Exploring uptake of HIV/STI knowledge and safer sex-efficacy in an arts-based sexual health workshop among Northern and Indigenous adolescents in the Northwest Territories, Canada.

ABSTRACTLimited research has evaluated sexual health promotion projects with adolescents living in Arctic regions. The study objective was to examine changes in STI knowledge and safer sex efficacy among youth in the Northwest Territories (NWT), Canada who participated in arts-based sexual health workshops. We used a pre/post-test design with a convenience sample of students aged 13-18 years recruited from 17 NWT communities. We conducted summary statistics and comparisons between pre and post-test scores using paired t-tests. Among participants (n = 610), we found statistically significant increases in STI knowledge overall (mean difference = 3.9; p < 0.001) and across gender and age stratifications. There were statistically significant increases in safer sex efficacy overall (mean difference = 0.9, p < 0.001), across genders, and among participants: aged <15 years, in rural communities, reporting food insecurity, reporting dating violence, and Indigenous youth. No statistically significant differences in safer sex efficacy were observed among participants who were aged ≥15, sexually active, reporting consistent condom use, and using drugs/alcohol. Findings signal the promise of youth-targeted, arts-based sexual health workshops for improving STI knowledge and safer sex efficacy among adolescents in the NWT. Further research can explore how safer sex efficacy may be shaped by age, substance use, and sexual experience to inform tailored interventions.

Contextual factors associated with depression among Northern and Indigenous adolescents in the Northwest Territories, Canada.

BACKGROUND: Persons in Arctic regions disproportionately experience depression. Knowledge gaps remain regarding factors associated with depression among adolescents in the Northwest Territories (NWT), Canada, where child and adolescent mental health hospitalizations are nearly 2.5 times the national rate. This study assesses correlates of depression among adolescents in the NWT. METHODS: We conducted a cross-sectional survey with adolescents aged 13-18 in 17 NWT communities. We assessed associations between socio-demographic characteristics, dating violence, food insecurity and depression, measured with the 9-item Patient Health Questionnaire. We conducted ordered logistic regressions to assess associations with no, mild, or moderate/severe depression scores. RESULTS: Participants (n = 399; mean age: 14.3, s.d.: 1.3) were mostly Indigenous (79%) and 45% reported food insecurity. Nearly half (47%) reported minimal/no depression symptoms, 25% mild symptoms and 28% moderate/severe symptoms. In multivariate analyses, participants who were cisgender women compared to other genders, sexually diverse v. heterosexual, and food insecure had double the odds of more severe depression symptoms. Among those dating, dating violence was associated with double the odds of moderate/severe depression symptoms. CONCLUSIONS: Findings support tailored interventions to address material (food insecurity), relational (dating violence) and symbolic (gender and sexual orientation norms) contextual factors associated with depression among adolescents in the NWT.

First Nation paths to well-being: lessons from the Poverty Action Research Project.

This paper describes a poverty reduction approach to addressing an important determinant of health and well-being among Canada's First Nations. The Poverty Action Research Project (PARP) has its origins in the Make Poverty History Committee established by the Assembly of First Nations (AFN) in 2008. Academic members of the Committee in cooperation with the AFN subsequently applied for an action research grant to the Canadian Institutes of Health Research (CIHR). The project selected five volunteer First Nations from different parts of Canada, hiring a coordinator in each, undertaking background research, developing a profile and working with First Nation representatives in the development of a strategy to address upstream determinants of health and well-being. Subsequently, project team members within each region assisted where needed with plan implementation, supporting some initiatives with small grants. This paper provides insights from the project in several key areas, including First Nation rejection of the concept of poverty as usually defined, the importance of taking action to strengthen collectivities as well as individuals, the feasibility of assisting First Nations who are at different points in their development journey, the strengths of the leadership within the First Nations, and finding the appropriate balance between the elected and business leadership. These insights emerged from dialogue and reflection among project team members and community participants over the life of the project. We also describe what we have learned about how to engage effectively and with mutual respect with First Nations in this kind of project. The paper concludes with a review of our experiences with the policies and practices of the national research granting councils and the universities, which have not fully adjusted to the requirements of action research involving First Nations.

Experiences of the HIV Cascade of Care Among Indigenous Peoples: A Systematic Review.

