Cultural interventions to treat addictions in Indigenous populations: findings from a scoping study

Engaging the Great Circle: a qualitative study of the Confederated Tribes of Grand Ronde’s mobile medication unit

BACKGROUND

The Confederated Tribes of the Grand Ronde Community of Oregon began a Mobile Medication Unit (MMU) as part of their Great Circle Recovery Opioid Treatment Program (OTP) to address elevated rates of opioid use disorder (OUD) among American Indians and Alaska Natives in Oregon. The MMU provides methadone or buprenorphine for individuals with OUD, enrolled in the OTP, who are living either on the reservation or in surrounding rural communities. An implementation study describes the service through document review and qualitatively assesses patient and staff experiences and the perceived barriers and facilitators to mobile services.

METHODS

Semi-structured qualitative interviews with patients (n = 11), MMU staff (n = 5), and the state opioid treatment authority (n = 1) gathered details on the initiative's development and operations. Provider interviews probed implementation experiences. Patient interviews focused on their experiences with the MMU and staff, changes in quality of life and recommendations for enhancing treatment. Interviews were transcribed and analysed using a Thematic Analysis approach.

RESULTS

Staff themes identified two driving forces (i.e. staff desire for an inclusive approach to wellness that is accessible to all community members; the catalysts for the MMU), two steps toward MMU development (i.e. Tribal approvals and support; the construction and maintenance of community relationships) and two perspectives on MMU implementation and impact (i.e. initial implementation barriers; facilitators and observations of how the MMU reduced stigma associated with agonist therapy). Patients' themes noted the MMU's professional and 'caring' environment, accessible rural locations and general suggestions including culturally responsive ancillary services.

CONCLUSION

The Great Circle MMU enhanced access to opioid agonist therapy for people with OUD (i.e. American Indians/Alaska Natives, and non-natives) living in rural communities. The Confederated Tribes of Grand Ronde operates the first Tribally owned OTP MMU, grounded in cultural humility and committed to Tribal members and the great circle of the larger community.

Healing and wellbeing outcomes of services for Aboriginal people based on cultural therapeutic ways: A systematic scoping review

Aboriginal Australians experience disproportionately high rates of mental health problems as the result of European colonisation, and Western evidence-based treatment has been strikingly ineffective in improving the situation. Cultural Therapeutic Ways is a culturally specific healing and wellbeing practice framework developed by the Victorian Aboriginal Child and Community Agency that focuses on culturally based practices, trauma awareness, and self-determination. Despite wide recognition of the importance of these elements in Indigenous healing and wellbeing programs, its measurable empirical impact is currently unclear. This paper summarises findings from a systematic scoping review to ascertain the published knowledge base for Cultural Therapeutic Ways and the gaps in knowledge that can inform future evaluation. Forty-two studies of programs that applied Cultural Therapeutic Ways with Indigenous participants from Australia, Canada, New Zealand, and the United States of America were identified from the literature search. Services based on Cultural Therapeutic Ways contributed to healing and wellbeing because they create safety, strengthen cultural connections, develop empowerment and provide opportunities to release emotion, and increase social and spiritual support. As the review set out to determine the published evidence base for Cultural Therapeutic Ways, other effective approaches may have been overlooked. To develop the evidence base for Cultural Therapeutic Ways, service design must clearly describe target groups, whether the program is delivered by Aboriginal people, the processes of Cultural Therapeutic Ways utilised in service delivery, and how they are blended with Western approaches. Research efforts could also productively be focused on identifying or constructing culturally appropriate outcome measures.

Interprofessional Care Models for Pregnant and Early-Parenting Persons Who Use Substances: A Scoping Review

Introduction

Use of substances during pregnancy is a global health concern. Interprofessional care teams can provide an optimal care approach to engage individuals who use substances during the perinatal period. The purpose of this scoping review is to provide a comprehensive summation of published literature reporting on interprofessional care models for perinatal individuals who use substances.

Methods

We conducted a systematic search for articles from health-related databases. The Preferred Reporting Items for Systematic Reviews for Scoping Reviews (PRISMA-ScR) was followed. Data were extracted and synthesized to identify the interprofessional care team roles, program and/or provider characteristics, and care outcomes of these models.

Results

We screened 645 publications for full text eligibility. Eleven articles met full inclusion criteria and were summarized. Programs were built on co-location of services, partnership with other agencies, available group/peer support and approaches inclusive of cultural care, trauma informed care, and harm reduction principles.

Discussion

There is growing evidence supporting integrated care models that are inclusive of relational care providers from multiple health care professions to achieve wraparound care.

Conclusions

Many of the interprofessional care models studied have successfully blended social, primary, pregnancy, and addictions care. The success and sustainability of programs varies, and more work is needed to evaluate program and patient outcomes.

Current stage of preclinical and clinical development of guggulsterone in cancers: Challenges and promises

Throughout human history, the utilization of medicinal herbs has been recognized as a crucial defense against various ailments, including cancer. Natural products with potential anticancer properties, capable of inducing apoptosis in cancer cells, have garnered substantial attention. One such agent under investigation is guggulsterone (GS), a phytosterol derived from the gum resin of the Commiphora mukul tree. This review aims to provide a comprehensive summary of recent studies elucidating the anticancer molecular mechanisms and molecular targets of GS, guiding future research and potential applications as an adjuvant drug in cancer therapy. Recent in vivo and in vitro studies have explored the biological activities of the active ingredients in Commiphora mukul. Specifically, GS emerges as a potential cancer chemopreventive and therapeutic agent. The investigations delve into the impact of GS on constitutively activated survival pathways, including Janus kinase/signal transducer and activator of transcription (JAK/STAT), nuclear factor-kappa B (NF-kB), and PI3-kinase/AKT signaling pathways. These pathways regulate antiapoptotic and proinflammatory genes, exerting control over growth and inflammatory responses. The findings highlight the potential of GS in disrupting survival pathways crucial for cancer cell viability. The inhibition of JAK/STAT, NF-kB, and PI3-kinase/AKT signaling pathways positions GS as a promising candidate for cancer therapy. The review synthesizes evidence from diverse studies, underscoring the multifaceted biological activities of GS in cancer prevention and treatment. To advance our understanding, future clinical and translational studies are imperative to determine effective doses in humans. Additionally, there is a need for the development of new pharmaceutical forms of GS to optimize therapeutic effects. This comprehensive review provides a foundation for ongoing research, offering insights into the potential of GS as a valuable addition to the armamentarium against cancer.

Profiles of childhood adversities in Inuit from Nunavik: description and associations with indicators of socioeconomic characteristics, support, and community involvement

OBJECTIVES

Distress and associated health problems reported by Nunavik Inuit emanate from heterogeneous roots, including adverse childhood experiences. This study aims to (1) identify distinct childhood adversity profiles and (2) examine associations between these profiles and sex, socioeconomic characteristics, social support, and community involvement among Nunavimmiut.

METHODS

In a sample of 1109 adult Nunavimmiut, sex, socioeconomic characteristics, support, community involvement, residential school attendance, and 10 forms of adverse childhood experiences (ACEs) were documented using questionnaires. Latent class analyses and weighted comparisons were performed for three subgroups: 18-49 years; 50 years and above with experience of residential school; and 50 years and above without experience of residential school. The analysis design, the manuscript drafts, and the key findings were discussed and co-interpreted with the collaboration of community representatives, taking into consideration Inuit culture and needs.

RESULTS

A total of 77.6% of Nunavimmiut reported having experienced at least one form of childhood adversity. Three ACE profiles were identified among the 18-49-year-olds: low ACEs (43.0%), household stressors (30.7%), and multiple ACEs (26.3%). Two profiles characterized ACEs experienced among the 50-year-olds and over with and without history of residential schooling: low ACEs (80.1% and 77.2%, respectively) and multiple ACEs (19.9% and 22.8%, respectively). Among the group of 18-49-year-olds, as compared to the low ACE profile, the profile with household stressors included proportionally more women (odds ratio [OR] = 1.5) and was associated with lower involvement in volunteering and community activities (mean score reduced by 0.29 standard deviation [SD]) and lower family cohesion (SD = - 0.11), while the multiple ACE profile was related to a lower rate of employment (OR = 0.62), lower family cohesion (SD = - 0.28), and lower satisfaction with ability to practice traditional activities (SD = - 0.26).

