Resolutividade no Subsistema de Atenção à Saúde Indígena no Brasil: revisão de escopo / Resolubility in the Indigenous Health Care Subsystem in Brazil: scope review / Resolución en el Subsistema de Atención de la Salud Indígena en Brasil: revisión del alcance

RESUMO: A resolutividade relaciona-se à capacidade de solução dos problemas de saúde nos serviços. Em 1999, o Subsistema de Atenção à Saúde Indígena foi integrado ao Sistema Único de Saúde no Brasil, passando a seguir os seus princípios e diretrizes. Este estudo teve por objetivo identificar e mapear os desafios ou problemas relacionados às práticas em saúde para a resolutividade no Subsistema de Saúde Indígena após a integração. Trata-se de uma revisão de escopo que utilizou seis bases de dados nacionais e internacionais. Os estudos elegíveis tiveram como critério base o mnemônico PCC (P: população indígena; C: desafios ou problemas para a resolutividade; C: subsistema de saúde indígena brasileiro). Foram encontrados 1.748 estudos e selecionados 33, com predomínio de estudos qualitativos. Os desafios ou problemas sensíveis para o processo da resolutividade foram encontrados nos aspectos que tangem à educação em saúde, à interculturalidade, ao acesso universal e aos recursos em gestão. O saber tradicional é pouco valorizado pelo sistema de saúde. A deficiência de recursos humanos e materiais, a falta de efetiva educação permanente e de capacitações para trabalhar no contexto intercultural produzem barreiras de acesso e comprometem a resolutividade nos serviços, aumentando assim as iniquidades em saúde.

ABSTRACT: Resolubility relates to the ability to solve health problems in services. In 1999, the Indigenous Health Care Subsystem was integrated into the Brazilian Unified Health System, following its principles and guidelines. The objective of this study was to identify and map the challenges or problems related to health practices for solving in the Indigenous Health Subsystem after integration. This is a scope review that used six national and international databases. Eligible studies were based on mnemonic PCC (P: indigenous population; C: challenges or problems for resolution; C: Brazilian indigenous health subsystem). A total of 1,748 studies were found and 33 were selected, with predominance of qualitative studies. The challenges or problems that are sensitive to the resolution process were found in the aspects that are related to health education, interculturality, universal access and management resources. Traditional knowledge is underrated by the health system. The deficiency of human and material resources, the lack of effective permanent education and capacitations to work in the intercultural context, produce barriers to access and compromise the resolubility in services, thus increasing the inequities in health.

RESUMEN: La resolución se refiere a la capacidad de resolver problemas de salud en los servicios. En 1999, el Subsistema de Atención de Salud Indígena se integró en el Sistema Único de Salud de Brasil, siguiendo sus principios y directrices. El objetivo de este estudio fue identificar y mapear los desafíos o problemas relacionados con las prácticas de salud para resolver en el Subsistema de Salud Indígena después de la integración. Esta es una revisión de alcance que utilizó seis bases de datos nacionales e internacionales. Los estudios elegibles se basaron en PCC mnemónicos (P: población indígena; C: desafíos o problemas para la resolución; C: subsistema de salud indígena brasileño). Se encontraron 1.748 estudios y se seleccionaron 33, con predominio de estudios cualitativos. Los desafíos o problemas que son sensibles al proceso de resolución se encontraron en los aspectos que están relacionados con la educación en salud, la interculturalidad, el acceso universal y los recursos de gestión. El conocimiento tradicional es subestimado por el sistema de salud. La deficiencia de recursos humanos y materiales, la falta de educación permanente efectiva y de capacitaciones para trabajar en el contexto intercultural, producen barreras para acceder y comprometer la solubilidad en los servicios, aumentando así las desigualdades en salud.

Active screening for tuberculosis in high-incidence Inuit communities in Canada: a cost-effectiveness analysis.

