Race as a determinant of prenatal depressive symptoms: analysis of data from the 'All Our Families' study.

OBJECTIVES: Prenatal depression is a serious maternal-child health concern. Risk factors and health consequences appear more prevalent in Indigenous communities and ethnic minority groups; however, research on these populations is limited. We examined the following questions: (A) How do pregnant Indigenous women, ethnic minority women, and White women compare on levels of depressive symptoms and possible clinical depression, and on major risk and protective factors? (B) Is non-dominant (non-White) race associated with higher depressive symptoms and possible clinical depression? (C) What factors mediate and moderate the relationship between race and depression? DESIGN: Data were from the All Our Families study (n = 3354 pregnant women from Alberta, Canada). Depressive symptoms were measured with the Edinburgh Postnatal Depression Scale (EPDS). Descriptive statistics and multivariable regression methods were used to assess the hypotheses that Indigenous and ethnic minority women would have significantly higher mean EPDS score estimates and higher proportions scoring above cut-offs for possible clinical depression, relative to White women. The association between race and depressive symptoms was hypothesised to be partially mediated by risk factors of socioeconomics, health background, discrimination, domestic violence, and psychosocial stress. Potential confounders were age, marital status, and parity. Diet and social support were hypothesised as protective buffers between stress and depressive symptoms. RESULTS: A higher proportion of White women were married, had family income over $80,000, were employed, and had adequate social support, relative to other women. They had significantly lower mean depressive symptom score, and a smaller proportion scored above cut-offs for possible clinical depression. The positive association between race and depressive symptoms appeared to be partially mediated by socioeconomic factors and psychosocial stress. Social support appeared to moderate the association between stress and depressive symptoms. CONCLUSIONS: Strategies to address socioeconomic status, stress, and social support among racialized minority women may reduce the risk for prenatal depression.

Understanding virtual primary healthcare with Indigenous populations: a rapid evidence review.

BACKGROUND: Virtual care has become an increasingly useful tool for the virtual delivery of care across the globe. With the unexpected emergence of COVID-19 and ongoing public health restrictions, it has become evident that the delivery of high-quality telemedicine is critical to ensuring the health and wellbeing of Indigenous peoples, especially those living in rural and remote communities. METHODS: We conducted a rapid evidence review from August to December 2021 to understand how high quality Indigenous primary healthcare is defined in virtual modalities. After completing data extraction and quality appraisal, a total of 20 articles were selected for inclusion. The following question was used to guide the rapid review: How is high quality Indigenous primary healthcare defined in virtual modalities? RESULTS: We discuss key limitations to the delivery of virtual care, including the increasing cost of technology, lack of accessibility, challenges with digital literacy, and language barriers. This review further yielded four main themes that highlight Indigenous virtual primary healthcare quality: (1) limitations and barriers of virtual primary healthcare, (2) Indigenous-centred virtual primary healthcare, (3) virtual Indigenous relationality, (4) collaborative approaches to ensuring holistic virtual care. DISCUSSION: For virtual care to be Indigenous-centred, Indigenous leadership and users need to be partners in the development, implementation and evaluation of the intervention, service or program. In terms of virtual models of care, time must be allocated to educate Indigenous partners on digital literacy, virtual care infrastructure, benefits and limitations. Relationality and culture must be prioritized as well as digital health equity. CONCLUSION: These findings highlight important considerations for strengthening virtual primary healthcare approaches to meet the needs of Indigenous peoples worldwide.

Effectiveness of RADAR: An Innovative Model to Organize Diabetes Care in First Nations Communities.

Challenges exist for the management of diabetes care in First Nations populations. RADAR (Reorganizing the Approach to Diabetes through the Application of Registries) is a culturally appropriate, innovative care model that incorporates a disease registry and electronic health record for local care provision with remote coordination, tailored for First Nations people. This study assessed the effectiveness of RADAR on patient outcomes and diabetes care organization in participating communities in Alberta, Canada. It revealed significant improvements in outcomes after 2 years, with 91% of patients achieving a primary combined end point of a 10% improvement in or persistence at target for A1C, systolic blood pressure, and/or LDL cholesterol. Qualitative assessment showed that diabetes care organization also improved. These multimethod findings support tailored diabetes care practices in First Nations populations.

Indigenous Mentorship in the Health Sciences: Actions and Approaches of Mentors.

