Implementation Science for HIV Prevention and Treatment in Indigenous Communities: a Systematic Review and Commentary.

PURPOSE OF REVIEW: We systematically reviewed implementation research conducted in Indigenous communities in the Americas and the Pacific that focused on improving delivery of HIV preventive or treatment services. We highlight strengths and opportunities in the literature and outline principles for Indigenous-led, HIV-related implementation science. RECENT FINDINGS: We identified 31 studies, revealing a consistent emphasis on cultural tailoring of services to Indigenous communities. Common barriers to implementation included stigma, geographic limitations, confidentiality concerns, language barriers, and mistrust. Community involvement in intervention development and delivery emerged as a key facilitator, and nearly half of the studies used community-based participatory research methods. While behavioral HIV prevention, especially among Indigenous youth, was a major focus, there was limited research on biomedical HIV prevention and treatment. No randomized implementation trials were identified. The findings underscore the importance of community engagement, the need for interventions developed within Indigenous communities rather than merely adapted, and the value of addressing the social determinants of implementation success. Aligned to these principles, an indigenized implementation science could enhance the acceptability and reach of critical HIV preventive and treatment services in Indigenous communities while also honoring their knowledge, wisdom, and strength.

Racism and Health Among Aotearoa New Zealand Young People Aged 15-24 years: Analysis of Multiple National Surveys.

PURPOSE: This Aotearoa New Zealand-based study addresses a gap in literature focusing on individual experiences of racism among adolescents and young adults and its links to health. METHODS: This cross-sectional study uses data from multiple instances of the New Zealand Health Survey (2002/03, 2006/07, 2011/12, 2016/17) and General Social Survey (2008-2016) restricted to participants aged 15-24 years. Prevalence of reported experiences of racism are estimated. Meta-analytic techniques to pool data and multiple regression analyses are used to examine associations between experiences of racism and outcomes measures (mental and physical health, general health and well-being, life satisfaction, inability to access health care, and identity). The study used an ethical co-design process between university researchers and a rangatahi Maori (Maori young people) partnership group. RESULTS: Racism was higher among Maori, Pacific, and Asian young people compared to European young people. Racism was associated with all negative health and well-being measures examined for young people, including negative mental and physical health measures (12-Item Short Form Survey, Kessler Psychological Distress Scale), lower self-rated health, negative life satisfaction, higher unmet need for primary care, and identity measures (feelings of not belonging in New Zealand, less able to express their identity). DISCUSSION: The results of this study are concerning. Non-European young people disproportionately bear the burden of racism in Aotearoa New Zealand with a potentially substantial impact on their health and well-being. This is a breach of Indigenous (for Maori) and other international human rights and should be motivation to act to eliminate racism in all its forms.

Co-design for indigenous and other children and young people from priority social groups: A systematic review.

Background: Co-design has increasingly been posited as a useful approach for Indigenous peoples and other social groups that experience inequities. However, the relatively rapid rise in co-design rhetoric has not necessarily been accompanied by increased understanding of whether co-design works for these social groups, and how equity is addressed. Methods: We conducted a systematic review to identify the current state of co-design as theory and praxis within the context of health and/or disability related interventions or services, with a specific focus on equity considerations for Indigenous and other children and young people from priority social groups. Six electronic databases were searched systematically to identify peer-reviewed papers and grey literature (dissertation and theses) published between January 1, 2000 to December 31, 2020, and a hand-search of reference lists for selected full texts was undertaken. Results: Fifteen studies met the inclusion criteria. Although all studies used the term 'co-design', only three provided a definition of what they meant by use of the term. Nine studies described one or more theory-based frameworks and a total of 26 methods, techniques and tools were reported, with only one study describing a formal evaluation. The key mechanism by which equity was addressed appeared to be the inclusion of participants from a social group experiencing inequities within an area of interest. Conclusion: A dearth of information limits the extent to which the literature can be definitive as to whether co-design works for Indigenous and other children and young people from priority social groups, or whether co-design reduces health inequities. It is critical for quality reporting to occur regarding co-design definitions, theory, and praxis. There is an urgent requirement for evaluation research that focuses on co-design impacts and assesses the contribution of co-design to achieving equity. We also recommend culturally safe ethical processes be implemented whenever undertaking co-design.

