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Published in final edited form as: Int J Indig Health. 2026 Jul 2;21(2):10.32799/ijih.v21i2.46812. doi: 10.32799/ijih.v21i2.46812

NAVIGATING BARRIERS: THE INTERSECTIONAL IMPACT OF COVID-19 ON ROUTINE HEALTHCARE ACCESS AMONG MARGINALIZED INDIGENOUS WOMEN IN VANCOUVER, CANADA

Chelsey Perry 1, Shira Goldenberg 2, Kathleen Deering 3, Lyana Patrick 4, Melissa Braschel 3, Kate Shannon 3, Brittany Bingham 3
PMCID: PMC13721949  NIHMSID: NIHMS2218847  PMID: 42964794

Abstract

This study investigates the intersectional barriers to routine healthcare access experienced by marginalized Indigenous women, including sex workers and women living with HIV, in Vancouver, Canada during the COVID-19 pandemic. Drawing on data from 142 Indigenous participants in the AESHA and SHAWNA cohorts collected between October 2020 and August 2021, the research employs bivariate and multivariable logistic regression with generalized estimating equations to identify factors linked to difficulties accessing family doctors, nurses, or clinics for routine care. Findings reveal that 27.5% of participants reported challenges in accessing healthcare during the pandemic. Key factors associated with increased difficulty include negative changes in psychological and emotional well-being (AOR: 3.99, 95% CI: 1.33–11.98) and concerns about community safety and violence (AOR: 2.72, 95% CI: 1.06–6.94). This study underscores how the COVID-19 pandemic exacerbated pre-existing structural inequities rooted in colonialism, racism, stigma, and violence, which disproportionately impact Indigenous women with intersecting marginalized identities. There is an urgent need for healthcare systems to implement culturally safe, trauma-informed, and anti-Indigenous racism practices that center Indigenous voices and sovereignty. Enhancing mental health supports and addressing community safety are critical to improving healthcare access and outcomes. The study calls for community-led, Indigenous-led approaches and policy reforms, including the decriminalization of sex work, to dismantle structural barriers and promote health equity among Indigenous women, sex workers and women living with HIV in Canada.

Keywords: Indigenous Women, COVID-19, Pandemic, Healthcare Access, Sex Workers, Women Living with HIV, Intersectionality, Culturally Safe Care, Mental Health, Community Safety and Violence

INTRODUCTION

The COVID-19 pandemic amplified existing social and structural health inequities disproportionately impacting Indigenous1 women, Two-Spirit2 (2S), and LGBTQQIA+ people. Indigenous women face multiple layers of ongoing discrimination and violence, rooted in historical and ongoing colonial practices that continue to undermine their health and well-being (McBride et al., 2020; Pearce et al., 2008; Sharma et al., 2021; Thumath et al., 2021; Wenham et al., 2020). Systemic exclusion from equitable healthcare is compounded by the intersectional stigma experienced by Indigenous women living with HIV and by sex workers (Nelson & Wilson, 2018; Deering et al., 2021; Socías et al., 2016).

The COVID-19 pandemic further intensified health inequities (Coen-Sanchez et al., 2022; Turpel-Lafond et al., 2020; Wenham et al., 2020), with sex workers and people living with HIV facing income loss, reduced outreach services, and stigmatization and harassment by governments and police (Goldenberg, 2020; McClelland & Luscombe, 2021). Gendered impacts of COVID-19 include increased economic insecurity, unplanned pregnancy, lack of access to health services, domestic violence, and mental health issues (Kia et al., 2022; McBride et al., 2023; Pearson et al., 2022; Wenham et al., 2020).

Lockdowns, social distancing, and fear of the virus have significantly increased psychological and emotional stress (Lawal et al., 2021; Menezes de Sousa Júnior et al., 2021; Sylliboy et al., 2022; Wenham et al., 2020; Winwood et al., 2021). Marginalized Indigenous women face intersecting forms of oppression, and psychological stress may further impede healthcare access and utilization. Considering how the intersection of gender and Indigeneity impact access to healthcare, 2S and gender diverse populations face health disparities (Velasco et al., 2022) and high rates of racism, stigma, transphobia, homophobia, and discrimination from healthcare providers, negatively impacting healthcare services (Chakanyuka et al., 2022; Kia et al., 2022; Monchalin, 2021; Tami et al., 2022). Sex workers and women living with HIV in Vancouver who identify as gender diverse face increased barriers to accessing healthcare (Goldenberg et al., 2022; Socías et al., 2016).

