Occurrence of and referral to specialists for pain-related diagnoses in First Nations and non-First Nations children and youth.

BACKGROUND: Indigenous youth have higher rates of chronic health conditions interfering with healthy development, including high rates of ear, dental, chest and musculoskeletal pain, as well as headache, arthritis and mental health issues. This study explores differences in pain-related diagnoses in First Nations and non-First Nations children. METHODS: Data from a study population of age- and sex-matched First Nations and non-First Nations children and youth were accessed from a specific region of Atlantic Canada. The primary objective of the study was to compare diagnosis rates of painful conditions and specialist visits between cohorts. The secondary objective was to determine whether there were correlations between early physical pain exposure and pain in adolescence (physical and mental health). RESULTS: Although ear- and throat-related diagnoses were more likely in the First Nations group than in the non-First Nations group (ear 67.3% v. 56.8%, p < 0.001; throat 89.3% v. 78.8%, p < 0.001, respectively), children in the First Nations group were less likely to see a relevant specialist (ear 11.8% v. 15.5%, p < 0.001; throat 12.7% v. 16.1%, p < 0.001, respectively). First Nations newborns were more likely to experience an admission to the neonatal intensive care unit (NICU) than non-First Nations newborns (24.4% v. 18.4%, p < 0.001, respectively). Non-First Nations newborns experiencing an NICU admission were more likely to receive a mental health diagnosis in adolescence, but the same was not found with the First Nations group (3.4% v. 5.7%, p < 0.03, respectively). First Nations children with a diagnosis of an ear or urinary tract infection in early childhood were almost twice as likely to have a diagnosis of headache or abdominal pain as adolescents (odds ratio [OR] 1.9, 95% confidence interval [CI] 1.1-3.0, and OR 1.7, 95% CI 1.2-2.3, respectively). INTERPRETATION: First Nations children were diagnosed with more pain than non-First Nations children, but did not access specific specialists or mental health services, and were not diagnosed with mental health conditions, at the same rate as their non-First Nations counterparts. Discrepancies in pain-related diagnoses and treatment are evident in these specific comparative cohorts. Community-based health care access and treatment inquiries are required to determine ways to improve care delivery for common childhood conditions that affect health and development.

Return on investment from service transformation for young people experiencing mental health problems: Approach to economic evaluations in ACCESS Open Minds (Esprits ouverts), a multi-site pan-Canadian youth mental health project.

Introduction: Mental health problems are common globally, and typically have their onset in adolescence and early adulthood-making youth (aged 11-25) an optimal target for prevention and early intervention efforts. While increasing numbers of youth mental health (YMH) initiatives are now underway, thus far few have been subject to economic evaluations. Here we describe an approach to determining the return on investment of YMH service transformation via the pan-Canadian ACCESS Open Minds (AOM) project, for which a key focus is on improving access to mental health care and reducing unmet need in community settings. Approach: As a complex intervention package, it is hoped that the AOM transformation will: (i) enable early intervention through accessible, community-based services; (ii) shift care away toward these primary/community settings and away from acute hospital and emergency services; and (iii) offset at least some of the increased costs of primary care/community-based mental health services with reductions in the volume of more resource-intensive acute, emergency, hospital or specialist services utilized. Co-designed with three diverse sites that represent different Canadian contexts, a return on investment analysis will (separately at each site) compare the costs generated by the intervention, including volumes and expenditures associated with the AOM service transformation and any contemporaneous changes in acute, emergency, hospital or service utilization (vs. historical or parallel comparators). Available data from health system partners are being mobilized to assess these hypotheses. Anticipated results: Across urban, semi-urban and Indigenous sites, the additional costs of the AOM transformation and its implementation in community settings are expected to be at least partially offset by a reduction in the need for acute, emergency, hospital or specialist care. Discussion: Complex interventions such as AOM aim to shift care "upstream": away from acute, emergency, hospital and specialist services and toward community-based programming which is more easily accessible, often more appropriate for early-stage presentations, and more resource-efficient. Carrying out economic evaluations of such interventions is challenging given the constraints of available data and health system organization. Nonetheless, such analyses can advance knowledge, strengthen stakeholder engagement, and further implementation of this public health priority.

Co-creating better healthcare experiences for First Nations children and youth: The FIRST approach emerges from Two-Eyed seeing.

To achieve health, Indigenous people seek a life that balances mental, spiritual, emotional, and physical wellness, yet the scope of these four dimensions is not typically considered in the Western-based health system. Indigenous people experience ongoing pain and hurt in all these dimensions as a result of a colonial legacy that persists in current-day policy and care contexts. Exploring ways to support Indigenous people to embrace ways of being well and reducing chronic pain has not been a priority area in health research. This community-based, qualitative study in four First Nations communities involved conversation sessions with 188 First Nations children, youth, parents, and Elders and 32 professionals who practice in those communities. The purpose was to gather perspectives related to pain expression, care experiences, and the strategies to improve the healthcare encounter. Thematic analysis was used to identify a more culturally thoughtful approach for clinicians to consider when First Nations people seek care. Two-Eyed Seeing consisting of four iterative steps was used to co-create the FIRST approach validating for community members that their perspectives were heard and providing a clinical approach for culturally safe practices with children, youth, and families. An overarching theme in the results was a clearer understanding about how pain and hurt translate into participants' health experiences and their desire to have their knowledge reflected in their health care. Participants describe experiencing pain and hurt in all four dimensions of health and from a historical, cultural, and spiritual identity, as well as from a community, family, and individual perspective. The FIRST approach captures Indigenous knowledge relating to Family, Information, Relationship, Safe-Space, and Two-Eyed treatment in the healthcare encounter. Considerations of this approach in clinical practice could enhance respectful and trusting relationships, knowledge exchange for better care experiences, and potentially improvement of culturally sensitive outcomes for Indigenous people.