Mortality after release from incarceration in New Zealand by gender: A national record linkage study.

Background: People who enter and leave places of incarceration experience considerable health inequities and are at increased risk of premature death compared to the general population. Causes of premature death in this population vary markedly between countries and so country-specific information is needed. Additionally, there is a lack of large population-based studies which can disaggregate mortality risk based on person and incarceration factors. This study is the first examination of mortality in the period following release from incarceration in New Zealand. Methods: We linked deidentified administrative data on incarceration and release between 1 January 1998 and 31 December 2016 with national mortality data for the same period to examine mortality after release in those who had been incarcerated for at least 1 day. Age standardised mortality rates and mortality ratios compared to the general New Zealand population were calculated separately for men and women, for releases from remand compared with prison, and by cause of death and time since release. Results: 90,195 individuals (13% women, 49% Maori) were followed up for 9.4 years after release from incarceration, with 4,764 deaths over the follow-up period. The overall standardised mortality ratio was 3.3 (95% CI 3.2, 3.4) compared to the general population, and higher for women (3.8) than men (2.7). The most common causes of death were cardiovascular disease, cancer and suicide. Rates of death were similar following release from remand versus prison, however suicide rates were highest following release from remand. Regardless of the type of incarceration, mortality was highest in the first month after release. Conclusion: Experience of incarceration in New Zealand is associated with high rates of mortality from both chronic conditions and external causes. There are urgent policy imperatives to recognise and actively address the increased health and mortality risks faced by people released from New Zealand prisons.

The Multidimensional Impacts of Inequities for Tangata Whaikaha Maori (Indigenous Maori with Lived Experience of Disability) in Aotearoa, New Zealand.

People with lived experience of disability have poorer health and socioeconomic outcomes than people without it. However, within this population, certain social groups are more likely to experience poorer outcomes due to the impacts of multiple intersecting forms of oppression including colonisation, coloniality and racism. This paper describes the multidimensional impacts of inequities for Indigenous tangata whaikaha Maori (Maori with lived experience of disability). Semi-structured in-depth interviews were conducted with 28 tangata whaikaha Maori and their whanau (extended family) using a kaupapa Maori Research methodology. An equity framework was used to analyse the data. The results describe: (1) inequitable access to the determinants of health and well-being; (2) inequitable access to and through health and disability care; (3) differential quality of health and disability care received; and (4) Indigenous Maori-driven solutions. These data confirm that tangata whaikaha Maori in the nation-state known as New Zealand experience racism, ableism and disablism, compounded by the intersection between these types of discrimination. Recommendations from the data support the inclusion of tangata whaikaha Maori in decision-making structures, including all policies and practices, along with equal partnership rights when it comes to designing health and disability systems and services.

We still don't count: the under-counting and under-representation of Maori in health and disability sector data.

AIM: To examine ethnicity data quality; in particular, the representation and potential under-counting of Maori in health and disability sector data, as well as implications for inequities. METHODS: Maori and non-Maori ethnicity data are analysed at: 1) a population aggregate level across multiple 2018 datasets (Estimated Resident Population, Census Usually Resident Population, Health Service User (HSU) population and Primary Health Organisation (PHO) enrolments); and 2) an individual level for those linked in PHO and 2018 Census datasets. Ethnicity is drawn from the National Health Index (NHI) in health datasets and variations by age and gender are explored. RESULTS: Aggregate analyses show that Maori are considerably under-represented in HSU and PHO data. In linked analysis Maori were under-counted on the NHI by 16%. Under-representation in data and under-counting occur across both genders but are more pronounced for Maori men with variations by age. CONCLUSION: High quality ethnicity data are fundamental for understanding and monitoring Maori health and health inequities as well as in the provision of targeted services and interventions that are responsive to Maori aspirations and needs. The continued under-counting of Maori in health and disability sector data is a breach of Te Tiriti o Waitangi and must be addressed with urgency.