Indigenous Health Inequalities Research Articles

Ngā Kaupapa Wawata me Uara: a narrative review exploring Tiriti o Waitangi-centred population health programmes in Aotearoa New Zealand

Globally, Indigenous Peoples experience widespread health inequities. Treaties provide a potential framework to uphold Indigenous rights and progress health equity. Te Tiriti o Waitangi (Māori language version of the Treaty of Waitangi) established the relationship between Māori, the Indigenous people of Aotearoa (New Zealand), and the British Crown. Grounded in Kaupapa Māori theory, this literature review used an Indigeneity-Grounded Analysis (IGA) policy lens to identify four characteristics of Tiriti-centred population health programmes: whanaungatanga (relationships), pro-equity actions, Te Ao Māori (Māori worldviews), and accountability. Although the evidence-base is emergent, a rights-based approach identifies the centrality of Indigenous self-determination, structural and system transformation, and freedom from discrimination. Indigenous knowledge provides the foundation for treaty-centered policy supportive of Indigenous rights and health equity.

Unmasking population undercounts, health inequities, and health service access barriers across Indigenous populations in urban Ontario.

Our Health Counts (OHC) methods are designed to address gaps in urban-based Indigenous health information. In partnership with local Indigenous health service providers, we have successfully implemented OHC in six Ontario cities. The aim of this study is to summarize findings regarding Indigenous population undercount, health inequities, and health service access barriers across study sites. We estimated Indigenous population size using OHC census participation survey responses and a multiplier approach. Health inequities between Indigenous populations and overall populations in each city were examined using respondent-driven sampling (RDS), adjusted OHC survey results, and existing public data. Measures included health status outcomes; determinants of health; barriers to health service access, including discrimination by health service providers; and unmet health needs. Indigenous social networks were strong and extensive, and the urban populations demonstrate resilience and cultural continuity across multiple measures. Self-reported rates of census participation for Indigenous populations were markedly lower than those for the general population in each city, and OHC Indigenous population size estimates were consistently 2‒4 times higher than reported in the census. Indigenous to general population health inequities cut across measures of chronic disease, determinants of health, and unmet health needs. Indigenous populations experienced multiple barriers to health services access, including racial discrimination by health service providers. The Canadian census appears to markedly underestimate Indigenous population size in urban areas. Indigenous health inequities and service access barriers are striking and cross-cutting. Timely adaptation of health policies, services, and funding allocations in response to these findings is recommended.

Incorporating First Nations, Inuit and Métis Traditional Healing Spaces within a Hospital Context: A Place-Based Study of Three Unique Spaces within Canada's Oldest and Largest Mental Health Hospital.

Globally and historically, Indigenous healthcare is efficacious, being rooted in Traditional Healing (TH) practices derived from cosmology and place-based knowledge and practiced on the land. Across Turtle Island, processes of environmental dispossession and colonial oppression have replaced TH practices with a colonial, hospital-based system found to cause added harm to Indigenous Peoples. Growing Indigenous health inequities are compounded by a mental health crisis, which begs reform of healthcare institutions. The implementation of Indigenous knowledge systems in hospital environments has been validated as a critical source of healing for Indigenous patients and communities, prompting many hospitals in Canada to create Traditional Healing Spaces (THSs). After ten years, however, there has been no evaluation of the effectiveness of THSs in Canadian hospitals in supporting healing among Indigenous Peoples. In this paper, our team describes THSs within the Center for Addiction and Mental Health (CAMH), Canada's oldest and largest mental health hospital. Analyses of 22 interviews with hospital staff and physicians describe CAMH's THSs, including what they look like, how they are used, and by whom. The results emphasize the importance of designating spaces with and for Indigenous patients, and they highlight the wholistic benefits of land-based treatment for both clients and staff alike. Transforming hospital spaces by implementing and valuing Indigenous knowledge sparks curiosity, increases education, affirms the efficacy of traditional healing treatments as a standard of care, and enhances the capacity of leaders to support reconciliation efforts.

How Education Shapes Indigenous Health Inequalities in the USA and Mexico.