Previous and ongoing work clearly articulates the deeply harmful roles of colonialism and racism in continuing to systemically exclude Indigenous Peoples from accessing equitable and culturally safe healthcare (Akter et al., 2019; Archibald, 2006; Burnett et al., 2020; Pilarinos et al., 2023; United Nations, 2007). These colonial acts have caused severe health inequities that were not present prior to colonization (MacDonald & Steenbeek, 2015; Nelson & Wilson, 2018; Pattison et al., 2018). Widespread racism, stigma, and violence against Indigenous Peoples in Canada led to the Truth and Reconciliation Commission of Canada’s (2016) Calls to Action; the National Inquiry into Missing and Murdered Indigenous Women, Girls, 2S/LGBTQQIA+ reports (NIMMIWG, 2019); and the BC-commissioned In Plain Sight inquiry (Turpel-Lafond et al., 2020). These reports highlight racism as a social determinant of health and describe barriers faced by Indigenous Peoples—including those who engage in sex work—and people living with HIV.

Compared to non-Indigenous people, Indigenous Peoples in BC face lower rates of continuity of care (i.e., receiving consistent, connected, and coordinated care) and healthcare access (Turpel-Lafond et al., 2020). Despite recommendations from key reports (NIMMIWG, 2019; Truth and Reconciliation Commission of Canada, 2016; Turpel-Lafond et al., 2020; United Nations, 2007), limited progress has been made to address these inequities. It is critical to build on these reports by addressing healthcare access among Indigenous Peoples with intersecting identities.

Indigenous women, sex workers, women living with HIV, and gender diverse people live at the intersections of multiple forms of structural violence (Deering et al., 2021; Shannon et al., 2022; Socías et al., 2016; Thumath et al., 2021). Sex workers and people living with HIV continue to face significant barriers to accessing healthcare that are rooted in sex work and HIV-related stigma and violence (Benoit & Unsworth, 2022; Deering et al., 2021; Erickson et al., 2021). Indigenous women are disproportionately represented in street-based sex work, accounting for over 50% of street-based sex workers in Canada (Wilson Narciso, 2020) despite being approximately 4% of the population (Statistics Canada, 2023). This is largely due to the intergenerational effects of colonial violence and policies (Bingham et al., 2014; Wilson Narciso, 2020).

Evidence shows how culturally safe and trauma-informed healthcare services may reduce barriers to healthcare services among racialized and minoritized populations (McGough et al., 2022; Nelson& Wilson, 2018; Petrov et al., 2023). Previous research and foundational reports call for addressing barriers and the urgent need for culturally safe care for Indigenous sex workers and people living with HIV (NIMMIWG, 2019; Turpel-Lafond et al., 2020).

This study draws on data from the Amplify project, described below, focusing on Indigenous health and gender equity. The aim of this study was to evaluate factors associated with difficulty accessing routine healthcare in a cohort of marginalized Indigenous women on the unceded and traditional lands of the xʷməθkʷəy̓əm (Musqueam), Sḵwx̱ wú7mesh (Squamish), and səlilwətaɬ (Tsleil-Waututh) Nations in what is now referred to as Vancouver, Canada during the COVID-19pandemic.

METHODS

The reporting of this study was guided by the Strengthening the Reporting of Observational Studies (STROBE) guidelines for cohort studies (STROBE, n.d.).

Introducing Ourselves

This research was conducted by a multidisciplinary team with long-standing commitments to Indigenous health equity, community-based research, and gender justice. The team included Indigenous health researchers from the Nisga’a First Nation, shíshálh First Nation, and Stellat’en First Nation, alongside settler researchers with extensive experience working in partnership with sex workers and women living with HIV, through community-based and longitudinal cohort research in Vancouver.

