Understanding the role of Indigenous community participation in Indigenous prenatal and infant-toddler health promotion programs in Canada: A realist review

Experiences of New Zealand Māori Mothers' Engagement with Health and Social Services Post-COVID-19 2020 Lockdown

BACKGROUND

Despite universal provision of maternity care, Māori (Indigenous peoples of Aotearoa/New Zealand) experience significant maternal and infant health disparities compared to their dominant Pākehā (non-Māori) counterparts. This paper examined the lived realities of postnatal Māori māmā (mothers) engaging with health and social services. Enablers and barriers were identified to better understand what is required to strengthen health services' responsiveness to Māori māmā health needs and aspirations.

METHODS

Underpinned by Kaupapa Māori research principles, which are grounded in Māori cultural values, emphasising self-determination, and Māori aspirations, a small cohort of 17 expectant Māori māmā were recruited from a Māori childbirth education programme to participate in a three-phase study. Phase three, the focus of this paper, involved seven semi-structured, open-ended telephone interviews with Māori māmā. A thematic analysis, underpinned by a mana wahine (authority inherent in Māori women) theoretical perspective amplified these experiences.

RESULTS

Five themes were identified that encapsulated participants' engagement and interactions with health and social services. These themes were as follows: (1) right to enact tino rangatiratanga (autonomy) and self-achievement; (2) responsiveness of services; (3) service and system issues; (4) need for greater choice and opportunity; and (5) impact of COVID-19.

CONCLUSIONS

This study privileged the voices of Māori wāhine, highlighting their experiences with a complex and often unresponsive health system. Participants valued services that enabled them to exercise tino rangatiratanga. Echoing the experiences of other Indigenous Peoples, incorporating culturally relevant practices into perinatal health services is crucial for achieving health equity and addressing disparities.

Psychometric properties of the rapid neurodevelopmental assessment in detecting social-emotional problems during routine child developmental monitoring in primary healthcare

BACKGROUND

The global prevalence of social-emotional problems in children and adolescents is nearly double in First Nations populations compared to non-First Nations populations, highlighting health inequities due to the impact of colonisation. Addressing this requires culturally responsive social-emotional screening in primary healthcare, enhanced by a simple, psychometrically sound tool. The Rapid Neurodevelopmental Assessment (RNDA) is user-friendly, incorporates child observations and parental input, and can be used by primary healthcare providers. This study evaluated the RNDA's performance in screening social-emotional problems during routine health checks with First Nations children.

METHODS

Working with an Aboriginal Community Controlled Health Organisation in Australia, children (60% male, 92% identifying as First Nations) aged 3 to 16 years (M = 8.40, SD = 3.33) and a caregiver participated in this study as part of a health check. The convergence with, and accuracy of, children's scores derived from single-item measures of seven social-emotional problems on the RNDA was compared to their corresponding multi-item scores from the parent-report Behavior Assessment System for Children 3rd Edition (BASC-3).

RESULTS

Each of the single-item measures on the RNDA were significantly correlated with the corresponding multi-item construct on the BASC-3, except for anxiety. The total accuracy of the RNDA relative to the BASC-3 was 58 to 81%, with high sensitivity for four of the seven items: hyperactivity (90%), attention problems (87%), externalising problems (82%) and behaviour symptoms index (88%). Sensitivity of the remaining items ranged from 14 to 71% and specificity ranged from 29 to 88%. The measure showed an average positive predictive value of 50% and negative predictive value of 75%.

CONCLUSIONS

The single-item measures within the RNDA's behaviour domain showed good convergent validity relative to the BASC-3. Most items had acceptable accuracy, comparable with similar screening measures. These findings further support the RNDA's integration into First Nations child health checks, allowing for a rapid, holistic assessment of child development to improve health equity.

Feeling the Structural: School-Based Educators' Perspectives on Indigenous Child Suicidality in Canada

Suicide is a critical public health issue disproportionately affecting Indigenous communities in Canada, especially children. Research on child suicide remains scarce, resulting in a limited understanding of its risk and protective factors. Identified risk dimensions include mental and behavioral health, relational issues, and significant adverse childhood experiences like abuse, and bullying. Studies on Indigenous youth and adults also emphasize the effects of colonization, public policy on child welfare, and systemic racism. The lack of research specifically addressing Indigenous child suicidality underscores the urgent need for tailored research. This article presents findings from a study engaging First Nations and Inuit educators, revealing factors linked to suicidal distress among Indigenous children. Through reflexive thematic analysis, three major themes emerged: the proximal emotional toll of distal risk factors, the impact of adverse childhood experiences, and the role of material deprivation in enhancing risk. Insights from educators are vital for developing targeted interventions to improve prevention efforts.

"If you show them respect, you're going to [get] respect back": a theory for engaging First Nations for knowledge translation within a national nutrition and health survey

BACKGROUND

Knowledge translation (KT) research aims to bridge the gap between research results and application which is vital to addressing health inequities. Despite the increasing emphasis on engaging Indigenous communities in research, there is limited research examining how to effectively engage communities to achieve Indigenous KT. The Food, Environment, Health, and Nutrition of First Nations Children and Youth (FEHNCY) is a nationally representative survey collaborating with First Nations' (FNs) communities across Canada to inform policies and programs. The FEHNCY Community Engagement and Mobilization (CEM) supports partnerships with participating FNs communities and the application of study findings into action. This formative research aimed to examine how, for whom, and in which circumstances community engagement approaches support KT within FNs communities.

METHODS

Data were generated with one rural and one semi-urban community participating in the FEHNCY pilot from the Atlantic and Eastern regions of Canada, respectively. A total of 26 in-depth interviews were conducted, 1 modified Talking Circle with community partners and 2 focus group discussions with the FEHNCY team. We used a realist approach combining inductive and deductive coding stages to develop a middle-range theory examining the connections between community engagement and KT.

RESULTS

Our findings highlight the contexts, interventions, mechanisms, and outcomes that create pathways to KT. The participants described the societal, study and community contexts that affected engagement processes. The essential community engagement strategies included supporting Indigenous leadership in the research, supporting community decision-making, promoting project visibility, applying youth-specific engagement strategies, and incorporating FNs knowledges. The participants also described that centering positive relationships between research and community partners and valuing FNs knowledge systems were essential mechanisms for supporting KT. Lastly, participants highlighted KT outcomes namely, community self-determination in research, improved research findings and application of results for FNs benefit.

CONCLUSION

This research can inform the strategic use of community engagement in research for KT among FNs. This study is the first to generate a middle-range theory using primary data collection for supporting KT through community engagement approaches in Indigenous health research.

Culturally responsive, trauma-informed, continuity of care(r) toolkits: A scoping review

BACKGROUND

Models of care that are culturally responsive, trauma-informed and provide continuity of care(r), are important components of care for Aboriginal and Torres Strait Islander parents during the broad perinatal period (pregnancy to 2 years after birth; first 1000 days). Many health services do aim to incorporate these concepts in care provision, but often focus on only one.

AIM

To identify practical toolkits that guide implementation of culturally responsive care, trauma-informed care, or continuity of care(r) in the perinatal period, and map the key elements.

METHODS

A scoping review was conducted. Relevant databases and grey literature were searched to identify toolkits that guided implementation of any one of the aforementioned concepts in the perinatal period. Toolkit context, principles, core components and processes were extracted and synthesised.

FINDINGS

Thirteen toolkits, from both Indigenous and non-Indigenous contexts, met the inclusion criteria. Six related to culturally responsive care, nine to trauma-informed care, and eight to continuity of care(r), with some overlap. Key principles included continuity of carer, collaboration, woman (or family) centred care, safety and holistic care. Individualised care, team work, having a safe service environment and continuity of care/r were highlighted as core components. Key processes related to planning, implementation, monitoring and evaluation, and sustainability.

DISCUSSION

There are no available resources that support holistic implementation of all three concepts of culturally responsive, trauma-informed continuity of care(r), spanning the first 1000 days, for Aboriginal and Torres Strait Islander families. A synthesised toolkit of key principles, core components and key processes would assist implementation of this.

