Introduction

Access to sexual reproductive health care is essential to a woman's overall health and well-being, irrespective of age. In 2010, women accounted for 50% of the Canadian population, a trend that is predicted to continue. The ethno-cultural characteristics of Canadian women indicate a growing number of Indigenous, immigrant and visible minorities.1 In Canada, from 2001 to 2006, for example, the Indigenous, immigrant and visible minority female population grew at a rate of 20%, 14% and 28%, respectively.1 Understanding current trends in diversity and gender can assist with informing health policy and planning about sexual reproductive health.

While both men and women require sexual reproductive health care, the implications for women are far more significant. A woman's ability to make choices and decisions about her life and participation in public and economic life depends on her ability to access such care.2 Canada has always prided itself on universal access to health care, including sexual reproductive health, for its citizens, and that health care is based on need and not tied to employment or dependent on income. This is a value held by Canadians since the conception of Medicare in 1948, and was harmonized into federal law in 1984 as the Canadian Health Act. This Act highlights five essential principles: i) universality, ii) comprehensiveness, iii) accessibility, iv) portability and v) public administration.3 Unquestionably, access to sexual reproductive health care has been at the forefront of considerable debate and placed on international health and policy agendas, and is carefully woven into the United Nations Sustainable Development Goals. Canada is committed to advancing sexual reproductive health initiatives that improve the health, rights and well-being of women and girls.4 At the 2019 Women Deliver Conference in British Columbia, Prime Minister Justin Trudeau pledged to increase sexual reproductive health funding in 2023 to 1.4 billion annually, particularly in "neglected" areas of maternal, child and reproductive health.5 Currently, Canada invests "1.1 billion, with 400 million focused directly on sexual and reproductive health rights."5^(para.6)

The issues women face around the globe pertaining to sexual reproductive health are complex. Much has been documented on this topic in low- and low-middle income countries, where 830 women die every day from causes related to pregnancy and childbirth,6 where women bear the burden of unintended pregnancy and sexually transmitted diseases, including the transmission of human immunodeficiency virus (HIV),7 where one in five women have unmet needs in family planning,8 where the incidence and mortality rates of cervical cancer steadily escalate,9 and where women fear violence if they refuse sex or use contraceptives against their partner's wishes.10

While Canadian women and girls do not experience difficulties with accessing sexual reproductive health care to the same extent as those in low- and low-middle income countries, difficulties still exist and must be explored. There is a need to understand the true extent of the issue in Canada as there is limited knowledge to draw a clear picture.2 What is known is that issues related to this care are rooted in the broader context of people's lives. This includes their economics, education, risk for sexual and gender-based violence, and social and cultural practices - what are known as the social determinants of health.11 This is particularly relevant for vulnerable populations living in Canada where questions about accessibility may arise. This includes, but is not limited to, a lack of universal pharmacare, which makes contraceptives out of reach to many women who cannot afford private health insurance and are unable to pay out of pocket.12 A lack of confidentiality can also be a barrier for some women and girls. While only a small portion of Canadian citizens live in rural communities, those women and girls who do can experience a lack of privacy. This is especially pertinent when addressing issues about contraceptive usage, treatment of sexually transmitted infections (STIs), and reporting domestic violence. Women and girls living in rural communities have limited access to health care providers, and are frequently acquainted with those employed at the local health clinic, which may lead to a breach in confidentiality.13 Research supports that women and girls of a lower socioeconomic status can often make choices jeopardizing their sexual reproductive health due to poverty, marginalization and/or low educational attainment. Homeless women, for example, are noted to have "a high burden of HIV and STIs in relation to the general population and have larger sexual reproductive health disparities, including poor access to pregnancy and parenting services, low rates of cervical cancer screening, a high burden of unwanted pregnancies and low contraception use."14^(p.2) Similarly, Indigenous Canadian women are more likely to experience a greater incidence of STIs, high-risk pregnancies, maternal mortality and sexual violence than their Canadian counterparts because of poor access to sexual reproductive health care.15

Finally, given the cultural diversity in Canada and the number of immigrants crossing Canada's borders, it is reasonable to assume that culture-related issues impact a woman's access to and experience with sexual reproductive health care. Research indicates that women's sexual reproductive health behavior is influenced by the precepts of their origin societies.16 This can have a great influence on women and girls immigrating to Canada from countries where they do not have the right to make certain decisions over their bodies.17 For example, more than 70% of African countries practice female genital circumcision. This is a practice that continues in some immigrant populations when they relocate to high-income countries like Canada, creating emotional and sexual distress.18 Due to the nature of female genital circumcision as a human rights violation, reliable data on the incidence of this practice is not obtainable. However, there is evidence to suggest that female genital circumcision is practiced across Canada in immigrant and refugee communities, and is impacting sexual reproductive health.19

