Why cultural safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition

Seeking Help From Primary Health-Care Providers in High-Income Countries: A Scoping Review of the Experiences of Migrant and Refugee Survivors of Domestic Violence

Migrant and refugee women experiencing domestic violence (DV) may face compounding factors that impact their ability and experiences of seeking help. Health-care providers are in a unique position to identify and assist victims of DV, however, they often lack the confidence and training to do this well. Little is known of the health-care experiences of migrant and refugee women experiencing abuse when they access primary health care (PHC). Using scoping review methodology, we undertook a systematic search of seven databases (Medline, Scopus, ProQuest, CINAHL, Informit Complete, and Google Scholar). We sought peer-reviewed and grey literature, published in English between January 1980 and August 2021 that identified women (18+) who had experienced DV, from low- or middle-income countries (LMICs), seeking help or health care in a primary care setting of a high-income country (HIC). Nine articles met the inclusion criteria. Findings identify sociocultural and sociopolitical barriers for migrant and refugee women seeking help for DV, which are contextualized within the ecological model. Migration-related factors and fear were major barriers for migrant and refugee women, while kindness, empathy and trust in health-care providers, and children's well-being were the strongest motivators for help-seeking and disclosure. This review provides insight into an under-researched and marginalized group of victim-survivors and highlights the need for increased awareness, guidance, and continuing education for health-care providers and health-care systems to provide best practice DV care for migrant and refugee women.

Refugee child health: a systematic review of health conditions in children aged 0-6 years living in high-income countries

This study describes the extent, quality and cultural appropriateness of current research on the health conditions of refugee children aged 0-6 years settled in high-income countries. A systematic review was conducted, including original articles published on the health conditions experienced by refugee children. A total of 71 papers were included. The studies varied considerably in their research design, population characteristics and health conditions. Studies included information on 37 different health conditions, with the majority non-communicable diseases, in particular growth, malnutrition and bone density. Although the studies identified a wide range of health issues, a coordinated effort to prioritise research on particular health topics was lacking, and health conditions studied do not align with the global burden of disease for this population. Additionally, despite being rated medium-high quality, most studies did not describe measures taken to ensure cultural competency and community involvement in their research. We suggest a coordinated research effort for this cohort, with greater emphasis on community engagement to improve the evidence-base of the health needs of refugee children after settlement.

Te Paatu o Te Ao Hurihuri - pandemic-related virtual adaptation of an established marae-based workshop for rural doctors: a qualitative study

Introduction Due to COVID-19 pandemic restrictions in Aotearoa New Zealand, an established remote community marae-based workshop (a component of a postgraduate rural medical programme) was converted into a virtual platform. Aim The aim of this study was to explore student and teacher experiences of this virtual adaptation with focus on cultural aspects. Methods A qualitative exploratory study was undertaken that involved document review and qualitative interviews. Students and teachers were invited to participate. Semi-structured interviews were conducted. Thematic analysis was undertaken using a framework-guided rapid analysis method. The two participant groups' data were analysed concurrently but separately. Results Students found the virtual workshop valuable in furthering their knowledge of Māori culture, cross-cultural communication skills and health inequities in rural clinical practice. Through the innovative efforts of their teachers, they felt some sense of connection with the remote locality and its people. Teachers were able to impart knowledge, connect and keep everyone culturally safe through their commitment and adaptability. However, moving to a virtual platform meant compromise to the cultural experience for students and loss of sharing the learning and experience with their place and their people. Discussion In the event of a further pandemic or other emergency situation, where strong established relationships exist, replacing an in-person remote marae-based workshop with a virtual workshop, while limited, is achievable and has value. When urban tertiary institutions partner with remote Māori communities to deliver virtual teaching, caution is needed in ensuring sustained transparency in priorities and expectations to avoid further exacerbations of power imbalance and resulting loss of value.

Correlation between cultural competence, xenophobia, and attitudes towards brain drain in nursing students

This study aimed to determine the correlation between cultural competence, xenophobia, and attitudes to brain drain in nursing students. Individuals with high levels of intercultural competence have more successful social and emotional interactions with people from various cultural backgrounds. A cross-sectional and correlational design was used. This study was conducted on 473 nursing students from two different provinces neighboring the Syrian border between October 28th and December 28th, 2021. An information form and nurse cultural competence, xenophobia, and attitude scales for brain drain were used to collect data. A negative nonsignificant correlation between cultural competence and xenophobia and a positive nonsignificant correlation between cultural competence and attitude towards brain drain were found. The students had high levels of cultural competence and positive attitudes towards brain drain, and a moderate level of xenophobia. Socio-demographic characteristics affected cultural competence, xenophobia, and attitudes towards brain drain.

Developing the intersectionality supplemented Consolidated Framework for Implementation Research (CFIR) and tools for intersectionality considerations

BACKGROUND

The concept of intersectionality proposes that demographic and social constructs intersect with larger social structures of oppression and privilege to shape experiences. While intersectionality is a widely accepted concept in feminist and gender studies, there has been little attempt to use this lens in implementation science. We aimed to supplement the Consolidated Framework for Implementation Research (CFIR), a commonly used framework in implementation science, to support the incorporation of intersectionality in implementation science projects by (1) integrating an intersectional lens to the CFIR; and (2) developing a tool for researchers to be used alongside the updated framework.

METHODS

Using a nominal group technique, an interdisciplinary framework committee (n = 17) prioritized the CFIR as one of three implementation science models, theories, and frameworks to supplement with intersectionality considerations; the modification of the other two frameworks are described in other papers. The CFIR subgroup (n = 7) reviewed the five domains and 26 constructs in the CFIR and prioritized domains and constructs for supplementation with intersectional considerations. The subgroup then iteratively developed recommendations and prompts for incorporating an intersectional approach within the prioritized domains and constructs. We developed recommendations and prompts to help researchers consider how personal identities and power structures may affect the facilitators and inhibitors of behavior change and the implementation of subsequent interventions.

RESULTS

We achieved consensus on how to apply an intersectional lens to CFIR after six rounds of meetings. The final intersectionality supplemented CFIR includes the five original domains, and 28 constructs; the outer systems and structures and the outer cultures constructs were added to the outer setting domain. Intersectionality prompts were added to 13 of the 28 constructs.

CONCLUSION

Through an expert-consensus approach, we modified the CFIR to include intersectionality considerations and developed a tool with prompts to help implementation users apply an intersectional lens using the updated framework.

Toward a new model of childhood asthma care: community needs assessment in an underserved urban population

OBJECTIVES

The objective of this study was to utilize a community-engaged research approach to better understand gaps and opportunities for improving asthma care from the perspectives of patients, caregivers, community organization representatives, and healthcare providers in a predominantly minority community.

METHODS

Forty-one participants from four groups (patients, caregivers, community organization representatives, healthcare providers) participated in interviews or focus groups. A phenomenological approach to this qualitative research allowed the research team to better understand the lived experiences of families seeking asthma care in this community.

RESULTS

Five gaps and five corresponding opportunities were identified. The gaps identified were unequal healthcare resource distribution; underrepresentation of health professionals from diverse backgrounds; experiences of environmental racism; mistrust, bias, and discrimination in healthcare encounters; and systemic marginalization of communities. The opportunities identified include increasing healthcare infrastructure and accessibility; increasing racially, culturally, and linguistically congruent healthcare; implementing equitable improvements to the built environment; building relationships with communities and individuals; and acknowledging communities' strengths and resilience.

CONCLUSION

This study identified systemic gaps to asthma care that are of prominent concern to the community.

An Evidence-Based Approach for Treating Stress and Trauma due to Racism

Racism can be stressful or even traumatizing. Psychological unwellness emerges out of the confluence of historical, cultural, and individual experiences, and resulting syndromes may or may not fit into a DSM-5 PTSD diagnostic framework. Although racial stress and trauma are common presentations in therapy, few therapists have the resources or training to treat these issues. Based on the empirical evidence to date, this article describes the essential components of treatment for racial stress and trauma from a cognitive-behavioral perspective, called the Healing Racial Trauma protocol. Each technique is described with reference to the literature supporting its use for racial stress and trauma, along with guidance for how therapists might implement the method with clients. Also provided is information about sequencing techniques for optimal outcomes. Critical therapist prerequisites for engaging in this work are also discussed, with an emphasis on an anti-racist, empathy-centered approach throughout.