STATEMENT OF SIGNIFICANCE

Problem: Aboriginal and Torres Strait Islander families experience health inequalities and poorer perinatal outcomes due to a legacy of colonisation and ongoing discrimination.

WHAT IS ALREADY KNOWN

Culturally responsive care, trauma-informed care and continuity of care(r) are elements of perinatal care shown to improve outcomes and experiences.

WHAT THIS PAPER ADDS

This review synthesises key aspects of culturally responsive, trauma-informed and continuity of care(r) models. It highlights the lack of resources to support services implementing models pertaining to these three concepts across the full First 1000 days, for Aboriginal and Torres Strait Islander families.

Design and implementation of the Our Health Counts (OHC) methodology for First Nations, Inuit, and Metis (FNIM) health assessment and response in urban and related homelands

OBJECTIVES

Methods for enumeration and population-based health assessment for First Nations, Inuit, and Metis (FNIM) living in Canadian cities are underdeveloped, with resultant gaps in essential demographic, health, and health service access information. Our Health Counts (OHC) was designed to engage FNIM peoples in urban centres in "by community, for community" population health assessment and response.

METHODS

The OHC methodology was designed to advance Indigenous self-determination and FNIM data sovereignty in urban contexts through deliberate application of Indigenous principles and linked implementation strategies. Three interwoven principles (good relationships are foundational; research as gift exchange; and research as a vehicle for Indigenous community resurgence) provide the framework for linked implementation strategies which include actively building and maintaining relationships; meaningful Indigenous community guidance, leadership, and participation in all aspects of the project; transparent and equitable sharing of project resources and benefits; and technical innovations, including respondent-driven sampling, customized comprehensive health assessment surveys, and linkage to ICES data holdings to generate measures of health service use.

RESULTS

OHC has succeeded across six urban areas in Ontario to advance Indigenous data sovereignty and health assessment capacity; recruit and engage large population-representative cohorts of FNIM living in urban and related homelands; customize comprehensive health surveys and data linkages; generate previously unavailable population-based FNIM demographic, health, and social information; and translate results into enhanced policy, programming, and practice.

CONCLUSION

The OHC methodology has been demonstrated as effective, culturally relevant, and scalable across diverse Ontario cities.

Keeping birth at home: Community and service provider visions for perinatal wellness and continued Inuit childbirth in Nunavik

PROBLEM

Childbirth on traditional territories is unattainable for many Indigenous peoples living in remote communities in Canada.

BACKGROUND

In Nunavik, Inuit territory in northern Quebec, rapid population growth risks exceeding local midwifery capacity. This poses challenges to community-based childbirth in a region recognized for reclaiming Inuit midwifery and local birthing.

AIM

To explore community views on protective factors of maternal and family perinatal wellness and continued local birthing.

METHODS

In ten communities, Inuit families and perinatal service providers created a total of 54 fuzzy cognitive maps on protective factors for (1) birth in a good way in Nunavik, (2) maternal and family perinatal wellness, and (3) community-based birthing in Nunavik. We used fuzzy transitive closure to examine direct and indirect connections and collated individual factors into categories using inductive thematic analysis.

FINDINGS

Well-equipped local medical facilities and services, community birthing centres run by Inuit midwives, and Inuit perinatal traditions had the strongest influence on experiencing birth in a good way in Nunavik. Inuit youth perspectives featured instrumental and emotional support for mothers and families, along with health and self-care in pregnancy as the most influential factors on maternal and family perinatal wellness. Prominent protective factors for community birth in Nunavik included maternal-infant health and wellness, local Inuit midwifery services, and well-resourced medical facilities.

DISCUSSION

Fuzzy cognitive mapping was helpful in informing community visioning of local childbirth and maternal and family perinatal wellness in Nunavik.

CONCLUSION

Inuit-led midwifery services are essential to continued local childbirth in the region.

Effect of Education on Adherence to Recommended Prenatal Practices among Indigenous Ngäbe-Buglé Communities of Panama

Background and Objectives: The primary objective of this study was to assess the adherence of Ngäbe-Buglé women to WHO-recommended prenatal practices. The secondary objective was to compare adherence levels between women who received prenatal education from official medical providers and those educated through traditional or community-based sources within Ngäbe-Buglé communities. Materials and Methods: An eight-question survey was verbally administered to 137 Ngäbe-Buglé women at clinics set up by the non-profit NGO Floating Doctors in eight communities. A two-sided Fisher's Exact test with a p = 0.05 was used to compare the results of mothers who received prenatal education from evidence-based sources to other groups. Results: Out of the 137 surveyed women, 65 reported taking prenatal vitamins, 21 had prenatal check-ups, 136 avoided alcohol, 31 increased caloric intake, and 102 maintained their activity levels. Significant differences were observed in prenatal vitamin adherence between those educated by official sources versus unofficial sources (p = 0.0029) and official sources compared to those with no prenatal education (p < 0.0001). The difference was also significant for education from an unofficial source versus no education (p = 0.0056). However, no significant differences were found in other prenatal practices based on education sources. Conclusions: Our findings highlight deficiencies in both prenatal education and adherence to recommended practices among Ngäbe-Buglé women. Prenatal education significantly improved adherence to taking prenatal vitamins, suggesting its effectiveness as an intervention. Future interventions should prioritize culturally competent prenatal education and address barriers to accessing prenatal healthcare in Ngäbe-Buglé communities.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Examining structural factors influencing cancer care experienced by Inuit in Canada: a scoping review

Inuit face worse cancer survival rates and outcomes than the general Canadian population. Persistent health disparities cannot be understood without examining the structural factors that create inequities and continue to impact the health and well-being of Inuit. This scoping review aims to synthesise the available published and grey literature on the structural factors that influence cancer care experienced by Inuit in Canada. Guided by Inuit input from Pauktuutit Inuit Women of Canada as well as the Joanna Briggs Institute scoping review methodology, a comprehensive electronic search along with hand-searching of grey literature and relevant journals was conducted. A total of 30 papers were included for analysis and assessment of relevance. Findings were organised into five categories as defined in the a priori framework related to colonisation, as well as health systems, social, economic, and political structures. The study results highlight interconnections between racism and colonialism, the lack of health service information on urban Inuit, as well as the need for system-wide efforts to address the structural barriers in cancer care.

Systematic review of Indigenous cultural safety training interventions for healthcare professionals in Australia, Canada, New Zealand and the United States

OBJECTIVE

To synthesise and appraise the design and impact of peer-reviewed evaluations of Indigenous cultural safety training programmes and workshops for healthcare workers in Australia, Canada, New Zealand and/or the United States.

DESIGN

Systematic review.

DATA SOURCES

Ovid Medline, Embase, PsycINFO, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Bibliography of Indigenous Peoples in North America, Applied Social Sciences Index & Abstracts, ERIC (Education Resources Information Center), International Bibliography of the Social Sciences, ProQuest Dissertations & Theses Global, Sociological Abstracts, and Web of Science's Social Sciences Citation Index and Science Citation Index from 1 January 2006 to 12 May 2022.

ELIGIBILITY CRITERIA

Studies that evaluated the outcomes of educational interventions for selecting studies: designed to improve cultural safety, cultural competency and/or cultural awareness for non-Indigenous adult healthcare professionals in Canada, Australia, New Zealand or the United States.

DATA EXTRACTION AND SYNTHESIS

Our team of Indigenous and allied scientists tailored existing data extraction and quality appraisal tools with input from Indigenous health service partners. We synthesised the results using an iterative narrative approach.

RESULTS

2442 unique titles and abstracts met screening criteria. 13 full texts met full inclusion and quality appraisal criteria. Study designs, intervention characteristics and outcome measures were heterogeneous. Nine studies used mixed methods, two used qualitative methods and two used quantitative methods. Training participants included nurses, family practice residents, specialised practitioners and providers serving specific subpopulations. Theoretical frameworks and pedagogical approaches varied across programmes, which contained overlapping course content. Study outcomes were primarily learner oriented and focused on self-reported changes in knowledge, awareness, beliefs, attitudes and/or the confidence and skills to provide care for Indigenous peoples. The involvement of local Indigenous communities in the development, implementation and evaluation of the interventions was limited.

