Creating exclusive breastfeeding knowledge translation tools with First Nations mothers in Northwest Territories, Canada

Infant feeding experiences among Indigenous communities in Canada, the United States, Australia, and Aotearoa: a scoping review of the qualitative literature

BACKGROUND

Although exclusive breastfeeding is recommended for the first six months of life, research suggests that breastfeeding initiation rates and duration among Indigenous communities differ from this recommendation. Qualitative studies point to a variety of factors influencing infant feeding decisions; however, there has been no collective review of this literature published to date. Therefore, the objective of this scoping review was to identify and summarize the qualitative literature regarding Indigenous infant feeding experiences within Canada, the United States, Australia, and Aotearoa.

METHODS

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses- Scoping Reviews and the Joanna Briggs Institute Guidelines, in October 2020, Medline, Embase, CINAHL, PsycINFO, and Scopus were searched for relevant papers focusing on Indigenous infant feeding experiences. Screening and full-text review was completed by two independent reviewers. A grey literature search was also conducted using country-specific Google searches and targeted website searching. The protocol is registered with the Open Science Framework and published in BMJ Open.

RESULTS

Forty-six papers from the five databases and grey literature searches were included in the final review and extraction. There were 18 papers from Canada, 11 papers in the US, 9 studies in Australia and 8 studies conducted in Aotearoa. We identified the following themes describing infant feeding experiences through qualitative analysis: colonization, culture and traditionality, social perceptions, family, professional influences, environment, cultural safety, survivance, establishing breastfeeding, autonomy, infant feeding knowledge, and milk substitutes, with family and culture having the most influence on infant feeding experiences based on frequency of themes.

CONCLUSIONS

This review highlights key influencers of Indigenous caregivers' infant feeding experiences, which are often situated within complex social and environmental contexts with the role of family and culture as essential in supporting caregivers. There is a need for long-term follow-up studies that partner with communities to support sustainable policy and program changes that support infant and maternal health.

Factors of success, barriers, and the role of frontline workers in Indigenous maternal-child health programs: a scoping review

BACKGROUND

Despite considerable investment in maternal-child programs in Canada, there has been little positive impact on the health of Indigenous mothers and their children. The reasons for this are unclear and there is a need to identify how such programs can be successfully implemented. Community input is essential for successful programs; however, it is unclear what the contributions of frontline workers have been in the health program process, i.e., program development, delivery, and evaluation. Based on these identified gaps, this scoping review aimed to: (1) identify factors of success and barriers to successful Indigenous maternal-child community health programs for mothers and their children aged 0-6 years; and (2) explore how frontline workers are included in the program process.

METHODS

This scoping review was completed using the Arksey and O'Malley framework, informed by Levac et al. Four data bases (Medline, CINAHL, Embase, and Scopus), grey literature, and reference lists were searched for relevant materials from 1990-2019. Data was extracted from included articles and analysed using descriptive statistics, thematic analysis with the Braun and Clarke framework, and a Principal Component Analysis.

RESULTS

Forty-five peer-reviewed and grey articles were included in the review. Factors of program success included: relationship building; cultural inclusion; knowledge transmission styles; community collaboration; client-centred approaches; Indigenous staff; and operational considerations. Barriers included: impacts of colonization; power structure and governance; client and community barriers to program access; physical and geographical challenges; lack of staff; and operational deficits. Frontline workers were found to have a role in program delivery (n = 45) and development (n = 25). Few (n = 6) had a role in program evaluation.

CONCLUSION

Although a better understanding of the frontline worker role in maternal-child health programs was obtained from the review, in a large proportion of literature the authors could not determine if the role went beyond program delivery. In addition, no direct input from frontline workers and their perspectives on program success or barriers were identified, suggesting areas to explore in future research. This review's findings have been applied to inform a community-based participatory research project and may also help improve the development, delivery, and evaluation of Indigenous maternal-child health programs.

Tuakana-teina peer education programme to help Māori elders enhance wellbeing and social connectedness

BACKGROUND

There are significant inequities between Māori (Indigenous people) and non-Māori in ageing outcomes. This study used a strengths-based approach based on the key cultural concept of mana motuhake (autonomy and self-actualisation) to develop a tuakana-teina (literally older sibling-younger sibling) peer education programme to assist kaumātua (elders) in addressing health and social needs. The purpose of this study was to test the impact on those receiving the programme. Three aims identify the impact on outcomes, resources received and the cost effectiveness of the programme.

METHODS

Five Kaupapa Māori (research and services guided by Māori worldviews) iwi (tribe) and community providers implemented the project using a partnership approach. Tuakana (peer educators) had up to six conversations each with up to six teina (peer learners) and shared information related to social and health services. A pre- and post-test, clustered staggered design was the research design. Participants completed a baseline and post-programme assessment of health and mana motuhake measures consistent with Māori worldviews. Open-ended questions on the assessments, five focus groups, and four individual interviews were used for qualitative evaluation.

