Conceptualising cultural safety at an Indigenous-focused midwifery practice in Toronto, Canada: qualitative interviews with Indigenous and non-Indigenous clients.

OBJECTIVE: Cultural safety is an Indigenous concept that can improve how healthcare services are delivered to both Indigenous and non-Indigenous peoples in Canada. This study explored how Indigenous and non-Indigenous clients at an urban, Indigenous-focused midwifery practice in Toronto, Canada (Seventh Generation Midwives Toronto, SGMT) conceptualised and experienced culturally safe care. DESIGN AND SETTING: Interviews were conducted with former clients of SGMT as a part of a larger evaluation of the practice. Participants were purposefully recruited. Interviews were transcribed and analysed thematically using an iterative, consensus-based approach and a critical, naturalistic, and decolonising lens. PARTICIPANTS: Saturation was reached after 20 interviews (n=9 Indigenous participants, n=11 non-Indigenous participants). RESULTS: Three domains of cultural safety emerged. Each domain included several themes: Relationships and Communication (respect and support for choices; personalised and continuous relationships with midwives; and being different from past experiences); Sharing Knowledge and Practice (feeling informed about the basics of pregnancy, birth, and the postpartum period; and having access to Indigenous knowledge and protocols), and Culturally Safe Spaces (feeling at home in practice; and having relationships interconnected with the physical space). While some ideas were shared across groups, the distinctions between the Indigenous and non-Indigenous participants were prominent. CONCLUSION: The Indigenous participants conceptualised cultural safety in ways that highlight the survival and resurgence of Indigenous values, understandings, and approaches in cities like Toronto, and affirm the need for Indigenous midwives. The non-Indigenous participants conceptualised cultural safety with both congruence, illuminating Black-Indigenous community solidarities in cultural safety, and divergence, demonstrating the potential of Indigenous spaces and Indigenous-focused midwifery care to also benefit midwifery clients of white European descent. We hope that the positive impacts documented here motivate evaluators and healthcare providers to work towards a future where 'cultural safety' becomes a standard of care.

Study protocol: Our Cultures Count, the Mayi Kuwayu Study, a national longitudinal study of Aboriginal and Torres Strait Islander wellbeing.

INTRODUCTION: Aboriginal and Torres Strait Islander peoples are Australia's first peoples and have been connected to the land for ≥65 000 years. Their enduring cultures and values are considered critical to health and wellbeing, alongside physical, psychological and social factors. We currently lack large-scale data that adequately represent the experiences of Aboriginal and Torres Strait Islander people; the absence of evidence on cultural practice and expression is particularly striking, given its foundational importance to wellbeing. METHOD AND ANALYSIS: Mayi Kuwayu: The National Study of Aboriginal and Torres Strait Islander Wellbeing (Mayi Kuwayu Study) will be a large-scale, national longitudinal study of Aboriginal and Torres Strait Islander adults, with linkage to health-related administrative records. The baseline survey was developed through extensive community consultation, and includes items on: cultural practice and expression, sociodemographic factors, health and wellbeing, health behaviours, experiences and environments, and family support and connection. The baseline survey will be mailed to 200 000 Aboriginal and Torres Strait Islander adults (≥16 years), yielding an estimated 16 000-40 000 participants, supplemented through face-to-face recruitment. Follow-up surveys will be conducted every 3-5 years, or as funding allows. The Mayi Kuwayu Study will contribute to filling key evidence gaps, including quantifying the contribution of cultural factors to wellbeing, alongside standard elements of health and risk. ETHICS AND DISSEMINATION: This study has received approval from national Human Research Ethics Committees, and from State and Territory committees, including relevant Aboriginal and Torres Strait Islander organisations. The study was developed and is conducted in partnership with Aboriginal and Torres Strait Islander organisations across states and territories. It will provide an enduring and shared infrastructure to underpin programme and policy development, based on measures and values important to Aboriginal and Torres Strait Islander peoples. Approved researchers can access confidentialised data and disseminate findings according to study data access and governance protocols.

Effect of a health literacy intervention trial on knowledge about cardiovascular disease medications among Indigenous peoples in Australia, Canada and New Zealand.

