Using latent class analysis to operationalize a wholistic assessment of Inuit health and well-being

Many indigenous cultures conceptualize health wholistically, whereby physical, mental, spiritual and relational dimensions of health are interconnected. Yet, quantitative approaches to studying Indigenous health remain anchored in western perspectives, that separate the dimensions of health. This paper aims to operationalize a wholistic indicator of health based on the IQI model of Inuit health. Variables from the 2017 Nunavik Health Survey (N = 1196) were selected based on their representativeness of IQI model. Exploratory Latent Class Analysis (LCA) was used to identify wholistic health profiles. Once participants assigned to their health profile, sociodemographic characteristics were compared across profiles, and multinomial regression models were used to examine the relationship between community-level social determinants of health and the profiles. The LCA revealed three health profiles, labelled as "excellent", "good" and "fair" based on the distribution of answers to the indicators. Nunavimmiut in "excellent" and "good" health were more likely to: rate their health positively; be over 30 years old; be in a relationship; and have participated or volunteered in community events. Nunavimmiut in "fair" health tended to report lower levels of community cohesion, family relationships, and emotional support. Intergrating culturally relevant models of health can support improved health status assessments and identify opportunities for health promotion.

Making Big Business Everybody's Business: Aboriginal leaders' perspectives on commercial activities influencing aboriginal health in Victoria, Australia

BACKGROUND

The commercial determinants of health is a rapidly expanding field of research; however Indigenous perspectives remain notably underrepresented. For Indigenous peoples the intersection of globalisation, colonialism and capitalism may amplify commercially-driven health inequities. This study aimed to explore the perspectives of Aboriginal leaders regarding the influence of commercial activities on Aboriginal health and wellbeing in Victoria, Australia.

METHODS

Semi-structured interviews with 23 Aboriginal leaders from across five sectors (n = 15 urban, n = 8 rural/regional) were analysed through reflexive thematic analysis.

RESULTS

Three overarching themes were identified encompassing (i) harmful commercial practices and processes, (ii) improving corporate engagement and (iii) opportunities for self-determination through business. Participants expressed concern over aggressive marketing by the gambling industry, commercial exploitation of Aboriginal culture, the privatisation of public services, and lack of oversignt of corporate social responsibility strategies. Simultaneously, Aboriginal-led businesses were viewed as opportunities for cultural connection, and financial empowerment and self-determination.

CONCLUSION

Numerous commercial entities and activities are perceived to influence Aboriginal health and wellbeing. This study highlights the need for stronger policy and regulation to mitigate harmful industry practices while incentivising the potential positive impacts of the commercial activities on Aboriginal health and wellbeing.

The participation of Aboriginal and Torres Strait Islander parents in Australian trials of parenting programs for improving children's health: a scoping review

OBJECTIVES

To assess the inclusion of Aboriginal and Torres Strait Islander parents in trials of parenting programs in Australia; the involvement of Indigenous fathers in such studies; and whether parenting programs are designed to be culturally appropriate for Aboriginal and Torres Strait Islander people.

STUDY DESIGN

Scoping review of peer-reviewed journal publications that report quantitative outcomes for Australian randomised control trials of parenting programs in which the participants were parents or caregivers of children under 18 years of age, and with at least one outcome related to children's health, health behaviour, or wellbeing.

DATA SOURCES

MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Scopus databases.

DATA SYNTHESIS

Of 109 eligible publications, nine reported how many participants were Aboriginal or Torres Strait Islander people; three specified whether they were Aboriginal, Torres Strait Islander, or both. Two publications described specific interventions for Aboriginal and Torres Strait Islander children; both reported consultation with Indigenous people regarding program design. Of the 15 559 participating parents in all included publications, 93 were identified as Aboriginal or Torres Strait Islander people. No publications noted as study limitations the absence of consultation with Indigenous people or the low participation rate of Aboriginal and Torres Strait Islander families.

CONCLUSIONS

The specific needs and interests of Aboriginal and Torres Strait Islander families have not generally been considered in Australian trials of parenting programs that aim to improve the mental and physical health of children. Further, Indigenous people are rarely involved in the planning and implementation of the interventions, few of which are designed to be culturally appropriate for Indigenous people. If parenting research in Australia is to support Aboriginal and Torres Strait Islander families, it must include consultation with local communities, adapt interventions and research methods to the needs of the participating parents and their communities, and improve the recruitment and retention of Aboriginal and Torres Strait Islander participants.

COVID-19 vaccination intention and vaccine hesitancy among citizens of the Métis Nation of Ontario

OBJECTIVE

The study objective is to measure the influence of psychological antecedents of vaccination on COVID-19 vaccine intention among citizens of the Métis Nation of Ontario (MNO).

METHODS

A population-based online survey was implemented by the MNO when COVID-19 vaccines were approved in Canada. Questions included vaccine intention, the short version of the "5C" psychological antecedents of vaccination scale (confidence, complacency, constraint, calculation, collective responsibility), and socio-demographics. Census sampling via the MNO Registry was used achieving a 39% response rate. Descriptive statistics, bivariate analyses, and multinomial logistic regression models (adjusted for sociodemographic variables) were used to analyze the survey data.

RESULTS

The majority of MNO citizens (70.2%) planned to be vaccinated. As compared with vaccine-hesitant individuals, respondents with vaccine intention were more confident in the safety of COVID-19 vaccines, believed that COVID-19 is severe, were willing to protect others from getting COVID-19, and would research the vaccines (Confident OR = 19.4, 95% CI 15.5-24.2; Complacency OR = 6.21, 95% CI 5.38-7.18; Collective responsibility OR = 9.83, 95% CI 8.24-11.72; Calculation OR = 1.43, 95% CI 1.28-1.59). Finally, respondents with vaccine intention were less likely to let everyday stress prevent them from getting COVID-19 vaccines (OR = 0.47, 95% CI 0.42-0.53) compared to vaccine-hesitant individuals.

CONCLUSION

This research contributes to the knowledge base for Métis health and supported the MNO's information sharing and educational activities during the COVID-19 vaccines rollout. Future research will examine the relationship between the 5Cs and actual uptake of COVID-19 vaccines among MNO citizens.

The Benefits of Cooperative Inquiry in Health Services Research: Lessons from an Australian Aboriginal and Torres Strait Islander Health Study

Health services research is underpinned by partnerships between researchers and health services. Partnership-based research is increasingly needed to deal with the uncertainty of global pandemics, climate change induced severe weather events, and other disruptions. To date there is very little data on what has happened to health services research during the COVID-19 pandemic. This paper describes the establishment of an Australian multistate Decolonising Practice research project and charts its adaptation in the face of disruptions. The project used cooperative inquiry method, where partner health services contribute as coresearchers. When the COVID-19 pandemic hit, data collection needed to be immediately paused, and when restrictions started to lift, all research plans had to be renegotiated with services. Adapting the research surfaced health service, university, and staffing considerations. Our experience suggests that cooperative inquiry was invaluable in successfully navigating this uncertainty and negotiating the continuance of the research. Flexible, participatory methods such as cooperative inquiry will continue to be vital for successful health services research predicated on partnerships between researchers and health services into the future. They are also crucial for understanding local context and health services priorities and ways of working, and for decolonising Indigenous health research.

Understanding Suicide from an Indigenous Cultural Lens: Insights from Elders in Canada

In this study, Indigenous Elders in Canada were interviewed to explore their conceptualizations of death and dying, particularly in relation to suicide. Through reflexive thematic analysis, three key themes were developed: Indigenous conceptions of death and dying, Christian influences on views of suicide, and indirect suicide. The theme of Indigenous conceptualizations of death and dying included the subthemes of spirituality and life after death, highlighting the importance of spiritual beliefs in Indigenous culture and knowledge systems. The impact of Christian influences on views of suicide was also explored, with participants discussing the complex nature of the relationship between Christianity and Indigenous peoples. Finally, the theme of indirect suicide was analyzed, referring to deaths resulting from behaviors that do not necessarily fit within the conventional definition of suicide. Overall, this study highlights the importance of honoring Indigenous cultural knowledge in research related to suicide prevention in Indigenous communities.

Hepatitis B genotypes in Aboriginal and Torres Strait Islander Australians: correlation with clinical course and implications for management

BACKGROUND

The prevalence of chronic hepatitis B (CHB) in Aboriginal and Torres Strait Islander Australians in Far North Queensland (FNQ) is greater than twice that of the general Australian population. CHB is common in Torres Strait Islanders diagnosed with hepatocellular carcinoma (HCC) - and in Aboriginals with HCC living in the Northern Territory - however, Aboriginals diagnosed with HCC in FNQ very rarely have CHB. The explanation for this apparent disparity is uncertain.

AIMS

To determine the HBV genotypes in the FNQ Aboriginal and Torres Strait Islander population and their correlation with clinical phenotype.

