Funding the pandemic response for Indigenous Peoples: an equity-based analysis of COVID-19 using a Health Equity Impact Assessment (HEIA) Indigenous lens tool.

This study examines the allocation of COVID-19 funding for Indigenous Peoples in Canada, Australia, New Zealand, and the United States during the pandemic's first wave. Indigenous communities, already facing health disparities, systemic discrimination, and historical forces of colonisation, found themselves further vulnerable to the virus. Analysing the funding policies of these countries, we employed a Health Equity Impact Assessment (HEIA) tool and an Indigenous Lens Tool supplement to evaluate potential impacts. Our results identify three major funding equity issues: unique health and service needs, socioeconomic disparities, and limited access to community and culturally safe health services. Despite efforts for equitable funding, a lack of meaningful consultation led to shortcomings, as seen in Canada's state of emergency declaration and legal disputes in the United States. New Zealand stood out for integrating Maori perspectives, showcasing the importance of consultation. The study calls for a reconciliation-minded path, aligning with Truth and Reconciliation principles, the UN Declaration on the Rights of Indigenous Peoples, and evolving government support. The paper concludes that co-creating equitable funding policies grounded in Indigenous knowledge requires partnership, meaningful consultation, and organisational cultural humility. Even in emergencies, these measures ensure responsiveness and respect for Indigenous self-determination.

Developing a Health Equity Impact Assessment 'Indigenous Lens Tool' to address challenges in providing equitable cancer screening for indigenous peoples.

BACKGROUND: In spite of past efforts to increase screening uptake, the rates of screening-detectable cancers including breast, cervical, colorectal and lung are rising among Indigenous persons in Ontario compared to other Ontarians. The Ontario Ministry of Health has an equity framework, the Health Equity Impact Assessment (HEIA) Tool, that was developed to guide organizations in the provision of more equitable health and social services. Although the HEIA Tool identifies that the health of Indigenous persons may benefit from more equitable provision of health and social services, it provides very little specific guidance on how to apply the HEIA Tool in a culturally relevant way to policies and programs that may impact Indigenous peoples. DISCUSSION: Guided by the Calls to Action from the Truth and Reconciliation Commission of Canada and the United Nations Declaration on the Rights of Indigenous Peoples, an Indigenous Lens Tool was developed through a collaborative and iterative process with stakeholders at Cancer Care Ontario and with representatives from Indigenous community-based organizations. The Indigenous Lens Tool consists of four scenarios, with supporting documentation that provide context for each step of the HEIA Tool and thereby facilitate application of the equity framework to programs and policies. The document is in no way meant to be comprehensive or representative of the diverse health care experiences of Indigenous peoples living in Canada nor the social determinants that surround health and well-being of Indigenous peoples living in Canada. Rather, this document provides a first step to support development of policies and programs that recognize and uphold the rights to health and well-being of Indigenous peoples living in Canada. CONCLUSIONS: The Indigenous Lens Tool was created to facilitate implementation of an existing health equity framework within Cancer Care Ontario (now Ontario Health). Even though the Indigenous Lens Tool was created for this purpose, the principles contained within it are translatable to other health and social service policy applications.

2023 Canadian Colposcopy Guideline: A Risk-Based Approach to Management and Surveillance of Cervical Dysplasia.

This guideline provides evidence-based guidance on the risk-based management of cervical dysplasia in the colposcopy setting in the context of primary HPV-based screening and HPV testing in colposcopy. Colposcopy management of special populations is also discussed. The guideline was developed by a working group in collaboration with the Gynecologic Oncology Society of Canada (GOC), Society of Colposcopists of Canada (SCC) and the Canadian Partnership Against Cancer (CPAC). The literature informing these guidelines was obtained through a systematic review of the relevant literature via a multi-step search process led by information specialists. The literature was reviewed up to June 2021 with manual searches of relevant national guidelines and more recent publications. Quality of the evidence and strength of recommendations was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. The intended users of this guideline include gynecologists, colposcopists, screening programs and healthcare facilities. Implementation of the recommendations is intended to promote equitable and standardized care for all people undergoing colposcopy in Canada. The risk-based approach aims to improve personalized care and reduce over-/under-treatment in colposcopy.

