"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.

Little Doctors: Agents of change in Indian rural communities

The child-to-child approach to health advocacy is one that draws on the strengths and agency of children to make a positive impact within their communities. The approach has been popularly used for health education in low- and middle-income countries. This article describes the 'Little Doctors' program that implemented the child-to-child approach in the towns of KC Patty and Oddanchatram, located in remote hilly regions of Tamil Nadu, India starting in 1986 to train middle- and high school children to respond to diseases prevalent in their communities along with practices for preventative measures. The program involved sessions that used a combination of creative instructional methods to engage students and provided take-home messages for them to act on with their families and community. The program was successful in creating a creative learning environment for children, offering a shift from the traditional methods of classroom instruction. Students who successfully completed the program were awarded certificates as 'Little Doctors' in their communities. Although the program did not conduct formal evaluations of the program effectiveness, students reported successfully recalling complex topics such as early signs of diseases like tuberculosis and leprosy that were prevalent in the community during the time. The program experienced several challenges and had to be discontinued despite its continued benefits to the communities.

Twelve tips for using ePosters as an active learning strategy

ePosters (electronic Posters), a modification of traditional paper-based posters have gained popularity in medical education conferences since 2011. ePoster in educational settings differs from the traditional poster in that it allows the ePoster creator to focus on the learning process rather than reporting scientific outcomes. However, there is limited literature comparing ePosters to traditional paper-based posters and their impact on the student learning experience. ePosters as an assessment tool are well suited for online learning. This article presents twelve tips for using ePosters as an active learning strategy in classrooms and describes how to incorporate ePosters as a formative and summative assessment tool in health professions education, at all levels.

Integrative review of the needs and challenges of indigenous palliative care in rural and remote settings

AIMS

To appraise and synthesize the empirical literature on the needs and challenges of Indigenous peoples' accessibility to palliative care in rural and remote settings.

DESIGN

Whittemore and Knafl's updated approach to integrative reviews, PRISMA guidelines and CASP (2020) checklists for narrative analysis were followed.

DATA SOURCES

A systematic search of the published empirical literature from 1 January 2015 to 31 December 2021 was undertaken in five databases.

REVIEW METHODS

Twenty-four studies met the research question and the inclusion criteria.

RESULTS

Four themes describe the findings: Respect of Indigenous cultural beliefs on death and dying, connection to the land, needs for culturally responsive care and presence of institutional and systemic barriers. These themes indicate a pressing need to increase the accessibility and utilization of palliative care. Most of the studies were qualitative and conducted by teams of Indigenous and non-Indigenous researchers.

CONCLUSION

Integrating Indigenous knowledge and providing culturally responsive palliative care are steps towards achieving the decolonization of palliative care and responding to Indigenous people's needs of palliative care services. Institutional and systemic racism affect Indigenous peoples' access and delivery of palliative services in Canada and globally.

IMPACT

The review highlights the need for establishing partnerships and building local capacity with Indigenous communities to develop and implement culturally responsive palliative care programmes in remote locations.

Choice of cover crop influences soil fungal and bacterial communities in Prince Edward Island, Canada

Soil fungal and bacterial communities play various roles in agroecosystems and are significantly influenced by agricultural management practices. Currently, little is known about the effects of selected cover crops on soil fungal and bacterial communities in no-till systems. In this study, eight cover crops, three mixed crops, and an unmanaged fallow control were evaluated over two years for their effects on the soil microbiome. ITS and 16S rRNA amplicon sequencing was performed to characterize fungal and bacterial communities in the soil during the cover crop growing season, and in the subsequent year. Fungal and bacterial alpha diversity significantly increased over time and were influenced in the subsequent growing season by choice of cover crops. Some fungal and bacterial trophic and functional groups were also affected by crop choice. Fungal pathotroph abundance was positively associated with oilseed radish, alfalfa, and phacelia, but negatively associated with sorghum-sudangrass. Beneficial symbiotrophic fungi and functional nitrification-related bacterial groups were also associated with sorghum-sudangrass and buckwheat. These findings suggest that choice of cover crops influences the soil microbial community composition and may impact plant health in the subsequent crops.

Endoplasmic reticulum stress, the unfolded protein response, and gene network modeling in antiestrogen resistant breast cancer

Lack of understanding of endocrine resistance remains one of the major challenges for breast cancer researchers, clinicians, and patients. Current reductionist approaches to understanding the molecular signaling driving resistance have offered mostly incremental progress over the past 10 years. As the field of systems biology has begun to mature, the approaches and network modeling tools being developed and applied therein offer a different way to think about how molecular signaling and the regulation of critical cellular functions are integrated. To gain novel insights, we first describe some of the key challenges facing network modeling of endocrine resistance, many of which arise from the properties of the data spaces being studied. We then use activation of the unfolded protein response (UPR) following induction of endoplasmic reticulum stress in breast cancer cells by antiestrogens, to illustrate our approaches to computational modeling. Activation of UPR is a key determinant of cell fate decision making and regulation of autophagy and apoptosis. These initial studies provide insight into a small subnetwork topology obtained using differential dependency network analysis and focused on the UPR gene XBP1. The XBP1 subnetwork topology incorporates BCAR3, BCL2, BIK, NFκB, and other genes as nodes; the connecting edges represent the dependency structures amongst these nodes. As data from ongoing cellular and molecular studies become available, we will build detailed mathematical models of this XBP1-UPR network.

Pitfalls in the diagnosis of epithelioid sarcoma presenting in an unusual site: a case report

The cytologic appearance of epithelioid sarcoma in fine-needle aspiration biopsy cytology (FNABC) smears has not been extensively described. We report a case of epithelioid sarcoma in a 55-year-old male who presented with nodular swellings in the abdominal wall and scrotum. The scrotal swelling was subsequently demonstrated to arise from the vas deferens. We highlight the cytomorphologic, immunocytochemical, and histopathologic features of this rare lesion in an unusual site, with particular emphasis on the dilemma encountered in the cytodiagnosis of this lesion.