The Yerin Dilly Bag Model of Indigenist Health Research

Improving Indigenous health equity within the emergency department: a global review of interventions

INTRODUCTION

Indigenous health equity interventions situated within emergency care settings remain underexplored, despite their potential to influence patient care satisfaction and empowerment. This study aimed to systematically review and identify Indigenous equity interventions and their outcomes within acute care settings, which can potentially be utilized to improve equity within Canadian healthcare for Indigenous patients.

METHODS

A database search was completed of Medline, PubMed, Embase, Google Scholar, Scopus and CINAHL from inception to April 2023. For inclusion in the review, articles were interventional and encompassed program descriptions, evaluations, or theoretical frameworks within acute care settings for Indigenous patients. We evaluated the methodological quality using both the Joanna Briggs Institute checklist and the Ways Tried and True framework.

RESULTS

Our literature search generated 122 publications. 11 articles were selected for full-text review, with five included in the final analysis. Two focusing on Canadian First Nations populations and three on Aboriginal Australians. The main intervention strategies included cultural safety training, integration of Indigenous knowledge into care models, optimizing waiting-room environments, and emphasizing sustainable evaluation methodologies. The quality of the interventions was varied, with the most promising studies including Indigenous perspectives and partnerships with local Indigenous organizations.

CONCLUSIONS

Acute care settings, serving as the primary point of access to health care for many Indigenous populations, are well-positioned to implement health equity interventions such as cultural safety training, Indigenous knowledge integration, and optimization of waiting room environments, combined with sustainable evaluation methods. Participatory discussions with Indigenous communities are needed to advance this area of research and determine which interventions are relevant and appropriate for their local context.

The Development of Elder-Governed Adjuvant Cultural Therapy for Aboriginal and/or Torres Strait Islander Young People With Mental Health Conditions

A 10-year review of the 2008 Council of Australian Governments' (COAG) Close the Gap Strategy identified the lack of involvement of Indigenous people in developing policies as a key reason health disparities persist. It also posits that disconnection from Country and culture have been crucial factors. Physical and mental health cannot be separated from spiritual health and well-being amongst Indigenous Australians. This article describes the co-development of a cultural enrichment research study with Indigenous Elders, health service leaders, and community members that places culture at the centre of care to augment traditional Western mental health management. The study has been overseen and nurtured from its inception by a governance board of Traditional Custodian Elders and an Advisory Group of Indigenous health workers. Qualitative data were collected through community 'zoom-yarns' between an Indigenous research assistant and 44 community members during COVID-19 lockdowns. These yarns were analysed through an innovative, constructivist, multi-perspectival discursive grounded theory method. Findings have led to an Elder-governed adjuvant cultural therapy which is currently being trialled and will be evaluated using the same multi-perspectival discursive grounded theory research methodology. One third of all Indigenous Australians now live in capital cities, so developing models to bring culture and Country into urban health facilities are becoming increasingly important. The Indigenous-led research approach outlined in this paper suggests a model for engaging Indigenous communities that mainly distrust Western research and have been failed by Western mental health care. It has the potential to shape future policy.

Murru Minya-informing the development of practical recommendations to support ethical conduct in Aboriginal and Torres Strait Islander health research: a protocol for a national mixed-methods study

INTRODUCTION

Conducting ethical and high-quality health research is crucial for informing public health policy and service delivery to reduce the high and inequitable burden of disease experienced by Aboriginal and Torres Strait Islander people. Ethical guidelines and principles specifically for health research with Aboriginal and Torres Strait Islander people have been developed for use since 1987. However, there has been limited examination of how these are being applied to the conduct of research.

METHODS AND ANALYSIS

Murru Minya will be a large-scale national study to examine the implementation of ethical processes in Aboriginal and Torres Strait Islander health research. A mixed-methods design will be used in four baarra (steps). The first three baarra will collect knowledge, experiences and wisdom from three key groups: Aboriginal and Torres Strait Islander communities, research academics, and Human Research Ethics Committees using online surveys, yarning, and semistructured interviews. This knowledge will inform the final baarra of developing a set of practical recommendations to support ethical conduct in Aboriginal and Torres Strait Islander health research into the future.

ETHICS AND DISSEMINATION

Ethical approval for this research project has been granted by National, State and Territory Human Research Ethics Committees. This research has been developed in collaboration with Aboriginal and Torres Strait Islander researchers, Aboriginal Community Controlled Health Organisation representatives, Aboriginal community members, the National Health Leadership Forum, and Aboriginal and Torres Strait Islander research team. The knowledge translation plan will be integrated and revised throughout the project as partnerships and engagement with Aboriginal and Torres Strait Islander communities continue. All findings will be shared with peak Aboriginal research bodies and Aboriginal and Torres Strait Islander communities in ways that are meaningful to them.