There is an abundance of literature on a woman's access to sexual reproductive health care in sub-Saharan Africa where several systematic reviews have emerged in the following areas: i) exploring implementation strategies to improve cervical cancer prevention in sub-Saharan Africa;9 ii) barriers to access and utilization of emergency obstetric care at health facilities in sub-Saharan Africa;20 iii) potential interventions for conceptive use, family planning in low- and middle-income countries;7,21 iv) improving adolescent sexual reproductive health in sub-Saharan Africa;18,22 v) the effects of cultural practices on sexual functioning;23 and vi) sexual and reproductive health knowledge, experiences and access to services among refugee, migrant and displaced girls and young women in Africa.24 The reviews found to date focus on a woman's access to sexual reproductive health care outside Canadian borders, where the economic, social, physical, political and cultural contexts may differ. This review will explore the knowledge generated concerning a woman's access to sexual reproductive health care in Canada, specifically women who are vulnerable - typically women who are young, Indigenous, living in poverty, and/or are immigrants or refugees and who experience economic, social, physical and/or cultural difficulties. Scoping reviews are an effective way to systematically map the current state of knowledge, potentially identifying gaps or areas of interest that require further investigation.25 A preliminary search of PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews and JBI Evidence Synthesis was conducted and no current or in-progress systematic reviews on the topic were identified. Therefore, this scoping review is necessary in order to describe, analyze and document the determinants of a vulnerable woman's access to primary sexual reproductive health care in Canada. The Social Ecological Model is used as a framework to identify, understand and analyse the complex associations between individual practices and physical environment, as well as health, social, and structural factors contributing to sexual reproductive health access. This model has been previously utilized to explore barriers to accessing sexual reproductive health services.26 Findings from this review will be used to pave the way for future implementation research, and to provide recommendations and strategies for health systems, primary care providers, policymakers, and researchers to improve the access to and quality of sexual reproductive health care for women in Canada. This research aligns with the Government of Canada's 2019 commitment to improving sexual reproductive health for all women.4

Review question

What are the determinants that impact a vulnerable woman's access to primary sexual reproductive health care in Canada?

Inclusion criteria

Participants

The review will consider studies that include vulnerable women and girls aged nine to 49 years who reside in Canada. While the World Health Organization (WHO)27 defines a woman's reproductive years as 15 to 49, evidence suggests that girls as young as nine can be included when considering sexual reproductive health. This is in line with Canada's recommendation for approving girls to be immunized for the human papillomavirus as early as nine years of age.28 Vulnerable women and girls are defined as females who are young, living in poverty (i.e. homeless), involved in high-risk sexual behaviors (i.e. street-involved women), have experienced or are at risk of intimate partner violence, and/or are Indigenous, immigrants and/or refugees. While vulnerable women and girls can also include those with physical and/or say psychological disabilities and/or who are part of the lesbian, gay, bisexual, transgender, and queer (LGBTQ) community, these women and girls will be excluded if they do not have one or more of the additional defining characteristics listed above. It is believed that sexual reproductive health issues pertaining to disabilities and LGBTQ are unique and warrant a separate review.

Concept

The concept being examined in this scoping review is the determinants of access to sexual reproductive health care, with access to health care defined as "the opportunity to identify health care needs, to seek healthcare services, to reach, to obtain, or use healthcare services and to actually have the need for services fulfilled."29^(p.8) Only access to primary health care will be considered. This is care that is provided in primary health clinics and/or community-based clinics and services (i.e. public health home visits, health promotion and wellness clinics). Sexual reproductive health embraces two concepts that are occasionally used interchangeably, and while the concepts have commonality, they are not synonymous. For the purpose of the review, we will use the WHO's definition of sexual reproductive health, whereby sexual health is defined as:

"A state of physical, mental and social well-being in relation to sexuality. It requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence."30^(para.4)

Reproductive health, on the other hand, "implies that people are able to have a responsible, satisfying and safer sex life and that they have the capacity to reproduce and the freedom to decide if, when and how often to do so."31^(para.1)

Finally, determinants is defined as the social, economic, political, structural and cultural factors that influence a woman's sexual reproductive health. These factors are an interplay between the individual, family, community and society at large influencing sexual reproductive health in positive and negative ways.32

Context

This review will consider studies that impact vulnerable women's or girls' access to sexual reproductive health, as previously discussed. Only primary access to sexual reproductive health will be considered, such as primary health or community-based clinics and services (i.e. public health home visits, health promotion, and wellness clinics). Only studies conducted in Canada will be included.32

Types of sources

This scoping review will consider both experimental and quasi-experimental study designs, including randomized controlled trials, non-randomized controlled trials, before-and-after studies and interrupted time-series studies. Analytical observational studies, including prospective and retrospective cohort studies, case-control studies and analytical cross-sectional studies, will be considered for inclusion. This review will also consider for inclusion descriptive observational study designs including case series, individual case reports and descriptive cross-sectional studies.

