Understanding inequalities in access to health care services for aboriginal people: a call for nursing action

The Use of Remote Presence Robotic Tele-Presentation in Rural and Remote Canada: A Systematic Review

Objective: One potential solution to limited health care in rural and remote regions is remote presence robotic tele-presentation to allow health care providers to care for patients in their home community via a robotic interface. We synthesized evidence regarding the use of remote presence robotic tele-presentation in rural and/or remote Canadian health settings. Methods: Medline, PubMed, and Embase were searched up to August 2023. Remote presence robotic tele-presentation refers to any robotic device used for the purpose of presenting and/or collecting patient information. Primary research was included if the patient was located in remote and/or rural Canada, featured remote presence robotic tele-presentation, and assessed patient, family, or clinician satisfaction, patient transport to nearby regional or urban center, health care costs, clinical outcomes, infrastructure outcomes, adverse events, or telementoring. Results: Six studies were included. Patients, nurses, and physicians all reported high levels of satisfaction when using the remote presence robotic tele-presentation. Fifty to sixty-three percent of patients were managed in their home community and did not require transfer to another center. Remote presence robotic sonography resulted in adequate imaging in 81% of first trimester ultrasound limited exams but was less useful for second trimester complete obstetric ultrasounds (20% adequate imaging). Two of eight laparoscopic colorectal surgeries had to be converted to open surgeries. Telerobotic ultrasound clinics resulted in a diagnosis in 70% of cases. Conclusions: Evidence suggests remote presence robotic tele-presentation is a safe and cost-effective approach to providing care in distant communities and can prevent some transfers and evacuations to tertiary hospitals.

Anti-Indigenous racism in Canadian healthcare: a scoping review of the literature

Health inequity between Indigenous (First Nations, Inuit, and Métis) peoples and other citizens is an important policy concern in Canada, as in other colonial countries. Racism in healthcare has been identified as contributing to poorer care and to worse outcomes. Despite a large literature regarding racism in other healthcare contexts, the dimensions of the existing literature on anti-Indigenous racism in Canadian healthcare are unclear. A scoping review examined the evidence of anti-Indigenous racist experiences in healthcare in the research literature, including the types of racist behaviours identified, settings studied, and Indigenous populations and geographic regions included. We identified English and French language journal articles on anti-Indigenous racism in Canadian healthcare settings in Scopus, PubMed, CINAHL, and the Bibliography of Indigenous Peoples in North America, and grey literature reports. A total of 2250 journal articles and 9 grey literature reports published since 2000 were included in screening, and 66 studies were included in the final review. Most used qualitative interviews with patients, but a large proportion included healthcare providers. Most were conducted in urban settings, a majority in Ontario or British Columbia, with mixed Indigenous populations. The largest proportion focussed on patient experiences with healthcare in general, rather than specific clinical contexts. Most racist experiences identified were 'covert' racism, including patients feeling treated differently from non-Indigenous patients, being ignored, treated more slowly, or not believed. Stereotyping of Indigenous peoples as substance users, poor patients, or poor parents was also commonly reported. 'Overt racism', including the use of racist slurs, was not widely found. Some quantitative studies did use standardized or validated instruments to capture racist experiences, but most did not result in generalizable estimates of their prevalence. The few studies linking racism to health outcomes found that experiencing racism was related to reluctance to seek healthcare, potentially leading to higher unmet healthcare needs. Gender was the intersecting dimension most identified as shaping healthcare experiences, with Indigenous women and girls at risk to specific stereotypes. Some papers suggested that socio-economically disadvantaged Indigenous people were at the highest risk to experiencing racism. Types of anti-Indigenous racism identified in Canadian healthcare appear similar to those reported in other jurisdictions. Indigenous peoples facing multiple dimensions of disadvantage, especially gender and social class, may be the most likely to experience racism. It is likely that the experience of racism in healthcare has implications for Indigenous peoples' health, mainly by reducing healthcare access.

A moral economy of care: How clinical discourses perpetuate Indigenous-specific discrimination and racism in western Canadian emergency departments

Recent research has unveiled the pervasiveness with which Indigenous patients are subjected to racialized stereotypes within the Canadian health system. Because discrimination in health care is associated with poor health outcomes and undertreated illness, there is a need to better understand how racism is perpetuated systemically in order to rectify the policies, practices, and attitudes that enable it. This article outlines a moral economy of care in emergency departments in western Canada by exploring the discourses that medical professionals employ when discussing cases of medical racism. While these discourses respond to the everyday realities of working in hospitals, they are also rooted in the colonial genealogy of health care in Canada and perpetuated by neoliberal shifts in health care services. By exploring the moral economy of care, this article sheds light on the way pervasive discourses contribute to reproducing and circulating Indigenous-specific racism and its role in decision-making.

"Navigating chaos": Urban, Rural, and Remote Patient Experiences in Accessing Healthcare with Indigenous and Non-Indigenous Perspectives of Living with Chronic Low Back Pain

Background

Healthcare access for chronic low back pain is complex and should consider not only the health system, but patient care seeking experiences as well. People who live in rural and remote communities and/or identify as being Indigenous may often encounter additional barriers to accessing care for chronic low back pain; thus, these contexts must be considered to fully understand barriers and facilitators.

Aims

The aim of this study was to understand care-seeking experiences of people living with chronic back pain in Saskatchewan and determine unique experiences facing urban, rural, remote, and/or Indigenous peoples.

Methods

Thirty-three participants with chronic low back pain completed a preliminary survey followed by individual semistructured interviews. Participants were categorized as urban, rural, or remote including Indigenous status. A qualitative interpretive research approach with inductive thematic analysis was employed.

Results

Three overarching themes were identified with the following subthemes: (1) healthcare access challenges: challenges to accessing care, challenges within the health system, and challenges leading to self-directed management/coping strategies; (2) healthcare access facilitators: funded care, participant education and knowledge, patient-provider communication, and care closer to home; and (3) participant recommendations for improved care provision: coordination of care, integrative and holistic care, and patient-centered care and support. Rural and remote participants highlighted travel as a main barrier. Indigenous participant experiences emphasized communication with healthcare providers and past experiences influencing desire to access care.

Conclusion

Participants identified a range of challenges and facilitators as well as recommendations for improving access to care for chronic low back pain, with unique barriers for rural, remote, and Indigenous participants.

Access to Specialized Care Across the Lifespan in Tetralogy of Fallot

Individuals living with tetralogy of Fallot require lifelong specialized congenital heart disease care to monitor for and manage potential late complications. However, access to cardiology care remains a challenge for many patients, as does access to mental health services, dental care, obstetrical care, and other specialties required by this population. Inequities in health care access were highlighted by the COVID-19 pandemic and continue to exist. Paradoxically, many social factors influence an individual's need for care, yet inadvertently restrict access to it. These include sex and gender, being a member of a racial or ethnic historically excluded group, lower educational attainment, lower socioeconomic status, living remotely from tertiary care centres, transportation difficulties, inadequate health insurance, occupational instability, and prior experiences with discrimination in the health care setting. These factors may coexist and have compounding effects. In addition, many patients believe that they are cured and unaware of the need for specialized follow-up. For these reasons, lapses in care are common, particularly around the time of transfer from paediatric to adult care. The lack of trained health care professionals for adults with congenital heart disease presents an additional barrier, even in higher income countries. This review summarizes challenges regarding access to multiple domains of specialized care for individuals with tetralogy of Fallot, with a focus on the impact of social determinants of health. Specific recommendations to improve access to care within Canadian and American systems are offered.

