Barriers and Mitigating Strategies to Healthcare Access in Indigenous Communities of Canada: A Narrative Review

An Exploration of the Goodness of Fit of Web-Based Tools for Māori: Qualitative Study Using Interviews and Focus Groups

BACKGROUND

Indigenous communities often have poorer health outcomes and services under traditional models of care. In New Zealand, this holds true for Māori people who are tāngata whenua (the indigenous people). Several barriers exist that decrease the likelihood of indigenous communities often have poorer health outcomes and poor service fit under traditional models of care, including access issues, systemic and provider racism, and a lack of culturally safe and responsive services. Web-based interventions (WBIs) have been shown to be effective in supporting mental health and well-being and can overcome some of these barriers. Despite the large number of WBIs developed, more investigation is needed to know how well WBIs fit with an indigenous worldview and how they meet the needs of indigenous communities so that a digitally based future does not drive social and health inequities.

OBJECTIVE

This study aims to explore the goodness-of-fit of WBIs of Māori individuals, the indigenous people of Aotearoa/New Zealand.

METHODS

We used interviews (n=3) and focus groups (n=5) with 30 Māori participants to explore their views about WBIs. Interviews were analyzed using reflexive thematic analysis by members of the research team.

RESULTS

Overall, there was a perception that the design of WBIs did not align with the Māori worldview, which centers around people, relationships, spirituality, and holistic views of well-being. A total of 4 key themes and several subthemes emerged, indicating that WBIs were generally considered a poor fit for Māori. Specifically, the themes were as follows: (1) WBIs are disconnected from the core values of te ao Māori (the Māori worldview), (2) WBIs could be helpful in the right context, (3) there are significant barriers that may make it harder for Māori to use WBIs than other groups, and (4) ways to improve WBIs to help engagement with Māori.

CONCLUSIONS

While WBIs are often considered a way to reduce barriers to care, they may not meet the needs of Māori when used as a stand-alone intervention. If WBIs are continued to be offered, developers and researchers need to consider how to develop WBIs that are responsive and engaging to the needs of indigenous communities rather than driving inequities. Ideally, WBIs should be developed by the people they are intended for to fit with those populations' world views.

Advancing health equity for Indigenous peoples in Canada: development of a patient complexity assessment framework

BACKGROUND

Indigenous patients often present with complex health needs in clinical settings due to factors rooted in a legacy of colonization. Healthcare systems and providers are not equipped to identify the underlying causes nor enact solutions for this complexity. This study aimed to develop an Indigenous-centered patient complexity assessment framework for urban Indigenous patients in Canada.

METHODS

A multi-phased approach was used which was initiated with a review of literature surrounding complexity, followed by interviews with Indigenous patients to embed their lived experiences of complexity, and concluded with a modified e-Delphi consensus building process with a panel of 14 healthcare experts within the field of Indigenous health to identify the domains and concepts contributing to health complexity for inclusion in an Indigenous-centered patient complexity assessment framework. This study details the final phase of the research.

RESULTS

A total of 27 concepts spanning 9 domains, including those from biological, social, health literacy, psychological, functioning, healthcare access, adverse life experiences, resilience and culture, and healthcare violence domains were included in the final version of the Indigenous-centered patient complexity assessment framework.

CONCLUSIONS

The proposed framework outlines critical components that indicate the presence of health complexity among Indigenous patients. The framework serves as a source of reference for healthcare providers to inform their delivery of care with Indigenous patients. This framework will advance scholarship in patient complexity assessment tools through the addition of domains not commonly seen, as well as extending the application of these tools to potentially mitigate racism experienced by underserved populations such as Indigenous peoples.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

What supports and services post COVID-19 do children with disabilities and their parents need and want, now and into the future?

Introduction

Children and youth with disabilities and special healthcare needs, and their families, have been uniquely affected by the COVID-19 pandemic. However, the voices of children themselves are still not well represented in the existing literature.

Methods

This qualitative descriptive study used a combination of visual methods and interviews to learn about the experiences of Canadian children with disabilities (n=18) and their parents (n=14) during the COVID pandemic and into the post-pandemic period. Data collection was carried out between January and July 2023. The aim was to identify the supports and services children and families need at present and moving forward.

Results

Families' pandemic experiences were complex and nuanced. For many, the pandemic complicated and disrupted everyday activities and supports. These disruptions were largely buffered by parents. However, some families also identified unexpected benefits. Key themes pertaining to present and future needs included the need for services that are flexible; consistent; conducive to relationship-building; comprehensive; coordinated across sectors; and designed to support the needs of the whole family.

Discussion

Implications for policy and practice are outlined.

GRAND PLAN: Safety and Efficacy of Glecaprevir/Pibrentasvir for the Treatment of Hepatitis C Virus Infection Among People Initially Disengaged From Health Care Who Use Drugs-A Systematic Multidisciplinary Approach

Background

GRAND PLAN is a prospective, open-label, phase 4 study. Based at a single center and with a single arm, GRAND PLAN evaluated the safety and efficacy of an 8-week course of glecaprevir/pibrentasvir (G/P) among active drug users with hepatitis C virus (HCV) infection in a population enriched for factors that may reduce treatment uptake and success, such as disengagement from health care and unstable housing.

Methods

Participants were ≥19 years old and actively using drugs and were confirmed viremic, noncirrhotic, and HCV treatment naive. All participants provided informed consent before any study procedures. They received G/P for 8 weeks within a multidisciplinary model of care, with daily, weekly, or monthly dispensing of medications to optimize adherence.