BACKGROUND: Active screening for tuberculosis (TB) involves systematic detection of previously undiagnosed TB disease or latent TB infection (LTBI). It may be an important step toward elimination of TB among Inuit in Canada. We aimed to evaluate the cost-effectiveness of community-wide active screening for TB infection and disease in 2 Inuit communities in Nunavik. METHODS: We incorporated screening data from the 2 communities into a decision analysis model. We predicted TB-related health outcomes over a 20-year time frame, beginning in 2019. We assessed the cost-effectiveness of active screening in the presence of varying outbreak frequency and intensity. We also considered scenarios involving variation in timing, impact and uptake of screening programs. RESULTS: Given a single large outbreak in 2019, we estimated that 1 round of active screening reduced TB disease by 13% (95% uncertainty range -3% to 27%) and was cost saving compared with no screening, over 20 years. In the presence of simulated large outbreaks every 3 years thereafter, a single round of active screening was cost saving, as was biennial active screening. Compared with a single round, we also determined that biennial active screening reduced TB disease by 59% (95% uncertainty range 52% to 63%) and was estimated to cost Can$6430 (95% uncertainty range -$29 131 to $13 658 in 2019 Can$) per additional active TB case prevented. With smaller outbreaks or improved rates of treatment initiation and completion for people with LTBI, we determined that biennial active screening remained reasonably cost-effective compared with no active screening. INTERPRETATION: Active screening is a potentially cost-saving approach to reducing disease burden in Inuit communities that have frequent TB outbreaks.

Role of Aboriginal Health Practitioners in administering and increasing COVID-19 vaccination rates in a Victorian Aboriginal Community Controlled Health Organisation.

The COVID-19 pandemic has devastated communities throughout the world and has required rapid paradigm changes in the manner in which health care is administered. Previous health models and practices have been modified and changed at a rapid pace. This commentary provides the experiences of a regional Victorian Aboriginal Community Controlled Organisation in a COVID-19 vaccination program led and managed by Aboriginal Health Practitioners.

Are we just dishing out pills constantly to mask their pain? Kaiawhina Maori health workers' perspectives on pain management for Maori.

AIM: To explore kaiawhina (Maori community health workers) perspectives on supporting whanau Maori with chronic pain, and to understand their views on the use of online resources for pain management. METHOD: A Maori-centred, qualitative design using focus groups as the primary data collection method. Analysis using the general inductive approach. RESULTS: Thirteen kaiawhina working in the Greater Wellington region took part in the focus groups. Four key themes were identified: (1) treatment of chronic pain in primary health relies exclusively on medication, (2) health literacy approaches to pain management are urgently required, (3) Maori have significant unmet need for culturally responsive pain management, and (4) the availability of, and referral practices to, specialist pain services are inadequate for Maori communities. CONCLUSION: Current chronic pain management was predominantly biomedical, and educational strategies lack health literacy approaches. Primary health services exclude traditional Maori methods of treating chronic pain and do not focus on whanau wellbeing. The lack of referral for Maori to specialist services highlights the existing health inequities for Maori. Developing new initiatives (both in-person and online) to address chronic pain management for Maori must be Maori-led and co-designed with whanau to result in holistic solutions for Maori.

Maori and Pacific peoples' experiences of a Maori-led diabetes programme.

AIM: Type 2 diabetes mellitus (T2DM) disproportionately affects Maori and Pacific peoples in Aotearoa (New Zealand). Despite this, the lived experiences of T2DM and its management by Maori and Pacific peoples are scarcely acknowledged in health literature. The present study examines the lived experiences of T2DM by Maori and Pacific participants in the Mana Tu diabetes programme. Mana Tu is a Maori-led diabetes support programme co-designed by the National Hauora Coalition (NHC) alongside patients with diabetes, clinicians, health service planners and whanau ora providers. METHOD: The study used qualitative methods underpinned by Kaupapa Maori (Maori approaches) approaches. Twenty-two semi-structured interviews were conducted with participants of the Mana Tu diabetes programme and their whanau (thirteen Maori, 9 Pacific) from Tamaki Makaurau (Auckland) and Te Tai Tokerau (Northland). RESULTS: The study identified barriers, facilitators and motivators for participants to live well with T2DM. Four key themes were constituted: (1) whanau experience of T2DM, (2) cultural safety in healthcare interactions, (3) whanau ora (collective family wellbeing) and (4) Kaupapa Maori approaches to health interventions. Themes were consistent across Maori and Pacific participants. CONCLUSION: Findings suggest that Maori-led health interventions can better support Maori and Pacific people living with T2DM and are needed to ensure these communities receive appropriate, responsive and equitable healthcare.

