Racism, early psychosis, and institutional contact: A qualitative study of Indigenous experiences.

BACKGROUND: There is evidence of Indigenous and ethnic minority inequities in the incidence and outcomes of early psychosis. Racism has been implicated as having an important role. AIM: To use Indigenous experiences to develop a more detailed understanding of how racism operates to impact early psychosis outcomes. METHODS: Critical Race Theory informed the methodology used. Twenty-three Indigenous participants participated in four family focus group interviews and thirteen individual interviews, comprising of 9 Maori youth with early psychosis, 10 family members and 4 Maori mental health professionals. An analysis of the data was undertaken using deductive structural coding to identify descriptions of racism, followed by inductive descriptive and pattern coding. RESULTS: Participant experiences revealed how racism operates as a socio-cultural phenomenon that interacts with institutional policy and culture across systems pertaining to social responsiveness, risk discourse, and mental health service structures. This is described across three major themes: 1) selective responses based on racial stereotypes, 2) race related risk assessment bias and 3) institutional racism in the mental health workforce. The impacts of racism were reported as inaction in the face of social need, increased use of coercive practices and an under resourced Indigenous mental health workforce. CONCLUSION: The study illustrated the inter-related nature of interpersonal, institutional and structural racism with examples of interpersonal racism in the form of negative stereotypes interacting with organizational, socio-cultural and political priorities. These findings indicate that organizational cultures may differentially impact Indigenous and minority people and that social responsiveness, risk discourse and the distribution of workforce expenditure are important targets for anti-racism efforts.

Pharmaceutical management of type 2 diabetes among Indigenous Australians living in urban or rural locations: a comparative study using a national general practice database.

INTRODUCTION: Type 2 diabetes is more prevalent among Aboriginal and Torres Strait Islander Peoples, especially those living in rural than urban areas. However, little is known about how diabetes is managed in different settings. OBJECTIVE: To investigate differences in the prevalence of diabetes and the prescription of antidiabetic medications for Aboriginal and/or Torres Strait Islander Peoples living in urban or rural Australia. DESIGN: Cross-sectional study using de-identified electronic medical records of 29,429 Aboriginal and/or Torres Strait Islander adults (60.4% females; mean age 45.2 ± 17.3 years) regularly attending 528 'mainstream' Australian general practices (MedicineInsight) in 2018. FINDINGS: The prevalence of diabetes was 16.0%, and it was more frequent among those living in rural areas (22.0; 95% CI 19.3-24.4) than inner regional (17.6%; 95% CI 16.0-19.2) or major cities (15.8%; 95% CI 14.7-17.0; p < 0.001). The highest prevalence of diabetes was for males living in rural settings (25.0%). Of those with diabetes, 71.6% (95% CI 69.0-74.0) were prescribed antidiabetics, with a similar frequency in urban and rural areas (p = 0.291). After adjustment for sociodemographics, the only difference in diabetes management was a higher prescription of sulfonylureas in rural areas than in major cities (OR 1.39; 1.07-1.80). DISCUSSION: The prevalence of diabetes was similar to other national data, although we found it was more frequent amongst Aboriginal and/or Torres Strait Islander males, especially those from rural areas. CONCLUSION: Despite current recommendations, one-in-four Indigenous Australians with diabetes were not prescribed antidiabetics. The clinical significance of more frequent prescriptions of sulfonylureas in rural locations remains unclear.

An exploration of the inverse care law and market forces in Australian primary health care.

This paper examines the implications of the second sentence in Tudor Harts statement about inverse care - that its operation was strongest when exposed to market forces. In the Australian context, we briefly review some available evidence for inverse care in three groups - Aboriginal and Torres Strait Islander people and those living in remote and socioeconomically disadvantaged areas. We then discuss the extent to which these examples can be attributed to the operation of supply-and-demand within Australia's hybrid fee-for-service system in general practice. Our analysis suggests disparities in workforce supply and the ability of disadvantaged groups to seek preventive and proactive care are critical factors. These, in turn, suggest the need to fund general practice to be responsible for proactive and preventive care of disadvantaged population groups alongside broader structural reforms in workforce, education and taxation.

Prevalence of diabetic retinopathy and reduced vision among indigenous Australians in the nurse-led integrated Diabetes Education and Eye Screening study in a regional primary care clinic.

