health care
utilization, including hospital admissions. We con-
ducted a systematic review and meta-analysis of
the effectiveness of quality improvement strategies
Effectiveness of quality improvement strategies
for coordination of care to reduce use of health care
services: a systematic review and meta-analysis
Andrea C. Tricco PhD, Jesmin Antony MSc, Noah M. Ivers MD
PhD, Huda M. Ashoor BSc, Paul A. Khan PhD,
Erik Blondal BSc, Marco Ghassemi MSc, Heather MacDonald
MLIS, Maggie H. Chen PhD, Lianne Kark Ezer MSc,
Sharon E. Straus MD MSc

65. Competing interests: None
declared.
Disclaimer: Sharon Straus
is an associate editor with
CMAJ and was not involved
in the editorial decision-
making process for this
article.
This article has been peer
reviewed.
Correspondence to:
Sharon Straus, sharon.straus
@utoronto.ca
CMAJ 2014. DOI:10.1503
/cmaj.140289
Background: Frequent users of health care ser-
vices are a relatively small group of patients who
account for a disproportionately large amount
of health care utilization. We conducted a meta-
analysis of the effectiveness of interventions to
improve the coordination of care to reduce
health care utilization in this patient group.
Methods: We searched MEDLINE, Embase and
the Cochrane Library from inception until May
2014 for randomized clinical trials (RCTs) assess-
ing quality improvement strategies for the
coordination of care of frequent users of the
health care system. Articles were screened, and
data abstracted and appraised for quality by 2
reviewers, independently. Random effects

66. meta-analyses were conducted.
Results: We identified 36 RCTs and 14 compan-
ion reports (total 7494 patients). Significantly
fewer patients in the intervention group than
in the control group were admitted to hospital
(relative risk [RR] 0.81, 95% confidence inter-
val [CI] 0.72–0.91). In subgroup analyses, a sim-
ilar effect was observed among patients with
chronic medical conditions other than mental
illness, but not among patients with mental ill-
ness. In addition, significantly fewer patients
65 years and older in the intervention group
than in the control group visited emergency
departments (RR 0.69, 95% CI 0.54–0.89).
Interpretation: We found that quality improve-
ment strategies for coordination of care
reduced hospital admissions among patients
with chronic conditions other than mental ill-
ness and reduced emergency department visits
among older patients. Our results may help cli-
nicians and policy-makers reduce utilization
through the use of strategies that target the
system (team changes, case management) and
the patient (promotion of self-management).
Abstract
See related commentary,
www.cmaj.ca/lookup/doi/10.1503/cmaj.141050
Research

67. CMAJ, October 21, 2014, 186(15) E569
for care coordination for patients who are frequent
users of the health care system.
Methods
We developed our protocol according to the
PRISMA-P (Preferred Reporting Items for Sys-
tematic review and Meta-analysis Protocols)
statement (available from the authors).
Literature search
The search strategies were developed by an experi-
enced librarian and were reviewed by a second
librarian using the Peer Review of Electronic
Search Strategies checklist.15 A comprehensive
search of MEDLINE, Embase and the Cochrane
Library was conducted from inception until May
5, 2014, and was limited to adults and humans.
The MEDLINE search strategy, outlined in
Appendix 1 (available at www.cmaj.ca/lookup
/suppl /doi:10.1503 /cmaj.140289/-/DC1), was
modified for the Embase and Cochrane Library
searches with the use of appropriate medical sub-
ject headings (available upon request). We also
searched trial registries and conference abstracts,
scanned the reference lists of included studies and
relevant reviews, contacted authors to request
other potentially relevant studies, searched the 10
most related citations in PubMed for each included
study and searched studies that referenced the
included studies in Web of Science (i.e., forward
citation searching).