FINDINGS

A total of 113 kaumātua were recruited, and 86 completed the programme. The analysis revealed improvements in health-related quality of life, needing more help with daily tasks, life satisfaction, paying bills and housing problems. Qualitative results supported impacts of the programme on mana motuhake and hauora (holistic health) through providing intangible and tangible resources. Cost-effectiveness analysis showed that the intervention is cost effective, with a cost per QALY of less than the conventional threshold of three times GDP per capita.

CONCLUSIONS

A culturally-resonant, strengths-based programme developed through a participatory approach can significantly improve health and social outcomes in a cost-effective way.

TRIAL REGISTRY

Clinical trial registry: Trial registration: (ACTRN12620000316909). Prospectively registered 06/03/2020, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=379302&isClinicalTrial=False .

Indigenous gender and wellness: a scoping review of Canadian research

This scoping review examined research publications related to health and/or wellness along with gender among Canadian Indigenous populations. The intent was to explore the range of articles on this topic and to identify methods for improving gender-related health and wellness research among Indigenous peoples. Six research databases were searched up to 1 February 2021. The final selection of 155 publications represented empirical research conducted in Canada, included Indigenous populations, investigated health and/or wellness topics and focused on gender. Among the diverse range of health and wellness topics, most publications focused on physical health issues, primarily regarding perinatal care and HIV- and HPV-related issues. Gender diverse people were seldom included in the reviewed publications. Sex and gender were typically used interchangeably. Most authors recommended that Indigenous knowledge and culture be integrated into health programmes and further research. More health research with Indigenous peoples must be conducted in ways that discern sex from gender, uplift the strengths of Indigenous peoples and communities, privilege community perspectives, and attend to gender diversity; using methods that avoid replicating colonialism, promote action, change stories of deficit, and build on what we already know about gender as a critical social determinant of health.

Breastfeeding in Canada: predictors of initiation, exclusivity, and continuation from the 2017-2018 Canadian Community Health Survey

Human milk is the ideal source of nutrition for infants; however, adherence to breastfeeding recommendations is suboptimal and availability of Canadian breastfeeding data are limited. Using the 2017-2018 Canadian Community Health Survey Public Use Microdata File (Maternal Experiences Module, n = 5558, weighted n = 1 669 462) we computed breastfeeding indicators and explored sociodemographic, health, and geographical predictors of breastfeeding with univariate logistic regression models. Nationally, of all participants who gave birth in the preceding 5 years, 91% initiated breastfeeding, 43% exclusively breastfed to ≥5 months and 35% to ≥6 months, 56% reported any breastfeeding at ≥6 months, and 31% reported breastfeeding at ≥12 months. Breastfeeding cessation was most commonly attributed to insufficient milk supply (25%), but reasons differed significantly by breastfeeding duration. Breastfeeding initiation, exclusivity for ≥5 months, and extended breastfeeding ≥12 months all differed by geographic region, and by most sociodemographic and health characteristics. Positive breastfeeding outcomes were highest in British Columbia, and lowest in Quebec and the Atlantic region, and generally higher if caregivers had recently immigrated to Canada, were married, were >30 years of age, were not White, were nonsmoking, had completed postsecondary education, and had an annual household income >$40 000. These disparities indicate the need for tailored, equitable approaches to breastfeeding support, and continued regional monitoring of breastfeeding outcomes.

Integrating Indigenous healing practices within collaborative care models in primary healthcare in Canada: a rapid scoping review

OBJECTIVES

In November 2020, a series of reports, In Plain Sight, described widespread Indigenous-specific stereotyping, racism and discrimination limiting access to medical treatment and negatively impacting the health and wellness of Indigenous Peoples in British Columbia, Canada. To address the health inequalities experienced by Indigenous peoples, Indigenous healing practices must be integrated within the delivery of care. This rapid scoping review aimed to identify and synthesise strategies used to integrate Indigenous healing practices within collaborative care models available in community-based primary healthcare, delivered by regulated health professionals in Canada.

ELIGIBILITY CRITERIA

We included quantitative, qualitative and mixed-methods studies conducted in community-based primary healthcare practices that used strategies to integrate Indigenous healing practices within collaborative care models.

SOURCES OF EVIDENCE

We searched MEDLINE, Embase, Indigenous Studies Portal, Informit Indigenous Collection and Native Health Database for studies published from 2015 to 2021.

CHARTING METHODS

Our data extraction used three frameworks to categorise the findings. These frameworks defined elements of integrated healthcare (ie, functional, organisational, normative and professional), culturally appropriate primary healthcare and the extent of community engagement. We narratively summarised the included study characteristics.