BACKGROUND: Nationally, Indigenous Australians are more likely to have diabetes and diabetic retinopathy (DR) than non-Indigenous Australians. However, the prevalence of DR and impaired vision in regional primary care settings is unclear. AIM: To describe the prevalence and severity of DR and presenting vision level among Indigenous Australian adults with diabetes attending an indigenous primary care clinic in regional Australia. METHODS: Participants underwent nurse-led retinal imaging and DR screening with offsite retinal grading in the integrated Diabetes Education and Eye Screening (iDEES) project implemented at a regional indigenous primary healthcare setting between January 2018 and March 2020. RESULTS: Of 172 eligible adults, 135 (79%) were recruited and screened for DR and vision level. The median age was 56 (46-67) years, 130 (96%) had type 2 diabetes of median (interquartile range) duration 6 (2-12) years and 48 (36%) were male. Images from 132 (97.8%) participants were gradable. DR was present in 38 (29%) participants: mild non-proliferative in 33 (25%); moderate-severe in three (2.5%); and sight-threatening two (1.5%). Subnormal presenting vision was present in 33%. CONCLUSIONS: A nurse-led model of care integrating diabetes eye screening and education at a single visit was successful at recruiting Indigenous Australian adults with diabetes, screening their vision and acquiring a high rate of gradable images. Even for a short duration of known diabetes, DR was present in three out of 10 patients screened.

Resolutividade no Subsistema de Atenção à Saúde Indígena no Brasil: revisão de escopo / Resolubility in the Indigenous Health Care Subsystem in Brazil: scope review / Resolución en el Subsistema de Atención de la Salud Indígena en Brasil: revisión del alcance

RESUMO: A resolutividade relaciona-se à capacidade de solução dos problemas de saúde nos serviços. Em 1999, o Subsistema de Atenção à Saúde Indígena foi integrado ao Sistema Único de Saúde no Brasil, passando a seguir os seus princípios e diretrizes. Este estudo teve por objetivo identificar e mapear os desafios ou problemas relacionados às práticas em saúde para a resolutividade no Subsistema de Saúde Indígena após a integração. Trata-se de uma revisão de escopo que utilizou seis bases de dados nacionais e internacionais. Os estudos elegíveis tiveram como critério base o mnemônico PCC (P: população indígena; C: desafios ou problemas para a resolutividade; C: subsistema de saúde indígena brasileiro). Foram encontrados 1.748 estudos e selecionados 33, com predomínio de estudos qualitativos. Os desafios ou problemas sensíveis para o processo da resolutividade foram encontrados nos aspectos que tangem à educação em saúde, à interculturalidade, ao acesso universal e aos recursos em gestão. O saber tradicional é pouco valorizado pelo sistema de saúde. A deficiência de recursos humanos e materiais, a falta de efetiva educação permanente e de capacitações para trabalhar no contexto intercultural produzem barreiras de acesso e comprometem a resolutividade nos serviços, aumentando assim as iniquidades em saúde.

ABSTRACT: Resolubility relates to the ability to solve health problems in services. In 1999, the Indigenous Health Care Subsystem was integrated into the Brazilian Unified Health System, following its principles and guidelines. The objective of this study was to identify and map the challenges or problems related to health practices for solving in the Indigenous Health Subsystem after integration. This is a scope review that used six national and international databases. Eligible studies were based on mnemonic PCC (P: indigenous population; C: challenges or problems for resolution; C: Brazilian indigenous health subsystem). A total of 1,748 studies were found and 33 were selected, with predominance of qualitative studies. The challenges or problems that are sensitive to the resolution process were found in the aspects that are related to health education, interculturality, universal access and management resources. Traditional knowledge is underrated by the health system. The deficiency of human and material resources, the lack of effective permanent education and capacitations to work in the intercultural context, produce barriers to access and compromise the resolubility in services, thus increasing the inequities in health.

RESUMEN: La resolución se refiere a la capacidad de resolver problemas de salud en los servicios. En 1999, el Subsistema de Atención de Salud Indígena se integró en el Sistema Único de Salud de Brasil, siguiendo sus principios y directrices. El objetivo de este estudio fue identificar y mapear los desafíos o problemas relacionados con las prácticas de salud para resolver en el Subsistema de Salud Indígena después de la integración. Esta es una revisión de alcance que utilizó seis bases de datos nacionales e internacionales. Los estudios elegibles se basaron en PCC mnemónicos (P: población indígena; C: desafíos o problemas para la resolución; C: subsistema de salud indígena brasileño). Se encontraron 1.748 estudios y se seleccionaron 33, con predominio de estudios cualitativos. Los desafíos o problemas que son sensibles al proceso de resolución se encontraron en los aspectos que están relacionados con la educación en salud, la interculturalidad, el acceso universal y los recursos de gestión. El conocimiento tradicional es subestimado por el sistema de salud. La deficiencia de recursos humanos y materiales, la falta de educación permanente efectiva y de capacitaciones para trabajar en el contexto intercultural, producen barreras para acceder y comprometer la solubilidad en los servicios, aumentando así las desigualdades en salud.

