Indigenous Health Research Monitoring, April 2024

In this issue:

Just Published

New scientific publications and articles

New INSPQ publications

Article Summaries: Subject Areas

Early childhood and child development

Screen time and socioemotional and behavioural difficulties among Indigenous children in Canada

Owais, S., Ospina, M. B., Ford, C., Hill, T., Savoy, C. D., and Van Lieshout, R. (2023). Screen time and socioemotional and behavioural difficulties among Indigenous children in Canada. The Canadian Journal of Psychiatry.

Context

The potential consequences of screen use on childhood development are a core concern of many organizations. In response to this issue, the World Health Organization recommends limiting screen time to one hour a day for children aged two to five. It should be noted that the Indigenous population under the age of 14 is growing rapidly and now represents nearly one third of the total Indigenous population. Due to social and health inequalities observed in Indigenous youth, a better understanding is needed of the developmental consequences of screen use.

Objective 

Describe screen time and study its associations with socioemotional and behavioural difficulties among Indigenous children under six years of age in Canada.

Methodology 

The data was taken from the Aboriginal Children’s Survey of children living off reserve in Canada conducted between October 2006 and March 2007. Children’s behavioural and socioemotional difficulties were analyzed using the Strengths and Difficulties Questionnaire completed by a parent or guardian. Difficulties were measured according to five subscales: emotional difficulties, behaviour problems, hyperactivity or inattention, peer relationship problems and prosocial behaviour, which refers to actions directed towards others intended to help, console, share or protect. In addition, the parent or guardian was asked to estimate the child’s daily screen time. The results were then adjusted according to the child’s age and sex, as well as the education level of the parent or guardian.

What was learned?  

A total of 6,505 children with an average age of 3.57 years participated in the study. They included 3,085 First Nations (53.5%), 2,430 Métis (39.2%) and 990 Inuit (7.3%). Nearly four of every five children exceed the recommended maximum screen time of less than one hour per day. Participants’ average daily screen time was 2 hours and 58 minutes for First Nations, 2 hours and 50 minutes for Métis, and 3 hours and 25 minutes for Inuit.

In comparison with data from another representative national survey, those averages are higher than for non-Indigenous children. Several hypotheses have been advanced to explain the gap, including the consequences of colonization on family life, a lack of positive parenting role models, socioeconomic inequalities, and a more hands-off parenting style, in which the child’s autonomy is prioritized.

The results demonstrate a significant association between greater screen time and increased socioemotional difficulties, as well as decreased prosocial behaviour in First Nations and Métis children, but not among the Inuit. The association remains significant when adjusted for confounding factors. In addition, the child’s sex did not moderate the association in any of the three groups.

Limitations 

The authors report that the potential benefits of screen time, such as the use of screens for educational purposes, were not evaluated. Moreover, the lack of data about the use of mobile devices such as tablets and smartphones, which has grown in the last 15 years, makes it impossible to assess their impact on the development of Indigenous children living off reserve. The 2022 version of the Indigenous Peoples Survey, whose results will be published in 2024, will serve to improve the current understanding. Finally, the authors point out that the cross-sectional nature of the data does not allow for causal links to be established.

Factors of success, barriers, and the role of frontline workers in Indigenous maternal-child health programs: A scoping review

Thompson, C., Million, T., Tchir, D., Bowen, A., and Szafron, M. (2024). Factors of success, barriers, and the role of frontline workers in Indigenous maternal-child health programs: A scoping review. International Journal for Equity in Health, 23(1), Article 28.

Context

In Canada, social inequalities in health are found among Indigenous mothers and their children. Gestational diabetes, anxiety and depression are more prevalent among Indigenous mothers than their non-Indigenous counterparts, and more babies are born prematurely. Although several mother-child health programs are intended to improve the situation, the results are limited. That said, it would appear that the success of any program depends on the involvement of the community where it is implemented. In that regard, the role of frontline workers over a program’s life cycle (design, implementation and evaluation) still needs to be studied.

Objectives

Identify the factors of success and barriers in Indigenous health programs targeting mothers and their children from birth to six years of age. Study the involvement of frontline workers in the life cycle of programs.

Methodology

A scoping review following the Arksey and O’Malley framework was conducted by a multidisciplinary team (public health, nursing and Indigenous studies). This methodology, which employs a broad document search, enables different types of data to be combined. In keeping with the selected framework, data quality was not evaluated in the interests of obtaining a wide range of results not limited by Western scientific quality standards. A search was made of grey literature and peer-reviewed articles published between 1990 and 2019. The articles selected were subject to a thematic analysis.

