Elevating the uses of storytelling approaches within Indigenous health research: a critical and participatory scoping review protocol involving Indigenous people and settlers

Barriers and unmet needs related to healthcare for American Indian and Alaska Native communities: improving access to specialty care and clinical trials

Substantial healthcare barriers, especially to specialty and cancer care, exist for American Indian and Alaska Native (AI/AN) individuals and communities at all levels. The unique history of AI/AN Tribal Nations and resulting policies, treaties, and relationships with the US government and federal agencies have created specific barriers to healthcare and clinical trial access for AI/AN peoples. Commonly, AI/AN peoples harbor a long-standing mistrust of the healthcare system based on lived and historical experiences. The intersection of various barriers to care for AI/AN communities results in health inequities, lack of representation in clinical research, and other disparities faced by historically marginalized and underrepresented peoples. AI/AN patients face unique barriers in their healthcare journey due to a disproportionate burden of life-threatening and chronic diseases, including many cancers. Identifying barriers specific to AI/AN peoples and improving access to high-quality care, with a focus on building on the strengths and capacities in each AI/AN community are vital to improving health equity. In this review, we describe patient, provider, and institutional barriers to healthcare, particularly specialty care and clinical research, for AI/AN peoples, with a focus on the Northern Plains AI communities. Examples and best practices to improve AI/AN patient access to health services, including screening and specialty care, as well as to clinical research, are provided. We emphasize the importance of longitudinal community-based partnerships and strength- and trust-based approaches as essential components of promoting equitable access to high-quality specialty care and recruitment and participation of AI/AN individuals and communities in clinical research.

Predictors of Supportive Care Needs During Serious Illness: Cross-sectional Analysis of Reservation-Based Informal Caregivers

Native Americans (Indigenous Americans) have high rates of serious illness in the United States. Informal caregivers are heavily relied on in caring for patients in low-resource settings. The needs of caregivers residing on reservations are sorely underreported. Therefore, our objective was to examine relationships between facilitators (communal mastery, cultural identity, and spirituality) and barriers (depression, anxiety, stress, and burden) with supportive care needs among adult informal caregivers in 1 reservation-based community. A cross-sectional survey was distributed in July and August 2022 as part of a larger multimethod, community-based participatory research study. We used descriptive statistics and linear regression models to examine relationships against the primary outcome, the Supportive Care Needs Assessment Tool for Indigenous People. Overall, 127 participants were included; most were female (n = 92, 72.4%), were between 30 and 49 years (n = 57, 44.9%), and had 6 months or less of caregiving experience (n = 41, 32.5%). Higher depression, anxiety, stress, and burden were significantly associated with higher Supportive Care Needs Assessment Tool for Indigenous People scores. Overall, mental health is a significant barrier that may indicate greater supportive care needs among informal caregivers, although further work is needed to differentiate symptoms and their impact on caregiving from a cultural perspective.

Community-engaged implementation of a safety bundle for pregnancy-related severe hypertension in the outpatient setting: protocol for a type 3 hybrid study with a multiple baseline design

BACKGROUND

Hypertensive disorders of pregnancy are among the leading causes of maternal mortality and morbidity in the U.S., with rates highest among birthing people who are Black, rural residents, and/or have low-income. Severe hypertension, in particular, increases risk of stroke and other serious pregnancy complications. To promote early detection and treatment of severe hypertension, the Alliance for Innovation on Maternal Health developed the Severe Hypertension During Pregnancy and Postpartum Period Safety Bundle (HTN Bundle). Multiple studies have demonstrated the HTN Bundle's effectiveness in the inpatient setting. With funding from the National Heart, Lung, and Blood Institute, we engaged community partners to adapt the HTN Bundle for the outpatient setting (i.e., O-HTN Bundle) and planned for its implementation. In this paper, we describe the protocol for a study evaluating O-HTN Bundle implementation in 20 outpatient clinics serving Black, rural, and/or low-income populations.