CONCLUSION

There is limited evidence regarding the effectiveness of specific content and approaches to cultural safety training on improving non-Indigenous health professionals' knowledge of and skills to deliver quality, non-discriminatory care to Indigenous patients. Future research is needed that advances the methodological rigour of training evaluations, is focused on observed clinical outcomes, and is better aligned to local, regional,and/or national Indigenous priorities and needs.

A realist review of best practices and contextual factors enhancing treatment of opioid dependence in Indigenous contexts

OBJECTIVES

The objective of this study was to examine international literature to identify best practices for treatment of opioid dependence in Indigenous contexts.

METHODS

We utilized a systematic search to identify relevant literature. The literature was analysed using a realist review methodology supported by a two-step knowledge contextualization process, including a Knowledge Holders Gathering to initiate the literature search and analysis, and five consensus-building meetings to focus and synthesize relevant findings. A realist review methodology incorporates an analysis of the complex contextual factors in treatment by identifying program mechanisms, namely how and why different programs are effective in different contexts.

RESULTS

A total of 27 sources were identified that met inclusion criteria. Contextual factors contributing to opioid dependence described in the literature often included discussions of a complex interaction of social determinants of health in the sampled community. Twenty-four articles provided evidence of the importance of compassion in treatment. Compassion was evidenced primarily at the individual level, in interpersonal relationships based on nonjudgmental care and respect for the client, as well as in more holistic treatment programs beyond biophysical supports such as medically assisted treatment. Compassion was also shown to be important at the structural level in harm reduction policies. Twenty-five articles provided evidence of the importance of client self-determination in treatment programs. Client self-determination was evidenced primarily at the structural level, in community-based programs and collaborative partnerships based in trust and meaningful engagement but was also shown to be important at the individual level in client-directed care. Identified outcomes moved beyond a reduction in opioid use to include holistic health and wellness goals, such as improved life skills, self-esteem, feelings of safety, and healing at the individual level. Community-level outcomes were also identified, including more families kept intact, reduction in drug-related medical evacuations, criminal charges and child protection cases, and an increase in school attendance, cleanliness, and community spirit.

CONCLUSIONS

The findings from this realist review indicate compassion and self-determination as key program mechanisms that can support outcomes beyond reduced incidence of substance use to include mitigating systemic health inequities and addressing social determinants of health in Indigenous communities, ultimately healing the whole human being.

A Mixed Methods Study of 15 Years of Aboriginal Health Research in the Kimberley: 'We've Been Researched, We Think, from Head to Toe, Inside and Outside, Upside Down'

Indigenous peoples have long been the subjects of research, with the burden generally outweighing the benefit. This mixed methods study investigates the characteristics and outcomes of Aboriginal health research in the Kimberley region of Western Australia from 2006-2020 to inform future research practices. Quantitative data from projects submitted to the Kimberley Aboriginal Health Planning Forum Research Subcommittee were reviewed, and key characteristics were recorded and descriptively analysed. Fifteen individuals from a range of local organisations who were involved with research during this time participated in qualitative semi-structured interviews, including 11 Aboriginal people. The project team, including Aboriginal investigators, integrated quantitative and qualitative findings. Three major interview themes were questionable 'research world' behaviours; translation of findings and impact of research; and local involvement and control. The experiences of interviewees were congruent with quantitative data for the larger body of projects (N = 230). Most projects (60%) were not initiated within the Kimberley, with positive impact for local communities often not clear. There were, however, examples of Kimberley Aboriginal-led research excellence. A way forward includes research that is developed, driven, and led by the community; alignment with research priorities; local Aboriginal involvement that is resourced and acknowledged; and comprehensive knowledge translation plans embedded in projects.

Best practices in prenatal health promotion: Perceptions, experiences, and recommendations of Ottawa, Canada, prenatal key informants

BACKGROUND

Prenatal health promotion includes the provision of evidence-based information and practical skills to optimize maternal-fetal outcomes. Increasingly, prenatal education is delivered by both healthcare professionals and allied childbirth educators, in community- or hospital-based group classes, targeted outreach programs, and online modules.

OBJECTIVES

To better understand how prenatal health promotion relates to a diverse urban community, we assessed the perspectives of Ottawa, Canada prenatal key informants.

DESIGN

This is a qualitative research with key informant interviews.

METHODS

Semi-structured interviews were conducted with 11 prenatal key informants, responsible for the design, delivery, or promotion of publicly available prenatal health services. Interviews explored concepts and delivery of prenatal health promotion, strategies to address existing and emerging prenatal topics, identification of barriers to prenatal health services, and recommendations.

RESULTS

Key informants recommended a lifespan approach to prenatal health promotion, with an emphasis on healthy behaviors, emotional health, labor and delivery, and postpartum/early parenting. Recognizing community health disparities, key informants used community outreach, and intersectoral collaborations for Indigenous and other at-risk communities to mitigate barriers to prenatal service uptake.

CONCLUSIONS

Ottawa key informants conceptualized prenatal health promotion as inclusive, comprehensive, and as an extension of preconception, school-based sexual education. Respondents recommended the design and delivery of prenatal interventions as culturally safe and trauma informed, using online modalities to complement in-person activities. The experience and intersectoral networks of community-based prenatal health promotion programs represent potential capacity to address emergent public health risks to pregnancy, particularly among at-risk populations.

PLAIN LANGUAGE SUMMARY

A broad and diverse community of professionals deliver prenatal education to help people have healthy babies. We interviewed Ottawa, Canada experts in prenatal care/education to learn about the design and delivery of reproductive health promotion. We found that Ottawa experts emphasized healthy behaviors beginning before conception and through pregnancy. Community outreach was identified as a successful strategy to promote prenatal education to marginalized groups.

Exploring the perspectives of caregivers of urban Inuit children on child health knowledge mobilisation

Our study sought to explore the experiences of caregivers of urban Inuit children with respect to child health knowledge acquisition to develop community-specific best practices for health promotion initiatives. A needs assessment was conducted to understand how caregivers access child health knowledge and services; what child health issues require improved knowledge mobilisation; and how caregivers would like to access this knowledge. Four focus groups were held with twenty-four parents and caregivers of Inuit children. Child health knowledge acquisition was influenced by dynamics of trust and discrimination, making caregivers' social networks and Indigenous health services highly valued sources. Health topics identified as requiring improved knowledge mobilisation were those in which caregivers faced tensions between Indigenous and non-Indigenous ways of knowing. Such topics included parenting and development, adolescent mental and sexual health, common childhood illnesses, infant care, and nutrition. Caregivers preferred a multi-modal approach to health promotion, highlighting importance of in-person gatherings while also valuing accessible multi-media components. The presence of Elders as facilitators was especially important for child development, parenting, and nutrition. For health promotion to be effective, it must consider community-specific health knowledge sharing processes; tensions between Indigenous and non-Indigenous ways of knowing; and community ownership in health promotion endeavors.

Smoking cessation support strategies for Aboriginal and Torres Strait Islander women of reproductive age: findings from the Which Way? study

OBJECTIVE

To identify smoking cessation support strategies that resonate with Aboriginal and Torres Strait Islander women.

DESIGN, SETTING AND PARTICIPANTS

A national cross-sectional survey of Aboriginal and Torres Strait Islander women aged 16-49 years who were smokers or ex-smokers was conducted online during the period July to October 2020.

MAIN OUTCOME MEASURES

Preferred strategies, providers and locations for smoking cessation support.

RESULTS

Among a total of 428 women who participated in the survey, group-based support and holistic support were the most preferred strategies (preferred by 31.8% and 22.2% of women, respectively). Use of an Aboriginal health service was positively associated with choosing holistic support programs (prevalence ratio, 1.14 [95% CI, ≥ 1.00-1.28]). Women with high or moderate nicotine dependency were more likely to consider group-based support to be helpful (prevalence ratio, 1.13 [95% CI, ≥ 1.00-1.27]) than those with low nicotine dependency. The most preferred providers for smoking cessation support were Aboriginal health workers (64.3%). Most women (73.4%) preferred face-to-face support at an Aboriginal health service, 38.8% preferred online support and 34.8% preferred phone support. A higher percentage of older women (≥ 35 years) preferred online or phone support (prevalence ratio, 1.70 [95% CI, 1.03-2.80]) compared with younger women (16-20 years). Use of an Aboriginal health service was positively associated with preference for an Aboriginal health worker (prevalence ratio, 1.35 [95% CI, 1.12-1.62]), and receiving face-to-face support at an Aboriginal health service (prevalence ratio, 1.28 [95% CI, 1.10-1.49]).