OBJECTIVES: To assess the effect of a customised, structured cardiovascular disease (CVD) medication health literacy programme on medication knowledge among Indigenous people with, or at high risk of, CVD. DESIGN: Intervention trial with premeasures and postmeasures at multiple time points. SETTING: Indigenous primary care services in Australia, Canada and New Zealand. PARTICIPANTS: 171 Indigenous people aged ≥20 years of age who had at least one clinical diagnosis of a CVD event, or in Canada and Australia had a 5-year CVD risk ≥15%, and were prescribed at least two of the following CVD medication classes: statin, aspirin, ACE inhibitors and beta blockers. INTERVENTION: An education session delivered on three occasions over 1 month by registered nurses or health educators who had received training in health literacy and principles of adult education. An interactive tablet application was used during each session and an information booklet and pill card provided to participants. PRIMARY OUTCOME MEASURES: Knowledge about the CVD medications assessed before and after each session. RESULTS: Knowledge at baseline (presession 1) was low, with the mean per cent correct answers highest for statins (34.0% correct answers), 29.4% for aspirin, 26.0% for beta blockers and 22.7% for ACE inhibitors. Adjusted analyses showed highly significant (P<0.001) increases in knowledge scores between preassessments and postassessments at all three time points for all medication classes. For the four medications, the absolute increases in adjusted per cent correct items from presession 1 to postsession 3 assessments were 60.1% for statins, 76.8% for aspirin, 71.4% for ACE inhibitor and 69.5% for beta blocker. CONCLUSIONS: The intervention was highly effective in contextually diverse Indigenous primary healthcare services in Australia, Canada and New Zealand. The findings from this study have important implications for health services working with populations with low health literacy more generally. TRIAL REGISTRATION NUMBER: ACTRN12612001309875.

Our Health Counts Toronto: using respondent-driven sampling to unmask census undercounts of an urban indigenous population in Toronto, Canada.

OBJECTIVES: To provide evidence of the magnitude of census undercounts of 'hard-to-reach' subpopulations and to improve estimation of the size of the urban indigenous population in Toronto, Canada, using respondent-driven sampling (RDS). DESIGN: Respondent-driven sampling. SETTING: The study took place in the urban indigenous community in Toronto, Canada. Three locations within the city were used to recruit study participants. PARTICIPANTS: 908 adult participants (15+) who self-identified as indigenous (First Nation, Inuit or Métis) and lived in the city of Toronto. Study participants were generally young with over 60% of indigenous adults under the age of 45 years. Household income was low with approximately two-thirds of the sample living in households which earned less than $C20 000 last year. PRIMARY AND SECONDARY OUTCOME MEASURES: We collected baseline data on demographic characteristics, including indigenous identity, age, gender, income, household type and household size. Our primary outcome asked: 'Did you complete the 2011 Census Canada questionnaire?' RESULTS: Using RDS and our large-scale survey of the urban indigenous population in Toronto, Canada, we have shown that the most recent Canadian census underestimated the size of the indigenous population in Toronto by a factor of 2 to 4. Specifically, under conservative assumptions, there are approximately 55 000 (95% CI 45 000 to 73 000) indigenous people living in Toronto, at least double the current estimate of 19 270. CONCLUSIONS: Our indigenous enumeration methods, including RDS and census completion information will have broad impacts across governmental and health policy, potentially improving healthcare access for this community. These novel applications of RDS may be relevant for the enumeration of other 'hard-to-reach' populations, such as illegal immigrants or homeless individuals in Canada and beyond.

Effective knowledge translation approaches and practices in Indigenous health research: a systematic review protocol.