METHODS

We determined the HBV genotype of Aboriginal and Torres Strait Islander Australians living with CHB in FNQ and correlated this with demographic and clinical findings.

RESULTS

134/197 (68%) enrolled individuals had a sufficient viral load for genotyping. All 40 people with HBV/D genotype had Aboriginal heritage, whereas 85/93 (91%) with HBV/C had Torres Strait Islander heritage (P < 0.0001). Individuals with HBV/D were younger than those with HBV/C (median (interquartile range) age: 43 (39-48) vs 53 (42-66) years, P = 0.0002). However, they were less likely to be HBeAg positive (1/40 (3%) vs 23/93 (25%), P = 0.001). All three HCCs developed in Torres Strait Islanders; two-thirds were infected with HBV/C14; genotyping was not possible in the other individual. All 10 diagnoses of cirrhosis occurred in Torres Strait Islanders, 6/10 were infected with HBV/C14, genotyping was not possible in the other four individuals.

CONCLUSIONS

HBV genotypes in Aboriginal and Torres Strait Islander Australians in FNQ differ markedly, which could explain the significant differences in the clinical phenotype in the two populations and might be used to inform cost-effective CHB care in the region.

Capacity building to address antimicrobial resistance in remote Australia: The inaugural HOT NORTH Antimicrobial Academy

BACKGROUND

Rates of antimicrobial resistance (AMR) for some pathogens in Australia are considerably higher in rural and remote compared to urban regions. The inaugural Hot North Antimicrobial Academy was a 9-month educational programme aimed to build workforce knowledge and capacity in antimicrobial use, audit, stewardship, surveillance and drug resistance in remote primary health care.

METHODS

The Academy was advertised to Aboriginal and Torres Strait Islander, regional and remote healthcare workers. Participants were Aboriginal health practitioners, nurses, pharmacists and doctors from Queensland, Northern Territory, South Australia and Western Australia working in remote primary health care with a focus on Indigenous health. Due to COVID-19 restrictions, the Academy ran virtually from February-November 2021 using Microsoft Teams. The Academy was evaluated using surveys and yarning circles to assess impact and knowledge gain.

RESULTS

Participants and faculty from across Australia attended 19 lectures and mentorship sessions. Eleven participants commenced and eight (73%) completed the Academy. The Academy raised participants awareness of AMR guidelines, governance and generating change; built confidence in advocacy; grew knowledge about drug resistant infections; and created a community of AMR champions in Indigenous health.

CONCLUSION

The evaluation confirmed the Academy met the needs of participants, provided opportunities to move stewardship from tertiary hospitals into Indigenous and remote clinics and developed skills in research, audit, stewardship and advocacy for all involved. All sessions were recorded for future use, with facilitation by the National Aboriginal Community Controlled Health Organisation (NACCHO) in future years.

Correlates of mental disorder and harmful substance use in an indigenous Australian urban sample: an analysis of data from the Queensland Urban Indigenous Mental Health Survey

PURPOSE

Limited data exists on the relationship between sociodemographic and cultural variables and the prevalence of specific mental and substance use disorders (MSDs) among Indigenous Australians, using diagnostic prevalence data. This paper utilises data from the Queensland Urban Indigenous Mental Health Survey (QUIMHS), a population-level diagnostic mental health survey, to identify socioeconomic and cultural correlates of psychological distress and specific MSDs in an urban Indigenous Australian sample.

METHODS

Using a mixture of household sampling (door-knocking) and snowball sampling (promotion of the survey in the community), 406 participants aged 18 to 89 were recruited across key locations in Southeast Queensland. The study investigated various demographic, socioeconomic, and cultural factors as predictors of psychological distress (measured by the Kessler-5) and MSD diagnoses (utilising the Composite International Diagnostic Interview, CIDI 3.0) using a series of univariate logistic regressions.

RESULTS

Individuals in unstable housing (homeless, sleeping rough) and those reporting financial distress were more likely to experience an MSD in the past 12 months and throughout their lifetime. Individuals reporting lower levels of connection and belonging, limited participation in cultural events, and lower empowerment were more likely to have a lifetime mental disorder.

CONCLUSION

This data emphasises the importance of addressing systemic and social determinants of health when designing and delivering community mental health services and underscores the need for holistic approaches when working with Indigenous communities.

The health risks of marine biotoxins associated with high seafood consumption: Looking beyond the single dose, single outcome paradigm with a view towards addressing the needs of coastal Indigenous populations in British Columbia

People who consume high quantities of seafood are at a heightened risk for marine biotoxin exposure. Coastal Indigenous peoples may experience higher levels of risk than the general population due to their reliance on traditional marine foods. Most evidence on the health risks associated with biotoxins focus on a single exposure at one point in time. There is limited research on other types of exposures that may occur among those who regularly consume large quantities of seafood. The objective of this review is to assess what is known about the unique biotoxin exposure risks associated with the consumption patterns of many coastal Indigenous populations. These risks include [1]: repeated exposure to low doses of a single or multiple biotoxins [2]; repeated exposures to high doses of a single or multiple biotoxins; and [3] exposure to multiple biotoxins at a single point in time. We performed a literature search and collected 23 recent review articles on the human health effects of different biotoxins. Using a narrative framework synthesis approach, we collated what is known about the health effects of the exposure risks associated with the putative consumption patterns of coastal Indigenous populations. We found that the health effects of repeated low- or high-dose exposures and the chronic health effects of marine biotoxins are rarely studied or documented. There are gaps in our understanding of how risks differ by seafood species and preparation, cooking, and consumption practices. Together, these gaps contribute to a relatively poor understanding of how biotoxins impact the health of those who regularly consume large quantities of seafood. In the context of this uncertainty, we explore how known and potential risks associated with biotoxins can be mitigated, with special attention to coastal Indigenous populations routinely consuming seafood. Overall, we conclude that there is a need to move beyond the single-dose single-outcome model of exposure to better serve Indigenous communities and others who consume high quantities of seafood.

The emergence of cultural safety within kidney care for Indigenous Peoples in Australia

Cultural safety is increasingly recognised as imperative to delivering accessible and acceptable healthcare for First Nations Peoples within Australia and in similar colonised countries. A literature review undertaken to inform the inaugural Caring for Australians with Renal Insufficiency (CARI) guidelines for clinically and culturally safe kidney care for Aboriginal and Torres Strait Islander peoples revealed a timeline of the emergence of culturally safe kidney care in Australia. Thirty years ago, kidney care literature was purely biomedically focused, with culture, family and community viewed as potential barriers to patient 'compliance' with treatment. The importance of culturally informed care was increasingly recognised in the mid-1990s, with cultural safety within kidney care specifically cited from 2014 onwards. The emergence timeline is discussed in this paper in relation to the five principles of cultural safety developed by Māori nurse Irihapeti Ramsden in Aotearoa/New Zealand. These principles are critical reflection, communication, minimising power differences, decolonisation and ensuring one does not demean or disempower. For the kidney care workforce, culturally safe care requires ongoing critical reflection, deep active listening skills, decolonising approaches and the eradication of institutional racism. Cultural safety is the key to truly working in partnership, increasing Indigenous Governance, respectful collaboration and redesigning kidney care.

Hepatitis C (HCV) prevalence in citizens of the Métis Nation of Ontario

BACKGROUND

Hepatitis C virus (HCV) infection is a major global concern, with Indigenous Peoples bearing the highest burden. Previous studies exploring HCV prevalence within Indigenous populations have predominantly used a pan-Indigenous approach, consequently resulting in limited availability of Métis-specific HCV data. The Métis are one of the three recognized groups of Indigenous Peoples in Canada with a distinct history and language. The Métis Nation of Ontario (MNO) is the only recognized Métis government in Ontario. This study aims to examine the prevalence of self-reported HCV testing and positive results among citizens of the MNO, as well as to explore the association between sociodemographic variables and HCV testing and positive results.

METHODS

A population-based online survey was implemented by the MNO using their citizenship registry between May 6 and June 13, 2022. The survey included questions about hepatitis C testing and results, socio-demographics, and other health related outcomes. Census sampling was used, and 3,206 MNO citizens responded to the hepatitis C-related questions. Descriptive statistics and bivariate analysis were used to analyze the survey data.

RESULTS

Among the respondents, 827 (25.8%, CI: 24.3-27.3) reported having undergone HCV testing and 58 indicated testing positive, resulting in a prevalence of 1.8% (CI: 1.3-2.3). Respondents with a strong sense of community belonging, higher education levels, and lower household income were more likely to report having undergone HCV testing. Among those who had undergone testing, older age groups, individuals with lower education levels, and retired individuals were more likely to test positive for HCV.

CONCLUSION

This study is the first Métis-led and Métis-specific study to report on HCV prevalence among Métis citizens. This research contributes to the knowledge base for Métis health and will support the MNO's health promotion program and resources for HCV. Future research will examine the actual HCV incidence and prevalence among MNO citizens.