Cultural safety in telehealth consultations with Indigenous people: A scoping review of global literature

INTRODUCTION

Telehealth has become increasingly routine within healthcare and has potential to reduce barriers to care, including for Indigenous populations. However, it is crucial for practitioners to first ensure that their telehealth practice is culturally safe. This review aims to describe the attributes of culturally safe telehealth consultations for Indigenous people as well as strategies that could promote cultural safety.

METHODS

A scoping review was conducted on key features of cultural safety in telehealth for Indigenous people using the Johanna Briggs Institute (JBI) guidelines and PRISMA-ScR checklist. Five electronic databases were searched, and additional literature was identified through handsearching.

RESULTS

A total of 649 articles were screened resulting in 17 articles included in the review. The central themes related to the provision of culturally safe telehealth refer to attributes of the practitioner: cultural and community knowledge, communication skills and the building and maintenance of patient-provider relationships. These practitioner attributes are modified and shaped by external environmental factors: technology, the availability of support staff and the telehealth setting.

DISCUSSION

This review identified practitioner-led features which enhance cultural safety but also recognised the structural factors that can contribute, both positively and negatively, to the cultural safety of a telehealth interaction. For some individuals, telehealth is not a comfortable or acceptable form of care. However, if strategies are undertaken to make telehealth more culturally safe, it has the potential to increase opportunities for access to care and thus contribute towards reducing health inequalities faced by Indigenous peoples.

Transforming Occupational Therapy for the 21st Century PAIRE: Recognize Privilege, Acknowledge Injustice, and Reframe Perspective to Reach Equity

Theories, models, and frameworks provide the foundation for occupational therapy education, research, and clinical practice. While most have a systems approach focus, other factors, such as societal influences and structural inequities, also contribute to health. Using a cross-sectional design, this study identified the gaps in occupational therapy models of practice and presents a novel approach, the PAIRE (Recognize Privilege, Acknowledge Injustice, and Reframe Perspective to Reach Equity) Model. PAIRE is focused on achieving occupational equity through the reciprocal and intersectional impact of the provider/team, the person/people seeking occupational therapy, and the occupation-in-context, with continuous influences of access, context, and justice. We describe the components of PAIRE and illustrate its functionality in education, research, and clinical practice contexts as well as case examples.

A scoping review of the barriers and facilitators to accessing and utilising mental health services across regional, rural, and remote Australia

BACKGROUND

Inadequate healthcare access and utilisation are implicated in the mental health burden experienced by those living in regional, rural, and remote Australia. Facilitators that better enable access and utilisation are also reported in the literature. To date, a synthesis on both the barriers and facilitators to accessing and utilising mental health services within the rural Australian context has not been undertaken. This scoping review aims to (1) synthesise the barriers and facilitators to accessing and utilising mental health services in regional, rural, and remote Australia, as identified using the Modified Monash Model; and (2) better understand the relationship between barriers and facilitators and their geographical context.

METHODS

A systematic search of Medline Complete, EMBASE, PsycINFO, Scopus, and CINAHL was undertaken to identify peer-reviewed literature. Grey literature was collated from relevant websites. Study characteristics, including barriers and facilitators, and location were extracted. A descriptive synthesis of results was conducted.

RESULTS

Fifty-three articles were included in this scoping review. Prominent barriers to access and utilisation included: limited resources; system complexity and navigation; attitudinal and social matters; technological limitations; distance to services; insufficient culturally-sensitive practice; and lack of awareness. Facilitators included person-centred and collaborative care; technological facilitation; environment and ease of access; community supports; mental health literacy and culturally-sensitive practice. The variability of the included studies precluded the geographical analysis from being completed.

CONCLUSION

Both healthcare providers and service users considered a number of barriers and facilitators to mental health service access and utilisation in the regional, rural, and remote Australian context. Barriers and facilitators should be considered when re-designing services, particularly in light of the findings and recommendations from the Royal Commission into Victoria's Mental Health System, which may be relevant to other areas of Australia. Additional research generated from rural Australia is needed to better understand the geographical context in which specific barriers and facilitators occur.

Systematic review of Indigenous cultural safety training interventions for healthcare professionals in Australia, Canada, New Zealand and the United States

OBJECTIVE

To synthesise and appraise the design and impact of peer-reviewed evaluations of Indigenous cultural safety training programmes and workshops for healthcare workers in Australia, Canada, New Zealand and/or the United States.

DESIGN

Systematic review.

DATA SOURCES

Ovid Medline, Embase, PsycINFO, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Bibliography of Indigenous Peoples in North America, Applied Social Sciences Index & Abstracts, ERIC (Education Resources Information Center), International Bibliography of the Social Sciences, ProQuest Dissertations & Theses Global, Sociological Abstracts, and Web of Science's Social Sciences Citation Index and Science Citation Index from 1 January 2006 to 12 May 2022.

ELIGIBILITY CRITERIA

Studies that evaluated the outcomes of educational interventions for selecting studies: designed to improve cultural safety, cultural competency and/or cultural awareness for non-Indigenous adult healthcare professionals in Canada, Australia, New Zealand or the United States.

DATA EXTRACTION AND SYNTHESIS

Our team of Indigenous and allied scientists tailored existing data extraction and quality appraisal tools with input from Indigenous health service partners. We synthesised the results using an iterative narrative approach.

RESULTS

2442 unique titles and abstracts met screening criteria. 13 full texts met full inclusion and quality appraisal criteria. Study designs, intervention characteristics and outcome measures were heterogeneous. Nine studies used mixed methods, two used qualitative methods and two used quantitative methods. Training participants included nurses, family practice residents, specialised practitioners and providers serving specific subpopulations. Theoretical frameworks and pedagogical approaches varied across programmes, which contained overlapping course content. Study outcomes were primarily learner oriented and focused on self-reported changes in knowledge, awareness, beliefs, attitudes and/or the confidence and skills to provide care for Indigenous peoples. The involvement of local Indigenous communities in the development, implementation and evaluation of the interventions was limited.

CONCLUSION

There is limited evidence regarding the effectiveness of specific content and approaches to cultural safety training on improving non-Indigenous health professionals' knowledge of and skills to deliver quality, non-discriminatory care to Indigenous patients. Future research is needed that advances the methodological rigour of training evaluations, is focused on observed clinical outcomes, and is better aligned to local, regional,and/or national Indigenous priorities and needs.

An evaluation of a prescribed joint book reading intervention for preschool children with speech, language and communication needs

Purpose: The aims of the present study were twofold: first, to investigate reading and screen time habits in a large clinical sample of caregivers of children with speech, language and communication needs (SLCN) before and after an 8 week intervention focussed on daily joint book reading and, second, to capture the caregivers' experiences of the activity.Method: Preschool aged children with SLCN and their caregivers were consecutively recruited during their first visit to the department of Speech and Language Pathology, Gävle County Hospital, Sweden. They participated in a survey-based interview before and after receiving an intervention with recommendations of at least 10 minutes of daily book reading with an interactional focus, as an add-on to ordinary speech-language pathology services. The results were analysed using descriptive statistics of the answers to the questions in the interview, as well as a thematic analysis of free-text comments.Result: The 135 families who participated in the pre-intervention interview survey reported variable reading frequency and screen time. The post-intervention interview survey was completed by 107 families. The results demonstrated significant increases in reading frequency and reading time, and a significant decrease in screen time per day. Caregivers also reported positive experiences of the daily interactive book reading.Conclusion: The results of this study demonstrate that a speech-language pathologist-(SLP) managed, caregiver-led book reading intervention is feasible and might have a positive impact on reading, other factors related to reading, and screen time in families of children with SLCN.

Locating Culturally Safe Care in Narratives of Historical Trauma and Health in Guam: A Third-Space Model of CHamoru Health

We sought to understand contemporary health beliefs and practices of the CHamorus of Guam in the context of their perceptions of historical trauma. Narrative analysis of 20 story-eliciting interviews with 10 CHamoru adults identified stories of health and illness and living in-betweenness, wherein participants described navigation between health practices of Traditional and Western cultures in the centuries-long involvement with the colonizing culture. Those connections pointed to a conceptual third-space, informed by Homi Bhabha, in which historical trauma and the in-betweenness of Traditional and Western health open new possibilities of what culturally safe health care might look like for CHamorus.