68. Study selection
Before screening began, a calibration exercise
was conducted to ensure high reliability in cor-
rectly selecting articles for inclusion. This exer-
cise entailed screening a random sample of 75
citations (titles and abstracts) using Synthesi.SR
(a proprietary online systematic review tool
developed by the Joint Program in Knowledge
Translation at St. Michael’s Hospital, Toronto).
The percentage agreement among these review-
ers was quantified. After high agreement was
achieved, each citation was screened by 2
authors using the predefined relevance criteria
form. Discrepancies were resolved by discussion
or the involvement of a third reviewer. The same
process was followed for full-text review of
potentially relevant articles identified through
citation screening. When eligibility of a particu-
lar study was unclear, the study’s authors were
contacted for additional information.
Eligible studies were randomized clinical tri-
als (RCTs) that assessed at least 1 of 5 pre-
defined quality improvement strategies targeting
adult patients (age ≥ 18 yr) who were frequent
users of the health care system. The quality
Box 1: Description of quality improvement strategies17
Care coordination
Care coordination is the deliberate organization of patient care
activities
between 2 or more participants (including the patient) involved
in a
patient’s care to facilitate the appropriate delivery of health

69. care services.
Organizing care involves the marshalling of personnel and other
resources
needed to carry out all required patient care activities; it is
often managed
by the exchange of information among participants responsible
for
different aspects of care.15
• Case management: The coordination of patient care, including
diagnosis,
treatment and ongoing patient management (e.g., arranging
referrals,
follow-up of test results, patient education, patient reminders)
by an
individual other than the primary care clinician.18
• Team changes: Changes to the primary health care team and
how it
functions, including routine patient visits with personnel other
than the
primary care physician, use of multidisciplinary teams and the
expansion
or revision of team members’ professional roles.18
• Promotion of self-management: Providing equipment (e.g.,
home
glucometers for patients with diabetes) or access to resources
(e.g.,
electronic systems for transferring glucose measurements for
patients
with diabetes) and establishing joint goals to empower patients
to
manage their disease on their own.18
• Decision support: Operational process of adjustment for a

70. system that
generates regular feedback (from registry data) to clinical teams
on
guideline compliance or organizational support to facilitate
other
mechanisms for coordinating care.19
• Clinical information system: A quality improvement strategy
encompassing numerous systems performing a wide variety of
functions;
distinguished from administrative information systems by the
requirement for data entry or data retrieval by clinicians at the
point of
care.20
Additional components
• Patient navigator: “Guide people through the health care maze,
connecting them with the right doctors and helping them gain
access to
available therapies.”21
• Outreach activities: Assessment, education or follow-up
conducted
outside the clinic or hospital, in or near the patient’s home.
Other quality improvement strategies
• Patient education: Educating patients about their disease,
including
prevention and treatment strategies.18
• Patient reminder systems: Reminding patients about upcoming
appointments or important aspects of self-care (e.g., glucose
monitoring
for patients with diabetes).18

71. • Clinician education: Educating clinicians about a particular
condition or
illness that their patients might face, including strategies for
prevention
and treatment (e.g., based on clinical practice guidelines); may
be
conducted through conferences, workshops, distribution of
educational
materials and one-on-one educational outreach meetings (or
academic
detailing).18
• Clinician reminders: Reminding clinicians to look up patients’
clinical
information or to conduct specific tasks.18
• Audit and feedback: Generating summaries of clinic’s or
individual
clinician’s performance, which are transmitted back to the
clinician.18
• Financial incentives: Providing clinicians with financial
incentives for
reaching pre-established goals or achievements; may also
include
incentives for patients or system-wide changes in
reimbursement.18
• Continuous quality improvement: Using specific processes to
identify
quality problems, developing solutions, and implementing and
evaluating changes; may include interventions, such as total
quality
management or plan–do–study–act.18

