Leaving emergency departments without completing treatment among First Nations and non-First Nations patients in Alberta: a mixed-methods study.

BACKGROUND: Our previous research showed that, in Alberta, Canada, a higher proportion of visits to emergency departments and urgent care centres by First Nations patients ended in the patient leaving without being seen or against medical advice, compared with visits by non-First Nations patients. We sought to analyze whether these differences persisted after controlling for patient demographic and visit characteristics, and to explore reasons for leaving care. METHODS: We conducted a mixed-methods study, including a population-based retrospective cohort study for the period of April 2012 to March 2017 using provincial administrative data. We used multivariable logistic regression models to control for demographics, visit characteristics, and facility types. We evaluated models for subgroups of visits with pre-selected illnesses. We also conducted qualitative, in-person sharing circles, a focus group, and 1-on-1 telephone interviews with health directors, emergency care providers, and First Nations patients from 2019 to 2022, during which we reviewed the quantitative results of the cohort study and asked participants to comment on them. We descriptively categorized qualitative data related to reasons that First Nations patients leave care. RESULTS: Our quantitative analysis included 11 686 287 emergency department visits, of which 1 099 424 (9.4%) were by First Nations patients. Visits by First Nations patients were more likely to end with them leaving without being seen or against medical advice than those by non-First Nations patients (odds ratio 1.96, 95% confidence interval 1.94-1.98). Factors such as diagnosis, visit acuity, geography, or patient demographics other than First Nations status did not explain this finding. First Nations status was associated with greater odds of leaving without being seen or against medical advice in 9 of 10 disease categories or specific diagnoses. In our qualitative analysis, 64 participants discussed First Nations patients' experiences of racism, stereotyping, communication issues, transportation barriers, long waits, and being made to wait longer than others as reasons for leaving. INTERPRETATION: Emergency department visits by First Nations patients were more likely to end with them leaving without being seen or against medical advice than those by non-First Nations patients. As leaving early may delay needed care or interfere with continuity of care, providers and departments should work with local First Nations to develop and adopt strategies to retain First Nations patients in care.

Assessing Breast Cancer Screening and Outcomes Among First Nations Women in Alberta.

BACKGROUND: Breast cancer (BC) incidence rates for First Nations (FN) women in Canada have been steadily increasing and are often diagnosed at a later stage. Despite efforts to expand the reach of BC screening programs for FN populations in Alberta (AB), gaps in screening and outcomes exist. METHODS: Existing population-based administrative databases including the AB BC Screening Program, the AB Cancer Registry, and an AB-specific FN registry data were linked to evaluate BC screening participation, detection, and timeliness of outcomes in this retrospective study. Tests of proportions and trends compared the findings between FN and non-FN women, aged 50-74 years, beginning in 2008. Incorporation of FN principles of ownership, control, access, and possession (OCAP®) managed respectful sharing and utilization of FN data and findings. RESULTS: The average age-standardized participation (2013-8) and retention rates (2015-6) for FN women compared to non-FN women in AB were 23.8% (P < .0001) and 10.3% (P = .059) lower per year, respectively. FN women were diagnosed with an invasive cancer more often in Stage II (P-value = .02). Following 90% completion of diagnostic assessments, it took 2-4 weeks longer for FN women to receive their first diagnosis as well as definitive diagnoses than non-FN women. CONCLUSION: Collectively, these findings suggest that access to and provision of screening services for FN women may not be equitable and may contribute to higher BC incidence and mortality rates. Collaborations between FN groups and screening programs are needed to eliminate these inequities to prevent more cancers in FN women.

Exploring paramedic care for First Nations in Alberta: a qualitative study.