CONCLUSION

Aboriginal and Torres Strait Islander women prefer a range of cessation supports, with most women preferring group support and holistic approaches. Cessation supports that resonated with women varied by age, remoteness, nicotine dependence, and whether participants used an Aboriginal health service. Women want support to quit smoking from the Aboriginal health workers at their Aboriginal health service, at their health care providers and in their community. Comprehensive, multifaceted supports are required. Online support and phone-based support are also preferred by some women, which helps to increase accessibility. Appropriate models of care - including sufficient funding for Aboriginal health services and Aboriginal health workers - are required and should be developed in partnership with communities to implement meaningful and culturally safe cessation care. This research demonstrates the need for and importance of multifaceted, comprehensive cessation support strategies.

Public health perinatal promotion during COVID-19 pandemic: a social media analysis

Background

Canadian public health agencies, both municipal/regional and provincial/territorial, are responsible for promoting population health during pregnancy and the early postnatal period. This study examines how these agencies use web-based and Facebook channels to communicate perinatal health promotion during the emergence of the COVID-19 pandemic.

Methods

Perinatal health promotion content of websites and Facebook posts from a multijurisdictional and geographically diverse sample of government and non-governmental organizations (NGO) were evaluated using thematic content analysis in 2020.

Results

Major Facebook perinatal health promotion themes included breastfeeding, infant care, labor/delivery, parenting support and healthy pregnancy. Facebook COVID-19-themed perinatal health promotion peaked in the second quarter of 2020. Websites emphasized COVID-19 transmission routes, disease severity and need for infection control during pregnancy/infant care, whereas Facebook posts focussed on changes to local health services including visitor restrictions. NGO perinatal health promotion reflected organizations’ individual mandates.

Conclusions

Canadian government use of Facebook to disseminate perinatal health promotion during the COVID-19 pandemic varied in terms of breadth of topics and frequency of posts. There were missed opportunities to nuance transmission/severity risks during pregnancy, thereby proactively countering the spread of misinformation.

Knowledge translation approaches and practices in Indigenous health research: A systematic review

Knowledge translation (KT) is a critical component of any applied health research. Indigenous Peoples' health research and KT largely continues to be taught, developed, designed, regulated, and conducted in ways that do not prioritize local Indigenous Peoples' ways of sharing knowledges. This review was governed and informed by Indigenous health scholars, Knowledge Guardians, and Elders. Our systematic review focused on answering, what are the promising and wise practices for KT in the Indigenous health research field? Fifty-one documents were included after screening published literature from any country and grey literature from what is now known as Canada. This included contacting 73 government agencies at the federal, territorial, and provincial levels that may have funded Indigenous health research. Only studies that: a) focused on Indigenous Peoples' health and wellness; b) documented knowledge sharing activities and rationale; c) evaluated the knowledge sharing processes or outcomes; and d) printed in English were included and appraised using the Well Living House quality appraisal tool. The analysis was completed using an iterative and narrative synthesis approach. Our systematic review protocol has been published elsewhere. We highlight and summarize the varied aims of Indigenous health research KT, types of KT methodologies and methods used, effectiveness of KT efforts, impacts of KT on Indigenous Peoples' health and wellness, as well as recommendations and lessons learned. Few authors reported using rigorous KT evaluation or disclosed their identity and relationship with the Indigenous communities involved in research (i.e. self-locate). The findings from this review accentuate, reiterate and reinforce that KT is inherent in Indigenous health research processes and content, as a form of knowing and doing. Indigenous health research must include inherent KT processes, if the research is by, for, and/or with Indigenous Peoples.

Pediatric oral health: community-based participatory research

Background

The most common chronic disease affecting children in Canada is dental caries. The objective of this study was to explore, identify, and address the strengths and barriers related to oral health services with an independent Indigenous community in Saskatchewan.

Methods

Community-based participatory research used interviews with Elders, health care providers, teachers, and parents/guardians of elementary school-aged children. The research focused on the development of genuine partnerships with the community. During data collection, the findings/results were returned to the community to establish direction, build success, and establish next steps. Thematic analysis was undertaken with the community. Descriptive statistics were analyzed using SPSS.

Results

The most commonly identified themes included: community resilience; the need for resource development and process to improve oral health literacy and skills; and how access to care barriers dually affected and related to personal and community cost, time, and human resources.

Conclusions

The research process involved the co-creation of tools to identify strengths within the community and drive opportunities for change; subsequently generating solutions to the practical problems and potentially transform the health system accessed by the community.

Are Indigenous research principles incorporated into maternal health research? A scoping review of the global literature

BACKGROUND

Indigenous women world-wide are diverse and heterogenous, yet many have similar experiences of colonization, land dispossession, and discrimination. These experiences along with inequitable access to, and quality of, maternal healthcare increase adverse maternal health outcomes. To improve health outcomes for Indigenous women, studies must be conducted with Indigenous involvement and reflect Indigenous research principles. Objectives/Aim: The aim of this review was to explore the range, extent, and nature of Indigenous maternal health research and to assess the reporting of Indigenous research principles in the global Indigenous maternal health literature.

METHODS

Following a systematic scoping review protocol, four scholarly electronic databases were searched. Articles were included if they reported empirical research published between 2000 and 2019 and had a focus on Indigenous maternal health. Descriptive data were extracted from relevant articles and descriptive analysis was conducted. Included articles were also assessed for reporting of Indigenous research principles, including Indigenous involvement, context of colonization, Indigenous conceptualizations of health, community benefits, knowledge dissemination to participants or communities, and policy or intervention recommendations.

RESULTS

Four-hundred and forty-one articles met the inclusion criteria. While studies were conducted in all continents except Antarctica, less than 3% of articles described research in low-income countries. The most researched topics were access to and quality of maternity care (25%), pregnancy outcome and/or complications (18%), and smoking, alcohol and/or drug use during pregnancy (14%). The most common study design was cross-sectional (49%), and the majority of articles used quantitative methods only (68%). Less than 2% of articles described or reported all Indigenous research principles, and 71% of articles did not report on Indigenous People's involvement.

CONCLUSIONS

By summarizing the trends in published literature on Indigenous maternal health, we highlight the need for increased geographic representation of Indigenous women, expansion of research to include important but under-researched topics, and meaningful involvement of Indigenous Peoples.

Maternal health and Indigenous traditional midwives in southern Mexico: contextualisation of a scoping review

OBJECTIVES

Collate published evidence of factors that affect maternal health in Indigenous communities and contextualise the findings with stakeholder perspectives in the Mexican State of Guerrero.

DESIGN

Scoping review and stakeholder fuzzy cognitive mapping.

INCLUSION AND EXCLUSION

The scoping review included empirical studies (quantitative, qualitative or mixed methods) that addressed maternal health issues among Indigenous communities in the Americas and reported on the role or influence of traditional midwives before June 2020. The contextualisation drew on two previous studies of traditional midwife and researcher perspectives in southern Mexico.

RESULTS

The initial search identified 4461 references. Of 87 selected studies, 63 came from Guatemala and Mexico. Three small randomised trials involved traditional midwives. One addressed the practice of traditional midwifery. With diverse approaches to cultural differences, the studies used contrasting definitions of traditional midwives. A fuzzy cognitive map graphically summarised the influences identified in the scoping review. When we compared the literature's map with those from 29 traditional midwives in Guerrero and eight international researchers, the three sources coincided in the importance of self-care practices, rituals and traditional midwifery. The primary concern reflected in the scoping review was access to Western healthcare, followed by maternal health outcomes. For traditional midwives, the availability of hospital or health centre in the community was less relevant and had negative effects on other protective influences, while researchers conditioned its importance to its levels of cultural safety. Traditional midwives highlighted the role of violence against women, male involvement and traditional diseases.