72. • Facilitated relay of information to clinicians: Transmitting
clinical
information from patients to clinicians by means other than the
existing
medical record.18
Research
E570 CMAJ, October 21, 2014, 186(15)
improvement interventions of interest, chosen to
fill gaps in the “expanded chronic care model”16
and described in Box 1,15,17–21 are closely related
to care coordination: case management, team
changes, promotion of self-management, deci-
sion support, and clinical information systems.
We also considered the effects of 2 additional
components to an intervention: patient naviga-
tors and outreach activities.
Quality improvement strategies were com-
pared with usual care, no intervention or other
quality improvement strategies, as listed in
Box 1. When more than one control arm was
available in the studies, we chose the usual-care
arm for inclusion in the analysis. Included stud-
ies had to report at least one of the eligible
health utilization outcomes, specifically emer-
gency department visits, hospital admissions or
clinic visits; the proportion of patients was the
primary outcome of interest. Studies written in
any language, whether published or unpub-
lished, and conducted at any point in time were
eligible for inclusion.

73. Data collection
A data abstraction form was drafted and pilot-
tested by 8 of us (A.C.T., N.M.I., H.M.A., P.A.K.,
E.B., M.G., H.M. and L.K.E.) working indepen-
dently on a random sample of 5 articles. Data
items we recorded were study characteristics (e.g.,
setting, type of study design), patient characteris-
tics (e.g., population examined, mean age), quality
improvement strategies examined and utilization
outcomes examined. Two reviewers (A.C.T.,
N.M.I., H.M.A., P.A.K., E.B., M.G., H.M. or
L.K.E.) independently read each article and
abstracted the relevant data. Differences in
abstraction were resolved by team discussion.
Because it is often difficult to classify quality
improvement strategies, classification of strategies
was performed independently by a systematic
review methodologist and a clinician. Conflicts
were resolved through discussion. Attempts were
made to identify related publications (referred to
as companion reports). Study authors were con-
tacted via email for clarification of data if neces-
sary (e.g., unreported standard deviations for con-
tinuous data, mean age of included patients).
Appraisal of risk of bias
We used the Cochrane Effective Practice and
Organisation of Care Risk-of-Bias Tool to assess
risk of bias.22 Each included article was indepen-
dently appraised by 2 reviewers (A.C.T., N.M.I.,
H.M.A., P.A.K., E.B., M.G., H.M. or L.K.E.).
Conflicts were resolved by discussion or the
involvement of a third reviewer (A.C.T. or S.E.S.).

74. Data synthesis
We used a random-effects meta-analysis to com-
bine data for outcomes reported in at least
2 RCTs.16 Mean differences were calculated for
studies reporting the average number of visits per
patient per month (i.e., continuous outcomes),
and relative risks (RRs) were calculated for stud-
ies reporting the proportion of patients with visits
(i.e., dichotomous outcomes). Funnel plots were
created to identify potential publication bias.23
Before conducting the meta-analysis, we
examined 3 types of heterogeneity: clinical (e.g.,
type of patient population, setting), methodologic
(e.g., quality improvement strategy examined)
and statistical (e.g., I2 statistic).24 Our approach
for dealing with significant heterogeneity was to
conduct appropriate subgroup analyses. We con-
ducted post hoc subgroup analyses to determine
the influence of the following factors: type of
patient (primarily those with mental illness v.
those with chronic medical conditions other than
mental illness; and age ≥ 65 yr v. < 65 yr), and
type of frequent user based on the RCT eligibility
criteria (at risk of being a frequent user = having
a history of inpatient care with other predisposing
factors, such as multiple comorbidities or psycho-
social morbidity; low utilization = “frequent use”
defined as 1 to 2 contacts with the health care
system in the past year among patients with mul-
tiple comorbidities or psychosocial morbidity;
moderate utilization = 3 to 4 contacts with the
health care system in the past year; and most fre-
quent/severe utilization = ≥ 5 contacts with the
health care system in the past year).