BACKGROUND: Prior work has shown that a greater proportion of First Nations patients than non-First Nations patients arrive by ambulance to emergency departments in Alberta. The objective of this study was to understand First Nations perspectives on transitions in care involving paramedics, and paramedic perspectives on serving First Nations communities. METHODS: Participants for this participatory qualitative study were selected by means of purposive sampling through author networks, established relationships and knowledge of the Alberta paramedicine system. First Nations research team members engaged First Nations community organizations to identify and invite First Nations participants. Four sharing circles were held virtually in July 2021 via Zoom by the Alberta First Nations Information Governance Centre. We analyzed the data from the sharing circles using a Western thematic approach. The data were reviewed by Indigenous researchers. RESULTS: Forty-four participants attended the 4 sharing circles (8-14 participants per circle), which ranged from 68 to 88 minutes long. We identified 3 major themes: racism, system barriers and solutions. First Nations participants described being stereotyped as misusing paramedic systems and substance using, which led to racial discrimination by paramedics and emergency department staff. Discrimination and lack of options to return home after care sometimes led First Nations patients to avoid paramedic care, and lack of alternative care options drove patients to access paramedic care. First Nations providers described facing racism from colleagues and completing additional work to act as cultural mentors to non-First Nations providers. Paramedics expressed moral distress when called on to handle issues outside their scope of practice and when they observed discrimination that interfered with patient care. Proposed solutions included First Nations self-determination in paramedic service design, cultural training and education for paramedics, and new paramedicine service models. INTERPRETATION: First Nations people face discrimination and systemic barriers when accessing paramedicine. Potential solutions include the integration of paramedics in expanded health care roles that incorporate First Nations perspectives and address local priorities, and First Nations should lead in the design of and priority setting for paramedic services in their communities.

Action, Accountability and Transparency for Indigenous Health Systems Safety.

Anti-Indigenous racism is prevalent in Canada, especially within healthcare systems. Consequences are catastrophic, including deaths of Indigenous patients. Systems change and critical education guided by the Indigenous Peoples and research into how racism operates within healthcare settings are needed. In Alberta, promising initiatives are under way, including a First Nations-led initiative identifying racism and colonialism as key health determinants, novel experiential education, transformative education for senior health leaders and reframing health system measures to reflect Indigenous Peoples' perspectives. The time is now for comprehensive action toward eliminating racism within healthcare systems and fostering Indigenous health systems safety. Indigenous lives depend on it.

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

OBJECTIVES: The objective of this study was to examine international literature to identify best practices for treatment of opioid dependence in Indigenous contexts. METHODS: We utilized a systematic search to identify relevant literature. The literature was analysed using a realist review methodology supported by a two-step knowledge contextualization process, including a Knowledge Holders Gathering to initiate the literature search and analysis, and five consensus-building meetings to focus and synthesize relevant findings. A realist review methodology incorporates an analysis of the complex contextual factors in treatment by identifying program mechanisms, namely how and why different programs are effective in different contexts. RESULTS: A total of 27 sources were identified that met inclusion criteria. Contextual factors contributing to opioid dependence described in the literature often included discussions of a complex interaction of social determinants of health in the sampled community. Twenty-four articles provided evidence of the importance of compassion in treatment. Compassion was evidenced primarily at the individual level, in interpersonal relationships based on nonjudgmental care and respect for the client, as well as in more holistic treatment programs beyond biophysical supports such as medically assisted treatment. Compassion was also shown to be important at the structural level in harm reduction policies. Twenty-five articles provided evidence of the importance of client self-determination in treatment programs. Client self-determination was evidenced primarily at the structural level, in community-based programs and collaborative partnerships based in trust and meaningful engagement but was also shown to be important at the individual level in client-directed care. Identified outcomes moved beyond a reduction in opioid use to include holistic health and wellness goals, such as improved life skills, self-esteem, feelings of safety, and healing at the individual level. Community-level outcomes were also identified, including more families kept intact, reduction in drug-related medical evacuations, criminal charges and child protection cases, and an increase in school attendance, cleanliness, and community spirit. CONCLUSIONS: The findings from this realist review indicate compassion and self-determination as key program mechanisms that can support outcomes beyond reduced incidence of substance use to include mitigating systemic health inequities and addressing social determinants of health in Indigenous communities, ultimately healing the whole human being.

Impacts of racism on First Nations patients' emergency care: results of a thematic analysis of healthcare provider interviews in Alberta, Canada.