Indigenous leaders remain concerned that systemic oppression and culturally unsafe care impede Indigenous peoples living with HIV from accessing health services that make up the HIV cascade of care. We conducted a systematic review to assess the evidence related to experiences of the HIV care cascade among Indigenous peoples in Australia, Canada, New Zealand, and United States. We identified 93 qualitative and quantitative articles published between 1996 and 2017 reporting primary data on cascade outcomes disaggregated by Indigenous identity. Twelve involved data from Australia, 52 from Canada, 3 from New Zealand and 26 from United States. The majority dealt with HIV testing/diagnosis (50). Relatively few addressed post-diagnosis experiences: linkage (14); retention (20); treatment initiation (21); adherence (23); and viral suppression (24). With the HIV cascade of care increasingly the focus of global, national, and local HIV agendas, it is critical that culturally-safe care for Indigenous peoples is available at all stages.

Xpey' Relational Environments: an analytic framework for conceptualizing Indigenous health equity. / Milieux relationnels Xpey' : un cadre analytique pour conceptualiser l'équité en santé autochtone.

INTRODUCTION: Both health equity research and Indigenous health research are driven by the goal of promoting equitable health outcomes among marginalized and underserved populations. However, the two fields often operate independently, without collaboration. As a result, Indigenous populations are underrepresented in health equity research relative to the disproportionate burden of health inequities they experience. In this methodological article, we present Xpey' Relational Environments, an analytic framework that maps some of the barriers and facilitators to health equity for Indigenous peoples. METHODS: Health equity research needs to include a focus on Indigenous populations and Indigenized methodologies, a shift that could fill gaps in knowledge with the potential to contribute to 'closing the gap' in Indigenous health. With this in mind, the Equity Lens in Public Health (ELPH) research program adopted the Xpey' Relational Environments framework to add a focus on Indigenous populations to our research on the prioritization and implementation of health equity. The analytic framework introduced an Indigenized health equity lens to our methodology, which facilitated the identification of social, structural and systemic determinants of Indigenous health. To test the framework, we conducted a pilot case study of one of British Columbia's regional health authorities, which included a review of core policies and plans as well as interviews and focus groups with frontline staff, managers and senior executives. CONCLUSION: ELPH's application of Xpey' Relational Environments serves as an example of the analytic framework's utility for exploring and conceptualizing Indigenous health equity in BC's public health system. Future applications of the framework should be embedded in Indigenous research methodologies.

INTRODUCTION: Si la recherche sur l'équité en santé et la recherche sur la santé autochtone ont toutes deux pour objectif de promouvoir des résultats équitables en santé parmi les populations marginalisées et à moindre accès aux soins, elles fonctionnent souvent de manière indépendante et sans collaboration, conduisant à une sous-représentation des populations autochtones dans la recherche sur l'équité en santé relativement au fardeau disproportionné des inégalités subies. Dans cet article méthodologique, nous présentons Milieux relationnels Xpey', un cadre analytique qui décrit certains obstacles et éléments facilitateurs en matière d'équité en santé pour les peuples autochtones. MÉTHODOLOGIE: La recherche sur l'équité en santé doit se concentrer sur les populations autochtones et les méthodologies autochtonisées, changement qui pourrait combler les lacunes dans les connaissances et contribuer à combler le fossé observé en santé autochtone. Dans ce cadre, le programme de recherche Optique d'équité en santé publique (Equity Lens in Public Health, ELPH) a adopté le cadre analytique Milieux relationnels Xpey' pour que la recherche sur la priorisation et la mise en oeuvre de l'équité en santé soit davantage centrée sur les populations autochtones. Le cadre analytique a ajouté à notre méthodologie une optique autochtonisée d'équité en santé qui a facilité la reconnaissance des déterminants sociaux, structurels et systémiques de la santé autochtone. Pour éprouver ce cadre analytique, nous avons mené une étude de cas pilote portant sur l'une des autorités sanitaires régionales de la Colombie-Britannique, consistant en un examen des politiques et des plans de référence et intégrant des entrevues et des groupes de travail avec du personnel de première ligne, des gestionnaires et des hauts dirigeants. CONCLUSION: L'application à ELPH de Milieux relationnels Xpey' illustre l'utilité de ce cadre analytique pour explorer et conceptualiser l'équité en santé autochtone dans le système de santé publique de la Colombie-Britannique. Des applications du cadre analytique devront être intégrées aux méthodes de recherche sur les Autochtones.