75. Potentially eligible reports identi�ed
through literature search
n = 11 107
Excluded n = 10 444
• Study design not relevant n = 9 920
• Not adult patients n = 443
• Not a quality improvement strategy n = 41
• Trial protocol, conference abstract, systematic
review, letter to the editor n = 40
Excluded n = 613
• Not adult patients n = 322
• Study design not relevant n = 154
• Trial protocol, conference abstract, systematic
review, letter to the editor n = 62
• No relevant/abstractable outcomes n = 37
• Not a quality improvement strategy n = 36
• Article not retrievable n = 2
Included in meta-analysis
n = 50 (36 RCTs, 14 companion reports)
Reports retrieved in full
n = 663
Figure 1: Selection of articles for the meta-analysis. RCT =
randomized clinical trial.
Research

76. CMAJ, October 21, 2014, 186(15) E571
Results
Search results and study characteristics
Of the 11 107 citations identified through the lit-
erature search, 663 full-text articles were
reviewed. After exclusion of 613 articles for var-
ious reasons (Figure 1), we included 36 RCTs
(total 7 494 patients)25–60 plus an additional 14
companion reports.61–74
The studies were published between 1987 and
2014 by researchers in North America (n = 24),
Europe (n = 8), Australia (n = 2), Israel (n = 1)
and South Africa (n = 1) (Table 1). One study
was a cluster RCT. The duration of follow-up
ranged from 1 to 36 months.
The definition of a frequent user of health care
services varied across the studies. Some studies
included patients who were at risk of being fre-
quent users (n = 11 studies), whereas others
included patients with low utilization (n = 8 stud-
ies), moderate utilization (n = 2 studies) or the
most frequent/severe utilization (n = 15 studies).
(Additional study and patient characteristics are
shown in Appendix 2, available at www.cmaj .
ca /lookup/suppl/doi:10.1503/cmaj.140289 /-/DC1).
Most of the studies included patients with a pri-
mary diagnosis of mental illness; 14 studies
included patients with a chronic medical condition
other than mental illness (Table 1). Twelve stud-
ies included patients with severe mental health
conditions, such as schizophrenia and substance
abuse disorders, and 12 studies included patients

77. who were homeless. The mean age of participants
ranged from 28.1 to 81.6 years. The studies
included from 25% to 77% women (Appendix 2).
Care coordination strategies
The following strategies were used to improve
care coordination: case management (n = 29 stud-
ies), team changes (n = 21), self- management (n =
19) and clinical information systems (n = 1) (de-
tails about the strategies are included in Appendi-
ces 3 and 4, available at www.cmaj.ca/lookup
/suppl/doi:10.1503/cmaj.140289/-/DC1). The
number of quality improvement strategies exam-
ined per study ranged from 1 to 5 (median 2.5).
The intervention included outreach activities in 23
studies and patient navigators in 6 studies. The
comparator group received patient education in 1
study or low-intensity case management in 11
studies involving patients with mental illness.
Risk of bias results
The risk of bias varied widely across the studies
(Table 2; Appendix 5, available at www.cmaj.ca
/lookup/suppl/doi:10.1503/cmaj.140289 /-/DC1).
One study had a high risk of bias on 4 criteria,
another had a high risk of bias on 3 criteria, 3 stud-
ies had a high risk of bias on 2 criteria, 18 had a
high risk of bias on 1 criterion, and the rest of the
studies did not have a high risk of bias on any of
the criteria. The risk of bias was unclear across
many of the criteria. Funnel plots did not reveal
evidence of publication bias (data not shown).
Effect on emergency department visits
After a median duration of 9 months of follow-