Phenomenon: Indigenous and non-Indigenous scholars have called for mentorship as a viable approach to supporting the retention and professional development of Indigenous students in the health sciences. In the context of Canadian reconciliation efforts with Indigenous Peoples, we developed an Indigenous mentorship model that details behavioral themes that are distinct or unique from non-Indigenous mentorship.Approach: We used Flanagan's Critical Incidents Technique to derive mentorship behaviors from the literature, and focus groups with Indigenous faculty in the health sciences associated with the AIM-HI network funded by the Canadian Institutes of Health Research. Identified behaviors were analyzed using Lincoln and Guba's Cutting-and-Sorting technique.Findings: Confirming and extending research on mainstream mentorship, we identified behavioral themes for 1) basic mentoring interactions, 2) psychosocial support, 3) professional support, 4) academic support, and 5) job-specific support. Unique behavioral themes for Indigenous mentors included 1) utilizing a mentee-centered approach, 2) advocating on behalf of their mentees and encouraging them to advocate for themselves, 3) imbuing criticality, 4) teaching relationalism, 5) following traditional cultural protocols, and 6) fostering Indigenous identity.Insights: Mentorship involves interactive behaviors that support the academic, occupational, and psychosocial needs of the mentee. Indigenous mentees experience these needs differently than non-Indigenous mentees, as evidenced by mentor behaviors that are unique to Indigenous mentor and mentee dyads. Despite serving similar functions, mentorship varies across cultures in its approach, assumptions, and content. Mentorship programs designed for Indigenous participants should consider how standard models might fail to support their needs.

Appraising Indigenous cultural safety within healthcare: Protocol of a scoping review of reviews.

AIM: The objective of this scoping review of reviews will be to synthesize the existing literature to identify key elements, conceptualizations and interventions of cultural safety to improve healthcare for Indigenous Peoples. DESIGN: Eligible studies will include reviews (e.g. scoping reviews, systematic reviews and narrative reviews) focused on Indigenous cultural safety in healthcare. METHODS: Guided by Weber-Pillwax's Indigenous principles of relationality and Arksey and O'Malley's scoping review framework, a review of reviews will be conducted by searching peer-reviewed literature published between January 2010 and December 2020. The database search will include CINAHL, PubMed, Scopus, Web of Science, and Google Scholar. This scoping review protocol was registered with the Joanna Briggs Institute on January 28, 2021. DISCUSSION: There is a paucity of knowledge on existing interventions and implementation strategies to support Indigenous cultural safety within the healthcare system. Improving Indigenous cultural safety in healthcare requires a comprehensive understanding of its core components and the specific interventions. IMPACT: This review will help guide future research and enhance cultural safety interventions for Indigenous Peoples, including Indigenous Peoples with diverse genders and sexualities. The findings from this review will provide critical insight and knowledge to inform cultural safety policies, programs and practices to support healthcare for Indigenous populations.

Indigenous strengths-based approaches to healthcare and health professions education - Recognising the value of Elders' teachings.

Background: A strengths-based lens is essential for the pursuit of health equity among Indigenous populations. However, health professionals are often taught and supported in practice via deficit-based approaches that perpetuate inequity for Indigenous peoples. Deficit narratives in healthcare and health education are reproduced through practices and policies that ignore Indigenous strengths, disregard human rights, and reproduce structural inequalities. When strengths are recognised it is possible to build capacities and address challenges, while not losing sight of the structural factors impacting Indigenous peoples' health. Objective: In this paper, we examine Indigenous strengths-based approaches to policy and practice in healthcare and health professions education when delivered alongside teachings shared by Elders from the Cree, Blackfoot and Métis Nations of Alberta, Canada. Method: Literature and Elders' teachings were used to shift strengths-based approaches from Western descriptions of what might be done, to concrete actions aligned with Indigenous ways. Results: Four pointers for future action adopting a strengths-based approach are identified: enacting gifts - focusing on positive attributes; upholding relationality - centring good relationships; honouring legacy - restoring self-determination; and reconciling truth - attending to structural determinants of health. Conclusion: Identified directions and actionable strategies offer a promising means to advance Indigenous health equity through strengths-based actions that change existing narratives and advance health equity.

Participant-reported effect of an Indigenous health continuing professional development initiative for specialists.