Rural-Urban Disparities in Video Telehealth Use During Rapid Mental Health Care Virtualization Among American Indian/Alaska Native Veterans

Importance

American Indian/Alaska Native veterans experience a high risk for health inequities, including mental health (MH) care access. Rapid virtualization of MH care in response to the COVID-19 pandemic facilitated care continuity across the Veterans Health Administration (VHA), but the association between virtualization of care and health inequities among American Indian/Alaska Native veterans is unknown.

Objective

To examine differences in video telehealth (VTH) use for MH care between American Indian/Alaska Native and non-American Indian/Alaska Native veterans by rurality and urbanicity.

Design, Setting, and Participants

In this cohort study, VHA administrative data on VTH use among a veteran cohort that received MH care from October 1, 2019, to February 29, 2020 (prepandemic), and April 1 to December 31, 2020 (early pandemic), were examined.

Exposures

At least 1 outpatient MH encounter during the study period.

Main Outcomes and Measures

The main outcome was use of VTH among all study groups (ie, American Indian/Alaska Native, non-American Indian/Alaska Native, rural, or urban) before and during the early pandemic. American Indian/Alaska Native veteran status and rurality were examined as factors associated with VTH utilization through mixed models.

Results

Of 1 754 311 veterans (mean [SD] age, 54.89 [16.23] years; 85.21% male), 0.48% were rural American Indian/Alaska Native; 29.04%, rural non-American Indian/Alaska Native; 0.77%, urban American Indian/Alaska Native; and 69.71%, urban non-American Indian/Alaska Native. Before the pandemic, a lower percentage of urban (b = -0.91; SE, 0.02; 95% CI, -0.95 to -0.87; P < .001) and non-American Indian/Alaska Native (b = -0.29; SE, 0.09; 95% CI, -0.47 to -0.11; P < .001) veterans used VTH. During the early pandemic period, a greater percentage of urban (b = 1.37; SE, 0.05; 95% CI, 1.27-1.47; P < .001) and non-American Indian/Alaska Native (b = 0.55; SE, 0.19; 95% CI, 0.18-0.92; P = .003) veterans used VTH. There was a significant interaction between rurality and American Indian/Alaska Native status during the early pandemic (b = -1.49; SE, 0.39; 95% CI, -2.25 to -0.73; P < .001). Urban veterans used VTH more than rural veterans, especially American Indian/Alaska Native veterans (non-American Indian/Alaska Native: rurality b = 1.35 [SE, 0.05; 95% CI, 1.25-1.45; P < .001]; American Indian/Alaska Native: rurality b = 2.91 [SE, 0.38; 95% CI, 2.17-3.65; P < .001]). The mean (SE) increase in VTH was 20.34 (0.38) and 15.35 (0.49) percentage points for American Indian/Alaska Native urban and rural veterans, respectively (difference in differences [DID], 4.99 percentage points; SE, 0.62; 95% CI, 3.77-6.21; t = -7.999; df, 11 000; P < .001), and 12.97 (0.24) and 11.31 (0.44) percentage points for non-American Indian/Alaska Native urban and rural veterans, respectively (DID, 1.66; SE, 0.50; 95% CI, 0.68-2.64; t = -3.32; df, 15 000; P < .001).

Conclusions and Relevance

In this cohort study, although rapid virtualization of MH care was associated with greater VTH use in all veteran groups studied, a significant difference in VTH use was seen between rural and urban populations, especially among American Indian/Alaska Native veterans. The findings suggest that American Indian/Alaska Native veterans in rural areas may be at risk for VTH access disparities.

The Human Library and the development of cultural awareness and sensitivity in occupational therapy students: a mixed methods study

Introduction

Monash university in Australia has adopted the Human Library as a teaching activity aimed at enhancing occupational therapy (OT) students' cultural awareness and sensitivity; however, its effect on cultural competence in healthcare profession students has not been previously investigated.

Aim

To examine whether participation in a Human Library can facilitate the development of OT students' cultural awareness and sensitivity and to understand the factors contributing to changes in cultural competence from the students' perspective.

Method

This is a mixed-method study. Quantitative data was collected by participant characteristic survey and pre/post-Human Library cultural competence assessment (CCA). The quantitative data was used to inform the selection of participants and questions for the second qualitative phase. Quantitative data were analyzed using independent samples and paired t-tests, analysis of variance and Pearson correlation. Qualitative data were analyzed using coding reliability thematic analysis.

Results

Statistically significant increases were noted in CAS, CCB and overall CCA scores from pre- to post-Human Library. Participant characteristics such as gender, work experience in aged care and the health sector had a positive effect on pre-Human Library CCA results. Qualitative data demonstrated that participants perceived they had a level of cultural competence prior to attending the Human Library however, still made gains in cultural awareness and sensitivity and were motivated and inspired to provide culturally congruent healthcare.

Conclusion

The Human Library can be considered for inclusion within a suite of learning methods for healthcare professional student curricula as a cost-effective, flexible teaching method for the development of competencies for culturally congruent healthcare.

Social determinants of health: critical consciousness as the core to collective impact

Social determinants of health have become widely recognized as important to overall health. Many areas of social determinants of health are growing from policy to reimbursement to the connecting of health and social care. The efforts around social determinants of health require reflection and awareness of structural issues. The work of Paulo Freire in critical consciousness provides guidance for how to engage in social determinants of health efforts. This manuscript offers a summary of the social determinants of health under the guidance of critical consciousness to build skills and interactions to promote social care to build toward health equity.

Implementing Parenting Programs in Primary Care: A Framework and a Call for Action

Healthy parent-child relationships are clearly critical to healthy child development. Parenting programs develop caregivers' skills to support the health and well-being of children. Rigorous evidence has demonstrated the efficacy of these programs. Rising rates of child and youth depression, anxiety, grief, and suicide, both prior to and compounded by the COVID-19 pandemic, provide further reasons to implement parenting programs that support all parents in their essential roles. Parents can act as a buffer to stressors and support for children's well-being when they have the knowledge and skills to do so. Pediatric primary care practices are a natural setting for parenting programs, but challenges, including stigma, technology, workflow issues, and funding, have prevented their broad dissemination, implementation, and sustainability. In this article, we develop a framework for implementing parenting programs in primary care and present key considerations for selecting programs that fit the needs of parents, providers, patients, and the practice. We offer lessons from our experiences in overcoming these challenges, using the updated Consolidated Framework for Implementation Research to structure our discussion. We also provide an initial stepwise process which readers may use to plan their own parenting program implementation. Pediatric clinicians and practices can use this article and associated resources to plan, implement, and evaluate parenting programs in their practices as a strategy to help address the growing youth mental health crisis. Improving parenting behaviors can reduce the need for current or future mental health interventions by supporting optimal child development, emotional regulation, and parent-child relationships.

Race, Healthcare, and Health Disparities: A Critical Review and Recommendations for Advancing Health Equity

An overwhelming body of evidence points to an inextricable link between race and health disparities in the United States. Although race is best understood as a social construct, its role in health outcomes has historically been attributed to increasingly debunked theories of underlying biological and genetic differences across races. Recently, growing calls for health equity and social justice have raised awareness of the impact of implicit bias and structural racism on social determinants of health, healthcare quality, and ultimately, health outcomes. This more nuanced recognition of the role of race in health disparities has, in turn, facilitated introspective racial disparities research, root cause analyses, and changes in practice within the medical community. Examining the complex interplay between race, social determinants of health, and health outcomes allows systems of health to create mechanisms for checks and balances that mitigate unfair and avoidable health inequalities. As one of the specialties most intertwined with social medicine, emergency medicine (EM) is ideally positioned to address racism in medicine, develop health equity metrics, monitor disparities in clinical performance data, identify research gaps, implement processes and policies to eliminate racial health inequities, and promote anti-racist ideals as advocates for structural change. In this critical review our aim was to (a) provide a synopsis of racial disparities across a broad scope of clinical pathology interests addressed in emergency departments-communicable diseases, non-communicable conditions, and injuries-and (b) through a race-conscious analysis, develop EM practice recommendations for advancing a culture of equity with the potential for measurable impact on healthcare quality and health outcomes.

Supporting the Respiratory Health of Migrants and Refugees

Migrants and refugees are at risk of developing acute and chronic respiratory diseases at their destination countries. Yet, people from these populations are also least likely to access care within the current health care system across the world. Although biological, psychological, and social factors play a role in influencing risk of respiratory diseases among these populations, the influences from cultural differences on health behaviors cannot be ignored. Cultural differences are influential in affecting an individual's level of health literacy. Health professionals can contribute to the provision of equitable care to diverse communities through addressing issues related to linguistic and cultural differences.