On the path to reclaiming Indigenous midwifery: Co-creating the Maternal Infant Support Worker pilot program.

OBJECTIVE: The aim of the Maternal Infant Support Worker (MiSW) pilot program was to implement a virtual training program for lay maternal-infant health providers in remote First Nations communities in Northwestern Ontario, Canada. METHODS: The MiSW pilot program was administered jointly by a community college and a university and consisted of a 20-week virtual course followed by a 9-month mentored work placement in the community. RESULTS: The MiSW pilot program was delivered successfully; 11 of 13 participants received a certificate from a community college. MiSWs provided culturally and linguistically appropriate care to women, infants, and families in their respective communities. MiSWs provided doula support in their communities-a first for our region since the policy of forced evacuation for birth was implemented. MiSWs developed a community of practice for ongoing education, as well as to support each other in their work. CONCLUSION: The MiSW pilot program demonstrated that it is possible to provide a virtual training program and then provide continued virtual mentorship as the participants work in their First Nations communities. By prioritizing Indigenous voices above those of the research team, we were able to gain the trust of the MiSWs and maintain engagement with communities.

Health Policy as a Barrier to First Nations Peoples' Access to Cancer Screening.

BACKGROUND: First Nations peoples in Ontario are facing increasing rates of cancer and have been found to have poorer survival. Cancer screening is an important strategy to improve cancer outcomes; yet, Indigenous people in Canada are less likely to participate in screening. Ontario has established organized breast, cervical and colorectal cancer screening programs; this paper examines the health policy context that informs these programs for First Nations peoples in the province. METHOD: This paper follows an embedded multiple-case study design, drawing upon a document review to outline the existing policy context and on key informant interviews to explore the aforementioned context from the perspective of stakeholders. RESULTS: Policies created by agencies operating across federal, regional and provincial levels impact First Nations peoples' access to screening. Interviews identified issues of jurisdictional ambiguity, appropriateness of program design for First Nations persons and lack of cultural competency as barriers to participation in screening. CONCLUSION: Federal, provincial and regional policy makers must work in collaboration with First Nations peoples to overcome barriers to cancer screening created and sustained by existing policies.

Cesarean Delivery and Vaginal Birth After Cesarean Delivery Rates in a First Nations Community-Based Obstetrical Program in Northwestern Ontario.

OBJECTIVE: To examine rates of cesarean delivery (CD) and vaginal birth after cesarean delivery (VBAC) and the patient profile in a community-based obstetrical practice. METHODS: Retrospective data from 2012 to 2017 for the Sioux Lookout Meno Ya Win Health Centre (SLMHC) were compared to data from the 30 hospitals providing the same level of services (Maternity 1b: maternity care by family physicians/midwives with CD and VBAC capacity) and Ontario. SLMHC VBAC patients were then compared to the general SLMC obstetrical population. Data included maternal age, parity, comorbidities, CD, VBAC, neonatal birth weight, and Apgar scores. RESULTS: The SLMHC obstetrical population differed from comparable obstetrical programs, with significantly higher rates of alcohol, tobacco, and opioid use and a higher prevalence of diabetes. CD rates were significantly lower (25% vs. 28%), and women delivering at SLMHC chose a trial of labour after CD almost twice as often (46% vs. 27%), resulting in a significantly higher VBAC rate (31% vs. 16%). Patients in the VBAC population differed from the general SLMHC obstetrical population, being older (7 years) and of greater parity. The neonates of VBAC patients had equivalent Apgar scores but lower rates of macrosomia and lower birth weights, although the average VBAC birth weight at 3346 g was equivalent to the provincial average. CONCLUSION: The SLMHC obstetrical program has lower CD and higher VBAC rates than expected, despite prevalent risk factors typically associated with CD. Our study demonstrates that VBAC can be safely performed in well-screened and monitored patients in a rural setting with emergency CD capacity.