BACKGROUND: Health outcomes of Indigenous patients are impacted by culturally unsafe specialty care environments. The 'Educating for Equity (E4E)' program is a continuing professional development (CPD) intervention which incorporates skill-based teaching to improve Indigenous patient experiences and outcomes in healthcare interactions. METHODS: The E4E program was delivered to rheumatologists in two phases, each delivered as experiential learning workshops where participants engaged with and applied course content within an interactive format focusing on real-time feedback. The phase 1 workshop focused on skill development of E4E Framework concepts and principles. Phase 2 concentrated on building capacity for teaching of E4E content. Evaluation of the program's effectiveness was through longitudinal responses to the Social Cultural Confidence in Care Survey (SCCCS), self-reported strategies employed to address social issues and improve therapeutic relationships, engagement with teaching others, and satisfaction with the program. RESULTS: Two cohorts of participants have participated in the program (n = 24 Phase 1, n = 10 Phase 2). For participants completing both phases of training, statistically significant improvements were observed in exploring social factors with patients, gaining knowledge and skills related to cultural aspects of care, improved communication and relationship building, and reflections on held stereotypes. Strategies to address social issues and build therapeutic relationships remained consistent throughout participation, while the training enhanced exploration and confidence to ask about cultural and traditional practices, and stronger communication strategies for exploring beliefs, expectations, social barriers, and residential school impacts on health. Participants reported feeling prepared to teach Indigenous health concepts to others and subsequently lead teaching with residents, fellows, and allied health professionals. Satisfaction with the delivery and content of the workshops was high, and participants valued interactions with peers in learning. CONCLUSIONS: This CPD intervention had a beneficial impact on self-reported confidence and enhanced practice strategies to engage with Indigenous patients.

"There are still a lot of things that I need": a qualitative study exploring opportunities to improve the health services of First Nations People with arthritis seen at an on-reserve outreach rheumatology clinic.

BACKGROUND: Arthritis is a highly prevalent disease and leading cause of disability in the Indigenous population. A novel model of care consisting of a rheumatology outreach clinic in an on-reserve primary healthcare center has provided service to an Indigenous community in Southern Alberta since 2010. Despite quality assessments suggesting this model of care improves accessibility and is effective in meeting treatment targets, substantial improvements in patient-reported outcomes have not been realized. Therefore, the objective of this study was to explore the experiences of Indigenous persons with arthritis and healthcare providers involved in this model of care to inform the development of health service improvements that enhance patient outcomes. METHODS: This was a narrative-based qualitative study involving a purposeful sample of 32 individuals involved in the Indigenous rheumatology model of care. In-depth interviews were conducted to elicit experiences with the existing model of care and to encourage reflections on opportunities to improve it. A two-stage analysis was conducted. The first stage aimed to produce a narrative synthesis of concepts through a dialogical method comparing people with arthritis and health providers' narratives. The second stage involved a collective effort to synthesize concepts and propose specific recommendations to improve the quality of the current model of care. Triangulation, through participant checking and discussion among researchers, was used to increase the validity of the final recommendations. RESULTS: Ten Indigenous people with arthritis lived experience, 14 health providers and 8 administrative staff were interviewed. One main overarching theme was identified, which reflected the need to provide services that improve people's physical and mental functioning. Further, the following specific recommendations were identified: 1) enhancing patient-provider communication, 2) improving the continuity of the healthcare service, 3) increasing community awareness about the presence and negative impact of arthritis, and 4) increasing peer connections and support among people living with arthritis. CONCLUSIONS: Improving the quality of the current Indigenous rheumatology model of care requires implementing strategies that improve functioning, patient-provider communication, continuity of care, community awareness and peer support. A community-based provider who supports people while navigating health services could facilitate the implementation of these strategies.

Educating for Equity Care Framework: Addressing social barriers of Indigenous patients with type 2 diabetes.