Decolonizing Global Child Health Education for More Equitable and Culturally Safe Collaborations

Global health (GH) as an academic field is fraught with both historical and present systemic injustice, including unilateral partnerships; power asymmetry in grant funding and research agenda setting; lack of acknowledgment of contributions from low- and middle-income country collaborators; and disadvantageous bias toward low- and middle-income country institutions. Reflecting on the legacies of colonialism and White supremacy is vital for training pediatricians to actively work to improve the health of all children worldwide, within bidirectional and culturally safe partnerships in which power dynamics and ethnocentrism are dismantled. In this article, we discuss the present challenges within academic GH education (GHE) and offer four key action steps to decolonize GHE: (1) reflecting on the history of global child health; (2) creating a new language framework on pertinent concepts in GHE; (3) developing cultural humility, antiracism, and decolonization curricula; and (4) intentional institutional action steps to decolonize and sustain culturally safe global child health education. [Pediatr Ann. 2023;52(9):e344-e350.].

Patient representation in New Zealand general practice and rural health case-based teaching: a quality improvement exercise

Introduction Healthcare inequity disproportionately affects minority populations in Aotearoa New Zealand. Healthcare providers may contribute to inequity due to their biases. Medical education can unintentionally promote biases by reinforcing stereotypes or limiting exposure to diversity. Teaching staff from the Department of General Practice and Rural Health suggested a need to review current teaching materials to ascertain if they have the potential to contribute to this bias. Aim The aim of this study was to review case-based teaching material to determine its representation of the New Zealand population, and whether there is potential to contribute to implicit bias. Methods Document analysis of 135 cases used to teach fourth- and fifth-year medical students in the Department of General Practice and Rural Health, Otago Medical School was performed. Demographic, clinical and social features of each case were recorded and analysed. Results Cases typically included patient age (129/135, 95.6%), sex (127/135, 94.1%) and occupation status (91/136, 66.9%). Ethnicity (31/135, 23.0%), living situation (55/135, 40.7%), relationship status (57/135, 42.2%) and sexual orientation (52/135, 40.0%) were less frequently defined. Cases typically represented the population majority norms. Discussion Case-based teaching materials require regular review and updating to match population demographics. There is potential to improve representation of diversity, and hence cultural safety, though review and revision of written teaching cases.

"The most culturally safe training I've ever had": the co-design of a culturally safe Managing hepatitis B training course with and for the Aboriginal health workforce of the Northern Territory of Australia

BACKGROUND

The Aboriginal health workforce provide responsive, culturally safe health care. We aimed to co-design a culturally safe course with and for the Aboriginal health workforce. We describe the factors which led to the successful co-design, delivery, and evaluation of the "Managing hepatitis B" course for the Aboriginal health workforce.

METHODS

A Participatory Action Research approach was used, involving ongoing consultation to iteratively co-design and then develop course content, materials, and evaluation tools. An Aboriginal and Torres Strait Islander research and teaching team received education in chronic hepatitis B and teaching methodologies. Pilot courses were held, in remote communities of the Northern Territory, using two-way learning and teach-back methods to further develop the course and assess acceptability and learnings. Data collection involved focus group discussions, in-class observations, reflective analysis, and use of co-designed and assessed evaluation tools.

RESULTS

Twenty-six participants attended the pilot courses. Aboriginal and Torres Strait Islander facilitators delivered a high proportion of the course. Evaluations demonstrated high course acceptability, cultural safety, and learnings. Key elements contributing to success and acceptability were acknowledging, respecting, and integrating cultural differences into education, delivering messaging and key concepts through an Aboriginal and Torres Strait Islander lens, using culturally appropriate approaches to learning including storytelling and visual teaching methodologies. Evaluation of culturally safe frameworks and findings from the co-design process led to the creation of a conceptual framework, underpinned by meeting people's basic needs, and offering a safe and comfortable environment to enable productive learning with attention to the following: sustenance, financial security, cultural obligations, and gender and kinship relationships.

CONCLUSIONS

Co-designed education for the Aboriginal health workforce must embed principles of cultural safety and meaningful community consultation to enable an increase in knowledge and empowerment. The findings of this research can be used to guide the design of future health education for First Nations health professionals and to other non-dominant cultures. The course model has been successfully transferred to other health issues in the Northern Territory.

Reflecting on choices and responsibility in palliative care in the context of social disadvantage

There is a need to understand how to improve palliative care provision for people impacted by social inequity. Social inequity, such as that related to socioeconomic circumstances, has profound impacts on experiences of death and dying, posing personal and professional challenges for frontline professionals tasked to ensure that everyone receives the best standard of care at the end of their lives. Recent research has highlighted an urgent need to find ways of supporting healthcare professionals to acknowledge and unpack some of the challenges experienced when trying to deliver equitable palliative care. For example, those involved in patient or person-centred activities within health settings often feel comfortable focusing on individual choice and responsibility. This can become ethically problematic when considering that inequities experienced towards the end of life are produced and constrained by socio-structural forces beyond one individual's control. Ideas and theories originating outside palliative care, including work on structural injustice, cultural safety and capabilities approach, offer an alternative lens through which to consider roles and responsibilities for attending to inequities experienced at the end of life. This paper draws upon these ideas to offer a new way of framing individual responsibility, agency and collective action that may help palliative care professionals to support patients nearing their end of life, and their families, in the context of socioeconomic disadvantage. In this paper, we argue that, ultimately, for action on inequity in palliative care to be effective, it must be coherent with how people understand the production of, and responsibility for, those inequities, something that there is limited understanding of within palliative care.

Embarking on a cultural journey: a qualitative study of new graduate physiotherapists' experiences of working in First Nations Australian health settings

INTRODUCTION

Internationally, there is growing momentum in the physiotherapy profession to improve the cultural safety and capabilities of physiotherapists. In Australia, this is essential given the important role physiotherapists play in the delivery of healthcare to First Nations Australians. Understanding the experiences of the newest members of the profession who work with First Nations Australians is an important step in exploring the broader professions' cultural safety journey.

OBJECTIVE

To explore new graduate physiotherapists' experiences working in First Nations Australian health settings.

METHODS

The study used an interpretative phenomenological approach through semi-structured interviews to explore the experiences of seven new graduate physiotherapists, in their first 2 years of practice. All participants worked within a First Nations Australian health setting for some or all of their experience as a new graduate physiotherapist.

RESULTS

Three themes were generated: 1) enrichment through connection; 2) navigating challenges; and 3) a catalyst for self-reflection.

CONCLUSION

New graduate physiotherapists reported positive experiences when working within a First Nations Australian health setting, underpinned by building a strong therapeutic relationship through rapport building; navigating challenges alongside their clients; and delving into critical self-reflection.

Plant medicine usage of people living with type 2 diabetes mellitus in Belize: A qualitative exploratory study

BACKGROUND

Type 2 Diabetes Mellitus (T2DM) is a primary cause of death in Belize, a low-income country with the highest rates in Central and South America. As many people in Belize cannot consistently access biomedical treatment, a reality that was exacerbated by the COVID-19 pandemic, plant medicine usage is estimated to have increased in recent years. This exploratory study seeks to understand which plants are being used, patterns of usage, and the state of patient-provider communication around this phenomenon.

METHODS

Implementing a Constructivist Grounded Theory qualitative design, the research team conducted 35 semi-structured interviews with adults living with T2DM, 25 informant discussions, and participant observation with field notes between February 2020 and September 2021. Data analysis followed systematized thematic coding procedures using Dedoose analytic software and iterative verification processes.

RESULTS

The findings revealed that 85.7% of participants used plants in their T2DM self-management. There were three main usage patterns, namely, exclusive plant use (31.4%), complementary plant use (42.9%), and minimal plant use (11.4%), related to factors impacting pharmaceutical usage. Almost none of participants discussed their plant medicine usage with their health care providers.

CONCLUSIONS

Plant species are outlined, as are patients' reasons for not disclosing usage to providers. There are implications for the advancement of understanding ethnobotanical medicine use for T2DM self-management and treatment in Belize and beyond.