Forensic psychiatry patients, services, and legislation in Nunavut and Greenland

Circumpolar regions face unique challenges in establishing and maintaining mental health care systems, including forensic psychiatry services. The scarcity of data and lack of evidence concerning the forensic psychiatry patient (FPP) populations of Nunavut and Greenland exacerbates the challenges of informing best practices and healthcare planning. By comparing the prevalence of forensic psychiatry patients, the mental health care services, and the legislation in these two relatively similar but unique regions, insight may be gained that can help inform healthcare planning. This cross-sectional study includes all forensic psychiatry in- and outpatients in one year from Nunavut (2018) and on February 29, 2020, in Greenland. The Greenland sample (n = 93) was nearly four times larger than the Nunavut sample (n = 15) at the population level. Despite considerable differences in forensic legislation and service supply, the forensic psychiatry patients in the two areas share several similarities. A total of 87% (n = 13) in the Nunavut sample were diagnosed with a DSM-5 schizophrenia spectrum disorder or other psychotic disorder. In Greenland, 82% (n = 76) were diagnosed with an ICD-10 F2 diagnosis (schizophrenia, schizotypal and delusional disorders). Approximately 2/3 of the patients in both populations were diagnosed with substance use disorder, and 60% of the Nunavut FPP received long-acting antipsychotic injections versus 62% in Greenland. Nearly half of the FPPs in both populations had never been convicted prior to entering the forensic psychiatry system; Nunavut 45% versus Greenland 47%. A substantial proportion of Greenlandic FPPs were outpatients compared to Nunavut (83% versus 47%). This study is an essential first step toward describing a Model of Care for forensic psychiatry patients in circumpolar regions; furthermore, the clinical similarities between the two populations provide support for future joint Arctic research and the inclusion of artic forensic patients in international studies.

Disparities in prostate cancer screening, diagnoses, management, and outcomes between Indigenous and non-Indigenous men in a universal health care system

BACKGROUND

Indigenous Peoples have higher morbidity rates and lower life expectancies than non-Indigenous Canadians. Identification of disparities between Indigenous and non-Indigenous men regarding prostate cancer (PCa) screening, diagnoses, management, and outcomes was sought.

METHODS

An observational cohort of men diagnosed with PCa between June 2014 and October 2022 was studied. Men were prospectively enrolled in the province-wide Alberta Prostate Cancer Research Initiative. The primary outcomes were tumor characteristics (stage, grade, and prostate-specific antigen [PSA]) at diagnosis. Secondary outcomes were PSA testing rates, time from diagnosis to treatment, treatment modality, and metastasis-free, cancer-specific, and overall survivals.

RESULTS

Examination of 1,444,974 men for whom aggregate PSA testing data were available was performed. Men in Indigenous communities were less likely to have PSA testing performed than men outside of Indigenous communities (32 vs. 46 PSA tests per 100 men [aged 50-70 years] within 1 year; p < .001). Among 6049 men diagnosed with PCa, Indigenous men had higher risk disease characteristics: a higher proportion of Indigenous men had PSA ≥ 10 ng/mL (48% vs. 30%; p < .01), TNM stage ≥ T2 (65% vs. 47%; p < .01), and Gleason grade group ≥ 2 (79% vs. 64%; p < .01) compared to non-Indigenous men. With a median follow-up of 40 months (interquartile range, 25-65 months), Indigenous men were at higher risk of developing PCa metastases (hazard ratio, 2.3; 95% CI, 1.2-4.2; p < .01) than non-Indigenous men.

CONCLUSIONS

Despite receiving care in a universal health care system, Indigenous men were less likely to receive PSA testing and more likely to be diagnosed with aggressive tumors and develop PCa metastases than non-Indigenous men.

Identifying barriers to preventive care among First Nations people at risk of lower extremity amputation: a qualitative study

BACKGROUND

First Nations people in Canada are overrepresented among those who have undergone nontraumatic lower extremity amputation, and are more likely to be younger, have diabetic foot infections and have no previous revascularization procedures than non-First Nations populations who have undergone lower extremity amputations. We sought to identify access barriers for high-risk First Nations patients, explore patients' experiences with health care systems and identify solutions.

METHODS

Employing a community participatory research design, we engaged representatives from 2 communities. They assisted with research design and data analysis, and approved the final manuscript. Using a hermeneutic phenomenological approach and purposeful sampling, we conducted 5 semistructured focus groups between August and December 2021 with community health care teams and patients at risk for, or who had previously undergone, a nontraumatic lower extremity amputation.

RESULTS

Patients' (n = 10) and community health care providers' (n = 18) perspectives indicated that barriers to health care access led to delayed care and increased complications and risk for lower extremity amputations, leading to aggressive procedures upon receiving care. Barriers to care led to negative experiences at urban centres and aggressive procedures created further distrust, leading to care disengagement and poor outcomes. Patients and providers both suggested building stronger partnerships between urban and rural health care providers, improving education for patients and health care providers and identifying innovative strategies to improve patients' overall health.

INTERPRETATION

Systemic changes, health promotional program and reliable on-reserve primary care are needed to create equitable access for First Nation patients at risk for lower extremity amputations. The study results imply that health care delivery for First Nations patients at risk for lower extremity amputations can be improved through stronger partnership and communication between urban and community providers, and continued education and cultural competency training for urban health care providers.

First Nations, Inuit and Métis Peoples Living in Urban Areas of Canada and Their Access to Healthcare: A Systematic Review

In Canada, approximately 52% of First Nations, Inuit and Métis (Indigenous) peoples live in urban areas. Although urban areas have some of the best health services in the world, little is known about the barriers or facilitators Indigenous peoples face when accessing these services. This review aims to fill these gaps in knowledge. Embase, Medline and Web of Science were searched from 1 January 1981 to 30 April 2020. A total of 41 studies identified barriers or facilitators of health service access for Indigenous peoples in urban areas. Barriers included difficult communication with health professionals, medication issues, dismissal by healthcare staff, wait times, mistrust and avoidance of healthcare, racial discrimination, poverty and transportation issues. Facilitators included access to culture, traditional healing, Indigenous-led health services and cultural safety. Policies and programs that remove barriers and implement the facilitators could improve health service access for Indigenous peoples living in urban and related homelands in Canada.

Looking beyond the individual-The importance of accessing health and cultural services for Indigenous women in Thunder Bay, Ontario

Access to cultural activities and culturally relevant healthcare has always been significant for achieving holistic Indigenous health and continues to be a key factor in shaping the health journey of Indigenous individuals and communities. Previous research has indicated the importance of cultural practices and services in sustaining cultural identity for Indigenous peoples, which is a major influence on their wellbeing. This study marks the first phase in a project aimed at establishing an Indigenous healing program and uses a qualitative research approach to understand the health and cultural services that Indigenous women want and require in Thunder Bay, Ontario. During interviews, participants (n = 22) answered questions around their understandings of health and wellbeing, and how they are able to incorporate cultural practices into their circle of care. Thematic analysis was performed on interview transcripts, and 4 key themes were identified: 'independence and self-care', 'external barriers to accessing services', 'finding comfort in the familiar' and 'sense of community'. Together these themes illustrate how Indigenous women feel a strong sense of personal responsibility for maintaining their health despite the multiple environmental factors that may act as barriers or supports. Furthermore, the necessity of embedding cultural practices into Indigenous women's circle of care is highlighted by the participants as they describe the mental, spiritual, social, and emotional health benefits of engaging in cultural activities within their community. The findings demonstrate the need for current modes of care to look beyond the individual and consider the impacts that socio-environmental factors have on Indigenous women. To accomplish this, we hope to increase access to health and cultural services through the creation of an Indigenous healing program that can be adequately incorporated into Indigenous women's circle of care if they wish to do so.