CONCLUSION

Childhood adversities among Nunavimmiut do not occur in isolation and experiencing multiple forms of childhood adversities predicts lower socioeconomic status, support, and community involvement in adulthood. Implications for the planning of health and community services in Nunavik are discussed.

Psychometric Evaluation of an Adapted Short-Form Spirituality Scale in a Sample of Predominantly White Adults in an Inpatient Substance Use Disorder Treatment Program

Spirituality is an important aspect of treatment and recovery for substance use disorders (SUDs), but ambiguities in measurement can make it difficult to incorporate as part of routine care. We evaluated the psychometric properties of an adapted short-form version of the Spirituality Scale (the Spirituality Scale-Short-Form; SS-SF) for use in SUD treatment settings. Participants were adult patients (N = 1,388; Mage = 41.23 years, SDage = 11.55; 68% male; 86% White) who entered a large, clinically mixed inpatient SUD treatment program. Factor analysis supported the two-dimensional structure, with factors representing Self-Discovery and Transcendent Connection. Tests of measurement invariance demonstrated that the scale was invariant across age and gender subgroups. The SS-SF exhibited convergent and concurrent validity via associations with participation in spiritual activities, hopefulness, life satisfaction, 12-step participation, and depressive symptoms. Finally, scores on the SS-SF were significantly higher at discharge compared to admission, demonstrating short-term sensitivity to change. These findings support use of the SS-SF as a concise, psychometrically sound measure of spirituality in the context of substance use treatment.

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

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

Traditional Ceremonial Practices as a Strategy to Reduce Problem Substance Use in American Indian Communities: A Systematic Review

Objective: This systematic review assessed the feasibility of American Indian traditional ceremonial practices (TCPs) to address problem substance use in both reservation and urban settings. Methods: Between September 24, 2021, and January 14, 2022, culturally specific review protocols were applied to articles retrieved from over 160 electronic databases-including PubMed, Global Health, Global Health Archive, CINAHL Complete, PsychInfo, Web of Science, Health and Wellness (Gale), Sage Online Journals, and ScienceDirect. Results: A total of 10 studies met the criteria for inclusion in the review. Studies were conducted with both urban (n = 7) and reservation (n = 3) American Indian and Alaska Native (AIAN) populations. The most common TCP activities reported were drumming (n = 9), sweat lodge (n = 7), and talking circles (n = 6). All 10 studies reported some type of quantitative data showing a reduction of substance use associated with TCP interventions or activities. Conclusions: The current status of the literature is emerging and does not allow for meta-analysis of existing studies. However, the existing literature does indicate promise for the use of TCPs to address problem substance use in AIAN communities in a way that is effective and also culturally congruent.

Physical pain among Indigenous Peoples in Canada: a scoping review

PURPOSE

Pain is a multifaceted experience shaped by various factors including context of pain, previous life events, and ongoing ethnocultural circumstances. Moreover, the definition of pain is inconsistent across cultures. Western medicine views physical pain (e.g., associated with a bone fracture) and nonphysical mental pain (e.g., depression) as two distinct conditions. Indigenous perspectives are often more wholistic, encompassing mental, spiritual, emotional, and physical hurt. The subjective nature of pain invites ample opportunity for discrimination in both its assessment and management. As such, it is important to consider Indigenous perspectives of pain in research and clinical practice. To investigate which aspects of Indigenous pain knowledge are currently considered by Western research, we conducted a scoping review of the literature on pain in Indigenous Peoples of Canada.

SOURCE

In June 2021, we searched nine databases and downloaded 8,220 papers after removal of duplicates. Two independent reviewers screened abstracts and full-text articles.

PRINCIPLE FINDINGS

Seventy-seven papers were included in the analysis. Using grounded theory, five themes emerged: pain measures/scales (n = 7), interventions (n = 13), pharmaceuticals (n = 17), pain expression/experiences (n = 45), and pain conditions (n = 70).

CONCLUSION

This scoping review shows that there is a paucity of research on pain measurement in Indigenous Peoples of Canada. This finding is concerning in light of numerous studies reporting that Indigenous Peoples experience their pain as ignored, minimized, or disbelieved. Furthermore, a clear disconnect emerged between pain expression in Indigenous Peoples and assessment in medical professionals. We hope that this scoping review will serve to translate current knowledge to other non-Indigenous academics and to initiate meaningful collaboration with Indigenous partners. Future research led by Indigenous academics and community partners is critically needed to better address pain needs in Canada.

Racial and Ethnic Disparities in Alcohol-Attributed Deaths in the United States, 1999-2020

The disparities in alcohol-attributed death rates among different racial and ethnic groups in the United States (US) have received limited research attention. Our study aimed to examine the burden and trends in alcohol-attributed mortality rates in the US by race and ethnicity from 1999 to 2020. We used national mortality data from the Centers for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) database and employed the ICD-10 coding system to identify alcohol-related deaths. Disparity rate ratios were calculated using the Taylor series, and Joinpoint regression was used to analyze temporal trends and calculate annual and average annual percentage changes (APCs and AAPCs, respectively) in mortality rates. Between 1999 and 2020, 605,948 individuals died from alcohol-related causes in the US. The highest age-adjusted mortality rate (AAMR) was observed among American Indian/Alaska Natives, who were 3.6 times more likely to die from alcohol-related causes than Non-Hispanic Whites (95% CI: 3.57, 3.67). An examination of trends revealed that recent rates have leveled among American Indians/Alaska Natives (APC = 17.9; 95% CI: -0.3, 39.3) while increasing among Non-Hispanic Whites (APC = 14.3; 95% CI: 9.1, 19.9), Non-Hispanic Blacks (APC = 17.0; 95% CI: 7.3, 27.5), Asians/Pacific Islanders (APC = 9.5; 95% CI: 3.6, 15.6), and Hispanics (APC = 12.6; 95% CI: 1.3, 25.1). However, when the data were disaggregated by age, sex, census region, and cause, varying trends were observed. This study underscores the disparities in alcohol-related deaths among different racial and ethnic groups in the US, with American Indian/Alaska Natives experiencing the highest burden. Although the rates have plateaued among this group, they have been increasing among all other subgroups. To address these disparities and promote equitable alcohol-related health outcomes for all populations, further research is necessary to gain a better understanding of the underlying factors and develop culturally sensitive interventions.

Looking beyond the individual-The importance of accessing health and cultural services for Indigenous women in Thunder Bay, Ontario

Access to cultural activities and culturally relevant healthcare has always been significant for achieving holistic Indigenous health and continues to be a key factor in shaping the health journey of Indigenous individuals and communities. Previous research has indicated the importance of cultural practices and services in sustaining cultural identity for Indigenous peoples, which is a major influence on their wellbeing. This study marks the first phase in a project aimed at establishing an Indigenous healing program and uses a qualitative research approach to understand the health and cultural services that Indigenous women want and require in Thunder Bay, Ontario. During interviews, participants (n = 22) answered questions around their understandings of health and wellbeing, and how they are able to incorporate cultural practices into their circle of care. Thematic analysis was performed on interview transcripts, and 4 key themes were identified: 'independence and self-care', 'external barriers to accessing services', 'finding comfort in the familiar' and 'sense of community'. Together these themes illustrate how Indigenous women feel a strong sense of personal responsibility for maintaining their health despite the multiple environmental factors that may act as barriers or supports. Furthermore, the necessity of embedding cultural practices into Indigenous women's circle of care is highlighted by the participants as they describe the mental, spiritual, social, and emotional health benefits of engaging in cultural activities within their community. The findings demonstrate the need for current modes of care to look beyond the individual and consider the impacts that socio-environmental factors have on Indigenous women. To accomplish this, we hope to increase access to health and cultural services through the creation of an Indigenous healing program that can be adequately incorporated into Indigenous women's circle of care if they wish to do so.