BACKGROUND: First Nations people experience racism in society and in the healthcare system. This study aimed to document emergency care providers' perspectives on care of First Nations patients. First Nations research partner organizations co-led all aspects of the research. METHODS: Sixteen semi-structured interviews were conducted with Alberta emergency department (ED) physicians and nurses between November 2019 and March 2020. RESULTS: ED providers reported that First Nations patients are exposed to disrespect through tone and body language, experience overt racism, and may be neglected or not taken seriously. They described impacts of racist stereotypes on patient care, and strategies they took as individuals to address patient barriers to care. Recognized barriers to care included communication, resources, access to primary care and the ED environment itself. CONCLUSIONS: Results may inform the content of anti-racist and anti-colonial pedagogy that is contextually tailored to ED providers, and inform wider systems efforts to counter racism against First Nations members and settler colonialism within healthcare.

Developing Data Governance Agreements with Indigenous Communities in Canada: Toward Equitable Tuberculosis Programming, Research, and Reconciliation.

Indigenous rights to self-determination and data sovereignty support Indigenous-led data governance, which, when adequately resourced, can act as a catalyst for Indigenous-led strategic planning and decision-making in public health research and programming. Respecting Indigenous data sovereignty and governance requires time, resources, education, and planning. Here we share our experiences and lessons learned when developing and implementing data governance agreements with select First Nations and Métis partnering communities in Canada in the context of tuberculosis prevention and care. We define the process undertaken to create a decision space, supported by data governance agreements, where researchers, program (government) stakeholders, and Indigenous community partners are equally and equitably informed to co-develop public health interventions. The decision space has implications for tackling all manner of public health concerns and can inform policy for nation-to-nation public health relationships to advance public health goals.

Mental health experiences with COVID-19 public health measures in an Alberta First Nations Community.

BACKGROUND: First Nations (FN) people of Canada experience health, social, and systemic inequities due to colonization. Consequently, COVID-19 has placed further mental health stress on people related to personal finances, employment security and worry over infection, resulting in exacerbated effects of unresolved past medical and physical traumas. This study aims to understand the experiences related to mental health in an Alberta FN community during the early stages of the pandemic. METHODS: In partnership with FN leadership, the study implemented an online cross-sectional survey. Adults from a large FN community in Alberta, Canada, were asked to complete a survey, including two mental health-related screening questionnaires: (1) Generalized Anxiety Disorder-2 item; and (2) Patient Health Questionnaire-2 item. In addition, respondents could provide responses to open-ended questions about their experiences. RESULTS: Among 106 respondents, 95 (89.6%) finished the survey; 18% of adults screened positive for depressive symptoms (score of 3 or greater) and reported difficulty following public health advice for using hand sanitizer, maintaining social distancing, or self-isolating. 21% of adults screened positive for symptoms of anxiety (score of 3 or greater) and reported difficulty maintaining social distance, self-isolating, obtaining food and clothing, or meeting other basic living requirements. CONCLUSIONS: FN communities may be disproportionately affected by COVID-19, and may experience exacerbated symptoms of anxiety, depression and overall poor mental health and well-being. Additional supports and services, including for mental health, should be considered for FN in the context of COVID-19 public health measures. HIGHLIGHTS: The COVID-19 pandemic has brought upon increased stress and accompanying symptoms of anxiety and depression for a First Nations community in Alberta. Studies, such as this one, that characterize the influence of the COVID-19 pandemic on mental health among First Nations people, are urgently needed because of increasing demands on healthcare systems due to the pandemic and potential delays in the care of patients living with pre-existing mental health conditions. There is an opportunity to capitalize on First Nations people's experiences of post-traumatic growth proactively supporting/maintaining their well-being and possibly the development of community-based mental health interventions and supports.

First Nations status and emergency department triage scores in Alberta: a retrospective cohort study.

BACKGROUND: Previous studies have found that race is associated with emergency department triage scores, raising concerns about potential health care inequity. As part of a project on quality of care for First Nations people in Alberta, we sought to understand the relation between First Nations status and triage scores. METHODS: We conducted a population-based retrospective cohort study of health administrative data from April 2012 to March 2017 to evaluate acuity of triage scores, categorized as a binary outcome of higher or lower acuity score. We developed multivariable multilevel logistic mixed-effects regression models using the levels of emergency department visit, patient (for patients with multiple visits) and facility. We further evaluated the triage of visits related to 5 disease categories and 5 specific diagnoses to better compare triage outcomes of First Nations and non-First Nations patients. RESULTS: First Nations status was associated with lower odds of receiving higher acuity triage scores (odds ratio [OR] 0.93, 95% confidence interval [CI] 0.92-0.94) compared with non-First Nations patients in adjusted models. First Nations patients had lower odds of acute triage for all 5 disease categories and for 3 of 5 diagnoses, including long bone fractures (OR 0.82, 95% CI 0.76-0.88), acute upper respiratory infection (OR 0.90, 95% CI 0.84-0.98) and anxiety disorder (OR 0.67, 95% CI 0.60-0.74). INTERPRETATION: First Nations status was associated with lower odds of higher acuity triage scores across a number of conditions and diagnoses. This may reflect systemic racism, stereotyping and potentially other factors that affected triage assessments.