Decolonizing health in Canada: A Manitoba first nation perspective.

INTRODUCTION & BACKGROUND: Global persistence of health inequities for Indigenous peoples is evident in ongoing discrepancies in health and standards of living. International literature suggests the key to transformation lies in Indigenous efforts to control Indigenous health and healthcare. Previous authors have focused upon participation, structural transformation, and culturally appropriate healthcare recognized as a political right as fundamental tenets of Indigenous control. Contextualizing Indigenous health and wellness falls within a growing discussion on decolonization - a resituating of expertise that privileges Indigenous voice and interests. METHODS: The study is a qualitative, grounded theory analysis, which is a constructivist approach to social research allowing for generation of theory in praxis, through interactions and conversations between researchers and participants. One hundred eighty-three interviews with additional focus groups were held between 2013-15 in eight Manitoba First Nation communities representing different models of health delivery, geographies, accessibilities, and Indigenous language groups. Community research assistants and respected Elders participated in data collection, analysis and interpretation. Line-by-line coding and constant comparative method led to the discovery of converging themes. FINDINGS: Ultimately four main themes arose: 1) First Nation control of healthcare; 2) traditional medicine and healing activities; 3) full and meaningful community participation; and 4) cleaning up impacts of colonization. Joint analyses and interpretation of findings revealed substantial evidence that communities were looking profoundly into problems of improperly delivered services and health inequities. Issues were consistent with those highlighted by international commissions on reconciliation, health, Indigenous rights and liberties. To those documents, these findings add ground upon which to build the transformative agenda. RESULTS & DISCUSSION: Communities discussed the need for creation of protocols, constitution and laws to ensure growth of a decolonizing agenda. Inclusive to the concept are holistic, preventative, traditional health perspectives, and Indigenous languages. Colonization impacts were of critical concern and in need of undoing. Sharing of social and political efforts is seen as pivotal to change and includes all members of communities.

Impact of a screen, triage and treat program for identifying chronic disease risk in Indigenous children.

BACKGROUND: The First Nations Community Based Screening to Improve Kidney Health and Prevent Dialysis project was a point-of-care screening program in rural and remote First Nations communities in Manitoba that aimed to identify and treat hypertension, diabetes and chronic kidney disease. The program identified chronic disease in 20% of children screened. We aimed to characterize clinical screening practices before and after intervention in children aged 10-17 years old and compare outcomes with those who did not receive the intervention. METHODS: This observational, prospective cohort study started with community engagement and followed the principles of ownership, control, access and possession (OCAP). We linked participant data to administrative data at the Manitoba Centre for Health Policy to assess rates of primary care and nephrology visits, disease-modifying medication prescriptions and laboratory testing (i.e., glycosylated hemoglobin [HbA1c], estimated glomerural filtration rate [eGFR] and urine albumin- or protein-to-creatinine ratio). We analyzed the differences in proportions in the 18 months before and after the intervention. We also conducted a 1:2 propensity score matching analysis to compare outcomes of children who were screened with those who were not. RESULTS: We included 324 of 353 children from the screening program (43.8% male; median age 12.3 yr) in this study. After the intervention, laboratory testing increased by 5.8% (95% confidence interval [CI] 1.1% to 10.1%) for HbA1c, by 9.9% (95% CI 4.2% to 15.5%) for eGFR and by 6.2% (95% CI 2.3% to 10.0%) for the urine albumin- or protein-to-creatinine ratio. We observed significant improvements in laboratory testing in screened patients in the group who were part of the program, compared with matched controls. INTERPRETATION: Chronic disease surveillance and care increased significantly in children after the implementation of a point-of-care screening program in rural and remote First Nation communities. Interventions such as active surveillance programs have the potential to improve the chronic disease care being provided to First Nations children.