Indigenous peoples around the world face significant health disparities relative to the dominant groups in their countries, yet the magnitude and patterns of health disparities vary across countries. We use data from the National Health Interview Survey and Mexican Family Life Survey to examine the health of Indigenous peoples in Mexico and American Indians and Alaska Natives in the USA and to evaluate how they fare relative to the majority populations in their countries (non-Indigenous Mexicans and non-Hispanic Whites, respectively). We assess disparities in self-rated health and activity limitations, with a focus on how Indigenous health disparities intersect with educational gradients in health. Regression analyses reveal three primary findings. First, Indigenous health disparities are larger in the USA than in Mexico. Second, differences in educational attainment account for most of the differences between Indigenous and non-Indigenous populations in Mexico, but less than half in the USA. Third, in both countries, health is moderated by educational attainment such that between-group disparities are largest at the highest levels of education. However, for Indigenous Mexicans there is a "cross-over" in which Indigenous Mexicans report better health at the lowest level of education. Overall, this study finds a weak relationship between education and Indigenous health, and raises the question about the validity of using traditional measures of SES in Indigenous contexts.

A narrative inquiry into non-Indigenous medical educators and leaders participation in reconcilatory work.

Globally, medical schools are operationalising policies and programming to address Indigenous health inequities. Although progress has been made, challenges persist. In Canada, where this research is conducted, Indigenous representation within medical schools remains low, leaving a small number of Indigenous advocates leading unprecedented levels of equity-related work, often with insufficient resources. The change needed within medical education cannot fall solely on the shoulders of Indigenous Peoples; non-Indigenous Peoples must also be involved. This work aims to better understand the pathways of those engaged in this work, with careful consideration given to the facilitators and barriers to ongoing engagement. Data collection and analysis were informed by narrative inquiry, a methodology that relies on storytelling to uncover nuance and prompt reflection. In this paper, we focus on interview data collected from Canadian non-Indigenous medical educators and leaders (n = 10). Participants represented different career stages, (early to late career) and occupied a mix of clinical, administrative and education roles. Although each participant's entry into reconciliatory work was unique, we identified common drivers actuating their engagement. Oftentimes their participation was tied to administrative work or propelled by experiences within their roles that forced them to confront the systemic inequalities borne by Indigenous Peoples in both academic and healthcare settings. Some admitted to struggling with understanding their appropriate role in Indigenous reconciliation; their participation often proceeded without firm support. Medical schools have an obligation to ensure their faculty, including non-Indigenous Peoples, are equipped to fulfil social accountability mandates regarding Indigenous health. Our findings generate a better understanding of the tensions inherent in this equity work. We urge others to reflect on their role in Indigenous reconciliation, or else medical schools risk generating a false sense of individual and institutional progress.

Research needed on urban Indigenous health inequalities.

Research needed on urban Indigenous health inequalities.

“We Make It Work Because We Must”: Narrating the Creation of an Urban Indigenous Food Bank in London, Ontario, Canada

This research draws from a community-engaged methodology and qualitative interviews to narrate the creation and daily operations of an Indigenous food bank in London, Ontario, Canada. In-depth interviews (n = 10) with program leaders, volunteers, and recipients detailed the day-to-day operations, including where and how foods were collected and distributed, and a preliminary analysis of the meanings and challenges of the food bank. The key strengths of the food bank are its focus on cultural safety, provision of traditional foods, and its community-led approach. The limitations of the food bank relate to the structure of the workload and sustainability of program funding. Community-led research with Indigenous non-profit organizations, such as that presented here, offer approaches that are critically important for creating culturally relevant and inclusive data that can both explain and address Indigenous health inequities, and provide the evidence needed to advocate for change.

Why and how is photovoice used as a decolonising method for health research with Indigenous communities in the United States and Canada? A scoping review.

