Indigenous perspectives on wellness and health in Canada: study protocol for a scoping review.

BACKGROUND: Indigenous communities are often portrayed from a deficit-based lens; however, Indigenous communities have self-determined perspectives of health and well-being that are strength based. The objective of this study will be to systematically map the literature on perspectives, concepts, and constructs of wellness and well-being in Indigenous communities in Canada. METHODS: A scoping review protocol was designed following the Arksey and O'Malley framework. We will search the following electronic databases (from inception onwards): MEDLINE, EMBASE, Web of Science, CINAHL, Academic Search Complete, Anthropology Plus, Bibliography of Native North Americans, Canadian Business and Current Affairs, and Circumpolar Health Bibliographic Database. Grey literature will be identified through searching dissertation databases, Google Scholar, and conference abstracts. We will include all types of literature in English, published and unpublished, including any study design, reviews and meta-analyses, dissertations, reports, and books. The literature considered should describe or reflect Indigenous perspectives that identify concepts or constructs related to well-being or wellness; literature can be from any setting in Canada. Two reviewers will independently screen all citations, full-text reports, and abstract data. Data analysis will involve quantitative descriptions (e.g. frequencies) and qualitative content analysis methods. DISCUSSION: This review will provide a synthesis of the literature on Indigenous perspectives, concepts, and constructs of wellness and well-being in Canada. We anticipate the study will contribute to improve our understanding of how Indigenous communities conceptualize and embody wellness. Our findings will provide a basis for engaging Indigenous stakeholders in future health research and informing future interpretations of how wellness is conceptualized, whether written or unwritten.

The Source of the Problem.

A 58-year-old lady presented to the Emergency Department with a two-day history of shortness of breath and confusion, on a background of one week's history of general malaise, vomiting, fevers and chills. Her past medical history was unremarkable except for a large, benign goitre. Systemic enquiry revealed no symptoms to suggest a focus of infection.

The Source of the Problem.

The portable chest x-ray (Figure 1) shows a widened cardiac silhouette. An endotracheal tube is in situ, indicating the patient is now intubated. The ECG (Figure 2) shows sinus rhythm with widespread mixed convex and concave ST elevation, most notable in V4, V5 and the lateral leads. There is a suggestion of PR depression in the inferior leads.

From sea to shining sea: making collaborative rural research work.

Rural researchers collaborate on many levels to collect and analyze data, develop research reports and disseminate findings. While this collaboration is critical, there is a dearth of literature about research team collaboration within all stages of the research process. The purpose of this article is to discuss the research experience of 10 rural researchers scattered across Canada who participated in the study, Health Research: Accessible, Applicable and Useable for Rural Communities and Practitioners. Using focused ethnography, one aim of this study was to discover how research is utilized in rural and remote settings. The necessity of establishing networks to collect and manage data, and jointly analyze 72 qualitative transcripts from different geographical sites led to innovations and unexpected lessons learned. The research design provided significant opportunities to mentor undergraduate, masters and doctoral nursing students and to enhance the development of newly graduated doctoral nurses. These opportunities are crucial in the development of new researchers and in creating ongoing interest in rural health research. In this article, we discuss how the research process evolved, the mentoring process used, the barriers identified related to collaboration across vast distances, and the strategies employed to enhance the study's trustworthiness. We also consider the advantages and challenges of using Elluminate, a web application, as an interactive forum for this qualitative health research.

Effect of repaglinide addition to metformin monotherapy on glycemic control in patients with type 2 diabetes.