OBJECTIVE: To present a clinical framework for addressing critical social elements for Indigenous patients with type 2 diabetes. SOURCES OF INFORMATION: The Educating for Equity (E4E) Care Framework was developed through a rigorous analysis of qualitative research that included the perspectives of Indigenous patients (n = 32), physicians (n = 28), and Indigenous health curriculum developers (n = 5) across Canada. A national advisory group of Indigenous health experts, educators, leaders, physicians, and community members provided feedback on integrating analysis from primary research into recommendations for physicians. Systematic literature reviews were conducted and a nominal group technique process helped forge research team consensus around the framework's themes and recommendations. MAIN MESSAGE: For Indigenous patients with type 2 diabetes, social factors arising from the legacy of colonization are often barriers to improved diabetes outcomes, while culture is often not recognized as a facilitator in diabetes management. Structural competency in balance with cultural safety should be central to the clinical process when negotiating diabetes management with Indigenous patients. The E4E Care Framework presented in this article provides recommendations to navigate this terrain. CONCLUSION: A focus on social and cultural elements is fundamental to effective diabetes care among Indigenous patients. The E4E Care Framework is a resource that can help clinicians improve Indigenous patients' capacity for change in a way that acknowledges the social factors that affect the increasing diabetes rates, while using a cultural lens to facilitate improved outcomes.

Health care experiences of Indigenous people living with type 2 diabetes in Canada.

BACKGROUND: Indigenous social determinants of health, including the ongoing impacts of colonization, contribute to increased rates of chronic disease and a health equity gap for Indigenous people. We sought to examine the health care experiences of Indigenous people with type 2 diabetes to understand how such determinants are embodied and enacted during clinical encounters. METHODS: Sequential focus groups and interviews were conducted in 5 Indigenous communities. Focus groups occurred over 5 sessions at 4 sites; 3 participants were interviewed at a 5th site. Participants self-identified as Indigenous, were more than 18 years of age, lived with type 2 diabetes, had received care from the same physician for the previous 12 months and spoke English. We used a phenomenological thematic analysis framework to categorize diabetes experiences. RESULTS: Patient experiences clustered into 4 themes: the colonial legacy of health care; the perpetuation of inequalities; structural barriers to care; and the role of the health care relationship in mitigating harm. There was consistency across the diverse sites concerning the root causes of mistrust of health care systems. INTERPRETATION: Patients' interactions and engagement with diabetes care were influenced by personal and collective historical experiences with health care providers and contemporary exposures to culturally unsafe health care. These experiences led to nondisclosure during health care interactions. Our findings show that health care relationships are central to addressing the ongoing colonial dynamics in Indigenous health care and have a role in mitigating past harms.

Facilitated access to an integrated model of care for arthritis in an urban Aboriginal population.

OBJECTIVE: To evaluate a model of care to improve arthritis detection and treatment in an urban Aboriginal population. DESIGN: Cohort study. SETTING: The Elbow River Healing Lodge in Calgary, Alta. PARTICIPANTS: A total of 26 participants with noninflammatory arthritis and 12 with inflammatory arthritis. INTERVENTION: A monthly rheumatology clinic was embedded in the primary health care service and received referrals from primary care providers and allied health care professionals, or self-referrals. All participants had a standardized assessment to determine their diagnosis. Those with noninflammatory musculoskeletal conditions were returned to primary care management and those with inflammatory arthritis conditions were followed by the rheumatologist. MAIN OUTCOME MEASURES: Accessibility, acceptability, effectiveness, and cultural safety were evaluated as measures of quality for the model of care. RESULTS: Nearly all participants (87%) thought the services were very easy or easy to obtain, and overall satisfaction with the model of care was high (89% were very satisfied or satisfied). For inflammatory arthritis patients, the swollen and tender joint counts improved over time (both P < .01) and patient safety was assured. A high degree of cultural safety was provided, with 95% of participants responding that they did not perceive discrimination on the basis of race. CONCLUSION: This model of care facilitated access for diagnosis and return to care of inflammatory arthritis conditions, and was acceptable to participants. This model of care removes the complexities of access to non-family physician specialty care while providing health care in a setting valued by Aboriginal patients.

'Stereotypes are reality': addressing stereotyping in Canadian Aboriginal medical education.