CONCLUSIONS

The literature and stakeholder maps showed maternal health resulting from complex interacting factors in which promotion of cultural practices was compatible with a protective effect on Indigenous maternal health. Future research challenges include traditional concepts of diseases and the impact on maternal health of gender norms, self-care practices and authentic traditional midwifery.

Client experiences of expertise in midwifery care in New Brunswick, Canada

OBJECTIVE

This study contextualizes client experiences of midwifery in New Brunswick within the broader literature on midwifery in Canada and contributes to understandings of how midwifery care fits into the landscape of reproductive healthcare in the province.

DESIGN

Semi structured interviews with 32 clients and supportive others of the New Brunswick midwifery program were carried out in 2019 and 2020, and transcripts were analysed using general thematic analysis.

SETTING

N New Brunswick, Canada PARTICIPANTS: Clients of midwifery care provided by the Fredericton Midwifery Centre, as well as their supportive others (partners and spouses, family members, friends) FINDINGS: Participants in this study reported a high degree of satisfaction with midwifery services and identified several approaches to practice that they felt contributed to high quality midwifery care. These include competence and expertise, time and access as abundance rather than scarcity, attention to the familial context, trauma informed care and attention to mental and emotional health, postpartum care, and supporting agency and autonomy. In short, participants' responses indicate that midwifery care in New Brunswick meets the criteria for respectful maternity care, as outlined by Shakibazadeh et al. (Shakibazadeh et al., 2018) and Butler et al. (Butler et al., 2020). Our findings are in line with research on midwifery care in other settings, although there is a significant emphasis on the medical expertise and training of midwives amongst our participants which is less evident in the scholarly literature.

KEY CONCLUSIONS

In a province where reproductive health care has been systematically underfunded, clients celebrate the expertise and competence of midwives, challenging the narrative which constructs midwifery as 'traditional' care, and hospital-based obstetrics as expert care. Instead, midwives are recognized as highly specialized evidence-based practitioners, and this is particularly prized by clients in relation to processes of information sharing.

Effectiveness of interventions to optimise dietary intakes in the first 1000 d of life in Indigenous children: a systematic review

Objective:

Indigenous infants are disproportionately more likely to have negative outcomes compared to non-Indigenous infants with suboptimal nutrition in the first 1000 d playing a major role. This review aimed to systematically assess the effectiveness of interventions designed to optimise dietary intake and/or nutrition-related behaviours among Indigenous infants globally and to identify whether Indigenous populations were involved in the co-design of the intervention.

Design:

Articles published before June 2020 that reported nutrition-related interventions and outcomes for Indigenous infants were identified from a database search. Data extracted included study aims and design, target population, geographical location, the health condition of the participants, intervention characteristics and outcomes. A narrative synthesis consisting of effects and acceptability of the interventions and involvement of participants in the study design were highlighted.

Settings:

Population-based intervention studies that focused on improving dietary intakes and/or nutrition-related behaviours of Indigenous infants in the first 1000 d of life were included in this review.

Results:

Of the 2784 studies identified, three studies met the inclusion criteria. These were conducted among two Indigenous tribes in Guatemala and the USA. Two studies reported the food and nutrient intake of participants with one study showing an improvement in dietary intake of the infants. Only one study reported community participation in the study design, intervention design and implementation, and acceptability of the intervention by the participants.

Conclusion:

Engaging Indigenous communities throughout the entire process of nutrition interventions could have beneficial effects through improved outcomes in the first 1000 d of life.

Decolonizing health in Canada: A Manitoba first nation perspective

INTRODUCTION & BACKGROUND

Global persistence of health inequities for Indigenous peoples is evident in ongoing discrepancies in health and standards of living. International literature suggests the key to transformation lies in Indigenous efforts to control Indigenous health and healthcare. Previous authors have focused upon participation, structural transformation, and culturally appropriate healthcare recognized as a political right as fundamental tenets of Indigenous control. Contextualizing Indigenous health and wellness falls within a growing discussion on decolonization - a resituating of expertise that privileges Indigenous voice and interests.

METHODS

The study is a qualitative, grounded theory analysis, which is a constructivist approach to social research allowing for generation of theory in praxis, through interactions and conversations between researchers and participants. One hundred eighty-three interviews with additional focus groups were held between 2013-15 in eight Manitoba First Nation communities representing different models of health delivery, geographies, accessibilities, and Indigenous language groups. Community research assistants and respected Elders participated in data collection, analysis and interpretation. Line-by-line coding and constant comparative method led to the discovery of converging themes.

FINDINGS

Ultimately four main themes arose: 1) First Nation control of healthcare; 2) traditional medicine and healing activities; 3) full and meaningful community participation; and 4) cleaning up impacts of colonization. Joint analyses and interpretation of findings revealed substantial evidence that communities were looking profoundly into problems of improperly delivered services and health inequities. Issues were consistent with those highlighted by international commissions on reconciliation, health, Indigenous rights and liberties. To those documents, these findings add ground upon which to build the transformative agenda.

RESULTS & DISCUSSION

Communities discussed the need for creation of protocols, constitution and laws to ensure growth of a decolonizing agenda. Inclusive to the concept are holistic, preventative, traditional health perspectives, and Indigenous languages. Colonization impacts were of critical concern and in need of undoing. Sharing of social and political efforts is seen as pivotal to change and includes all members of communities.

From controlling to connecting: M'Wikwedong as a place of urban Indigenous health promotion in Canada

In recent years, health promotion has come under critique for being framed according to the contexts and priorities of Western communities, with the notion of 'control' underpinning much of its theoretical and practical development. Ceding space to Indigenous voices and knowledge is one way forward to overcoming this limitation and decolonizing the field. This paper reports on insights gained from a participatory digital storytelling project focused on Indigenous health promotion that took place at M'Wikwedong Indigenous Friendship Centre in the city of Owen Sound, Canada. The research team was formed by M'Wikwedong's Executive Director, five Indigenous youth and two university researchers. We co-created data through an 8-month digital storytelling process that involved 13 weekly research meetings, the creation of 4 digital stories and video screenings. We analysed data from seven group interview transcriptions, field notes and video transcripts through qualitative coding and theme building. The four themes we identified speak to the ways M'Wikwedong reinforced connections to youth, their sense of self, place in the city and Indigenous cultures. From our findings, we theorize that egalitarianism of knowledge, restoring balance in relationships and Indigenous leadership are core components of an 'ethos of connection' that underlies Indigenous health promotion. The 'ethos of connection' challenges Western notions of 'control' and brings attention to the unique expertise and practices of urban Indigenous communities and organizations as a primary basis for health promotion.

Long-distance travel for birthing among Indigenous and non-Indigenous pregnant people in Canada

BACKGROUND:

For Indigenous Peoples in Canada, birthing on or near traditional territories in the presence of family and community is of foundational cultural and social importance. We aimed to evaluate the association between Indigenous identity and distance travelled for birth in Canada.

METHODS:

We obtained data from the Maternity Experiences Survey, a national population-based sample of new Canadian people aged 15 years or older who gave birth (defined as mothers) and were interviewed in 2006–2007. We compared Indigenous with non-Indigenous Canadian-born mothers and adjusted for geographic and sociodemographic factors and medical complications of pregnancy using multivariable logistic regression. We categorized the primary outcome, distance travelled for birth, as 0 to 49, 50 to 199 or 200 km or more.

RESULTS:

We included 3100 mothers living in rural or small urban areas, weighted to represent 31 100 (1800 Indigenous and 29 300 non-Indigenous Canadian-born mothers). We found that travelling 200 km or more for birth was more common among Indigenous compared with non-Indigenous mothers (9.8% v. 2.0%, odds ratio [OR] 5.45, 95% confidence interval [CI] 3.52–8.48). In adjusted analyses, the association between Indigenous identity and travelling more than 200 km for birth was even stronger (adjusted OR 16.44, 95% CI 8.07–33.50) in rural regions; however, this was not observed in small urban regions (adjusted OR 1.04, 95% CI 0.37–2.91).

INTERPRETATION:

Indigenous people in Canada experience striking inequities in access to birth close to home compared with non-Indigenous people, primarily in rural areas and independently of medical complications of pregnancy. This suggests inequities are rooted in the geographic distribution of and proximal access to birthing facilities and providers for Indigenous people.

