title: Exploring policy driven systemic inequities leading to differential access to care among Indigenous populations with obstructive sleep apnea in Canada.
abstract: In settler societies such as Australia, Canada, New Zealand and the United States, health inequities drive lower health status and poorer health outcomes in Indigenous populations. This research unravels the dense complexity of how historical policy decisions in Canada can influence inequities in health care access in the 21(st) century through a case study on the diagnosis and treatment of obstructive sleep apnea (OSA). In Canada, historically rooted policy regimes determine current discrepancies in health care policy, and in turn, shape current health insurance coverage and physician decisions in terms of diagnosis and treatment of OSA, a clinical condition that is associated with considerable morbidity in Canada.
  
  
  
  This qualitative study was based in Saskatchewan, a Western Canadian province which has proportionately one of the largest provincial populations of an Indigenous subpopulation (status Indians) which is the focus of this study. The study began with determining approaches to OSA care provision based on Canadian Thoracic Society guidelines for referral, diagnosis and treatment of sleep disordered breathing. Thereafter, health policy determining health benefits coverage and program differences between status Indians and other Canadians were ascertained. Finally, respirologists who specialized in sleep medicine were interviewed. All interviews were audio-recorded and the transcripts were thematically analyzed using NVIVO.
  
  
  
  In terms of access and provision of OSA care, different patient pathways emerged for status Indians in comparison with other Canadians. Using Saskatchewan as a case study, the preliminary evidence suggests that status Indians face significant barriers in accessing diagnostic and treatment services for OSA in a timely manner.
  
  
  
  In order to confirm initial findings, further investigations are required in other Canadian jurisdictions. Moreover, as other clinical conditions could share similar features of health care access and provision of health benefits coverage, this policy analysis could be replicated in other provincial and territorial health care systems across Canada, and other settler nations where there are differential health coverage arrangements for Indigenous peoples.
authors.affiliation: Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada. greg.marchildon@utoronto.ca.
authors.forename: Gregory P
authors.initials: GP
authors.lastname: Marchildon
authors.affiliation: Johnson Shoyama Graduate School of Public Policy, University of Regina, Regina, Canada. tarun.katapally@uregina.ca.|Indigenous Peoples' Health Research Centre, University of Regina, Regina, Canada. tarun.katapally@uregina.ca.|Canadian Centre for Health and Safety in Agriculture, University of Saskatchewan, Saskatoon, Canada. tarun.katapally@uregina.ca.
authors.forename: Tarun R
authors.initials: TR
authors.lastname: Katapally
authors.affiliation: Johnson Shoyama Graduate School of Public Policy, University of Regina, Regina, Canada. beck202c@uregina.ca.
authors.forename: Caroline A
authors.initials: CA
authors.lastname: Beck
authors.affiliation: Department of Community Health and Epidemiology, College of Medicine, University of Saskatchewan, Saskatoon, Canada. Sylvia.abonyi@usask.ca.
authors.forename: Sylvia
authors.initials: S
authors.lastname: Abonyi
authors.affiliation: Indigenous Peoples' Health Research Centre, University of Regina, Regina, Canada. jo-ann.episkenew@uregina.ca.
authors.forename: JoAnn
authors.initials: J
authors.lastname: Episkenew
authors.affiliation: Canadian Centre for Health and Safety in Agriculture, University of Saskatchewan, Saskatoon, Canada. pup165@mail.usask.ca.|Department of Community Health and Epidemiology, College of Medicine, University of Saskatchewan, Saskatoon, Canada. pup165@mail.usask.ca.
authors.forename: Punam
authors.initials: P
authors.lastname: Pahwa
authors.affiliation: Canadian Centre for Health and Safety in Agriculture, University of Saskatchewan, Saskatoon, Canada. james.dosman@usask.ca.
authors.forename: James A
authors.initials: JA
authors.lastname: Dosman
mesh_terms: D002170:Canada / Q000453:epidemiology / Q000208:ethnology; D006291:Health Policy; D006297:Health Services Accessibility / Q000592:standards*; D006304:Health Status; D054625:Healthcare Disparities / Q000706:statistics & numerical data*; D006801:Humans; D007198:Indians, North American / Q000706:statistics & numerical data*; D036301:Qualitative Research; D020181:Sleep Apnea, Obstructive / Q000191:economics / Q000628:therapy*