Qualitative studies that focus on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, qualitative description, action research, and feminist research will be considered. Mixed methods studies that meet the inclusion criteria will also be considered.

In addition, text, opinion papers, dissertations, theses and conference reports will be considered for inclusion. Gray literature such as unpublished papers and reports will also be taken into account in this scoping review.

Studies published since 2008 will be included. Retrieving studies over a 10-year time span is deemed comprehensive, relevant and feasible.

Methods

The proposed scoping review will be conducted in accordance with JBI methodology.25

Search strategy

The search strategy aims to find published and unpublished literature. Discussion between the librarian and the primary reviewer, along with an examination of sample-included articles, was used to inform the search strategy. Titles, abstracts and indexed subject headings of the sample articles were examined, and a full search strategy was developed in PubMed. The full detailed search strategy is shown in Appendix I. Reference lists of articles selected for inclusion will be scanned for any additional articles to include. For gray literature, Google searches will be conducted, looking at results in the first five pages or until no relevant results are displayed. Specific association, conference and society websites will also be examined for relevant reports and other unpublished material.

Information sources

Databases to be searched include: PubMed, Embase, CINAHL via EBSCO, PsycINFO via EBSCO, Sociological Abstracts via ProQuest, and Women's Studies International via EBSCO.

A search for unpublished studies will include, but not be limited to: Action Canada for Sexual Health and Rights, Canadian Foundation for Women's Health, Canada-International Planned Parenthood Federation, Foundation for Gender Equality, Canadian Nurses Association, Canadian Medical Association, Society of Obstetricians and Gynaecologists of Canada, Public Health Agency of Canada, Canadian Health Authorities and Google.

Study selection

Following the search, all identified citations will be collated and uploaded into EndNote VX8.2 (Clarivate Analytics, PA, USA) and duplicates removed. All remaining results will be uploaded to Covidence (Veritas Health Innovation, Melbourne, Australia) for initial title/abstract screening. Titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria for the review. Potentially relevant studies will be retrieved in full and their citation details imported into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; JBI, Adelaide, Australia). The full text of selected citations will be assessed in detail against the inclusion criteria by two independent reviewers. Given that only one reviewer is fluent in French, abstracts that meet the study's criteria for full review will be translated from French to English to allow for data extraction and analysis by the other reviewers. Reasons for exclusion of full-text studies that do not meet the inclusion criteria will be recorded and reported in the final scoping review report. Any disagreements that arise between the reviewers at each stage of the study selection process will be resolved through discussion or with a third reviewer. The results of the search will be reported in full in the final report and presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram.33

Data extraction

Data will be extracted from papers included in the scoping review by two independent reviewers using a data extraction tool developed by the reviewers. The data extracted will include specific details about the population, concept, context, study methods and key findings relevant to the review objective. A draft charting table is provided (see Appendix II). The draft data extraction tool will be modified and revised as necessary during the process of extracting data from each included study. Modifications will be detailed in the full scoping review report. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. Authors of papers will be contacted to request missing or additional data, where required.

Data presentation

The extracted data from relevant published and unpublished literature will be presented in diagrammatic or tabular form in a manner that aligns with the objective of this scoping review. Data presented in diagrammatic or tabular form will correspond with the information collected using the data extraction tool shown in Appendix II. This will include: i) author and publication date; ii) study purpose/objectives; iii) study design; iv) geographic location; v) setting; vi) target population; vii) determinants impacting access to sexual reproductive health care; viii) gaps/key findings; and ix) study recommendations.

The narrative summary will accompany the diagrammatic or tabulated results to describe, synthesize, and document a vulnerable woman's access to primary sexual reproductive health care. Additionally, the exclusion of full-text studies that do not meet the inclusion criteria will be recorded in the final scoping review report.

Acknowledgments

Michelle Swab, health research librarian from Memorial University of Newfoundland, Canada, for assisting with the development of the literature search strategy.

Appendix I: Search strategy

PubMed

Conducted on December 13, 2019

Appendix II: Data extraction tool

Identification of the determinants and their impact on access to sexual reproductive health care will be further developed and revised as necessary during the process of extracting data.

References