Study Design

This study is nested within a larger project called Amplify (PI: Brittany Bingham). Amplify is an Indigenous community-based project that aims to uplift Indigenous voices to directly inform culturally safe and equitable health and justice for Indigenous women, 2S, and gender diverse peoples. Amplify and this research is guided by an Indigenous Matriarch Advisory Council which consists of Indigenous Matriarchs, Elders, Knowledge Holders, researchers, and community members.

Data for this study were drawn from two community-based studies of women in Vancouver, Canada: An Evaluation of Sex Workers’ Health Access (AESHA) and Sexual Health and HIV/AIDS: Women’s Longitudinal Needs Assessment (SHAWNA). AESHA was developed in 2010 based on extensive community collaborations with sex work agencies, and is monitored by a Community Advisory Board. SHAWNA began in 2014 and operates as a partnership that includes women living with HIV and community services providers. SHAWNA is also guided by the Community Advisory Board and the Positive Women’s Advisory Board (Duff et al., 2018; Thumath et al., 2021). Eligibility for AESHA and SHAWNA includes identifying as a cisgender or transgender woman,3 being 14 years of age or older, and being able to provide informed consent. AESHA eligibility includes having exchanged sex for money within the last 30 days (i.e., active engagement in sex work), and SHAWNA eligibility includes being diagnosed with HIV and living in and/or accessing healthcare services in Vancouver. The AESHA and SHAWNA studies are harmonized cohorts that work in close collaboration out of the same research office and via a number of harmonized procedures. Participants across both studies are issued a unique study code and are only followed up by one of the studies, so there is no unaccounted-for overlap in participants. There are some sex workers living with HIV and we have a harmonized questionnaire, so these people could be included in either AESHA or SHAWNA but would not be enrolled or followed by both studies. Further details are available on the origins of AESHA (Shannon et al., 2007) and SHAWNA (Barreto et al., 2024).

Participants completed baseline and semi-annual questionnaires that included detailed measures of socio-demographics, work and living environments, and healthcare access. Additionally, both AE-SHA and SHAWNA asked detailed check-box response questions regarding impacts of COVID-19, including self-reported assessment of how the pandemic affected health access, work environment, housing and economic factors, violence, policing, and social outcomes. Informed consent was obtained for AESHA and SHAWNA participants. To protect participants from potential legal and social harms associated with disclosing engagement in sex work, all study data were anonymized using unique study identification codes, and no identifying information was included in analytic datasets. Interviews were conducted in confidential settings by trained community interviewers with extensive lived and/or professional experience working with sex workers and women living with HIV. A unique COVID-19 supplementary questionnaire was developed alongside community members and staff who work with the cohorts’ populations. Questions and response options were based on community reports and feedback regarding these communities’ key issues and concerns during the early months of the pandemic. Due to challenges connecting with participants amid COVID-19 pandemic response measures (i.e., lockdowns, closures), the sample in this study represents a sub-sample of Indigenous participants from the AESHA and SHAWNA cohorts. All participants received an honorarium of $65 CAD at each bi-annual visit and an additional $20 for completion of the COVID-19 supplementary questions. Questionnaire visits were administered by community interviewers with extensive lived and/or professional experience working with community members.

Analytical Approach

This research aligns with the Grandmothers Perspective on disaggregated data, viewing data as a tool of care to address health inequities faced by Indigenous Peoples in Canada (BC Office of the Human Rights Commissioner, 2020). It responds to calls from key reports for research on health inequities impacting Indigenous women (cis and trans) and 2S Peoples (NIMMIWG, 2019; Truth and Reconciliation Commission, 2016; Turpel-Lafond et al., 2020). Variables were chosen and interpreted using an intersectional stigma and social determinants of health lens, considering factors like laws, policies, racialization, and health environments that shape lived experiences (Absolon et al., 2005; Logie et al., 2014; Sister Song, 2020; Tuck & Yang, 2012).

Data Analysis

Analyses were restricted to participants who self-identified as Indigenous (i.e., status [Registered First Nation band members under the Indian Act in Canadaf or non-status First Nations, Métis, and Inuit) by answering “yes” to the questionnaire measure, “Do you identify as an Aboriginal person, that is, First Nations, Métis, or Inuit?” Exposure and outcome variables are time-updated and measured semi-annually, capturing current and past six months occurrences at each study visit, unless otherwise specified. Indigenous ancestry, gender identity, and sexual orientation are treated as time-fixed variables.

