How the choice of ethnic indicator influences ethnicity-based inequities in maternal health care in four Latin American countries: who is indigenous?

Indigenous identity identification in administrative health care data globally: A scoping review

OBJECTIVE

Both Indigenous and non-Indigenous governments and organizations have increasingly called for improved Indigenous health data in order to improve health equity among Indigenous peoples. This scoping review identifies best practices, potential consequences and barriers for advancing Indigenous health data and Indigenous data sovereignty globally.

METHODS

A scoping review was conducted to capture the breadth and nature of the academic and grey literature. We searched academic databases for academic records published between 2000 and 2021. We used Google to conduct a review of the grey literature. We applied Harfield's Aboriginal and Torres Strait Islander Quality Appraisal Tool (QAT) to all original research articles included in the review to assess the quality of health information from an Indigenous perspective.

RESULTS

In total, 77 academic articles and 49 grey literature records were included. Much of the academic literature was published in the last 12 years, demonstrating a more recent interest in Indigenous health data. Overall, we identified two ways for Indigenous health data to be retrieved. The first approach is health care organizations asking clients to voluntarily self-identify as Indigenous. The other approach is through data linkage. Both approaches to improving Indigenous health data require awareness of the intergenerational consequences of settler colonialism along with a general mistrust in health care systems among Indigenous peoples. This context also presents special considerations for health care systems that wish to engage with Indigenous communities around the intention, purpose, and uses of the identification of Indigenous status in administrative databases and in health care settings. Partnerships with local Indigenous nations should be developed prior to the systematic collection of Indigenous identifiers in health administrative data. The QAT revealed that many research articles do not include adequate information to describe how Indigenous communities and stakeholders have been involved in this research.

CONCLUSION

There is consensus within the academic literature that improving Indigenous health should be of high priority for health care systems globally. To address data disparities, governments and health organizations are encouraged to work in collaboration with local Indigenous nations and stakeholders at every step from conceptualization, data collection, analysis, to ownership. This finding highlights the need for future research to provide transparent explanation of how meaningful Indigenous collaboration is achieved in their research.

Ethnic disparities in out-of-pocket expense on medicines in Peru: Evidence from a nationwide survey

Background

Despite improvements in health insurance coverage, out-of-pocket (OOP) health spending remains a public health issue in Peru, and OOP payment has implications for disease treatment in ethnic minorities. We aimed to analyze the ethnic disparities in the OOP payment and estimate the gaps related to observable risk factors in the OOP payment on medicines by ethnic conditions during 2014-2016 in Peru.

Study design

cross-sectional study.

Methods

We conducted a secondary data analysis using the National Health User Satisfaction Survey. The outcome was the participants' OOP payment in self-reported medications. Ethnic minorities were considered participants who habitually spoke a language other than Spanish at home. Crude and adjusted linear regression models were performed, and the Oaxaca-Blinder decomposition method was used to assess the OPP payment differential by ethnic minority condition, explained by their individual and sociodemographic characteristics.

Results

We analyzed 11,346 surveyed, the mean age was 40.78 years, and 57.67 % were women. There was lower OOP payment in medications among ethnic minorities in the adjusted analysis (Beta coefficient [β]: -0.11; 95 % confidence interval [95%CI]: -0.21 to -0.01; p = 0.043). In the Oaxaca-Blinder decomposition analysis, a gap of 0.19 USD in the OOP payment in medicines among ethnic minorities was found (p < 0.001), and the explained component by the variables measured in this research only represents 40.5 % of the gap (p = 0.001).

Conclusion

There was less OOP expenditure on medicines in ethnic minorities. However, the measured variables explain only 40.5 % of these gaps. Therefore, we recommend future research that measures other variables that explain aspects of OOP spending on medicines not identified in this research. Likewise, our findings can be used to establish policies with an intercultural approach that adapt health documents to native languages or are disseminated by trained people from their communities.

Reduction in contraceptive use during the COVID-19 pandemic among women in an indigenous Mexican community: a retrospective crossover study

Background

Being indigenous, being a woman, and living in poverty are social determinants that contribute to reduced access to healthcare, including reproductive health services. The COVID-19 pandemic might have exacerbated this lag.

Objective

This study explored how the COVID-19 pandemic affected the contraceptive use of a group of indigenous Mexican women and adolescents in their community.

Methods

Between June and December of 2021, 158 indigenous Mexican women who had experienced recurrent pregnancies were interviewed at two health centers in San Cristóbal de las Casas, Chiapas. Participants were either pregnant when they completed the questionnaire or had been pregnant during the COVID-19 pandemic. Women were asked about their contraceptive practices before and during the pandemic. The change in contraceptive practice was estimated using a logistic model.

Results

The COVID-19 pandemic reduced contraceptive use by 50%. Among women who wanted contraception, 58% did not receive it. During the pandemic, 77% of previous contraceptive users reported difficulty obtaining contraception, and only 23% sought family planning assistance.

Conclusion

During the COVID-19 pandemic, indigenous women in the studied community used fewer contraceptive methods and did not use intrauterine devices. Additionally, there was a decline in the percentage of women using contraceptives. These results highlight the impact on indigenous populations and the difficulties they could face in accessing reproductive health services during health emergencies.

Inequalities in the health, nutrition, and wellbeing of Afrodescendant women and children: A cross-sectional analysis of ten Latin American and Caribbean countries

BACKGROUND

Afrodescendants are systematically affected by discrimination in the Americas and few multi-country studies addressed ethnic inequalities in health and wellbeing in the region. We aimed to investigate gaps in coverage of key health outcomes and socioeconomic inequalities between Afrodescendants and non-Afrodescendants populations in Latin American and Caribbean countries.