Centering Indigenous knowledge in suicide prevention: a critical scoping review

BACKGROUND

Indigenous peoples of Canada, United States, Australia, and New Zealand experience disproportionately high rates of suicide as a result of the collective and shared trauma experienced with colonization and ongoing marginalization. Dominant, Western approaches to suicide prevention-typically involving individual-level efforts for behavioural change via mental health professional intervention-by themselves have largely failed at addressing suicide in Indigenous populations, possibly due to cultural misalignment with Indigenous paradigms. Consequently, many Indigenous communities, organizations and governments have been undertaking more cultural and community-based approaches to suicide prevention. To provide a foundation for future research and inform prevention efforts in this context, this critical scoping review summarizes how Indigenous approaches have been integrated in suicide prevention initiatives targeting Indigenous populations.

METHODS

A systematic search guided by a community-based participatory research (CBPR) approach was conducted in twelve electronic bibliographic databases for academic literature and six databases for grey literature to identify relevant articles. the reference lists of articles that were selected via the search strategy were hand-searched in order to include any further articles that may have been missed. Articles were screened and assessed for eligibility. From eligible articles, data including authors, year of publication, type of publication, objectives of the study, country, target population, type of suicide prevention strategy, description of suicide prevention strategy, and main outcomes of the study were extracted. A thematic analysis approach guided by Métis knowledge and practices was also applied to synthesize and summarize the findings.

RESULTS

Fifty-six academic articles and 16 articles from the grey literature were examined. Four overarching and intersecting thematic areas emerged out of analysis of the academic and grey literature: (1) engaging culture and strengthening connectedness; (2) integrating Indigenous knowledge; (3) Indigenous self-determination; and (4) employing decolonial approaches.

CONCLUSIONS

Findings demonstrate how centering Indigenous knowledge and approaches within suicide prevention positively contribute to suicide-related outcomes. Initiatives built upon comprehensive community engagement processes and which incorporate Indigenous culture, knowledge, and decolonizing methods have been shown to have substantial impact on suicide-related outcomes at the individual- and community-level. Indigenous approaches to suicide prevention are diverse, drawing on local culture, knowledge, need and priorities.

Mental health and cultural continuity among an urban Indigenous population in Toronto, Canada

OBJECTIVES

Mental health and psychiatric disorders significantly affect individuals on personal and social levels. Indigenous populations in Canada have disproportionately high rates of mental health diagnoses. Our Health Counts (OHC) Toronto assessed mental health, racism, family disruption, and cultural continuity among urban Indigenous people. The objectives of this study were to understand (1) the demographics and characteristics of Indigenous adults with a diagnosed psychological/mental health disorder and (2) potential associations of psychological/mental health diagnoses with experiences of colonization and cultural continuity among Indigenous adults in Toronto.

METHODS

Using community-based participatory research methods, Indigenous adults in Toronto were recruited by respondent-driven sampling (RDS) to complete a comprehensive health assessment survey. RDS-II weights were applied to calculate population-based estimates, and adjusted odds ratios with 95% confidence intervals were produced using logistic regression, controlling for age and gender.

RESULTS

Among Indigenous adults, nearly half (45%) reported receiving a mental health diagnosis. Participants reported lifetime anxiety disorders (53%), major depression (51%), and high rates of suicide ideation (78%). Of Indigenous adults with a diagnosed mental health disorder, 72.7% reported participating in ceremony. Attending residential schools (OR: 7.82) and experiencing discrimination (OR: 2.69) were associated with having a mental health disorder.

CONCLUSION

OHC Toronto responded to the gaps in health assessment data for urban Indigenous people. Despite historic and ongoing trauma, Indigenous people have maintained cultural practices and a strong sense of identity. Efforts aimed at supporting Indigenous well-being must respond to the roots of trauma, racism, and existing Indigenous community knowledge and strengths.

Implementation and evaluation of a two-eyed seeing approach using traditional healing and seeking safety in an indigenous residential treatment program in Northern Ontario

Indigenous clients in need of residential care for substance use disorders (SUD) often present with the diagnosis of substance use disorder (SUD) combined with intergenerational trauma (IGT) or both. SUD is exceedingly prevalent amongst Indigenous peoples due to the health impacts of colonisation, residential school trauma, and IGT on this population’s health. We evaluated the effectiveness of a Two-Eyed Seeing approach in a four-week harm reduction residential treatment programme for clients with a history of SUD and IGT. This treatment approach blended Indigenous Healing practices with Seeking Safety based on Dr. Teresa Marsh’s research work known as Indigenous Healing and Seeking Safety (IHSS). The data presented in this study was drawn from a larger trial. This qualitative study was undertaken in collaboration with the Benbowopka Treatment Centre in Blind River, Northern Ontario, Canada. Patient characteristic data were collected from records for 157 patients who had enrolled in the study from April 2018 to February 2020. Data was collected from the Client Quality Assurance Survey tool. We used the qualitative thematic analysis method to analyse participants’ descriptive feedback about the study. Four themes were identified: (1) Motivation to attend treatment; (2) Understanding Benbowopka’s treatment programme and needs to be met; (3) Satisfaction with all interventions; and (4) Moving forward. We utilised a conceptualised descriptive framework for the four core themes depicted in the medicine wheel. This qualitative study affirmed that cultural elements and the SS Western model were highly valued by all participants. The impact of the harm reduction approach, coupled with traditional healing methods, further enhanced the outcome. This study was registered with clinicaltrials.gov (identifier number NCT0464574).

Adapting narrative exposure therapy with a tribal community: A community-based approach

OBJECTIVE

American Indian (AI) individuals are at increased risk for present-day trauma exposure and associated negative outcomes, as well as ongoing effects of intergenerational trauma exposure and adversity. However, few empirically supported treatments exist that are specifically tailored and/or tested with AI communities. This study describes the process of selecting, adapting, and implementing narrative exposure therapy (NET) with an AI community.

METHODS

A community and academic partnership was formed and worked together to make culturally mindful changes to NET to best fit the needs of the community. The partnership incorporated community leaders/Elders (n = 7), providers (n = 11), and participants seeking treatment (n = 50) to implement an iterative process of adapting and implementing the adapted form of NET.

RESULTS

Key adaptions included addressing historical and intergenerational trauma, greater protections for confidentiality in a small community, and incorporation of cultural customs and traditions. Overall, the adapted form of NET was favorably received by the participants, and the implementation appeared to be feasible, with improved retention over past trials of adapted trauma-focused treatments with this community and with highly positive satisfaction ratings and feedback.

CONCLUSIONS

NET was shown to be an appropriate approach for this AI community and should be considered as a treatment option for other AI communities. Future work should consider strategies outlined in this adaption as well as following a similar process for working with AI communities to implement culturally appropriate interventions for trauma-related symptoms.

Using Concept Mapping to Define Indigenous Housing First in Hamilton, Ontario

BACKGROUND

The lasting impact of colonization contributes to the disproportionate rates of homelessness experienced by Indigenous people in Canada.

METHODS

This study used participatory mixed methods to evaluate an urban, Indigenous-led Housing First program in Ontario to fill knowledge gaps on wise practices addressing the unique dimensions of Indigenous homelessness. Using concept mapping, staff perspectives were engaged to generate 65 unique statements describing program delivery and their interrelationships using a six-cluster map.

RESULTS

'Team's Professional Skills' and 'Spiritual Practices' rated high in importance (mean = 4.75 and 4.73, respectively), and feasibility (mean = 4.31 and 4.33, respectively). While fairly important, 'Partnerships and Agency Supports' was ranked least feasible (mean = 3.89). On average, clusters rated higher in importance than feasibility.