The primary outcome variable, “difficulty accessing a family doctor, nurse, or clinic for routine healthcare during the COVID-19 pandemic,” was a binary variable based on asking participants whether they had experienced these changes in the prior six months since the onset of the COVID-19 pandemic. The following response options were coded as “yes”: canceled or reduced services; not able to or don’t know how to access telehealth or other virtual, phone, or online services; family doctor, nurse, or clinic doesn’t have these virtual, phone, or online services; less time to devote to people’s concerns; and afraid to use or avoid using due to fear of getting sick. Relevant other responses that were coded as “yes” included: difficulty using telehealth/virtual services; telehealth/virtual services are not sufficient to meet needs (e.g., no physical check-ups/assessments, no blood work services, etc.); longer wait times; does not have access to a doctor; less outreach services available; doctor was not helpful with answering COVID questions; and clinic closures. Participants who did not report any of these options or who did not have a family doctor, nurse, or location for accessing routine healthcare were coded as “no.”

Based on existing evidence on access to routine healthcare services among Indigenous women, 2S,4 sex workers, and women living with HIV, key individual (age, income) and structural (violence, criminalization, safety) explanatory variables were considered for inclusion in multivariable analysis. Individual and demographic variables included age; Indigenous identity (First Nations, Métis, Inuit); accessed Canada Emergency Response Benefit (CERB—governmental COVID-19 economic relief support; Pearson et al., 2022); gender identity (gender minority at any study visit, inclusive of trans [transgender, transsexual, other transfeminine identity], gender nonbinary [nonbinary, genderqueer], and/or 2S Indigenous women vs. cisgender at all study visits); sexual orientation (sexual minority identity at any study visit, inclusive of lesbian, gay, bisexual, asexual, queer, and Indigenous 2S women vs. heterosexual at all study visits); 2S identity; self-rated health as good; history of pregnancy (in lifetime); living with HIV; exchanged sex for money, goods, and services (in last six months); and lifetime mental health diagnosis. Structural variables included any physical/sexual violence by any perpetrator (in lifetime and in the last six months), non-injection or injection drug use in last six months (excluding alcohol and cannabis), and history of incarceration in lifetime (defined as in jail overnight or longer). Self-reported impacts of the COVID-19 pandemic in the last six months included experiencing changes or concerns related to psychological/emotional well-being, community safety/violence, and lacked access to culturally safe health or social services.

Statistical Analyses

Analyses were restricted to 142 participants who self-identified as Indigenous (First Nations, Métis, and Inuit) at baseline and who participated in AESHA and SHAWNA and answered the COVID-19 supplementary questionnaire for two six-month follow up periods: (1) October 2020 to March 2021, and (2) March 2021 to August 2021. Explanatory variables were stratified by outcome, and differences were compared using Pearson’s chi-squared test for categorical variables (or Fisher’s exact test where cell counts were small), and the Wilcoxon rank-sum test for continuous variables. Factors hypothesized to be associated with difficulty accessing routine healthcare during the COVID-19 pandemic were assessed using bivariate logistic regression with generalized estimating equations (GEE) using an exchangeable correlation structure. Variable selection for the multivariable model was based on theoretical considerations as well as findings of bivariate analysis (p < 0.10). Collinearity was examined in the final model using variance inflation factors. Statistical analyses were performed in SAS version 9.4 (SAS, Cary, NC). Odds ratios (OR) and adjusted odds ratios (AOR) are reported with 95% confidence intervals (CI), and all p-values are two-sided. Study visits with any missing data were excluded from the analysis. Missing data were handled using a complete case approach.

RESULTS

The analysis included 142 Indigenous participants contributing 199 observations between October2020 to August 2021. During this period, 27.5% reported experiencing difficulty accessing a family doctor/nurse/clinic for routine healthcare during the COVID-19 pandemic.