Results

We identified 117 eligible patients with a median age of 46 years (range, 22-75): 27% were female, 21.4% were Indigenous, 48.7% were unstably housed, and 95.7% were active drug users (94.9% fentanyl). One patient did not start treatment, and 4 underwent <1 week of treatment, leaving 112 completed treatments with 94.6% picking up medications weekly. HCV RNA was undetectable at the end of treatment in all 112 patients. One died of unknown causes shortly after treatment. A cure was demonstrated in 108 of 111 (97.3%) cases at the SVR12 time point (sustained virologic response at ≥12 weeks); the other 3 experienced virologic relapse. Considering the entire cohort, the intent-to-treat success rate was 92.3% (108/117). HCV reinfection was documented at SVR24 in 5 cases, 2 of which were successfully retreated.

Conclusions

GRAND PLAN demonstrates that administration of an 8-week course of G/P to inner-city residents with HCV infection leads to a cure >95%. With a short course of treatment, G/P is an attractive option for this population in helping us achieve the World Health Organization's HCV objectives by 2030.

Adapting the Community Paramedicine at Clinic (CP@clinic) program to a remote northern first nation community: a qualitative study of community members' and local health care providers' views

The views of community Elders and health care providers in a rural remote First Nation community in Ontario, Canada on their health care landscape and adapting the Community Paramedicine at Clinic (CP@clinic) Program to their community are presented. Key informant interviews took place between September 2020 and March 2021, and were thematically analysed using the Framework Hierarchical Analysis. There were seven themes that emerged with many subthemes: available services in the community, health care access, health challenges in community, causes of frailty, health care and community appreciations, community-specific benefits of CP@clinic, and CP@clinic program considerations for adaptation. CP@clinic program considerations for adaptation included defining the role of CP, refining referral processes to capture the target population, advertising and promoting, ensuring community awareness, determining clinic setting and composition, focusing on advocacy and timely continuity, adding to the program through time, managing resistance, engaging community and partners, deploying cultural training and language accommodations, leveraging community assets, and ensuring sustainability. Focusing on continuity, engagement, and leveraging available resources may support the success of the CP@clinic program implementation. Findings from this study may be useful to other underserved communities in Canada seeking health programming.

Identifying Research Priorities to Promote the Well-Being of Family Caregivers of Canadians with Intellectual and/or Developmental Disabilities: A Pilot Delphi Study

Current programming and resources aimed at supporting the well-being of family caregivers often fail to address considerations unique to those caring for people with intellectual and/or developmental disabilities (IDDs). As a result, many caregivers of people with IDD feel isolated, stressed, and burnt out. A targeted research agenda informed by key stakeholders is needed and would allow research teams to coordinate resources, talents, and efforts to progress family caregiver well-being research in this area quickly and effectively. To address this aim, this pilot study used a Delphi design based on 2 rounds of questionnaires. In round 1, 19 stakeholders (18 females, 1 male), including 12 family caregivers, 3 rehabilitation providers, 2 researchers, and 2 organizational representatives, identified broad areas for caregiver well-being research. After collating the responses from round 1, stakeholders were asked to rank whether each area was considered a research priority in round 2. Data were analyzed using descriptive statistics and conventional content analysis. Eighteen stakeholders completed the round 2 survey (1 caregiver did not complete the round 2 survey), after which a consensus was reached. Stakeholders identified nine broad priorities, including system-level programs and services, models of care, health promotion, social inclusion, equity and diversity, capacity building, care planning along the lifespan, and balancing formal and natural community-based supports. Although preliminary in nature, the research priorities generated using an inclusive and systematic process may inform future efforts to promote the well-being of caregivers of Canadians with IDD.

"I haven't even taken them to the doctors, because I have that fear of what to expect": a qualitative description study exploring perceptions and experiences of early childhood healthcare among ethnically diverse caregivers in Aotearoa New Zealand

Background

Equity underpins Aotearoa New Zealand's publicly funded healthcare system; however, ethnic inequality persists. This qualitative study explored the perceptions and experiences of ethnically diverse parents accessing health services for their children.

Methods

A qualitative description methodology informed interviews and focus groups that were conducted with caregivers of preschool aged children who identified as being of Māori, Pacific, Asian and/or European ethnicity (n = 145). Data were analysed following a reflexive thematic analytic approach.

Findings

Five themes were constructed. Hierarchies of knowledge and trust Caregivers relied on multiple sources of health information and particularly trusted providers or other caregivers who had children. Relational versustransactional health encounters Caregivers were often disappointed that health providers did not build trusting relationships to support positive experiences. Bad mother vibe Mothers often felt judged by providers when accessing care and felt pressure to conform. The 'slow burn' of waiting Caregivers were often frustrated by how slow and fragmented the health system was, which was particularly distressing if their child was unwell or required referral. Navigating complexity Caregivers had to be proactive and assertive to ensure their child received care amidst the numerous barriers they faced, including discrimination and bias. While many commonalities were shared by ethnicity, unique to Indigenous Māori caregivers were the ongoing colonial traumas that impacted their ability to trust the healthcare system.