Globally, including in North America, Indigenous populations have poorer health than non-Indigenous populations. This health disparity results from inequality and marginalisation associated with colonialism. Photovoice is a community-based participatory research method that amplifies the voices of research participants. Why and how photovoice has been used as a decolonising method for addressing Indigenous health inequalities has not been mapped. A scoping review of the literature on photovoice for Indigenous health research in the United States and Canada was carried out. Five electronic databases and the grey literature were searched, with no time limit. A total of215titles and abstracts and 97 full texts were screened resulting in 57 included articles. Analysis incorporated Lalita Bharadwaj's Framework For Building Research Partnerships with First Nations Communities. Photovoice was selected to improve knowledge mobilisation and participant empowerment and engagement. Studies incorporated relationship building, meaningful data collection, and public dissemination but had a lesser focus on the inclusion of Indigenous peer researchers or participant involvement in analysis. For photovoice to truly realise its decolonising potential, it must be incorporated into a broader participatory and decolonising research paradigm. In addition, more resources are required to support the involvement of Indigenous people in the research process.

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.

The Long Story of an Indigenous Health Research Project

Indigenous health inequities represent a significant challenge for health research and programming. The research seeking to address these inequities also faces significant challenges. To guide researchers through these challenges, several resources exist. That said, the real world of Indigenous research is complex and contains much that, experience suggests, is not accounted for by existing resources. Therefore, this article tells the full and honest story of conducting research within largely Western systems the barriers they present to Indigenous community-based health research that respects self-determination and culture. When relevant to discussion, examples will be provided from a recently completed COVID-19 vaccine promotion research project. In telling this story, many questions are posed, some of these are tentatively answered, and many are left for contemplation and future work. When answers are provided, they often stem from personal experience, and so, conclusions should be approached cautiously. Regardless, prioritizing respectful and authentic relationships appears to be a universal compass that can guide researchers to the good way. Still, more consistent and honest reporting of barriers, failures, and opportunities may be needed to truly reflect the challenging realities of ethical Indigenous research.

The economic cost of Indigenous child health inequities in Aotearoa New Zealand-an updated analysis for 2003-2014.

This study estimates of the cost of Indigenous child health inequities in New Zealand. Standard quantitative epidemiological and cost of illness methodologies were used within a Kaupapa Māori framework. Data for 2003-2014 on children under 15 years were obtained from government datasets. Rates of potentially avoidable hospitalisations and mortality, as well as excess or under-utilisation were calculated. Publicly funded health sector costs, costs to families and costs of premature mortality were used to estimate the costs (or savings) of inequities. Māori children had lower utilisation rates than non-Māori for primary healthcare, outpatient care, medicines, laboratory investigations and care after an accident/injury. Māori children had greater rates of avoidable hospitalisation (RR=1.36, 95% CI 1.35-1.37) and death (RR 1.98, 95% CI 1.84-2.13). Inequalities between Māori and non-Māori children cost in excess of $170 million NZD each year. This includes an annual net savings for the government health sector of $4 million NZD, with an annual cost to society of around $175 million NZD. The under-serving of Māori children in the health sector saves the government health system money, yet imposes a huge cost on Māori families and society. In addition to avoiding considerable human suffering, reducing child health inequities would result in significant economic benefits.

Indigenous Health Inequities Arising From Inadequate Transfer Systems for Patients With Critical Illness

This Viewpoint describes how the systems for delivering emergency care for Indigenous and rural communities were strained during the COVID-19 pandemic and proposes policy solutions to advance health care equity.

Estimating the economic costs of Indigenous health inequities in New Zealand: a retrospective cohort analysis

ObjectivesDespite significant international interest in the economic impacts of health inequities, few studies have quantified the costs associated with unfair and preventable ethnic/racial health inequities. This Indigenous-led study is the...

Māori experiences of hospital care: a qualitative systematic review

Indigenous experiences of hospitalisation may contribute to maintenance of Indigenous health inequities. We undertook a qualitative systematic review of Māori experiences of hospital care within New Zealand. We performed electronic database searches and used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement to assist study selection. We were guided by Kaupapa Māori (Māori centred) research methodology and used the CONSolIDated critERtia statement to evaluate completeness of reporting against recommended Indigenous ethical guidelines. The Betancourt framework for addressing ethnic disparities in health care was utilised to synthesise findings. Seven studies were included. Studies enlisting Indigenous research expertise and Kaupapa Māori research methodology demonstrated clearer links between participant voices and critique of hospital experiences. Multiple barriers were identified within clinical, organisational and structural loci of practice. Proposed interventions focused on building cultural safety against these barriers. Strategies promoting access to care for Māori and cultural safety training for the workforce are needed.

