Perceived Access to Health Care of Indigenous Peoples in Canada with Rheumatoid Arthritis and their First-Degree Relatives.

OBJECTIVE: There are complex and interrelated factors that lead to inequitable healthcare delivery in Canada. Many of the factors that underlie these inequities for Canada's geographically dispersed Indigenous Peoples remain underexamined. METHODS: A cohort of 831 First Nations (FN) individuals from urban and remote communities were recruited into a longitudinal study of rheumatoid arthritis (RA) risk from 2005-2017. Data from each participant's initial enrollment visit was assessed using a survey that captured concerns with health care access. RESULTS: We found that remote participants with RA reported poor access compared to remote First-Degree Relatives (FDR, p<0.001), this difference was not observed for urban RA participants. We observed substantial differences based on sex; Females perceived access to care to be more difficult than males in both urban and remote cohorts (p<0.001). We also observed that male participants with RA reported poor access to care compared to male FDR. Importantly, access to care in remote communities appeared to improve over the duration of the study (p=0.01). In a logistic regression analysis, female sex, remote location, and older age were independent predictors of poor access to care. Predictors of poor access in participants with RA were also female sex, remote location and older age. CONCLUSION: FN peoples living in remote communities, particularly those with an established RA diagnosis, report more problems accessing healthcare. Sex-based inequities exist, with FN females reporting greater difficulties in accessing appropriate healthcare, irrespective of RA diagnosis. Addressing these sex-based inequities should be a high priority for improving healthcare delivery.

Experiences and Outcomes of Indigenous Patients Undergoing Bariatric Surgery: a Mixed-Method Scoping Review.

Obesity and type 2 diabetes (T2D) are growing global health concerns. Evidence suggests that Indigenous peoples are at higher lifetime risk of obesity and its associated conditions. Obesity increases the risk of T2D, cardiovascular disease, and all-cause mortality. Bariatric surgery is the most sustained and effective intervention for treating obesity-associated medical problems. This review aims to explore the experiences and outcomes of Indigenous peoples undergoing bariatric surgery in Canada, the USA, Australia, and New Zealand (CANZUS). Analysis of quantitative data revealed that Indigenous patients had fewer bariatric procedures, poorer clinic attendance, similar weight loss outcomes and slightly higher post-operative complication rates. Qualitative data analysis revealed that Indigenous patients living with obesity have a desire to improve their health and quality of life.

Disparities in rheumatoid arthritis outcomes for North American Indigenous populations.

Advances in rheumatoid arthritis (RA) management have significantly improved clinical outcomes of this disease; however, some Indigenous North Americans (INA) with RA have not achieved the high rates of treatment success observed in other populations. We review factors contributing to poor long-term outcomes for INA with RA. We conducted a narrative review of studies evaluating RA in INA supplemented with regional administrative health and clinical cohort data on clinical outcomes and health care utilisation. We discuss factors related to conducting research in INA populations including studies of RA prevention. NA with RA have a high burden of genetic and environmental predisposing risk factors that may impact disease phenotype, delayed or limited access to rheumatology care and advanced therapy. These factors may contribute to the observed increased rates of persistent synovitis, premature end-stage joint damage and mortality. Novel models of care delivery that are culturally sensitive and address challenges associated with providing speciality care to patients residing in remote communities with limited accessibility are needed. Progress in establishing respectful research partnerships with INA communities has created a foundation for ongoing initiatives to address care gaps including those aimed at RA prevention. This review highlights some of the challenges of diagnosing, treating, and ultimately perhaps preventing, RA in INA populations.

Can Studying Genetically Predisposed Individuals Inform Prevention Strategies for RA?

Rheumatoid arthritis (RA) is a prevalent autoimmune disorder in which complex genetic predisposition interacts with multiple environmental factors to precipitate chronic and progressive immune-mediated joint inflammation. Currently, in most affected individuals, ongoing suppression of the inflammation is required to prevent irreversible damage and functional loss. The delineation of a protracted preclinical period in which autoimmunity is initially established and then evolves to become pathogenic provides unprecedented opportunities for interventions that have the potential to prevent the onset of this lifelong disease. Clinical trials aimed at assessing the impact of specific prevention strategies require the identification of individuals who are at high risk of future RA development. Currently, these risk factors include a strong family history of RA, and the detection of circulating RA-associated autoantibodies, particularly anti-citrullinated protein antibodies (ACPA). Yet, even in such individuals, there remains considerable uncertainty about the likelihood and the timeframe for future disease development. Thus, individuals who are approached to participate in such clinical trials are left weighing the risks and benefits of the prevention measures, while having large gaps in our current understanding. To address this challenge, we have undertaken longitudinal studies of the family members of Indigenous North American RA patients, this population being known to have a high prevalence of RA, early age of onset, and familial clustering of cases. Our studies have indicated that the concepts of "risk" and "prevention" need to be communicated in a culturally relevant manner, and proposed prevention interventions need to have an appropriate balance of effectiveness, safety, convenience, and cultural acceptability. We have focused our proposed prevention studies on immunomodulatory/anti-inflammatory nutritional supplements that appear to strike such a complex balance.

Decolonising qualitative research to explore the experiences of Manitoba's urban Indigenous population living with type 2 diabetes mellitus, obesity and bariatric surgery.

INTRODUCTION: Obesity and type 2 diabetes mellitus (T2DM) are growing global health concerns associated with significant morbidity, mortality and healthcare expenditures. Due to histories of colonisation and contemporary marginalisation, Canada's Indigenous populations are disproportionately burdened by obesity, T2DM and many other chronic illnesses. Culturally appropriate research on experiences and outcomes of Indigenous patients undergoing bariatric surgery in Canada is scarce. This qualitative study protocol will use a decolonising approach guided by an Indigenous Elder to explore the perspectives and experiences of urban Indigenous Manitobans with respect to T2DM, obesity and bariatric surgery. This knowledge will guide the development and implementation of culturally sensitive bariatric care. METHODS AND ANALYSIS: Sequential sharing circles (SSCs) and semistructured conversational interviews that have been purposefully designed to be culturally relevant with the guidance of an Indigenous Elder and advisory group (IAG) will be carried out in Winnipeg, Manitoba, Canada. Indigenous adults who are obese (body mass index >35 kg/m2), have T2DM and live in an urban centre will be recruited. Three groups will be investigated: (1) those who have had bariatric surgery; (2) those on the wait list for bariatric surgery and (3) those not associated with a bariatric surgery programme. Each group of 10-12 participants will be guided through a semistructured script led by an Indigenous Elder. Elder-facilitated conversational interviews will also be completed following the SSCs. All content will be audio recorded and transcribed. Thematic analysis will be used to identify emerging patterns using a constructive grounded theory approach. ETHICS AND DISSEMINATION: This study has received ethical approval from the University of Manitoba Health Research Ethics Board. Findings will inform the development and implementation of culturally sensitive programmes at Manitoba's Centre for Metabolic and Bariatric Surgery. Results will be disseminated in peer-reviewed scientific journals, at obesity and Indigenous health conferences, and knowledge sharing ceremonies.