Comparison of healthcare quality for uninsured and underinsured children through community health centres in Canada and the USA: a scoping review protocol

Background and rationale

Federally qualified health centres (FQHCs) and community health centres (CHCs) were both created to care for marginalised populations to improve healthcare outcomes.1 Developed in 1965, CHCs are not-for-profit organisations that are typically self-governed by community members, and aim to provide holistic primary healthcare in the community.2 In the USA, some CHCs qualify to receive federal funding, and are designated as FQHCs. In Canada, a similar model of healthcare delivery has also been developed, usually under the oversight of provincial government health authorities. Currently, there are over 1400 Health Resources and Services Administration (HRSA)-funded CHCs in the USA and over 200 in Canada.3 4

One of the main intents of FQHCs and CHCs is to provide access to healthcare for individuals who face marginalisation, including children who are newcomers, from families who are low-income, or have limited or no healthcare insurance.2 3 5 Although Canada has provincial health insurance, many residents are ineligible and uninsured because of their immigration status: in most provinces, provincial health insurance is only provided to citizens, permanent residents and select few other immigration classes.6 In Canada, it has been estimated that nearly 150 000 children may be uninsured7–9; in the USA, there were 5 million uninsured children from 2020 to 2021, while nearly 35.9% of all children are on Children’s Health Insurance Program (CHIP)/Medicaid.10 The number of uninsured people is expected to rise in 2023, as the continuous Medicaid coverage requirement is set to end in April, and terminations are set to resume.11

Although both countries’ models serve similar population targets, no study has examined the quality of healthcare provided for children, who remain uniquely vulnerable to poor health outcomes if unable to access care in a timely manner.12 Comparative health policy across countries can help each see their policies more clearly, and act as a barometer for policy development.13 As policy-makers face increased calls for better access to healthcare for uninsured and underinsured children and families in both Canada and the USA,11 14 this scoping review will provide a synthesis of best practices to guide decision-making at a critical time. As the purpose of this study is to synthesise knowledge and identify gaps and opportunities, a scoping review is most appropriate for this type of work.15 We could not identify a similar completed or ongoing knowledge synthesis review in searching Ovid MEDLINE ALL 1947-Present (includes Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE Daily and Ovid MEDLINE), Cochrane Library, the Open Science Framework, Google Scholar and PROSPERO as of August 2022.

Review question

What is the quality of healthcare for uninsured and underinsured children received through CHCs and FQHCs in the USA and Canada?


This scoping review protocol is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Protocols (PRISMA).16 17 The scoping review manuscript will be reported in accordance to the Scoping Review extension of PRISMA.18 We have chosen the updated methodological guidelines for scoping reviews from the Joanna Briggs Institute Evidence Synthesis to guide our work.19

Conceptual model

The Donabedian model is a well-known conceptual framework to assess healthcare quality across three major domains: structure, processes and outcomes.20 ‘Structure’ refers to the physical environment, and the administrative organisation of the healthcare setting. ‘Processes’ refer to the way healthcare is delivered, such as the appropriateness of therapies and diagnostics and care coordination. The last domain, ‘outcomes’, can be difficult to measure in a short time period, but are ultimately the indicators that improve mortality and morbidity in patients, such as time to recovery or reduced length of stay in an inpatient setting. In a primary care or outpatient setting, this may include patient-reported outcomes, time to diagnosis or referrals.21 22 The Donabedian model has been used in other similar studies, and thus is well suited to this scoping review.1


In this study, our population of interest are newborns, infants and children (0–18 years of age) living in the USA or Canada, who are uninsured or underinsured, and have received care at, or been referred to a CHC and/or FQHC for general paediatric or subspecialty care. These include newborns, infants and children in Canada or the USA, or are underinsured, which defined as being covered by Medicaid or CHIP in the USA, or the Interim Federal Health Programme in Canada. Such individuals could be citizens of the USA or Canada; permanent residents; government-assisted or privately sponsored refugees; asylees and asylum seekers; or undocumented children and youth who do not have any private or public health insurance. In contrast, adequately insured children and youth under 0–18 years of age would include children who have public health insurance in Canada (ie, Ontario Health Insurance Programme), or private health insurance in either the USA or Canada.

Inclusion criteria

To capture all perspectives, study designs will be considered eligible for inclusion if they meet the following inclusion criteria: (a) any study design type (ie, original research, review, commentary); (b) written in the official languages of Canada and the USA (English and/or French); (c) if the study location is in the USA or Canada; (d) if the study population includes uninsured or underinsured newborns, infants, children (0–18) seen in a CHC or FQHC, as all FQHCs operate as CHCs but not all CHCs are considered FQHCs and (e) if the study was published between 1965 and present, as 1965 marks the advent of the concept of the modern CHC.

Exclusion criteria

Study protocol publications will be excluded from this review, as they are not relevant to the research questions. Additionally, studies that are not written in English or French will be excluded, as the multilingual research team does not have the capacity to assess these studies. Studies that are published before 1965 will be excluded, as these will not use the modern, and now used, CHC model. Other exclusion criteria include studies which have been conducted outside of USA or Canada, if the study population does not include a CHC or FQHC, and if the study participants do not include any subjects under the age of 18 years old.