Interpretation

A non-judgemental, competent, and culturally sensitive approach by healthcare professionals and services may help foster trusting relationships and positive health encounters. Strategies to improve trust, ease of access and navigation are needed to mitigate existing complexity, fragmentation, and counter-intuitive nature of the NZ healthcare system. Caregivers require more autonomy over decisions about their child's care and availability of services that reflect their cultural values. Policies are required to alleviate the indirect costs of accessing healthcare, prioritising of whānau/family-centred care, and addressing pervasive racism and bias within the system.

Funding

Health Research Council of New Zealand (19/263) .

NorthBEAT: exploring the service needs of youth experiencing early psychosis in Northern Ontario

Introduction

Early Psychosis Intervention (EPI) is critical for best outcomes. Among 369 diseases, psychosis is among those causing the greatest disability. Evidence-based interventions for youth in early stages of psychosis (EPI programs) have prevented chronic disability. Yet, EPI is frequently inaccessible for youth living in rural communities. Moreover, Indigenous youth often face more precipitous situations given inadequate staffing, and culturally unsafe care. The NorthBEAT (Barriers to Early Assessment and Treatment) project sought to understand the service needs of youth with psychosis in Northern Ontario. The goals were: (1) to describe the mental health of a subset of adolescents receiving EPI care; (2) examine Indigenous youth as a significant and vulnerable population; (3) to understand the barriers and facilitators for Indigenous and non-Indigenous youth receiving EPI.

Methods

Mixed methods (structured and narrative interviews) included: psychometric scales interviews with youth, and narrative interviews with youth, their family, and service providers Data validation workshops were held with participants.

Results

Structured interviews with 26 youth (M = 17 years) found the participants functioning moderately well with duration of untreated psychosis ranging from 1 to 96 months (M = 26 months). No significant differences were found in functioning or duration of psychosis between Indigenous and non-Indigenous youth. Narrative interviews were conducted with 18 youth, 11 family members, and 14 service providers. Identified barriers were a lack of knowledge about psychosis among service providers, a disconnected system leading to delays in treatment, help not wanted by youth, expansive geographical context. Service needs were: finding the right point of access, support for families, pre-crisis intervention, reduced stigma for youth and their families, and an EPI approach to care.

Discussion

Rural and northern youth face similar barriers to accessing EPI as urban youth. However, northern youth face additional unique challenges due to expansive geographical context, limited resources and lack of knowledge about services.

Identifying barriers to preventive care among First Nations people at risk of lower extremity amputation: a qualitative study

BACKGROUND

First Nations people in Canada are overrepresented among those who have undergone nontraumatic lower extremity amputation, and are more likely to be younger, have diabetic foot infections and have no previous revascularization procedures than non-First Nations populations who have undergone lower extremity amputations. We sought to identify access barriers for high-risk First Nations patients, explore patients' experiences with health care systems and identify solutions.

METHODS

Employing a community participatory research design, we engaged representatives from 2 communities. They assisted with research design and data analysis, and approved the final manuscript. Using a hermeneutic phenomenological approach and purposeful sampling, we conducted 5 semistructured focus groups between August and December 2021 with community health care teams and patients at risk for, or who had previously undergone, a nontraumatic lower extremity amputation.

RESULTS

Patients' (n = 10) and community health care providers' (n = 18) perspectives indicated that barriers to health care access led to delayed care and increased complications and risk for lower extremity amputations, leading to aggressive procedures upon receiving care. Barriers to care led to negative experiences at urban centres and aggressive procedures created further distrust, leading to care disengagement and poor outcomes. Patients and providers both suggested building stronger partnerships between urban and rural health care providers, improving education for patients and health care providers and identifying innovative strategies to improve patients' overall health.

INTERPRETATION

Systemic changes, health promotional program and reliable on-reserve primary care are needed to create equitable access for First Nation patients at risk for lower extremity amputations. The study results imply that health care delivery for First Nations patients at risk for lower extremity amputations can be improved through stronger partnership and communication between urban and community providers, and continued education and cultural competency training for urban health care providers.

Wellness Wheel Clinics: A First Nation community-partnered care model improving healthcare access, from healthcare providers' perspectives

First Nation people residing in rural and remote communities have limited primary healthcare access, which often affects chronic disease management leading to poor health outcomes. Individuals with lived experiences of chronic disease and substance use, along with health directors, advocated for improved services. Subsequently, an urban healthcare team in partnership with four First Nation communities developed an Outreach clinic to address healthcare access barriers. Established in 2016, this community-led clinic improves primary care access and chronic disease management in First Nation communities. Employing a qualitative research design, interviews were conducted with 15 clinic providers and 9 community members to explore the clinic's 1-year post-implementation impacts. Thematic data analysis indicated that engagement and approval by community leadership, support from Elders and community members and collaboration with existing community healthcare staff were crucial for establishing the Outreach clinic. Initial logistical challenges with space allocation, equipment, medical supplies, funding, staffing, medical records and appointment scheduling were resolved through community consultation and creative solutions. A nurse coordinator ensured continuity of care and was integral to ensuring clients receive seamless care. The commitment of the outreach team and the collective goal of providing client-centered care were instrumental in the clinic's success. In partnership with communities, access to healthcare in First Nation communities can be enhanced by coordinating Outreach clinics through existing community healthcare facilities.

Indigenous birth support worker (IBSW) program evaluation: a qualitative analysis of program workers and clients' perspectives

BACKGROUND

The Indigenous Birth Support Worker (IBSW) Program provides Indigenous women with respectful, culturally safe, and trauma-informed care and supports women and families during labor and delivery. Located in the Jim Pattison Children's Hospital (JPCH) Maternal Care Centre in Saskatoon, Saskatchewan, Canada, the program served 1023 clients between December 2019 and January 2021.