Improving interagency service integration of the Australian Nurse Family Partnership Program for First Nations women and babies: a qualitative study.

BACKGROUND: The Australian Nurse Family Partnership Program (ANFPP) is an evidence-based, home visiting program that offers health education, guidance, social and emotional support to first-time mothers having Aboriginal and/or Torres Strait Islander (First Nations) babies. The community-controlled sector identified the need for specialised support for first time mothers due to the inequalities in birthing and early childhood outcomes between First Nations' and other babies in Australia. The program is based on the United States' Nurse Family Partnership program which has improved long-term health outcomes and life trajectories for mothers and children. International implementation of the Nurse Family Partnership program has identified interagency service integration as key to program recruitment, retention, and efficacy. How the ANFPP integrates with other services in an Australian urban setting and how to improve this is not yet known. Our research explores the barriers and enablers to interagency service integration for the Australian Nurse Family Partnership Program ANFPP in an urban setting. METHODS: A qualitative study using individual and group interviews. Purposive and snowball sampling was used to recruit clients, staff (internal and external to the program), Elders and family members. Interviews were conducted using a culturally appropriate 'yarning' method with clients, families and Elders and semi-structured interview guide for staff. Interviews were audio-recorded and transcribed prior to reflexive thematic analysis. RESULTS: Seventy-six participants were interviewed: 26 clients, 47 staff and 3 Elders/family members. Three themes were identified as barriers and three as enablers. Barriers: 1) confusion around program scope, 2) duplication of care, and 3) tensions over 'ownership' of clients. Enablers (existing and potential): 1) knowledge and promotion of the program; 2) cultural safety; and 3) case coordination, co-location and partnership forums. CONCLUSION: Effective service integration is essential to maximise access and acceptability of the ANFPP; we provide practical recommendations to improve service integration in this context.

Putting them on a strong spiritual path: Indigenous doulas responding to the needs of Indigenous mothers and communities.

OBJECTIVE: In the past few years, increasing numbers of Indigenous doula collectives have been forming across Canada. Indigenous doulas provide continuous, culturally appropriate support to Indigenous women during pregnancy, birth, and the post-partum period. This support is critical to counter systemic medical racism and socioeconomic barriers that Indigenous families disproportionately face. This paper analyzes interviews with members of five Indigenous doula collectives to demonstrate their shared challenges, strategies, and missions. METHODS: Qualitative interviews were conducted with members of five Indigenous doula collectives across Canada in 2020. Interviews were transcribed and returned to participants for their approval. Approved transcripts were then coded by all members of the research team to ascertain the dominant themes emerging across the interviews. RESULTS: Two prominent themes emerged in the interviews. The first theme is "Indigenous doulas responding to community needs." Participants indicated that responding to community needs involves harm reduction and trauma-informed care, supporting cultural aspects of birthing and family, and helping clients navigate socioeconomic barriers. The second theme is "Indigenous doulas building connections with mothers." Participants' comments on providing care to mothers emphasize the importance of advocacy in healthcare systems, boosting their clients' confidence and skills, and being the "right" doula for their clients. These two inter-related themes stem from Indigenous doulas' efforts to counter dynamics in healthcare and social services that can be harmful to Indigenous families, while also integrating cultural teachings and practices. CONCLUSION: This paper illustrates that Indigenous doula care responds to a wide range of issues that affect Indigenous women's experiences of pregnancy, birth, and the post-partum period. Through building strong, trusting, and non-judgemental connections with mothers and responding to community needs, Indigenous doulas play a critical role in countering medical racism in hospital settings and advancing the resurgence of Indigenous birthing sovereignty.

