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.

Assessing primary health care provider and organization readiness to address family violence in Alberta, Canada: development of a Delphi consensus readiness tool.

BACKGROUND: Family violence, which includes intimate partner abuse, child abuse, and elder abuse, is a serious public health concern. Primary healthcare (PHC) offers a vital opportunity to identify and address family violence, yet barriers prevent the effective implementation of family violence interventions in PHC settings. The purpose of this study is to improve family violence identification and response in Alberta's PHC settings by exploring readiness factors. METHODS: An integrated knowledge translation approach, combining implementation science and participatory action research, was employed to develop a readiness assessment tool for addressing family violence within PHC settings in Alberta. The research involved three phases: phase 1 involved a rapid evidence assessment, phase 2 engaged a panel of healthcare and family violence experts to explore readiness components in the Alberta context, and phase 3 utilized a 3-round Delphi consensus-building process to refine readiness indicators. RESULTS: Phase 1 findings from a rapid evidence assessment highlighted five main models/tools for assessing readiness to implement family violence interventions in PHC settings. In phase 2, additional concepts were identified through exploration with healthcare and family violence expert panel members, resulting in a total of 16 concepts for assessing family violence readiness within the Alberta PHC context. The 3-round Delphi consensus-building process in Phase 3 involved nine panelists, who collectively agreed on the inclusion of all concepts and indicators, yielding a total of 60 items for the proposed readiness assessment tool for addressing family violence in PHC within Alberta. CONCLUSION: The current study lays the groundwork for future family violence intervention programs, offering insights into key components that promote readiness for implementing comprehensive programs and supporting PHC organizations in effectively addressing family violence.

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.

Truth and Reconciliation in Medical Schools: Forging a Critical Reflective Framework to Advance Indigenous Health Equity.

In 2015, the Truth and Reconciliation Commission (TRC) of Canada outlined 94 Calls to Action, which formalized a responsibility for all people and institutions in Canada to confront and craft paths to remedy the legacy of the country's colonial past. Among other things, these Calls to Action challenge medical schools to examine and improve existing strategies and capacities for improving Indigenous health outcomes within the areas of education, research, and clinical service. This article outlines efforts by stakeholders at one medical school to mobilize their institution to address the TRC's Calls to Action via the Indigenous Health Dialogue (IHD). The IHD used a critical collaborative consensus-building process, which employed decolonizing, antiracist, and Indigenous methodologies, offering insights for academic and nonacademic entities alike on how they might begin to address the TRC's Calls to Action. Through this process, a critical reflective framework of domains, reconciliatory themes, truths, and action themes was developed, which highlights key areas in which to develop Indigenous health within the medical school to address health inequities faced by Indigenous peoples in Canada. Education, research, and health service innovation were identified as domains of responsibility, while recognizing Indigenous health as a distinct discipline and promoting and supporting Indigenous inclusion were identified as domains within leadership in transformation. Insights are provided for the medical school, including that dispossession from land lays at the heart of Indigenous health inequities, requiring decolonizing approaches to population health, and that Indigenous health is a discipline of its own, requiring a specific knowledge base, skills, and resources for overcoming inequities.

Examining the role of Indigenous primary healthcare across the globe in supporting populations during public health crises.

When health systems are overwhelmed during a public health crisis regular care is often delayed and deaths result from lapses in routine care. Indigenous primary healthcare (PHC) can include a range of programmes that incorporate treatment and management, prevention and health promotion, as well as addressing the social determinants of health (SDoH) and a focus on redressing health inequities. We examined how Indigenous PHC mobilises and innovates during a public health crisis to address patient needs and the broader SDoH. A rapid review methodology conducted from January 2021 - March 2021 was purposefully chosen given the urgency with COVID-19, to understand the role of Indigenous PHC during a public health crisis. Our review identified five main themes that highlight the role of Indigenous PHC during a public health crisis: (1) development of culturally appropriate communication and education materials about vaccinations, infection prevention, and safety; (2) Indigenous-led approaches for the prevention of infection and promotion of health; (3) strengthening intergovernmental and interagency collaboration; (4) maintaining care continuity; and (5) addressing the SDoH. The findings highlight important considerations for mobilising Indigenous PHC services to meet the needs of Indigenous patients during a public health crisis such as the COVID-19 pandemic.

Patient complexity assessment tools containing inquiry domains important for Indigenous patient care: A scoping review.