METHODS

The study objective was to explore the perspectives of the IBSWs and program clients one year post-implementation. The research plan was developed in collaboration with the IBSW program director and manager, IBSWs, and partners from the First Nation and Métis Health departments within the health region. A focus group with four IBSWs and individual interviews with ten clients who received services were conducted using a qualitative research design.

RESULTS

Thematic analysis revealed that clients greatly appreciated and respected the IBSWs' cultural support and their compassionate, nonjudgmental, and safe care. IBSWs emphasized the importance of culturally safe and client-centered treatment, more effective pain management solutions, and that relationships with Elders and community healthcare personnel should be built and strengthened to improve pregnancy and postnatal care delivery. IBSWs desire to work with community healthcare providers to provide prenatal care and build relationships before delivery. IBSWs advocated for collaborative cooperation with community healthcare professionals and rural healthcare teams to enable a smooth care flow to and from communities.

CONCLUSION

The Indigenous Birth Support Worker (IBSW) Program provides safe and client-centred care to Indigenous women during pregnancy, labour, and postpartum, consistent with the six principles proposed by BC perinatal services. IBSWs advocate for and assist Indigenous women in obtaining quality healthcare, provide traditional and cultural support, and positively affect mental health. However, the evaluation has revealed that healthcare provider insensitivity towards Indigenous clients persists. There is a need for greater role clarity and collaboration with healthcare practitioners to ensure evidence-based healthcare of the highest standard. This requires a commitment to addressing systemic issues and implementing broader calls to action and justice proposed by the Truth and Reconciliation Commission Calls to Action, the Missing and Murdered Indigenous Women and Girls Calls for Justice, and the United Nations Declaration on the Rights of Indigenous Peoples. The IBSW program offers vital support to Indigenous women during childbirth, but it must be viewed in the context of ongoing colonialism and the need for reconciliation and decolonization, requiring genuine collaboration with Indigenous peoples.

Partnering with First Nations in Northern British Columbia Canada to Reduce Inequity in Access to Genomic Research

Indigenous-led, culturally safe health research and infrastructure are essential to address existing inequities and disparities for Indigenous Peoples globally. Biobanking, genomic research, and self-governance could reduce the existing divide and increase Indigenous participation in health research. While genomic research advances medicine, barriers persist for Indigenous patients to benefit. In northern BC, Canada, the Northern Biobank Initiative (NBI), with guidance from a Northern First Nations Biobank Advisory Committee (NFNBAC), has engaged in consultations with First Nations on biobanking and genomic research. Key informant interviews and focus groups conducted with First Nations leaders, Elders, Knowledge Keepers, and community members established culturally safe ways of biobanking and exploring genomic research. Strong support for a Northern British Columbia First Nations Biobank (NBCFNB) that will promote choice, inclusion, and access to health research opportunities emerged. The acceptance and enthusiasm for the development of this NBCFNB and its governance table highlight the shift towards Indigenous ownership and support of health research and its benefits. With engagement and partnership, community awareness, multigenerational involvement, and support from diverse and experienced healthcare leaders, the NBCFNB will establish this culturally safe, locally driven, and critically important research priority that may serve as an example for diverse Indigenous groups when designing their unique biobanking or genomic research opportunities.

Examining Indigenous emergency care equity projects: a scoping review protocol

INTRODUCTION

Indigenous peoples across the globe face inequitable access to high-quality care. Emergency departments are the first point of access for many Indigenous peoples and are the interface between the individual and the healthcare system. There is a reliance on emergency services due to a lack of primary healthcare, a history of mistreatment from providers and increased disease complexity. As such, a potential place for health equity reform is within these departments and other acute care settings. It is the purpose of this review to determine what projects have occurred that address emergency care inequities in four countries such as Australia, Canada, New Zealand and the USA and explore their successes and failures.

METHODS AND ANALYSIS

Using search strategies developed with a research librarian, publications will be identified from indexed databases including Medline, Embase, Web of Science, Cochrane Central, CINAHL and Scopus. Grey literature will also be searched and scanned for inclusion. To be included in the review, articles must describe interventions developed to address Indigenous health equity occurring within emergency care settings. Articles will include both programme descriptions and programme evaluations and be quality appraised by analysing study design and Indigenous research methodologies.

ETHICS AND DISSEMINATION

This review does not require ethics approval. This protocol describes a review that attempts to map Indigenous health equity interventions taking place within emergency care settings. It will contribute to Indigenous health scholarship and equity research. Results will be made available in multiple dissemination methods to ensure accessibility by researchers and community members.

Indigenous communities in Colombia: A cultural and holistic view of cancer management

Cancer is one of the most burdening global health challenges. Indigenous communities are at high risk for worse healthcare outcomes because of inequalities in the incidence, prevalence, and mortality of oncological diseases, that arise from socioeconomic, racial, cultural, religious beliefs, and ethnic factors. Their perception about themselves is closely related to what affects their territory, making them possess a profound rooted feeling with their surroundings, and intense spiritual believes. Consequently, the disease process is linked to physical and emotional imbalances and alterations in their territory. Researchers from the United States, Canada, New Zealand, and Australia have worked diligently to learn about barriers to cancer management among these populations. Unfortunately, robust cancer data is lacking for most of the world's Indigenous, leading to obstacles in information systems and consequently, inequities in healthcare with the perpetuation of the problem. Therefore, a better understanding of cancer as a global health problem is required. Our study aims to propose a holistic and culturally adapted framework to improve cancer health services and outcomes among Indigenous peoples in Colombia.