Information sources

An information specialist (SC) will search the following five databases: (a) Ovid MEDLINE ALL 1947-Present (includes Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE Daily and Ovid MEDLINE); (b) CINAHL Complete via EbscoHost; (c) Scopus; (d) Health Business Elite via EbscoHost and (e) Sociological Abstracts via ProQuest. In addition to the peer-reviewed literature, we will also review sources from the grey literature including federal policies in both Canada and the USA; white papers and policy briefs published by federal, state or provincial government bodies; and information shared by relevant stakeholder groups (ie, Council of CHCs). Additionally, we may speak with included study authors to identify further sources of information. Once the final articles are selected after the double screening stages, the reference lists of those selected articles will be searched to identify additional papers that were not captured in the search.

Search strategy

A comprehensive search in Ovid MEDLINE ALL 1947-Present (includes Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE Daily and Ovid MEDLINE) will be conducted using the identified search terms (online supplemental appendix 1). The search will include a combination of subject headings and text words for the concepts of medically uninsured newborns, infants and children, and CHCs and FQHCs. Date limits will be set from 1965- present, and results will be limited to English or French language only. The search strategy was peer-reviewed by another Information Specialist using Canada’s Drug and Health Technology Agency (CADTH)’s Peer Review of Electronic Search Strategies checklist23 before being finalised in this protocol, and translated as appropriate into CINAHL Complete via EbscoHost, Scopus, Health Business Elite via EbscoHost and Sociological Abstracts via ProQuest.

Supplemental material

In addition to the peer-reviewed literature, we will also search the grey literature following the methodology outlined by Godin et al (online supplemental appendix 2).24 First, we will search grey literature databases in Canada and the USA, such as the Agency for Health Research and Quality. Next, we will conduct a search of targeted websites. This will involve two steps: first, we will use the CADTH Grey Matters tool25 to identify organisations that have published information on healthcare utilisation in CHCs and FQHCs. Next, we will conduct a Google search to identify key organisations and associations, and subsequently review their websites for any publications that may be relevant (ie, reports). All elements of the search will be recorded, including the date, specific terms used, the number of websites retrieved and screened into our reference manager. Lastly, to identify other grey literature sources, we will speak with a variety of stakeholders that have understand the context of practice in FQHCs or CHCs. This may include physicians who care for children, including paediatricians in the FQHC listserv with the American Academy of Pediatrics, managers, administrators, policy-makers such as health departments. We will contact context experts from the Canadian Association of Community Health Centres and the National Association of Community Health Centers in the USA by email to connect us with any relevant reports or documents or connect with other providers. The number of individuals contacted, responded and the number of documents recommended and subsequently included will be recorded.

Supplemental material

Data management

After running the searches, the information specialist (SC) will deduplicate all database results in EndNote V.X9 using a simplified version of the Bramer method.26 These deduplicated results will then be imported into the screening and data extraction software Covidence.

Selection process

Pilot screening among the team will take place before the formal screening process using the titles and abstracts of 10% of the total number of titles and abstracts in Covidence to determine inter-rater reliability. Two levels of screening will take place in Covidence: double-blind title and abstract screening, and double-blind full-text screening using the predetermined inclusion and exclusion criteria to determine eligibility. Disagreements will be resolved by assessment by a third, independent reviewer. Articles will be then read by two reviewers for full-text review and excluded articles at the full-text screening stage will be reported in a PRISMA flow chart automated by Covidence. After undergoing full-text review, the references of articles that meet inclusion criteria will be reviewed and cross-checked to determine if any additional articles may meet inclusion criteria.

Data extraction

We are using the Donabedian conceptual framework to measure health quality to guide data extraction performed in Covidence. Data extracted include year of publication, year of data collection, country and city of study, setting (CHC or FQHC), population, study design and objectives. Study population data to be extracted include age, sex, immigration status (ie, immigrant, refugee), insurance status. Variables relating to structure may include items related to administrative or governance structure and staff knowledge. With respect to processes, we will extract information related to how paediatric care is obtained, including utilisation measure (ie, number of children seen) or referral rates. Outcomes will relate to data that describes the impact on children seen in these centres, based on the simplified framework from the Agency for Healthcare Quality and Research: care that is safe, effective and efficient.27 Additional variables will be determined once an abstract review is completed.

Quality assessment

As this is a scoping review intended to identify gaps in the published literature, we will not be conducting a quality assessment.19

Data synthesis

Data will be described in a narrative format, using thematic analysis based on the three major components of the Donabedian framework: structure, processes and outcomes. It is our intent that the results of this analysis will serve the basis of opportunities for improved service provision through CHCs in both Canada and the US and for future research directions.

Patient and public involvement


Ethics and dissemination

As this review is only accessing publicly available and published literature, and is not using any patient-related data, we are exempt from requiring a submission to an ethics review board. This scoping review is the first part of a study to compare the quality of healthcare provided to uninsured and underinsured children in the USA and Canada through CHCs. We plan to share our results in at national and international conferences and submit our findings to a peer-reviewed journal. In addition, as there are relevant policy decisions that can be gleaned from our findings, we also have an additional knowledge translation and advocacy angle to our dissemination. We plan to prepare a policy brief or white paper to accompany our peer-reviewed publication, which will be shared with state, provincial and federal policy-makers. At a time when access to adequate paediatric care is of concern in both the USA and Canada, we hope that our review identifies opportunities to improve models of care for children living at the margins in both countries.

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