CONCLUSION

Concept mapping draws from local knowledge, elicits strong engagement, and captured the holistic and client-centred approach of an Indigenous Housing First Model.

Navigating Paths to Wellness: A Strengths-Based Photovoice Study Conducted with One First Nation in Southern Ontario, Canada

Research on substance use challenges in First Nations communities is often deficit-focused and can reinforce paternalistic stereotypes that lead to further discrimination. In this article, we report on findings of a strengths-based Photovoice project done in collaboration with a First Nations' community in southern Ontario, Canada to better understand experiences with substance use challenges in the community. We analyzed interview data collected with seventeen individuals who have lived experience or are supporting a loved one with lived experience with a substance use challenge. Participants described sources of strength that characterized their path to wellness, including strong family and social connections, cultural practices, identity, spirituality, day-to-day activities, and helpful supports and services. Furthermore, participants made several suggestions for improving services, including the need for integrated and flexible systems of care and trustful client-provider relationships. At its core, nurturing wellness involved a transformative process involving social and/or cultural connections. The stories shared by participants demonstrate the unique and varied strengths drawn from by individuals dealing with a substance use challenge.

Community trial evaluating the integration of Indigenous healing practices and a harm reduction approach with principles of seeking safety in an Indigenous residential treatment program in northern Ontario

Objective

Our primary objective was to evaluate how the Indigenous Healing and Seeking Safety (IHSS) model impacted residential addiction treatment program completion rates. Our secondary objective was to evaluate health service use 6 months before and 6 months after residential treatment for clients who attended the program before and after implementing IHSS.

Methods

We observed clients of the Benbowopka Residential Treatment before IHSS implementation (from April 2013 to March 31, 2016) and after IHSS implementation (from January 1, 2018 – March 31, 2020). The program data were linked to health administration data, including the Ontario Health Insurance Plan (OHIP) physician billing, the Registered Persons Database (RPDB), the National Ambulatory Care Reporting System (NACRS), and the Discharge Abstract Database (DAD). Chi-square tests were used to compare patient characteristics in the no-IHSS and IHSS groups. We used logistic regression to estimate the association between IHSS and treatment completion. We used generalized estimating equation (GEE) regression model to evaluate health service use (including primary care visits, ED visits overall and for substance use, hospitalizations and mental health visits), Results: There were 266 patients in the no-IHSS group and 136 in the IHSS group. After adjusting for individual characteristics, we observed that IHSS was associated with increased program completion rates (odds ratio = 1.95, 95% CI 1.02-3.70). There was no significant association between IHSS patients’ health service use at time one or time two. Primary care visits time 1: aOR 0.55, 95%CI 0.72-1.13, time 2: aOR 1.13, 95%CI 0.79-1.23; ED visits overall time 1: aOR 0.91, 95%CI 0.67-1.23, time 2: aOR 1.06, 95%CI 0.75-1.50; ED visits for substance use time 1: aOR 0.81, 95%CI 0.47-1.39, time 2: aOR 0.79, 95%CI 0.37-1.54; Hospitalizations time 1: aOR 0.78, 95%CI 0.41-1.47, time 2: aOR 0.76, 95%CI 0.32-1.80; Mental health visits time 1: aOR 0.66, 95%CI 0.46-0.96, time 2: aOR 0.92 95%CI 0.7-1.40.

Conclusions

Our results indicate that IHSS positively influenced program completion but had no significant effect on health service use.

Trial registration

This study was registered with clinicaltrials.gov (identifier number NCT04604574). First registration 10/27/2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08406-3.

Adverse Childhood Experiences (ACEs) and Health Histories Among Clients in a First Nations-Led Treatment for Substance Use

First Nations adults continue to experience significant health disparities compared to non-First Nations adults in Canada. Ongoing difficulties associated with intergenerational trauma among First Nations peoples may be examined using the adverse childhood experiences (ACEs) model, which measures various forms of abuse, neglect, and household dysfunction. We examined prevalence rates of ACEs and physical and mental health outcomes within a predominately First Nation sample of clients seeking substance use treatment from a First Nations-led treatment facility. The prevalence of ACEs was higher than national averages and previous data collected with broader Indigenous samples in Canada. Descriptive analyses of ACEs and health outcomes for those seeking First Nations-led substance use treatment showed these participants had more chronic health difficulties co-morbid with clinical levels of problematic substance use. To improve ongoing best-treatment options for those seeking substance use treatment, continued assessment and promotion of broader aspects of health and wellbeing are required, including the balance of physical, emotional, spiritual, and mental health and wellbeing across a lifespan.

Exploring Culturally Based Treatment Options for Opioid Use Disorders Among American Indian and Alaska Native Adults in California

OBJECTIVE

American Indian and Alaska Native (AIAN) communities have been severely affected by the opioid epidemic, resulting in high opioid overdose death rates and disrupted community life. An added complexity is the diversity of AIAN communities throughout California, with regional differences, resources, infrastructure, and economic opportunities. This study examined the perspective of 163 AIANs in California to assess culturally based or traditional healing treatment modalities to treat opioid/substance use disorder.

METHOD

A total of 21 adult focus groups were conducted throughout 10 counties in California reaching 20 urban and tribal communities. Eight of these focus groups were conducted in recovery centers and 13 focus groups were conducted in tribal and urban organizations. Interviews were transcribed and coded using NVivo software utilizing an iterative coding approach with a priori domains.

RESULTS

Participants emphasized building a sense of belonging, connecting with their culture, and having awareness of substance use disorder and treatment as protective factors.

CONCLUSIONS

Findings indicate that medications for opioid use disorder programs serving AIAN communities should include cultural components that resonate with urban and tribal communities.

Exploring Culturally Based Treatment Options for Opioid Use Disorders Among American Indian and Alaska Native Adults in California

OBJECTIVE

American Indian and Alaska Native (AIAN) communities have been severely affected by the opioid epidemic, resulting in high opioid overdose death rates and disrupted community life. An added complexity is the diversity of AIAN communities throughout California, with regional differences, resources, infrastructure, and economic opportunities. This study examined the perspective of 163 AIANs in California to assess culturally based or traditional healing treatment modalities to treat opioid/substance use disorder.

METHOD

A total of 21 adult focus groups were conducted throughout 10 counties in California reaching 20 urban and tribal communities. Eight of these focus groups were conducted in recovery centers and 13 focus groups were conducted in tribal and urban organizations. Interviews were transcribed and coded using NVivo software utilizing an iterative coding approach with a priori domains.

RESULTS

Participants emphasized building a sense of belonging, connecting with their culture, and having awareness of substance use disorder and treatment as protective factors.

CONCLUSIONS

Findings indicate that medications for opioid use disorder programs serving AIAN communities should include cultural components that resonate with urban and tribal communities.

Predictors of Land-Based Activity Participation in a National Representative Sample of Indigenous Individuals Living Off-Reserve

This study examined data from the 2017 Aboriginal Peoples Survey to consider predictors of land-based activity engagement. We hypothesized that higher self-reported mental and physical health scores, an increased sense of cultural belonging, living in a rural community, and no prior individual or family history of residential school attendance would predict a higher frequency of land-based activity engagement among First Nations individuals living off-reserve. Results from linear regression analyses suggested that an increased sense of cultural belonging, being male, and living in a rural community with a population of less than 1000 people were significant predictors of the frequency of land-based activity engagement. With these preliminary findings, further research can explore how physical and mental health outcomes influence the frequency of land-based activity engagement, in addition to how community-specific indicators may promote higher frequency of these activities, particularly among First Nations individuals living off-reserve.