A community-led design for an Indigenous Model of Mental Health Care for Indigenous people with depressive disorders.

OBJECTIVE: To generate outcomes for the development of a culturally appropriate mental health treatment model for Indigenous Australians with depression. METHODS: Three focus group sessions and two semi-structured interviews were undertaken over six months across regional and rural locations in South West Queensland. Data were transcribed verbatim and coded using manual thematic analyses. Transcripts were thematically analysed and substantiated. Findings were presented back to participants for authenticity and verification. RESULTS: Three focus group discussions (n=24), and two interviews with Elders (n=2) were conducted, from which six themes were generated. The most common themes from the focus groups included Indigenous autonomy, wellbeing and identity. The three most common themes from the Elder interviews included culture retention and connection to Country, cultural spiritual beliefs embedded in the mental health system, and autonomy over funding decisions. CONCLUSIONS: A treatment model for depression must include concepts of Indigenous autonomy, identity and wellbeing. Further, treatment approaches need to incorporate Indigenous social and emotional wellbeing concepts alongside clinical treatment approaches. Implications for public health: Any systematic approach to address the social and cultural wellbeing of Indigenous peoples must have a community-led design and delivery.

Wabishki Bizhiko Skaanj: a learning pathway to foster better Indigenous cultural competence in Canadian health research.

OBJECTIVE: In Canada, Indigenous people experience racism across diverse settings, including within the health sector. This has negatively impacted both the quality of care that Indigenous people receive as well as how research related to Indigenous populations is conducted. Therefore, an Indigenous-led council at a kidney research network, in partnership with other key stakeholders, sought to create a learning pathway that aims to distill the racism that Indigenous people face, and build cultural competence, within the health sector. PARTICIPANTS: The learning pathway was designed for researchers, health care providers, patient partners and administrators. SETTING: Various components of the pathway are established trainings in healthcare and research settings at provincial and national levels. Provincially, some components are implemented in British Columbia, Alberta, Saskatchewan, Manitoba and Ontario. INTERVENTION: The pathway, called Wabishki Bizhiko Skaanj (meaning "White Horse" in Anishinaabemowin), involves six key steps: a culturally tailored blanket exercise that walks participants through the history of local Indigenous Nations/peoples; a more detailed online training program (San'yas); a series of webinars on Indigenous research ethics and protocols; an educational booklet about engaging Knowledge Keepers in research, as well as sharing details about their traditional knowledge and culture; two certification programs about Indigenous ownership of data; and a "book club," wherein the conversation of racism-and the goal for finding solutions-is continually discussed. OUTCOMES: Wabishki Bizhiko Skaanj is working to build cultural competence in the Canadian health sector. IMPLICATIONS: This learning pathway has the potential to address racial disparities across the country and improve health outcomes for Indigenous peoples.