Release of the National Scheme's Aboriginal and Torres Strait Islander Health and Cultural Safety Strategy 2020-2025; the impacts for podiatry in Australia: a commentary.

BACKGROUND: Developing since colonisation, Australia's healthcare system has dismissed an ongoing and successful First Nations health paradigm in place for 60,000 years. From Captain James Cook documenting 'very old' First Nations Peoples being 'far more happier than we Europeans' and Governor Arthur Phillip naming Manly in admiration of the physical health of Gadigal men of the Eora Nation, to anthropologist Daisy Bates' observation of First Nations Peoples living 'into their eighties' and having a higher life expectancy than Europeans; our healthcare system's shameful cultural safety deficit has allowed for an Aboriginal and Torres Strait Islander child born in Australia today to expect to live 9 years less than a non-Indigenous child. Disproportionately negative healthcare outcomes including early onset diabetes-related foot disease and high rates of lower limb amputation in Aboriginal and Torres Strait Islander Peoples contribute to this gross inequity. MAIN BODY: In 2020, the Australian Health Practitioner Regulation Authority released the National Scheme's Aboriginal and Torres Strait Islander Health and Cultural Safety Strategy 2020-2025 - empowering all registered health practitioners within Australia to provide health care to Aboriginal and Torres Strait Islander Peoples that is inclusive, respectful and safe, as judged by the recipient of care. This recently released strategy is critically important to the podiatry profession in Australia. As clinicians, researchers and educators we have a collective responsibility to engage with this strategy of cultural safety. This commentary defines cultural safety for podiatry and outlines the components of the strategy in the context of our profession. Discussion considers the impact of the strategy on podiatry. It identifies mechanisms for podiatrists in all settings to facilitate safer practice, thereby advancing healthcare to produce more equitable outcomes. CONCLUSION: Aboriginal and Torres Strait Islander Peoples access health services more frequently and have better health outcomes where provision of care is culturally safe. By engaging with the National Scheme's Aboriginal and Torres Strait Islander Health and Cultural Safety Strategy, all registered podiatrists in Australia can contribute to achieving equity in health outcomes for Aboriginal and Torres Strait Islander Peoples.

Educating for Indigenous Health Equity: An International Consensus Statement.

The determinants of health inequities between Indigenous and non-Indigenous populations include factors amenable to medical education's influence-for example, the competence of the medical workforce to provide effective and equitable care to Indigenous populations. Medical education institutions have an important role to play in eliminating these inequities. However, there is evidence that medical education is not adequately fulfilling this role and, in fact, may be complicit in perpetuating inequities.This article seeks to examine the factors underpinning medical education's role in Indigenous health inequity, to inform interventions to address these factors. The authors developed a consensus statement that synthesizes evidence from research, evaluation, and the collective experience of an international research collaboration including experts in Indigenous medical education. The statement describes foundational processes that limit Indigenous health development in medical education and articulates key principles that can be applied at multiple levels to advance Indigenous health equity.The authors recognize colonization, racism, and privilege as fundamental determinants of Indigenous health that are also deeply embedded in Western medical education. To contribute effectively to Indigenous health development, medical education institutions must engage in decolonization processes and address racism and privilege at curricular and institutional levels. Indigenous health curricula must be formalized and comprehensive, and must be consistently reinforced in all educational environments. Institutions' responsibilities extend to advocacy for health system and broader societal reform to reduce and eliminate health inequities. These activities must be adequately resourced and underpinned by investment in infrastructure and Indigenous leadership.

Demonstrating a new approach to planning and monitoring rural medical training distribution to meet population need in North West Queensland.