A Comprehensive Review of Optimal Approaches to Co-Design in Health with First Nations Australians

BACKGROUND

Australia's social, structural, and political context, together with the continuing impact of colonisation, perpetuates health care and outcome disparities for First Nations Australians. A new approach led by First Nations Australians is required to address these disparities. Co-design is emerging as a valued method for First Nations Australian communities to drive change in health policy and practice to better meet their needs and priorities. However, it is critical that co-design processes and outcomes are culturally safe and effective. Aims: This project aimed to identify the current evidence around optimal approaches to co-design in health with First Nations Australians.

METHODS

First Nations Australian co-led team conducted a comprehensive review to identify peer-reviewed and grey literature reporting the application of co-design in health-related areas by and with First Nations Australians. A First Nations Co-Design Working Group (FNCDWG) was established to guide this work and team.A Collaborative Yarning Methodology (CYM) was used to conduct a thematic analysis of the included literature.

RESULTS

After full-text screening, 99 studies were included. Thematic analysis elicited the following six key themes, which included 28 practical sub-themes, relevant to co-design in health with First Nations Australians: First Nations Australians leadership; Culturally grounded approach; Respect; Benefit to First Nations communities; Inclusive partnerships; and Evidence-based decision making.

CONCLUSION

The findings of this review provide a valuable snapshot of the existing evidence to be used as a starting point to guide appropriate and effective applications of co-design in health with First Nations Australians.

Combatting neo-Colonialism in Health Research: What can Aboriginal Health Research Ethics and Global Health Research Ethics Teach Each Other?

The ethics of research involving Aboriginal populations and low and middle-income country populations each developed out of a long history of exploitative research projects and partnerships. Commonalities and differences between the two fields have not yet been examined. This study undertook two independent literature searches for Aboriginal health research ethics and global health research ethics. Content analysis identified shared and differently emphasised ethical principles and concepts between the two fields. Shared ethical concepts like "benefit" and "capacity development" have been developed to guide collaborations in both Aboriginal health research and global health research. However, Aboriginal health research ethics gives much greater prominence to ethical principles that assist in decolonising research practice such as "self-determination", "community-control", and "community ownership". The paper argues that global health research ethics would benefit from giving greater emphasis to these principles to guide research practice, while justice as approached in global health research ethics may inform Aboriginal health research practice. With increasing attention being drawn to the need to decolonise global health research, the lessons Aboriginal health research ethics can offer may be especially timely.

'Dalarinji': A flexible clinic, belonging to and for the Aboriginal people, in an Australian emergency department

OBJECTIVE

Equity and access to high-quality healthcare for Aboriginal and Torres Strait Islander (Aboriginal) people has remained refractory for complex and multifactorial reasons, and there are sound ethical arguments for addressing this urgently. In EDs all patients who 'leave at own risk' (LAOR) or 'do not wait to be seen' (DNW) are at increased risk of readmission, morbidity or death. This also incurs additional resource costs to the health system. Aboriginal patients have high rates of DNW and LAOR. The Flexiclinic model of care was co-designed to better support the needs of Aboriginal patients in the ED and to reduce the rates of DNW and LAOR.

METHODS

'Dalarinji', or Flexiclinic, is a flexible model of care within the ED collaboratively devised with the Aboriginal Health Unit to address the major factors that influence this vulnerable cohort leaving the St Vincent's Hospital ED (SVHED) prior to being assessed or before completion of treatment.

RESULTS

In the 3 months since its introduction, the Flexiclinic approach has significantly improved the quality and equity of access to medical care at SVHED for Aboriginal patients with the average summed rate of DNW and LAOR falling to 5.2% of presentations, representing a fivefold decrease in the probability of Aboriginal patients receiving incomplete care.

CONCLUSION

The Flexiclinic approach has significantly improved medical care at SVHED for Aboriginal patients. It has been well received by both staff and patients and has had no adverse effects on delivery of services to other patient groups.

Recommended methodologies to determine Australian Indigenous community members' perceptions of their health needs: a literature review

When addressing disparities in health status of Indigenous Australians, it is necessary to consult with Indigenous people to explore their health needs. The process of improving health outcomes is complex; it requires acknowledgement of underlying cultural and social determinants of health and active engagement of Indigenous people to define the issues and identify solutions. The aim of this study is to explore the most appropriate research methodologies to determine Australian Indigenous community members' perceptions of their health needs. A scoping review was conducted in BioMed Central, CINAHL, Informit Health, MEDLINE Ovid, ProQuest and Scopus databases and Google Scholar for all relevant literature published between 2009 and 2018. Extensive manual searches of reference lists were also undertaken. The limited number of articles relating to needs assessment with Indigenous community members prescribed broadening the scope of the review to include articles that describe methodologies to enhance Indigenous people's engagement in the research process. Twelve papers met the inclusion criteria. Three major themes emerged: (1) the imperative to develop and implement Indigenist research methodologies; (2) participatory action research (PAR) and community-based participatory research (CBPR) as appropriate methodologies to conduct research with Indigenous community members; and (3) yarning or storytelling as a culturally appropriate Indigenous method of data collection.