78. up, the proportion of patients who visited emer-
gency departments did not differ significantly
between the intervention and control groups (RR
1.11, 95% confidence interval [CI] 0.65 to 1.90; 6
studies; I2 = 0.85%) (Figure 2; Appendix 6, avail-
able at www.cmaj.ca/lookup/suppl/doi:10.1503
/cmaj.140289/-/DC1). The effect was significant
only among older patients, with fewer in the
intervention group than in the control group visit-
ing emergency departments (RR 0.69, 95% CI
0.54 to 0.89; 2 studies; I2 = 0%).
In the analysis of studies that reported the
mean number of emergency department visits per
patient per month, no difference was found
between the intervention and control groups after
a median duration of 12 months of follow-up
(mean difference −0.02, 95% CI −0.06 to 0.03;
7 studies; I2 = 0%) (Appendices 6 and 7, available
at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj
.140289/-/DC1). None of the subgroup analyses
was statistically significant.
Effect on hospital admissions
After a median duration of 12 months of follow-
up, significantly fewer patients in the intervention
group than in the control group were admitted to
hospital (RR 0.81, 95% CI, 0.72 to 0.91; 18 stud-
ies; I2 = 58%) (Figure 3; Appendix 6). Specific
quality improvement strategies that significantly
reduced the number of admissions were case
management, team changes, promotion of self-
management and patient education. Among
patients with chronic conditions other than mental
illness, significantly fewer patients in the interven-
tion group than in the control group were admitted

79. to hospital. No difference was found between the
intervention and control groups among patients
with mental illness or severe mental illness (e.g.,
schizophrenia and severe bipolar disorder). Inter-
ventions that had a significant effect were those
with an outreach component and those aimed at
patients with the most frequent/severe utilization
rate and those at risk of frequent use. Statistically
significant results were not observed with inter-
ventions that used patient navigators or those
aimed at patients with low utilization rates.
In the analysis of studies that reported the mean
number of hospital admissions per patient per
month, no difference was found between the inter-
Research
E572 CMAJ, October 21, 2014, 186(15)
vention and control groups after a median duration
of 18 months of follow-up (mean difference 0.00,
95% CI −0.01 to 0.01; 12 studies; I2 = 0%) (Appen-
dices 6 and 8, available at www.cmaj.ca /lookup
/suppl/doi:10.1503/cmaj.140289/-/DC1). None of
the subgroup analyses was statistically significant.
Table 1: Study and patient characteristics
Study* Country
Quality
improvement

80. strategy
Patients with
mental illness
Homeless
patients
Age, yr,
mean ± SD
Duration of
follow up, mo
Botha et al., 201425 [61] South Africa CM, TC Yes‡ Yes 32.3
± 9.9 36
Burns et al., 201426 United States CM, SM, PE No No NR 1
Gellis et al., 201427 [62] United States FR, CM, SM, PE, CE
Yes No 79.2 ± 7.4 12
Ruchlewska et al., 201428 Europe SM Yes‡ Yes 40.0 ± 11.6
18
Puschner et al., 201129 Europe TC, SM Yes‡ Yes 41.3 ± 11.2
18
Courtney et al., 200930 Australia CM, TC, SM, PE Yes No 78.8
± 6.9 6
Killaspy et al., 200931 [63] Europe CM, TC Yes No 39.0 ±
11.0 36
Koehler et al., 200932 United States TC, CM, PE, SM, CIS No
No 78.5 ± 5.5 2

81. Bellon et al., 200833 Europe SM, CQI, CE Yes§ No 48.4 ± NR
15
Lichtenberg et al., 200834 Israel CM, TC, SM Yes No 28.1 ±
11.0 12
Shumway et al., 200835 United States CM Yes§ No 43.3 ± 9.5
24
Rivera et al., 200736 United States CM Yes‡ Yes 38.3 ± 12.8
12
Schreuders et al., 200737 [64,65] Europe CM, SM Yes No 52.9
± 14.8 3
Sledge et al., 200638 United States CM, TC, SM No No 51.0 ±
52.8 12
Scott et al., 200439 [66] United States TC, PE No No 74.2 ± 7.5
24
Castro et al., 200340 United States CM, PE, SM No No 36.4 ±
11.5 12
Laramee et al., 200341 United States CM, TC, PE, SM No No
70.7 ± 11.8 2
Harrison-Read et al., 200242 Europe CM, TC, SM Yes‡ Yes
39.2 ± 39.2 24
Kasper et al., 200243 United States CM, TC, PE, SM, FI No No
61.9 ± 13.4 6
Katzelnick et al., 200044 [67] United States CM, PE, CE Yes
No 45.5 ± NR 12