BACKGROUND: Improving the health of rural populations requires developing a medical workforce with the right skills and a willingness to work in rural areas. A novel strategy for achieving this aim is to align medical training distribution with community need. This research describes an approach for planning and monitoring the distribution of general practice (GP) training posts to meet health needs across a dispersed geographic catchment. METHODS: An assessment of the location of GP registrars in a large catchment of rural North West Queensland (across 11 sub-regions) in 2017 was made using national workforce supply, rurality and other indicators. These included (1): Index of Access -spatial accessibility (2); 10-year District of Workforce Shortage (DWS) (3); MMM (Modified Monash Model) rurality (4); SEIFA (Socio-Economic Indicator For Areas) (5); Indigenous population and (6) Population size. Distribution was determined relative to GP workforce supply measures and population health needs in each health sub-region of the catchment. An expert panel verified the approach and reliability of findings and discussed the results to inform planning. RESULTS: 378 registrars and 582 supervisors were well-distributed in two sub-regions; in contrast the distribution was below expected levels in three others. Almost a quarter of registrars (24%) were located in the poorest access areas (Index of Access) compared with 15% of the population located in these areas. Relative to the population size, registrars were proportionally over-represented in the most rural towns, those consistently rated as DWS or those with the poorest SEIFA value and highest Indigenous proportion. CONCLUSIONS: Current regional distribution was good, but individual town-level data further enabled the training provider to discuss the nuance of where and why more registrars (or supervisors) may be needed. The approach described enables distributed workforce planning and monitoring applicable in a range of contexts, with increased sensitivity for registrar distribution planning where most needed, supporting useful discussions about the potential causes and solutions. This evidence-based approach also enables training organisations to engage with local communities, health services and government to address the sustainable development of the long-term GP workforce in these towns.

A Systematic Review of Services to DHH Children in Rural and Remote Regions.

Children in regional, rural and remote areas have less access to services than those living in urban areas. Practitioners serving children with a hearing loss have attempted to address this gap, however there are few studies investigating service access and experiences of non-metropolitan families and professionals. This systematic review evaluates the literature on service provision to children with a hearing loss living in regional, rural and remote areas of Australia. A search of five databases, the gray literature and a prominent author located 37 relevant documents. The journal articles were rated for quality and the findings of all documents were themed. The evidence from this review indicates that children with a hearing loss living in regional, rural and remote Australia experience reduced quality and frequency of service. Further investigation is needed to identify the accessibility and suitability of services for children with a hearing loss in non-metropolitan areas.

The need to train uncertified rural practitioners in India.

Uncertified rural practitioners (URPs) without formal medical qualification occupy an indispensable yet dangerous position in the rural health care system in India. The low cost, close proximity, and higher health hazards in rural areas along with the inability of established health-care setups to fulfill existing demands have favored the flourishing trade of URPs. Irrational and dangerous drug prescriptions, unauthorized interventions, improper waste disposal, and several cases of malpractice by URPs are serious threats to the exposed population. However, because of the practical compulsion and real-world necessity of their existence, URPs should be scientifically trained and sensitized to regulate, qualify, and integrate them as a part of the existing health care system in India.

Aging in rural, indigenous communities: an intercultural and participatory healthcare approach in Mexico.

From an ethno-gerontological perspective, new models are needed to fulfill the health needs of the indigenous older adult population in Mexico. In this paper we developed a comprehensive healthcare model, interculturally appropriate, designed to meet the needs of Mexican indigenous older adults. The model was constructed using a qualitative design with semi-structured interviews of older adults, health providers, and available health resources in three Mexican indigenous regions. An ethnographical review was carried out to contextually characterize these communities. At the same time, a comprehensive bibliographic revision was made to identify socio-demographic markers. Results pointed out that Mexican indigenous older adults are not covered by any type of social health insurance program. Their health problems tend in large part to be chronic in nature due to the lack of early diagnosis and treatment. There is a need for trained human resources in the field of gerontology encompassing the sociocultural context of the indigenous groups. The geographical location of these communities limits the permanent presence of healthcare givers and thus limits access to continuous care. Traditional healthcare givers, able to speak the native language, are a great asset allowing the invaluable possibility of direct verbal communication. Based upon the data gathered from indigenous older adults and service providers, in tandem with evidence from the literature, we identified key elements for successful intervention and designed an intervention model. We concluded that indigenous older adults are a more vulnerable group, given that aside from being elderly in a country where the health needs of these populations exceed the capacity of existing healthcare services, their ethnicity serves as an added barrier preventing their access to the limited available healthcare resources. To achieve uniformity in providing health care, today's health systems need to address intercultural and participative aspects of healthcare models.