Assessing the perioperative timeline and incidence of postoperative complications to optimize care for pediatric surgery patients from Northern Quebec

BACKGROUND

Patients from remote communities often require relocation to urban centres to receive surgical care. This study examines the timeline of care for pediatric surgical patients presenting to the Montreal Children's Hospital from two remote communities in Quebec serving largely Indigenous populations. It aims to identify factors contributing to length of stay, including the incidence of post-operative complications and risk factors for complications.

METHODOLOGY

This was a single-center retrospective study of children from Nunavik and Terres-Cries-de-la-Baie-James who underwent general or thoracic surgery between 2011 and 2020. Patient characteristics, including risk factors for complications, and any postoperative complications were summarized descriptively. The timeline of the patient's stay from consultation to post-operative follow-up was determined through chart review, identifying the dates and modality of post-operative follow up.

RESULTS

There were 271 eligible cases, including 213 urgent (79.8%) and 54 elective (20.2%) procedures. In total, four patients (1.5%) experienced a postoperative complication at follow-up. All complications occurred among patients who underwent urgent surgery. Three complications (75%) were surgical site infections, managed conservatively. Among patients who underwent elective surgery, 20% waited over 5 days prior to operation The average length of time between discharge and follow-up was one week, regardless of surgical urgency. This was the main contributor to the total time in Montreal.

CONCLUSION

Postoperative complications identified at one-week follow-up were rare and only seen following urgent surgery, suggesting that telemedicine can safely replace many in-person post-surgical follow up visits. In addition, there is room to improve wait times for those from remote communities by prioritizing displaced patients where possible.

Public health in undergraduate nursing education and workforce readiness

Student engagement with the community is a cornerstone of undergraduate nursing education in Canada. Working with community from perspectives of social justice, health equity, advocacy, and political action are essential for workforce readiness. We suggest that the erosion of public health theory and clinical courses in baccalaureate nursing programs undermines the potential capability of nurses to address the intersectionality of the social determinants of health. The impact of the COVID-19 pandemic on populations further demonstrates inequities, particularly among marginalized populations. Public health nursing education supports students' understanding about the health impacts of social injustice, how systemic racism is embedded in colonial and Eurocentric structures, and practices of superiority and privileges.We, as a national group of public health nursing educators, set out to investigate how existing guidelines and competencies support public health in undergraduate education across Canada. Results from a national questionnaire of educators, and of PHN leaders on new graduate practice readiness are presented. Questionnaire responses confirm an erosion of PHN theory and practice in baccalaureate nursing education (BNE) curricula. The results of the questionnaires combined with evidence of PHN since the global pandemic provide educators and practitioners more insight to inform future directions to respond to workforce readiness.

Access Denied: Nurses' Perspectives of Access to Oncology Care Among Indigenous Peoples in Canada

Inequitable access to oncology care is a significant issue among Indigenous Peoples in Canada; however, the perspectives of oncology nurses have not been explored. Guided by an interpretive descriptive methodology, we explored nurses' perspectives on access to oncology care among Indigenous Peoples in Canada. Nurses described the health care system as "broken" and barriers to accessing oncology care as layered and compounding. Lack of culturally safe care was articulated as a significant issue impacting equitable access, while biomedical discourses were pervasive and competed with nurses' attempts at providing culturally safe and trauma- and violence-informed care by discounting the relational work of nurses.

Patient complexity assessment tools containing inquiry domains important for Indigenous patient care: A scoping review

Patient complexity assessment tools (PCATs) are utilized to collect vital information to effectively deliver care to patients with complexity. Indigenous patients are viewed in the clinical setting as having complex health needs, but there is no existing PCAT developed for use with Indigenous patients, although general population PCATs may contain relevant content. Our objective was to identify PCATs that include the inquiry of domains relevant in the care of Indigenous patients with complexity. A scoping review was performed on articles published between 2016 and 2021 to extend a previous scoping review of PCATs. Data extraction from existing frameworks focused on domains of social realities relevant to the care of Indigenous patients. The search resulted in 1078 articles, 82 underwent full-text review, and 9 new tools were identified. Combined with previously known and identified PCATs, only 6 items from 5 tools tangentially addressed the domains of social realities relevant to Indigenous patients. This scoping review identifies a major gap in the utility and capacity of PCATs to address the realities of Indigenous patients. Future research should focus on developing tools to address the needs of Indigenous patients and improve health outcomes.

Pursuing Connectivity in Cardio-Oncology Care-The Future of Telemedicine and Artificial Intelligence in Providing Equity and Access to Rural Communities

The aim of this review is to discuss the current health disparities in rural communities and to explore the potential role of telehealth and artificial intelligence in providing cardio-oncology care to underserviced communities. With advancements in early detection and cancer treatment, survivorship has increased. The interplay between cancer and cardiovascular disease, which are the leading causes of morbidity and mortality in this population, has been increasingly recognized. Worldwide, cardio-oncology clinics (COCs) have emerged to deliver a multidisciplinary approach to the care of patients with cancer to mitigate cardiovascular risks while minimizing interruptions in cancer treatment. Despite the value of COCs, the accessibility gap between urban and rural communities in both oncology and cardio-oncology contributes to health care disparities and may be an underrecognized determinant of health globally. Telehealth and artificial intelligence offer opportunities to provide timely care irrespective of rurality. We therefore explore current developments within this sphere and propose a novel model of care to address the disparity in urban vs. rural cardio-oncology using the experience in Canada, a geographically large country with many rural communities.

Impacts of racism on First Nations patients' emergency care: results of a thematic analysis of healthcare provider interviews in Alberta, Canada

Background

First Nations people experience racism in society and in the healthcare system. This study aimed to document emergency care providers’ perspectives on care of First Nations patients. First Nations research partner organizations co-led all aspects of the research.

Methods

Sixteen semi-structured interviews were conducted with Alberta emergency department (ED) physicians and nurses between November 2019 and March 2020.

Results

ED providers reported that First Nations patients are exposed to disrespect through tone and body language, experience overt racism, and may be neglected or not taken seriously. They described impacts of racist stereotypes on patient care, and strategies they took as individuals to address patient barriers to care. Recognized barriers to care included communication, resources, access to primary care and the ED environment itself.

Conclusions

Results may inform the content of anti-racist and anti-colonial pedagogy that is contextually tailored to ED providers, and inform wider systems efforts to counter racism against First Nations members and settler colonialism within healthcare.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08129-5.