Healthcare professionals' cultural safety practices for indigenous peoples in the acute care setting - a scoping review

BACKGROUND

For Indigenous Peoples the disparities in health status are largely associated with the direct social determinants of invasion and colonisation, marginalisation, intergenerational traumas, and lack of conscious government policy to address these ongoing effects. There is currently limited evidence in the literature on what Cultural Safety practices mean in acute care settings.

OBJECTIVE

We aimed to understand the extent and type of evidence in relation to current knowledge and evidence regarding Cultural Safety practices for Indigenous Peoples in acute care settings.

DESIGN

This is a scoping review.

METHODS

We searched six databases in consultation with a librarian experienced in health research.

RESULTS

A total of 16 papers were included in the scoping review. Four main barriers to Cultural Safety in practice were identified; Among the included studies, only one quality improvement study reported an intervention, which improved culturally safe care.

CONCLUSION

The four barriers identified each have a variable impact on Indigenous Peoples' health outcomes and are dependent upon the circumstances and experiences of both Indigenous Peoples and healthcare professionals.

Navigating and manipulating childbirth services in Afar, Ethiopia: A qualitative study of cultural safety in the birthing room

Access to maternal health services has increased in Ethiopia during the past decades. However, increasing the demand for government birthing facility use remains challenging. In Ethiopia's Afar Region, these challenges are amplified given the poorly developed infrastructure, pastoral nature of communities, distinct cultural traditions, and the more nascent health system. This paper features semi-structured interviews with 22 women who were purposively sampled to explore their experiences giving birth in government health facilities in Afar. We used thematic analysis informed by a cultural safety framework to interpret findings. Our findings highlight how women understand, wield, and relinquish power and agency in the delivery room in government health facilities in Afar, Ethiopia. We found that Afari women are treated as 'others', that they manipulate their care as they negotiate 'cultural safety' in the health system, and that they use trust as a pathway towards more cultural safety. As the cultural safety framework calls for recognizing and navigating the diverse and fluid power dynamics of healthcare settings, the onus of negotiating power dynamics cannot be placed on Afari women, who are already multiply marginalized due to their ethnicity and gender. Health systems must adopt cultural safety in order to ensure health quality. Providers, particularly in regions with rich cultural diversity, must be trained in the cultural safety framework in order to be aware of and challenge the multidimensional power dynamics present in health encounters.

Improving continence management for people with dementia in the community in Aotearoa, New Zealand: Protocol for a mixed methods study

BACKGROUND

The number of people living with dementia (PLWD) in Aotearoa New Zealand (NZ) was estimated at 96,713 in 2020 and it is anticipated that this number will increase to 167,483 by 2050, including an estimated 12,039 Māori (indigenous people of NZ) with dementia. Experiencing urinary incontinence (UI) or faecal incontinence (FI) is common for PLWD, particularly at the later stages of the disease. However, there is no robust estimate for either prevalence or incidence of UI or FI for PLWD in NZ. Although caregivers rate independent toilet use as the most important activity of daily living to be preserved, continence care for PLWD in the community is currently not systematised and there is no structured care pathway. The evidence to guide continence practice is limited, and more needs to be known about caregiving and promoting continence and managing incontinence for PLWD in the community. This project will seek to understand the extent of the challenge and current practices of health professionals, PLWD, caregivers and family; identify promising strategies; co-develop culturally appropriate guidelines and support materials to improve outcomes; and identify appropriate quality indicators so that good continence care can be measured in future interventions.

METHODS AND ANALYSIS

A four-phase mixed methods study will be delivered over three years: three phases will run concurrently, followed by a fourth transformative sequential phase. Phase 1 will identify the prevalence and incidence of incontinence for PLWD in the community using a cohort study from standardised home care interRAI assessments. Phase 2 will explore continence management for PLWD in the community through a review of clinical policies and guidance from publicly funded continence services, and qualitative focus group interviews with health professionals. Phase 3 will explore experiences, strategies, impact and consequences of promoting continence and managing incontinence for PLWD in the community through secondary data analysis of an existing carers' study, and collecting new cross-sectional and longitudinal qualitative data from Māori and non-Māori PLWD and their caregivers. In Phase 4, two adapted 3-stage Delphi processes will be used to co-produce clinical guidelines and a core outcome set, while a series of workshops will be used to co-produce caregiver resources.

Russian nurses' readiness for transcultural care of palliative patients

Palliative care involves an approach aimed at improving the quality of life of patients and their families, who are forced to cope with the problems associated with life-threatening diseases. This definition includes a growing group of patients around the world. It requires an extension of the definition of patients in need of palliative care in countries such as Russia and a significant improvement in the work of nursing personnel with these patients. This study aims to determine the level of preparedness of nursing personnel for specialized care (transcultural care) and the quality of care provided to palliative patients. The presented findings of the study demonstrate the relevance of developing transcultural competence, which enables significant improvement in the quality of life of palliative patients. The analysis of medical workers' assessment of the level of specific training and their intercultural preparedness was conducted based on hospices (Moscow). A survey was conducted among 113 medical workers of the middle level of education aged between 28 and 56 (average of 44.2 years) and experience in palliative care ranged from 3 to 18 years (average of 9.5 years). The Intercultural Readiness Check (IRC) test, widely used to assess nursing staff worldwide, was used for the survey to determine the level of readiness for transcultural care. A strong correlation was found between a number of the test scales and measures of participants' age and experience. The presented material demonstrates the realization of an interdisciplinary approach to the issues of specific training of nursing personnel in the field of "transcultural care" in providing palliative care to incurable patients.

Canadian service providers' perspectives on reproductive coercion and abuse: a participatory action research to address their needs and support their actions

Reproductive coercion and abuse (RCA) is a form of violence that affects sexual and reproductive health. Women and individuals who experienced RCA in an intimate relationship frequently consult service providers (SPs), such as health professionals or violence counselors. The objective of this article, which is the result of a participative action research project targeting RCA perpetrated by in an intimate partner, is twofold: (1) to better understand the practices as well as the barriers and facilitators encountered by SPs and (2) to develop information and awareness tools with them that meet their needs. To this end, we first held focus groups with 31 SPs. The use of thematic analysis revealed intervention strategies that focus on caring and listening, identifying signs of RCA, and creating a safe environment for disclosure. Their practices also focused on harm-reduction strategies and effective referrals. Despite the importance they gave to this issue, lack of time, inappropriate settings, and inadequate training hindered them from intervening effectively with individuals who were victims of RCA. They also indicated the need for easy-to-follow practice guidelines and patient education tools. Based on these findings and the best practices identified in the grey and scientific literature, we developed a practice guide for SPs and a booklet on RCA. The development of these guide and booklets involved a lot of back and forth to meet the needs expressed by the community and health professionals.

Better cardiac care - the patient experience - a qualitative study

BACKGROUND

In 2015, a Brisbane tertiary hospital's cardiac unit implemented a new model of multidisciplinary care (Better Cardiac Care (BCC)) for Aboriginal and Torres Strait Islander patients. Since then, clinical indicators for Aboriginal and Torres Strait Islander cardiac patients have improved, but the recipients' voices have not been heard. This research aimed to determine the acceptability and appropriateness, features of value, and opportunities for improvements in this model of care, from the perspective of patients and their family members.

METHODS

This descriptive qualitative study employed a narrative methodology. BCC Health Workers contacted prospective participants; with consent, interested individuals were then contacted by the Aboriginal Research Officer (RO) who arranged yarning sessions and consent. Family members were also invited to share their stories of their loved ones' hospitalisation. Two researchers conducted the interviews, using a yarning approach. Inductive narrative analysis, informed by Aboriginal and Torres Strait Islander ways of Being, Knowing, and Doing, focused on enabling participants' stories to be heard and understood from their perspectives.

RESULTS

Relationality was at the heart of the BCC model of care, particularly between patients and Aboriginal and Torres Strait Islander staff. The relationality included a responsibility for holistic care, extending beyond hospital discharge, although support and handover for family members required improvement. The Aboriginal and Torres Strait Islander staff understood the contextual and structural challenges faced by participants, including the disempowerment and racism experienced in healthcare. This understanding was shared with the BCC team who, in turn, protected, advocated for, and holistically supported participants through their cardiac health journeys.

CONCLUSIONS

Empowering (and employing) Aboriginal and Torres Strait Islander staff, and relating to patients as people, enabled BCC to meet Aboriginal and Torres Strait Islander patient's needs and improve outcomes. The wider health system and health academia could benefit from exploring and valuing Aboriginal and Torres Strait Islander discourses of relationality.