First Nations emergency care in Alberta: descriptive results of a retrospective cohort study.

BACKGROUND: Worse health outcomes are consistently reported for First Nations people in Canada. Social, political and economic inequities as well as inequities in health care are major contributing factors to these health disparities. Emergency care is an important health services resource for First Nations people. First Nations partners, academic researchers, and health authority staff are collaborating to examine emergency care visit characteristics for First Nations and non-First Nations people in the province of Alberta. METHODS: We conducted a population-based retrospective cohort study examining all Alberta emergency care visits from April 1, 2012 to March 31, 2017 by linking administrative data. Patient demographics and emergency care visit characteristics for status First Nations persons in Alberta, and non-First Nations persons, are reported. Frequencies and percentages (%) describe patients and visits by categorical variables (e.g., Canadian Triage and Acuity Scale). Means, medians, standard deviations and interquartile ranges describe continuous variables (e.g., age). RESULTS: The dataset contains 11,686,288 emergency care visits by 3,024,491 unique persons. First Nations people make up 4% of the provincial population and 9.4% of provincial emergency visits. The population rate of emergency visits is nearly 3 times higher for First Nations persons than non-First Nations persons. First Nations women utilize emergency care more than non-First Nations women (54.2% of First Nations visits are by women compared to 50.9% of non-First Nations visits). More First Nations visits end in leaving without completing treatment (6.7% v. 3.6%). CONCLUSIONS: Further research is needed on the impact of First Nations identity on emergency care drivers and outcomes, and on emergency care for First Nations women.

Characterization of indigenous community engagement in arthritis studies conducted in Canada, United States of America, Australia and New Zealand.

BACKGROUND: Research adhering to community engagement processes leads to improved outcomes. The level of Indigenous communities' engagement in rheumatology research is unknown. OBJECTIVE: To characterize the frequency and level of community engagement reporting in arthritis studies conducted in Australia (AUS), Canada (CAN), New Zealand (NZ) and the United States of America (USA). METHODS: Studies identified through systematic reviews on topics of arthritis epidemiology, disease phenotypes and outcomes, health service utilization and mortality in Indigenous populations of AUS, CAN, NZ and USA, were evaluated for their descriptions of community engagement. The level of community engagement during inception, data collection and results interpretation/dissemination stages of research was evaluated using a custom-made instrument, which ranked studies along the community engagement spectrum (i.e. inform-consult-involve-collaborate-empower). Meaningful community engagement was defined as involving, collaborating or empowering communities. Descriptive analyses for community engagement were performed and secondary non-parametric inferential analyses were conducted to evaluate the possible associations between year of publication, origin of the research idea, publication type and region of study; and meaningful community engagement. RESULTS: Only 34% (n = 69) of the 205 studies identified reported community engagement at ≥ 1 stage of research. Nearly all studies that engaged communities (99% (n = 68)) did so during data collection, while only 10% (n = 7) did so at the inception of research and 16% (n = 11) described community engagement at the results' interpretation/dissemination stage. Most studies provided community engagement descriptions that were assessed to be at the lower end of the spectrum. At the inception of research stage, 3 studies reported consulting communities, while 42 studies reported community consultation at data collection stage and 4 studies reported informing or consulting communities at the interpretation/dissemination of results stage. Only 4 studies described meaningful community engagement through all stages of the research. Inferential statistics identified that studies with research ideas that originated from the Indigenous communities involved were significantly more associated with achieving meaningful community engagement. CONCLUSIONS: The reporting of Indigenous community engagement in published arthritis studies is limited in frequency and is most frequently described at the lower end of the community engagement spectrum. Processes that support meaningful community engagement are to be promoted.