BACKGROUND: Effective knowledge translation (KT) is critical to implementing program and policy changes that require shared understandings of knowledge systems, assumptions, and practices. Within mainstream research institutions and funding agencies, systemic and insidious inequities, privileges, and power relationships inhibit Indigenous peoples' control, input, and benefits over research. This systematic review will examine literature on KT initiatives in Indigenous health research to help identify wise and promising Indigenous KT practices and language in Canada and abroad. METHODS: Indexed databases including Aboriginal Health Abstract Database, Bibliography of Native North Americans, CINAHL, Circumpolar Health Bibliographic Database, Dissertation Abstracts, First Nations Periodical Index, Medline, National Indigenous Studies Portal, ProQuest Conference Papers Index, PsycInfo, Social Services Abstracts, Social Work Abstracts, and Web of Science will be searched. A comprehensive list of non-indexed and grey literature sources will also be searched. For inclusion, documents must be published in English; linked to Indigenous health and wellbeing; focused on Indigenous people; document KT goals, activities, and rationale; and include an evaluation of their KT strategy. Identified quantitative, qualitative, and mixed methods' studies that meet the inclusion criteria will then be appraised using a quality appraisal tool for research with Indigenous people. Studies that score 6 or higher on the quality appraisal tool will be included for analysis. DISCUSSION: This unique systematic review involves robust Indigenous community engagement strategies throughout the life of the project, starting with the development of the review protocol. The review is being guided by senior Indigenous researchers who will purposefully include literature sources characterized by Indigenous authorship, community engagement, and representation; screen and appraise sources that meet Indigenous health research principles; and discuss the project with the Indigenous Elders to further explore the hazards, wisdom, and processes of sharing knowledge in research contexts. The overall aim of this review is to provide the evidence and basis for recommendations on wise practices for KT terminology and research that improves Indigenous health and wellbeing and/or access to services, programs, or policies that will lead to improved health and wellbeing. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42016049787 .

Effective strategies to reduce commercial tobacco use in Indigenous communities globally: A systematic review.

BACKGROUND: All over the world, Indigenous populations have remarkably high rates of commercial tobacco use compared to non-Indigenous groups. The high rates of commercial tobacco use in Indigenous populations have led to a variety of health issues and lower life expectancy than the general population. The objectives of this systematic review were to investigate changes in the initiation, consumption and quit rates of commercial tobacco use as well as changes in knowledge, prevalence, community interest, and smoke-free environments in Indigenous populations. We also aimed to understand which interventions had broad reach, what the common elements that supported positive change were and how Aboriginal self-determination was reflected in program implementation. METHODS: We undertook a systematic review of peer-reviewed publications and grey literature selected from seven databases and 43 electronic sources. We included studies between 1994 and 2015 if they addressed an intervention (including provision of a health service or program, education or training programs) aimed to reduce the use of commercial tobacco use in Indigenous communities globally. Systematic cross-regional canvassing of informants in Canada and internationally with knowledge of Indigenous health and/or tobacco control provided further leads about commercial tobacco reduction interventions. We extracted data on program characteristics, study design and learnings including successes and challenges. RESULTS: In the process of this review, we investigated 73 commercial tobacco control interventions in Indigenous communities globally. These interventions incorporated a myriad of activities to reduce, cease or protect Indigenous peoples from the harms of commercial tobacco use. Interventions were successful in producing positive changes in initiation, consumption and quit rates. Interventions also facilitated increases in the number of smoke-free environments, greater understandings of the harms of commercial tobacco use and a growing community interest in addressing the high rates of commercial tobacco use. Interventions were unable to produce any measured change in prevalence rates. CONCLUSIONS: The extent of this research in Indigenous communities globally suggests a growing prioritization and readiness to address the high rates of commercial tobacco use through the use of both comprehensive and tailored interventions. A comprehensive approach that uses multiple activities, the centring of Aboriginal leadership, long term community investments, and the provision of culturally appropriate health materials and activities appear to have an important influence in producing desired change.

Inequity to the utilization of bariatric surgery: a systematic review and meta-analysis.

This systematic review explores the sociodemographic factors associated with the utilization of bariatric surgery among eligible patients. Electronic databases were searched for population-based studies that explored the relationship between sociodemographic characteristics of patients eligible for bariatric surgery to those who actually received the procedure. Twelve retrospective cohort studies were retrieved, of which the results of 9 studies were pooled using a random effects model. Patients who received bariatric surgery were significantly more likely to be white versus non-white (OR 1.54; 95% CI 1.08, 2.19), female versus male (OR 2.80; 95% CI 2.46, 3.22), and have private versus government or public insurance (OR 2.51; 95% CI 1.04, 6.05). Prospective cohort studies are warranted to further determine the relative effect of these factors, adjusting for confounding factors.

Evaluation of the acceptability of a CD-Rom as a health promotion tool for Inuit in Ottawa.