Improving outcomes for hospitalised First Nations peoples though greater cultural safety and better communication: the Communicate Study Partnership study protocol

BACKGROUND

The Communicate Study is a partnership project which aims to transform the culture of healthcare systems to achieve excellence in culturally safe care for First Nations people. It responds to the ongoing impact of colonisation which results in First Nations peoples experiencing adverse outcomes of hospitalisation in Australia's Northern Territory. In this setting, the majority of healthcare users are First Nations peoples, but the majority of healthcare providers are not. Our hypotheses are that strategies to ensure cultural safety can be effectively taught, systems can become culturally safe and that the provision of culturally safe healthcare in first languages will improve experiences and outcomes of hospitalisation.

METHODS

We will implement a multicomponent intervention at three hospitals over 4 years. The main intervention components are as follows: cultural safety training called 'Ask the Specialist Plus' which incorporates a locally developed, purpose-built podcast, developing a community of practice in cultural safety and improving access to and uptake of Aboriginal language interpreters. Intervention components are informed by the 'behaviour change wheel' and address a supply-demand model for interpreters. The philosophical underpinnings are critical race theory, Freirean pedagogy and cultural safety. There are co-primary qualitative and quantitative outcome measures: cultural safety, as experienced by First Nations peoples at participating hospitals, and proportion of admitted First Nations patients who self-discharge. Qualitative measures of patient and provider experience, and patient-provider interactions, will be examined through interviews and observational data. Quantitative outcomes (documentation of language, uptake of interpreters (booked and completed), proportion of admissions ending in self-discharge, unplanned readmission, hospital length of stay, costs and cost benefits of interpreter use) will be measured using time-series analysis. Continuous quality improvement will use data in a participatory way to motivate change. Programme evaluation will assess Reach, Effectiveness, Adoption, Implementation and Maintenance ('RE-AIM').

DISCUSSION

The intervention components are innovative, sustainable and have been successfully piloted. Refinement and scale-up through this project have the potential to transform First Nations patients' experiences of care and health outcomes.

TRIAL REGISTRATION

Registered with ClinicalTrials.gov Protocol Record 2008644.

Family & bystander experiences of emergency ambulance services care: a scoping review

BACKGROUND

Emergency ambulance personnel respond to a variety of incidents in the community, including medical, trauma and obstetric emergencies. Family and bystanders present on scene may provide first aid, reassurance, background information or even act as proxy decision-makers. For most people, involvement in any event requiring an emergency ambulance response is a stressful and salient experience. The aim of this scoping review is to identify and synthesise all published, peer-reviewed research describing family and bystanders' experiences of emergency ambulance care.

METHODS

This scoping review included peer-reviewed studies that reported on family or bystander experiences where emergency ambulance services responded. Five databases were searched in May 2022: Medline, CINAHL, Scopus, ProQuest Dissertation & Theses and PsycINFO. After de-duplication and title and abstract screening, 72 articles were reviewed in full by two authors for inclusion. Data analysis was completed using thematic synthesis.

RESULTS

Thirty-five articles reporting heterogeneous research designs were included in this review (Qualitative = 21, Quantitative = 2, Mixed methods = 10, Evidence synthesis = 2). Thematic synthesis developed five key themes characterising family member and bystander experiences. In an emergency event, family members and bystanders described chaotic and unreal scenes and emotional extremes of hope and hopelessness. Communication with emergency ambulance personnel played a key role in family member and bystander experience both during and after an emergency event. It is particularly important to family members that they are present during emergencies not just as witnesses but as partners in decision-making. In the event of a death, family and bystanders want access to psychological post-event support.

CONCLUSION

By incorporating patient and family-centred care into practice emergency ambulance personnel can influence the experience of family members and bystanders during emergency ambulance responses. More research is needed to explore the needs of diverse populations, particularly regarding differences in cultural and family paradigms as current research reports the experiences of westernised nuclear family experiences.

Discharge interventions for First Nations people with a chronic condition or injury: a systematic review

BACKGROUND

Aboriginal and Torres Strait Islander peoples have a unique place in Australia as the original inhabitants of the land. Similar to other First Nations people globally, they experience a disproportionate burden of injury and chronic health conditions. Discharge planning ensures ongoing care to avoid complications and achieve better health outcomes. Analysing discharge interventions that have been implemented and evaluated globally for First Nations people with an injury or chronic conditions can inform the implementation of strategies to ensure optimal ongoing care for Aboriginal and Torres Strait Islander people.

METHODS

A systematic review was conducted to analyse discharge interventions conducted globally among First Nations people who sustained an injury or suffered from a chronic condition. We included documents published in English between January 2010 and July 2022. We followed the reporting guidelines and criteria set in Preferred Reporting Items for Systematic Review (PRISMA). Two independent reviewers screened the articles and extracted data from eligible papers. A quality appraisal of the studies was conducted using the Mixed Methods Appraisal Tool and the CONSIDER statement.

RESULTS

Four quantitative and one qualitative study out of 4504 records met inclusion criteria. Three studies used interventions involving trained health professionals coordinating follow-up appointments, linkage with community care services and patient training. One study used 48-hour post discharge telephone follow-up and the other text messages with prompts to attend check-ups. The studies that included health professional coordination of follow-up, linkage with community care and patient education resulted in decreased readmissions, emergency presentations, hospital length of stay and unattended appointments.

CONCLUSION

Further research on the field is needed to inform the design and delivery of effective programs to ensure quality health aftercare for First Nations people. We observed that discharge interventions in line with the principal domains of First Nations models of care including First Nations health workforce, accessible health services, holistic care, and self-determination were associated with better health outcomes.

REGISTRATION

This study was prospectively registered in PROSPERO (ID CRD42021254718).

How pharmacist-led health services are tailored to minoritized populations, their acceptability and effectiveness: A scoping literature review

BACKGROUND

Worldwide, minoritized populations experience inequitable health risks and outcomes. The importance of offering tailored services to meet the specific needs of target populations should be addressed during service development. Within healthcare systems, pharmacists play a crucial role in supporting patients to manage their medicines and health conditions.

OBJECTIVES

This scoping review aims to identify, collate and analyse literature describing pharmacist-led services tailored for minoritized populations in order to strengthen the knowledge base and support for achieving health equity.

METHODS

A scoping review was guided by the PRISMA-ScR checklist and the five-stage process outlined by Arksey and O'Malley. Medline, EMBASE, Scopus, CINAHL Plus, International Pharmaceutical Abstracts, and Google Scholar databases, plus grey literature were searched to identify relevant studies published up to October 2022. Texts were included if they reported on a pharmacist-led health service tailored to meet the needs of a minoritized population. The review protocol was registered with the Open Science Framework (https://doi.org/10.17605/OSF.IO/E8B7D).

RESULTS

Of the 566 records initially identified, 16 full-text articles were assessed for eligibility and 9 articles describing 6 unique services met the criteria and were included in the review. Three services were non-health-condition-specific, 2 targeted type two diabetes and 1 focussed on opioid dependency disorders. Service acceptability was consistently explored, and all services ensured that pharmacists' views were considered. However, only 4 consulted with the people from the group that the service targeted. Where reported, the effectiveness was not comprehensively evaluated.

CONCLUSION

There is limited literature in this area and a critical need for more evidence on the effectiveness of pharmacist-led services for minoritized populations. We need a better understanding of how pharmacists contribute to health equity pathways and how to expand this. Doing so will inform future services and contribute towards achieving equitable health outcomes.

Cultural Marginalization and Mental Health

Cultural marginalization refers to the process of being on the fringe of two distinct cultures. Culture represents the values, beliefs, knowledge, and norms that are common to a group of people. Globalization contributes to an increasingly diverse population and leads to frequent interaction, collaboration, and sharing of space between various cultures. Cultural minority groups experience varied stages of acculturation with the dominant culture which may have an impact on physical and mental health. Understanding the marginalizing experiences of cultural minority groups creates a more accommodating social environment and helps provide culturally safe healthcare experiences for these people.

Successes, weaknesses, and recommendations to strengthen primary health care: a scoping review

BACKGROUND

Primary health care (PHC) is a roadmap for achieving universal health coverage (UHC). There were several fragmented and inconclusive pieces of evidence needed to be synthesized. Hence, we synthesized evidence to fully understand the successes, weaknesses, effective strategies, and barriers of PHC.