Bronchiectasis among Indigenous adults in the Top End of the Northern Territory, 2011-2020: a retrospective cohort study

OBJECTIVES

To assess the prevalence of bronchiectasis among Aboriginal and Torres Strait Islander (Indigenous) adults in the Top End of the Northern Territory, and mortality among Indigenous adults with bronchiectasis.

STUDY DESIGN

Retrospective cohort study.

SETTING, PARTICIPANTS

Aboriginal and Torres Strait Islander adults (18 years or older) living in the Top End Health Service region of the NT in whom bronchiectasis was confirmed by chest computed tomography (CT) during 1 January 2011 - 31 December 2020.

MAIN OUTCOME MEASURES

Prevalence of bronchiectasis, and all-cause mortality among Indigenous adults with CT-confirmed bronchiectasis - overall, by sex, and by health district - based on 2011 population numbers (census data).

RESULTS

A total of 23 722 Indigenous adults lived in the Top End Health Service region in 2011; during 2011-2020, 459 people received chest CT-confirmed diagnoses of bronchiectasis. Their median age was 47.5 years (interquartile range [IQR], 39.9-56.8 years), 254 were women (55.3%), and 425 lived in areas classified as remote (93.0%). The estimated prevalence of bronchiectasis was 19.4 per 1000 residents (20.6 per 1000 women; 18.0 per 1000 men). The age-adjusted prevalence of bronchiectasis was 5.0 (95% CI, 1.4-8.5) cases per 1000 people in the Darwin Urban health area, and 18-36 cases per 1000 people in the three non-urban health areas. By 30 April 2023, 195 people with bronchiectasis had died (42.5%), at a median age of 60.3 years (IQR, 50.3-68.9 years).

CONCLUSION

The prevalence of bronchiectasis burden among Indigenous adults in the Top End of the NT is high, but differed by health district, as is all-cause mortality among adults with bronchiectasis. The socio-demographic and other factors that contribute to the high prevalence of bronchiectasis among Indigenous Australians should be investigated so that interventions for reducing its burden can be developed.

Oral histories: lessons we can learn from the past

The COVID-19 pandemic has brought to light the importance of hindsight in response to global health crises. Although globalization has amplified worldwide perspectives, many lessons learned from past outbreaks in Indigenous communities have been overlooked. Oral histories are deeply rooted traditions that have played a significant role in the health practices of Indigenous communities across Canada. These practices can provide valuable insights into past epidemics or casualty events and their short- to long-term impacts. They have shaped responses to COVID-19, with Indigenous communities implementing self-determination efforts, such as community closures, contact tracing, and isolation measures. These traditions have heavily influenced population health practices in other contexts, such as the 1700 Cascadia earthquake, smallpox, and tuberculosis outbreaks. However, challenges remain in facilitating disease data transparency and Indigenous sovereignty. Efforts should be made to promote recognizing and respecting Indigenous knowledge and practices within the broader health system.

Translating research into a relevant education activity to fulfil pharmacists' continuing professional development requirements

Background

In New Zealand (NZ), provision of culturally safe care by pharmacists is mandated, including an expectation of understanding issues relevant to Māori, the Indigenous people of NZ, yet there are few pharmacy-specific resources to support attainment.

Objectives

To: i) test whether a research-informed education activity (short video summarising research findings plus reflective exercises) meets NZ pharmacists' annual continuing professional development requirements including those relating to culturally safe care ii) identify suggested improvements to the education activity; and iii) identify individual pharmacists' proposed actions in response to reflection prompted by the education activity.

Methods

Previous research was utilised to develop an education activity (short, animated research summary video and reflective questions). Participants (NZ-registered pharmacists or intern pharmacists) were asked to watch the video and respond to questions online related to perceived relevance and usefulness of the video to informing practice and meeting CPD requirements. Simple descriptive analysis (quantitative data) and general inductive thematic analysis (qualitative data) were applied to the research data.

Results

Thirty-three people participated from Nov-Dec 2022. Most participants said the video was relevant/very relevant to practice (91%), that the reflective exercise was very or extremely useful (100%) and that it met their CPD requirements as relevant to cultural safety (100%).

Conclusion

The education activity appeared to be an appropriate and relevant for CPD and was seen to be concise and exposed ideas in a logical and succinct manner with the potential to benefit the populations receiving care from these providers.

Indigenous approaches to health assessment: a scoping review protocol

BACKGROUND

Health assessment tools developed using mainstream or Western concepts have been widely used in clinical practice worldwide. However, even culturally adapted or culturally based tools may not be relevant in other social contexts if they are grounded in Western beliefs and perspectives. The application of mainstream assessment tools, when used in Indigenous populations, can lead to the inappropriate application of normative data and inaccurate or biased diagnosis of conditions as Indigenous concepts of health differ from Western biomedical concepts of health. Thus, considering the need for culturally meaningful, sensitive, safe, and unbiased health assessment approaches and instruments over recent years, tools have been developed or adapted by and with Indigenous populations in Australia, Aotearoa/New Zealand, Canada, and the United States. However, there is no existing systematic or scoping review to identify the methods and approaches used in adapting or developing health assessment tools for use with the Indigenous population in Australia, Aotearoa/New Zealand, Canada, and the United States.

METHODS

In response to these gaps, we are working with a First Nations Community Advisory Group in Northern Ontario, Canada, to undertake a scoping review following the 2020 JBI methodology for scoping reviews. A systematic search will be conducted in PubMed, APA PsychINFO, CINAHL, MEDLINE, Web of Science, Bibliography of Native North Americans, Australian Indigenous Health info data set, and Indigenous Health Portal. Two reviewers will independently screen all abstracts and full-text articles for inclusion using criteria co-developed with an advisory group. We will chart the extracted information and summarize and synthesize the data. The summarized findings will be presented to a Community Advisory Group, including First Nations community partners, an Elder, and community members, and their feedback will be incorporated into the discussion section of the scoping review.

DISCUSSION

This scoping review involves iterative consultation with the Indigenous and non-Indigenous scholars, First Nations Community Advisory Group, and community partners throughout the research process. This review aims to summarize the evidence on standard ethical approaches and practices used in Indigenous research while adapting or developing health assessment tools. It will inform the larger study focused on developing an Indigenous Functional Assessment tool. Further, it will seek whether the Indigenous ways of knowing and equitable participation of Indigenous people and communities are incorporated in the Indigenous research process.

SYSTEMATIC REVIEW REGISTRATION

Open Science Framework https://osf.io/yznwk .

A Critical Understanding of Inclusion in Oral Microbiome Research through the Lens of Racial Capitalism

There are important calls for greater inclusion of Indigenous and racialised communities in oral microbiome research. This paper uses the concept of racial capitalism (the extractive continuity of colonialism) to critically examine this inclusion agenda. Racial capitalism explicitly links capitalist exploitations with wider social oppressions e.g., racisms, sexism, ableism. It is not confined to the commercial sector but pervades white institutions, including universities. By using the lens of racial capitalism, we find inclusion agendas allow white institutions to extract social and economic value from relations of race. Racially inclusive research is perceived as a social good, therefore, it attracts funding. Knowledge and treatments developed from research create immense value for universities and pharmaceutical companies with limited benefits for the communities themselves. Moreover, microbiome research tends to drift from conceptualisations that recognise it as something that is shaped by the social, including racisms, to one that is determined genetically and biologically. This location of problems within racialised bodies reinforces racial oppressions and allows companies to further profit from raciality. Inclusion in oral microbiome research must consider ways to mitigate racial capitalism. Researchers can be less extractive by using an anti-racism praxis framework. This includes working with communities to co-design studies, create safer spaces, giving marginalised communities the power to set and frame agendas, sharing research knowledges and treatments through accessible knowledge distributions, open publications, and open health technologies. Most importantly, inclusion agendas must not displace ambitions of the deeper anti-oppression social reforms needed to tackle health inequalities and create meaningful inclusion.

How Education Shapes Indigenous Health Inequalities in the USA and Mexico

Indigenous peoples around the world face significant health disparities relative to the dominant groups in their countries, yet the magnitude and patterns of health disparities vary across countries. We use data from the National Health Interview Survey and Mexican Family Life Survey to examine the health of Indigenous peoples in Mexico and American Indians and Alaska Natives in the USA and to evaluate how they fare relative to the majority populations in their countries (non-Indigenous Mexicans and non-Hispanic Whites, respectively). We assess disparities in self-rated health and activity limitations, with a focus on how Indigenous health disparities intersect with educational gradients in health. Regression analyses reveal three primary findings. First, Indigenous health disparities are larger in the USA than in Mexico. Second, differences in educational attainment account for most of the differences between Indigenous and non-Indigenous populations in Mexico, but less than half in the USA. Third, in both countries, health is moderated by educational attainment such that between-group disparities are largest at the highest levels of education. However, for Indigenous Mexicans there is a "cross-over" in which Indigenous Mexicans report better health at the lowest level of education. Overall, this study finds a weak relationship between education and Indigenous health, and raises the question about the validity of using traditional measures of SES in Indigenous contexts.