OBJECTIVE: To compare the effect of repaglinide in combination with metformin with monotherapy of each drug on glycemic control in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: A total of 83 patients with type 2 diabetes who had inadequate glycemic control (HbA1c > 7.1%) when receiving the antidiabetic agent metformin were enrolled in this multicenter, double-blind trial. Subjects were randomized to continue with their prestudy dose of metformin (n = 27), to continue with their prestudy dose of metformin with the addition of repaglinide (n = 27), or to receive repaglinide alone (n = 29). For patients receiving repaglinide, the optimal dose was determined during a 4- to 8-week titration and continued for a 3-month maintenance period. RESULTS: In subjects receiving combined therapy, HbA1c was reduced by 1.4 +/- 0.2%, from 8.3 to 6.9% (P = 0.0016) and fasting plasma glucose by 2.2 mmol/l (P = 0.0003). No significant changes were observed in subjects treated with either repaglinide or metformin monotherapy in HbA1c (0.4 and 0.3% decrease, respectively) or fasting plasma glucose (0.5 mmol/l increase and 0.3 mmol/l decrease respectively). Subjects receiving repaglinide either alone or in combination with metformin, had an increase in fasting levels of insulin between baseline and the end of the trial of 4.04 +/- 1.56 and 4.23 +/- 1.50 mU/l, respectively (P < 0.02). Gastrointestinal adverse events were common in the metformin group. An increase in body weight occurred in the repaglinide and combined therapy groups (2.4 +/- 0.5 and 3.0 +/- 0.5 kg, respectively; P < 0.05). CONCLUSIONS: Combined metformin and repaglinide therapy resulted in superior glycemic control compared with repaglinide or metformin monotherapy in patients with type 2 diabetes whose glycemia had not been well controlled on metformin alone. Repaglinide monotherapy was as effective as metformin monotherapy.

The relative effectiveness of educational and behavioral instruction programs for patients with NIDDM: a randomized trial.

In this randomized trial patients with non-insulin-dependent diabetes were allocated to one of four programs: a minimal instruction program (n = 59), and education program of individual visits (n = 57), an education program incorporating a group education course (n = 66), and a behavioral program (n = 59). Individual and group education programs had higher attrition rates than the behavioral and minimal programs. The four programs, which involved different amounts of patient contact time, delivery format, and instructional strategies, all produced reductions in HbA1 and BMI, with no significant differences between the programs. There were no differences between groups over three time periods in total cholesterol, HDL cholesterol, systolic blood pressure, or proportion of patients consulting an ophthalmologist. The behavioral program produced a greater reduction in diastolic blood pressure over 12 months than the education programs and a greater reduction in the cholesterol risk ratio over 3 months than the other programs. The behavioral program patients were more likely to have visited a podiatrist after 6 months and reported higher satisfaction.

The use of portable blood glucose monitors by trained lay operators.

OBJECTIVE: To evaluate the use of Reflolux II blood glucose reflectance meters by trained lay operators in a community survey. DESIGN: A random household survey involving assessment of participants' blood glucose levels by Reflolux II. For a random subsample of participants an additional sample of blood was placed onto filter paper strips and stored for later examination and assay. SETTING: The survey was conducted in the Newcastle and Lake Macquarie areas of New South Wales. PARTICIPANTS: Of the 1275 participants 15 years and over, 1229 consented to have their blood glucose assessed and 163 of these also had blood stored on filter paper strips. Data were collected by 25 interviewers. MAIN OUTCOME MEASURES: Application of blood spots to filter paper assessed the interviewers' capacity to collect samples of minimal acceptability for Reflolux II operation. Samples were considered adequate if they covered at least a 6 mm soaked disk and there was no evidence that they had been smeared or applied from both sides of the paper. The Reflolux II readings obtained by the interviewers were compared with the blood glucose values from assay of the filter paper samples. RESULTS: Only 63% of the 163 samples collected on filter paper were of acceptable quality for adequate Reflolux II operation. The overall correlation between Reflolux II blood glucose values and those determined from the blood collected on filter paper was good (r = 0.893). However, three of the eight interviewers who had five or more readings for comparison achieved correlation coefficients of < r = 0.20. Of the survey participants identified as having elevated blood glucose levels (> 8 mmol/L) by the filter paper assay, 58% (7 of 12) were not detected by the lay operated reflectance meters. Twenty-two per cent of the individuals assessed by the reflectance meter, compared with 0.5% of a population sample surveyed by the National Heart Foundation, had blood glucose values of less than 3.5 mmol/L. CONCLUSION: It would appear that there may be a considerable error rate in blood glucose values obtained by lay operators using reflectance meters, resulting in underestimation of blood glucose levels. The findings have implications for community awareness programs for diabetes and highlight the need for careful training and monitoring of lay operators in their obtaining of finger-prick blood samples and their use of reflectance meters.

Multipartite structure of a negative regulatory element associated with a steroid hormone-inducible promoter.