CONTEXT: Efforts are underway in many parts of the world to develop medical education curricula that address the health care issues of indigenous populations. The topic of stereotypes and their impact on such peoples' health, however, has received little attention. An examination of stereotypes will shed light on dominant cultural attitudes toward Aboriginal people that can affect quality of care and health outcomes in Aboriginal patients. OBJECTIVES: This study examines the views of undergraduate medical students regarding Canadian Aboriginal stereotypes and how they potentially affect Aboriginal people's health. The goal of this study was to gain insight into how medical learners perceive issues related to racism, discrimination and social stereotypes and to draw attention to gaps in Aboriginal health curricula. METHODS: This study involved a convenience sample of medical learners drawn from one undergraduate medical programme in western Canada. Using a semi-structured interview guide, we conducted a total of seven focus group interviews with 38 first- and second-year undergraduate medical students. Data were analysed using a thematic content analysis approach. RESULTS: Medical students recognise that stereotypes are closely related to processes of racism and discrimination. However, they generally feel that stereotypes of Aboriginal people are rooted in reality. Students also identified medical school as one of the environments in which they are commonly exposed to negative views of Aboriginal people. Student responses suggest they see the cultural gap between Aboriginal and non-Aboriginal people as being both a cause and a consequence of discrimination against Aboriginal people. CONCLUSIONS: The results of this study suggest that teaching medical students about the realities and impacts of stereotypes on Aboriginal peoples is a good starting point from which to address issues of racism and health inequities affecting the health of Aboriginal people.

Association between First Nations ethnicity and progression to kidney failure by presence and severity of albuminuria.

BACKGROUND: Despite a low prevalence of chronic kidney disease (estimated glomerular filtration rate [GFR]<60 mL/min per 1.73 m2), First Nations people have high rates of kidney failure requiring chronic dialysis or kidney transplantation. We sought to examine whether the presence and severity of albuminuria contributes to the progression of chronic kidney disease to kidney failure among First Nations people. METHODS: We identified all adult residents of Alberta (age≥18 yr) for whom an outpatient serum creatinine measurement was available from May 1, 2002, to Mar. 31, 2008. We determined albuminuria using urine dipsticks and categorized results as normal (i.e., no albuminuria), mild, heavy or unmeasured. Our primary outcome was progression to kidney failure (defined as the need for chronic dialysis or kidney transplantation, or a sustained doubling of serum creatinine levels). We calculated rates of progression to kidney failure by First Nations status, by estimated GFR and by albuminuria category. We determined the relative hazard of progression to kidney failure for First Nations compared with non-First Nations participants by level of albuminuria and estimated GFR. RESULTS: Of the 1 816 824 participants we identified, 48 669 (2.7%) were First Nations. First Nations people were less likely to have normal albuminuria compared with non-First Nations people (38.7% v. 56.4%). Rates of progression to kidney failure were consistently 2- to 3-fold higher among First Nations people than among non-First Nations people, across all levels of albuminuria and estimated GFRs. Compared with non-First Nations people, First Nations people with an estimated GFR of 15.0-29.9 mL/min per 1.73 m2 had the highest risk of progression to kidney failure, with similar hazard ratios for those with normal and heavy albuminuria. INTERPRETATION: Albuminuria confers a similar risk of progression to kidney failure for First Nations and non-First Nations people.

Likelihood of coronary angiography among First Nations patients with acute myocardial infarction.

BACKGROUND: Morbidity due to cardiovascular disease is high among First Nations people. The extent to which this may be related to the likelihood of coronary angiography is unclear. We examined the likelihood of coronary angiography after acute myocardial infarction (MI) among First Nations and non-First Nations patients. METHODS: Our study included adults with incident acute MI between 1997 and 2008 in Alberta. We determined the likelihood of angiography among First Nations and non-First Nations patients, adjusted for important confounders, using the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) database. RESULTS: Of the 46,764 people with acute MI, 1043 (2.2%) were First Nations. First Nations patients were less likely to receive angiography within 1 day after acute MI (adjusted odds ratio [OR] 0.73, 95% confidence interval [CI] 0.62-0.87). Among First Nations and non-First Nations patients who underwent angiography (64.9%), there was no difference in the likelihood of percutaneous coronary intervention (PCI) (adjusted hazard ratio [HR] 0.92, 95% CI 0.83-1.02) or coronary artery bypass grafting (CABG) (adjusted HR 1.03, 95% CI 0.85-1.25). First Nations people had worse survival if they received medical management alone (adjusted HR 1.38, 95% CI 1.07-1.77) or if they underwent PCI (adjusted HR 1.38, 95% CI 1.06-1.80), whereas survival was similar among First Nations and non-First Nations patients who received CABG. INTERPRETATION: First Nations people were less likely to undergo angiography after acute MI and experienced worse long-term survival compared with non-First Nations people. Efforts to improve access to angiography for First Nations people may improve outcomes.