Interventions to improve cancer survivorship among Indigenous Peoples and communities: a systematic review with a narrative synthesis

PURPOSE

The purpose of this systematic review is to synthesize the evidence on the types of interventions that have been utilized by Indigenous Peoples living with cancer, and report on their relevance to Indigenous communities and how they align with holistic wellness.

METHODS

A systematic review with narrative synthesis was conducted.

RESULTS

The search yielded 7995 unique records; 27 studies evaluating 20 interventions were included. The majority of studies were conducted in USA, with five in Australia and one in Peru. Study designs were cross-sectional (n=13); qualitative (n=5); mixed methods (n=4); experimental (n=3); and quasi-experimental (n=2). Relevance to participating Indigenous communities was rated moderate to low. Interventions were diverse in aims, ingredients, and outcomes. Aims involved (1) supporting the healthcare journey, (2) increasing knowledge, (3) providing psychosocial support, and (4) promoting dialogue about cancer. The main ingredients of the interventions were community meetings, patient navigation, arts, and printed/online/audio materials. Participants were predominately female. Eighty-nine percent of studies showed positive influences on the outcomes evaluated. No studies addressed all four dimensions of holistic wellness (physical, mental, social, and spiritual) that are central to Indigenous health in many communities.

CONCLUSION

Studies we found represented a small number of Indigenous Nations and Peoples and did not meet relevance standards in their reporting of engagement with Indigenous communities. To improve the cancer survivorship journey, we need interventions that are relevant, culturally safe and effective, and honoring the diverse conceptualizations of health and wellness among Indigenous Peoples around the world.

Effect of a Birthing on Country service redesign on maternal and neonatal health outcomes for First Nations Australians: a prospective, non-randomised, interventional trial

BACKGROUND

There is an urgency to redress unacceptable maternal and infant health outcomes for First Nations families in Australia. A multi-agency partnership between two Aboriginal Community-controlled health services and a tertiary hospital in urban Australia designed, implemented, and evaluated the new Birthing in Our Community (BiOC) service. In this study, we aimed to assess and report the clinical effectiveness of the BiOC service on key maternal and infant health outcomes compared with that of standard care.

METHODS

Pregnant women attending the Mater Mothers Public Hospital (Brisbane, QLD, Australia) who were having a First Nations baby were invited to receive the BiOC service. In this prospective, non-randomised, interventional trial of the service, we specifically enrolled women who intended to birth at the study hospital, and had a referral from a family doctor or Aboriginal Medical Service. Participants were offered either standard care services or the BiOC service. Prespecified primary outcomes to test the effectiveness of the BiOC service versus standard care were the proportion of women attending five or more antenatal visits, smoking after 20 weeks of gestation, who had a preterm birth (<37 weeks), and who were exclusively breastfeeding at discharge from hospital. We used inverse probability of treatment weighting to balance confounders and calculate treatment effect. This trial is registered with the Australian New Zealand Clinical Trial Registry, ACTRN12618001365257.

FINDINGS

Between Jan 1, 2013, and June 30, 2019, 1867 First Nations babies were born at the Mater Mothers Public Hospital. After exclusions, 1422 women received either standard care (656 participants) or the BiOC service (766 participants) and were included in the analyses. Women receiving the BiOC service were more likely to attend five or more antenatal visits (adjusted odds ratio 1·54, 95% CI 1·13-2·09; p=0·0064), less likely to have an infant born preterm (0·62, 0·42-0·93; p=0·019), and more likely to exclusively breastfeed on discharge from hospital (1·34, 1·06-1·70; p=0·014). No difference was found between the two groups for smoking after 20 weeks of gestation, with both showing a reduction compared with smoking levels reported at their hospital booking visit.

INTERPRETATION

This study has shown the clinical effectiveness of the BiOC service, which was co-designed by stakeholders and underpinned by Birthing on Country principles. The widespread scale-up of this new service should be prioritised. Dedicated funding, knowledge translation, and implementation science are needed to ensure all First Nations families can access Birthing on Country services that are adapted for their specific contexts.

FUNDING

Australian National Health and Medical Research Council.

A call for action that cannot go to voicemail: Research activism to urgently improve Indigenous perinatal health and wellbeing

In this call to action, a coalition of Indigenous and non-Indigenous researchers from Australia, Aotearoa New Zealand, United States and Canada argue for the urgent need for adequately funded Indigenous-led solutions to perinatal health inequities for Indigenous families in well-resourced settler-colonial countries. Authors describe examples of successful community-driven programs making a difference and call on all peoples to support and resource Indigenous-led perinatal health services by providing practical actions for individuals and different groups.

Meeting Indigenous youth where they are at: knowing and doing with 2SLGBTTQQIA and gender non-conforming Indigenous youth: a qualitative case study

Background

Research carried out in partnership with Indigenous youth at The Native Youth Sexual Health Network (NYSHN) demonstrates that Indigenous youth can (and do) develop and implement public health interventions amongst their peers and within their communities, when supported by non-youth allies and mentors.

Methods

Together, NYSHN and Well Living House researchers co-designed a qualitative case study to demonstrate and document how Indigenous youth can and do practice their own form of public health implementation research (PHIR) in the realm of mental health promotion for 2SLGBTTQQIA and Gender Non-Conforming Indigenous youth. Academic and Indigenous youth researchers were: participant observers; conducted a focus group; and designed and implemented an online survey with Indigenous youth project participants. Governance, intellectual property, financial terms and respective academic and NYSHN roles and responsibilities were negotiated using a customized community research agreement. The data were thematically analyzed using a critical decolonizing lens that recognizes the historic and ongoing marginalization of Indigenous peoples while also highlighting the unique and diverse strengths of Indigenous communities’ knowledge and practice in maintaining their health and wellbeing.

Results

Analysis revealed how colonialism and intergenerational trauma have impacted Indigenous youth identity and the value of self-determination as it relates to their identity, their relationships, health and wellbeing. We also learned how knowing and doing about and for Indigenous youth needs to be youth determined – ‘nothing about us, without us’ -- yet also supported by allies. Finally, our analysis shares some promising practices in knowing and doing for and with Indigenous youth.

Conclusions

This study provides a reminder of the need to centre Indigenous youth throughout PHIR in order to realize sustainable benefit from research, services and programming. It emphasizes the need to recognize Indigenous youth as leaders and partners in these initiatives, support their efforts to self-determine, compensate them as partners, and prioritize Indigenous youth-determined frameworks and accountability mechanisms.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-09863-3.

Feasibility and ethical issues: experiences and concerns of healthcare workers regarding a new RSV prophylaxis programme in Nunavik, Quebec

Background: The respiratory syncytial virus (RSV) is a major cause of hospitalisation in young Inuit children. Prophylaxis with palivizumab is routinely recommended for premature infants and those with severe pulmonary or cardiac diseases. In the fall 2016, the Quebec Ministry of Health expanded the criteria to include healthy full-term (HFT) newborns from Nunavik based on their high RSV hospitalisation rates.Objectives: The aim of this study was to describe the impact of this programme on Nunavik health services during the first RSV season after its implementation (2016-2017) by studying challenges, concerns and needs of healthcare workers (HCWs).Methods: An ethnographic approach was used. Semi-structured interviews focusing on HCWs experiences, and opinions to improve the new programme were conducted with 20 HCWs involved in its implementation.Results: Main reported challenges and concerns were: additional work(over)load, lack of information and evidence about the need and efficacy of palivizumab in HFT newborns, communication issues between stakeholders, and ethical issues regarding the Inuit population.Conclusion: The study revealed significant feasibility and acceptability issues. The programme was highly resource consuming. To address HCWs' concerns, evidence-based data regarding palivizumab effectiveness in HFT infants, as well as consultation and involvement of Inuit population are warranted.