Baseline demographics (Table 1) indicate the median age of participants was 46 (IQR: 37–53). Most participants identified as First Nations (73.3%), followed by Métis (14.1%), combined First Nations and Métis (7.0%), and some unspecified Indigenous ancestry (5.6%). One-fifth identified as gender minorities, over half as sexual minorities, and 16.2% as 2S. A majority had experienced pregnancy (78.2%), nearly half were living with HIV (46.5%), and 41.6% had exchanged sex for money or goods. Most participants had a prior mental health diagnosis (75.4%) and a history of incarceration (88.7%). Almost all had experienced physical or sexual violence in their lifetime (95.8%), with 20.4% experiencing violence in the past six months. Regarding COVID-19 impacts, 70.4% reported negative changes in psychological and emotional well-being,15.5% expressed concerns about community safety or violence, 4.9% lacked access to culturally safe health or social services, and just over half (51.4%) accessed emergency economic relief (CERB).

Table 1.

Baseline demographic and structural characteristics amongst marginalized Indigenous women, stratified by difficulty accessing family doctor/nurse/clinic for routine healthcare in Metro Vancouver, Canada, 2020–2021 (n = 142)

Characteristic Total (%) (n = 142) Difficulty accessing routine healthcare*
 p-value
Yes (%) (n = 30) No (%) (n = 112)
Individual and Demographic Factors
Age (med, IQR) 45.5 (37–53) 42 (36–50) 47 (38–53) 0.269
Indigenous Identity/Ancestry
First Nation 104 (73.3) 18 (60.0) 86 (76.8) 0.196
Métis 20 (14.1) 7 (23.3) 13 (11.6)
First Nation & Métis 10 (7.0) ns 8 (7.1)
Indigenous unspecified 8 (5.6) ns 5 (4.5)
Women living with HIV 66 (46.5) 15 (50.0) 51 (45.5) 0.663
Exchanged sex for money, goods, and services* 59 (41.6) 10 (33.3) 49 (34.8) 0.367
Mental Health Diagnosis 107 (75.4) 24 (80.0) 83 (74.1) 0.506
Non-injection drug use* 73 (51.4) 15 (50.0) 58 (51.8) 0.901
Injection drug use* 41 (28.9) 6 (20.0) 35 (31.3) 0.295
Any drug use* 85 (59.9) 17 (56.7) 68 (60.7) 0.958
Minority gender identity 28 (19.7) ns 25 (22.3) 0.132
Minority sexual orientation 75 (52.8) 19 (63.6) 56 (50.0) 0.194
Two-Spirit identity 23 (16.2) ns 20 (17.9) 0.408
Minority gender identity and/or sexual orientation and/or Two-Spirit 90 (56.3) 19 (63.3) 61 (54.5) 0.384
Pregnant ever 111 (78.2) 27 (90.0) 84 (75.0) 0.136
Structural Factors
Incarceration ever 126 (88.7) 28 (93.3) 98 (87.5) 0.523
Physical/sexual violence by any perpetrator 136 (95.8) 30 (100.0) 106 (94.6) 1.00
Physical/sexual violence by any perpetrator* 29 (20.4) 8 (26.7) 21 (18.8) 0.439
COVID-19 Variables
Negative changes to psychological/emotional well-being* 100 (70.4) 28 (93.3) 72 (64.3) 0.002
Positive changes to psychological/emotional well-being* 20 (14.1) ns 17 (15.2) 0.567
Self-rated health was good* 82 (57.8) 15 (50.0) 67 (59.8) 0.282
Lacked access to culturally safe health or social services* 7 (4.9) ns ns 0.037
Increased police/security presence* 8 (5.6) ns 5 (4.5) 0.366
Concerns regarding safety or violence in community* 22 (15.5) 10 (33.3) 12 (10.7) 0.008
Accessed Canadian Emergency Response Benefit (CERB) 73 (51.4) 13 (43.3) 60 (53.6) 0.470
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All data refer to n (%) of participants unless otherwise specified

*

In the last 6 months

Note. ns = Not shown to protect the identities of marginalized participants (n < 5).

Bivariate GEE analysis (Table 2) showed that negative impacts on psychological and emotional well-being and concerns about community safety or violence were significantly associated with in-creased difficulty accessing routine healthcare. In multivariable GEE analysis (Table 2), experiencing the following self-reported impacts since the onset of the COVID-19 pandemic was associated with increased difficulty accessing routine healthcare during the pandemic: negative changes in psycho-logical and emotional well-being (AOR: 3.99, 95% CI: 1.33–11.98), lack of access to culturally safe health services (AOR: 4.67, 95% CI: 1.43–15.25), lifetime history of pregnancy (AOR: 4.71, 95% CI:1.33–16.66), and concerns regarding community safety/violence (AOR: 2.72, 95% CI: 1.06–6.94).