METHODS

We followed the PRISMA extension for scoping reviews checklist. Qualitative, quantitative, or mixed-approach studies were included. The result synthesis is in a realistic approach with identifying which strategies and challenges existed at which country, in what context and why it happens.

RESULTS

A total of 10,556 articles were found. Of these, 134 articles were included for the final synthesis. Most studies (86 articles) were quantitative followed by qualitative (26 articles), and others (16 review and 6 mixed methods). Countries sought varying degrees of success and weakness. Strengths of PHC include less costly community health workers services, increased health care coverage and improved health outcomes. Declined continuity of care, less comprehensive in specialized care settings and ineffective reform were weaknesses in some countries. There were effective strategies: leadership, financial system, 'Diagonal investment', adequate health workforce, expanding PHC institutions, after-hour services, telephone appointment, contracting with non-governmental partners, a 'Scheduling Model', a strong referral system and measurement tools. On the other hand, high health care cost, client's bad perception of health care, inadequate health workers, language problem and lack of quality of circle were barriers.

CONCLUSIONS

There was heterogeneous progress towards PHC vision. A country with a higher UHC effective service coverage index does not reflect its effectiveness in all aspects of PHC. Continuing monitoring and evaluation of PHC system, subsidies to the poor, and training and recruiting an adequate health workforce will keep PHC progress on track. The results of this review can be used as a guide for future research in selecting exploratory and outcome parameters.

Training Student Pharmacists How to Mitigate Racial or Ethnic Microaggressions in Patient Encounters

The experience of interfacing with the health care system is a taxing one for racially or ethnically marginalized patients (REMPs). The seemingly inevitable occurrence of encountering microaggressions is reason enough to avoid the interaction for many resulting in worse health outcomes. Microaggressions result in conflict, loss to follow-up, and reinforcing the unwelcome atmosphere of the health care system to REMPs. Teaching antimicroaggressive content in doctor of pharmacy curricula is critical for reducing strain on the fragile relationship between REMPs and the health care system. Whether it is gathering a patient history, devising a patient-centered care plan, or counseling patients, there is an opportunity for an interaction that could sever the patient's trust in the health care system. Teaching each of these skills-based learning activities should be combined with didactic lessons in nonjudgmental and nonmicroaggressive communication approaches. In addition, lessons regarding the impact of microaggressions on REMPs should also be present so that learners may appreciate the impact of a clinician's actions on REMPs in this regard. To establish evidence-based best practices, more research on teaching antimicroaggressive didactic and skills-based content to student pharmacists is needed.

Policy responses to COVID-19 in Sri Lanka and the consideration of Indigenous Peoples

COVID-19 has had uneven impacts on health and well-being, with Indigenous communities in the Global South facing some of the highest risks. Focusing on the experience of Sri Lanka, this study identifies key policy responses to COVID-19, documents how they evolved over two years of the pandemic, and examines if and how government responses have addressed issues pertaining to Indigenous Peoples. Drawing upon an analysis of policy documents (n = 110) and interviews with policymakers (n = 20), we characterize seven key policy responses implemented by the Sri Lankan government: i) testing for and identifying COVID-19; ii) quarantine procedures; iii) provisional clinical treatments; iv) handling other diseases during COVID-19; v) movement; vi) guidelines to be adhered to by the general public; and vii) health and vaccination. The nature of these responses changed as the pandemic progressed. There is no evidence that policy development or implementation incorporated the voices and needs of Indigenous Peoples.

Exploration of Existing Integrated Mental Health and Addictions Care Services for Indigenous Peoples in Canada

Due to the persistent impacts of colonialism, Indigenous peoples of Canada face disproportionate rates of mental health and substance use disorders, which are often insufficiently addressed by Eurocentric 'mainstream' mental health and addiction services. The need to better address Indigenous mental health has led to Indigenous mental health integrated care (hereafter integrated care): programs using both Indigenous and Western practices in their care delivery. This research describes the common lessons, disjunctures, and solutions experienced by existing integrated care programs for Indigenous adults across Canada. It reveals the best practices of integrated care for programs, and contributes to the Truth and Reconciliation Commission of Canada's Calls to Action #20 and #22. This study, co-designed by an Indigenous Knowledge Keeper and Practitioner, explores the programs' relational processes through interviews with key informants. The data was analyzed in consultation with Indigenous collaborators to highlight Indigenous values and interpretations, and knowledge co-production. In highlighting the complexity of integrated care, study results show the lessons of 'Real Commitment to Communities and Community Involvement,' and tensions and disjunctures of 'Culture as Healing,' 'People-focused vs. Practitioner-focused Programs,' 'Community-oriented vs. Individual-oriented Programs,' and 'Colonial Power Dynamics in Integrated Care.' The discussion explores why tensions and disjunctures exist, and suggests how to move forward using integrated care's lessons and the concept of IND-equity. Ultimately, Indigenous-led partnerships are paramount to integrated care because they leverage Indigenous knowledge and approaches to achieve health equity within integrated care.

Racial microaggressions and interculturality in remote Central Australian Aboriginal healthcare

BACKGROUND

An epidemic of type 2 diabetes in remote Aboriginal people in Central Australia, contributes to high rates of morbidity and mortality. Remote non-Aboriginal Health Care Workers (HCW) and the Aboriginal people they serve inhabit a complex cultural interface. This study aimed to recognise racial microaggressions in the everyday discourse of HCWs. It proposes a model of interculturality for remote HCWs that avoids racialisation and essentialising of Aboriginal people's identities and cultures.

METHODS

Semi-structured in-depth interviews were undertaken with HCWs from two Primary Health Care services in very remote Central Australia. Fourteen interviews were analysed from seven Remote Area Nurse, five Remote Medical Practitioners and two Aboriginal Health Practitioners. Discourse analysis was employed to explore racial microaggressions and power relations. NVivo software assisted in the thematic organisation of microaggressions according to a predefined taxonomy.

RESULTS

Seven microaggression themes were identified - racial categorization and sameness, assumptions about intelligence and competence, false colour blindness, criminality and dangerousness, reverse racism and hostility, treatment as second-class citizens and pathologizing culture. A model of interculturality for remote HCWs was based on concepts of the third space, deCentred hybrid identities and small culture formation on-the-go combined with a duty-conscious ethic, cultural safety and humility.

CONCLUSIONS

Racial microaggressions are common in the discourse of remote HCWs. The model of interculturality proposed could improve intercultural communication and relationships between HCWs and Aboriginal people. This improved engagement is required to address the current diabetes epidemic in Central Australia.

Models, theoretical design and formal evaluation of integrated specialist community health service provision for the first 2000 days: a scoping review

OBJECTIVE

This scoping review identifies evidence for design, models and evaluation of integrated care service provision for families and children in the first 2000 days, in the context of community-based specialised health, education and welfare services.

DESIGN

Scoping review following the Joanna Briggs scoping review method.

DATA SOURCES

Medline, CINAHL, Cochrane and PsycINFO. Grey literature used a manual search of original articles, and snowball technique to identify government and policy documents relevant to Australia.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Inclusion criteria were 'population' of prebirth to age 5; 'concept' of design, models and delivery of integrated specialist care for children and families; and 'context' of community-based specialised health, education and welfare services. Medical Subject Heading (MeSH) and free text searches were conducted in electronic database sources. Limits January 2010 to October 2022, full text, English language, human.

DATA EXTRACTION AND SYNTHESIS

Data were extracted independently by two authors using a piloted data extraction table and presented in table and narrative form.

RESULTS

Full text of 11 articles were reviewed, domains were coded using four domains of a framework identified in one reviewed article to maintain consistency of reporting; 'governance,' 'leadership,' 'organisational culture and ethos,' and 'front-line interdisciplinary practice.' A fifth domain was identified, 'access.'

CONCLUSIONS

Services providing integrated care for families in the early years will ideally be based on values generated through codesign with families and the community. Considerations include sound governance and leadership, shared vision, and commitment to providing accessible and culturally safe family-centred care.