Mobile primary health care clinics for Indigenous populations in Australia, Canada, New Zealand and the United States: a systematic scoping review

BACKGROUND

Mobile clinics have been used to deliver primary health care to populations that otherwise experience difficulty in accessing services. Indigenous populations in Australia, Canada, New Zealand, and the United States experience greater health inequities than non-Indigenous populations. There is increasing support for Indigenous-governed and culturally accessible primary health care services which meet the needs of Indigenous populations. There is some support for primary health care mobile clinics implemented specifically for Indigenous populations to improve health service accessibility. The purpose of this review is to scope the literature for evidence of mobile primary health care clinics implemented specifically for Indigenous populations in Australia, Canada, New Zealand, and the United States.

METHODS

This review was undertaken using the Joanna Brigg Institute (JBI) scoping review methodology. Review objectives, inclusion criteria and methods were specified in advance and documented in a published protocol. The search included five academic databases and an extensive search of the grey literature.

RESULTS

The search resulted in 1350 unique citations, with 91 of these citations retrieved from the grey literature and targeted organisational websites. Title, abstract and full-text screening was conducted independently by two reviewers, with 123 citations undergoing full text review. Of these, 39 citations discussing 25 mobile clinics, met the inclusion criteria. An additional 14 citations were snowballed from a review of the reference lists of included citations. Of these 25 mobile clinics, the majority were implemented in Australia (n = 14), followed by United States (n = 6) and Canada (n = 5). No primary health mobile clinics specifically for Indigenous people in New Zealand were retrieved. There was a pattern of declining locations serviced by mobile clinics with an increasing population. Furthermore, only 13 mobile clinics had some form of evaluation.

CONCLUSIONS

This review identifies geographical gaps in the implementation of primary health care mobile clinics for Indigenous populations in Australia, Canada, New Zealand, and the United States. There is a paucity of evaluations supporting the use of mobile clinics for Indigenous populations and a need for organisations implementing mobile clinics specifically for Indigenous populations to share their experiences. Engaging with the perspectives of Indigenous people accessing mobile clinic services is imperative to future evaluations.

REGISTRATION

The protocol for this review has been peer-reviewed and published in JBI Evidence Synthesis (doi: 10.11124/JBISRIR-D-19-00057).

Understanding Mi'kmaq Women's Experiences Accessing Prenatal Care in Rural Nova Scotia

Indigenous women experience a higher incidence of maternal complications compared with non-Indigenous women. Despite this, little is known about access to prenatal care for Mi'kmaq women in Nova Scotia. The intent of this study was to gain a more comprehensive understanding of Mi'kmaq women's experiences accessing prenatal care. The findings from this study highlight key implications for nursing practice such as promoting the nurse's role in supporting and advocating for Mi'kmaq women's health and for providing culturally safe care. This research will highlight that access to prenatal care is a complex issue for some women.

The "realist search": A systematic scoping review of current practice and reporting

The requirement for literature searches that identify studies for inclusion in systematic reviews should be systematic, explicit, and reproducible extends, at least by implication, to other types of literature review. However, realist reviews commonly require literature searches that challenge systematic reporting; searches are iterative and involve multiple search strategies and approaches. Notwithstanding these challenges, reporting of the "realist search" can be structured to be transparent and to facilitate identification of innovative retrieval practices. Our six-component search framework consolidates and extends the structure advanced by Pawson, one of the originators of realist review: formulating the question, conducting the background search, searching for program theory, searching for empirical studies, searching to refine program theory and identifying relevant mid-range theory, and documenting and reporting the search process. This study reviews reports of search methods in 34 realist reviews published within the calendar year of 2016. Data from all eligible reviews were extracted from the search framework. Realist search reports poorly differentiate between the different search components. Review teams often conduct a single "big bang" multipurpose search to fulfill multiple functions within the review. However, it is acknowledged that realist searches are likely to be iterative and responsive to emergent data. Overall, the search for empirical studies appears most comprehensive in conduct and reporting detail. In contrast, searches to identify and refine program theory are poorly conducted, if at all, and poorly reported. Use of this framework offers greater transparency in conduct and reporting while preserving flexibility and methodological innovation.

Strategies to support culturally safe health and wellbeing evaluations in Indigenous settings in Australia and New Zealand: a concept mapping study

BACKGROUND

In recent decades, financial investment has been made in health-related programs and services to overcome inequities and improve Indigenous people's wellbeing in Australia and New Zealand. Despite policies aiming to 'close the gap', limited evaluation evidence has informed evidence-based policy and practice. Indigenous leaders have called for evaluation stakeholders to align their practices with Indigenous approaches.

METHODS

This study aimed to strengthen culturally safe evaluation practice in Indigenous settings by engaging evaluation stakeholders, in both countries, in a participatory concept mapping study. Concept maps for each country were generated from multi-dimensional scaling and hierarchical cluster analysis.

RESULTS

The 12-cluster Australia map identifies four cluster regions: An Evaluation Approach that Honours Community; Respect and Reciprocity; Core Heart of the Evaluation; and Cultural Integrity of the Evaluation. The 11-cluster New Zealand map identifies four cluster regions: Authentic Evaluation Practice; Building Māori Evaluation Expertise; Integrity in Māori Evaluation; and Putting Community First. Both maps highlight the importance of cultural integrity in evaluation. Differences include the distinctiveness of the 'Respecting Language Protocols' concept in the Australia map in contrast to language being embedded within the cluster of 'Knowing Yourself as an Evaluator in a Māori Evaluation Context' in the New Zealand map. Participant ratings highlight the importance of all clusters with some relatively more difficult to achieve, in practice. Notably, the 'Funding Responsive to Community Needs and Priorities' and 'Translating Evaluation Findings to Benefit Community' clusters were rated the least achievable, in Australia. The 'Conduct of the Evaluation' and the 'Prioritising Māori Interests' clusters were rated as least achievable in New Zealand. In both countries, clusters of strategies related to commissioning were deemed least achievable.

CONCLUSIONS

The results suggest that the commissioning of evaluation is crucial as it sets the stage for whether evaluations: reflect Indigenous interests, are planned in ways that align with Indigenous ways of working and are translated to benefit Indigenous communities Identified strategies align with health promotion principles and relational accountability values of Indigenous approaches to research. These findings may be relevant to the commissioning and conduct of Indigenous health program evaluations in developed nations.

Implementing Birthing on Country services for Aboriginal and Torres Strait Islander families: RISE Framework

BACKGROUND

Birthing on Country is an international movement to return maternity services to First Nations communities and community control for improved health and wellbeing.

QUESTION

How can we implement Birthing on Country services for Aboriginal and/or Torres Strait Islander families across Australia?

METHODS

We have developed a framework from theoretical, policy and research literature on Birthing on Country; Aboriginal and Torres Strait Islander voices from across Australia; reviews exploring programs that have improved outcomes for Indigenous mothers and infants; and the retrospective synthesis of learnings from two empirical studies that have redesigned maternal infant health services and improved outcomes for Aboriginal and Torres Strait Islander families.

RESULTS

The RISE Framework has four pillars to drive important reform: (1) Redesign the health service; (2) Invest in the workforce; (3) Strengthen families; and, (4) Embed Aboriginal and/or Torres Strait Islander community governance and control. We present the evidence base for each pillar and practical examples of moving from the standard 'western' model of maternity care towards Birthing on Country services.

CONCLUSIONS

Application of the RISE framework to plan, develop and monitor Birthing on Country services is likely to result in short and long-term health gains for Aboriginal and Torres Strait Islander families.

Unmet health needs and discrimination by healthcare providers among an Indigenous population in Toronto, Canada

Objectives

Inequalities between Indigenous and non-Indigenous peoples in Canada persist. Despite the growth of Indigenous populations in urban settings, information on their health is scarce. The objective of this study is to assess the association between experience of discrimination by healthcare providers and having unmet health needs within the Indigenous population of Toronto.

Methods

The Our Health Counts Toronto (OHCT) database was generated using respondent-driven sampling (RDS) to recruit 917 self-identified Indigenous adults within Toronto for a comprehensive health assessment survey. This cross-sectional study draws on information from 836 OHCT participants with responses to all study variables. Odds ratios and 95% confidence intervals were estimated to examine the relationship between lifetime experience of discrimination by a healthcare provider and having an unmet health need in the 12 months prior to the study. Stratified analysis was conducted to understand how information on access to primary care and socio-demographic factors influenced this relationship.