The steroid hormone-inducible promoter from mouse mammary tumor virus is associated with a distal negative regulatory element that represses its inherent basal activity. Deletion analysis localized the sequences required for repression to 64 base pairs of DNA between -427 and -364 with respect to the transcription initiation site. Transient transfection experiments with a series of linker scanning and small internal deletion mutations revealed two mutation-sensitive domains separated by a region of relative resistance to sequence alterations. DNase I footprinting and gel electrophoresis mobility shift experiments with crude nuclear extracts identified at least one protein-binding site within each of the two mutation-sensitive regions. An oligonucleotide corresponding to one of these sites is able to repress transcription, but only when linked to the promoter in multiple copies. This negative regulatory element functions synergistically with a promoter proximal negative element to mediate efficient promoter repression, selectively affecting basal relative to steroid hormone-induced transcription and thus increasing the ratio of promoter activity observed in the presence and absence of hormone.

Sleep difficulties, pain and other correlates.

A multiple regression analysis was used with variables relevant to sleeping problems from a large community health survey in South Australia. The variables that were found to be most strongly correlated with sleep problems were, in order of importance, pain, anxiety, age, somatic health and annual household income, all of which accounted for 22% of the variance. Weight problems, depression and sex of the respondent were not so important in this analysis. Arthritis, which often increases with age, appeared to be most strongly associated with pain, explaining in part why sleeping problems increase with age. Anxiety, pain and poor somatic health were most strongly associated with lying awake at night or sleeping badly, and anxiety and pain were most strongly correlated with taking longer to get to sleep. Poor somatic health and anxiety were most strongly associated with waking early, and age and pain were the most important variables in taking tablets to aid sleep.

Update and implications from the Newcastle diabetic retinopathy study.

Over 11 years from 1977 a large study of diabetic retinopathy has been conducted in Newcastle and in 1988, 5519 diabetic subjects had been assessed. Where possible, all had retinal photography. Prevalence rates for any retinopathy, proliferative retinopathy and maculopathy were assessed in relation to the known duration of diabetes for subjects diagnosed before or after age 30 years. These data indicate a peak of retinopathy prevalence in the second or third decade of diabetes with slightly lower rates in longer survivors. Treatment with insulin was associated with a higher retinopathy prevalence. Incidence rates for the new development of background retinopathy in previously unaffected subjects show a peak late in the first decade of diabetes in young-onset cases, while in the older-onset group, the peak occurs in the second decade of diabetes. Over all, 8% of diabetics without retinopathy developed it per year. The implications of this data for the routine management of diabetic patients is discussed and the current recommendations for retinal screening by the Australian Diabetes Society are outlined.

Influence of variable content of dietary zinc on copper metabolism of weanling foals.

The influence of variable zinc content (29.1, 250, 1,000 and 2,000 mg/kg of dry weight) in a basic diet containing 7.7 mg of copper/kg on the ability of weanling foals to maintain normal copper balance was investigated. Serum copper and zinc concentrations were monitored, and terminal hepatic copper and zinc contents were measured in 4 weanling foals fed the basic diet containing 29.1 mg of zinc/kg and in 2 foals each fed the higher-zinc diets. Foals fed the lower-zinc diets (29.1 and 250 mg/kg) maintained normal serum copper and zinc concentrations for 14 to 15 weeks, whereas those fed the 2 higher-zinc diets became hypocupremic within 5 to 6 weeks and were lame within 6 weeks, owing to cartilaginous disease characteristic of osteochondritis dissecans. Serum zinc concentration in the foals fed the 2 higher-zinc diets increased to greater than 2 micrograms/ml within 2 weeks. Foals fed the high-zinc diets became lame after serum copper concentration had remained at 0.3 micrograms/ml for greater than 1 week. Serum copper concentration in these arthritic foals was less than or equal to 0.2 micrograms/ml at the end of the study. In lame foals, fractures of the cartilage of the articular and growth physes occurred through the zone of hypertrophic cells, and varied from bilateral to unilateral and from small to large. Free masses and flaps of cartilage attached to one side were numerous.

Diabetes and glucose tolerance in New South Wales coastal Aborigines: possible effects of non-Aboriginal genetic admixture.

