Indigenous engagement in health: lessons from Brazil, Chile, Australia and New Zealand.

BACKGROUND: Given the persistence of Indigenous health inequities across national contexts, many countries have adopted strategies to improve the health of Indigenous peoples. Governmental recognition of the unique health needs of Indigenous populations is necessary for the development of targeted programs and policies to achieve universal health coverage. At the same time, the participation of Indigenous peoples in decision-making and program and policy design helps to ensure that barriers to health services are appropriately addressed and promotes the rights of Indigenous peoples to self-determination. Due to similar patterns of Indigenous health and health determinants across borders, there have been calls for greater global collaboration in this field. However, most international studies on Indigenous health policy link Anglo-settler democracies (Canada, Australia, Aotearoa/New Zealand and the United States), despite these countries representing a small fraction of the world's Indigenous people. AIM: This paper examines national-level policy in Australia, Brazil, Chile and New Zealand in relation to governmental recognition of differential Indigenous health needs and engagement with Indigenous peoples in health. The paper aims to examine how Indigenous health needs and engagement are addressed in national policy frameworks within each of the countries in order to contribute to the understanding of how to develop pro-equity policies within national health care systems. METHODS: For each country, a review was undertaken of national policies and legislation to support engagement with, and participation of, Indigenous peoples in the identification of their health needs, development of programs and policies to address these needs and which demonstrate governmental recognition of differential Indigenous health needs. Government websites were searched as well as the following databases: Google, OpenGrey, CAB Direct, PubMed, Web of Science and WorldCat. FINDINGS: Each of the four countries have adopted international agreements regarding the engagement of Indigenous peoples in health. However, there is significant variation in the extent to which the principles laid out in these agreements are reflected in national policy, legislation and practice. Brazil and New Zealand both have established national policies to facilitate engagement. In contrast, national policy to enable engagement is relatively lacking in Australia and Chile. Australia, Brazil and New Zealand each have significant initiatives and policy structures in place to address Indigenous health. However, in Brazil this is not necessarily reflected in practice and although New Zealand has national policies these have been recently reported as insufficient and, in fact, may be contributing to health inequity for Maori. In comparison to the other three countries, Chile has relatively few national initiatives or policies in place to support Indigenous engagement or recognise the distinct health needs of Indigenous communities. CONCLUSIONS: The adoption of international policy frameworks forms an important step in ensuring that Indigenous peoples are able to participate in the formation and implementation of health policy and programs. However, without the relevant principles being reflected in national legislature, international agreements hold little weight. At the same time, while a national legislative framework facilitates the engagement of Indigenous peoples, such policy may not necessarily translate into practice. Developing multi-level approaches that improve cohesion between international policy, national policy and practice in Indigenous engagement in health is therefore vital. Given that each of the four countries demonstrate strengths and weaknesses across this causal chain, cross-country policy examination provides guidance on strengthening these links.

Reflections on ethics in Indigenous health research in Chile / Reflexiones sobre la ética en la investigación de la salud de la población indígena en Chile / Reflexões sobre a ética na pesquisa em saúde indígena no Chile

Abstract The article aims to reflect on the creation of a more solid ethical research infrastructure in relation to Indigenous health research in Chile. It presents an ethical research framework that aims to support a more equitable and collaborative relationship between academics and Indigenous communities, which may lead to more relevant research and increased benefits for communities in accordance with bioethical research principles. We use international experiences to inform consideration of how ethical Indigenous health research infrastructure could be established in the Chilean context. We then present the development and adoption of guidelines for ethical Indigenous health research and orientation towards collaborative and community-led research as mechanisms that may assist in achieving these aims.

Resumen El objetivo de este artículo es reflexionar sobre la creación de una infraestructura de investigación ética más sólida en relación con la investigación de la salud de la población indígena en Chile. Se expone un marco de investigación ética que apunta a apoyar una relación más equitativa y colaborativa entre académicos y comunidades indígenas, lo que puede conducir a investigaciones más pertinentes y a mayores beneficios para las comunidades de conformidad con los principios de la investigación bioética. Se emplearon experiencias internacionales para informar sobre la forma en que se podría establecer una infraestructura de investigación de la salud de la población indígena en el contexto chileno. Luego, se presenta el desarrollo y la adopción de directrices para la investigación ética de la salud de la población indígena y la orientación hacia la investigación colaborativa y dirigida por la comunidad como mecanismos que pueden ayudar a lograr estos objetivos.

Resumo O artigo busca refletir sobre a criação de uma infraestrutura de pesquisa ética mais sólida em relação à pesquisa em saúde indígena no Chile. Apresenta-se um âmbito de pesquisa ética que visa corroborar um relacionamento mais justo e colaborativo entre a academia e as comunidades indígenas, o que pode resultar em estudos mais relevantes e no aumento dos benefícios para as comunidades, de acordo com os princípios bioéticos da pesquisa. Usamos experiências internacionais para indicar como a infraestrutura da pesquisa em saúde indígena poderia ser estabelecida no contexto chileno. Em seguida, apresentamos o desenvolvimento e adoção de diretrizes para a pesquisa ética em saúde indígena e a orientação em direção a uma pesquisa colaborativa e à comunidade como mecanismos que podem ajudar a alcançar esses objetivos.

Differences in low-birthweight among documented and undocumented foreign-born and US-born Latinas.

In the USA foreign-born women tend to have fewer low-birthweight births than US-born women from the same ethnicity. This "healthy migrant" effect could be caused by immigration of the fittest or by healthy people being deliberately selected in the immigration process. This study tests these hypotheses by comparing self-reported history of low-birth-weight among foreign-born documented and undocumented Latinas and US-born Latinas. The sample includes 2398 (57.5%) documented foreign-born Latinas, 782 (18.7%) undocumented foreign-born Latinas, and 993 (23.4%) US-born Latinas who initiated prenatal care at MIC-Women's Health Services/MHRA in New York City during 1996-1997. Only women who reported previous live births were included in the sample. Documented foreign-born Latinas were less likely than US-born Latinas to have low-birth-weight babies taking into account parity, age, risk, and education. There were no significant differences between rates of low-birthweight for undocumented foreign-born Latinas and US-born Latinas, or documented foreign-born Latinas. There was, however, a significant trend for rates of low-birthweight to increase from documented foreign-born to undocumented foreign-born to US-born women. This suggests that both official screening and migration of the fittest play a role in lower rates of low-birthweight among foreign-born Latinas compared to US-born Latinas.