Indigenous Health Research Monitoring, July 2023

In this issue:

Just Published

 New scientific publications and articles

Article Summaries: Subject Areas

Social inequalities and determinants of health

A qualitative study exploring access barriers to abortion services among Indigenous Peoples in Canada

Monchalin, R., Piñán, A. V. P., Wells, M., Paul, W., Jubinville, D., Law, K., Chaffey, M., Pruder, H. et Ross, A. (2023). A qualitative study exploring access barriers to abortion services among Indigenous Peoples in Canada. Contraception, 110056.

Context

Access barriers to abortion persist in Canada, and their repercussions vary from one population to another. Indigenous experiences around access to abortion have rarely been explored. The resulting lack of knowledge is of concern given that one of every three Canadian women has had an abortion.

The unique and persistent barriers to accessing health care services faced by Canadian First Nations, Inuit and Métis are specifically related to colonialism. Indigenous women have a history of suffering violence and prejudice associated with reproductive health, including abortion experiences, forced sterilization and coerced contraception.

Objective

Describe the experiences of Indigenous peoples in Canada with abortion and access to abortion services.

Methodology

This qualitative research takes a community-based approach and is rooted in Indigenous feminism in a perspective of decolonization and support for self-determination. The approach taken aims to explore how intersections between gender, race and sexuality shape the experiences of Indigenous populations.

Open-ended interviews were conducted using a conversational methodology, which fosters the development of relationships and is consistent with Indigenous methods of gathering and sharing knowledge through storytelling.

The entire research team was involved in analyzing the data, from reading the transcripts to coding and analyzing the contents. A committee formed of representatives from Indigenous organizations supported the team at every stage of the project.

What was learned?

The fifteen participants came from nine Canadian provinces and territories and identified as members of the Métis, Cree, Dene, Inuit, Haudenosaunee, Anishinaabe and/or Mi’kmaq nations. They ranged in age from 16 to 29 at the time of their abortion.

The participants addressed six themes:

Logistical barriers (mentioned by 7 of the 15 women): Abortion services are located far away and require several hours of travel by car or plane at considerable expense.

Poor treatment (12/15): Experiences mentioned include experiencing judgment and mistreatment and having their decision called into question. The participants believe that their experience was worse than that of non-Indigenous women.

Stigma (15/15): All participants shared a sense of shame and of being judged by the community.

Impacts of colonialism on attitudes towards abortion (15/15): Religion and colonialism negatively impacted the transmission of knowledge pertaining to reproductive health, resulting in the fracturing of intergenerational knowledge transmission.

Traditional knowledge (15/15): Indigenous knowledge and practices, including medicinal herbs, should have a greater place in the abortion experience.

Follow-up care and support (8/15): Some participants remarked on a lack of follow-up and recommended more local support.

The barriers to abortion services mentioned by participants, such as distance, stigma and a lack of support, are also reported in studies looking at the Canadian population as a whole.

Limitations

The results cannot be generalized due to the small sample size and the study’s exploratory nature. The interviews were conducted by video call, which may constitute a barrier for women without access to that technology.

Cultural safety

Indigenous cultural safety training for applied health, social work, and education professionals: A PRISMA scoping review

MacLean, T. L., Qiang, J. R., Henderson, L., Bowra, A., Howard, L., Pringle, V., Butsang, T., Rice, E., Di Ruggiero, E. et Mashford-Pringle, A. (2023). Indigenous cultural safety training for applied health, social work, and education professionals: A PRISMA scoping review. International Journal of Environmental Research and Public Health, 20(6), 5217.

Context

Racism against Indigenous populations in the education and health systems is a generalized reality. Studies report that, in Canada, 39% to 43% of Indigenous respondents have experienced racism. In response to this issue, a growing number of cultural safety training programs have been developed, but little information is available about their implementation and evaluation.

Objective

Conduct a scoping review of scientific literature about the design, implementation and evaluation of cultural safety training within the health, social work and education fields in Canada, the United States, Australia and New Zealand.

Methodology

An exploratory search of scientific articles published between 1996 and 2020 was conducted in five databases. To be included, articles had to deal with concepts defining cultural safety and have been peer-reviewed.

What was learned? 

A total of 134 articles were included and analyzed. They addressed two main themes:

  • Cultural safety training offer

    The number of cultural safety training programs has increased significantly over the last thirty years. Those programs can be differentiated by their objectives, length of training and education and evaluation approaches.

    All of the training programs used a variety of learning formats, including lectures, workshops, discussion sessions and immersive experiences.

    While 70% of the articles describing the cultural safety training development process mention the involvement of Indigenous people, their role is rarely specified. The authors suggest that efforts should be made to ensure that the involvement of Indigenous persons be effective and ongoing from the outset of the project.

  • Evaluation of existing cultural safety training programs

    Nearly a third of the projects studied described a training assessment strategy primarily based on gathering feedback from participants, who were asked to describe their experiences, needs and preferences with respect to the training. Other studies emphasized the skills, learning and attitudes of participants. Half of the assessments employed both qualitative and quantitative methodologies, while more than a third were exclusively quantitative.