Barriers, supports, and effective interventions for uptake of human papillomavirus- and other vaccines within global and Canadian Indigenous peoples: a systematic review protocol.

BACKGROUND: Despite the existence of human papilloma virus (HPV) vaccines with demonstrated safety and effectiveness and funded HPV vaccination programs, coverage rates are persistently lower and cervical cancer burden higher among Canadian Indigenous peoples. Barriers and supports to HPV vaccination in Indigenous peoples have not been systematically documented, nor have interventions to increase uptake in this population. This protocol aims to appraise the literature in Canadian and global Indigenous peoples, relating to documented barriers and supports to vaccination and interventions to increase acceptability/uptake or reduce hesitancy of vaccination. Although HPV vaccination is the primary focus, we anticipate only a small number of relevant studies to emerge from the search and will, therefore, employ a broad search strategy to capture literature related to both HPV vaccination and vaccination in general in global Indigenous peoples. METHODS: Eligible studies will include global Indigenous peoples and discuss barriers or supports and/or interventions to improve uptake or to reduce hesitancy, for the HPV vaccine and/or other vaccines. Primary outcomes are documented barriers or supports or interventions. All study designs meeting inclusion criteria will be considered, without restricting by language, location, or data type. We will use an a priori search strategy, comprised of key words and controlled vocabulary terms, developed in consultation with an academic librarian, and reviewed by a second academic librarian using the PRESS checklist. We will search several electronic databases from date of inception, without restrictions. A pre-defined group of global Indigenous websites will be reviewed for relevant gray literature. Bibliographic searches will be conducted for all included studies to identify relevant reviews. Data analysis will include an inductive, qualitative, thematic synthesis and a quantitative analysis of measured barriers and supports, as well as a descriptive synthesis and quantitative summary of measures for interventions. DISCUSSION: To our knowledge, this study will contribute the first systematic review of documented barriers, supports, and interventions for vaccination in general and for HPV vaccination. The results of this study are expected to inform future research, policies, programs, and community-driven initiatives to enhance acceptability and uptake of HPV vaccination among Indigenous peoples. SYSTEMATIC REVIEW REGISTRATION: PROSPERO Registration Number: CRD42017048844.

In the eyes of Indigenous people in Canada: exposing the underlying colonial etiology of hepatitis C and the imperative for trauma-informed care.

Background: The distribution of hepatitis C (HCV) infection in Canada signals a widening gap between Indigenous and non-Indigenous people. Current evidence demonstrates that the rate of HCV infection among Indigenous people is at least five times higher than the rest of Canada. This analysis provides a reconciliatory response, which exposes the colonial etiology of the HCV gap in Canada and proposes potential anti-colonial approaches to HCV wellness and health care for Indigenous people. Methods: This analysis applies Two-Eyed Seeing as a reconciliatory methodology to advance the understanding of HCV burden and identify the key elements of responsive HCV care in the context of Indigenous nations in Canada. Results: The analysis underlines the colonial distribution of HCV burden in Canada, highlights Indigenous perspectives on HCV infection, hypothesizes a clinical pathway for the underlying colonial etiology of HCV infection, and identifies Indigenous healing as a promising anti-colonial conceptual approach to HCV wellness and health care among Indigenous people. Conclusions: In the eyes of Indigenous people, HCV infection is a colonial illness that entails healing as an anti-colonial approach to achieving wellness and gaining health. Future empirical research should elaborate on the colonial HCV pathway hypothesis and inform the development of a framework for HCV healing among Indigenous people in Canada.

Claims for disease-modifying therapy by Alberta non-insured health benefits clients.