Breast Reconstruction Perceptions and Access in First Nations Women are Influenced by Colonization

Purpose: This qualitative study explored First Nations (FN) women's perceptions about breast reconstruction (BR) after breast cancer surgery. Method: Participants were recruited through purposive and snowball sampling via Aboriginal health and community organizations, breast and plastic surgeons, an Aboriginal health liaison and an FN elder. Semistructured one-on-one interviews and an FN sharing circle were conducted, transcribed, and analyzed using thematic content analysis. Results: Nine women participated in the interviews. Three (33%) had been offered and had pursued BR, while 6 (67%) were either not offered or had not pursued breast reconstruction. Two of these 6 stated that they were not interested in BR. Four women participated in the sharing circle; 2 had been interviewed prior and 2 were new participants who shared similar themes and experiences to other participants also interviewed. Four key themes were identified: identity, information gaps, financial and transportation barriers, and consequences of colonization. Reasons cited to pursue BR were consistent with non-FN women such as improving self-image, concepts of femininity, and sense of normalcy. All participants reported that accessible, appropriate, and timely and culturally sensitive BR information was lacking. Living on reserve and the attendant expenses related to attending medical appointments was another barrier experienced by women in our study. The devastating impacts of colonization also deeply impacted several women in our study. Conclusion: When offered, FN women were receptive to pursuing BR. FN women have a particular set of obstacles related to consequences of colonization. Culturally sensitive and relevant oral communications grounded in first-hand experiences are desired. The 4 themes identified did influence the rate of BR uptake in the FN women who participated in our study and provided significant and unique obstacles to FN women.

Health equity related challenges and experiences during the rapid implementation of virtual care during COVID-19: a multiple case study

BACKGROUND

Virtual care quickly became of crucial importance to health systems around the world during the COVID-19 pandemic. Despite the potential of virtual care to enhance access for some communities, the scale and pace at which services were virtualized did not leave many organizations with sufficient time and resources to ensure optimal and equitable delivery of care for everyone. The objective of this paper is to outline the experiences of health care organizations rapidly implementing virtual care during the first wave of the COVID-19 pandemic and examine whether and how health equity was considered.

METHODS

We used an exploratory, multiple case study approach involving four health and social service organizations providing virtual care services to structurally marginalized communities in the province of Ontario, Canada. We conducted semi-structured qualitative interviews with providers, managers, and patients to understand the challenges experienced by organizations and the strategies put in place to support health equity during the rapid virtualization of care. Thirty-eight interviews were thematically analyzed using rapid analytic techniques.

RESULTS

Organizations experienced challenges related to infrastructure availability, digital health literacy, culturally appropriate approaches, capacity for health equity, and virtual care suitability. Strategies to support health equity included the provision of blended models of care, creation of volunteer and staff support teams, participation in community engagement and outreach, and securement of infrastructure for clients. We put our findings into the context of an existing framework conceptualizing access to health care and expand on what this means for equitable access to virtual care for structurally marginalized communities.

CONCLUSION

This paper highlights the need to pay greater attention to the role of health equity in virtual care delivery and situate that conversation around existing inequitable structures in the health care system that are perpetuated when delivering care virtually. An equitable and sustainable approach to virtual care delivery will require applying an intersectionality lens on the strategies and solutions needed to address existing inequities in the system.

The rights and interests of First Nations, Métis, and Inuit in debates over deemed consent legislation for deceased organ donation in Canada: calls to action

Nova Scotia, Canada is the first jurisdiction in North America to pass deemed consent legislation for organ donation. Individuals medically suitable to be deceased organ donors are considered to have authorised post-mortem organ removal for transplantation unless they opt out of the system. While governments do not have a legal duty to consult Indigenous nations before passing health legislation, this does not diminish Indigenous interests and rights in relation to the legislation. This analysis discusses impacts of the legislation, specifically intersectionality with Indigenous rights, trust in the healthcare system, transplant inequities, and distinctions-based health legislation. How governments engage Indigenous groups about the legislation is yet to unfold. Consultation with Indigenous leaders and engagement and education of Indigenous peoples is, however, key to moving forward legislation that respects Indigenous rights and interests. What happens in Canada is being watched globally, as deemed consent is debated as a solution to organ transplant shortages.

Positive oral health outcomes: A partnership model improves care in a rural Indigenous community

OBJECTIVE

The purpose of this study was to explore the benefits of a partnership between a university dental school and a Community Controlled Health Service, specifically in relation to improving the oral health of an underserved rural Indigenous community. We sought community opinions on health and social outcomes arising from the service provided by the dental student clinical outplacement.

SETTING

In Dalby, Queensland.

PARTICIPANTS

In total, 38 participants in five focus groups were representative of local Indigenous community Elders, community health support group members and management and staff.

DESIGN

A descriptive qualitative study employing semi-structured audio-recorded focus group discussions conducted with purposefully selected Indigenous community groups to explore participant views and experience of the partnership model. Qualitative data were analysed using thematic content analysis.

RESULTS

The Indigenous community representatives expressed positive benefit in both their general and oral health awareness, in improved access to dental care provided in their own safe space, while they were pleased to assist with students' learning. They viewed the partnership as mutually beneficial. Suggestions for enhancement of the oral health service were also offered.