Reclaiming Land, Identity and Mental Wellness in Biigtigong Nishnaabeg Territory

Indigenous peoples globally are pursuing diverse strategies to foster mental, emotional, and spiritual wellness by reclaiming and restoring their relationships to land. For Anishinaabe communities, the land is the source of local knowledge systems that sustain identities and foster mino-bimaadiziwin, that is, living in a good and healthy way. In July 2019, the community of Biigtigong Nishnaabeg in Ontario, Canada hosted a week-long land camp to reclaim Mountain Lake and reconnect Elders, youth and band staff to the land, history, and relationships of this place. Framed theoretically by environmental repossession, we explore the perceptions of 15 participating community members and examine local and intergenerational meanings of the camp for mental wellness. The findings show that the Mountain Lake camp strengthened social relationships, supported the sharing and practice of Anishinaabe knowledge, and fostered community pride in ways that reinforced the community’s Anishinaabe identity. By exploring the links between land reclamation, identity, and community empowerment, we suggest environmental repossession as a useful concept for understanding how land reconnection and self-determination can support Indigenous mental wellness.

What public health interventions do people in Canada prefer to fund? A discrete choice experiment

Objective

To assess public support of tailored and targeted public health interventions for marginalized communities.

Methods

We conducted a discrete choice experiment using a web-based survey advertised to Facebook and Instagram users living in Canada, aged > 16. Participants were asked to choose between funding two hypothetical public health programs. Each program was described by its purpose; expected increase in life expectancy; and target audience. Demographically weighted generalized linear mixed-effects models were constructed to identify program factors associated with program selection.

Results

Participants completed up to 8 discrete choice comparison exercises each resulting in 23,889 exercises were completed by 3054 participants. Selected programs were less likely to focus on prevention (vs. treatment). For each 1-year increase in the marginal years of life gained, there was a 15% increase in the odds of a program being selected. Interventions tailored to marginalized communities or targeting stigmatized health conditions were less likely to be selected compared to interventions targeted to the general population or targeting chronic health conditions. Noteworthy exceptions included an increased preference for interventions aligning with the perceived needs or cultural expectations for marginalized communities.

Conclusions

Stigmatizing perceptions of health conditions and key populations likely influence public health programming preferences of Canadians.

Public health implications

Informational campaigns highlighting disparities experienced by marginalized populations may improve support for targeted and tailored interventions.

Indigenous Culture-as-Health: A Systematized Literature Review

This paper has two goals regarding cultural rigor, defined as privileging cultural ways of knowing and being as a means to achieving health and well-being for future generations. First, we move the continuum of health practices beyond cultural grounding to include Indigenous Culture-as-Health. Second, this project expands the concept of Indigenous Culture-as-Health in addiction and recovery to include a broader range of health, inclusive of prevention, to further understand this emerging model. Our review of the literature yielded an expanded cultural continuum that includes Indigenous Culture-as-Health, which appears to rely on four modalities: 1) Indigenous ways of knowing, 2) Indigenous cultural practices, 3) place-based/sacred sites, and 4) Indigenous spirituality. For Indigenous health, standards are defined by centuries of ancestral consciousness among Indigenous people across generations, in spite of settler-colonial systems that do not serve them. In other words, Indigenous Culture-as-Health practices contribute to self-determination, sovereignty, and liberation. Incorporating these strategies also will ameliorate other problems related to White supremacy and health, such as epistemic exploitation. Additional implications for prevention practice and policy are described.

Pregnant and early parenting Indigenous women who use substances in Canada: A scoping review of health and social issues, supports, and strategies

This study reviews and synthesizes the literature on Indigenous women who are pregnant/early parenting and using substances in Canada to understand the scope and state of knowledge to inform research with the Aboriginal Health and Wellness Centre of Winnipeg in Manitoba and the development of a pilot Indigenous doula program. A scoping review was performed searching ten relevant databases, including one for gray literature. We analyzed 56 articles/documents. Themes include: (1) cyclical repercussions of state removal of Indigenous children from their families; (2) compounding barriers and inequities; (3) prevalence and different types of substance use; and (4) intervention strategies. Recommendations for future research are identified and discussed.

Access to Medications for Opioid Use Disorder and Associated Factors Among Adolescents and Young Adults: A Systematic Review

IMPORTANCE

The ongoing overdose crisis continues to adversely affect adolescents and young adults (AYAs) and has led to numerous preventable deaths. Medications for opioid use disorder (MOUD), such as methadone, buprenorphine, and naltrexone, have the potential to reduce opioid use and associated harms; however, there are concerns that AYAs lack access to these potentially life-saving medications.

OBJECTIVE

To systematically review peer-reviewed literature on MOUD access and associated factors to synthesize strategies that can improve MOUD access for AYAs who use opioids.

EVIDENCE REVIEW

The MEDLINE, Embase, PsycINFO, CINAHL, Sociological Abstracts, Web of Science, and Global Dissertations & Theses databases were searched from database inception until May 3, 2021. English, French, Russian, or Spanish peer-reviewed studies that evaluated the availability, prescription receipt, or initiation of MOUD were eligible for inclusion.

FINDINGS

This systematic review identified 37 cohort (n = 17), cross-sectional (n = 15), and qualitative (n = 5) studies that accounted for 179 785 AYAs (mean [SD] age, 24.4 [3.9] years; 148 779 [85%] were female; 67 771 [84%] were White) and examined access to methadone (30 studies), buprenorphine (26 studies), and naltrexone (10 studies). Findings reinforce concerns that AYAs were less likely to access MOUD and suggest that adolescents were more likely to receive naltrexone or buprenorphine-naloxone, which have a lower potential for abuse, in comparison with young adults. This review also identified other factors that were associated with MOUD access, including criminal justice involvement, residing in the US South, living in a limited-income area, Black race, and Hispanic or Latino ethnicity, suggesting ways in which treatment services may be improved to increase MOUD access and meet the treatment goals of AYAs.

CONCLUSION AND RELEVANCE

This systematic review found gaps in MOUD access between AYAs and non-AYA populations in addition to differences in MOUD access between adolescents and young adults. Considering that existing clinical guidelines recommend the use of MOUD among AYAs, and in light of the increasing number of opioid toxicity deaths, there is a need to improve MOUD access among AYAs by reducing barriers to MOUD and providing AYAs with a continuum of health and social supports alongside MOUD. Future research into ways to encourage MOUD uptake among AYAs may improve the treatment and health outcomes for this population.

“Wherever I Go, I Have It Inside of Me”: Indigenous Cultural Dance Narratives as Substance Abuse and HIV Prevention in an Urban Danza Mexica Community

Introduction

“Mexican American Indian” (MAI) is a large and diverse population for which little empirical research on alcohol and other drug (AOD) use and HIV is available, yet for which there is a disproportionate risk. Indigenous health narratives and participation in place- and settings-based cultural practices can be protective in chronic and co-occurring disease prevention and health promotion for Indigenous people. This study explores the role of participation in cultural dance in generating narratives of prevention and health promotion among a sample of MAIs from an Urban Danza Mexica Community (UDMC), framed within a decolonizing narratives of health (DNOH) model.

Methods

This secondary data analysis (n = 9) is drawn from a qualitative AOD and HIV health needs assessment of UDMC living in the Pacific Northwest and the Rocky Mountain West (n = 21). This study uses a community-based participatory research approach and employs narrative, Indigenized methods to analyze in-depth interviews from adult cisgender females (n = 5) and males (n = 4). The DNOH model is developed as a relational, analytic framework that contextualizes Indigenous stories in relationship to three distinct yet interconnected levels—the personal, the communal, and Indigeneity in the larger world. These levels of narrative analysis function as culturally grounded, relational pathways through which to articulate health education and promotion approaches.

Results

Narratives delve into the complex and nuanced relationships within participants' internal worlds (personal), between themselves and their Danza community (communal), and between themselves and their complex, intersectional Indigenous identities within society (Indigeneity). Stories of ancestral teachings about health and prevention shared within the Danza circle create spaces wherein participants navigate complex conversations that resist oppressive colonial narratives, reconnect with and strengthen their Indigenous identities, and strive toward ancestral visions of health and well-being.

Discussion

This study contributes to Indigenized theoretical and methodological expansion and the development of place/settings-based, narrative, cultural health interventions aimed at preventing chronic and co-occurring disease and promoting wellness among populations similar to the UDMC. Identifying cultural practices as Native Hubs (relational, socially constructed places) that foster decolonizing narratives helps increase understanding of their role in public health education and promotion through recognition of Indigenous knowledge systems and frameworks.