Cultural Safety as an Outcome of a Dynamic Relational Process: The Experience of Inuit in a Mainstream Residential Addiction Rehabilitation Centre in Southern Canada

Few addiction treatment options are available in Arctic Canada, leading many Inuit to seek treatment programs in southern cities. We conducted a case study to understand what contributes to a culturally safe experience for Inuit in a mainstream addiction rehabilitation centre in Southern Canada. We carried out more than 700 hours of participant observation, in addition to semi-structured interviews and member-checking activities with 20 Inuit residents, 18 staff and four managers. Data were analysed using an inductive interpretative process. Throughout their journey in the program, Inuit navigated through contrasting situations and feelings that we grouped under six broad themes: having Inuit peers, having limitations imposed on one's ways of being and doing, facing ignorance and misperceptions, having conversations and dialogue, facing language barriers and being in a supportive and caring environment. This study highlights how cultural safety varies according to people, context and time, and relates to developing trustful relationships.

Appropriateness of COVID-19 public health guidelines for an Alberta First Nations community

Objectives

The First Nations people experience significant challenges that may influence the ability to follow COVID-19 public health directives on-reserve. This study aimed to describe experiences, perceptions and circumstances of an Alberta First Nations community, related to COVID-19 public health advice. We hypothesized that many challenges ensued when following and implementing advice from public health experts.

Methods

With First Nations leadership and staff, an online cross-sectional survey was deployed between April 24 and June 25, 2020. It assessed the appropriateness of public health advice to curb COVID-19 within this large First Nations community. Both quantitative and qualitative data were captured and described.

Results

A total of 106 adults living on-reserve responded; over 80% were female. Difficulty accessing food was significant by employment status (p = 0.0004). Those people with lower income found accessing food (p = 0.0190) and getting essential medical care (p = 0.0060), clothing (p = 0.0280) and transportation (p = 0.0027) more difficult. Some respondents described lost income associated with COVID-19 experiences, as well as difficulties accessing essential supplies. Respondents found “proper handwashing” most easy (98%) and “keeping a distance of 2 m from others” most difficult (23%). Many respondents found following public health advice within their personal domain easy and put “family safety” first but experienced some difficulties when navigating social aspects and obligations, particularly when unable to control the actions of others. People stated wanting clear information, but were sometimes critical of the COVID-19 response.

Conclusion

First Nations people face many additional challenges within the COVID-19 response, driven in part by ongoing issues related to significant societal, economic, and systemic factors.

Supplementary Information

The online version contains supplementary material available at 10.17269/s41997-021-00579-4.

Holistic Health of Two Spirit People in Canada: A Call for Nursing Action

Purpose: In response to item 7.1 from the Missing and Murdered Indigenous Women and Girls Report (2019), calling on health service providers to recognize the importance in inclusive services with and for Indigenous peoples including Two Spirit, lesbian, bisexual, transgender, queer, questioning, intersex, and asexual (2SLGBTQQIA) peoples, we undertook a review of the literature to identify the gaps in understanding and to better situate the health and resiliencies of Two Spirit people in Canada. Method: We conducted a review of 13 articles related to the health and wellness of the Canadian Two Spirit community. Overall, there was a dearth of Two Spirit specific health-related information. Results: Identified themes were grounded in the holistic Medicine Wheel teachings. These themes directly parallel holistic nursing in their demonstration that health is complex, and that there are many facets that make up an individuals’ health. Conclusion: Assessing the impact that colonization has had on the intersections of gender, race, sexuality, class, culture, and spirituality, Two Spirit people face unique health concerns. Considering the intersections of identity and structural barriers in place for this community, more research led by and in collaboration with the Two Spirit community is needed.

Appraising Indigenous cultural safety within healthcare: Protocol of a scoping review of reviews

AIM

The objective of this scoping review of reviews will be to synthesize the existing literature to identify key elements, conceptualizations and interventions of cultural safety to improve healthcare for Indigenous Peoples.

DESIGN

Eligible studies will include reviews (e.g. scoping reviews, systematic reviews and narrative reviews) focused on Indigenous cultural safety in healthcare.

METHODS

Guided by Weber-Pillwax's Indigenous principles of relationality and Arksey and O'Malley's scoping review framework, a review of reviews will be conducted by searching peer-reviewed literature published between January 2010 and December 2020. The database search will include CINAHL, PubMed, Scopus, Web of Science, and Google Scholar. This scoping review protocol was registered with the Joanna Briggs Institute on January 28, 2021.

DISCUSSION

There is a paucity of knowledge on existing interventions and implementation strategies to support Indigenous cultural safety within the healthcare system. Improving Indigenous cultural safety in healthcare requires a comprehensive understanding of its core components and the specific interventions.

IMPACT

This review will help guide future research and enhance cultural safety interventions for Indigenous Peoples, including Indigenous Peoples with diverse genders and sexualities. The findings from this review will provide critical insight and knowledge to inform cultural safety policies, programs and practices to support healthcare for Indigenous populations.

Health Systems Responsiveness in Addressing Indigenous Residents' Health and Mental Health Needs Following the 2016 Horse River Wildfire in Northern Alberta, Canada: Perspectives From Health Service Providers

Following the 2016 Horse River Wildfire in northern Alberta, the provincial health authority, the ministry of health, non-profit and charitable organizations, and regional community-based service agencies mobilized to address the growing health and mental health concerns among Indigenous residents and communities through the provision of services and supports. Among the communities and residents that experienced significant devastation and loss were First Nation and Métis residents in the region. Provincial and local funding was allocated to new recovery positions and to support pre-existing health and social programs. The objective of this research was to qualitatively describe the health systems response to the health impacts following the wildfire from the perspective of service providers who were directly responsible for delivering or organizing health and mental wellness services and supports to Indigenous residents. Semi-structured qualitative interviews were conducted with 15 Indigenous and 10 non-Indigenous service providers from the Regional Municipality of Wood Buffalo (RMWB). Interviews were transcribed verbatim and a constant comparative analysis method was used to identify themes. Following service provider interviews, a supplemental document review was completed to provide background and context for the qualitative findings from interviews. The document review allowed for a better understanding of the health systems response at a systems level following the wildfire. Triangulation of semi-structured interviews and organization report documents confirmed our findings. The conceptual framework by Mirzoev and Kane for understanding health systems responsiveness guided our data interpretation. Our findings were divided into three themes (1) service provision in response to Indigenous mental health concerns (2) gaps in Indigenous health-related services post-wildfire and (3) adopting a health equity lens in post-disaster recovery. The knowledge gained from this research can help inform future emergency management and assist policy and decision makers with culturally safe and responsive recovery planning. Future recovery and response efforts should consider identifying and addressing underlying health, mental health, and emotional concerns in order to be more effective in assisting with healing for Indigenous communities following a public health emergency such as a wildfire disaster.

Indigenous-specific cultural safety within health and dementia care: A scoping review of reviews

Globally, health inequities experienced by Indigenous communities are often described and documented in terms of deficits and disease. However, health disparities are complex and involve numerous underlying issues beyond the social determinants of health. Indigenous Peoples face unique barriers to accessing culturally safe and equitable healthcare, including racism, systemic injustice, and a historical legacy of colonialism. There is a paucity of knowledge on Indigenous-specific cultural safety interventions to support health and dementia care. The objective of this scoping review of reviews was to appraise the existing literature to identify key elements, conceptualizations, and interventions of cultural safety to improve health services and dementia care for Indigenous Peoples. Guided by Indigenous principles of relationality, we conducted a scoping review of reviews published between January 2010 to December 2020. We searched CINAHL, PubMed, Scopus, Web of Science, and Google Scholar. Given the limited literature focusing specifically on Indigenous people with dementia, our inclusion criteria focused broadly on Indigenous cultural safety in healthcare. A collaborative and relational rights-based approach co-led by Indigenous cisgender, Two-Spirit, and non-Indigenous cisgender health care providers was used to re-center Indigenous ways of knowing. A total of seventeen articles met our inclusion criteria. Our review identified a range of cultural safety themes from education initiatives to collaborative partnerships with Indigenous communities. Themes emerged at three levels: person-centered/individual level, health practitioner/student level, and healthcare organizational level. Few reviews described specific interventions, implementation strategies, evaluation methods, or the concept of sex and gender to improve cultural safety in healthcare delivery. Findings from this review can help to inform future research, inspire innovative collaborative methodologies, and enhance cultural safety interventions. In moving forward, there is an urgent need for anti-racism education, self-determination, and authentic partnerships to achieve Indigenous-specific cultural safety inclusive of sex and gender considerations in health and dementia care.