BACKGROUND: There are few health promotion tools for urban Inuit, and there is a specific dearth of evaluations on such tools. OBJECTIVE: The current study used a community-specific approach in the evaluation of a health promotion tool, based on an urban Inuit community's preferences of health knowledge sources and distribution strategies. In partnership with the Tungasuvvingat Inuit Family Health Team in Ottawa, a CD-Rom was developed featuring an Inuk Elder presenting prenatal health messages in both Inuktitut and English. Also, relevant evaluation materials were developed. DESIGN: Using a mixed methods approach, 40 participants completed interviews prior to viewing the CD-Rom and participated in a focus group at follow-up. Questionnaires were also completed pre- and post-viewing to assess changes between expectations and reactions in order to document acceptability. RESULTS: Significant increases were found on satisfaction, acceptability of medium and relevance of content ratings. Qualitative findings also included (a) interest, uncertainty and conditional interest prior to viewing; and (b) positive evaluations of the CD-Rom. CONCLUSIONS: This suggests that CD-Rom technology has the potential for health promotion for urban Inuit, and the community-specific evaluation approach yielded useful information.

Health Systems Performance Measurement Systems in Canada: How Well do They Perform in First Nations, Inuit, and Métis Contexts?

OBJECTIVE: To inventory and describe currently available health performance measurement systems for First Nations, Inuit, and Métis people in Canada to identify why current measurement systems are inadequate to inform community or regional level health planning. METHODS: Inventory, classification, and synthesis of strengths and weaknesses among existing health system performance measures through systematic literature review and key informant interviews. RESULTS: Indigenous-specific health indicators are available at national, provincial, regional, and community levels, but there is a paucity of data for non-registered First Nations, Métis, and Inuit people. Barriers to the effective use of these indicators include: indicator selection driven by accountability rather than public health requirements; poor data quality; inadequate infrastructure and human resources; minimal information returned to communities; tension between agencies collecting universal indicators and Indigenous-determined processes; and, mistrust by Indigenous communities of externally imposed processes. The focus on national systems results in greater attention to disease-based measures and less focus on regional cultural diversity and Indigenous-specific values and priorities. CONCLUSION: Indigenous health system performance measurement infrastructure in Canada is underdeveloped, particularly at the local level, and hence deficient in its ability to support community or regional health planning.

Examining Evidence for Autonomy and Relatedness in Urban Inuit Parenting.

Inuit have experienced significant lifestyle changes in the past 50 years. Most recently, urbanization has resulted in greater numbers of Inuit living in urban centres in southern Canada. Little is known about Inuit parenting, and nothing has been published on Inuit parenting in an urban context. The present study sought to address this gap by describing the parenting of Inuit living in a large Canadian city and examining emergent themes for evidence of autonomy and relatedness. In partnership with the Tungasuvvingat Inuit Family Resource Centre, 39 Inuit parents completed an interview about their parenting experiences. Based on interviews, major parenting themes included: child characteristics; parenting behaviours and beliefs; affection and love; stressors; and responsive and respectful parenting. The majority of parenting themes linked to relatedness, although there was evidence of autonomy in both parenting behaviours and child characteristics. Results are interpreted in light of the autonomy-relatedness framework and theoretical implications of findings are discussed.

Guiding health promotion efforts with urban Inuit: a community-specific perspective on health information sources and dissemination strategies.

OBJECTIVE: To develop a community-specific perspective of health information sources and dissemination strategies of urban Inuit to better guide health promotion efforts. METHODS: Through a collaborative partnership with the Tungasuvvingat Inuit Family Resource Centre, a series of key informant interviews and focus groups were conducted to gather information on specific sources of health information, strategies of health information dissemination, and overall themes in health information processes. FINDINGS: Distinct patterns of health information sources and dissemination strategies emerged from the data. Major themes included: the importance of visual learning, community Elders, and cultural interpreters; community cohesion; and the Inuit and non-Inuit distinction. The core sources of health information are family members and sources from within the Inuit community. The principal dissemination strategy for health information was direct communication, either through one-on-one interactions or in groups. CONCLUSION: This community-specific perspective of health information sources and dissemination strategies shows substantial differences from current mainstream models of health promotion and knowledge translation. Health promotion efforts need to acknowledge the distinct health information processes of this community, and should strive to integrate existing health information sources and strategies of dissemination with those of the community.