Trauma-informed Approaches to Substance Use Interventions with Indigenous Peoples: A Scoping Review

Indigenous Peoples experience disproportionately higher rates of problematic substance use. These problems are situated in a context of individual and intergenerational trauma from colonization, residential schools, and racist and discriminatory practices, policies, and services. Therefore, substance use interventions need to adopt a trauma-informed approach. We aimed to synthesize and report the current literature exploring the intersection of trauma and substance use interventions for Indigenous Peoples. Fourteen databases were searched using keywords for Indigenous Peoples, trauma, and substance use. Of the 1373 sources identified, 117 met inclusion criteria. Literature on trauma and substance use with Indigenous Peoples has increased in the last 5 years (2012-2016, n = 29; 2017-2021, n = 48), with most literature coming from the United States and Canada and focusing on historical or intergenerational trauma. Few articles focused on intersectional identities such as 2SLGBTQIA+ (n = 4), and none focused on veterans. There were limited sources (n = 25) that reported specific interventions at the intersection of trauma and substance use. These sources advocate for multi-faceted, trauma-informed, and culturally safe interventions for use with Indigenous Peoples. This scoping review illuminates gaps in the literature and highlights a need for research reporting on trauma-informed interventions for substance use with Indigenous Peoples.

Untangling the Complexities of Substance Use Initiation and Recovery: Client Reflections on Opioid Use Prevention and Recovery From a Social-Ecological Perspective

Background:

In Canada, the rate of opioid use, opioid use disorder (OUD), and associated mortality and morbidity are higher among Indigenous Peoples than the general population. Indigenous Peoples on medications for opioid use disorders (MOUD) often face distinct barriers that hinder their clinical progress, leading to treatment attrition.

Methods:

We used a social-ecological model to inquire into clients’ experiences with a history of treatment failure for OUD. We used exploratory qualitative research to engage 22 clients with a history of OUD treatment dropouts and who are currently on MOUD. In-depth, semi-structured interviews lasting an average of 30 minutes were conducted on-site.

Results:

We identified 4 themes from the study: (a) risk for substance use; (b) factors sustaining substance use; (c) factors leading to treatment, and (d) treatment failure and re-enrollment.

Conclusion:

Using a socio-ecological model helps to understand factors that influence an individual’s risk for OUD, decision to pursue treatment, and treatment outcomes. Furthermore, social ecological model also creates possibilities to develop supportive, multilevel interventions to prevent OUD risks and support for clients on MOUD. Such interventions include mitigating adverse childhood experiences, supporting families, and creating safe community environments.

Assessing Social Determinants of Health in a Prenatal and Perinatal Cultural Intervention for American Indians and Alaska Natives

American Indians and Alaska Natives (AIANs) refer to cultural traditions and values to guide resilient and strength-based practices to address maternal and infant health disparities.

METHODS

A case study of a culturally-based educational intervention on AIAN maternal and child health.

RESULTS

Cultural teachings have successfully been applied in AIAN behavioral interventions using talking circles and cradleboards, but maternal and child health interventions are not well-represented in peer-reviewed literature. Zero publications included interventions centered around cradleboards and safe sleep.

DISCUSSION

There is a need for rigorous published research on culturally based interventions and effectiveness on health outcomes for mothers and babies.

CONCLUSIONS

This paper discusses how a cradleboard educational intervention incorporates national guidelines to address maternal and infant health while mediating social determinants of health.

Spiritual connectedness through prayer as a mediator of the relationship between Indigenous language use and positive mental health

OBJECTIVE

The objective of this study is to understand how Indigenous language and spirituality revitalization efforts may affect mental health within Indigenous communities. Although Indigenous communities experience disproportionate rates of mental health problems, research supporting language and spirituality's role in improving mental health is under-researched and poorly understood.

METHOD

Data for this study are from a Community-based Participatory Research Project involving five Anishinaabe tribes in Minnesota and Wisconsin. Participants were sampled from clinic records of adults with a diagnosis of type 2 diabetes, living on or near the reservation, and self-identifying as American Indian (mean age = 46.3; n = 191).

RESULT

Structural equation modeling illustrates that language use in the home is associated with positive mental health through spiritual connectedness.

CONCLUSION

Results support tribal community expressions of the positive effects of cultural involvement for Indigenous wellbeing, and improve what is known about the interconnectedness of language and spirituality. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Dissecting systemic racism: policies, practices and epistemologies creating racialized systems of care for Indigenous peoples

In this paper we explore some of the ways systemic racism operates and is maintained within our health and social services. We look at a very specific context, that of Nunavik Quebec, land and home to 13,000 Nunavimmiut, citizens of Quebec and Canada, signatories of the James Bay and Northern Quebec Agreement. We operationalize some of the ways in which policies and practices create and support social hierarchies of knowledges, also called epistemic racism, and how it impacts our ability to offer quality care that Indigenous peoples can trust and use.

Patient ethnicity and cascade genetic testing: a descriptive study of a publicly funded hereditary cancer program

Cascade genetic testing for hereditary cancer is highly accurate and cost-effective for identifying individuals at high risk for cancer; however, not all eligible people utilize this service. While sociodemographic factors related to the uptake of cascade genetic testing, such as age and sex, have been fairly well described in the literature, there is limited data available regarding patient ethnicity. We analyzed four years of testing data for this factor, as well as sex, age and genes tested. The patients were seen by the Hereditary Cancer Program of BC Cancer, which serves the entire population of British Columbia and Yukon, Canada. Patient ethnicity was compared to the 2016 Census data from the same region. Fisher's exact test was conducted to explore the cascade genetic testing uptakes. Chi-square test was used to compare the major ethnicity groups to Census data. There was significant variability in the uptake of cascade genetic testing in the three largest population groups (p < 0.05), with individuals of European ethnic origin overrepresented, individuals of Asian ethnic origin modestly underrepresented, and individuals of North American Indigenous origin considerably underrepresented for cascade genetic testing. The proportions represented compared to those expected from census data were significantly different for these three largest groups (p < 0.01). The majority of cascade genetic tests were for BRCA1/BRCA2 (58.8%), followed by 16.9% for Lynch syndrome genes. Most patients were female (70%), and the mean age of patients was 49 years old. This study provides further insight into uptake of cascade genetic testing by patient ethnicity. Examining patient ethnicity and cascade genetic testing rates helps to identify underserved populations. Our analysis highlights significant underrepresentation of North American Indigenous individuals for hereditary cancer cascade genetic testing, and helps recognize the need for development of culturally-safe alternatives to outreach and service promotion.

Coming of age: 21 years of providing opioid substitution treatment within an Aboriginal community-controlled primary health service

In Australia, Aboriginal and Torres Strait Islander community controlled health services have been established since 1971 to provide accessible, quality and culturally-appropriate primary healthcare. The first of these services, the Aboriginal Medical Service Cooperative Redfern ('the AMS'), created its own Drug and Alcohol Unit ('the Unit') in 1999. The Unit initially prescribed opioid substitution treatment (OST) and its coordinator, Bradley Freeburn, a Bundjalung man, provided counselling. Soon afterwards, the Unit started dispensing OST. It now cares for around 150 individuals, each of whom is understood in the context of family, community and culture. The Unit is on the same site as the AMS's primary care service, specialised medical and mental health clinics, and dental clinic. This allows for integrated physical and mental health care. The Unit contributes to drug and alcohol workforce development for other AMS staff, state-wide and nationally. Several Aboriginal and Torres Strait Islander community controlled health services around Australia now offer OST prescription, and a small number administer slow-release buprenorphine. We are not aware of others that dispense Suboxone. In the USA and Canada, over the last 10 years, First Nations communities have also responded to lack of treatment access, by creating standalone OST clinics. We were not able to find examples of Māori-controlled OST clinics in Aotearoa, New Zealand. The feasibility of this model of readily accessible OST, situated within a holistic, culturally-grounded primary health-care service recommends it for consideration and evaluation, for Indigenous or non-Indigenous communities.