Evidências advindas da implantação do PMM nos territórios indígenas

Esta súmula tem como objetivo apresentar uma síntese de experiências, resultados e apontamentos obtidos de fontes bibliográficas que versam sobre a inserção do Programa Mais Médicos na atenção à saúde da população indígena, visando fornecer substrato teórico aos gestores para a avaliação dos êxitos e dificuldades, desvelando os desafios futuros para a implantação de um sistema de saúde equânime e integral para os povos indígenas.

Intervenciones para mejorar el acceso a los servicios de salud de los pueblos indígenas en las Américas / Interventions to improve access to health services by indigenous peoples in the Americas

RESUMEN Objetivo Sintetizar la evidencia sobre la efectividad de intervenciones diseñadas para mejorar el acceso de los pueblos indígenas a los servicios de salud. Métodos Revisión de revisiones sistemáticas publicadas hasta julio de 2015, de las cuales se seleccionaron y analizaron solamente los estudios realizados en la Región de las Américas. La búsqueda bibliográfica abarcó Medline, Lilacs, Scielo, EMBASE, DARE, HTA, The Cochrane Library y sitios web de organizaciones. Dos revisores independientes seleccionaron los estudios y analizaron su calidad metodológica. Se realizó una síntesis narrativa de los resultados. Resultados Veintidós revisiones cumplieron los criterios de inclusión. Todos los estudios seleccionados se realizaron en Canadá y Estados Unidos de América (EE.UU.). La mayoría de las intervenciones fueron preventivas, para sortear barreras geográficas, aumentar el uso de medidas efectivas, desarrollar recursos humanos y mejorar las destrezas o disposición de las personas para atenderse. Los temas incluyeron embarazo, factores de riesgo cardiovascular, diabetes, abuso de sustancias, desarrollo infantil, cáncer, salud mental, oral y lesiones. Algunas intervenciones mostraron efectividad con estudios de calidad moderada o alta: estrategias educativas para prevención de depresión, intervenciones para prevención de caries infantiles y programas multicomponente para promover el uso de asientos de seguridad en niños. En enfermedades crónicas no transmisibles los resultados fueron en general negativos o inconsistentes. Conclusiones Existen algunas intervenciones que tienen potencial de producir efectos positivos en el acceso a los servicios de salud de las poblaciones indígenas en las Américas, pero los estudios disponibles se limitan a Canadá y EE.UU. Existe una significativa brecha de investigación sobre el tema en América Latina y el Caribe.

ABSTRACT Objective Synthesize evidence on effectiveness of interventions designed to improve access to health services by indigenous populations. Methods Review of systematic reviews published as of July 2015, selecting and analyzing only studies in the Region of the Americas. The bibliographic search encompassed MEDLINE, Lilacs, SciELO, EMBASE, DARE, HTA, The Cochrane Library, and organization websites. Two independent reviewers selected studies and analyzed their methodological quality. A narrative summary of the results was produced. Results Twenty-two reviews met the inclusion criteria. All selected studies were conducted in Canada and the United States of America. The majority of the interventions were preventive, to surmount geographical barriers, increase use of effective measures, develop human resources, and improve people’s skills or willingness to seek care. Topics included pregnancy, cardiovascular risk factors, diabetes, substance abuse, child development, cancer, mental health, oral health, and injuries. Some interventions showed effectiveness with moderate or high quality studies: educational strategies to prevent depression, interventions to prevent childhood caries, and multicomponent programs to promote use of child safety seats. In general, results for chronic non-communicable diseases were negative or inconsistent. Conclusions Interventions do exist that have potential for producing positive effects on access to health services by indigenous populations in the Americas, but available studies are limited to Canada and the U.S. There is a significant research gap on the topic in Latin America and the Caribbean.

The role and potential of community-based cancer care for Maori in Aotearoa/New Zealand.

AIM: To investigate the contribution to cancer care and prevention by Maori health provider organisations (MHPs) in Aotearoa/New Zealand. METHODS: A nationwide postal survey of all MHPs (n=253) was undertaken in 2011. The response rate was 55%. RESULTS: We found that MHPs are delivering a wide range of programmes including cancer prevention services focussed on health promotion, advocacy, information and support. MHPs identified financial hardship, transport difficulties, and lack of information as the greatest barriers to cancer care. Culturally safe care by mainstream providers would improve cancer service provision overall. The importance of trust and long-term relationships, with a focus on families rather than individual-based care, was highlighted. CONCLUSION: These findings could lead to substantial improvements in quality of life for Maori cancer patients. This is the first study to show how indigenous health providers contribute to cancer care and prevention in Aotearoa/New Zealand.