METHODS

This study is a hybrid type 3 effectiveness-implementation trial with a multiple baseline design. We will implement the O-HTN Bundle in three successive cohorts of clinics using a multicomponent implementation strategy to engage community partners (coalition, patient workgroup) and support clinics (training, facilitation, education materials, and simulations of severe hypertension events). To test the strategy, we will compare clinic fidelity to evidence-based guidelines for (a) patient education on hypertension and (b) blood pressure measurement technique, with repeated measures occurring before and after strategy receipt. We will also observe strategy effects on community- and clinic-level intermediate outcomes (community engagement, organizational readiness), implementation outcomes (reach, adoption, fidelity, maintenance), and effectiveness outcomes (receipt of guideline concordant care). Analyses will address whether outcomes are equitable across Black, rural, and/or low-income subgroups. Guided by the Consolidated Framework for Implementation Research 2.0, we will use mixed methods to identify adaptations and other determinants of implementation success.

DISCUSSION

This study integrates community engagement and implementation science to promote equitable and timely response to severe HTN in the outpatient setting during pregnancy and postpartum. This is one of the first studies to implement an outpatient HTN Bundle and to use simulation as a strategy to reinforce team-based delivery of guideline concordant care.

TRIAL REGISTRATION

This study was registered with ClinicalTrials.gov as "Testing Implementation Strategies to Support Clinic Fidelity to an Outpatient Hypertension Bundle (AC3HIEVE)." Registration number NCT06002165, August 21, 2023: https://clinicaltrials.gov/study/NCT06002165 .

The Role Nurses Can Play in Addressing and Preventing the Prevalence of Missing or Murdered Indigenous Women and Girls (MMIWG)

INTRODUCTION

In 2016, 5,712 American Indian/Alaskan Native (AI/AN) women and girls were reported missing in the United States. In Canada, 4% of the population is Indigenous, yet Indigenous females represent 50% of all sex trafficking victims. This systematic mixed-studies review examined the effects of Missing and Murdered Indigenous Women and Girls (MMIWG) to define a role for nurses.

METHODS

We used five databases with keywords, inclusion criteria, and the Mixed Methods Appraisal Tool.

RESULTS

Findings of 22 papers discuss: (a) demographic data; (b) factors that increase vulnerability of AI/AN women; and (c) how nurses can decrease the prevalence of MMIW.

DISCUSSION

Nurses are the first provider patients see when accessing care. Increasing knowledge about the impact of violence against AI/AN women and girls is the first step in identifying measures needed to address this public health concern.

Informing the Co-Development of Culture-Centered Dietary Messaging in the Inuvialuit Settlement Region, Northwest Territories

Northern Indigenous communities require collaborative approaches to health communication about food that are grounded in Indigenous knowledges and cultures; however, preferences and best methods for this process remain understudied. This participatory study discusses how Inuvialuit (Inuit from the Western Arctic) knowledge and the perspectives of territorial, regional, and local dietary message stakeholders can inform the co-development of culture-centered dietary messaging to support healthy, safe, and culturally appropriate diets in Tuktoyaktuk, NWT. A community researcher in Tuktoyaktuk conducted storytelling interviews with country food knowledge holders (n = 7) and community members (n = 3), and a talking circle with local public health dietary message disseminators (n = 2) in June-July 2021. The lead author conducted key informant telephone and videoconference interviews with territorial and regional dietary message disseminators (n = 5) in June 2021. Interviews were coded and analyzed thematically. Our findings indicate that participants at all levels support increased inclusion of cultural and community perspectives about food to develop regionally and locally tailored dietary messaging. While most dietary message stakeholders wish to be involved in co-development processes, some country food knowledge holders in Tuktoyaktuk expressed a desire to lead local communications about country foods. Informed by participants' experiences and needs, we provide recommendations for future community-led approaches to further (co-)develop and communicate effective, culturally meaningful dietary messaging that promotes Inuvialuit food sovereignty.