Table 2.

Bivariate and multivariable GEE analysis of correlates of difficulty accessing family doctor/nurse/clinic for routine healthcare among marginalized Indigenous women in Vancouver, Canada, 2020–2021 (n = 142)

Unadjusted OR (95% CI) Adjusted OR* (95% CI)
Individual and Demographic Factors
Age (per year older) 1.01 (0.97–1.05)
Women living with HIV 1.54 (0.76–3.11)
Exchanged sex for money, goods, and services* 0.64 (0.31–1.33)
Mental health diagnosis 0.91 (0.43–1.93)
Non-injection Drug use* 1.27 (0.60–2.68)
Injection Drug use* 0.54 (0.23–1.25)
Any Drug Use* 1.16 (0.53–2.53)
Minority gender identity 0.61 (0.25–1.50)
Minority sexual orientation 1.57 (0.77–3.18)
Two-Spirit identity 0.58 (0.22–1.55)
Minority gender identity and/or sexual orientation and/or Two-Spirit 1.47 (0.72–3.01) 1.58 (0.74–3.40)
Pregnant ever 2.74 (0.93–8.10) 4.71 (1.33–16.66)
Structural Factors
Physical/sexual violence by any perpetrator* 0.99 (0.39–2.50)
Incarceration ever 1.99 (0.42–9.37)
COVID-19 Variables
Negative changes to psychological/emotional wellbeing* 2.72 (1.11–6.69) 3.99 (1.33–11.98)
Positive changes to psychological/emotional wellbeing* 0.93 (0.32–2.67)
Self-rated health was good 0.75 (0.40–1.41) 1.08 (0.51–2.26)
Lacked access to culturally safe health or social services* 3.12 (0.99–9.79) 4.67 (1.43–15.25)
Concerns regarding safety or violence in community* 2.57 (1.09–6.06) 2.72 (1.06–6.94)
Increased police/security presence* 2.06 (0.58–7.35)
Accessed CERB 0.67 (0.33–1.36)
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*

Time-updated measure using the last six months as reference.

DISCUSSION

This study evaluated factors associated with difficulties in accessing routine healthcare among marginalized Indigenous women in Vancouver, Canada during the early COVID-19 pandemic (October 2020 to August 2021). Among 142 participants, 27.5% reported difficulty accessing a family doctor, nurse, or clinic for routine healthcare during this period. In the multivariable analysis, negative changes in psychological and emotional well-being, concerns regarding community safety and violence, lack of access to culturally safe health or social services, and lifetime history of pregnancy were associated with increased odds of difficulty accessing routine healthcare during the pandemic. These findings underscore the urgent need for healthcare systems to provide accessible, culturally safe, gender-inclusive, and sex work-, HIV-, and trauma-informed care.

In this study, lacking access to culturally safe health or social services was significantly associated with increased odds of difficulty accessing routine healthcare during the COVID-19 pandemic. This finding reinforces longstanding evidence that culturally unsafe healthcare environments remain acritical barrier to care for Indigenous Peoples, sex workers, and women living with HIV (Bingham et al., 2025; First Nations Health Authority, 2022; Hendry et al., 2025; Nelson & Wilson, 2018; Turpel-Lafond et al., 2020). Indigenous-specific racism, sexism, stigma, discrimination, and power imbalances within healthcare systems continue to negatively shape healthcare experiences and trust in services (Pilarinos et al., 2023; Graham et al., 2023). During the pandemic, disruptions to community organizations, outreach programs, and culturally grounded supports may have further intensified barriers to accessing safe and responsive care (Amnesty International, 2020; McBride et al., 2023). These findings underscore the urgent need for Indigenous-led, place-based, culturally safe, trauma-informed, and anti-racist healthcare systems that meaningfully centre Indigenous knowledge, leadership, self-determination, and sovereignty in healthcare delivery.