Sex workers as peer health advocates: community empowerment and transformative learning through a Canadian pilot program.

BACKGROUND: Social marginalization and criminalization create health and safety risks for sex workers and reduce their access to health promotion and prevention services compared to the general population. Community empowerment-based interventions that prioritize the engagement of sex workers show promising results. Peer-to-peer interventions, wherein sex workers act as educators of their colleagues, managers, clients and romantic partners, foster community mobilization and critical consciousness among sex workers and equip them to exercise agency in their work and personal lives. METHODS: A pilot peer health education program was developed and implemented, with and for sex workers in one urban centre in Canada. To explore how the training program contributed to community empowerment and transformative learning among participants, the authors conducted qualitative interviews, asked participants to keep personal journals and to fill out feedback forms after each session. Thematic analysis was conducted on these three data sources, with emerging themes identified, organized and presented in the findings. RESULTS: Five themes emerged from the analysis. Our findings show that the pilot program led to reduced internalized stigma and increased self-esteem in participants. Participants' critical consciousness increased concerning issues of diversity in cultural background, sexual orientation, work experiences and gender identity. Participants gained knowledge about how sex work stigma is enacted and perpetuated. They also became increasingly comfortable challenging negative judgments from others, including frontline service providers. Participants were encouraged to actively shape the training program, which fostered positive relationships and solidarity among them, as well as with colleagues in their social network and with the local sex worker organization housing the program. Resources were also mobilized within the sex worker community through skills building and knowledge acquisition. CONCLUSION: The peer education program proved successful in enhancing sex workers' community empowerment in one urban setting by increasing their knowledge about health issues, sharing information about and building confidence in accessing services, and expanding capacity to disseminate this knowledge to others. This 'proof of concept' built the foundation for a long-term initiative in this setting and has promise for other jurisdictions wishing to adapt similar programs.

Arts-based HIV and STI prevention intervention with Northern and Indigenous youth in the Northwest Territories: study protocol for a non-randomised cohort pilot study.

INTRODUCTION: Indigenous youth are disproportionately represented in new HIV infection rates in Canada. Current and historical contexts of colonisation and racism, disconnection from culture and land, as well as intergenerational trauma resulting from the legacy of residential schools are social drivers that elevate exposure to HIV among Indigenous peoples. Peer-education and arts-based interventions are increasingly used for HIV prevention with youth. Yet limited studies have evaluated longitudinal effects of arts-based approaches to HIV prevention with youth. The authors present a rationale and study protocol for an arts-based HIV prevention intervention with Northern and Indigenous youth in the Northwest Territories (NWT), Canada. METHODS AND ANALYSIS: This is a multicentre non-randomised cohort pilot study using a pretest/post-test design with a 12-month follow-up. The target population is Northern and Indigenous youth in 18 communities in the NWT. The aim is to recruit 150 youth using venue-based sampling at secondary schools. Participants will be involved in an arts-based intervention, Fostering Open eXpression among Youth (FOXY). Participants will complete a pretest, post-test survey directly following the intervention, and a 12-month follow-up. The primary outcome is new or enhanced HIV knowledge, and secondary outcomes to include: new or enhanced sexually transmitted infections knowledge, and increased self-esteem, resilience, empowerment, safer sex self-efficacy and cultural connectedness. Mixed effects regression analyses will be conducted to evaluate pretest and post-test differences in outcome measurement scores. ETHICS AND DISSEMINATION: This study has received approval from the HIV Research Ethics Board at the University of Toronto (REB: 31602). In addition, the project is currently registered in the NWT with the Aurora Research Institute (Licence: 15741). Trial results will be published according to the Transparent Reporting of Evaluations with Nonrandomised Designs statement. TRIAL REGISTRATION NUMBER: NCT02743026; Pre-results.

Culturally Competent Service Provision Issues Experienced By Aboriginal People Living With HIV/AIDS.