Wild fish consumption and latitude as drivers of vitamin D status among Inuit living in Nunavik, northern Québec

OBJECTIVE

To measure vitamin D status and estimate factors associated with serum 25-hydroxyvitamin D (25(OH)D) in Nunavimmiut (Inuit living in Nunavik) adults in 2017.

DESIGN

Data were from Qanuilirpitaa? 2017 Nunavik Inuit Health Survey, a cross-sectional study conducted in August-October 2017. Participants underwent a questionnaire, including an FFQ, and blood samples were analysed for total serum 25(OH)D.

SETTING

Nunavik, northern Québec, Canada.

PARTICIPANTS

A stratified proportional model was used to select respondents, including 1,155 who identified as Inuit and had complete data.

RESULTS

Geometric mean serum vitamin D levels were 65·2 nmol/l (95 % CI 62·9-67·6 nmol/l) among women and 65·4 nmol/l (95 % CI 62·3-68·7 nmol/l) among men. The weighted prevalence of serum 25(OH)D < 75 nmol/l, <50 nmol/l <30 nmol/l was 61·2 %, 30·3 % and 7·0 %, respectively. Individuals who were older, female, lived in smaller and/or more southerly communities and/or consumed more country (traditional) foods were at a reduced risk of low vitamin D status. Higher consumption of wild fish was specifically associated with increased serum 25(OH)D concentration.

CONCLUSION

It is important that national, regional and local policies and programs are in place to secure harvest, sharing and consumption of nutritious and culturally important country foods like Arctic char and other wild fish species, particularly considering ongoing climate change in the Arctic which impacts the availability, access and quality of fish as food.

Who smokes in Australia? Cross-sectional analysis of Australian Bureau of Statistics survey data, 2017-19

OBJECTIVES

To assess the socio-demographic and health-related characteristics of people who smoke daily, people who formerly smoked, and people who have never smoked in Australia.

STUDY DESIGN

Cross-sectional analysis of Australian Bureau of Statistics (ABS) survey data.

SETTING, PARTICIPANTS

Adult participants (16 370 people aged 18 years or older) in the ABS 2017-18 National Health Survey (NHS); adult participants in the ABS 2018-19 National Aboriginal and Torres Strait Islander Health Survey (NATSIHS) (6423 people aged 18 years or older).

MAIN OUTCOME MEASURES

Socio-demographic and health-related characteristics of people who smoke daily, people who formerly smoked, and people who have never smoked, expressed as population-weighted proportions, overall and by Indigeneity.

RESULTS

Among adult NHS respondents, an estimated 58.8% of people who smoked daily (95% confidence interval [CI], 56.2-61.4%) were men, 61.3% (95% CI, 58.7-63.9%) were 25-54 years old, 72.5% (95% CI, 70.0-74.8%) were born in Australia, and 65.4% (95% CI, 62.8-67.8%) lived in major cities and 54.3% (95% CI, 51.6-57.0%) in areas in the two socio-economically most disadvantaged quintiles; 75.9% (95% CI, 73.5-78.1%) reported good to excellent health, 73.0% (95% CI, 70.5-75.4%) reported low to moderate psychological distress, 69.0% of those aged 25-64 years (ie, of working age) had completed year 12 (high school), and 68.5% were currently employed. An estimated 2.57 million people smoke daily in Australia: 2.37 million non-Indigenous people (92%) and 195 700 Aboriginal or Torres Strait Islander people (8%).

CONCLUSIONS

While smoking is more frequent among people living in socio-economically disadvantaged areas and in certain population sub-groups, this first quantitative national profile indicates that most people who smoke daily are in paid employment, are non-Indigenous, are in good physical and mental health, and have completed year 12. Improved comprehensive structural supply- and demand-based tobacco control, informed by the needs of priority groups and the overall profile of people who smoke, is needed to reduce daily smoking prevalence among adults to the 2030 targets of 5% or less for all Australians and 27% or less for Aboriginal and Torres Strait Islander people.

The Social and Home Environment: Impacts of Determinants of Health on Atopic Dermatitis, Pathways Toward Solutions, and Unique Considerations for Rural and Remote North American Indigenous Populations

Disparities in environmental and social determinants of health (DOH) are associated with morbidity in atopic dermatitis (AD). The socioecological model (SEM) is a framework that can be applied to better understand how such DOH impacts patients with AD. We include a case scenario of a remote Indigenous patient reflective of real-world situations of living with AD and examine relevant impact, gaps in knowledge, and further research needs. This review highlights a variety of social and environmental exposures as important DOH which must be addressed to achieve optimal management in AD. The "rainbow model" is a modified framework to help illustrate how complex environmental and social forces impact both AD presentation and therapeutic success. However, practical applications and outcome metrics for health promotion are limited. An inter- and transdisciplinary approach is paramount to address the complex challenges associated with AD care, as well as multistakeholder approach integrating culturally-competent equitable health frameworks. This review underscores the importance of expanding the focus of AD management beyond basic science and clinical trials to recognize and address health disparities and to promote optimal health and well-being in patients with AD, and contributes a working approach to mapping the complex interventions and patient-oriented research needed using a focus on remote North American Indigenous patients affected by AD.

"There are still broken or fragmented systems": Qualitative assessment of needs to strengthen adolescent mental health services in American Samoa

Mental health challenges appear common among adolescents in American Samoa. There is a community-identified need to better understand the health burden and identify opportunities to strengthen the mental health system to better meet adolescent mental health needs. The goal of this qualitative study was to gather community stakeholders' perceptions of common mental health problems among adolescents in American Samoa, identify existing services for adolescent mental health, and highlight strength-based opportunities to enhance care. Using the Fa'afaletui research framework, semi-structured in-depth interviews (n = 28) were conducted between October 2020 and February 2021 using Zoom. Key informants were adults living in American Samoa, sampled for diversity in profession, age, gender, education, and region of residence. Transcripts were coded in duplicate and analysed using deductive thematic analysis. Participants reported that suicide, depression, anxiety, and post-traumatic stress disorder are the conditions of highest burden. Participants identified an impressive amount of infrastructure and community mobilization, but also limitations in these services in addressing adolescents' health needs. Four themes arose related to the need to: (1) strengthen existing infrastructure; (2) reduce barriers to treatment access; (3) improve sustainability; and (4) encourage collaboration among leaders. Policymakers should prioritize the allocation of resources to strengthen infrastructure, public education, and stakeholder collaboration to improve adolescent mental health in American Samoa.

Traditional activities and general and mental health of adult Indigenous peoples living off-reserve in Canada

Introduction

We examined associations between traditional Indigenous activities and self-perceived general and mental health in adult Indigenous persons living off-reserve in Canada using the 2012 and 2017 Aboriginal Peoples Surveys (APS), the two most recent datasets. We utilized four traditional Indigenous activities including hunting, making clothes or footwear, making arts or crafts, and gathering wild plants to investigate these self-reported data.

Methods

Data from 9,430 and 12,598 respondents from the 2012 and 2017 APS, respectively, who responded to 15 questions concerning traditional activities were assessed using multivariable logistic regression to produce odds ratios (OR) and 95% confidence intervals (CI). Covariates included age, sex, education-level, income-level, Indigenous identity, residential school connection, ability to speak an Indigenous language, smoking status, and alcohol consumption frequency.

Results

Using the 2012 APS, clothes-making was associated with poor self-reported general (OR = 1.50, 95%CI: 1.12-1.99) and mental (OR = 1.59, 95%CI: 1.14-2.21) health. Hunting was associated with good mental health (OR = 0.71 95%CI: 0.56-0.93). Similarly, 2017 analyses found clothes-making associated with poor general health (OR = 1.25, 95%CI: 1.01-1.54), and hunting associated with good general (OR = 0.76, 95%CI: 0.64-0.89) and mental (OR = 0.69, 95%CI: 0.58-0.81) health. Artmaking was associated with poor general (OR = 1.37, 95%CI: 1.17-1.60) and mental (OR = 1.85, 95%CI: 1.58-2.17) health.

Conclusion

Hunting had protective relationships with mental and general health, which may reflect benefits of participation or engagement of healthier individuals in this activity. Clothes-making and artmaking were associated with poor general and poor mental health, possibly representing reverse causation as these activities are often undertaken therapeutically. These findings have implications for future research, programs and policies concerning Indigenous health.