Patient complexity assessment tools (PCATs) are utilized to collect vital information to effectively deliver care to patients with complexity. Indigenous patients are viewed in the clinical setting as having complex health needs, but there is no existing PCAT developed for use with Indigenous patients, although general population PCATs may contain relevant content. Our objective was to identify PCATs that include the inquiry of domains relevant in the care of Indigenous patients with complexity. A scoping review was performed on articles published between 2016 and 2021 to extend a previous scoping review of PCATs. Data extraction from existing frameworks focused on domains of social realities relevant to the care of Indigenous patients. The search resulted in 1078 articles, 82 underwent full-text review, and 9 new tools were identified. Combined with previously known and identified PCATs, only 6 items from 5 tools tangentially addressed the domains of social realities relevant to Indigenous patients. This scoping review identifies a major gap in the utility and capacity of PCATs to address the realities of Indigenous patients. Future research should focus on developing tools to address the needs of Indigenous patients and improve health outcomes.

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.

Social-Ecological Factors Associated With Higher Levels of Resilience in Children and Youth After Disaster: The Importance of Caregiver and Peer Support.

Children and youth are among the most vulnerable to the devastating effects of disaster due to the physical, cognitive, and social factors related to their developmental life stage. Yet children and youth also have the capacity to be resilient and act as powerful catalysts for change in their own lives and wider communities following disaster. Specific factors that contribute to resilience in children and youth, however, remain relatively unexplored. This article examines factors associated with high levels of resilience in 100 children and youth aged 5- to 18-years old who experienced the 2016 Fort McMurray, Alberta wildfire. A mixed-methods design was employed combining quantitative and qualitative data. Quantitative data was obtained from the Children and Youth Resilience Measure (CYRM-28) which measured individual, caregiver, and context factors influencing resilience processes among the participants. Qualitative data was collected through semi-structured interviews to gain further insight into the disaster experiences of children and youth. Quantitative findings reveal higher than average levels of resilience among the participants compared to normative scores. Qualitative findings suggest high levels of resilience were associated with both caregiver factors (specifically physical caregiving), and individual factors (primarily peer support). We discuss how physical caregiving and peer support during and after the wildfire helped mitigate the negative effects of disaster, thus bolstering children and youth's resilience. Implications for understanding the specific social-ecological factors that facilitate and support resiliency processes and overall recovery of children and youth following disaster are also discussed.

The Indigenous primary health care and policy research network: Guiding innovation within primary health care with Indigenous peoples in Alberta.

In 2015, the Truth and Reconciliation Commission of Canada released its Final Report with 94 Calls to Action, several of which called upon the health care sector to reform based on the principles of reconciliation. In the province of Alberta, Canada, numerous initiatives have arisen to address the health legacy Calls to Action, yet there is no formal mechanism to connect them all. As such, these initiatives have resulted in limited improvements overall. Recognizing the need for clear leadership, responsibility, and dedicated funding, stakeholders from across Alberta were convened in the Spring of 2019 for two full-day roundtable meetings to provide direction for a proposed Canadian Institutes of Health Research Network Environment for Indigenous Health Research that focused on primary health care and policy research. The findings from these roundtable meetings were synthesized and integrated into the foundational principles of the Indigenous Primary Health Care and Policy Research (IPHCPR) Network. The IPHCPR Network has envisioned a renewed and transformed primary health care system to achieve Indigenous health equity, aligned with principles and health legacy Calls to Action advocated by the Truth and Reconciliation Commission of Canada.

A Comparative Analysis of Physiotherapy for Stress Urinary Incontinence after Open or Robotic-Assisted Radical Prostatectomy.

Purpose: We determined whether the patient-reported benefits of physiotherapy for stress urinary incontinence (SUI) symptoms differ significantly between men who have had open prostatectomy and those who have had robotic-assisted laparoscopic prostatectomy. Method: We conducted a retrospective analysis of data collected from the Rapid Access Clinic 4 offered by the Prostate Cancer Centre in Calgary, Alberta. Baseline characteristics were measured at the pre-surgery appointment, including demographics, health factors, and potential risk factors for SUI. Patient-reported SUI symptoms were measured pre- and post-surgery using the global score of the International Consultation on Incontinence Questionnaire-Urinary Incontinence. Results: Data from 56 men were included in the analysis, evenly split between the open and robotic sub-groups. At 3 months post-surgery, no statistically significant differences were found in the factors associated with incontinence between the two sub-groups. There was a statistically significant improvement in self-reported incontinence symptom severity from 3-month to 2-year follow-up for both sub-groups. Physiotherapy did not differentially affect either sub-group in a significant way. Conclusions: The self-reported benefits of physiotherapy for SUI symptoms did not differ significantly between the two types of prostatectomy surgery at 2 years post-surgery.

