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.

Exploring the Lived Experience of Self-Management Practices of Indigenous Men, Women, and Two Spirited Individuals Living with Type 2 Diabetes in Canada, the USA, Australia, and New Zealand: A Scoping Review

BACKGROUND

Indigenous men, women and two-spirted individuals have been significantly impacted by type 2 diabetes mellitus (T2DM) and its complications. It is believed that T2DM in Indigenous Peoples is a direct result of colonization and the introduction of changes to traditional Indigenous ways of knowing, being and living.

OBJECTIVES

The broader question will guide the aim of this scoping review: What is currently known about the lived experience of self-managing diabetes in Indigenous men, women and 2S individuals living with T2DM in Canada, USA, Australia and New Zealand? Specific objectives of this scoping review include 1) to explore the lived experience of self-management practices of Indigenous men, women, and two spirited individuals living with T2DM and 2) to describe how self-management experiences, differ from physical, emotional, mental, and spiritual perspectives.

METHODS

A total of six databases were searched and included Ovid Medline, Embase, PsychINFO, CINAHL, Cochrane, and the Native Health Database. An example of keywords searched included self-management, Indigenous, Type 2 Diabetes Mellitus. A total of 37 articles were included in the synthesis of results and the four quadrants of the Medicine Wheel were used to organize and interpret data.

RESULTS

The use of culture within self-management practices was important for Indigenous Peoples. Demographic data was collected for many of the studies including sex and gender characteristics, however only a small number of studies discussed the influence of sex and gender on outcomes.

CONCLUSIONS

Results inform future Indigenous diabetes education and health care service delivery and future research.

The Role of the Indigenous Patient Navigator: A Scoping Review

Background

Healthcare systems are complex and as a result patients may experience fragmentation of services. Indigenous populations experience increasingly disproportionate health disparities compared to non-Indigenous populations. Patient navigation is known as a patient-centered approach to empower individuals to connect with appropriate services. Literature surrounding the Indigenous Patient Navigator (IPN) remains sparse necessitating this scoping review. Purpose: To map the current state of the role of the IPN internationally within Canada, United States, Australia and New Zealand.

Methods

Estalished methodological framework by Arksey and O’Malley and the PRISMA extension for scoping reviews was used.

Results

A total of 820 articles were reviewed from four databases, yielding sixteen articles.

Conclusions

The absence of published literature surrounding the IPN role in Australia and New Zealand was surprising considering similar histories of colonization. The term navigator was used most often and was typically used when describing lay/peer roles. Professional roles were described using specific role descriptions. Six IPN roles were identified including: (1) social service navigation, (2) wholistic support of Indigenous people, (3) advocacy/building capacity, (4) health assessment, (5) administrative navigation, and (6) outreach. Additionally, barriers and enablers IPNs address are identified. This scoping review will assist to promote and reinforce the IPN role.

The Perinatal Mental Health of Indigenous Women: A Systematic Review and Meta-Analysis

OBJECTIVE

Although Indigenous women are exposed to high rates of risk factors for perinatal mental health problems, the magnitude of their risk is not known. This lack of data impedes the development of appropriate screening and treatment protocols, as well as the proper allocation of resources for Indigenous women. The objective of this systematic review and meta-analysis was to compare rates of perinatal mental health problems among Indigenous and non-Indigenous women.

METHODS

We searched Medline, EMBASE, PsycINFO, CINAHL, and Web of Science from their inceptions until February 2019. Studies were included if they assessed mental health in Indigenous women during pregnancy and/or up to 12 months postpartum.

RESULTS

Twenty-six articles met study inclusion criteria and 21 were eligible for meta-analysis. Indigenous identity was associated with higher odds of mental health problems (odds ratio [OR] 1.62; 95% confidence interval [CI], 1.25 to 2.11). Odds were higher still when analyses were restricted to problems of greater severity (OR 1.95; 95% CI, 1.21 to 3.16) and young Indigenous women (OR 1.86; 95% CI, 1.51 to 2.28).

CONCLUSION

Indigenous women are at increased risk of mental health problems during the perinatal period, particularly depression, anxiety, and substance misuse. However, resiliency among Indigenous women, cultural teachings, and methodological issues may be affecting estimates. Future research should utilize more representative samples, adapt and validate diagnostic and symptom measures for Indigenous groups, and engage Indigenous actors, leaders, and related allies to help improve the accuracy of estimates, as well as the well-being of Indigenous mothers, their families, and future generations.