RéSUMé: OBJECTIF: Au Canada, les autochtones font face au racisme dans divers milieux, y compris dans le secteur de la santé. Cela a eu une incidence négative sur la qualité des soins que reçoivent les peuples autochtones, ainsi que sur la façon dont la recherche sur les populations autochtones est menée. Par conséquent, un conseil dirigé par des Autochtones dans un réseau de recherche sur les reins, en partenariat avec d'autres parties prenantes, a cherché à créer une voie d'apprentissage visant à réduire le racisme auquel les peuples autochtones sont confrontés et à renforcer les compétences culturelles au sein du secteur de la santé. PARTICIPANTS: La voie d'apprentissage a été conçue pour les chercheurs, les fournisseurs de soins de santé, les patients partenaires et les administrateurs. CADRE: Cette voie d'apprentissage est composée de formations établies dans le milieu de la santé et de la recherche au niveau provincial et national. À l'échelle provinciale, il y a des programmes ayant lieu en Colombie-Britannique, en Alberta, en Ontario, en Saskatchewan et au Manitoba. INTERVENTION: La voie d'apprentissage, appelée Wabishki Bizhiko Skaanj (qui signifie « cheval blanc ¼ en Anishinaabemowin), comporte six étapes clés : un exercice culturel sur mesure qui guide les participants à travers l'histoire des nations/peuples autochtones locaux à l'aide de diverses couvertures culturelles; un programme de formation en ligne détaillé (San'yas); une série de webinaires sur l'éthique et les protocoles autochtones en matière de recherche; un livret pédagogique sur l'engagement des gardiens de la connaissance en recherche ainsi que le partage d'informations sur leur connaissance et leur culture traditionnelle; deux programmes de certification sur la propriété autochtone des données; et un « club de lecture ¼ dans lequel nous ne cessons de discuter du racisme tout en cherchant des solutions. RéSULTATS: Wabishki Bizhiko Skaanj s'efforce de renforcer les compétences culturelles dans le secteur de la santé au Canada. IMPLICATIONS: Cette voie d'apprentissage a le potentiel de s'attaquer aux disparités raciales à l'échelle nationale et d'améliorer les résultats en matière de santé pour les peuples autochtones.

A casemix study of patients seen within an urban Aboriginal Health Service dermatology clinic over a five-year period.

This is the largest study of Aboriginal and Torres Strait Islander dermatologic presentations to an urban specialist clinic within a community-controlled health organisation. It adds to our understanding of Aboriginal and Torres Strait Islander dermatoepidemiology. Patient files were reviewed over the five-year audit period, with age, gender, Indigenous status, diagnosis, disease category, 'new' or 'review consultation' and 'did not attend' (DNA) data recorded. Our study shows that eczema and benign, pre-malignant or malignant neoplasms are the most common presentations for urban Aboriginal and Torres Strait Islander patients. Lupus erythematosus and cutaneous infections were less prominent in comparison to data from rural and remote populations. Overall, a broad casemix of dermatologic presentations was observed. Similar to other studies, adult male patients were under-represented. Most skin malignancies were diagnosed in this cohort; this, therefore, identifies a possible target for public health intervention. A high ratio of new to review patients is consistent with the clinic offering a consultation model of care facilitated by primary health-care providers' support within Aboriginal Community-Controlled Health Service. DNA rates in this study were lower than hospital outpatient rates in a comparative study and may be attributed to specialist dermatology care being offered in a more culturally sensitive environment. The dermatology clinic at the Victorian Aboriginal Health Services (VAHS) provides a good breadth of specialist dermatology care. The community health-care model could be replicated in centres elsewhere, including interstate, to help overcome barriers to specialist dermatology care experienced by Aboriginal and Torres Strait Islander populations. Additionally, this model improves trainee exposure and understanding of Aboriginal and Torres Strait Islander health.

Considering difference: clinician insights into providing equal and equitable burns care for Aboriginal and Torres Strait Islander children.

OBJECTIVE: To better understand issues driving quality in burn care related to equity of outcomes and equality of provision for Aboriginal and Torres Strait Islander children. METHODS: Seventy-six interviews with team members who provide care for Aboriginal and Torres Strait Islander children in six paediatric burn units across five Australian jurisdictions were completed. Interface research methodology within a qualitative design guided data collection and analysis. RESULTS: Three themes were identified: i) Burn team members who identify the requirement to meet the specific needs of Aboriginal and Torres Strait Islander children and deliver differential care; ii) Burn team members who believe in equal care, but deliver differential care based on the specific needs of Aboriginal and Torres Strait Islander children; and iii) Burn team members who see little need for provision of differential care for Aboriginal and Torres Strait Islander children and rather, value the provision of equal care for all. CONCLUSION: Burn team members conflate equitable and equal care, which has implications for the delivery of care for Aboriginal and Torres Strait Islander children. Equitable care is needed to address disparities in post-burn outcomes, and this requires clinicians, healthcare services and relevant system structures to work coherently and intentionally to reflect these needs. Implications for public health: Changes in health policy, the embedding of Aboriginal and Torres Strait Islander liaison officers in burn care teams and systems that prioritise critical reflexive practice are fundamental to improving care.