A survey of adults living in two predominantly Aboriginal communities in eastern New South Wales revealed a crude prevalence of clinically diagnosed diabetes of 6.7% in Aboriginals. 1.4% of Aboriginal subjects investigated with 75 g oral glucose tolerance tests were found to have previously undiagnosed diabetes, and 2.8% had impaired glucose tolerance. 53% of women and 27% of men were obese as judged by body mass index. The age-sex standardised prevalence of diabetes in Aboriginals (previously diagnosed and newly detected) was 7.8%, which is substantially lower than the 15.6% prevalence found in the Aboriginal population of Bourke (central New South Wales). HLA antigen studies on these same individuals suggest approximately 60% genetic admixture from non-Aboriginal sources. Insulin response to oral glucose and mean body mass index were both related to non-Aboriginal genetic admixture with higher values in Aboriginal subjects than in their non-Aboriginal neighbours, and highest values were found in those with no detectable non-Aboriginal HLA haplotypes. The extent of genetic admixture in these communities may partly explain the lower prevalence of diabetes when compared with that found in the Aboriginal population of Bourke.

Diabetes mellitus in the Australian aborigines of Bourke, New South Wales.

294 subjects, 89% of the adult Aboriginal population of Bourke and Enngonia, New South Wales, were investigated for diabetes and IGT (impaired glucose tolerance). The prevalence of known diabetes was 9.5%, that of previously unknown diabetes 6.1% and that of IGT 2.4% (all defined according to World Health Organization criteria). A serum glucose value 2 h after 75 g of glucose was found to be an acceptable screening test but not HbA1 due to a large number of false positives. The total prevalence of diabetes (15.6%) was lower than the 19.0% described in the study of Aboriginals in Davenport [Wise et al., Med. J. Aust., 2: 1001-1006, 1970]. However, when these crude prevalences are standardized, the prevalence in Bourke and Enngonia (15.6%) is higher than that calculated for Davenport (11.2%) and higher than that found in a previous report of the Bourke population [Kamien, Med. J. Aust., Spec. Suppl., April: 38-44, 1976]. In contrast to Davenport a large proportion (67%) of diabetic subjects in Bourke were under the age of 50. This may be partly attributable to obesity which, relative to older subjects, was common in young adults in Bourke, particularly men. The consumption of alcohol in this population, though high, was not associated with abnormal glucose tolerance.

Mental health in marriage: the roles of need for affiliation, sensitivity to rejection, and other factors.

This study reports on the associations between a number of personality factors and spouse mental health, happiness, and communication (N = 78). Lower Affiliative Drive and higher Sensitivity to Rejection emerge in this sample as being associated in wives (but not husbands) with increased psychological morbidity. Wives had higher levels of both Need for Affiliation and Sensitivity to Rejection than husbands, which possibly may lead to higher internal conflict for them. Although causality cannot necessarily be assumed, these results are consistent with the hypothesis that wives' mental health is more "relationship related" than that of husbands.

Factorial structure of the aftermath of suicide instrument.

Initial factor-analytic studies of the Aftermath of Suicide Instrument suggested that there may be four broad areas of social reaction to suicide. In a replication study, this 25-item questionnaire was administered to a community sample of 54 persons aged between 21 and 77 years. Factor analysis of their responses identified five factors, but only one of these was similar to any of the original factors. This marked variation is probably due to differences in the population sampled, with the present group of respondents more heterogeneous. While the content of the Aftermath of Suicide Instrument remains valid, it appears that its factorial structure requires further clarification. This is consistent with the emotional and clinical complexities of the subject of suicide.

Human (semisynthetic) insulin and porcine insulin in the treatment of non-insulin-dependent diabetes. A double-blind, comparative clinical trial.

Twenty-one patients with non-insulin-dependent diabetes, who had not previously received insulin therapy, participated in a double-blind comparative trial of six months' duration to evaluate the efficacy of human (semisynthetic) insulin. Patients were allocated at random to treatment either with human (semisynthetic) insulin (10 patients) or with an equivalent porcine insulin regimen (11 patients). Sex ratio, age, body mass index, duration of diabetes, C-peptide concentrations, baseline metabolic control and initial insulin requirements were similar in both groups. After six months, no significant differences between the treatment effects of human (semisynthetic) insulin and porcine insulin, as assessed by measurements of fasting and postprandial plasma glucose levels, the concentration of glycosylated haemoglobin, serum lipid levels, insulin dose, and body weight, were found. No adverse reactions, injection-site anomalies, or drug-related biochemical abnormalities were noted in either group. It was concluded that human (semisynthetic) insulin is as effective as porcine insulin in initiating the treatment of patients with non-insulin-dependent diabetes who require insulin therapy.