Producing knowledge together: a participatory approach to synthesising research across a large-scale collaboration in Aboriginal and Torres Strait Islander health

BACKGROUND

Despite that stakeholder participation in evidence synthesis could result in more useful outcomes, there are few examples of processes that actively involve them in synthesis work. Techniques are needed that engage diverse stakeholders as equal partners in knowledge co-production. The aims of this paper are to describe an innovative participatory process of synthesising a large body of academic research products and compare the findings of the participatory process against two traditional approaches to synthesis: a rapid review and a structured review.

METHODS

First, a rapid synthesis of all research outputs (n = 86) was conducted by researchers with in-depth knowledge of the collaboration's research. Second, a team of researchers and service providers conducted a structured synthesis of seventy-eight peer-reviewed articles and reports generated by the collaboration. Fifty-five publications were brought forward for further synthesis in part three, a facilitated participatory synthesis. Finally, we explored the value added by the participatory method by comparing findings generated across the three synthesis approaches.

RESULTS

Twelve researchers and 11 service providers/policy partners-8 self-identified as Aboriginal and/or Torres Strait Islander-participated in two facilitated workshops (totalling 4 h). Workshop activities engaged participants in reviewing publication summaries, identifying key findings, and evoked review, discussion and refinement. The process explicitly linked experiential knowledge to citations of academic research, clearly connecting the two knowledge types. In comparing the findings generated across all three methods we found mostly consistencies; the few discrepancies did not contradict but gave deeper insights into statements created by the other methods. The participatory synthesis generated the most, detailed, and unique findings, and contextual insights about the relevance of the key messages for practice.

CONCLUSION

The participatory synthesis engaged stakeholders with diverse backgrounds and skillsets in synthesising a large body of evidence in a relatively short time. The participatory approach produced findings comparable to traditional synthesis methods while extending knowledge and identifying lessons most relevant for the participants who, ultimately, are the end users of the research. This process will interest other large-scale research collaborations seeking to engage stakeholders in evidence synthesis.

Culturally and contextually adaptive indicators of organizational success: Nunavik, Quebec

OBJECTIVE

This study aimed to develop a preliminary guide to culturally and contextually relevant indicators to assess community resources in the 14 communities of the Inuit territory of Nunavik, Quebec.

METHODS

As part of the Community Component of Qanuilirpitaa? of the 2017 Nunavik Health Survey, data were collected from 354 organizations located across Nunavik. Data were collected via short structured interviews with representatives of the organization. An inductive qualitative analysis was conducted to identify emerging themes describing the contexts that influence organizations, how key informants conceptualized what is a successful resource, and the facilitators and needs to achieving these indicators of success. Inuit partners were involved throughout the project to offer insight and to ascertain its pertinence and validity.

RESULTS

Interviews revealed structural and community realities that influenced organizations. Three main indicators were used to describe successes: (1) team efficiency and dynamics; (2) accessibility of the resource; and (3) ability to impact clients and the community. The third indicator was by far the most discussed indicator of success. Participants and leaders offer suggestions as to how to achieve these indicators and advocate for the conditions necessary for organizational sustainability.

CONCLUSION

This data-driven framework suggests that the measures of success that are frequently used by funding agencies (e.g., number of people reached, number of activities) may not fully represent the potential of local services in a given community. Indeed, services may be creating job opportunities for Inuit, instilling pride, offering cultural opportunities, and increasing capital (human, economic, health) within the community, all of which are equally important indicators of success that may more adequately further improve the social determinants of health among communities.

Addressing experiences of trauma within Indigenous-focused substance use residential treatment: a systematic review and environmental scan

Indigenous individuals in Canada disproportionally experience higher rates of substance use concerns. This study examined clinical practices currently implemented with Indigenous-led residential treatment facilities to simultaneously address substance use and post-traumatic stress. A systematic review of relevant literature retrieved published approaches to address these concurrent disorders with Indigenous individuals. This review retrieved 35 sources related to trauma and substance use treatment among Indigenous individuals or communities. Among these sources, all leveraged cultural approaches as a dual treatment for trauma symptoms and substance use. Inconsistent results were reported among those sources (n = 3) who analyzed comparisons with wait-list controls or used randomized-controlled designs. Using culture-as-treatment was elaborated upon in the second goal of this study: an environmental scan of Indigenous-led treatment programs and qualitative interviews with 10 treatment center staff to understand how programs may address both substance use and traumatic symptoms among Indigenous-led substance use treatment centers across Canada. When we searched the websites of these centers, we found that approximately 38% (16 of 43) of treatment centers discussed implementing some form of treatment that addressed trauma symptoms in conjunction with primary substance use. Among the 10 staff participants, all discussed how trauma can impede client success in treatment, and ACE-specific programming is useful within their respective treatment programs. Results showed that when manualized treatments are used, they must be adapted to meet the specific needs of Indigenous communities, and culture-as-treatment is a popular approach among Indigenous-led treatment centers, particularly for addressing trauma symptoms.

Determinants of Anishinabeck infant and early childhood growth trajectories in Northwestern Ontario, Canada: a cohort study

BACKGROUND

The Developmental Origins of Health and Disease (DOHaD) paradigm emphasizes the significance of early life factors for the prevention of chronic health conditions, like type 2 diabetes (T2DM) and obesity, which disproportionately affect First Nations communities in Canada. Despite increasing DOHaD research related to maternal health during pregnancy, early childhood growth patterns, and infant feeding practices with many populations, data from First Nations communities in Canada are limited. In partnership with Sandy Lake First Nation, the aims of this project were to characterize birthweights and growth patterns of First Nations infants/children over the first 6 years of life and to study the impact of maternal and infant social and behavioral factors on birthweight and growth trajectories.

METHODS

We recruited 194 families through community announcements and clinic visits. Infant/child length/height and weight were measured at 1 and 2 weeks; 1, 2, 6, 12, and 18 months; and 2, 3, 4, 5 and 6 years. Maternal and infant/child questionnaires captured data about health, nutrition, and social support. Weight-for-Age z-score (WAZ), Height-for-Age z-score (HAZ), and BMI-for-Age z-score (BAZ) were calculated using WHO reference standards and trajectories were analyzed using generalized additive models. Generalized estimating equations and logistic regression were used to determine associations between exposures and outcomes.

RESULTS

WAZ and BAZ were above the WHO mean and increased with age until age 6 years. Generalized estimating equations indicated that WAZ was positively associated with age (0.152; 95% CI 0.014, 0.29), HAZ was positively associated with birthweight (0.155; 95% CI 0.035, 0.275), and BAZ was positively associated with caregiver's BMI (0.049; 95% CI 0.004, 0.090). There was an increased odds of rapid weight gain (RWG) with exposure to gestational diabetes (OR: 7.47, 95% CI 1.68, 46.22). Almost 70% of parents initiated breastfeeding, and breastfeeding initiation was modestly associated with lower WAZ (-0.18; 95% CI -0.64, 0.28) and BAZ (-0.23; 95% CI -0.79, 0.34).

CONCLUSIONS

This work highlights early life factors that may contribute to T2DM etiology and can be used to support community and Indigenous-led prevention strategies.

Exploring Whether the Electronic Optimization of Routine Health Assessments Can Increase Testing for Sexually Transmitted Infections and Provider Acceptability at an Aboriginal Community Controlled Health Service: Mixed Methods Evaluation

BACKGROUND

In the context of a syphilis outbreak in neighboring states, a multifaceted systems change to increase testing for sexually transmitted infections (STIs) among young Aboriginal people aged 15 to 29 years was implemented at an Aboriginal Community Controlled Health Service (ACCHS) in New South Wales, Australia. The components included electronic medical record prompts and automated pathology test sets to increase STI testing in annual routine health assessments, the credentialing of nurses and Aboriginal health practitioners to conduct STI tests independently, pathology request forms presigned by a physician, and improved data reporting.

OBJECTIVE

We aimed to determine whether the systems change increased the integration of STI testing into routine health assessments by clinicians between April 2019 and March 2020, the inclusion of syphilis tests in STI testing, and STI testing uptake overall. We also explored the understandings of factors contributing to the acceptability and normalization of the systems change among staff.

METHODS

We used a mixed methods design to evaluate the effectiveness and acceptability of the systems change implemented in 2019. We calculated the annual proportion of health assessments that included tests for chlamydia, gonorrhea, and syphilis, as well as an internal control (blood glucose level). We conducted an interrupted time series analysis of quarterly proportions 24 months before and 12 months after the systems change and in-depth semistructured interviews with ACCHS staff using normalization process theory.

RESULTS

Among 2461 patients, the annual proportion of health assessments that included any STI test increased from 16% (38/237) in the first year of the study period to 42.9% (94/219) after the implementation of the systems change. There was an immediate and large increase when the systems change occurred (coefficient=0.22; P=.003) with no decline for 12 months thereafter. The increase was greater for male individuals, with no change for the internal control. Qualitative data indicated that nurse- and Aboriginal health practitioner-led testing and presigned pathology forms proved more difficult to normalize than electronic prompts and shortcuts. The interviews identified that staff understood the modifications to have encouraged cultural change around the role of sexual health care in routine practice.