Acute health care among Indigenous patients in Canada: a scoping review

A recent report by the Chief Public Health Officer of Canada demonstrates the inferior health status of Indigenous Peoples in Canada when compared to non-Indigenous populations. This scoping review maps out the available literature concerning acute health care for Indigenous Peoples in Canada in order to better understand the health care issues they face. All existing articles concerning health care provided to Indigenous Peoples in Canada in acute settings were included in this review. The targeted studied outcomes were access to care, health care satisfaction, hospital visit rates, mortality, quality of care, length of stay and cost per hospitalisation. 114 articles were identified. The most studied outcomes were hospitalisation rates (58.8%), length of stay (28.0%), mortality (25.4%) and quality of care (24.6%) Frequently studied topics included pulmonary disease, injuries, cardiovascular disease and mental illness. Indigenous Peoples presented lower levels of satisfaction and access to care although they tend to be over-represented in hospitalisation rates for acute care. Greater inclusion of Indigenous Peoples in the health care system and in the training of health care providers is necessary to ensure a better quality of care that is culturally safe for Indigenous Peoples.

Addressing the need for indigenous and decolonized quantitative research methods in Canada

Though qualitative methods are often an appropriate Indigenous methodology and have dominated the literature on Indigenous research methods, they are not the only methods available for health research. There is a need for decolonizing and Indigenizing quantitative research methods, particularly in the discipline of epidemiology, to better address the public health needs of Indigenous populations who continue to face health inequities because of colonial systems, as well as inaccurate and incomplete data collection about themselves. For the last two decades, researchers in colonized countries have been calling for a specifically Indigenous approach to epidemiology that recognizes the limits of Western epidemiological methods, incorporates more Indigenous research methodologies and community-based participatory research methods, builds capacity by training more Indigenous epidemiologists, and supports Indigenous self-determination. Indigenous epidemiology can include a variety of approaches, including: shifting standards, such as age standardization, according to Indigenous populations to give appropriate weight to their experiences; carefully setting recruitment targets and using appropriate recruitment methods to fulfill statistical standards for stratification; acting as a bridge between Indigenous and Western technoscientific perspectives; developing culturally appropriate data collection tools; and developing distinct epidemiological methods based on Indigenous knowledge systems. This paper explores how decolonization and Indigenization of epidemiology has been operationalized in recent Canadian studies and projects, including the First Nations Regional Longitudinal Health Survey and how this decolonization and Indigenization might be augmented with the capacity-building of the future Our Health Counts Applied Indigenous Epidemiology, Health Information, and Health Services and Program Evaluation Training and Mentorship Program in Canada.

A critical exploration of nurses' perceptions of access to oncology care among Indigenous peoples: Results of a national survey

Inequities in access to oncology care among Indigenous peoples in Canada are well documented. Access to oncology care is mediated by a range of factors; however, emerging evidence suggests that healthcare providers, including nurses, play a significant role in shaping healthcare access. The purpose of this study was to critically examine access to oncology care among Indigenous peoples in Canada from the perspective of oncology nurses. Guided by postcolonial theoretical perspectives, interpretive descriptive and critical discourse analysis methodologies informed study design and data analysis. Oncology nurses were recruited from across Canada to complete an online survey (n = 78). Nurses identified a range of barriers experienced by Indigenous peoples when accessing oncology care, yet located these barriers primarily at the individual and systems levels. Nurses perceived themselves as mediators of access to oncology care; however, their efforts to facilitate access to care were constrained by the dominance of biomedicine within healthcare. Nurses' constructions of access to oncology care highlight the embedded narrative of individualism within nursing practice and the relative invisibility of racism as a determinant of equitable access to care among Indigenous peoples. This suggests a need for oncology nurses to better understand and incorporate structural determinants of health perspectives.

Factors influencing the provision of care for Inuit in a mainstream residential addiction rehabilitation centre in Southern Canada, an instrumental case study into cultural safety

BACKGROUND

Provision of culturally safe care has been proposed to address health inequity, including in the areas of mental health and addiction. The factors that influence the provision of culturally safe care remain understudied. This paper explores the factors influencing the efforts of a mainstream residential addiction rehabilitation centre to provide culturally appropriate and quality care for Inuit.

METHODS

An instrumental case study was conducted, informed by ethnographic and creative research methods. Over 700 h of participant observation were carried out between March 2018 and January 2020, in addition to qualitative semi-structured interviews (34 participants) and/or member-checking activities (17 participants) conducted with a total of 42 individuals: 20 Inuit residents, 18 clinical/specialized staff, and 4 clinical/administrative managers. An interpretive thematic analysis was performed to examine the factors that may influence the provision of culturally safe care for Inuit residents.

RESULTS

Ten categories of interrelated factors were identified and classified according to whether they relate to individual, programmatic, organizational, or systemic levels. These categories covered: (1) residents' and staff's life experiences; (2) personal and relational qualities and skills; (3) the model of care; (4) model flexibility; (5) ways in which relational aspects were considered; (6) sensitivity of the organization towards the population served; (7) human resources and professional development issues; (8) social climate; (9) political, relational, and funding climate; and (10) legislative, regulatory, and professional environment. While system-level factors generally had a negative effect on experiences of cultural safety, most factors at other levels had both favourable and unfavourable effects, depending on the context and dimensions examined.

CONCLUSIONS

The results offer insight into the interplay between the challenges and barriers that mainstream organizations face when working with Inuit, and the opportunities and enablers that organizations can build on to improve their services. This paper contributes to a better understanding of the challenges and opportunities to providing culturally safe addiction programs to Inuit within a complex intervention setting. It concludes by highlighting some areas for improvement to advance cultural safety in this context.

Physician Communication in Injectable Opioid Agonist Treatment: Collecting Patient Ratings With the Communication Assessment Tool

OBJECTIVE

Patient ratings of physician communication in the setting of daily injectable opioid agonist treatment are reported. Associations between communication items and demographic, health, drug use, and treatment characteristics are explored.

METHODS

Participants (n = 121) were patients receiving treatment for opioid use disorder with hydromorphone (an opioid analgesic) or diacetylmorphine (medical grade heroin). Ratings of physician communication were collected using the 14-item Communication Assessment Tool. Items were dichotomized and associations were explored using univariate and multivariable logistic regression models for each of the 14 items.

RESULTS

Ratings of physician communication were lower than reported in other populations. In nearly all of the 14 multivariable models, participants with more physical health problems and with lower scores for treatment drug liking had lower odds of rating physician communication as excellent.