Results

The RDS-adjusted prevalence of discrimination by a healthcare provider was 28.5% (95% CI 20.4–36.5) and of unmet health needs was 27.3% (95% CI 19.1–35.5). Discrimination by a healthcare provider was positively associated with unmet health needs (OR 3.1, 95% CI 1.3–7.3).

Conclusion

This analysis provides new evidence linking discrimination in healthcare settings to disparities in healthcare access among urban Indigenous people, reinforcing existing recommendations regarding Indigenous cultural safety training for healthcare providers. Our study further demonstrates Our Health Counts methodologies, which employ robust community partnerships and RDS to address gaps in health information for urban Indigenous populations.

Lay counselors: Thoughts on the crossing of ecological frameworks and the use of lay counselors in the scale up of early infant mental health interventions

The recent call for the scale-up of evidence-based early childhood development interventions, in lower and middle-income countries and for minority groups in high-income countries, has seen numerous suggestions to train greater numbers of lay mental health workers to fulfill these functions. While studies have found that concepts from developed country settings, such as attachment, parental sensitivity, and containment, find purchase and relevance within developing settings, the management of contextual and cultural factors and the tensions of cultural interfacing in the rollout of these programs in developing country settings require consideration. Drawing on the experiences of two successful South African mother-infant home-visiting programs as examples, this article discusses some of the challenges in provision of attachment-based infant mental health programs and highlights the need for careful consideration of a number of factors pertaining to the recruitment, supervision, and management of lay mental health workers before large-scale rollout is conducted.

Reducing preterm birth amongst Aboriginal and Torres Strait Islander babies: A prospective cohort study, Brisbane, Australia

BACKGROUND

Prevention of avoidable preterm birth in Aboriginal and Torres Strait Islander (Indigenous) families is a major public health priority in Australia. Evidence about effective, scalable strategies to improve maternal and infant outcomes is urgently needed. In 2013, a multiagency partnership between two Aboriginal Community Controlled Health Organisations and a tertiary maternity hospital co-designed a new service aimed at reducing preterm birth: 'Birthing in Our Community'.

METHODS

A prospective interventional cohort study compared outcomes for women with an Indigenous baby receiving care through a new service (n = 461) to women receiving standard care (n = 563), January 2013-December 2017. The primary outcome was preterm birth (< 37 weeks gestation). One to one propensity score matching was used to select equal sized standard care and new service cohorts with similar distribution of characteristics. Conditional logistic regression calculated the odds ratio with matched samples.

FINDINGS

Women receiving the new service were less likely to give birth to a preterm infant than women receiving standard care (6·9% compared to 11.6%). After controlling for confounders, the new service significantly reduced the odds of having a preterm birth (unmatched, n = 1024: OR = 0·57, 95% CI 0·37, 0·89; matched, n = 690: OR = 0·50, 95% CI 0·31, 0·83).

INTERPRETATION

The short-term results of this service redesign send a strong signal that the preterm birth gap can be reduced through targeted interventions that increase Indigenous governance of, and workforce in, maternity services and provide continuity of midwifery carer, an integrated approach to supportive family services and a community-based hub.

How Indigenous mothers experience selecting and using early childhood development services to care for their infants

Purpose: Promoting a child’s healthy growth and development in the first six years of life is critical to their later health and well-being. Indigenous infants experience poorer health outcomes than non-Indigenous infants, yet little is understood about how parents access and use health services to optimize their infants’ growth and development. Exploring the experiences of Indigenous mothers who select and use early childhood development (ECD) services provides important lessons into how best to promote their access and use of health services.

Methods: This qualitative interpretive description study was guided by the Two-Eyed Seeing framework and included interviews with 19 Indigenous mothers of infants less than two years of age and 7 providers of ECD services.

Results: Mainstream (public) and Indigenous-led health promotion programs both promoted the access and use of services while Indigenous-led programs further demonstrated an ability to provide culturally safe and trauma and violence-informed care.

Conclusions: Providers of Indigenous-led services are best suited to deliver culturally safe care for Indigenous mothers and infants. Providers of mainstream services, however, supported by government policies and funding, can better meet the needs of Indigenous mothers and infants by providing cultural safe and trauma and violence-informed care.

Best Practices for the Design, Implementation and Evaluation of Prenatal Health Programs

Introduction Prenatal health programs provide health education, reproductive care and related services to women. Programs may be administered individually or collaboratively by agencies including public health units, hospitals, health clinics, community and non-governmental organizations. Prenatal health disparities among populations at-risk may be reduced through the provision of accessible health education, services and resources to help women mitigate modifiable risks to pregnancy. Although standardized guidelines inform clinical screening, testing and maternity care, gaps exist regarding the design, implementation and evaluation for comprehensive prenatal health programs. Methods Using a multijurisdictional approach, prenatal health guidance documents released by clinical associations and regional governments across Canada, Australia, the United States, the United Kingdom and Ireland were systematically evaluated to identify standards and practices regarding the design, implementation and evaluation of prenatal health programs. Results Evidence-based, surveillance/monitoring, and expert/stakeholder collaborations were principles affirmed by guidance documents across all jurisdictions. Each jurisdiction described tailored strategies to optimize prenatal health in their respective communities. Divergence between jurisdictions was noted for patient care models and promotion of providers and companions of choice. Discussion A best practices model is proposed describing recommendations as follows: prenatal health programs should be grounded in a theoretical approach, fundamentally woman-centered and designed to address interacting prenatal health determinants across the lifespan. Accessible and inclusive prenatal health care can be achieved through provider training and community stakeholder collaborations. Identification of best practices for prenatal health program design, implementation and evaluation ensures that service standards are harmonized across communities, thereby optimizing maternal and child health.

"I feel safe just coming here because there are other Native brothers and sisters": findings from a community-based evaluation of the Niiwin Wendaanimak Four Winds Wellness Program

BACKGROUND

Urban Indigenous populations in Canada are steadily growing and represent diverse and culturally vibrant communities. Disparities between Indigenous and non-Indigenous peoples' experiences of the social determinants of health are a growing concern. Under the guidance of the West End Aboriginal Advisory Council (WEAAC), Parkdale Queen West Community Health Centre (PQWCHC) launched the Niiwin Wendaanimak Four Winds Wellness Program that seeks to enhance health and community services for homeless and at-risk Indigenous populations in Toronto.

OBJECTIVES

A process evaluation was carried out to (1) assess the collaborative service delivery model; (2) identify service gaps and issues for homeless and at-risk Indigenous populations; and (3) develop recommendations for how non-Indigenous organizations can provide culturally responsive services for Indigenous populations.

METHODS

In consultation with the WEAAC, a thematic analysis of qualitative data collected from 2 focus groups with community members who access the Niiwin Wendaanimak program and 17 key informant interviews with staff and peers was conducted.

RESULTS

The Niiwin Wendaanimak program bridges teachings of inclusivity and the practice of harm reduction to create a non-judgemental space where community members' dignity and autonomy is respected. Strengths of the program include Indigenous leadership and access to activities that promote wellness and community building.

CONCLUSIONS

As a non-Indigenous service provider, PQWCHC is meeting the needs of homeless and at-risk Indigenous populations in Toronto. Program strengths, system gaps, and challenges including policy recommendations were identified.

In search of Pan-American indigenous health and harmony

The objective of this article is to describe the state of North, Central, South American and Caribbean (Pan-American) indigenous health. The second objective is to identify recommendations for optimal healthcare and research strategies to achieve indigenous health equity. Current health disparities continue to present between indigenous populations and general populations. Research foci of Pan-American indigenous health center on health outcomes for chronic and acute disease as well as presence of indigenous in data sets. Research is both qualitative and quantitative. Recommendations to improve indigenous health in effort of health equity are variable yet feasible. Stronger epidemiology, continued cohesive Pan-American global strategies, better research alignment with emphasis to quality and comprehensive metric analyses in healthcare delivery are all avenues to improve the health of the indigenous. Research and healthcare delivery on the Pan-American indigenous must be maximized for optimal results, must be representative of the indigenous communities, must be implemented in best practice and must introduce sustainable healthcare delivery for Pan-American indigenous health equity.