Suicide rates for young Aboriginal and Torres Strait Islander people: the influence of community level cultural connectedness.

OBJECTIVES: To examine associations between community cultural connectedness indicators and suicide mortality rates for young Aboriginal and Torres Strait Islander people. STUDY DESIGN: Retrospective mortality study. SETTING, PARTICIPANTS: Suicide deaths of people aged 10-19 years recorded by the Queensland Suicide Register, 2001-2015. MAIN OUTCOME MEASURES: Age-standardised suicide death rates, by Indigenous status, sex, and age group; age-standardised suicide death rates for young First Nations people by area level remoteness and Index of Relative Socioeconomic Advantage and Disadvantage, and by cultural connectedness indicators (at statistical area level 2): cultural social capital index score, community Indigenous language use, and reported discrimination. RESULTS: The age-specific suicide rate was 21.1 deaths per 100 000 persons/year for First Nations young people and 5.0 deaths per 100 000 persons/year for non-Indigenous young people (rate ratio [RR], 4.3; 95% CI, 3.5-5.1). The rate for Aboriginal and Torres Strait Islander young people was higher in areas with low levels of cultural social capital (greater participation of community members in cultural events, ceremonies, organisations, and community activities) than in areas classified as having high levels (RR, 1.8; 95% CI, 1.2-2.7), and also in communities with high levels of reported discrimination (RR, 2.7; 95% CI, 1.7-4.3). Associations with proportions of Indigenous language speakers and area level socio-economic resource levels were not statistically significant. CONCLUSION: We found that suicide mortality rates for Aboriginal and Torres Strait Islander young people in Queensland were influenced by community level culturally specific risk and protective factors. Our findings suggest that strategies for increasing community cultural connectedness at the community level and reducing institutional and personal discrimination could reduce suicide rates.

Using community-led development to build health communication about rheumatic heart disease in Aboriginal children: a developmental evaluation.

OBJECTIVE: A high prevalence of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) among Aboriginal children in northern Australia is coupled with low understanding among families. This has negative impacts on children's health, limits opportunities for prevention and suggests that better health communication is needed. METHODS: During an RHD echocardiography screening project, Aboriginal teachers in a remote community school created lessons to teach children about RHD in their home languages, drawing on principles of community-led development. Access to community-level RHD data, previously unknown to teachers and families, was a catalyst for this innovative work. Careful, iterative discussions among speakers of four Aboriginal languages ensured a culturally coherent narrative and accompanying teaching resources. RESULTS: The evaluation demonstrated the importance of collective work, local Indigenous Knowledge and metaphors. As a result of the lessons, some children showed new responses and attitudes to skin infections and their RHD treatment. Language teachers used natural social networks to disseminate new information. A community interagency collaboration working to prevent RHD commenced. Conclusions and implications for public health: Action to address high rates of RHD must include effective health communication strategies that value Indigenous Knowledge, language and culture, collaborative leadership and respect for Indigenous data sovereignty.

[Gorgeous Colorful Rainbow: The Beauty and Sorrow of Indigenous People`s Health].