Differences in hospital length of stay between neonates exposed to buprenorphine versus methadone in utero: A retrospective chart review.

INTRODUCTION: Neonatal abstinence syndrome is a growing concern in neonatal intensive care units in rural and remote settings. METHODS: A retrospective chart review was conducted of 180 mother-infant dyads born with in utero exposure to buprenorphine (n=60), methadone (n=60) or to other opioids (n=60) to determine neonatal length of stay in hospital, number of days on morphine, day of life of initiation of morphine and the need for phenobarbital. RESULTS: The length of stay in hospital for neonates was 5.8 days shorter (95% confidence interval [CI] 6.1 to 8.5 days) for buprenorphine exposure in utero compared to methadone (P=0.001). For neonates requiring treatment for Neonatal abstinence syndrome, those with in utero exposure to buprenorphine required 6.1 fewer days (95% CI 2.5 to 9.7) of treatment with morphine then those exposed to methadone (P<0.0005). There were no statistically significant differences in day of life of initiation of morphine therapy for each of the study groups. The proportion of neonates requiring adjuvant therapy with phenobarbital was statistically significantly higher in neonates exposed to methadone in utero than either buprenorphine or illicit opioids (P<0.0005). CONCLUSIONS: Retrospective data suggest that neonates with in utero exposure to buprenorphine experience a shorter length of stay in hospital, fewer days of treatment with morphine for neonatal abstinence syndrome, and less use of phenobarbital than neonates exposed in utero to methadone. This suggests that Ontario provincial guidelines should be updated to recommend buprenorphine as first line for replacement therapy in pregnancy.

Opioid use in pregnancy and parenting: An Indigenous-based, collaborative framework for Northwestern Ontario.

Opioid use affects up to 30% of pregnancies in Northwestern Ontario. Health care providers in Northwestern Ontario have varying comfort levels providing care to substance-involved pregnant women. Furthermore, health care practitioners, social service agencies and community groups in Northwestern Ontario often work in isolation with little multidisciplinary communication and collaboration. This article describes two workshops that brought together health and social service providers, community organizations, as well as academic institutions and professional organizations involved in the care of substance-involved pregnant and parenting women. The initial workshop presented best practices and local experience in the management of opioid dependence in pregnancy while the second workshop asked participants to apply a local Indigenous worldview to the implementation of clinical, research and program priorities that were identified in the first workshop. Consensus statements developed by workshop participants identified improved transitions in care, facilitated access to buprenorphine treatment, stable funding models for addiction programs and a focus on Indigenous-led programming. Participants identified a critical need for a national strategy to address the effects of opioid use in pregnancy from a culturally safe, trauma-informed perspective that takes into account the health and well-being of the woman, her infant, her family and her community.

Teaching tools to engage Anishinaabek First Nations women in cervical cancer screening: Report of an educational workshop.

OBJECTIVE: To explore educational strategies for engaging First Nations women in Canada to attend cervical cancer screening. DESIGN: Within a participatory action research framework, semi-structured interviews with health-care providers in First Nations communities revealed that education about the value of screening is perceived as being a key factor to promote cervical cancer screening. SETTING: To obtain feedback from workshop informants, a 1-day educational workshop was held to identify appropriate educational intervention strategies, which would be applied in a forthcoming randomised controlled cervical screening trial. METHODS: Common discussion and discussion groups, which were facilitated by a First Nations workshop moderator and a note taker. RESULTS: This workshop helped to strengthen the ethical space dialogue with the First Nations communities with whom the study team had established research partnerships. The workshop atmosphere was relaxed and the invited informants decided that an educational health promotion event for community women needed to be held prior to inviting them to the cervical screening trial. Such an event would provide an opportunity to communicate the importance of attending regular cervical screening allowing women to make informed decisions about screening participation. Complementary promotional items, including an eye-catching pamphlet and storytelling, were also suggested. CONCLUSION: The key messages from the events and promotional items can help to destigmatise women who develop a type of cancer that is caused by a sexually transmitted virus that affects both men and women. Developing and implementing positive health education that respectfully depicts female bodies, sexuality and health behaviours through a First Nations lens is strongly warranted.