Concerns regarding community safety and violence were significantly associated with difficulty accessing routine healthcare. Urban poverty—which stems from income inequalities, expansion of the criminal justice system in areas more populated with racialized and marginalized populations, and spatial segregation, an ongoing issue prior to the pandemic—disproportionately affects Indigenous Peoples, sex workers, and women living with HIV (McNeil et al., 2015), raising barriers to healthcare access (Argento et al., 2014; Bingham et al., 2014; Goldenberg et al., 2017, 2020; Shannon et al., 2008; Tung et al., 2017). Studies in Canada and the US confirm that perceived community violence reduces routine healthcare utilization (Ceasar et al., 2020; Goldenberg et al., 2017). Our findings reinforce the importance of community safety as a determinant of healthcare access and the need for community-based strategies to support safe, uninterrupted access to care.

In our study, 70.4% of participants reported experiencing negative changes to psychological and emotional well-being during the COVID-19 pandemic, and this was associated with almost four-fold higher odds of difficulty accessing routine healthcare. This aligns with evidence of elevated stress, anxiety, and depression among Indigenous Peoples and women living with HIV during the COVID-19 pandemic (Lawal et al., 2021; Ponton et al., 2024; Sylliboy et al., 2022; Winwood et al., 2021). Poor mental health is a known barrier to primary care utilization (Barbo & Alam, 2024; Tami et al., 2022). Co-occurring public health crises, such as the COVID-19 pandemic and the ongoing toxic drug crisis in BC Canada, likely have long-term detrimental impacts on marginalized women with intersecting identities.

Although in this study gender identity and experiences of physical and sexual violence were not significantly associated with difficulty accessing routine healthcare, many participants who reported barriers to care identified as 2S/LGBTQQIA+, and almost all participants had experienced violence in their lifetime (95.8%). Lifetime history of pregnancy was associated with increased odds of difficulty accessing routine healthcare during the COVID-19 pandemic, although this finding should be interpreted cautiously given the wide confidence interval. Previous research demonstrates that stigma, discrimination, violence, and disruptions to reproductive and gender-related healthcare remain important barriers to healthcare access for Indigenous women and 2S/LGBTQQIA+ people, and these inequities were further intensified during the COVID-19 pandemic (Bodkin et al., 2015; Battered Women’s Support Services & BC Association of Aboriginal Friendship Centres, 2022; Coen-Sanchez et al., 2022; Kia et al., 2022; Tami et al., 2022; Velasco et al., 2022).

Strengths and Limitations

The study has some notable limitations. First, the COVID-19 supplementary questionnaire was introduced shortly after the pandemic began in 2020, resulting in only two data collection cycles for analysis. The sample was restricted to 142 participants who self-identified as Indigenous and completed the COVID-19 questionnaire, limiting statistical power and precision. Additionally, the study employed a community-developed measure of healthcare access, which may limit comparability with standardized measures used elsewhere but represents a strength in centering community-informed understandings and experiences of healthcare access among Indigenous participants. Data were self-reported, which can introduce recall and social desirability biases; however, the involvement of experiential and community-based interviewers helped mitigate these biases. The quantitative design limited exploration of nuanced experiences behind difficulties accessing healthcare. Findings highlight critical social and structural inequities affecting marginalized Indigenous women with intersecting identities. Future research should investigate facilitators of healthcare access and prioritize culturally safe, community-led approaches to addressing systemic barriers within the Canadian healthcare system.