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.

A process of healing for the Labrador Innu: Improving health and wellbeing in the context of historical and contemporary colonialism

In light of the negative effects of historical and contemporary colonialism on the Labrador Innu, healing initiatives grounded in self-determination, renewal of cultural practices, and non-reliance on Western bio-medicine, are known, taught and widely practiced among the Innu. The value of Indigenous healing practices in the treatment of Indigenous people is well-recognized in Indigenous wellness literature, yet non-Indigenous health practitioners know little about healing processes. Moreover, to our knowledge, no studies have examined any contemporary Labrador Innu healing process. The main aim of this paper is to describe the process of healing among the Innu. Although there may be multiple processes of healing, we shed light on a major process that emerged from interviews and focus groups with 39 participants. Five stages of healing were described: being "under the blanket"; finding spiritual strength; extending hands out; finding strength and power; and helping others. Findings highlighted enablement of healing through spiritualities, support from Elders, return to culture, and resistance to negative stereotypes. We provide health professionals with valuable information for considering Innu healing as a model that expands their views for the benefit of Innu seeking mental health services. Implications for non-Innu health and social service providers are about broadening their understanding of the significant role of self-determination among Innu, learning Innu ways-of-knowing and being, recognizing one's own biases, and acknowledging the power imbalances between themselves and Innu people.

A study protocol for a quasi-experimental community trial evaluating the integration of indigenous healing practices and a harm reduction approach with principles of seeking safety in an indigenous residential treatment program in Northern Ontario

Background

Indigenous communities in Canada face significant challenges with intergenerational trauma, which manifests in substance use disorders. There is consensus that connecting treatment approaches to culture, land, community, and spiritual practices is a pathway to healing trauma and substance use disorders for Indigenous peoples. Indigenous residential addiction treatment programs have been established as the primary intervention to provide healing for Indigenous peoples with substance use disorders and intergenerational trauma. However, there is limited evidence demonstrating the effectiveness of these programs. In collaboration with the Benbowopka Treatment Centre, this paper describes a study protocol which aims to evaluate the effectiveness of blending Indigenous Healing Practices and Seeking Safety for the treatment of Indigenous patients with intergenerational trauma and substance use disorders.

Methods

We will conduct a pre/post Quasi Experimental Community trial, to compare historical treatment outcomes for patients following the implementation of Indigenous Healing and Seeking Safety. We will conduct quantitative and qualitative analyses to understand the differences before and after the intervention is implemented. The pre- Indigenous Healing and Seeking Safety intervention study window will span from 2013 to 2016; n = 343, and the post-Indigenous Healing and Seeking Safety intervention study window from 2018 to 2020; n > 300. All participants will be enrolled in the Benbowopka residential treatment for the first time during the study periods. All data will be anonymized at the time of data entry. Propensity matching will be undertaken for patient characteristics, including sex/gender, age, and substance use type.

Results and conclusions

The study findings could be used to inform intergenerational trauma and substance use disorders residential treatment programming for Indigenous communities across Canada. Our work will contribute to the field of community-based intergenerational trauma and substance use disorders programming by addressing objectives that consider: (a) the patient perspective, (b) the program perspective, and (c) the community perspective. The study findings may validate an innovative approach for evaluating the effectiveness of residential addiction treatment and particularly the effective and appropriate care for Indigenous patients with intergenerational trauma and substance use disorders.

Addiction peer recovery coach training pilot: assessment of confidence levels

BACKGROUND

Peer recovery coaches (PRCs) have become a critical tool in addiction treatment in many areas of the world. Despite this fact, no identified research has examined the process or impact of PRC training. Furthermore, no scales were identified to measure trainee confidence in various PRC techniques. The goal of this article is to analyze the process and immediate impact of PRC training of twelve American Indians (AIs) in a culturally-specific program. We focus most specifically on trainee confidence levels.

METHODS

No written consent was obtained and completion of the assessment was considered consent. Trainees completed self-assessments before and after the training. The self-assessment examined nine areas ranging from understanding the role of PRCs to knowledge of effective PRC techniques. Paired t-tests were used to assess for changes in individual trainee responses between the pre- and post-assessments.

RESULTS

Pre-training responses ranged from moderate to high. Questions with the lowest average confidence levels address PRC activities or specific techniques to facilitate recovery. All nine questions showed statistically significant mean improvements in the post-training self-assessments. Questions regarding specific PRC activities and techniques showed the greatest improvement. Questions relating to helping people more generally showed the smallest improvement. Average post-training responses fell within a very narrow range indicating relatively consistent confidence levels across skills. Analysis indicates participants were possibly over-confident in certain areas (i.e., maintaining boundaries). This small pilot represents an initial attempt to measure confidence levels of PRC trainees. The findings may inform future training by identifying certain areas where emphasis might be most helpful for trainees. In addition, it is hoped that this work will encourage more systematic analysis of the impact of PRC training on individuals.

Tobacco cessation in low- to middle-income countries: A scoping review of randomized controlled trials

OBJECTIVE

The growing prevalence of tobacco use in low "to middle" income countries (LMICs) and the hurdles of conducting tobacco cessation in that context necessitates a focus on the scope of randomized controlled trials (RCTs) in LMICs to guide tobacco cessation in this environment. We conducted a scoping review to identify LMIC tobacco cessation RCTs.

METHODS

Consistent with PRISMA-ScR guidelines and without language restrictions, we systematically searched peer-reviewed databases (MEDLINE, Embase, PsycINFO, articles published since inception, latest searches in March 2020) and gray literature (clinical trials registries, searches between September and December 2019). We searched for data on RCT type, outcome significance and intervention description. Inclusion: research conducted in LMICs; tobacco cessation; RCT. Exclusion: research conducted in high income countries; non-RCT; studies involving only those aged <18. Data was extracted from published reports. We generated narrative summaries of each LMIC's tobacco cessation RCT research environment.

RESULTS

Of 8404 articles screened, we identified 92 studies. Tobacco cessation RCTs were recorded in 16 of 138 countries/territories in LMICs. Evidence was weak in quality and severely limited. Most RCTs were psychosocial, with limited behavioral and pharmacological variants.

CONCLUSIONS

Tobacco control within LMICs is essential to reduce the tobacco mortality burden. Researchers should be cognizant that tobacco cessation in LMICs is still not an environment where best practice has been established. We suggest that developing solutions specific for LMICs is key to effective tobacco control in LMICs.

Recovery in Special Emphasis Populations

Special emphasis populations in the current context can be defined as groups experiencing health disparities resulting in elevated risk to health, safety, and well-being from drinking alcohol. Individuals from marginalized minority populations often encounter barriers to accessing and receiving effective alcohol treatment due to social inequities and disadvantaged life contexts, which also may adversely affect recovery from alcohol use disorder (AUD). Recovery from AUD often involves the adoption of a stable non-drinking lifestyle (sobriety), increased health and well-being, and increased social connection. Although there has been considerable work on AUD epidemiology among special emphasis populations, little research exists directly examining recovery among racial/ethnic minority populations and/or sexual and gender minority populations. The current narrative review hopes to spark scholarly interest in this critically neglected area. This article opens with a review of special emphasis populations and their alcohol-related risks. Next, definitions of recovery, Alcoholics Anonymous, and culturally adapted recovery models for racial/ethnic minority populations are explored. This is followed by a discussion of factors that may particularly influence recovery among marginalized minority populations. This narrative review concludes with a discussion of research priorities for promoting health equity through studies focused on understanding and supporting recovery from AUD among marginalized minority populations.