A strengths-based approach to exploring diabetes management in an Indigenous minority population: A mixed methods study

Indigenous and other marginalized racial/ethnic minorities have poorer health status than majority populations, including higher rates of type 2 diabetes. These disparities have typically been addressed using a 'deficit-based' discourse that isolates disease management from the broader social, economic, political context and does not incorporate patient perspectives. We aimed to explore factors affecting glycemic control among Indigenous Arabs with diabetes in Israel using a strengths-based approach that centered participants' knowledge of their context, needs, resources and strengths. We conducted an exploratory sequential mixed methods study, which included 10 focus groups (5 men's, 5 women's) and 296 quantitative in-person surveys. Participants with diagnosed diabetes were randomly drawn from the patient list of the largest healthcare service organization (survey response rate: 93%). Prominent and interconnected themes emerged from focus group discussions, including: diet, physical activity, and social, economic, mental/psychological and political stress. The discussions raised the need for adapting diabetes management approaches to incorporate participants' communal, physical and psychological well-being, and socioeconomic/political realities. The connections between these factors and diabetes management were also reflected in multivariable analyses of the survey data. Women (OR: 2.03; 95% CI: 1.09-4.63), people with disabilities (OR: 2.43; 95% CI: 1.28-4.64), and unemployed people (OR: 2.64; 95% CI: 1.28-5.44) had higher odds of economic barriers to diabetes management. Furthermore, female sex (OR: 2.26; 95% CI: 1.25-4.09), unemployment (OR: 4.07; 95% CI: 1.64-10.10), and suboptimal glycemic control (OR: 1.20, 95% CI: 1.03-1.41 per 1-unit increase in HbA1c) were associated with moderate-to-severe depressive symptoms. A pro-active, team-based healthcare approach incorporating Indigenous/minority participants' knowledge, experience, and strengths has the potential to improve individuals' diabetes management. Healthcare services should be structured in ways that enable providers to listen to their patients, address their key concerns, and foster their strengths.

Digital Storytelling as a Patient Engagement and Research Approach With First Nations Women: How the Medicine Wheel Guided Our Debwewin Journey

When research is conducted from a Western paradigm alone, the findings and resultant policies often ignore Indigenous peoples' health practices and fail to align with their health care priorities. There is a need for decolonized approaches within qualitative health research to collaboratively identify intersecting reasons behind troubling health inequities and to integrate Indigenous knowledge into current health care services. We engaged with First Nations women to explore to what extent digital storytelling could be a feasible, acceptable, and meaningful research method to inform culturally safe health care services. This novel approach created a culturally safe and ethical space for authentic patient engagement. Our conversations were profound and provided deep insights into First Nations women's experiences with breast cancer and guidance for our future qualitative study. We found that the digital storytelling workshop facilitated a Debwewin journey, which is an ancient Anishinabe way of knowing that connects one's heart knowledge and mind knowledge.

Reclaiming Mountain Lake: Applying environmental repossession in Biigtigong Nishnaabeg territory, Canada

The concept of environmental repossession responds to a global movement led by Indigenous peoples to reclaim their territories and ways of life. As Indigenous wellness is intimately tied to relationships to land, processes of environmental repossession are a means to revitalize knowledge systems, identities and relationships that foster strong and healthy communities. Due to historic and ongoing forces of dispossession, the Anishinaabe community of Biigtigong Nishnaabeg has experienced limited access to Mountain Lake, a culturally and historically significant place in their ancestral territory. In the summer of 2018, the Chief and Council of Biigtigong constructed two cabins along the shores of Mountain Lake for community use and, one year later, hosted a week-long camp to bring Elders, youth and band staff together in this place. Drawing from 15 in-depth interviews with participating community members, this study documented the planning and implementation of the cabins and camp at Mountain Lake and examined the community meanings of this process. The findings suggest that the cabins and camp functioned as a local process of environmental repossession through multiple and interconnected steps to reclaim access to Mountain Lake, reintroduce the community to this place and begin remaking community relationships to this land. As Indigenous communities globally seek to reclaim their territories and rights to land, this article speaks to the tensions of this work and the structures that support its practice locally.