CONCLUSIONS

In physician interactions with patients with opioid use disorder, there is a critical need to address comorbid physical health problems and account for patient medication preferences.

PRACTICE IMPLICATIONS

Findings reinforce the role physicians can play in communicating with patients about their comorbid conditions and about medication preferences. In the patient-physician interaction efforts to meet patients' evolving treatment needs and preferences can be made by offering patients access to all available evidence-based treatments.

Association of socioeconomic status with medical assistance in dying: a case-control analysis

OBJECTIVES

Economic constraints are a common explanation of why patients with low socioeconomic status tend to experience less access to medical care. We tested whether the decreased care extends to medical assistance in dying in a healthcare system with no direct economic constraints.

DESIGN

Population-based case-control study of adults who died.

SETTING

Ontario, Canada, between 1 June 2016 and 1 June 2019.

PATIENTS

Patients receiving palliative care under universal insurance with no user fees.

EXPOSURE

Patient's socioeconomic status identified using standardised quintiles.

MAIN OUTCOME MEASURE

Whether the patient received medical assistance in dying.

RESULTS

A total of 50 096 palliative care patients died, of whom 920 received medical assistance in dying (cases) and 49 176 did not receive medical assistance in dying (controls). Medical assistance in dying was less frequent for patients with low socioeconomic status (166 of 11 008=1.5%) than for patients with high socioeconomic status (227 of 9277=2.4%). This equalled a 39% decreased odds of receiving medical assistance in dying associated with low socioeconomic status (OR=0.61, 95% CI 0.50 to 0.75, p<0.001). The relative decrease was evident across diverse patient groups and after adjusting for age, sex, home location, malignancy diagnosis, healthcare utilisation and overall frailty. The findings also replicated in a subgroup analysis that matched patients on responsible physician, a sensitivity analysis based on a different socioeconomic measure of low-income status and a confirmation study using a randomised survey design.

CONCLUSIONS

Patients with low socioeconomic status are less likely to receive medical assistance in dying under universal health insurance. An awareness of this imbalance may help in understanding patient decisions in less extreme clinical settings.

Wabishki Bizhiko Skaanj: a learning pathway to foster better Indigenous cultural competence in Canadian health research

Objective

In Canada, Indigenous people experience racism across diverse settings, including within the health sector. This has negatively impacted both the quality of care that Indigenous people receive as well as how research related to Indigenous populations is conducted. Therefore, an Indigenous-led council at a kidney research network, in partnership with other key stakeholders, sought to create a learning pathway that aims to distill the racism that Indigenous people face, and build cultural competence, within the health sector.

Participants

The learning pathway was designed for researchers, health care providers, patient partners and administrators.

Setting

Various components of the pathway are established trainings in healthcare and research settings at provincial and national levels. Provincially, some components are implemented in British Columbia, Alberta, Saskatchewan, Manitoba and Ontario.

Intervention

The pathway, called Wabishki Bizhiko Skaanj (meaning “White Horse” in Anishinaabemowin), involves six key steps: a culturally tailored blanket exercise that walks participants through the history of local Indigenous Nations/peoples; a more detailed online training program (San’yas); a series of webinars on Indigenous research ethics and protocols; an educational booklet about engaging Knowledge Keepers in research, as well as sharing details about their traditional knowledge and culture; two certification programs about Indigenous ownership of data; and a “book club,” wherein the conversation of racism—and the goal for finding solutions—is continually discussed.

Outcomes

Wabishki Bizhiko Skaanj is working to build cultural competence in the Canadian health sector.

Implications

This learning pathway has the potential to address racial disparities across the country and improve health outcomes for Indigenous peoples.

First Nations emergency care in Alberta: descriptive results of a retrospective cohort study

Background

Worse health outcomes are consistently reported for First Nations people in Canada. Social, political and economic inequities as well as inequities in health care are major contributing factors to these health disparities. Emergency care is an important health services resource for First Nations people. First Nations partners, academic researchers, and health authority staff are collaborating to examine emergency care visit characteristics for First Nations and non-First Nations people in the province of Alberta.

Methods

We conducted a population-based retrospective cohort study examining all Alberta emergency care visits from April 1, 2012 to March 31, 2017 by linking administrative data. Patient demographics and emergency care visit characteristics for status First Nations persons in Alberta, and non-First Nations persons, are reported. Frequencies and percentages (%) describe patients and visits by categorical variables (e.g., Canadian Triage and Acuity Scale). Means, medians, standard deviations and interquartile ranges describe continuous variables (e.g., age).

Results

The dataset contains 11,686,288 emergency care visits by 3,024,491 unique persons. First Nations people make up 4% of the provincial population and 9.4% of provincial emergency visits. The population rate of emergency visits is nearly 3 times higher for First Nations persons than non-First Nations persons. First Nations women utilize emergency care more than non-First Nations women (54.2% of First Nations visits are by women compared to 50.9% of non-First Nations visits). More First Nations visits end in leaving without completing treatment (6.7% v. 3.6%).

Conclusions

Further research is needed on the impact of First Nations identity on emergency care drivers and outcomes, and on emergency care for First Nations women.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06415-2.

Nurses as agents of disruption: Operationalizing a framework to redress inequities in healthcare access among Indigenous Peoples

Health equity is a global concern. Although health equity extends far beyond the equitable distribution of healthcare, equitable access to healthcare is essential to the achievement of health equity. In Canada, Indigenous Peoples experience inequities in health and healthcare access. Cultural safety and trauma- and violence-informed care have been proposed as models of care to improve healthcare access, yet practitioners lack guidance on how to implement these models. In this paper, we build upon an existing framework of equity-oriented care for primary healthcare settings by proposing strategies to guide nurses in operationalizing cultural safety and trauma- and violence-informed care into nursing practice at the individual level. This component is one strategy to redress inequitable access to care among Indigenous Peoples in Canada. We conceptualize barriers to accessing healthcare as intrapersonal, interpersonal, and structural. We then define three domains for nursing action: practicing reflexivity, prioritizing relationships, and considering the context. We have applied this expanded framework within the context of Indigenous Peoples in Canada as a way of illustrating specific concepts and focusing our argument; however, this framework is relevant to other groups experiencing marginalizing conditions and inequitable access to healthcare, and thus is applicable to many areas of nursing practice.

First Nations members' emergency department experiences in Alberta: a qualitative study

OBJECTIVES

In Alberta, First Nations members visit Emergency Departments (EDs) at almost double the rate of non-First Nations persons. Previous publications demonstrate differences in ED experience for First Nations members, compared to the general population. The Alberta First Nations Information Governance Centre (AFNIGC), First Nations organizations, Universities, and Alberta Health Services conducted this research to better understand First Nations members' ED experiences and expectations.

METHODS

This was a participatory research project. Elders selected topics of focus through discussion with the research team, and approved our method of data collection. Sharing circles were held in February 2018 with Elders, First Nations patients, healthcare providers and health administrators from across Alberta. We analyzed data using the Western approach of thematic analysis, with review by two Indigenous team members. AFNIGC is custodian of the research data on behalf of Alberta First Nations, and approves publication of this work.

RESULTS

Forty-six persons participated in four sharing circles lasting between one and a half and three hours. Findings included First Nations patients' understandings of ED work, limited access to primary care services driving ED use, expectations of different treatment in ED based on race, experiences of racism, concerns about interactions with Children's Services, healthcare avoidance, and avoiding specific hospitals. Equity approaches were identified as key to improving First Nations patients' ED experiences.