Working with Aboriginal young people in sexual health research: a peer research methodology in remote Australia

In a context of ongoing colonization and dispossession in Australia, many Aboriginal people live with experiences of health research that is done "on" rather than "with" or "by" them. Recognizing the agency of young people and contributing to Aboriginal self-determination and community control of research, we used a peer research methodology involving Aboriginal young people as researchers, advisors, and participants in a qualitative sexual health study in one remote setting in the Northern Territory, Australia. We document the methodology, while critically reflecting on its benefits and limitations as a decolonizing method. Findings confirm the importance of enabling Aboriginal young people to play a central role in research with other young people about their own sexual health. Future priorities include developing more enduring forms of coinvestigation with Aboriginal young people beyond data collection during single studies, and support for young researchers to gain formal qualifications to enhance future employability.

Developing an Innu framework for health research: The canoe trip as a metaphor for a collaborative approach centered on valuing Indigenous knowledges

Indigenous communities increasingly assert their right to self-determination by requiring that participatory research approaches be used, valuing and prioritizing Indigenous knowledges, for the purpose of improving Indigenous health. While frameworks that focus on Indigenous knowledges are being developed, these must be adapted or developed by Indigenous communities because their knowledge is specific to place and inherent to their lived experience. No community-based participatory research (CBPR) framework for health research has been developed with the Labrador Innu. In addition, while the literature emphasizes the importance of relationship in research with Indigenous communities, the process of establishing relationships is underspecified. Within this context, we describe our experience in developing a CBPR framework for health research in a study that is community-initiated and fitting within Innu self-determination. We highlight the importance of paying attention to the theoretical roots of CBPR, arguing that this helps researchers focus on the centrality of Indigenous knowledges (in this case, Innu knowledge). This requires that non-Indigenous researchers question assumptions of universality regarding their own knowledge and see all knowledges as equitable. Such posture of humility allows non-Indigenous researchers to enter relational spaces that join researchers and Indigenous communities. Within these spaces, a true collaborative approach is enabled and Indigenous knowledges are uncovered and become foundational in the inquiry process. We illustrate these ideas by describing a model for opening relational spaces that include Indigenous and non-Indigenous researchers. We then present a framework that uses the metaphor of canoeing together to capture our CBPR approach for use in Innu health research. We outline the behaviors of non-Indigenous researchers to build and solidify relationships with Indigenous community researchers over time. This article is useful for non-Indigenous researchers interested in relational approaches to research with Indigenous communities, and for Indigenous leaders and researchers who seek community solutions through research.

A Qualitative Analysis of the Accessibility and Connection to Traditional Food for Aboriginal Chronic Maintenance Hemodialysis Patients

BACKGROUND

Due to the lack of resources in remote Aboriginal communities within the Northern Territory of Australia, Aboriginal people requiring chronic maintenance hemodialysis often must relocate from their home communities to Darwin city permanently to receive ongoing care. This phenomenon can cause distressing isolation from important traditional food, land, and family.

OBJECTIVE

The aim was to identify the relation to traditional food from an Aboriginal perspective and the enablers and barriers to accessing traditional food post-relocation from remote regions of the Northern Territory, Australia, to the urban city of Darwin.

METHODS

This was a qualitative study design with a total of 12 Aboriginal participants (4 males, 8 females) receiving ongoing hemodialysis at the Nightcliff Renal Unit. Participants had all relocated from a remote region to Darwin. Interviews were conducted between July and September 2018 in Darwin, Australia. Data interpretation was conducted by an Aboriginal researcher and co-authors with a combined 30 y of experience conducting research with Aboriginal people in a health context. Data analysis comprised an inductive thematic analysis approach with an indigenist knowledge interpretation lens to construct, reaffirm, and protect Indigenous views.

RESULTS

Traditional food was an important part of participants' identity and strongly connected to social, emotional, spiritual and physical health, and well-being. Access to traditional food post-relocation is associated with enablers and barriers including mobility, local knowledge, social support networks, commercial access, and economics.

CONCLUSIONS

Dialysis patients who are dislocated from remote Aboriginal communities to Darwin experience clear disruption to traditional food access, consumption, availability, and knowledge dissemination to the younger generations.

What Contributions, if Any, Can Non-Indigenous Researchers Offer Toward Decolonizing Health Research?