A community partnership to explore mental health services in First Nations communities in Nova Scotia.

OBJECTIVE: This study aimed at identifying the gaps, barriers and successes/solutions associated with mental health services in Mi'kmaq communities in Nova Scotia. METHODS: Community-based participatory research, which is consistent with Ownership, Control, Access and Possession principles of research with Aboriginal communities, was employed for this work. Health directors of the 13 Mi'kmaq communities in Nova Scotia were involved with the research question, design and write-up of the study. This qualitative descriptive study consisted of open-ended structured interviews with consumers, family members and health care providers. Systematic data collection and analysis of interviews present an understanding of issues of mental health services in the communities. RESULTS: The findings identified barriers and successes/solutions in mental health services in First Nations communities, where services and resources are different from those in more urban communities. Core programs, covering aspects of education, collaboration and culturally relevant community-based services, were identified as solutions to problems identified by participants. Service providers specified core funding for services as essential for continuity and sustainability. DISCUSSION: While efforts have been made in the past to address mental illness in Mi'kmaq communities, many of these efforts have been proposal driven or crisis oriented. The need for community-based, culturally appropriate, coordinated and sustainable services is evident on the basis of the study's findings. The final report has been disseminated to local community members, participants, Atlantic First Nations and Inuit Health Branch, the Provincial Department of Health and the Atlantic Policy Congress to provide evidence that can inform policy and practice related to mental health in Mi'kmaq communities in Nova Scotia.

Creating a safe space for First Nations youth to share their pain.

INTRODUCTION: Indigenous children and youth may be quiet about the way they express their pain and hurt which is in contrast to how health professionals are trained to assess it. OBJECTIVES: The aim was to understand how youth from 4 First Nation communities express pain using narratives and art-based methods to inform culturally appropriate assessment and treatment. METHODS: This qualitative investigation used a community-based participatory action methodology to recruit 42 youth between 8 and 17 years of age to share their perspectives of pain using ethnographic techniques including a Talking Circle followed by a painting workshop. Physical pain perspectives were prominent in circle conversations, but emotional pain, overlapping with physical, mental, and spiritual pain perspectives, was more evident through paintings. Art themes include causes of pain and coping strategies, providing a view into the pain and hurt youth may experience. Youth were more comfortable expressing emotional and mental pain through their artwork, not sharing verbally in conversation. RESULTS: Circle sessions and artwork data were themed using the Indigenous Medicine Wheel. Content of the circle conversations centered on physical pain, whereas paintings depicted mainly emotional pain (eg, crying or loneliness; 74% n = 31) with some overlap with physical pain (eg, injuries; 54%), mental pain (eg, coping strategies; 31%), and spiritual pain (eg, cultural symbols; 30%). Common threads included hiding pain, resilience, tribal consciousness, persistent pain, and loneliness. CONCLUSION: Once a safe space was created for First Nation youth, they provided a complex, culturally based understanding of the pain and coping experience from both an individual and community perspective. These engaging, culturally sensitive research methods provide direction for health providers regarding the importance of creating a safe space for young people to share their perspectives.

Expression of pain among Mi'kmaq children in one Atlantic Canadian community: a qualitative study.

BACKGROUND: First Nation children have the highest rates of pain-related conditions among Canadian children, yet there is little research on how this population expresses its pain or how and whether the pain is successfully treated. The aim of this study was to understand how Mi'kmaq children express pain and how others interpret it. METHODS: We conducted a qualitative ethnographic study in a large Canadian Mi'kmaq community using interviews and conversation sessions. Participants included children and youth (n = 76), parents (n = 12) teachers (n = 7), elders (n = 6) and health care professionals (n = 13). RESULTS: Interpretive descriptive analysis was used and themes regarding pain expression, care seeking and pain management were identified. Pain expression included stoicism and hiding behaviour, and, when pain was discussed, it was via storytelling and descriptive language, such as similes. Participants reported feeling unheard, stereotyped and frustrated when they sought pain care. Frustration led to avoidance of seeking further care, perceptions of racism and repeat visits because of unsuccessful previous treatment. Participants voiced concerns about the utility of the numeric and faces pain scales to describe pain meaningfully. Positive encounters occurred when participants felt respected and heard. INTERPRETATION: Mi'kmaq children are stoic and often hide their pain. Community members feel frustrated and discriminated against when their pain is not identified, and conventional pain assessment tools may not be useful. If clinicians consider cultural context, build trust and allow for additional time to assess pain via storytelling or word descriptions as well as a family-centred approach, better pain care may occur.