Prioritizing indigenous health equity in health registers: an environmental scan of strategies for equitable ascertainment and quality data

BackgroundCerebral palsy (CP) registers serve as instrumental tools to support development of care pathways, preventative strategies, and health gains. Such health gains, however, are not always universal, with Indigenous health inequities common. To support Indigenous health, health registers need complete, consistent, and high-quality data. The aim of this study was to identify perceived barriers to the ascertainment of Indigenous peoples on health registers and to collate strategies supporting comprehensive ascertainment and achievement of high-quality Indigenous data.MethodsEnvironmental scanning methods were utilized within a Kaupapa Māori theoretical framework, which aims to produce research that is transformational and supportive of Indigenous health gain. Knowledge and insights were obtained from CP registers in countries with Indigenous populations and complemented by information from health registers in Aotearoa New Zealand (NZ). Data collection methods included an online survey and scan of organizational websites. Data extraction focused on general information about the register, barriers to ascertainment, and strategies to support ascertainment and high data quality.Results52 registers were identified, 20 completed the survey and 19 included in the study (CP registers, n = 10, NZ health registers, n = 9). Web scan data were included for the other 32 registers (CP registers, n = 21, NZ health registers, n = 11). Indigenous health equity was identified in the visions and aims of only two health registers. Ethnicity data collection was identified in nearly three quarters of survey respondents and a limited number of organizational websites. Over half of survey respondents described system, health provider/service, or workforce barriers to ascertainment. Strategies were categorized into collaboration, health provider/service, workforce, and systems-levels. Indigenous-specific strategies were limited and focused on personal behaviour and access to registration.ConclusionsCP and other health registers can have a significant role in identifying and addressing Indigenous health inequities. However, this is not currently an overt priority for many registers in this study and few registers describe ascertainment and data quality strategies specific to Indigenous peoples. Significant opportunity exists for health registers to be accountable and to implement approaches to support Indigenous health equity, address structural determinants of inequities, and achieve health gain for all.

“I feel like the worst mother in the world”: Neoliberal subjectivity in Indigenous Australian oral health

Neoliberalism gained popularity during the post-Cold War period as a set of dominating ideologies, practices and policies that underpinned the movement towards globalisation. Neoliberalism champions competitive private markets, deregulation that facilitates economic activity, personal responsibility, and reduced public expenditure on infrastructure. A decade after the initial rise of neoliberalism, health inequities became concerns on the global stage. Oral health inequities aptly reflect social injustices due to the unique relation between material circumstances, access to health services and structural inequities. In Australia, Indigenous children experience early childhood caries at alarmingly higher rates than non-Indigenous children. Recently, neoliberalism has been suggested as an overwhelming contributor to Indigenous oral health disparities. This qualitative research is an extension of a single-blind parallel-arm randomised control trial that aimed to identify factors related to the increased occurrence of dental caries in Indigenous children. The objective of this constructivist grounded theory study was to generate an understanding of how neoliberal subjectivity exists for Indigenous peoples in the context of oral health in Australia. Experiences of ownership, guilt, failure, embarrassment, shame, and judgment were key in participants’ experiences of neoliberal subjectivity; these feelings were exacerbated by experiences of bullying, financial limitations, and institutional racism. We argue that individual responsibility for health, as a tenet of neoliberal ideologies, furthers Indigenous oral health inequities and that neoliberalism as a societal discourse perpetuates colonial values by benefitting the privileged and further oppressing the disadvantaged. Trial registrationAustralian New Zealand Clinical Trial Registry ACTRN12611000111976; registered February 01, 2011.