Commentary on the impact of the COVID-19 pandemic on opioid use disorder treatment among Indigenous communities in the United States and Canada

This commentary focuses on how some Indigenous communities in the United States (U.S.) and Canada are addressing the opioid epidemic within the context of the COVID-19 pandemic, from the perspective of the co-authors as researchers, clinicians, and pharmacists working within or among Indigenous communities in three eastern Canadian provinces and two western U.S. states. The pandemic has likely exacerbated opioid use problems among Indigenous communities, especially for individuals with acute distress or comorbid mental illness, or who are in need of withdrawal management or residential services. In response to the pandemic, we discuss first how greater prescription flexibility has facilitated and even increased access to medications for opioid use disorder. Second, we describe how Indigenous-serving clinics have expanded telemedicine services, albeit not without some challenges. Third, we note challenges with restricted participation in traditional Indigenous healing practices that can be helpful for addiction recovery. Fourth, we mention providers' worries about the pandemic's impact on their patients' mental health and safety. We argue that certain treatment transformations may be helpful even after the pandemic is over, through enhancing access to community-grounded treatment, decreasing stigma, and promoting patient self-efficacy.

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COVID-19 pandemic has challenged opioid use treatment for Indigenous peoples.

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Treatment has been aided through expanded telemedicine and prescription flexibility.

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These adjustments may expand future treatment access to Indigenous communities.

Kaumātua Mana Motuhake Pōi: a study protocol for enhancing wellbeing, social connectedness and cultural identity for Māori elders

BACKGROUND

The Aotearoa New Zealand population is ageing accompanied by health and social challenges including significant inequities that exist between Māori and non-Māori around poor ageing and health. Although historically kaumātua (elder Māori) faced a dominant society that failed to realise their full potential as they age, Māori culture has remained steadfast in upholding elders as cultural/community anchors. Yet, many of today's kaumātua have experienced 'cultural dissonance' as the result of a hegemonic dominant culture subjugating an Indigenous culture, leading to generations of Indigenous peoples compelled or forced to dissociate with their culture. The present research project, Kaumātua Mana Motuhake Pōī (KMMP) comprises two interrelated projects that foreground dimensions of wellbeing within a holistic Te Ao Māori (Māori epistemology) view of wellbeing. Project 1 involves a tuakana-teina/peer educator model approach focused on increasing service access and utilisation to support kaumātua with the greatest health and social needs. Project 2 focuses on physical activity and cultural knowledge exchange (including te reo Māori--Māori language) through intergenerational models of learning.

METHODS

Both projects have a consistent research design and common set of methods that coalesce around the emphasis on kaupapa kaumatua; research projects led by kaumātua and kaumātua providers that advance better life outcomes for kaumātua and their communities. The research design for each project is a mixed-methods, pre-test and two post-test, staggered design with 2-3 providers receiving the approach first and then 2-3 receiving it on a delayed basis. A pre-test (baseline) of all participants will be completed. The approach will then be implemented with the first providers. There will then be a follow-up data collection for all participants (post-test 1). The second providers will then implement the approach, which will be followed by a final data collection for all participants (post-test 2).

DISCUSSION

Two specific outcomes are anticipated from this research; firstly, it is hoped that the research methodology provides a framework for how government agencies, researchers and relevant sector stakeholders can work with Māori communities. Secondly, the two individual projects will each produce a tangible approach that, it is anticipated, will be cost effective in enhancing kaumātua hauora and mana motuhake.

TRIAL REGISTRATION

Australia New Zealand Clinical Trial Registry ( ACTRN12620000316909 ). Registered 6 March 2020.

What can primary care services do to help First Nations people with unhealthy alcohol use? A systematic review: Australia, New Zealand, USA and Canada

Background

First Nations peoples of Australia, New Zealand, the United States of America (USA) and Canada are more likely to be non-drinkers than other people in these countries. However, those who do drink may be at greater risk of alcohol-related harms (at a population level) due to the ongoing impacts from colonisation and associated oppression. Addressing unhealthy drinking (drinking above recommended limits including alcohol use disorders) in primary care settings is one important way to increase accessibility of treatment.

Methods

This systematic review identifies peer-reviewed studies of alcohol treatments delivered in primary care or other non-residential settings for First Nations peoples of Australia, New Zealand, USA and Canada. Literature searches were conducted in seven academic databases from their inception until March, 2020. We assessed evidence of treatment or implementation effectiveness, perceived acceptability or accessibility, and the study quality as assessed by the AXIS tool and by a measure of community participation in the research process.

Results

Twenty-eight studies were included, published between 1968 and 2018. Studies reported on a range of alcohol treatments, from brief intervention to ambulatory withdrawal management, relapse prevention medicines, and cultural therapies. Brief intervention was the most studied approach. Cultural healing practices and bicultural approaches were a key theme amongst several studies. Four studies measured treatment effectiveness, including one randomised controlled trial (naltrexone vs naltrexone plus sertraline vs placebo) and two uncontrolled trials of disulfiram. Of the six implementation studies, three were (hybrid) effectiveness-implementation designs. Most of the remaining studies (n = 21) focused on treatment accessibility or acceptability. Community participation in the research process was poorly reported in most studies.

Conclusions

Research evidence on how best to care for First Nations peoples with unhealthy alcohol use is limited. Trials of naltrexone and disulfiram presented promising results. Cultural and bicultural care were perceived as highly important to clinical staff and clients in several studies. More effectiveness studies on the full scope of alcohol treatments are needed. Greater community participation in research and more transparent reporting of this in study methods will be key to producing quality research that combines scientific rigour with cultural appropriateness.

Traditional Indigenous medicine in North America: A scoping review

Background

Despite the documented continued use of traditional healing methods, modalities and its associated practitioners by Indigenous groups across North America, it is presumed that widespread knowledge is elusive amongst most Western trained health professionals and systems. This despite that the approximately 7.5 million Indigenous peoples who currently reside in Canada and the United States (US) are most often served by Western systems of medicine. A state of the literature is currently needed in this area to provide an accessible resource tool for medical practitioners, scholars, and communities to better understand Indigenous traditional medicine in the context of current clinical care delivery and future policy making.

Methods

A systematic search of multiple databases was performed utilizing an established scoping review framework. A consequent title and abstract review of articles published on traditional Indigenous medicine in the North American context was completed.

Findings

Of the 4,277 published studies identified, 249 met the inclusion criteria divided into the following five categorical themes: General traditional medicine, integration of traditional and Western medicine systems, ceremonial practice for healing, usage of traditional medicine, and traditional healer perspectives.

Conclusions

This scoping review was an attempt to catalogue the wide array of published research in the peer-reviewed and online grey literature on traditional Indigenous medicine in North America in order to provide an accessible database for medical practitioners, scholars, and communities to better inform practice, policymaking, and research in Indigenous communities.

La Cultura Cura: Latino Culture, Shared Experiences, and Recovery in Northern Californian Anexos

This article examines the anexo's use of Latino culture and shared experiences to promote recovery and its appeal to 1.5- and second-generation Latinos. Anexos are grassroots recovery groups with origins in Mexico that offer a residential Alcoholics Anonymous program in Latino communities. Data were gathered from a two-year (2014-2016) ethnographic study of anexos in Northern California and were analyzed thematically. Despite having access to publicly funded treatment, many 1.5- and second-generation Latinos accessed anexos based on cultural familiarity, shared experiences, and a desire to recuperate cultural practices lost during their substance use.

"Being on the Walk Put It Somewhere in My Body": The Meaning of Place in Health for Indigenous Women

Relationship to place is integral to Indigenous health. A qualitative, secondary phenomenological analysis of in-depth interviews with four non-Choctaw Indigenous women participating in an outdoor, experiential tribally-specific Choctaw health leadership study uncovered culturally grounded narratives using thematic analysis as an analytic approach. Results revealed that physically being in historical trauma sites of other Indigenous groups involved a multi-faceted process that facilitated embodied stress by connecting participants with their own historical and contemporary traumas. Participants also experienced embodied resilience through connectedness to place and collective resistance. Implications point to the role of place in developing collective resistance and resilience through culturally and methodologically innovative approaches.