CONCLUSIONS

This study provides evidence for the first time that optimizing health assessments electronically is an effective and acceptable strategy to increase and sustain clinician integration and the completeness of STI testing among young Aboriginal people attending an ACCHS. Future strategies should focus on increasing the uptake of health assessments and promote whole-of-service engagement and accountability.

Contaminated Sites and Indigenous Peoples in Canada and the United States: A Scoping Review

Indigenous communities are disproportionately exposed to contaminated sites, and this poses unique challenges as many Indigenous peoples consider land as an integral part of their culture and economy. This scoping review aimed to identify and map information on contaminated sites and Indigenous peoples in Canada and the US, namely: 1) the relationship between contaminated sites and Indigenous people, and their land and food systems; 2) strategies, challenges, and successes for contaminated sites assessment and management on Indigenous land; and 3) Indigenous leadership and inclusion in contaminated site assessment and management. We followed a PRISMA-ScR (Transparent Reporting of Systematic Reviews and Meta-Analyses-Extension for Scoping Reviews) checklist to collect data that could be categorized into these three objectives. Between October 2021 and July 2023, information from three data streams was retrieved: systematic literature search; a grey literature search; and federal site data retrieval (Canada's Federal Contaminated Sites Inventory, US EPA's contaminated sites databases, including Superfund). This search yielded 51 peer-reviewed articles, 21 grey literature articles, and 11,404 federal site records, evidencing the contamination of the lands of 875 Indigenous communities and the presence of 440 different contaminants or contaminant groups. The body of information was categorized into three themes within the above objectives: Objective 1) Indigenous communities and geographic patterns; Contaminated sites, sources, and media; Contaminated sites and Indigenous lands; Contaminated sites and Indigenous food systems; Contaminated sites and the health of Indigenous peoples; Objective 2) Site management and classification processes; Health risk assessment; Risk management; Long-term management; Objective 3) Collaborative research, Collaborative site management; Traditional knowledge and contaminated sites. Results highlighted a need to prioritize holism, efficiency, and Indigenous leadership in site assessment, management, and research, including a focus on community-specific approaches to site assessment and management; a re-conceptualization of risks that privileges Indigenous epistemologies; and greater collaboration between stakeholder networks.

Developing a Health Equity Impact Assessment 'Indigenous Lens Tool' to address challenges in providing equitable cancer screening for indigenous peoples

BACKGROUND

In spite of past efforts to increase screening uptake, the rates of screening-detectable cancers including breast, cervical, colorectal and lung are rising among Indigenous persons in Ontario compared to other Ontarians. The Ontario Ministry of Health has an equity framework, the Health Equity Impact Assessment (HEIA) Tool, that was developed to guide organizations in the provision of more equitable health and social services. Although the HEIA Tool identifies that the health of Indigenous persons may benefit from more equitable provision of health and social services, it provides very little specific guidance on how to apply the HEIA Tool in a culturally relevant way to policies and programs that may impact Indigenous peoples.

DISCUSSION

Guided by the Calls to Action from the Truth and Reconciliation Commission of Canada and the United Nations Declaration on the Rights of Indigenous Peoples, an Indigenous Lens Tool was developed through a collaborative and iterative process with stakeholders at Cancer Care Ontario and with representatives from Indigenous community-based organizations. The Indigenous Lens Tool consists of four scenarios, with supporting documentation that provide context for each step of the HEIA Tool and thereby facilitate application of the equity framework to programs and policies. The document is in no way meant to be comprehensive or representative of the diverse health care experiences of Indigenous peoples living in Canada nor the social determinants that surround health and well-being of Indigenous peoples living in Canada. Rather, this document provides a first step to support development of policies and programs that recognize and uphold the rights to health and well-being of Indigenous peoples living in Canada.

CONCLUSIONS

The Indigenous Lens Tool was created to facilitate implementation of an existing health equity framework within Cancer Care Ontario (now Ontario Health). Even though the Indigenous Lens Tool was created for this purpose, the principles contained within it are translatable to other health and social service policy applications.

Ensuring Indigenous co-leadership in health research: a Can-SOLVE CKD case example

BACKGROUND

Indigenous people are insightful and informed about their own health and wellness, yet their visions, strengths and knowledge are rarely incorporated into health research. This can lead to subpar engagement or irrelevant research practices, which exacerbates the existing health inequities Indigenous people experience compared to the non-Indigenous population. Data consistently underscores the importance of Indigenous self-determination in research as a means to address health inequities. However, there are few formal methods to support this goal within the existing research context, which is dominated by Western perspectives.

MAIN TEXT

Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease (Can-SOLVE CKD) is a patient-oriented research network in Canada that recognizes the need to create the space to facilitate Indigenous self-determination in research. Indigenous members of the network therefore created and evolved a unique group, called the Indigenous Peoples' Engagement and Research Council (IPERC). IPERC plays a critical role in informing Can-SOLVE CKD research priorities, as well as creating tools to support Indigenous-specific research and engagement. This approach ensures that Indigenous voices and knowledge are critical threads within the fabric of the network's operations and research projects. Here, we describe the methods taken to create a council such as IPERC, and provide examples of initiatives by the council that aim to increase Indigenous representation, participation and partnership in research. We share lessons learned on what factors contribute to the success of IPERC, which could be valuable for other organizations interested in creating Indigenous-led research councils.

CONCLUSION

Indigenous self-determination in research is critical for addressing health inequities. Here, we present a unique model, led by a council of diverse Indigenous people, which could help reduce health equities and lead to a better era of research for everyone.

Heart failure among Indigenous and non-Indigenous Australians in remote Central Australia

BACKGROUND

There is a paucity of data on the burden of heart failure (HF) in Central Australia, the most populous Indigenous region in the country.

AIMS

To characterize Indigenous and non-Indigenous Australians with HF in Central Australia.

METHODS

Consecutive patients with HF and reduced ejection fraction <50% were included for the period 2019 to 2021. Clinical, echocardiographic and major adverse cardiovascular events (MACE) data were collected.

RESULTS

Four hundred twenty-four patients with HF were included (70% Indigenous, 59% male; follow-up 2.2 ± 0.5 years). Indigenous Australians were younger (53 ± 15 vs 68 ± 13 years, P < 0.001) with higher rates of rheumatic heart disease (18% vs 1%, P < 0.001), diabetes (63% vs 33%, P < 0.001) and severe chronic kidney disease (CKD; 32% vs 7%, P < 0.001). HF was more prevalent among Indigenous (138 [95% confidence interval (CI), 123-155] per 10 000) compared with non-Indigenous Australians (53 [95% CI, 44-63] per 10 000), particularly among younger individuals and females. There were similar HF aetiologies between groups. Guideline-directed medical therapy (GDMT) was suboptimal and similar between the groups: angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (64% vs 67%, P = 0.47) and β-blockers (68% vs 71%, P = 0.47). Indigenous Australians had a significantly higher rate of MACE (54% vs 28%, P < 0.001) and death from any cause (24% vs 13%, P = 0.013).

CONCLUSIONS

HF is more than two times as prevalent among Indigenous Central Australians, particularly among younger individuals and females. Despite similar HF aetiologies and GDMT, MACE and mortality outcomes are higher in Indigenous individuals with HF. These data have implications for efforts to close the Indigenous gap in morbidity and mortality.

Diving below the surface: A framework for arctic health research to support thriving communities

AIMS

Historically, health research in the Arctic has focused on documenting ill-health using a narrow set of deficit-oriented epidemiologic indicators (i.e., prevalence of disease and mortality rates). While useful, this type of research does not adequately capture the breadth and complexities of community health and well-being, and fails to highlight solutions. A community's context, strengths, and continued expressions of well-being need to guide inquiries, inform processes, and contextualize recommendations. In this paper, we present a conceptual framework developed to address the aforementioned concerns and inform community-led health and social research in the Arctic.

METHODS

The proposed framework is informed by our collective collaborations with circumpolar communities, and syntheses of individual and group research undertaken throughout the Circumpolar North. Our framework encourages investigation into the contextual factors that promote circumpolar communities to thrive.

RESULTS

Our framework centers on the visual imagery of an iceberg. There is a need to dive deeper than superficial indicators of health to examine individual, family, social, cultural, historical, linguistic, and environmental contexts that support communities in the Circumpolar North to thrive. A participatory community-based approach in conjunction with ongoing epidemiologic research is necessary in order to effectively support health and wellness. Conclusions: The iceberg framework is a way to conceptualize circumpolar health research and encourage investigators to both monitor epidemiologic indicators and also dive below the surface using participatory methodology to investigate contextual factors that support thriving communities.