Observational study of the safety of buprenorphine+naloxone in pregnancy in a rural and remote population.

OBJECTIVES: To describe the effect of in utero exposure to the buprenorphine+naloxone combination product in a rural and remote population. SETTING: A district hospital that services rural and remote, fly-in communities in Northwestern Ontario, Canada. PARTICIPANTS: A retrospective cohort study was conducted of 855 mother infant dyads between 1 July 2013 and 30 June 2015. Cases included all women who had exposure to buprenorphine+naloxone during pregnancy (n=62). 2 control groups were identified; the first included women with no opioid exposure in pregnancy (n=618) and the second included women with opioid exposure other than buprenorphine+naloxone (n=159). Women were excluded if they had multiple pregnancy or if they were part of a methadone programme (n=16). The majority of women came from Indigenous communities. OUTCOMES: The primary outcomes were birth weight, preterm delivery, congenital anomalies and stillbirth. Secondary neonatal outcomes included gestational age at delivery, Apgar scores at 1 and 5 min, NAS Score >7 and treatment for neonatal abstinence syndrome (NAS). Secondary maternal outcomes included the number of caesarean sections, postpartum haemorrhages, out of hospital deliveries and transfer of care to tertiary centres. RESULTS: No difference was found in the primary outcomes or in the Apgar score and caesarean section rate between in utero buprenorphine+naloxone exposure versus no opioid exposure in pregnancy. Compared to women taking other opioids, women taking buprenorphine+naloxone had higher birthweight babies (p=0.001) and less exposure to marijuana (p<0.001) during pregnancy. CONCLUSIONS: Retrospective data suggest that there likely is no harm from taking buprenorphine+naloxone opioid agonist treatment in pregnancy. Larger, prospective studies are needed to further assess safety.

Rural, Pregnant, and Opioid Dependent: A Systematic Review.

The nature, impact, and treatment of substance use during pregnancy are well described for women living in urban settings. Less is known about pregnant substance-using women living in rural communities. The objective of this review is to describe the existing evidence for the management of substance use in pregnant women living in rural areas. A systematic review of the literature was conducted using PubMed, Embase, and the Cochrane Database of Systematic Reviews, and the quality of the evidence was assessed using the GRADE system. Twenty-two articles that met the inclusion criteria were identified. Descriptive studies document high rates of smoking, marijuana, and polysubstance use among rural, substance-using pregnant women compared to their urban counterparts. Management of substance use disorders is limited by access to and acceptability of treatment modalities. Several innovative, integrated addiction and prenatal care programs have been developed, which may serve as models for management of substance use during pregnancy in rural settings.

A Canadian survey of postgraduate education in Aboriginal women's health in obstetrics and gynaecology.

OBJECTIVE: To assess Canadian obstetrics and gynaecology residents' knowledge of and experience in Indigenous women's health (IWH), including a self-assessment of competency, and to assess the ability of residency program directors to provide a curriculum in IWH and to assess the resources available to support this initiative. METHODS: Surveys for residents and for program directors were distributed to all accredited obstetrics and gynaecology residency programs in Canada. The resident survey consisted of 20 multiple choice questions in four key areas: general knowledge regarding Indigenous peoples in Canada; the impact of the residential school system; clinical experience in IWH; and a self-assessment of competency in IWH. The program director survey included an assessment of the content of the curriculum in IWH and of the resources available to support this curriculum. RESULTS: Residents have little background knowledge of IWH and the determinants of health, and are aware of their knowledge gap. Residents are interested in IWH and recognize the importance of IWH training for their future practice. Program directors support the development of an IWH curriculum, but they lack the resources to provide a comprehensive IWH curriculum and would benefit from having a standardized curriculum available. CONCLUSION: A nationwide curriculum initiative may be an effective way to facilitate the provision of education in IWH while decreasing the need for resources in individual programs.