Four non-Indigenous academics share lessons learned through our reflective processes while working with Indigenous Australian partners on a health research project. We foregrounded reflexivity in our work to raise consciousness regarding how colonizing mindsets-that do not privilege Indigenous ways of knowing or recognize Indigenous land and sovereignty-exist within ourselves and the institutions within which we operate. We share our self-analyses and invite non-Indigenous colleagues to also consider socialized, unquestioned, and possibly unconscious assumptions about the dominance of Western paradigms, asking what contributions, if any, non-Indigenous researchers can offer toward decolonizing health research. Our processes comprise of three iterative features-prioritizing attempts to decolonize ourselves, acknowledging the necessary role of discomfort in doing so, and moving through nonbinary and toward nondualistic thinking. With a nondual lens, working to decolonize ourselves may itself be seen as one contribution non-Indigenous researchers may offer to the collective project of decolonizing health research.

Disability "In-Justice": The Benefits and Challenges of "Yarning" With Young People Undergoing Diagnostic Assessment for Fetal Alcohol Spectrum Disorder in a Youth Detention Center

Undertaking research with young people presents an array of methodological challenges. We report the findings from a qualitative study that took place alongside a fetal alcohol spectrum disorder (FASD) prevalence study among detainees in Australia. Of 38 participants, 27 were Aboriginal youth. Interviews were conducted using "social yarning" and "research topic yarning," an Indigenous research method which allows for data collection in an exploratory, culturally safe way. A complex interplay emerged between social yarning and research topic yarning which provided a space to explore responsively with participants their experiences of FASD assessments. Flexibility, including language adaptation and visual descriptions about assessments, was utilized to assist participants recall and retell their experiences. There were, however, challenges in gathering data on the assessment experiences of some participants. We describe how employing a "yarning" method for collecting data could benefit children and young people undergoing neurodevelopmental assessments in the future.

Geographical analysis of evaluated chronic disease programs for Aboriginal and Torres Strait Islander people in the Australian primary health care setting: a systematic scoping review

BACKGROUND

Targeted chronic disease programs are vital to improving health outcomes for Indigenous people globally. In Australia it is not known where evaluated chronic disease programs for Aboriginal and Torres Strait Islander people have been implemented. This scoping review geographically examines where evaluated chronic disease programs for Aboriginal people have been implemented in the Australian primary health care setting. Secondary objectives include scoping programs for evidence of partnerships with Aboriginal organisations, and use of ethical protocols. By doing so, geographical gaps in the literature and variations in ethical approaches to conducting program evaluations are highlighted.

METHODS

The objectives, inclusion criteria and methods for this scoping review were specified in advance and documented in a published protocol. This scoping review was undertaken in accordance with the Joanna Briggs Institute (JBI) scoping review methodology. The search included 11 academic databases, clinical trial registries, and the grey literature.

RESULTS

The search resulted in 6894 citations, with 241 retrieved from the grey literature and targeted organisation websites. Title, abstract, and full-text screening was conducted by two independent reviewers, with 314 citations undergoing full review. Of these, 74 citations evaluating 50 programs met the inclusion criteria. Of the programs included in the geographical analysis (n = 40), 32.1% were implemented in Major Cities and 29.6% in Very Remote areas of Australia. A smaller proportion of programs were delivered in Inner Regional (12.3%), Outer Regional (18.5%) and Remote areas (7.4%) of Australia. Overall, 90% (n = 45) of the included programs collaborated with an Aboriginal organisation in the implementation and/or evaluation of the program. Variation in the use of ethical guidelines and protocols in the evaluation process was evident.

CONCLUSIONS

A greater focus on the evaluation of chronic disease programs for Aboriginal people residing in Inner and Outer Regional areas, and Remote areas of Australia is required. Across all geographical areas further efforts should be made to conduct evaluations in partnership with Aboriginal communities residing in the geographical region of program implementation. The need for more scientifically and ethically rigorous approaches to Aboriginal health program evaluations is evident.

Interactions Between Indigenous Women Awaiting Childbirth Away From Home and Their Southern, Non-Indigenous Health Care Providers

We examine patient-provider interactions for Indigenous childbirth evacuees. Our analysis draws on in-depth interviews with 25 Inuit and First Nations women with medically high-risk pregnancies who were transferred or medevacked from northern Quebec to receive maternity care at a tertiary hospital in a southern city in the province. We supplemented the patient data with interviews from eight health care providers. Three themes related to patient-provider interactions are discussed: evacuation-related stress, hospital bureaucracy, and stereotypes. Findings show that the quality of the patient-provider interaction is contingent on individual health care providers' ability to connect with Indigenous patients and overcome cultural and institutional barriers to communication and trust-building. The findings point to the need for further training of medical professionals in the delivery of culturally safe care and addressing bureaucratic constraints in the health care system to improve patient-provider communication and overall relationship quality.