METHODS

Using national household surveys (2011-2019) from ten countries, we analyzed absolute inequalities between Afrodescendants and a comparison group that includes non-Afrodescendants and non-Indigenous individuals (henceforth non-Afrodescendants) across 17 indicators in the continuum of reproductive, maternal, newborn, child, and adolescent health. These include indicators of family planning, antenatal care, delivery assistance, child nutrition, immunization coverage, child protection, access to improved water, sanitation and hygiene, adolescent fertility, and early childhood mortality. Inequalities between country-specific subgroups of Afrodescendants were also explored. The slope index of inequality was used to assess wealth-based inequalities within each ethnic group.

FINDINGS

Afrodescendants represented from 2·8% (Honduras) to 59·1% (Brazil) of the national samples. Of the 128 combinations of country and indicators with data, Afrodescendants fared worse in 78 (of which 33 were significant) and performed better in 50 (15 significant). More systematic disadvantages for Afrodescendants were found for demand for family planning satisfied, early marriage, and household handwashing and sanitation facilities. In contrast, Afrodescendants tended to present lower c-section rates and lower stunting prevalence. Honduras was the only country where Afrodescendants performed better than non-Afrodescendants in several indicators. Wealth gaps among Afrodescendants were wider than those observed for non-Afrodescendants for most indicators and across all countries.

INTERPRETATION

Gaps in health outcomes between Afrodescendants and non-Afrodescendants were observed in most countries, with more frequent disadvantages for the former although, in many cases, the gaps were reversed. Wealth inequalities within Afrodescendants tended to be wider than for non-Afrodescendants.

FUNDING

Pan American Health Organization, Bill and Melinda Gates Foundation, and the Wellcome Trust.

Ethnic inequalities in health intervention coverage among Mexican women at the individual and municipality levels

BACKGROUND

Using data from Mexico, the country with the largest indigenous population in Latin America, we describe ethnic inequalities in coverage with women's health interventions at individual and municipal levels.

METHODS

Cross-sectional study using data from the National Health and Nutrition Survey 2018 and the Mexican Intercensal Survey 2015. We selected five outcomes: modern contraceptive use, content-qualified antenatal care (ANCq), and skilled birth attendant (SBA) for women aged 15-49 years; Pap smear test and mammogram among women aged 25-64 and 40-69 years respectively. Municipalities were classified into three groups by the percentage of indigenous population: <10%, 10% - 39%, and ≥40%. We calculated crude and adjusted coverage ratios (CR) and 95% confidence intervals (CI) using Poisson regression.

FINDINGS

Women living in municipalities with indigenous population ≥40% were poorer, less educated, and more rural. Coverage was lower for indigenous than non-indigenous for modern contraceptive use (CR: 0·73; CI 0·65-0·83), ANCq (CR: 0·72; CI 0·62-0·83), SBA (CR: 0·83; CI 0·77-0·90) and undergoing a mammogram (CR: 0·54; CI 0·41-0·71), but not for Pap smears (CR: 0·94; CI 0·83-1·07). Coverage with the five interventions increased as the municipal proportions of indigenous population decreased, both for indigenous and non-indigenous women. Coverage gaps at municipal level tended to be wider than at individual level.

INTERPRETATION

Both indigenous and non-indigenous women living in municipalities with high proportions of indigenous people were systematically excluded from reproductive and maternal interventions. Our findings suggest that social and health interventions targeted at the individual level should be complemented by structural interventions in municipalities with high proportions of indigenous people, including strengthening health and social services.

Public health insurance and ethnic disparities in maternal health care: the case of vulnerable Mexican women over the last 25 years

This article examines the coverage in the continuum of antenatal-postnatal care for vulnerable women in Mexico according to indigenous status and assesses the influence of public health insurance strategies on the evolution of coverage over the last 25 years. We studied a total of 19 613 567 Mexican women, aged 12-54 years at last birth, based on a pooled cross-sectional analysis of data from the 1997, 2009, 2014 and 2018 waves of the National Survey of Demographic Dynamics. After describing sociodemographic characteristics and maternal-health coverage by indigenous status, we constructed a pooled fixed-effects and interaction multivariable regression model to assess the influence of the Seguro Popular programme on continuum of care. We estimated adjusted continuum of care coverage between 1994 and 2018 according to Seguro Popular affiliation and indigenous status. Prior to the Seguro Popular programme, crude coverage in the continuum of care for non-indigenous women stood at 14.5% [95% confidence interval (CI): 13.2-15.8%] or 11 percentage points higher than for indigenous women. During the last period of the programme, it rose to 46.5% [95% CI: 45.6-47.5%] and 34.1% [95% CI: 30.7-37.4%], respectively. Our regression analysis corroborated findings that, on average, indigenous women faced lower odds of benefiting from continuum of care [adjusted odds ratio (aOR) = 0.48, 95% CI: 0.40-0.57] than did their non-indigenous counterparts. It also revealed that coverage for indigenous women without Seguro Popular affiliation was 26.7% [95% CI: 23.3-30.1%] or 12 percentage points lower than for those with Seguro Popular affiliation (38.6%, 95% CI: 35.7-41.4%). Our regression results confirmed that the latter benefited from higher odds of continuum of care (aOR = 1.67, 95% CI: 1.36-2.26). Gaps between those of indigenous and non-indigenous status have persisted, but the Seguro Popular clearly contributed to reducing the coverage gaps between these two groups of women. Strategies yielding better outcomes are required to improve the structural conditions of indigenous populations.