CONCLUSION

This partnership between a university and a Community Controlled Health Service provides sustainable positive social and health benefits for the targeted Indigenous community and for the wider local population, while simultaneously providing enhanced educational benefits for students on clinical outplacement. Translation and uptake of this successful model of care would benefit both underserved communities and dental and other health care professional educators worldwide.

Supporting Indigenous Child Suicide Prevention Within Classrooms in Canada: Implications for School Psychologists and Educators

Indigenous young people in Canada are disproportionately overrepresented in suicide rates and alarmingly, young children are accounted for in these disparities. Since children spend much of their day at school, schools are a vital context for suicide prevention, identification, and intervention. However, research indicates that educators often report that they feel unprepared to address mental health challenges within the classroom. Indigenous communities are developing community driven responses to suicide that are culturally relevant and strengths based. It is critical that these models are considered when developing such suicide prevention within schools as they diverge from medicalized focused approaches and attend to broader social dimensions. It is imperative that educators and the education system are properly equipped with the training and resources to provide suicide prevention within schools and communities servicing Indigenous children. School psychologists can play an important role in providing this prevention leadership. Through interviews with educators, we learned about the types of supports that are needed within schools to address Indigenous child suicide, and in what ways school psychologists could enhance prevention efforts. Using a reflexive approach to thematic analysis, we identified four main themes related to support needed. Findings are discussed in conversation with the current state of child specific suicide and suicide prevention literature. Applied implications for suicide prevention within schools for Indigenous children, as well as future research and community-based recommendations are considered.

Systematic Review and Meta-analysis: First Nations, Inuit, and Métis Youth Mental Health

OBJECTIVE

The ongoing effects of colonialism disproportionately place Indigenous youth at risk for mental health challenges. This meta-analysis examined lifetime and past-year prevalence estimates of mental health challenges among First Nations, Inuit, and Métis youth in Canada.

METHOD

Five electronic databases were searched from their inceptions until June 17, 2021. Studies were included if they assessed mental health challenges among First Nations, Inuit, and/or Métis youth (≤18 years old). Risk of bias was assessed using the Newcastle-Ottawa Scale.

RESULTS

A total of 28 articles were eligible. Sixteen studies contained data on First Nations, 2 on Inuit, one on Métis, and 10 aggregated Indigenous participants. Among First Nations participants, pooled prevalence estimates for past-year suicidality (8.9%), mood and/or anxiety (<2.9%), attention-deficit/hyperactivity (2.9%), oppositional defiant (8.8%), and conduct (12.8%) disorder diagnoses were identified. Limited studies containing Inuit, Métis, and aggregated Indigenous participants also found high levels of disruptive disorder symptoms. Data were very limited for lifetime prevalence estimates. Studies assessed to have a moderate or high methodological risk of bias (k = 19) or using measures that are not yet culturally validated (k = 25) may contribute to inaccuracies in prevalence estimates.

CONCLUSION

Existing data suggest that Indigenous youth have a low prevalence of mental health challenges, with the exception of disruptive behaviors. Future studies should use culturally validated tools and partner with Indigenous communities to ensure optimal identification of mental health challenges.

Identifying priorities, directions and a vision for Indigenous mental health using a collaborative and consensus-based facilitation approach

Background

Mental health disparities between Indigenous and non-Indigenous people in Canada are related to underlying economic, social, and political inequities that are legacies of colonization and the oppression of Indigenous cultures. It also widely acknowledged that mental health services currently available may not be culturally appropriate in supporting the health needs of Indigenous Canadians. A two-day Indigenous mental health forum examined mental health needs and gaps among Indigenous communities across the Regional Municipality of Wood Buffalo (RMWB) on Treaty 8 territory, in northern Alberta, Canada. This paper outlines the insights generated by stakeholder engagement at the forum to identify and prioritize directions for Indigenous mental health and build a vision and strategy for improving mental health services and programs for the region’s diverse Indigenous population.

Methods

We applied a modified nominal group technique (NGT) consensus method embedded within Indigenous knowledge to determine key priorities and directions for Indigenous-focused mental health and synthesize information from discussions that occurred at the forum. Following the NGT, a participatory community visioning exercise was conducted with participants to develop a vision, guiding principles, and components of an action plan for an Indigenous mental health strategy for the RMWB.

Results

Four key themes for setting priorities and directions for Indigenous mental health emerged from roundtable group discussions: 1) understand the realities of mental health experiences for Indigenous peoples, 2) design a holistic and culturally rooted mental health system, 3) foster cross-sectoral engagement and collaboration on mental health service delivery, and 4) focus on children and youth. The community visioning exercise helped stakeholders to visualize a direction or path forward for addressing existing gaps in the mental health system and opportunities for strengthening Indigenous mental health in the region.

Conclusions

Forum participants described mental health and well-being around holistic concepts of social and emotional well-being. Addressing Indigenous mental health and wellness involves multi-sectoral action in various settings including community and school through programs, policies, and other interventions that promote mental health for all Indigenous peoples, as well as for those at greater risk such as children and youth.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07682-3.

Association between intergenerational solidarity involving elders and mental health of Indigenous people living off reserve

Background

Indigenous elders play an important role in transmitting knowledge, values and practices, hence fostering identity-building through intergenerational solidarity. We aimed to verify the association between intergenerational solidarity involving Indigenous elders and mental health of Indigenous people living off reserve.