Identifying the barriers and facilitators to culturally responsive HIV and PrEP screening for racial, ethnic, sexual, and gender minoritized patients: A scoping review protocol

INTRODUCTION

While mainstream messaging about human immunodeficiency virus (HIV) disparities continues to highlight individual risk-taking behavior among historically marginalized groups, including racial, ethnic, sexual, and gender minoritized patients, the effect of structural factors and social determinants of health (SDOH) on morbidity and mortality remain underestimated. Systemic barriers, including a failure of adequate and acceptable screening, play a significant role in the disparate rates of disease. Primary care practitioner (PCP) competency in culturally responsive screening practices is key to reducing the impact of structural factors on HIV rates and outcomes. To address this issue, a scoping review will be performed to inform the development of a training series and social marketing campaign to improve the competency of PCPs in this area.

OBJECTIVES

This scoping review aims to analyze what recent literature identify as facilitators and barriers of culturally responsive HIV and pre-exposure prophylaxis (PrEP) screening practices for historically marginalized populations, specifically racial, ethnic, sexual, and gender minoritized groups. A secondary aim is to identify themes and gaps in the literature to help guide future opportunities for research.

METHODS

This scoping review will be performed following the framework set forth by Arksey and O'Malley and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR). Relevant studies between the years 2019-2022 will be identified using a rigorous search strategy across four databases: MEDLINE (via PubMed), Scopus, Cochrane (CENTRAL; via Wiley), and CINAHL (via EBSCO), using Boolean and Medical Subject Headings (MeSH) search terms. Studies will be uploaded to the data extraction tool Covidence to remove duplicates and perform a title/abstract screening, followed by a full-text screening and data extraction.

RESULTS

Data will be extracted and analyzed for themes related to culturally responsive HIV and PrEP screening practices in clinical encounters with the identified target populations. Results will be reported according to PRISMA-ScR guidelines.

DISCUSSION

To our knowledge, this is the first study to use scoping methods to investigate barriers and facilitators to culturally responsive HIV and PrEP screening practices for racial, ethnic, sexual, and gender minoritized populations. The limitations of this study include the analysis restrictions of a scoping review and the timeframe of this review. We anticipate that this study's findings will interest PCPs, public health professionals, community activists, patient populations, and researchers interested in culturally responsive care. The results of this scoping review will inform a practitioner-level intervention that will support culturally sensitive quality improvement of HIV-related prevention and care for patients from minoritized groups. Additionally, the themes and gaps found during analysis will guide future avenues of research related to this topic.

Menstruation and social inequities in Spain: a cross-sectional online survey-based study

BACKGROUND

Available research suggests that menstrual inequity has an impact on (menstrual) health outcomes and emotional wellbeing. It is also a significant barrier to achieve social and gender equity and compromises human rights and social justice. The aim of this study was to describe menstrual inequities and their associations with sociodemographic factors, among women and people who menstruate (PWM) aged 18-55 in Spain.

METHODS

A cross-sectional survey-based study was conducted in Spain between March and July 2021. Descriptive statistical analyses and multivariate logistic regression models were performed.

RESULTS

A total of 22,823 women and PWM were included in the analyses (Mean age = 33.2, SD = 8.7). Over half of the participants had accessed healthcare services for menstruation (61.9%). The odds for accessing menstrual-related services were significantly higher among participants with university education (aOR: 1.48, 95% CI, 1.13-1.95). Also, 57.8% reported having had partial or no menstrual education pre-menarche, with odds being higher among participants born in non-European or Latin American countries (aOR: 0.58, 95% CI, 0.36-0.93). Lifetime self-reported menstrual poverty was between 22.2-39.9%. Main risk factors for menstrual poverty were identifying as non-binary (aOR: 1.67, 95% CI, 1.32-2.11), being born in non-European or Latin American countries (aOR: 2.74, 95% CI, 1.77-4.24), and not having a permit to reside in Spain (aOR: 4.27, 95% CI, 1.94-9.38). Completed university education (aOR: 0.61, 95% CI, 0.44-0.84) and no financial hardship < 12 months (aOR: 0.06, 95% CI, 0.06-0.07) were protective factors for menstrual poverty. Besides, 75.2% reported having overused menstrual products due to lack of access to adequate menstrual management facilities. Menstrual-related discrimination was reported by 44.5% of the participants. Non-binary participants (aOR: 1.88, 95% CI, 1.52-2.33) and those who did not have a permit to reside in Spain (aOR: 2.11, 95% CI, 1.10-4.03) had higher odds of reporting menstrual-related discrimination. Work and education absenteeism were reported by 20.3% and 62.7% of the participants, respectively.

CONCLUSIONS

Our study suggests that menstrual inequities affect a high number of women and PWM in Spain, especially those more socioeconomically deprived, vulnerabilised migrant populations and non-binary and trans menstruators. Findings from this study can be valuable to inform future research and menstrual inequity policies.

Designing accountability measures for health professionals: results from a community-based micro-credential: case study on Indigenous cultural safety

BACKGROUND

There is a widespread commitment to implementing anti-Indigenous racism with health organizations in Canada by introducing cultural safety staff training. In partnership with a public health unit in Ontario, Canada, we developed an evaluation tool to assess the performance of staff who completed an online Indigenous cultural safety education course.

AIMS

To develop an accountability checklist that could be used for annual employee performance reviews to assess the use and level of knowledge received in professional cultural safety training.

INTERVENTION

We co-created a professional development accountability checklist. Five areas of interest were identified: terminology, knowledge, awareness, skills, and behaviours. The checklist comprises of 37 indicators linked to our community collaborators' intended goals as defined in our partnership agreement.

OUTCOMES

The Indigenous Cultural Safety Evaluation Checklist (ICSEC) was shared with public health managers to use during regularly scheduled staff performance evaluations. The public health managers provided feedback on the design, checklist items, and useability of the ICSEC. The pilot of the checklist is in the preliminary stage and data is unavailable about effectiveness.

IMPLICATIONS

Accountability tools are important to sustain the long-term effects of cultural safety education and prioritize the wellbeing of Indigenous communities. Our experience can provide guidance to health professionals in creating and measuring the efficacy of Indigenous cultural safety education to foster an anti-racist work culture as well as improved health outcomes among Indigenous communities.

Culturally Safe Neonatal Care: Talking With Health Practitioners Identified as Champions by Indigenous Families

The burden of health inequities borne by Indigenous peoples can be overwhelming, especially when mothers and newborns' lives are at stake and health services seem slow to invest in responsiveness. In Aotearoa (New Zealand), urgent action is required to eliminate persistent systemic inequities for Māori (Indigenous) whānau (family collectives that extend beyond the household). This Kaupapa Māori (by Māori, for Māori) qualitative study aimed to explore the views of health practitioners identified as champions by whānau of preterm Māori infants. Ten health practitioners were interviewed and asked about their involvement with the whānau, their role in explanations and communication, and their thoughts on whānau coping. Interview data were analysed using interpretative phenomenological analysis. Three superordinate themes were identified: working together in partnership, a problem shared is a problem halved, and sacred space. Collaboration between health practitioners and with whānau was important to the champions and central to their goal of enabling whānau autonomy. This was built on a foundation of connectivity, relationships, and a full appreciation that childbirth is a sacred time that is potentially disrupted when an infant is born prematurely. The values- and relationship-based practices of these champions protected and uplifted whānau. They showed that health practitioners have important roles in both the elimination of inequities and the sustaining of Māori self-determination. This championship is an exemplar of what culturally safe care looks like in day-to-day practice with Māori and is a standard that other health practitioners should be held to.

Investigating the health status of primary school children in Tonga: Lessons learnt and reflections on field work in the Pacific Islands

Globally, the child health focus has been on reducing under-5-year mortality, with large populations in low-resource regions prioritised. Children in older age groups, particularly in less populated regions such as the Pacific, have received limited attention. Child health research in the Pacific region has been lacking, and research approaches for the region have historically been from Western biomedical paradigms. We completed the study of primary school children's health over a period of 5 years. Firstly, we conducted a literature review, then we completed an audit of hospital admissions of primary school children, then we completed a two-round Delphi process and finally, we piloted the survey in three primary schools. Our results found there were high levels of oral health problems, ear health, obesity and exposure to violence and poverty impacting on the quality of health of primary school-age children. Identifying these indicators was made possible by the partnerships and trust established by the study team and provides specific and measurable targets for future work to improve the quality of child health outcomes. This paper describes key field work lessons learnt for research in the Pacific region. It must: (i) be on the platform of relationship, cultural safety and local ownership; (ii) include consideration of holistic Pacific paradigms of health; (iii) be adaptive to the context and environment; and (iv) be committed to long-term partnership and work.