RESULTS

We identified 2573 citations and included 31 in our review. Thirty-nine per cent of reported strategies used functional integration (n=12), 26% organisational (n=8), 19% normative (n=6) and 16% professional (n=5). Eighteen studies (58%) integrated all characteristics of culturally appropriate Indigenous healing practices into primary healthcare. Twenty-four studies (77%) involved Indigenous leadership or collaboration at each phase of the study and, seven (23%) included consultation only or the level of engagement was unclear.

CONCLUSIONS

We found that collaborative and Indigenous-led strategies were more likely to facilitate and implement the integration of Indigenous healing practices. Commonalities across strategies included community engagement, elder support or Indigenous ceremony or traditions. However, we did not evaluate the effectiveness of these strategies.

Protocol for a scoping review of the qualitative literature on Indigenous infant feeding experiences

INTRODUCTION

Prudent infant nutrition, including exclusive breastfeeding to 6 months, is essential for optimal short-term and long-term health. Quantitative research to date has documented that many Indigenous communities have lower breastfeeding rates than the general population and that this gap in breastfeeding initiation and maintenance may have an important impact on chronic disease risk later in life. However, there are critical knowledge gaps in the literature regarding factors that influence infant feeding decisions. Qualitative research on infant feeding experiences provides a broader understanding of the challenges that Indigenous caregivers encounter, and insights provided by this approach are essential to identify research gaps, community engagement strategies, and programme and policy development. The objective of this review is to summarise the qualitative literature that describes breastfeeding and other infant feeding experiences of Indigenous caregivers.

METHODS AND ANALYSIS

This scoping review will follow guidelines from Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews, the Joanna Briggs Institute and the methodological framework from Arksey and O'Malley. In October 2020, we will conduct an electronic database search using Medline, Embase, The Cumulative Index to Nursing & Allied Health Literature (CINAHL), PsycINFO, and Scopus, and will focus on qualitative studies. Publications that have a focus on infant feeding in Canada, the USA, Australia and New Zealand, and the Indigenous caregiver experience from the caregiver perspective, will be included. We will conduct a grey literature search using Indigenous Studies Portal, country-specific browser searches, and known government, association, and community websites/reports. We will map themes and concepts of the publications, including study results and methodologies, to identify research gaps, future directions, challenges and best practices in this topic area.

ETHICS AND DISSEMINATION

Ethical approval is not required for this review as no unpublished primary data will be included. The results of this review will be shared through peer-reviewed publications and conference presentations. This protocol is registered through the Open Science Framework (osf.io/4su79).

Kaumātua Mana Motuhake: peer education intervention to help Māori elders during later-stage life transitions

BACKGROUND

Aotearoa/New Zealand has a population that is ageing and there are challenges to health and social outcomes related to related to key life transitions (e.g., retirement, change in health conditions, loss of spouse). Further, there are significant inequities between Māori (Indigenous people) and non-Māori in ageing outcomes. The purpose of this study was to test the impacts and cost effectiveness of a tuakana/teina (peer education) intervention on kaumātua (elders) receiving the intervention. This study was framed by a strengths-based approach based on the key cultural concept of mana motuhake (autonomy and self-actualisation).

METHODS

This study was grounded in principles of Kaupapa Māori and community-based participatory research to bring together a diverse group of stakeholders to co-develop and co-evaluate the intervention. The intervention had tuakana (peer educators) having conversations with up to six teina (recipients) and providing information related to health and social services. The research design was a pre- and post-test, clustered staggered design. Participants completed a baseline assessment of health and mana motuhake measures consistent with Māori worldviews along with two follow-up assessments (one after the first intervention group completed its activities and a second after the second intervention group completed its activities). Additionally, five focus groups and open-ended questions on the assessments were used to provide qualitative evaluation.

FINDINGS

A total of 180 kaumātua were recruited to the intervention with 121 completing it. The analysis revealed improvements over time in the expected direction on most of the variables. However, only three of the variables had statistically significant intervention effects: received support, tribal identity, and trouble paying bills. Qualitative results supported impacts of the intervention on mana motuhake, social connectedness, and tangible/information support related to services. Cost-effectiveness analysis showed that the intervention is cost effective, with a cost per QALY of less than the conventional threshold of three times gross domestic product per capita.

CONCLUSIONS

The findings support the relevancy and importance of kaumātua knowledge to create a strengths-based approach to improve health and social outcomes. This study demonstrates that a contextually based and culturally safe age-friendly environments can facilitate engagement and participation by kaumātua for kaumātua.

TRIAL REGISTRY

Australia New Zealand Clinical Trial Registry (ACTRN12617001396314); Date Registered: 3 October 2017 (retrospectively registered); https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373733&isClinicalTrial=False.