Discordant indigenous and provider frames explain challenges in improving access to arthritis care: a qualitative study using constructivist grounded theory.

INTRODUCTION: Access to health services is a determinant of population health and is known to be reduced for a variety of specialist services for Indigenous populations in Canada. With arthritis being the most common chronic condition experienced by Indigenous populations and causing high levels of disability, it is critical to resolve access disparities through an understanding of barriers and facilitators to care. The objective of this study was to inform future health services reform by investigating health care access from the perspective of Aboriginal people with arthritis and health professionals. METHODS: Using constructivist grounded theory methodology we investigated Indigenous peoples' experiences in accessing arthritis care through the reports of 16 patients and 15 healthcare providers in Alberta, Canada. Semi-structured interviews were conducted between July 2012 and February 2013 and transcribed verbatim. The patient and provider data were first analyzed separately by two team members then brought together to form a framework. The framework was refined through further analysis following the multidisciplinary research team's discussions. Once the framework was developed, reports on the patient and provider data were shared with each participant group independently and participants were interviewed to assess validity of the summary. RESULTS: In the resulting theoretical framework Indigenous participants framed their experience with arthritis as 'toughing it out' and spoke of racism encountered in the healthcare setting as a deterrent to pursuing care. Healthcare providers were frustrated by high disease severity and missed appointments, and framed Indigenous patients as lacking 'buy-in'. Constraints imposed by complex healthcare systems contributed to tensions between Indigenous peoples and providers. CONCLUSION: Low specialist care utilization rates among Indigenous people cannot be attributed to cultural and social preferences. Further, the assumptions made by providers lead to stereotyping and racism and reinforce rejection of healthcare by patients. Examples of 'working around' the system were revealed and showed potential for improved utilization of specialist services. This framework has significant implications for health policy and indicates that culturally safe services are a priority in addressing chronic disease management.

Cadre de soins fondé sur l'éducation pour l'équité: Éliminer les obstacles sociaux des patients autochtones vivant avec le diabète de type 2.

OBJECTIF: Présenter un cadre clinique afin de prendre en considération les éléments sociaux critiques pour les patients autochtones atteints de diabète de type 2. SOURCES DE L'INFORMATION: Le Cadre de soins fondé sur l'éducation pour l'équité (Educating for Equity [E4E] Care Framework) a été produit à la suite de l'analyse rigoureuse d'une recherche qualitative portant sur les points de vue de patients autochtones (n = 32), de médecins (n = 28) et d'élaborateurs de cursus en santé autochtone (n = 5) dans toutes les régions du Canada. Un groupe consultatif national formé d'experts en santé autochtone, d'enseignants, de dirigeants, de médecins et de membres de la collectivité a exprimé des commentaires sur une analyse intégrant la recherche primaire dans les recommandations à l'intention des médecins. Des revues systématiques de la documentation ont été effectuées, et la technique du groupe nominal a servi à en arriver à un consensus de l'équipe de recherche sur les thèmes et les recommandations du cadre. MESSAGE PRINCIPAL: Pour les patients autochtones atteints du diabète de type 2, les facteurs sociaux découlant des séquelles de la colonisation sont souvent des obstacles à l'amélioration des issues du diabète, et la culture n'est souvent pas reconnue comme une facilitatrice dans la gestion du diabète. Il est essentiel que le processus clinique unisse la compétence structurelle en juste équilibre avec la sécurité culturelle dans la négociation de la gestion du diabète avec des patients autochtones. Le Cadre de soins fondé sur l'éducation pour l'équité présenté dans cet article propose des recommandations pour naviguer dans ces eaux. CONCLUSION: Il est fondamental de mettre l'accent sur les éléments sociaux et culturels pour offrir des soins du diabète efficaces aux patients autochtones. Le Cadre de soins fondé sur l'éducation pour l'équité est une ressource qui peut aider les cliniciens à améliorer la capacité des patients autochtones à apporter des changements d'une façon qui reconnaît les facteurs sociaux qui influencent les taux croissants de diabète, tout en ayant une perspective culturelle pour favoriser de meilleurs résultats.

Advancing health equity for Indigenous peoples in Canada: development of a patient complexity assessment framework.