Methods

We carried secondary analyses of data for a subsample from the cross-sectional 2012 Aboriginal Peoples Survey (total sample: n = 28,410 Indigenous persons aged ≥6 years old living off reserve; subsample: n = 13,020 aged 18–44 years old). Controlling for age as well as material and social deprivation, we used logistic regressions to verify the association between intergenerational solidarity (proxied as time spent with an elder and potential of turning to an elder or grandparent for support in times of need) and mental health (perceived mental health, mood disorders, anxiety, suicidal thoughts and attempts).

Results

About 39 and 9% of the respondents respectively reported having spent time with an elder and would have turned to an elder or grandparent for support in times of need. Women who would not turn to an elder or grandparent for support in times of need were more likely to report fair or poor perceived mental health (OR = 1.69, p = 0.03). Men not spending time with an elder were more likely to experience mood disorders (OR = 1.66, p = 0.004). Women who would not turn to an elder or grandparent for support in times of need were more likely to experience anxiety disorders (OR = 1.57, p = 0.04). Women not spending time with an elder or who would not turn to an elder or grandparent for support in times of need were respectively more likely to have suicidal thoughts (OR = 1.62, p = 0.04) or to have attempted suicide (OR = 3.38, p = 0.04).

Conclusion

Intergenerational solidarity is associated with better mental health outcomes of Indigenous people living off reserve. These results could guide policies and practices that aim to enhance mental health and wellness in Indigenous populations.

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.

Health Monitoring Using Smart Home Technologies: A Scoping Review (Preprint)

BACKGROUND

The Internet of Things (IoT) has become integrated into everyday life, with devices becoming permanent fixtures in many homes. As countries face increasing pressure on their health care systems, smart home technologies have the potential to support population health through continuous behavioral monitoring.

OBJECTIVE

This scoping review aims to provide insight into this evolving field of research by surveying the current technologies and applications for in-home health monitoring.

METHODS

Peer-reviewed papers from 2008 to 2021 related to smart home technologies for health care were extracted from 4 databases (PubMed, Scopus, ScienceDirect, and CINAHL); 49 papers met the inclusion criteria and were analyzed.

RESULTS

Most of the studies were from Europe and North America. The largest proportion of the studies were proof of concept or pilot studies. Approximately 78% (38/49) of the studies used real human participants, most of whom were older females. Demographic data were often missing. Nearly 60% (29/49) of the studies reported on the health status of the participants. Results were primarily reported in engineering and technology journals. Almost 62% (30/49) of the studies used passive infrared sensors to report on motion detection where data were primarily binary. There were numerous data analysis, management, and machine learning techniques employed. The primary challenges reported by authors were differentiating between multiple participants in a single space, technology interoperability, and data security and privacy.

CONCLUSIONS

This scoping review synthesizes the current state of research on smart home technologies for health care. We were able to identify multiple trends and knowledge gaps-in particular, the lack of collaboration across disciplines. Technological development dominates over the human-centric part of the equation. During the preparation of this scoping review, we noted that the health care research papers lacked a concrete definition of a smart home, and based on the available evidence and the identified gaps, we propose a new definition for a smart home for health care. Smart home technology is growing rapidly, and interdisciplinary approaches will be needed to ensure integration into the health sector.

Inclusion, diversity, equity, and accessibility: From organizational responsibility to leadership competency

An awakening to systemic anti-Black racism, anti-Indigenous racism, and harmful colonial structures in the context of a pandemic has made health inequities and injustices impossible to ignore, and is driving healthcare organizations to establish and strengthen approaches to inclusion, diversity, equity, and accessibility (IDEA). Health research and care organizations, which are shaping the future of healthcare, have a responsibility to make IDEA central to their missions. Many organizations are taking concrete action critically important to embedding IDEA principles, but durable change will not be achieved until IDEA becomes a core leadership competency. Drawing from the literature and consultation with individuals recognized for excellence in IDEA-informed leadership, this study will help Canadian healthcare and health research leaders—particularly those without lived experience—understand what it means to embed IDEA within traditional leadership competencies and propose opportunities to achieve durable change by rethinking governance, mentorship, and performance management through an IDEA lens.

Building Bridges for Indigenous Children's Health: Community Needs Assessment Through Talking Circle Methodology

Objective

The Stollery Children's Hospital in Edmonton, Alberta, introduced the Stollery Awasisak team to provide targeted support to Indigenous families and their children. Talking Circles were conducted across northern communities from 2017 to 2019 to better understand how Indigenous people perceive the current state of healthcare services delivered by the Stollery Hospital.

Methods

The 2019 Talking Circles were held in six cities: Grande Prairie, Slave Lake, High Level, Fort McMurray, Edmonton, and Cold Lake, which were the biggest circles held to date with an attendance of 160 participants. Participants included members of Treaties 6 and 8, and Metis Nations of Alberta, as well as healthcare professionals in those regions.

Results

Talking Circles identified challenges Indigenous (First Nation, Inuit and Metis) pediatric patients and their families experienced from accessing care to transitioning home to exploring their positive experiences with the Stollery Hospital and other frontline collaborates. Through these circles guided by Elders in ceremonies, priorities and recommendations were made to help support pediatric patients and their families.