Implications and Directions for Future Research

The findings from this study underscore the urgent need to address systemic and individual racism, stigma, and structural barriers within healthcare systems that marginalize Indigenous women, sex workers, people living with HIV, and gender-diverse individuals. Grounded in the calls to action from Indigenous foundational reports (NIMMIWG, 2019; Truth and Reconciliation Commission, 2016; Turpel-Lafond et al., 2020; United Nations, 2007) it is essential that Canadian healthcare systems meaningfully implement practices that are culturally safe, trauma-informed, and opposed to anti-Indigenous racism. This includes moving beyond physical accessibility to consider social and structural determinants of health, such as community safety and experiences of violence, which were strongly associated with difficulty accessing routine healthcare in this study. The implementation of culturally safe care must be Indigenous-led, centering Indigenous voices, leadership, and self-determination to ensure healthcare sovereignty and foster trust within these communities (Petrov et al., 2023). Enhancing mental health services tailored to Indigenous Peoples, sex workers, and women living with HIV is critical, especially considering the significant psychological and emotional impacts of the COVID-19 pandemic identified here. Integrating Indigenous knowledge, ceremony, and the involvement of Elders within healthcare settings can create safer, more welcoming environments that improve engagement and health outcomes (Pilarinos et al., 2023; Graham et al.,2023; Tu et al., 2019). Training for healthcare providers on cultural safety, anti-Indigenous racism, and sex work, HIV, and gender-informed care is crucial to dismantle ongoing biases, stigma, and discrimination (Lovejoy et al., 2021; McGough et al., 2022; Graham et al., 2023). Furthermore, community-based strategies that address concerns about violence and safety in neighbourhoods are necessary to ensure uninterrupted and equitable access to healthcare. The decriminalization of sex work is also recommended to reduce fear-based policing tactics that hinder access to services. Future research should prioritize partnering with Indigenous communities to understand what facilitates ac-cess to care and to co-develop actionable solutions that transform healthcare policies and practices. Involving host Nations in these efforts honours the land that health systems and services are on and respects Indigenous sovereignty. Collectively, these actions are imperative to advance health equity and justice for Indigenous women with intersecting and marginalized identities.

CONCLUSION

This study highlights the significant challenges faced by marginalized Indigenous women in accessing routine healthcare during the COVID-19 pandemic, with nearly one-third reporting difficulties. Key factors associated with these challenges include negative changes in psychological and emotional well-being, concerns about community safety and violence, and lack of access to culturally safe health services. These finding emphasize the urgent need for healthcare systems to implement culturally safe, anti-Indigenous racism, and HIV- and sex work-informed practices. Enhancing mental health services and addressing structural inequities are critical to improving health outcomes for Indigenous women, sex workers, and people living with HIV. Future efforts must prioritize Indigenous voices, leadership, and self-determination to drive actionable changes in healthcare policies and ensure equitable access for all communities disproportionately impacted by ongoing social and structural inequities.

Acknowledgements

We thank all those who contributed their time and expertise to this project, particularly participants, community advisory board members and partner agencies, and research staff, including the AMPLIFY team: Logan Burd and Sasha Askarian; the AESHA team: Emma Ettinger, Christie Gabriel, Jennifer Morris, Jennifer McDermid, Jennie Pearson, Emily Luba, Becca Norris, Danielle O’Callaghan, Natasha Feuchuk, Alex Martin, Lois Luo, Minshu Mo, Sherry Wu, Chantel Lee, Alaina Ge, and Preet Dhanda; And the SHAWNA team: the Positive Women’s Advisory Board, Community Advisory Board members, and the current SHAWNA research project staff, including Elissa Aikema, Tara Axl-Rose, Emma Kuntz, Melanie Lee, Lois Luo, Desire King, Patience Magagula, Kat Mortimer, Candice Norris, Colleen Thompson, and Larissa Wakatsuki. We also thank Majka Hahn, Melissa Braschel, Riley Tozier, Shivangi Sikri, Amber Stefanson, and Peter Vann for their operations, communications, research, and administrative support.

Footnotes

1

While the term “Indigenous” is used throughout this paper, we acknowledge the diversity in culture, traditions, and languages among and between First Nations, Inuit, and Métis Peoples of Canada.

2

Two-Spirit (2S) identity is Nation-speciJic and is an organizing strategy and or tool that is used to identify Indigenous Peoples from North America who embody diverse sexualities, genders, gender identities, and gender expressions (Hunt, 2016; Pruden & Salway, 2020).

3

Eligibility and recruitment criteria for AESHA and SHAWNA is inclusive of cis women, transgender women, transexual women, and other self-reported transfeminine identities at enrolment. We acknowledge that gender identity is Jluid and recognize that participants’ gender presentation and expression may differ throughout various times of their lives.

4

Two-Spirit identities and roles in community were drastically altered by historical and ongoing colonial violence. While Two-Spirit identity is only descriptively looked at in this study, we honour Two-Spirit roles within communities that were disrupted by colonialism and want to support the resurgence and well-being of Two-Spirit Peoples (Hunt,2016; Pruden & Salway, 2020).

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