Routine ear health and hearing checks for Aboriginal and Torres Strait Islander children aged under 6 years attending primary care: a national consensus statement

This consensus statement provides new recommendations for primary care assessment of ear health and hearing status of young Aboriginal and Torres Strait Islander children who are not known to have, or are not being actively managed for, ear health and hearing problems. Any child identified with otitis media should be actively managed. This national consensus statement extends existing treatment and management guidelines. MAIN RECOMMENDATIONS: Undertake checks at least 6-monthly, commencing at 6 months until 4 years of age, then at 5 years. Undertake checks more frequently in high risk settings for children under 2 years, when acceptable to families, or in response to parent/carer concerns. Ask parents/carers about concerns, signs, and symptoms; check children's listening and communication skills; and assess middle ear appearance and mobility. Otoacoustic emissions testing is suggested when equipment is available, primary health practitioners have capability and confidence to use the equipment, and there is local preference for its use. Video otoscopy is suggested for health promotion purposes, and/or for sharing images with other health practitioners. Audiometry should be done as per existing guidelines: when there are parent/carer concerns, signs of persistent/recurrent otitis media, or when listening and communication development is not yet on track. CHANGES IN MANAGEMENT AS A RESULT OF THIS STATEMENT: Key practice changes include routine use of tympanometry, and listening and communication skills checklists. Implementation will require access to equipment and training; clear information on immediate, practical actions for families; timely pathways to referral services; and a change management process that shifts perception and tolerance of otitis media and its impacts and raises expectations that Aboriginal and Torres Strait Islander children can have healthy ears and hearing.

Visioning an Effective Health Encounter: Indigenous Healthcare Experiences and Recommendations for Health Professionals

PURPOSE

Indigenous patients experience challenges while accessing and utilizing healthcare services that relate to worsened health experiences. Bias towards Indigenous patients is prevalent in healthcare settings and leads to poor health outcomes. The purpose of this study was to learn about the healthcare experiences, both positive and negative, of Indigenous patients and solicit subsequent recommendations to improve care delivered to this population.

METHODS

This study sampled Indigenous patients (n = 20) from an Indigenous-serving health clinic to discuss participants' health experiences and elicit recommendations for improved care. Four focus groups were conducted, and template analysis was employed to analyze the data.

RESULTS

A total of 15 themes were developed under the category of an effective health encounter. Highlighted themes include healthcare that is free of stigma, quality care, respecting trauma experiences, expanded integrated care and the patient-provider relationship. Based on participant recommendations, a checklist was created for healthcare professionals to improve care delivery to Indigenous patients. Results indicated that bias in healthcare settings may masquerade as poor clinical care but is really founded in biased beliefs and healthcare delivery. Alternatively, when patients received good quality care, their healthcare outcomes improved. Further, effective healthcare incorporates culture, family, tribe, and community and addresses these aspects of health in both clinical and systemic settings.

CONCLUSIONS

With some of the largest proportions of health disparities and bias experiences in the US, it is critical that healthcare delivered to Indigenous patients incorporate culturally safe care to regain dignity and improve health outcomes for this population.

Aldosterone and renin concentrations and blood pressure in young Indigenous and non-Indigenous adults in the Northern Territory: a cross-sectional study

OBJECTIVES

To evaluate aldosterone and renin levels and aldosterone-to-renin ratios (ARRs) in young Indigenous and non-Indigenous adults in the Northern Territory, and their association with blood pressure levels.

DESIGN

Cross-sectional study; single time point sub-study of two prospective birth cohort studies.

SETTING, PARTICIPANTS

Participants in the Aboriginal Birth Cohort (ABC) - born to Indigenous mothers at the Royal Darwin Hospital during 1987-1990 - and the Top End Cohort (TEC) - people born to non-Indigenous mothers in Darwin, recruited during 2007-2009 - aged 32-35 years at the time of this sub-study.

MAIN OUTCOME MEASURES

Plasma aldosterone and direct renin concentrations; ARRs (positive screening test result for primary aldosteronism defined as > 70 pmol/mU); systolic and diastolic blood pressure.

RESULTS

A total of 255 ABC (205 in remote, 50 in urban locations) and 76 TEC members participated. Median aldosterone concentration was similar for all three groups. The median renin concentration was 7.5 mU/L (interquartile range [IQR], 4.1-12.4 mU/L) in the TEC group, 12.4 mU/L (IQR, 5.1-19 mU/L) in the urban ABC group, and 29.3 mU/L (IQR, 15.0-52.9 mU/L) in the remote ABC group. The median ARR was 10 pmol/mU (IQR, 6-19 pmol/mU) in the remote ABC group, 28 pmol/mU (IQR, 16-70 pmol/mU) in the urban ABC group, and 43 pmol/mU (IQR, 26-74 pmol/mU) in the TEC group. Thirteen urban ABC participants (26%), 21 TEC participants (28%), and six people in the remote ABC group (3%) had ARR values above 70 pmol/mU. Adjusted for age and body mass index (BMI), mean systolic and diastolic blood pressure were lower for women than men in all participant groups; after adjusting for age, sex, and BMI, larger ARR was associated with higher systolic blood pressure in the TEC group but not the two ABC groups.

CONCLUSION

Screening test results for primary aldosteronism were positive for about one-quarter of urban Indigenous and non-Indigenous participants. A prospective study that includes confirmatory testing would more accurately assess the prevalence of primary aldosteronism among Indigenous Australians in the Northern Territory.

Transformation to a patient-centred medical home led and delivered by an urban Aboriginal and Torres Strait Islander community, and association with engagement and quality-of-care: quantitative findings from a pilot study

BACKGROUND

The patient-centred medical home (PCMH) is a model of team-based primary care that is patient-centred, coordinated, accessible, and focused on quality and safety. In response to substantial population growth and increasing demand on existing primary care services, the Institute for Urban Indigenous Health (IUIH) developed the IUIH System of Care-2 (ISoC2), based on an international Indigenous-led PCMH. ISoC2 was piloted at an urban Aboriginal and Torres Strait Islander Community-Controlled Health Service in South-East Queensland between 2019-2020, with further adaptations made to ensure its cultural and clinical relevance to local Aboriginal and Torres Strait Islander people. Little is known on the implementation and impact of PCMH in the Australian Indigenous primary care setting. Changes in implementation process measures and outcomes relating to engagement and quality-of-care are described here.

METHODS

De-identified routinely collected data extracted from electronic health records for clients regularly attending the service were examined to assess pre-post implementation changes relevant to the study. Process measures included enrolment in PCMH team-based care, and outcome measures included engagement with the health service, continuity-of-care and clinical outcomes.

RESULTS

The number of regular clients within the health service increased from 1,186 pre implementation to 1,606 post implementation; representing a small decrease as a proportion of the services' catchment population (38.5 to 37.6%). In clients assigned to a care team (60% by end 2020), care was more evenly distributed between providers, with an increased proportion of services provided by the Aboriginal and Torres Strait Islander Health Worker (16-17% versus 10-11%). Post-implementation, 41% of clients had continuity-of-care with their assigned care team, while total, preventive and chronic disease services were comparable pre- and post-implementation. Screening for absolute cardiovascular disease risk improved, although there were no changes in clinical outcomes.

CONCLUSIONS

The increase in the number of regular clients assigned to a team and their even distribution of care among care team members provides empirical evidence that the service is transforming to a PCMH. Despite a complex transformation process compounded by the COVID-19 pandemic, levels of service delivery and quality remained relatively stable, with some improvements in risk factor screening.

From biocolonialism to emancipation: considerations on ethical and culturally respectful omics research with indigenous Australians

As part of a (bio)colonial project, the biological information of Indigenous Peoples has historically been under scientific scrutiny, with very limited benefits for communities and donors. Negative past experiences have contributed to further exclude Indigenous communities from novel developments in the field of omics research. Over the past decade, new guidelines, reflections, and projects of genetic research with Indigenous Peoples have flourished in Australia, providing opportunities to move the field into a place of respect and ethical relationships. This review explores the ethical and cultural implications of the use of biological samples from Indigenous communities in biomedical research. A structured framework outlining emerging topics of interest for the development of respectful omics research partnerships with Indigenous Australians is presented. This paper highlights aspects related to Indigenous governance, community and individual consent, respectful handling of biological samples, data management, and communication in order to protect Indigenous interests and rights and to promote communities' autonomy.

Identifying the barriers to kidney transplantation for patients in rural and remote areas: a scoping review

BACKGROUND

Populations in rural and remote areas have higher rates of chronic kidney disease and kidney failure than those in urban or metropolitan areas, and mortality rates for chronic kidney disease are almost twice as high in remote areas compared to major cities. Despite this, patients residing in regional, rural, or remote areas are less likely to be wait-listed for or receive a kidney transplant. The objective of this scoping review is to identify specific barriers to kidney transplantation for adult patients residing in rural and remote areas from the perspectives of health professionals and patients/carers.