For this scoping review, an Indigenous maternal-child health program was deemed to be an action or approach on one or more levels (individual, family, entire community, etc.) intended to improve the health and wellbeing of mothers and children. Frontline workers are those with a daily involvement in the program, such as nurses, midwives, and social or community workers.

What was learned? 

A total of 45 publications were selected. The positionality of the authors—who they are and how their perspective shapes their research—was determined in only 17 cases.

As for the factors of success in the programs under study, seven themes emerged: relationship building, cultural inclusion, knowledge transmission styles, community collaboration, client‑centred approaches, Indigenous staff, and community barriers to program success (e.g., long-term funding and welcoming spaces for participants).

Six themes contributing to program barriers were identified: impacts of colonization, power structure and governance, client and community barriers to program success, physical and geographical challenges (such as remoteness and transportation to program), lack of staff, and operational deficits (such as lack of technology, paperwork and bureaucracy).

The role of frontline workers in the program’s life cycle, other than for implementation, was not spelled out in 29 publications. In less than half the programs, frontline workers were involved solely in the design. Only six studies report on their involvement in program evaluation.

The authors point out, however, that frontline workers understand and have a relationship with the local community. They also have a unique perspective that can be used to identify the needs of communities and establish program action priorities. The authors therefore suggest that a greater role for frontline workers could improve the relevance and effectiveness of programs.

Limitations

The authors emphasize that data extraction was limited by the information presented in the selected publications. Moreover, given that determining the social position of the authors required additional research into published biographies, it is possible that potentially relevant information was overlooked. This scoping review was limited to four countries (Canada, Australia, New Zealand and the United States), and the results are therefore not easily applicable elsewhere. Finally, generalizing the results within the countries studied is limited by the heterogeneity of peoples and communities.

Cultural safety

Randomized controlled trial demonstrates novel tools to assess patient outcomes of Indigenous cultural safety training

Smylie, J., Rotondi, M. A., Filipenko, S., Cox, W. T. L., Smylie, D., Ward, C., Klopfer, K., Lofters, A. K., O’Neill, B., Graham, M., Weber, L., Damji, A. N., Devine, P. G., Collins, J., and Hardy, B.-J. (2024). Randomized controlled trial demonstrates novel tools to assess patient outcomes of Indigenous cultural safety training. BMC Medicine, 22(1), Article 3.

Context 

Anti-Indigenous racism in healthcare has negative consequences on the health and wellbeing of Indigenous peoples, who are being left out. Programs have been put in place to provide training in Indigenous cultural safety for clinicians. A majority of those programs are evaluated according training participants self-perceived effects. Positive self-evaluation on the part of clinicians, however, does not necessarily translate into better health outcomes for Indigenous patients. One avenue for research is to use visits by mystery patients—actors playing the role of patients—as a tool to evaluate cultural safety training in the context of randomized controlled trials.

Objective

Compare the effects on clinicians of two interventions: a short anti-bias training adapted to Indigenous realities and the intensive San’yas Indigenous Cultural Safety Training Program. A second objective was to establish the feasibility of using unannounced Indigenous standardized patients (UISPs) as a tool to evaluate cultural safety training.

Methodology 

A randomized controlled multi-site trial was conducted with 58 non-Indigenous clinicians in the Toronto region (staff physicians, resident physicians and nurse practitioners at four teaching hospitals). In parallel, three similarly sized groups randomly received either the short intervention (one hour at the workplace with researchers in attendance), the intensive program (eight to ten hours of interactive online training led by qualified facilitators) or a continuing medical education program of a length comparable to the intensive training (control group).

For the second objective, professional actors were trained, without the knowledge of the clinicians, to role-play a situation in which an Indigenous patient visits a clinic or emergency department while a clinician participating in the study was on duty. Only the coordinators at each site were informed of the research.

Measured outcomes:

  • The quality of care provided during the UISPs visits, including the probability that the patient would recommend the health care provider to a friend or family member;
  • The patient’s evaluation of the care experience;
  • Clinical practice guideline adherence for the renewal of non-steroidal anti-inflammatory drugs and pain assessment.

Multiple regression analyses were performed to control the effects of participants’ age, sex and level of experience with Indigenous patients.

What was learned? 