TRIAL REGISTRATION

PROSPERO-CRD42018108638.

Postoperative Remote Automated Monitoring: Need for and State of the Science

Worldwide, more than 230 million adults have major noncardiac surgery each year. Although surgery can improve quality and duration of life, it can also precipitate major complications. Moreover, a substantial proportion of deaths occur after discharge. Current systems for monitoring patients postoperatively, on surgical wards and after transition to home, are inadequate. On the surgical ward, vital signs evaluation usually occurs only every 4-8 hours. Reduced in-hospital ward monitoring, followed by no vital signs monitoring at home, leads to thousands of cases of undetected/delayed detection of hemodynamic compromise. In this article we review work to date on postoperative remote automated monitoring on surgical wards and strategy for advancing this field. Key considerations for overcoming current barriers to implementing remote automated monitoring in Canada are also presented.

Primary care intervention to address cardiovascular disease medication health literacy among Indigenous peoples: Canadian results of a pre-post-design study

CONTEXT

Cardiovascular diseases (CVD) are a leading cause of illness and death for Indigenous people in Canada and globally. Appropriate medication can significantly improve health outcomes for persons diagnosed with CVD or for those at high risk of CVD. Poor health literacy has been identified as a major barrier that interferes with client understanding and taking of CVD medication. Strengthening health literacy within health services is particularly relevant in Indigenous contexts, where there are systemic barriers to accessing literacy skills.

OBJECTIVE

The aim of this study is to test the effect of a customized, structured health literacy educational program addressing CVD medications.

METHODS

Pre-post-design involves health providers and Indigenous clients at the De dwa da dehs nye>s Aboriginal Health Centre (DAHC) in Ontario, Canada. Forty-seven Indigenous clients with or at high risk of CVD received three educational sessions delivered by a trained Indigenous nurse over a 4- to 7-week period. A tablet application, pill card and booklet supported the sessions. Primary outcomes were knowledge of CVD medications and health literacy practices, which were assessed before and after the programe.

RESULTS

Following the program compared to before, mean medication knowledge scores were 3.3 to 6.1 times higher for the four included CVD medications. Participants were also more likely to refer to the customized pill card and booklet for information and answer questions from others regarding CVD.

CONCLUSIONS

This customized education program was highly effective in increasing medication knowledge and health literacy practice among Indigenous people with CVD or at risk of CVD attending the program at an urban Indigenous health centre.

Phenotypic relationships between docility and reproduction in Angus heifers

The objective of this study was to elucidate the phenotypic relationships between docility and first-service AI conception rate in heifers. Data ( = 337) collected from 3 cooperator herds in Kansas at the start of synchronization protocol included exit velocity (EV), chute score (CS), fecal cortisol (FC), and blood serum cortisol (BC). Data were analyzed using logistic regression with 30-d pregnancy rate as the dependent variable. The model included the fixed effect of contemporary group and the covariates FC, BC, EV, CS, BW, and age. Correlation coefficients were calculated between all continuous traits. Pregnancy rate ranged from 34% to 60% between herds. Blood cortisol positively correlated with EV ( = 0.22, < 0.01), negatively correlated with age ( = -0.12, < 0.03), and tended to be negatively correlated with BW ( = -0.10, = 0.09). Exit velocity was positively correlated with CS ( = 0.24, < 0.01) and negatively correlated with BW ( = -0.15, < 0.01) and age ( = -0.12, < 0.03). Chute score negatively correlated with age ( = -0.14, < 0.01), and age and BW were moderately positively correlated ( = 0.42, < 0.01), as expected. Older, heavier animals generally had better temperament, as indicated by lower BC, EV, and CS. The power of our test could detect no significant predictors of 30-d pregnancy for the combined data from all ranches. When the data were divided by ranch, CS ( < 0.03) and BW ( < 0.01) were both significant predictors for 30-d pregnancy for ranch 1. The odds ratio estimate for CS has an inverse relationship with pregnancy, meaning that a 1-unit increase in average CS will reduce the probability of pregnancy at ranch 1 by 48.1%. Weight also has a negative impact on pregnancy because a 1-kg increase in BW will decrease the probability of pregnancy by 2.2%. Fertility is a complex trait that depends on many factors; our data suggest that docility is 1 factor that warrants further investigation.