Health Inequalities and Social Determinants of Indigenous Peoples’ Health in Australia, Canada, and the United States: Causes and Policies Options

The author of the paper investigates the issue of Indigenous health inequalities. The main purpose of the research is to assess the causes of health inequalities among Indigenous people and policy options to reduce the health gaps. Systematization of the literary sources shows that there are health disparities between Indigenous people and non-Indigenous people and approaches for solving the problem come in different forms. The methodological basis of this study is a comparative analysis that used secondary data to capture health inequalities among the Indigenous populations in Australia, Canada, and the United States. These countries have adopted different policy options to reduce these inequalities. The paper presents the results of a comparative analysis that contributes to knowledge by articulating what is not known about Indigenous health inequalities and social determinants of health and policy response. The study contributes to understanding by articulating what is not known about Indigenous health inequalities and social determinants of health and policy response. Aside from the study being useful to policymakers, politicians, development experts and the academic environments, the study provides the opportunity to assess some of the policy interventions. When necessary, it provides ample opportunity if there is a need to reform the social and health policies meant to reduce health inequalities among Indigenous populations. The author found that both grey and academic studies have examined policy options and governance meant to reduce health inequalities among Indigenous people in Australia, Canada, and the U.S. However, there is a lack of quality studies that have evaluated these policy options, limiting the strength to determine achievement associated with such policy options and governance. Further, there is limited information on whether these policy options are suitable for the Indigenous population to enhance their health status. With these limitations, future studies need to assess the effectiveness of these policy options and determine if the policy options are culturally suitable to reduce Indigenous people’s health inequalities.

Building structures of environmental repossession to reclaim land, self-determination and Indigenous wellness.

In Canada, Indigenous health inequalities are sustained by colonial structures that create social disadvantage and limit Indigenous self-determination to Land. Drawing on the concept of environmental repossession, this study explores how Indigenous communities are building local structures to reclaim their territories and renew the values, responsibilities and knowledges tied to these places for wellness. Specifically, this study examines the meanings of the everyday work of the Department of Sustainable Development in Biigtigong Nishnaabeg and shares lessons for other communities seeking to foster self-determination over Land, identity and wellness. Qualitative analysis of interviews with current and former department staff members support an advanced understanding of how repossession strategies are sustained by Indigenous communities to foster place-based goals and address structural barriers to wellness.

Black to the Future: Making the Case for Indigenist Health Humanities.

This paper outlines the development of Indigenist Health Humanities as a new and innovative field of research building an intellectual collective capable of bridging the knowledge gap that hinders current efforts to close the gap in Indigenous health inequality. Bringing together health and the humanities through the particularity of Indigenous scholarship, a deeper understanding of the human experience of health will be developed alongside a greater understanding of the enablers to building a transdisciplinary collective of Indigenist researchers. The potential benefits include a more sustainable, relational, and ethical approach to advancing new knowledge, and health outcomes, for Indigenous people in its fullest sense.

Culturally Adaptive Governance-Building a New Framework for Equity in Aboriginal and Torres Strait Islander Health Research: Theoretical Basis, Ethics, Attributes and Evaluation.

Indigenous health inequities persist in Australia due to a system of privilege and racism that has political, economic and social determinants, rather than simply genetic or behavioural causes. Research involving Aboriginal and Torres Strait Islander (‘Indigenous’) communities is routinely funded to understand and address these health inequities, yet current ethical and institutional conventions for Indigenous health research often fall short of community expectations. Typically, mainstream research projects are undertaken using traditional “top-down” approaches to governance that hold inherent tensions with other dominant governance styles and forms. This approach perpetuates long-held power imbalances between those leading the research and those being researched. As an alternative, Indigenous governance focuses on the importance of place, people, relationships and process for addressing power imbalances and achieving equitable outcomes. However, empowering principles of Indigenous governance in mainstream environments is a major challenge for research projects and teams working within organisations that are regulated by Western standards and conventions. This paper outlines the theoretical basis for a new Culturally Adaptive Governance Framework (CAGF) for empowering principles of Indigenous governance as a prerequisite for ethical conduct and practice in Indigenous health research. We suggest new orientations for mainstream research project governance, predicated on translating theoretical and practical attributes of real-world ethics, adaptive governance and critical allyship frameworks to Indigenous health research. The CAGF is being implemented in a national Indigenous multicenter trial evaluating the use of continuous blood glucose monitors as a new technology with the potential to improve diabetes care and treatment for Indigenous Australians—the FlashGM Study. The CAGF is a governance framework that identifies the realities of power, acknowledges the complexities of culture and emerging health technologies, and foregrounds the principle of equity for mainstream Indigenous health research.