BACKGROUND: Indigenous patients often present with complex health needs in clinical settings due to factors rooted in a legacy of colonization. Healthcare systems and providers are not equipped to identify the underlying causes nor enact solutions for this complexity. This study aimed to develop an Indigenous-centered patient complexity assessment framework for urban Indigenous patients in Canada. METHODS: A multi-phased approach was used which was initiated with a review of literature surrounding complexity, followed by interviews with Indigenous patients to embed their lived experiences of complexity, and concluded with a modified e-Delphi consensus building process with a panel of 14 healthcare experts within the field of Indigenous health to identify the domains and concepts contributing to health complexity for inclusion in an Indigenous-centered patient complexity assessment framework. This study details the final phase of the research. RESULTS: A total of 27 concepts spanning 9 domains, including those from biological, social, health literacy, psychological, functioning, healthcare access, adverse life experiences, resilience and culture, and healthcare violence domains were included in the final version of the Indigenous-centered patient complexity assessment framework. CONCLUSIONS: The proposed framework outlines critical components that indicate the presence of health complexity among Indigenous patients. The framework serves as a source of reference for healthcare providers to inform their delivery of care with Indigenous patients. This framework will advance scholarship in patient complexity assessment tools through the addition of domains not commonly seen, as well as extending the application of these tools to potentially mitigate racism experienced by underserved populations such as Indigenous peoples.

Effectiveness of RADAR on diabetes processes of care for First Nations communities in Alberta, Canada.

The epidemic of type-2 diabetes in First Nations communities is tragic. Culturally-appropriate approaches addressing multiple components, focusing beyond glycemic control, are urgently needed. Using an intention-to-treat framework, 13 processes of care indicators were assessed to compare proportions of patients who received care at baseline relative to 2-year follow-up. Clinical improvements were demonstrated across major process of care indicators (e.g. screening, education, and vaccination activities). We found RADAR improved reporting for most diabetes processes of care across seven FN communities and was effective in supporting diabetes care for FN communities, in Alberta Canada.

Readiness to Practice in Health Care: An Empirical Definition Based on a Content Analysis of the Literature.

BACKGROUND: Health care services require practitioners to be ready to practice (R2P), but evidence shows new graduates vary in R2P. Unfortunately, there is a lack of clarity about what R2P entails. METHOD: A content analysis of the empirical literature (Gaur & Kumar, 2018) was used to quantify the elements and higher-order categories of R2P. RESULTS: Across 108 articles, professional development activities, communication, previous experience, confidence, clinical skills, patient-centered care, integration of knowledge, teamwork, competency, management, and interpersonal skills were used to define R2P at least 25% of the time. We identified seven domains of R2P: clinical experience, social experiences, professional development experiences, personal attributes, cognitive aspects, onboarding experiences, and educational experiences. CONCLUSION: Our study empirically defined what is associated with health professionals who were perceived as or perceived themselves as R2P in health care. Our results inform training, preparation, research, and the transition from medical training to the workplace. [J Contin Educ Nurs. 2023;54(7):302-312.].

Critically examining health complexity experienced by urban Indigenous peoples in Canada by exploring the factors that allow health complexity to persist: a qualitative study of Indigenous patients in Calgary, Alberta.

OBJECTIVES: This study aims to identify and critically examine the components of health complexity, and explore the factors that allow it to exist, among urban Indigenous peoples in Canada. DESIGN: Qualitative exploration with relational conversations. SETTING: Calgary, Alberta, Canada. PARTICIPANTS: A total of nine urban Indigenous patients were recruited from a multidisciplinary primary healthcare clinic that serves First Nations, Métis and Inuit peoples. Recruitment and data collection took place between September and November 2021. RESULTS: Thematic analysis revealed three main themes, namely: sources of health complexity, psychological responses to adversity, and resilience, strengths, and protective factors. Key sources of health complexity arose from material resource disparities and adverse interpersonal interactions within the healthcare environment, which manifest into psychological distress while strengths and resilience emerged as protective factors. CONCLUSION: The healthcare system remains inapt to address complexity among urban Indigenous peoples in Canada. Healthcare violence experienced by Indigenous peoples only further perpetuates health complexity. Future clinical tools to collect information about health complexity among urban Indigenous patients should include questions about the factors defined in this study.