Cultural identity is an important factor in how well Aboriginal people respond to HIV/AIDS prevention or, once diagnosed with HIV or AIDS, how it affects their health care. This study explores the cultural skills among service providers who see Aboriginal people living with HIV/AIDS (APHAs) and the perspectives of APHAs. The purpose is to better understand the wellness needs of APHAs and how culturally competent care affects health service access and use. Data collection included face-to-face semi-structured interviews with APHAs and focus groups/interviews with community-based and primary health professionals in five regions of Canada. Interviews and focus groups were voice-recorded, verbatim transcribed, and coded using Atlas.ti(®) software. Thirty-five APHAs and fifty-two service providers were reached. Two key themes were noticed:Active addictions are a major obstacle to adherence to HIV drug regimes. Half of APHA participants said addictions are a major factor. A similar portion noted intensified substance use was an initial coping strategy when diagnosed. A slightly smaller portion noted that addictions were dealt with soon after diagnosis in order to begin antiretroviral treatment. Service providers who inform, encourage, and support APHAs' choices are viewed as "culturally competent."Addictions and HIV must be "treated together," reflecting a holistic worldview of Aboriginal people. Programs that integrate addiction treatment with HIV/AIDS and service providers who encourage and support APHA's choices are viewed as "wise practice" models by both sets of study participants offering some convergence and a set of five wise practices are identified.

Measures of cultural competence: examining hidden assumptions.

PURPOSE: The authors critically examined the quantitative measures of cultural competence most commonly used in medicine and in the health professions, to identify underlying assumptions about what constitutes competent practice across social and cultural diversity. METHOD: A systematic review of approximately 20 years of literature listed in PubMed, the Cumulative Index of Nursing and Allied Health Literature, Social Services Abstracts, and the Educational Resources Information Center identified the most frequently used cultural competence measures, which were then thematically analyzed following a structured analytic guide. RESULTS: Fifty-four instruments were identified; the 10 most widely used were analyzed closely, identifying six prominent assumptions embedded in the measures. In general, these instruments equate culture with ethnicity and race and conceptualize culture as an attribute possessed by the ethnic or racialized Other. Cultural incompetence is presumed to arise from a lack of exposure to and knowledge of the Other, and also from individual biases, prejudices, and acts of discrimination. Many instruments assume that practitioners are white and Western and that greater confidence and comfort among practitioners signify increased cultural competence. CONCLUSIONS: Existing measures embed highly problematic assumptions about what constitutes cultural competence. They ignore the power relations of social inequality and assume that individual knowledge and self-confidence are sufficient for change. Developing measures that assess cultural humility and/or assess actual practice are needed if educators in the health professions and health professionals are to move forward in efforts to understand, teach, practice, and evaluate cultural competence.

Learning from the grandmothers: incorporating indigenous principles into qualitative research.

In this article, the author describes the process she undertook to incorporate Indigenous principles into her doctoral research about the midlife health experiences of elder Aboriginal women in Nova Scotia, Canada. By employing qualitative methods within the context of an Indigenous worldview, she gained knowledge of and developed competence in Aboriginal health research. The emergent partnership among Aboriginal community research facilitators, participating Mi'kmaq women, and the researcher provided many opportunities for the researcher to incorporate the paradigmatic and methodological traditions of Western science and Indigenous cultures. The application of these principles to this study might provide a useful example for other health researchers who are attempting to incorporate diverse methodological principles.

"Far as I get is the clothesline": the impact of leisure on women's health and unpaid caregiving experiences in Nova Scotia, Canada.

This qualitative study explored the unique ways in which caregiving and leisure are conceptualized and mediated among diverse groups of female caregivers (n = 98) in the province of Nova Scotia, Canada. Data were obtained through 17 focus group discussions between March and June of 2002. Findings reveal that the contexts within which caregivers experience the health effects of caregiving create meanings, opportunities, and challenges for leisure. This study of diverse caregiving experiences fills a significant gap in the existing literature by integrating considerations of subjectivity and the ways in which caregiving influences women's perceptions and engagement in leisure pursuits. Constructivism guides the interpretive framework upon which the data were analyzed; results inform recommendations relative to policy and program audiences associated with unpaid caregiving.

A feminist analysis of the menopause discourse.

Menopause has been viewed as a medical condition which needs to be treated. The discourse surrounding the process reflects a positivist paradigm without acknowledgement of the lived experiences of women who have been given conflicitng information. In this paper we write about the dilemmas faced by peri menopausal, menopausal and post menopausal women as they grapple with the issues that focus on 'symptoms', rather than a natural phenomenon. We point out that the 'science' of menopause is class, race and gender biased as we present a feminist analysis of the concerns facing mid life women.