BACKGROUND: Uncontrolled disease activity in inflammatory diseases of the joints, skin and bowel leads to morbidity and disability. Disease-modifying therapies are widely used to suppress this disease activity, but cost-coverage is variable. For Treaty First Nations and Inuit people in Canada without alternative private or public health insurance, cost-coverage for disease-modifying therapy is provided through Non-Insured Health Benefits (NIHB). Our objective was to describe the prevalence and patterns of treatment with disease-modifying therapy for the NIHB claimant population, and also examine adjuvant therapy (analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids) use. METHODS: Cases (n = 2512) were defined by ≥1 claim for a disease-modifying anti-rheumatic drug (DMARD) or biologic between 1999 and 2012 in the NIHB pharmacy claim database. The proportion of the population with claims for individual agents and drug classes annually was calculated to estimate annual incidence and prevalence rates for use of disease-modifying therapy, and the prevalence of use of individual DMARDs, biologics and adjuvants. Differences in the proportion accessing adjuvant therapies and median doses in the 6 months following initiation of disease-modifying therapies was estimated. RESULTS: The incidence rate of treatment was calculated at an average of 127.5 cases per 100,000 population between 2001 and 2012, and the cumulative prevalence, accounting for patients lost to the database, increased and then stabilized at 1.3 % in the last three years of the study. Annual dispensation of methotrexate, combination DMARD therapy and biologic therapy approached 35 %, 19 %, and 10 % of the cohort respectively. A declining prevalence of claims for acetaminophen (28 % to 15 %) and anti-inflammatories (73 % to 63 %) occurred from 2000 to 2012, however corticosteroid (32 %) and opioid (65 %) dispensation remained stable. The proportion of patients with claims for NSAIDs (69.9 % to 61.1 %, p = 0.002), oral corticosteroids (45.4 % to 33.6 %, p < 0.001) and parenteral corticosteroids (16.2 % to 8.3 %, p = 0.002) decreased in the 6 months following biologic initiation. CONCLUSIONS: The proportion of NIHB clients with active claims for disease-modifying therapy is lower than expected based on existing epidemiologic knowledge of the prevalence of inflammatory conditions in the First Nations and Inuit populations. These findings should be further explored in order to optimize treatment outcomes for NIHB claimants with inflammatory disease.

Cancer incidence in indigenous people in Australia, New Zealand, Canada, and the USA: a comparative population-based study.

INTRODUCTION: Indigenous people have disproportionally worse health and lower life expectancy than their non-indigenous counterparts in high-income countries. Cancer data for indigenous people are scarce and incidence has not previously been collectively reported in Australia, New Zealand, Canada, and the USA. We aimed to investigate and compare, for the first time, the cancer burden in indigenous populations in these countries. METHODS: We derived incidence data from population-based cancer registries in three states of Australia (Queensland, Western Australia, and the Northern Territory), New Zealand, the province of Alberta in Canada, and the Contract Health Service Delivery Areas of the USA. Summary rates for First Nations and Inuit in Alberta, Canada, were provided directly by Alberta Health Services. We compared age-standardised rates by registry, sex, cancer site, and ethnicity for all incident cancer cases, excluding non-melanoma skin cancers, diagnosed between 2002 and 2006. Standardised rate ratios (SRRs) and 95% CIs were computed to compare the indigenous and non-indigenous populations of each jurisdiction, except for the Alaska Native population, which was compared with the white population from the USA. FINDINGS: We included 24 815 cases of cancer in indigenous people and 5 685 264 in non-indigenous people from all jurisdictions, not including Alberta, Canada. The overall cancer burden in indigenous populations was substantially lower in the USA except in Alaska, similar or slightly lower in Australia and Canada, and higher in New Zealand compared with their non-indigenous counterparts. Among the most commonly occurring cancers in indigenous men were lung, prostate, and colorectal cancer. In most jurisdictions, breast cancer was the most common cancer in women followed by lung and colorectal cancer. The incidence of lung cancer was higher in indigenous men in all Australian regions, in Alberta, and in US Alaska Natives than in their non-indigenous counterparts. For breast cancer, rates in women were lower in all indigenous populations except in New Zealand (SRR 1·23, CI 95% 1·16-1·32) and Alaska (1·14, 1·01-1·30). Incidence of cervical cancer was higher in indigenous women than in non-indigenous women in most jurisdictions, although the difference was not always statistically significant. INTERPRETATION: There are clear differences in the scale and profile of cancer in indigenous and non-indigenous populations in Australia, New Zealand, Canada, and the USA. Our findings highlight the need for much-improved, targeted programmes of screening, vaccination, and smoking cessation, among other prevention strategies. Governments and researchers need to work in partnership with indigenous communities to improve cancer surveillance in all jurisdictions and facilitate access to cancer data. FUNDING: International Agency for Research on Cancer-Australia Fellowship.