  • Participation in either the short anti-bias intervention or the intensive cultural safety program increased the probability that the UISPs would strongly recommend their clinicians to a friend or family member. It also resulted in an improved assessment by patients, in comparison with the control group, of the quality of their relationship with the clinicians.
  • The study demonstrated the feasibility of using UISPs as an evaluation tool for clinical cultural safety training. In fact, none of the UISPs visits were detected by the participating clinicians. The authors consider this to be an innovative tool not only for the burgeoning field of cultural safety training but also in the broader fight against prejudice and oppression.
  • Given the small sample size, it was not possible to detect an influence on adherence to clinical practice guidelines.
  • Age, sex and previous experience in providing care to Indigenous patients had no effect on the UISP experience.

Limitations 

The sample size was reduced due to the difficulty of recruiting participants in the context of a work overload exacerbated by the SARS-CoV-2 pandemic. Moreover, the voluntary recruitment may have biased selection towards participants with a greater awareness of anti-Indigenous racism. Finally, the presence at the same site of participants from both intervention groups and the control group may have created a contamination bias.

Promotion of wellbeing and mental health

Negative affect and drinking among Indigenous youth: Disaggregating within- and between-person effects 

Reynolds, A., Paige, K. J., Colder, C. R., Mushquash, C. J., Wendt, D. C., Burack, J. A., and O’Connor, R. M. (2024). Negative affect and drinking among Indigenous youth: Disaggregating within- and between-person effects. Research on Child and Adolescent Psychopathology.

Context  

Despite the challenges and trauma associated with colonial policies, Indigenous populations have demonstrated strong resilience and a capacity to prosper. Social inequalities in mental health are among those challenges, specifically depression and anxiety, which are part of what is known as negative affect, as well as drinking. According to one American study, more than three of every five Indigenous adolescents have experienced symptoms of depression. Moreover, individuals with high levels of depression had a greater probability of exhibiting alcohol use disorder.

Objective  

Study the associations between negative affect and drinking among in-school Indigenous adolescents in a northern Québec community.

 Methodology  

In this longitudinal study, two self-report questionnaires were submitted to 110 participants. With the authorization of a parent or guardian, several cohorts of students aged 12 to 16 were recruited between 2011 and 2018. A vast majority of the participants self-identify as First Nations, while a few others are Métis or Inuit.

Three hypotheses were formulated concerning the associations between negative affect and drinking:

  • On average, a high level of negative affect is associated with a high level of alcohol consumption.
  • On the within-person level, a high level of negative affect predicts a high level of alcohol use over time.
  • On the within-person level, a high level of alcohol use predicts a high level of negative affect over time.

The hypotheses were evaluated with a prospective analysis model calibrated for sex. It was used to study the relationship over time between the two concepts, i.e. negative affect and alcohol use. The model disaggregates within- and between-person effects. Within-person effects refer to individual changes over time in the measured concepts. Between-person effects are differences between participants in the measured concepts.

What was learned?   

Girls (66%) reported higher levels of negative affect and alcohol use than boys (44%). With respect to the three hypotheses:

  • In contrast to the first hypothesis, the initial level of depression or anxiety experienced by the participants is not significantly associated with changes in alcohol use over time.
  • In contrast with the second hypothesis, depression and anxiety do not necessarily predict within-person alcohol use among Indigenous adolescents. Alcohol use during adolescence is more easily influenced by the social context.
  • In keeping with the final hypothesis, the results show that when a participant reported consuming more alcohol than usual at one evaluation, their level of depression and anxiety was higher than expected at the next evaluation. This result suggests that alcohol use preceded negative affect for study participants.

Limitations 

The authors point out that only one community in northern Québec was included in the study. However, the decision to focus on one homogenous group lends reliability to the results. Moreover, this study could serve as a preliminary step to collecting further data in various communities about similarities and differences in alcohol use and negative affect. The self-report questionnaire was not culturally adapted to the community’s world view or its expression of depression and negative affect, thereby limiting the validity of the results. Finally, the sample size is limited, in addition to being composed solely of in-school adolescents.

If you are experiencing emotional distress, you can call the Hope for Wellness Help Line (1-855-242-3310) or chat online. This service is available 24/7 for all Indigenous people in Canada.

For other available services, see the list of Centres d’écoute par région (regional support lines).

The inclusion of articles presented in this monitoring newsletter does not represent their endorsement by the Institut. Professional judgment remains essential in assessing the value of these articles for your work. You can also consult the Methodology for Indigenous Health Research Monitoring.