Objectif : déterminer si les avantages de la physiothérapie décrits par les patients pour contrer l'incontinence urinaire à l'effort (IUE) sont très différents entre les hommes qui ont subi une prostatectomie ouverte et ceux qui ont subi une prostatectomie par laparoscopie robotisée. Méthodologie : les chercheurs ont procédé à l'analyse rétrospective des données extraites du programme Rapid Access Clinic 4 offert par le Prostate Cancer Centre de Calgary, en Alberta. Ils ont mesuré les caractéristiques de référence au rendez-vous avant l'opération, y compris les données démographiques, les facteurs liés à la santé et les facteurs de risque potentiels d'IUE. Ils ont mesuré les symptômes d'IUE décrits par les patients avant et après l'opération au moyen du score global du questionnaire international de consultation sur l'incontinence ­ incontinence urinaire. Résultats : les données de 56 hommes ont été incluses dans l'analyse, réparties également entre le groupe de chirurgie ouverte et celui de laparoscopie robotisée. Trois mois après l'opération, il n'y avait pas de différence statistiquement significative entre les deux groupes pour ce qui est des facteurs associés à l'incontinence. Les deux groupes présentaient une diminution statistiquement significative de la gravité des symptômes d'incontinence décrits par les patients entre le suivi au bout de trois mois et celui au bout de deux ans. La physiothérapie n'avait pas d'effet différentiel significatif sur l'un ou l'autre sous-groupe. Conclusions : deux ans après l'opération, les avantages de la physiothérapie décrits par les patients pour contrer les symptômes d'IUE ne différaient pas de manière significative entre les deux types de prostatectomie.

From Prostate Health to Overactive Bladder: Developing a Crosswalk for the IPSS to OAB-V8.

OBJECTIVES: To develop a statistical model to facilitate the comparison of 2 common patient-reported outcome (PRO) instruments in male lower urinary tract symptoms. METHODS: Two PROs used by urologists are the International Prostate Symptoms Severity (IPSS) and the Overactive Bladder-Validated 8 questions (OAB-V8). The former measures symptoms related to prostate cancer, the latter measures the severity of symptoms related to OAB. Ordinary least squares regression was used to develop 3 models for translating responses to the IPSS into OAB-V8 scores. The root mean square error was used to compare the models. RESULTS: The sample consisted of 493 participants, ranging from 18 to 93 years of age. The recommended model included the individual responses to the IPSS' items and participants' age. Due to the low root mean square error (0.7606), indicating low variation and high precision, we can explain about 63% (R2 = 0.6260) relationship between IPSS and OAB-v8. CONCLUSION: This study successfully modeled global OAB-V8 scores from IPSS responses. This model performed comparably well to others developed using similar methods.

Evaluating the 8-item overactive bladder questionnaire (OAB-v8) using item response theory.

AIMS: The OAB-v8 is a patient-reported outcome questionnaire used to screen for overactive bladder and measure symptom bother. This study uses modern validation methods to assess the item and test characteristics of the OAB-v8, and determine whether it should be scored differently for men and women. METHODS: A secondary analysis of data from patients with lower urinary tract symptoms prospectively recruited from a urology clinic in Calgary, Canada. Item-response theory (IRT) was used to evaluate the dimensionality, reliability, and validity of the OAB-v8, and differential functioning analysis (DIF) was used to determine whether the OAB-v8 should be scored differently for men and women. RESULTS: A total of 1128 patients were included for analysis, of which 28% were female. Mean OAB-v8 scores indicated meaningful levels of symptom bother, and women scored 2 points higher, on average, than men (P = 0.005). Reliability was high (Cronbach's alpha = 0.901) for a wide range of patients (between -2 and 2.5 standard deviations of the mean). Samejima's graded response model best fit the data, and the scale demonstrated essential unidimensionality. Items #5 and #6 were excessively correlated. There was no evidence of differential functioning. CONCLUSIONS: OAB-v8 demonstrated high reliability and would be appropriate for a wide range of patients. Items #5 and #6 may need to be re-worded. The OAB-v8 should not be scored differently for men and women, although women do appear to experience higher average levels of symptom bother from OAB than men.