Marginalization in health care

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Ribeiro, A., Khamis, N. Marginalization in health care. UBCMJ. 2016: 7.2 (4).

The United Nations’ Millennium Development Goals were celebrated as a groundbreaking achievement in identifying— and initiating the process of reversing—some of the world’s most dire problems.1 Fifteen years later, the United Nations is focusing its attention on the Sustainable Development Goals (SDGs), which includes health  as one of the 17 core targets having “critical importance for humanity and the planet”.1 The health agenda of the SDGs brings issues of health inequity to the forefront of public attention by declaring health as a prerequisite for personal and societal development.1 Although the importance of leveling health inequities may be evident from a global perspective, identifying and reversing these inequities is equally important on a national level. In the Canadian context, certain sub– populations face a disproportionately high burden of health inequities compared with the general population, which limits the ability of these populations to achieve full potential in life.2 While the underlying causes of health marginalization are complex, engaging in dialogue around the nature of marginalization and  possible  solutions  may  stimulate the creation of an equal and healthy population.

Healthcare providers play an integral role in identifying and meeting the unique health needs of marginalized populations; therefore, it is important to understand what it means to be marginalized by the healthcare system. Health Canada defines underserved individuals as having “increased likelihood [to] experience difficulties in obtaining needed care, receive less care or a lower standard of care, experience different treatment by healthcare providers, receive treatment that does not adequately meet their needs, or be less satisfied with healthcare services than the general population”.2 With such a diverse population, it is difficult to define which groups are marginalized in Canada. Generally, those at risk exist on the boundaries of the mainstream population, from a geographical or societal perspective.3 These can include those without shelter in rural or urban centres, those living in remote parts of the country, families of lower socioeconomic status, disabled persons, recent immigrants and refugees, Indigenous populations, and seniors. Adequately identifying and gaining access to vulnerable communities are essential steps for the health system in order to recognize and address their unique health needs.

The personal and societal factors that subject a person or population to health marginalization is equally complex. McMaster University’s Collaboratory for Research on Urban Neighbourhoods, Community Health and Housing (CRUNCH) is a multidisciplinary team of researchers and facilities that  seeks to explore various factors affecting the health of populations.4 Their Canadian Marginalization Index, known as CAN-Marg, tracks geographical and temporal changes in marginalization in order to assess the needs of sub–populations and orchestrate appropriate  healthcare   interventions.4  The index is founded on four dimensions that capture the principal determinants of health marginalization: residential instability, material deprivation, ethnic concentration, and dependency.4 Residential instability is a measure of the consistency in a person’s living situation, including location, type of residence, and residential partners.4 Material deprivation encompasses both material wealth and level of education.4 Ethnic concentration summarizes the proportion of members of a population who are either recent immigrants or visible minorities, while dependency refers to the proportion of persons who do not participate in the labour force.4 The CAN- Marg index has been shown to correlate with health outcomes,4 and therefore these four dimensions provide a good overview of the factors influencing health marginalization.

The scope of articles in this issue of the UBCMJ highlights many potential barriers to receiving  adequate  care, both  unique and common, faced by marginalized populations around the world, but especially in Canada. Our feature articles include an opinion piece by Dr. Stephen Yau, MD, CCFP, focusing on health care in Vancouver’s Downtown Eastside, an interview discussing prison health with Dr. Ruth Martin, MD, FCFP, MPH, and a piece on vulnerability and child development by Dr. Christine Loock, MD, FRCPC. Student authors discuss transgender Canadian health (Jones), refugee and immigrant health (Lake), mental health and substance use (Rheaume), as well as contents in the medical curricula that address the needs of marginalized populations (Jutras).This issue also includes an interview with a physician focusing on elder health (Ip, Madden) and an interview with the Director of Clinical Education at the BC Centre of Excellence HIV/AIDS that reviews the HIV situation in Canada (Galts). Research shows that access to care alters the health of a population.3 Thus, it is vital for healthcare professionals, researchers, policymakers, and other stakeholders to work together to identify and reduce barriers faced by patients in accessing adequate and appropriate care.


The authors do not have any conflicts of interest.


  1. United Transforming our world: the 2030 agenda for sustainable development. United Nations, The General Assembly; 2015 Oct 21. Cat. No.: A/ RES/70/1.
  2. Health Canada.‘Certain circumstances’: issues in equi- ty and responsiveness in access to health care in Can- ada. Ottawa: Health Canada; 256 p. Cat. No.: H39-618/2002E.
  3. Hay D,Varga-Toth J, Hines Frontline health care in Canada: Innovations in delivering services to vulner- able populations. Ottawa: Canadian Policy Research Networks; 2006 Sep. 106 p. Research Report F|63.
  4. Matheson FI, Dunn JR, Smith KLW, Moineddin R, Gla- zier CAN-Marg Canadian Marginalization Index: User guide version 1.0.Toronto: Centre for Research on Inner City Health; 2012. 11 p.