METHODS

Studies were identified through database (MEDLINE, CINAHL, Emcare, Scopus) searches and assessed against inclusion criteria to determine eligibility. A descriptive content analysis was undertaken to identify and describe barriers as key themes.

RESULTS

The 24 selected studies included both quantitative (n = 5) and qualitative (n = 19) methodologies. In studies conducted in health professional populations (n = 10) the most prevalent themes identified were perceived social and cultural issues (80%), burden of travel and distance from treatment (60%), and system-level factors as barriers (60%). In patient/carer populations (n = 14), the most prevalent themes were limited understanding of illness and treatment options (71%), dislocation from family and support network (71%), and physical and psychosocial effects of treatment (71%).

CONCLUSIONS

Patients in regional, rural, and remote areas face many additional barriers to kidney transplantation, which are predominantly associated with the need to travel or relocate to access required medical testing and transplantation facilities.

COVID-19 vaccine behaviour among citizens of the Métis Nation of Ontario: A qualitative study

BACKGROUND

The burden of the current COVID-19 pandemic is not shared equally in Canadian society, with Indigenous Peoples being disproportionately affected. Moreover, there is a lack of research pertaining to vaccination behaviour in Métis communities. This Métis-specific and Métis-led qualitative study endeavours to understand COVID-19 vaccine behaviour among citizens of the Métis Nation of Ontario (MNO).

METHODS

Data was collected via one-on-one interviews. Participants were recruited via the MNO's existing social media channels. Participants filled out a screening survey indicating their intention to vaccinate against COVID-19 as yes, no, or unsure. Sixteen participants (9 yes, 3 unsure, 4 no) were interviewed. Interviews averaged 30 min, and the questions and probes were developed in collaboration with the MNO. The interviewer received Métis-specific cultural safety training. Interviews were transcribed verbatim and uploaded to NVivo 12.

RESULTS

A deductive analysis using the Social Ecological Model framework (SEM) for vaccine behaviour and two blinded coders was used to understand the data. An additional factor, COVID-19 public health measures, was added to the framework to better capture the experiences of participants during the COVID-19 pandemic. Overall, the factors with the greatest number of coded references included Vaccine roll-out and availability, Organization of the public into priority groups, Public discourse, Interpersonal influences, Interface with health professionals, Knowledge state, Trust, and Vaccine risk perception. Bandwagoning (following others' behaviour) and Freeloading (perceiving enough people have been vaccinated), both factors of the SEM, were not discussed. Yes, no, and unsure participant groups were compared to understand the influences of each factor based on COVID-19 vaccination intention.

CONCLUSIONS

MNO citizens COVID-19 vaccine behaviour was negatively and positively influenced by a number of factors. This information will allow the MNO and public health units to better tailor their messaging for COVID-19 vaccine uptake campaigns and future pandemic emergencies.

Closing the health gap in Central Australia: reduction in Indigenous Australian inpatient self-discharge rates following routine collaboration with Aboriginal Health Workers

BACKGROUND

Indigenous Australians experience significant socioeconomic disadvantage and healthcare disparity compared to non-Indigenous Australians. A retrospective cohort study to describe the association between rates of self-discharge in Indigenous orthopaedic patients and the introduction of routine Aboriginal Liaison Officers (ALO) within the Orthopaedic multi-disciplinary team (MDT) was performed.

METHODS

ALO were introduced within our routine Orthopaedic MDT on the 22nd of February 2021. Two patient cohorts were analysed, Group 1; patients admitted in the 9-months prior to inclusion of ALO, and Group 2; patients admitted within 9-months thereafter. The primary outcome of interest was the rate of self-discharge among Indigenous patients. Secondary outcomes of interest were the stage of treatment when patients self-discharged, recurrent self-discharge, risk factors for self-discharge and association between self-discharge and length of hospital stay.

RESULTS

Introduction of ALO within routine Orthopaedic MDT was associated with a significant 37% reduced risk of self-discharge among Indigenous patients (p = 0·009), and significantly fewer self-discharges before their definitive surgical and medical treatment (p = 0·0024), or before completion of postoperative intravenous antibiotic treatment (p = 0·030). There was no significant change in the risk of recurrent self-discharge (p = 0·557). Risk factors for self-discharge were younger age; pensioners or unemployed; residents of Alice Springs Town-Camps or of communities within 51 to 100 km of Alice Springs; and those diagnosed with lacerations of the upper limb, but without tendon injury, wound and soft tissue infections or osteomyelitis. In Group 2, the odds of self-discharge decreased with increased length of hospital stay (p = 0·040).

CONCLUSIONS

Routine inclusion of ALO within the Orthopaedic MDT reduced the risk of self-discharge in Indigenous patients. Those who self-discharged did so only after critical aspects of their care were met.

Using environmental health dialogue in a Diné-centered approach for individualized results reporting in an environmental exposure study following the Gold King Mine Spill

BACKGROUND

On August 5, 2015, the Gold King Mine Spill (GKMS) resulted in 3 million gallons of acid mine drainage spilling into the San Juan River impacting the Diné Bikeyah (traditional homelands of the Navajo people). The Gold King Mine Spill Diné Exposure Project was formed to understand the impacts of the GKMS on the Diné (Navajo). Reporting individualized household results in an exposure study is becoming more common; however, materials are often developed with limited community input with knowledge flowing in one direction - from researcher to participant. In this study we examined the development, dissemination, and evaluation of individualized results materials.

METHODS

In August 2016, Navajo Nation Community Health Representatives (Navajo CHRs) sampled household water, dust, and soil, and resident blood and urine for lead and arsenic, respectively. From May-July 2017, iterative dialogue with a wide range of community partners and a community focus groups guided the development of a culturally-based dissemination process. In August 2017, Navajo CHRs reported individualized results and they surveyed the participants on the report-back process at that time.

RESULTS

All of the 63 Diné adults (100%) who participated in the exposure study received their results by a CHR in person and 42 (67%) completed an evaluation. Most of those participants (83%) were satisfied with the result packets. Respondents ranked the individual and overall household results as the most important information they received (69% and 57%, respectively), while information on metals exposures and their health effects were the least helpful.

CONCLUSIONS

Our project illustrates how a model of environmental health dialogue, defined by iterative, multidirectional communication among Indigenous community members, trusted Indigenous leaders, Indigenous researchers, non-Indigenous researchers, can improve reporting individualized study results. Findings can inform future research to encourage multi-directional environmental health dialogue to craft more culturally responsive and effective dissemination and communication materials.

Wellness Wheel Clinics: A First Nation community-partnered care model improving healthcare access, from healthcare providers' perspectives

First Nation people residing in rural and remote communities have limited primary healthcare access, which often affects chronic disease management leading to poor health outcomes. Individuals with lived experiences of chronic disease and substance use, along with health directors, advocated for improved services. Subsequently, an urban healthcare team in partnership with four First Nation communities developed an Outreach clinic to address healthcare access barriers. Established in 2016, this community-led clinic improves primary care access and chronic disease management in First Nation communities. Employing a qualitative research design, interviews were conducted with 15 clinic providers and 9 community members to explore the clinic's 1-year post-implementation impacts. Thematic data analysis indicated that engagement and approval by community leadership, support from Elders and community members and collaboration with existing community healthcare staff were crucial for establishing the Outreach clinic. Initial logistical challenges with space allocation, equipment, medical supplies, funding, staffing, medical records and appointment scheduling were resolved through community consultation and creative solutions. A nurse coordinator ensured continuity of care and was integral to ensuring clients receive seamless care. The commitment of the outreach team and the collective goal of providing client-centered care were instrumental in the clinic's success. In partnership with communities, access to healthcare in First Nation communities can be enhanced by coordinating Outreach clinics through existing community healthcare facilities.

Understanding how whānau-centred initiatives can improve Māori health in Aotearoa New Zealand

This article highlights the significance of prioritizing Indigenous voices and knowledge systems, using whānau-centred initiatives (a concept that encompasses the broader family and community) as a foundation for health promotion within an Indigenous context. Tū Kahikatea, a conceptual framework, is used to demonstrate the relationship between the values underpinning different whānau-centred initiatives and their corresponding outcomes. The framework highlights the capacity of whānau-centred initiatives to support whānau in attaining mana motuhake, which represents collective self-determination and the ability to exercise control over their own future. By doing so, these initiatives contribute to the improvement of whānau health outcomes. With recent changes to Aotearoa New Zealand's health system, the findings underscore the benefits and potential of whānau-centred initiatives in enhancing whānau health outcomes, and advocate for continued strengths-based practices in Aotearoa New Zealand's health system. By bridging the gap between academia and grassroots community action, the article demonstrates the potential of whānau-centred initiatives and contributes to a global call for integrating Indigenous viewpoints and practices into Westernized healthcare, in order to improve Indigenous health outcomes.