CONCLUSIONS

Bringing First Nations perspectives to Western understandings of ED care is an important step toward identifying required improvements in the health system for better patient experiences and outcomes.

Non-disclosure of drug use in outpatient health care settings: Findings from a prospective cohort study in Vancouver, Canada

BACKGROUND

Illicit drug use is associated with severe health-related harms, yet people who use drugs (PWUD) face substantial barriers to healthcare. We sought to identify factors associated with disclosure of drug use to a healthcare provider and describe differences in self-reported quality of care received based on disclosure status.

METHODS

A client-reported experience questionnaire on healthcare access and quality, adapted from the World Health Organization Survey on Health and Health System Responsiveness, was administered within two ongoing prospective cohort studies of PWUD in Vancouver, Canada. Respondents not currently receiving addiction treatment were asked about experience of care and drug use disclosure to their most commonly accessed outpatient healthcare provider in the past 6 months. We used an adjusted logistic regression model to identify client characteristics associated with disclosure.

RESULTS

From a total of 261 respondents (34.1% female), less than half (n = 125, 47.8%) reported disclosing drug use to their healthcare provider. Indigenous participants were less likely to disclose compared to non-Indigenous participants (adjusted OR: 0.55, 95% confidence interval: 0.30, 0.97). Disclosure was associated with lower self-reported quality of care (overall rating: disclosed 8.2 vs. did not disclose 8.8, p = 0.04).

CONCLUSIONS

In a sample of PWUD accessing outpatient healthcare services, we observed low rates of drug use disclosure, particularly for Indigenous respondents, and reduced quality of care for those who disclosed. These findings highlight the need for culturally safe and non-stigmatizing care to address pervasive stereotyping in the healthcare system and improved screening for substance use disorder in outpatient healthcare services.

Barriers and Mitigating Strategies to Healthcare Access in Indigenous Communities of Canada: A Narrative Review

The objective of this review is to document contemporary barriers to accessing healthcare faced by Indigenous people of Canada and approaches taken to mitigate these concerns. A narrative review of the literature was conducted. Barriers to healthcare access and mitigating strategies were aligned into three categories: proximal, intermediate, and distal barriers. Proximal barriers include geography, education attainment, and negative bias among healthcare professionals resulting in a lack of or inadequate immediate care in Indigenous communities. Intermediate barriers comprise of employment and income inequities and health education systems that are not accessible to Indigenous people. Distal barriers include colonialism, racism and social exclusion, resulting in limited involvement of Indigenous people in policy making and planning to address community healthcare needs. Several mitigation strategies initiated across Canada to address the inequitable health concerns include allocation of financial support for infrastructure development in Indigenous communities, increases in Indigenous education and employment, development of culturally sensitive education and medical systems and involvement of Indigenous communities and elders in the policy-making system. Indigenous people in Canada face systemic/policy barriers to equitable healthcare access. Addressing these barriers by strengthening services and building capacity within communities while integrating input from Indigenous communities is essential to improve accessibility.

Experiences of Māori of Aotearoa New Zealand's public health system: a systematic review of two decades of published qualitative research

OBJECTIVE

This paper aims to synthesise the broader perspectives of Māori patients and their whānau (extended family, family group) of their treatment within the public health system. Our research question was 'What are the experiences of Māori in the public health and/or hospital system in Aotearoa New Zealand?'

METHODS

A systematic search using PRISMA protocols and reflexive typology organised around the categories of Māori, public healthcare and qualitative research identified 14 papers that covered all three categories. We undertook a qualitative metasynthesis on these papers using a critical community psychology approach.

RESULTS

Māori patients and whānau from the included papers mention both barriers and facilitators to health. We categorised barriers as organisational structures, staff interactions and practical considerations. Facilitators were categorised as the provision of whānau support in the form of practical assistance, emotional care and health system navigation.

CONCLUSIONS

For many Māori, the existing public health system is experienced as hostile and alienating. Whānau members provide support to mitigate this, but it comes as a cost to whānau. Implications for public health: Public health providers must find ways to ensure that Māori consistently experience positive, high-quality healthcare interactions that support Māori ways of being.

Use of the health care system by Ontario First Nations people with diabetes: a population-based study

BACKGROUND

First Nations people in Ontario have an increased prevalence of diabetes compared to other people in the province. This study examined use of health care services by First Nations people with diabetes and other people with diabetes in Ontario.

METHODS

Using linked health administrative databases, we identified all people in Ontario with diabetes as of Apr. 1, 2014. We identified First Nations people using the Indian Register. We looked at outcomes from Apr. 1, 2014, to Mar. 31, 2015. We determined the proportion of people with a regular family physician and their continuity of care with that physician. We also examined visits with specialists for diabetes care, hospital admissions for ambulatory-care-sensitive conditions, and emergency department visits for hypo- or hyperglycemia.

RESULTS

There were 1 380 529 people diagnosed with diabetes in Ontario as of Apr. 1, 2014, of whom 22 952 (1.7%) were First Nations people. First Nations people were less likely to have a regular family physician (85.3% v. 97.7%) and had lower continuity of care with that physician (mean score for continuity of care 74.6 v. 77.7) than other people in Ontario. They were also less likely to see specialists. First Nations people were more likely to be admitted to hospital for ambulatory-care-sensitive conditions (2.4% v. 1.2%) and to have an emergency department visit for hypo- or hyperglycemia (1.5% v. 0.8%). Disparities were particularly marked for those living in First Nations communities.

INTERPRETATION

First Nations people with diabetes in Ontario had poorer access to and use of primary care than other people with diabetes in the province. These findings may help explain continued disparities in the rates of complications related to diabetes.

Enhancing access to care in northern rural communities via telehealth

The cost of providing health care in northern Canada is higher than the rest of Canada. Telehealth has the potential to reduce health care expenditures. Yet this is still underutilised in Canada and globally. This paper describes the services provided through telehealth in some northern regions of Canada. It provides recommendations on the requirements for setting up real presence telehealth and how utilisation can be enhanced. Telehealth offers potential benefits for health outcomes by increasing access to healthcare, and reducing expenditures.

EQUIP Emergency: study protocol for an organizational intervention to promote equity in health care

Background

Social inequities are widening globally, contributing to growing health and health care inequities. Health inequities are unjust differences in health and well-being between and within groups of people caused by socially structured, and thus avoidable, marginalizing conditions such as poverty and systemic racism. In Canada, such conditions disproportionately affect Indigenous persons, racialized newcomers, those with mental health and substance use issues, and those experiencing interpersonal violence. Despite calls to enhance equity in health care to contribute to improving population health, few studies examine how to achieve equity at the point of care, and the impacts of doing so. Many people facing marginalizing conditions experience inadequate and inequitable treatment in emergency departments (EDs), which makes people less likely to access care, paradoxically resulting in reliance on EDs through delays to care and repeat visits, interfering with effective care delivery and increasing human and financial costs. EDs are key settings with potential for mitigating the impacts of structural conditions and barriers to care linked to health inequities.