Objectif : Évaluer les connaissances des résidents canadiens en obstétrique-gynécologie en matière de santé des femmes autochtones (SFA) et leur expérience dans ce domaine (y compris une auto-évaluation de la compétence), et déterminer la capacité des directeurs de programme de résidence d'offrir un curriculum en SFA et d'évaluer les ressources disponibles en vue de soutenir cette initiative. Méthodes : Des sondages destinés aux résidents et aux directeurs de programme ont été distribués dans tous les programmes de résidence agréés en obstétrique-gynécologie du Canada. Le sondage destiné aux résidents comptait 20 questions à choix multiple couvrant quatre domaines clés : connaissances générales au sujet des peuples autochtones du Canada; les effets du système de pensionnat; l'expérience clinique en SFA; et une auto-évaluation de la compétence en SFA. Le sondage destiné aux directeurs de programme comptait une évaluation du contenu du curriculum en SFA et des ressources disponibles en vue de soutenir ce curriculum. Résultats : Les résidents détiennent peu de connaissances préalables au sujet de la SFA et des déterminants de la santé, et sont conscients de ces lacunes. Ils s'intéressent à la SFA et reconnaissent l'importance de pouvoir disposer d'une formation dans ce domaine pour leurs activités professionnelles à venir. Les directeurs de programme soutiennent l'élaboration d'un curriculum en SFA, mais ne détiennent pas les ressources nécessaires pour offrir un curriculum exhaustif dans ce domaine et tireraient avantage de la disponibilité d'un curriculum standardisé. Conclusion : La mise sur pied d'une initiative nationale en ce qui concerne l'élaboration d'un curriculum pourrait constituer une façon efficace de faciliter l'offre d'une formation en SFA, tout en atténuant la nécessité pour chacun des programmes de chercher à obtenir des ressources à cette fin.

Assessment of the ideal body image of women in Accra, Ghana.

The hypothesis tested in this study was that the 'traditional build' is the culturally valued body shape by Ghanaian women. Culturally sensitive figural stimuli were designed to assess the current body image (CBI) and the ideal body image (IBI) of Ghanaian women. The most frequently selected model for the CBI was one that represented a slightly overweight woman; the IBI selected was consistent with a representation of normal body mass index; and the least healthy image was that figure that represented morbidly obesity.

Interest in healthy living outweighs presumed cultural norms for obesity for Ghanaian women.

BACKGROUND: Cultural norms indicate that obesity reflects increased wealth and prosperity. Yet obesity is linked to serious medical illnesses. The purpose of this study was to determine if Ghanaian women would change their body image if it meant a healthier life. METHODS: A questionnaire was administered to 305 Ghanaian women waiting for clinic appointments at Korle Bu Teaching Hospital, Accra Ghana. This survey included questions on current health, selection of figural stimuli, decision making on health and social determinants and 5 questions on self-perception of health from SF-36. Anthropometric measures were taken and body mass index calculated. Women were also provided with health related information at the conclusion of the interview. RESULTS: The majority of all women surveyed would reduce their current body image if it meant that they would have an overall healthier life and reduce the risks of obesity-linked illnesses and complications. Currently obese women were significantly more likely than non-obese women to reduce their body image to reduce the risk of hypertension (OR 2.03 [1.64 - 2.51],<0.001); cardiovascular accident (OR 1.96 [1.61 - 2.38],<0.001); diabetes (OR 2.00 [1.63 - 2.44],<0.001); myocardial infarction (OR 2.27 [1.80 - 2.86],<0.001); if requested by a spouse(OR 2.64 [1.98 - 3.52],<0.001); and to improve overall health (OR 1.95 [1.60 - 2.37], <0.001). There was no association with current body image and responses to SF-36. The decision to select a new body image was not influenced by education, income, marital status or parity. Age 50 years old and less was significantly associated with the body image size reduction to reduce the risk of hypertension, diabetes, and a cardiovascular accident. CONCLUSION: The Ghanaian women interviewed in this study are interested in living a healthy life and are willing to reduce their body size to reduce the risk of obesity-linked illnesses. The target group for any interventional studies and measures to reduce obesity appears to be women age 50 and younger.