Health literacy: health professionals' understandings and their perceptions of barriers that Indigenous patients encounter

BACKGROUND

Despite the growing interest in health literacy, little research has been done around health professionals' knowledge of health literacy or understandings of the barriers to health literacy that patients face when navigating the health care system. Indigenous peoples in New Zealand (NZ), Canada and Australia experience numerous inequalities in health status and outcomes and international evidence reveals that Indigenous, minority, and socio-economically disadvantaged populations have greater literacy needs. To address concerns in Indigenous health literacy, a two-pronged approach inclusive of both education of health professionals, and structural reform reducing demands the system places on Indigenous patients, are important steps towards reducing these inequalities.

METHODS

Four Indigenous health care services were involved in the study. Interviews and one focus group were employed to explore the experiences of health professionals working with patients who had experienced cardiovascular disease (CVD) and were taking medications to prevent future events. A thematic analysis was completed and these insights were used in the development of an intervention that was tested as phase two of the study.

RESULTS

Analysis of the data identified ten common themes. This paper concentrates on health professionals' understanding of health literacy and perceptions of barriers that their patients face when accessing healthcare. Health professionals' concepts of health literacy varied and were associated with their perceptions of the barriers that their patients face when attempting to build health literacy skills. These concepts ranged from definitions of health literacy that were focussed on patient deficit to broader definitions that focussed on both patients and the health system. All participants identified a combination of cultural, social and systemic barriers as impediments to their Indigenous patients improving their health literacy knowledge and practices.

CONCLUSIONS

This study suggests that health professionals have a limited understanding of health literacy and of the consequences of low health literacy for their Indigenous patients. This lack of understanding combined with the perceived barriers to improving health literacy limit health professionals' ability to improve their Indigenous patients' health literacy skills and may limit patients' capacity to improve understanding of their illness and instructions on how to manage their health condition/s.

Head injury and family carers: a pilot study to investigate an innovative community-based educational programme for family carers and patients

PRIMARY OBJECTIVE

The incidence of head injury is increasing among younger people with more family members undertaking their life-long care. Many research studies have highlighted the emotional well-being of such family carers and their unmet needs, however only a few consider the formal help provided for carers. Using a longitudinal, mixed variable, within and between-subject design, this pilot study evaluated the impact of an educational programme for family carers and their head-injured relatives in reducing carer and patient psychological distress and improving their coping ability.

MAIN OUTCOMES AND RESULTS

The study comprised experimental and control samples each with carer and patient groups. The experimental sample had eight sessions of educational input. All groups were assessed pre- and post-intervention and at 3 months follow-up. The patient sample was further assessed using cognitive measures. There was evidence of reduction in psychological distress in the experimental carer group following the educational input, but these results were not statistically significant. However, the experimental patient population at follow-up assessment showed statistically significant improvements.

CONCLUSIONS

A larger scale multi-centre study with a longer follow-up period of assessment is required for the generalization of findings. The pilot study identifies points for consideration in a potential main study.

Anatomical and possible clinical relationships between the calcaneofibular ligament and peroneus brevis--a pilot study

The authors have observed in their clinical practice patients presenting with chronic retromalleolar pain following lateral ankle injuries. It has been hypothesized that persistent retromalleolar pain following a supination sprain may be due to peroneus brevis (PB) tendon tears (Boruta et al. 1990). The aims of this study were to investigate whether an anatomical relationship exists between the calcaneofibular ligament (CFL) and PB, and if so, the significance of this relationship in the positions of supination sprain and talar tilt test. Seven out of eight cadaveric ankles demonstrated fibrous connecting tissue between the tendon of PB and CFL. Four of the eight ankles demonstrated PB tendon abnormalities. The presence of connecting tissue between CFL and PB suggests an anatomical basis for concomitant damage to the PB tendon with a supination sprain, thus supporting the hypothesis that there may be an anatomical basis for persistent retromalleolar pain subsequent to injury to the lateral ankle complex.