Methods

EQUIP is an organizational intervention to promote equity. Building on promising research in primary health care, we are adapting EQUIP to emergency departments, and testing its impact at three geographically and demographically diverse EDs in one Canadian province. A mixed methods multisite design will examine changes in key outcomes including: a) a longitudinal analysis of change over time based on structured assessments of patients and staff, b) an interrupted time series design of administrative data (i.e., staff sick leave, patients who leave without care being completed), c) a process evaluation to assess how the intervention was implemented and the contextual features of the environment and process that are influential for successful implementation, and d) a cost-benefit analysis.

Discussion

This project will generate both process- and outcome-based evidence to improve the provision of equity-oriented health care in emergency departments, particularly targeting groups known to be at greatest risk for experiencing the negative impacts of health and health care inequities. The main deliverable is a health equity-enhancing framework, including implementable, measurable interventions, tested, refined and relevant to diverse EDs.

Trial registration

Clinical Trials.gov #NCT03369678 (registration date November 18, 2017).

Healthcare Access Experiences Among Indigenous Women in Northern Rural Thailand: A Focused Ethnographic Study

Introduction

Persistent inequities in health and access to healthcare services for indigenous women living in Thailand remain a significant challenge. This study provides narrative accounts of Indigenous women’s experiences accessing healthcare in northern and rural Thailand and explores the complexity of culture and its interaction with multiple intersecting influences on health behaviours.

Methods

A focused ethnographic study was conducted to understand and describe the culture of health behaviors and other cultural phenomena. We recruited 21 female participants aged 20–41 years between March and April of 2017. In-depth semi-structured interviews conducted in Thai were used to explore the experiences of the participants living in a northern rural village. Data analysis was informed and guided by Roper and Shapira’s framework for ethnographic analysis.

Results

Seven themes presented across three phases of experience (pre-access, making choices, and encountering difficulties) revealed an in-depth understanding of the Indigenous women’s lives, the broader sociocultural context in which they lived, and the challenges they faced when accessing healthcare. Analysis of data showed that the participants did not have equal access to healthcare and often disproportionately experienced discriminatory practices and negative attitudes of mainstream healthcare providers.

Conclusions

This is the only study to date that discusses healthcare access challenges experienced by Indigenous women living in a northern rural Thai village. There is an urgent need to focus on citizenship, employment, and general health conditions; gender, familial, and labor roles; specific health conditions, wellness, and cultural practices; the seeking of healthcare services; healthcare provider relationships; the ability to access needed care; and optimization of self-care. Future efforts to improve healthcare access and reduce disease burden might benefit from these findings and allow for the development of more effective strategies, programs, and policies.

Health Outcome and Follow-up Care Differences Between First Nation and Non-First Nation Coronary Angiogram Patients: A Retrospective Cohort Study

BACKGROUND

First Nations (FN) people experience high rates of ischemic heart disease (IHD) morbidity and mortality. Increasing access to angiography may lead to improved outcomes. We compared various outcomes and follow-up care post-index angiography between FN and non-FN patients.

METHODS

All index angiography patients in Manitoba were identified between April 1, 2000 and March 31, 2009 and categorized into acute myocardial infarction (AMI) or non-AMI groups based on whether their angiogram occurred within 7 days of an AMI. Cox proportional hazard models estimated associations between FN status and outcomes related to mortality, subsequent hospitalizations, revascularizations, and physician visits.

RESULTS

Cardiovascular mortality was higher among FN patients in the non-AMI group (hazard ratio [HR] = 1.50, 95% confidence interval [CI], 1.17-1.94) and in the AMI group (HR = 1.57, 95% CI, 1.05-2.35). FN patients were also more likely to have a subsequent hospitalization for AMI (HR = 2.26, 95% CI, 1.79-2.85) in the non-AMI group. FN patients in the non-AMI group were less likely to receive percutaneous coronary intervention (HR = 0.85, 95% CI, 0.73-0.99) and more likely to undergo coronary artery bypass graft (HR = 1.26, 95% CI, 1.10-1.45). FN patients in both groups were less likely to visit a cardiologist/cardiac surgeon, internal medicine specialist, or family physician within 3 months and 1 year of angiography.

CONCLUSIONS

Cardiovascular health and follow-up care outcomes of FN and non-FN patients who undergo angiography are not the same. Addressing Indigenous determinants of health are necessary to improve cardiovascular outcomes.

Understanding access to healthcare among Indigenous peoples: A comparative analysis of biomedical and postcolonial perspectives

As nursing professionals, we believe access to healthcare is fundamental to health and that it is a determinant of health. Therefore, evidence suggesting access to healthcare is problematic for many Indigenous peoples is concerning. While biomedical perspectives underlie our current understanding of access, considering alternate perspectives could expand our awareness of and ability to address this issue. In this paper, we critique how access to healthcare is understood through a biomedical lens, how a postcolonial theoretical lens can extend that understanding, and the subsequent implications this alternative view raises for the nursing profession. Drawing on peer-reviewed published and gray literature concerning healthcare access and Indigenous peoples to inform this critique, we focus on the underlying theoretical lens shaping our current understanding of access. A postcolonial analysis provides a way of understanding healthcare as a social space and social relationship, presenting a unique perspective on access to healthcare. The novelty of this finding is of particular importance for the profession of nursing, as we are well situated to influence these social aspects, improving access to healthcare services broadly, and among Indigenous peoples specifically.

Understanding the space of nursing practice in Colombia: A critical reflection on the effects of health system reform

Worldwide, healthcare has been touched by neoliberal policies to the extent that it has some of its characteristics, such as being asymmetrical, competitive, dehumanized, and profit driven. In Colombia, Law 100/93 was created as an ambitious reform aimed at integrating the social security and public sectors of healthcare in order to create universal access, and at the same time to generate market competence with the objective of improving effectiveness and responsiveness. Instead, however, Colombian health reform has served to generate competition which has aggravated inequalities among people. Within this context, we practice nursing. As nurses, our responsibility is to advocate for our patients. We cannot ignore what is happening worldwide in hospitals and community health settings because our responsibility is to promote health, prevent disease, and care for human beings. So, today, when the world pushes for economical profit and competence on one hand, and, on the other, for moral compromises to care, respect, and advocacy for all human beings, being a nurse in the Colombian health system represents a challenge for us. This challenge is especially significant because harm and benefit, justice and injustice, respect and disrespect are separated by a fine line that is easy to transgress.

Examining Injury Among Indigenous Young People: A Narrative Scoping Review

Indigenous young people of circumpolar developed countries experience a disproportionate incidence of injury compared with non-Indigenous young people. Much has been published about the experience of injury within the general Indigenous population, but literature is limited with regard to Indigenous young people. Trauma nurses, who are important members of the multidisciplinary team that provides injury intervention to Indigenous populations, need to be aware of this literature, as well as subsequent research gaps, to provide effective care to Indigenous young people experiencing injury. The purpose of this study was to provide an updated comprehensive review of the research-based evidence related to all-cause injury for Indigenous young people. An exploratory scoping review was conducted with a narrative synthesis. To locate literature, 7 electronic databases were searched from 2003 to 2017. Criteria were applied to all located articles to determine inclusion and then data were extracted from each study's findings. A total of 15 studies were included in this review that met the inclusion criteria. Themes derived from the knowledge synthesis process are as follows: incidence rates, mechanisms of injury, risk factors, and gaps in research. A strong epidemiological focus has emerged from the research found in this review of injury among Indigenous young people. The results of this review serve as a starting point for trauma nurses to successfully assess, build trusting relationships with, and further research injury among Indigenous young people.