Residing across this island for over 8,000 years, Taiwan`s indigenous people represent the world`s northernmost population of Austronesian islanders. Although Taiwan`s more than 500,000 indigenous citizens today account for only 0.11% of the 300 million Austronesians worldwide, Taiwan and Taiwan`s long-thriving Austronesian culture played an indispensable role in the historical migrations of ancient Austronesian peoples from Mainland Asia and their proliferation throughout the Pacific (Council on Indigenous Peoples, n.d.). The cultural diversity of Taiwan`s indigenous people allowed their many ethnic groups to adapt to the island`s climatic and environmental diversity, ranging from high, temperate mountains to tropical coastlines, for thousands of years. These groups have adapted well to local conditions, developing living habits, livelihood patterns, life customs, and ceremonies suited to their lives. Traditional wisdom and knowledge, like a colorful rainbow, have shone from ancient times up through the present and are woven deeply through the unique life values of the 16 ethnic tribal groups on Taiwan Island. However, the modernization and transformation of Taiwan`s economy during the past three decades have left indigenous citizens significantly behind mainstream society in many important aspects, including average lifespan, income, education level, and access to medical resources, with mainstream society enjoying more social advantages and a longer average life span (Health Promotion Administration, 2017). Thus, social determinants have promoted various inequalities in health, and the rainbow is no longer beautiful under the impact of modern values. The inequitable distribution of healthcare resources and inadequate human resources have cast a shadow of sadness over this originally beautiful rainbow. Some scholars have raised the cultural security model as a possible framework for formulating policies and regulations to protect the health rights of disadvantaged groups (Coffin, 2007). Using knowledge and values to emphasize cultural safety in the health field and cultural awareness holds the potential of reversing the role of traditional wisdom and knowledge transmitters to gain a deep understanding of the health needs of ethnic groups and of implementing related strategies in acute, chronic, and long-term medical care. This issue is rooted in the current, inequitable deployment of long-term care resources and provision of policy recommendations. In this paper, we discuss strategies for considering and actualizing the main concerns and priorities of ethnic groups, cultivating long-term care 2.0 cultural safety seed tutors, and employing ethnically indigenous nurses in their hometowns / communities. Furthermore, in terms of caring for minorities, we also discuss the long-term care needs of disadvantaged groups such as individuals with mental health needs to achieve the goal of holistic care. We look forward to seeing the bright and colorful rainbow once again. From systemic, educational, and practice perspectives, we will jointly promote public health for all and work to let the beauty of the rainbow surpass the traces of sorrow.

[Health of Indigenous People and Cultural Sovereignty: Developing the Competence of Culture Safety Instructors Under the Long-Term Care 2.0 Program].

Taiwan`s various ethnic groups, including 16 indigenous groups, represent disparate distinct cultures and backgrounds. In long-term care, culturally safe services that reflect cultural expectations and practices must be provided to older-adult recipients of care. As frontline healthcare workers face practical challenges in providing these services appropriately, "cultural safety instructors" may be used to help facilitate indigenous cultural care. Therefore, it is vital to develop the role function and cultural competence of these instructors. In this article, related instructor qualifications, course contents, and expected results of an indigenous cultural safety instruction program are presented based on the theory of cultural competence and cultural safety. In addition, relevant perspectives on cultural safety instructors and their cross-cultural competence specific to indigenous peoples, including Dimitrov and Haque (2016) and Leininiger (1996), are integrated. It is hoped that this study promotes reflection and provides a reference on practice and policies related to long-term care for indigenous people.

[Do We Need More Indigenous Nurses?]

Data collected over the past four decades show the life expectancy of indigenous Taiwanese to be 8 to 10 years lower than the general, predominantly Han Chinese, population. This suggests the persistence of inequities in the public health system in Taiwan. Several facets of this issue, including lack of consideration of the characteristics and lifestyle of ethnic populations in health policy planning and implementation work and the continued location-based focus of medical care resource distribution policies, are being actively discussed. However, investigations of factors related to the relatively poor health status of indigenous Taiwanese have not considered the traumatic and lingering effects of colonisation. This article briefly introduces the health status of indigenous Taiwanese and the indigenous nursing workforce and then presents a review of the literature on factors related to the under-representation of indigenous Taiwanese in nursing programs and the nursing workforce. Indigenous Taiwanese were found to be absent from public-health policymaking. Moreover, indigenous-related traditional knowledge and values are not being effectively transmitted to younger generations. A diverse nursing workforce should reflect and respond to not only indigenous peoples but also the general population in Taiwan.