Conclusion

Multiple perspectives provided rich data on how best to adhere to the Truth Reconciliation of Canada 19th mandate and ensure equitable healthcare access to all Indigenous children. Together, leaders, healthcare providers, service providers and community members reflected on the lessons of the Medicine Wheel quadrants and the Seven Sacred Teachings, and brought forward four priorities; capacity building, continuity of care, culturally responsive care and increased communication.

Incidence and trends of limb amputation in first nations and general population in Saskatchewan, 2006-2019

BACKGROUND

There is conflicting evidence whether limb amputation (LA) disproportionately affects indigenous populations. To better understand this disparity, we compared the LA incidence rate between First Nations persons registered under the Indian Act of Canada (RI) and the general population (GP) in Saskatchewan.

METHODS

We used Saskatchewan's retrospective administrative data containing hospital discharge LA cases, demographic characteristics (age and sex), and residents population reported in the database stratified by RI and GP from 2006-2019. The LA cases for each stratified group were first disaggregated into three broad categories: overall LA (all reported LA), primary LA (first reported LA), and subsequent LA (revision or contralateral LA), with each category further split into the level of amputation defined as major amputation (through/above the ankle/wrist joint) and minor amputation (below the ankle/wrist joint). LA rates were calculated using LA cases as the numerator and resident population as the denominator. Joinpoint and negative binomial regressions were performed to explore the trends further.

RESULTS

Overall, there were 1347 RI and 4520 GP LA cases reported in Saskatchewan from 2006-2019. Primary LA made up approximately 64.5% (869) of RI and 74.5% (3369) of GP cases, while subsequent LA constituted 35.5% (478) of RI and 25.5% (1151) of GP cases. The average age-adjusted LA rate was 153.9 ± 17.3 per 100,000 in the RI cohort and 31.1 ± 2.3 per 100,000 in the GP cohort. Overall and primary LA rates for the GP Group declined 0.7% and 1.0%, while subsequent LA increased 0.1%. An increased LA rate for all categories (overall 4.9%, primary 5.1%, and subsequent 4.6%) was identified in the RI group. Overall, minor and major LA increased by 6.2% and 3.3%, respectively, in the RI group compared to a 0.8% rise in minor LA and a 6.3% decline in major LA in the GP group. RI females and males were 1.98-1.66 times higher risk of LA than their GP counterparts likewise, RI aged 0-49 years and 50+ years were 2.04-5.33 times higher risk of LA than their GP cohort. Diabetes mellitus (DM) was the most prevalent amputation predisposing factor in both groups with 81.5% of RI and 54.1% of GP diagnosed with DM. Also, the highest proportion of LA was found in the lowest income quintile for both groups (68.7% for RI and 45.3% for GP).

CONCLUSION

Saskatchewan's indigenous individuals, specifically First Nations persons registered under the Indian Act of Canada, experience LA at a higher rate than the general population. This disparity exists for all variables examined, including overall, primary, and subsequent LA rates, level of amputation, sex, and age. Amplification of the disparities will continue if the rates of change maintain their current trajectories. These results underscore the need for a better understanding of underlying causes to develop a targeted intervention in these groups.

Royal society of Canada COVID-19 report: Enhancing COVID-19 vaccine acceptance in Canada

COVID-19 vaccine acceptance exists on a continuum from a minority who strongly oppose vaccination, to the “moveable middle” heterogeneous group with varying uncertainty levels about acceptance or hesitancy, to the majority who state willingness to be vaccinated. Intention for vaccine acceptance varies over time. COVID-19 vaccination decisions are influenced by many factors including knowledge, attitudes, and beliefs; social networks; communication environment; COVID-19 community rate; cultural and religious influences; ease of access; and the organization of health and community services and policies.

Reflecting vaccine acceptance complexity, the Royal Society of Canada Working Group on COVID-19 Vaccine Acceptance developed a framework with four major factor domains that influence vaccine acceptance (people, communities, health care workers; immunization knowledge; health care and public health systems including federal/provincial/territorial/indigenous factors)—each influencing the others and all influenced by education, infection control, extent of collaborations, and communications about COVID-19 immunization. The Working Group then developed 37 interrelated recommendations to support COVID vaccine acceptance nested under four categories of responsibility: 1. People and Communities, 2. Health Care Workers, 3. Health Care System and Local Public Health Units, and 4. Federal/Provincial/Territorial/Indigenous. To optimize outcomes, all must be engaged to ensure co-development and broad ownership.

Healthcare and Health Problems from the Perspective of Indigenous Population of the Peruvian Amazon: A Qualitative Study

Indigenous communities usually experience higher levels of mortality and poorer access to healthcare services compared to non-indigenous communities. This study aims to understand the most prevalent health problems and their treatment in the Asháninka indigenous communities of the Peruvian Amazon. We conducted an ethnographic study in order to explore the perceived health problems, the use of traditional medicine and the resources offered by the official Peruvian healthcare system. Field notes and semi-structured interviews were used. A total of 16 indigenous and four non-indigenous people were interviewed, and interpretative analysis was used to identify themes. The Asháninka community is an overlooked population, which, due to distance restrictions, misconceptions and ethnical disparities, is far away from an appropriate healthcare system and is subjected to acute medical conditions such as infections and gastrointestinal problems. This group tends to seek traditional medicine, mostly herbal medications and traditional healers. The use of a health professional is seen as a last resort. Although the official Peruvian health system incorporates community participation strategies to improve the healthcare of indigenous people, the shortage of material, human resources and cultural sensitivity makes this difficult. Healthcare strategies should be devised and implemented in order to minimize health inequality in this population.