    In conclusion, the authors underscored the importance of clarifying the nature of cultural safety and related concepts throughout a project by considering the context of the training.

Limitations

This study did not include publications looking at projects conducted during or after the COVID 19 pandemic. Only five databases were consulted and grey literature was excluded. Only publications in English were included. Finally, it is possible that publications mentioning the name of a specific nation but not the word “Indigenous” did not appear in the search results.

Giving birth in a good way when it must take place away from home: Participatory research into visions of Inuit families and their Montreal-based medical providers

Silver, H., Tukalak, S., Sarmiento, I., Budgell, R., Cockcroft, A., Vang, Z. M. et Andersson, N. (2023). Giving birth in a good way when it must take place away from home: Participatory research into visions of Inuit families and their Montreal-based medical providers. Birth.

Context

In Nunavik, women whose pregnancy is considered to present a low medical risk can choose to deliver in a local birthing centre staffed by Inuit and non-Inuit midwives. The authors estimate, however, that 14% to 33% of women are evacuated to Montreal for delivery. This contrasts with elsewhere in Inuit Nunangat, where up to 100% of births, regardless of the medical risk, are transferred out of the community despite extensive research documenting the negative impact of evacuation on mothers, their families and the communities.

Objective

Describe visions of giving birth “in a good way,” i.e. one that is culturally safe, for Inuit families as well as for qallunaat (non-Inuit) perinatal providers in Montreal.

Methodology

Eight Inuit and twenty-four perinatal staff members shared their visions for giving birth “in a good way” using fuzzy cognitive mapping. The maps locate concepts (nodes) pertaining to the question “What do Inuit families need to give birth in a good way in Montreal?” The arrows show causal relationships among the concepts.

Mapping sessions were held in Inuktitut and English. Working in groups of one to four participants, the Inuit produced five maps and the perinatal staff another thirteen. Guided by the participants, the mapping facilitators drew concepts and arrows on a whiteboard, which were then digitalized. Inductive thematic analysis was used to condense concepts into categories. The categories were then weighted from 0 to 1, where 0 is the weakest causal relationship and 1 the strongest. The category and weighting analyses were used to design final maps for the Inuit and staff participants.

What was learned?

Seventeen recommendations emerged from the study concerning giving birth “in a good way” in the context of an evacuation. Primary recommendations include family presence, financial assistance, engagement of the patient and family, and staff training. Participants also stressed the need for culturally adapted services, availability of traditional foods and presence of Inuit perinatal care providers.

Some of those recommendations found consensus among the Inuit and perinatal staff participants, including:

  • A sense of security and feeling at home have an influence on the wellbeing of the mother and child. A family transit home offering support and independence was suggested by the participants.
  • Both groups saw the services of an Inuit midwife as a priority for fostering the wellbeing of the mother and child, independence of the family and continuity of care, although the score was slightly lower for the perinatal staff.

In other cases, the priority of recommendations diverged between Inuit and perinatal staff participants, specifically:

  • Inuit participants wanted access to greater financial assistance so that they could be accompanied by family members, such as other children.
  • Access to traditional food at the accommodation centre and hospital was also a more important concern for Inuit participants.
  • Cultural safety training and skills were of greater concern to the perinatal staff members.

Limitations

The authors noted several limitations, specifically pertaining to the fuzzy cognitive mapping methodology, without being more specific. Data for the study was collected in Montreal, which explains why more maps were created by perinatal staff than by Inuit families. Stress associated with evacuation may explain the lower number of Inuit participants compared with perinatal staff. Translation of the Inuktitut maps into English certainly resulted in the alteration of some ideas and concepts. Finally, the results represent points of view about the context in Nunavik and are therefore not representative of other regions of Inuit Nunangat.

Infectious disease prevention

SMS reminders increase on-time vaccination in Aboriginal and Torres Strait Islander infants

Manderson, J. L., Smoll, N. R., Krenske, D. L., Nedwich, L., Harbin, L., Charles, M. G., Wyatt, A., Schulz, C. N. et Khandaker, G. M. (2023). SMS reminders increase on-time vaccination in Aboriginal and Torres Strait Islander infants. Communicable Diseases Intelligence, 46.

Context

Ensuring that children are vaccinated regularly, within thirty days of scheduled dates, is essential to protecting them from vaccine-preventable diseases and thereby to reducing their burden. Among Aboriginals and Torres Strait Islanders, the vaccination rate for infants under the age of two is lower than for the non-Indigenous population, which contributes to health gaps between the two groups. One strategy that could be implemented in order to reach a 95% coverage rate is SMS reminders. This would be effective in harder-to-reach communities and useful for reminding parents of their children’s vaccination dates.

Objective

Measure the effectiveness of SMS reminders on vaccination timeliness for Aboriginal and Torres Strait Islander infants in the Central Queensland region of Australia.

Methodology

The study used a quasi-experimental approach in which the intervention was not randomly assigned. The control group included children born between October 1, 2016, and September 30, 2018. For the intervention cohort, immunization timeliness was verified for infants born between October 1, 2018, and March 31, 2020. During that period, all new parents received an SMS reminder five days before a scheduled vaccination date based on the child’s age (six weeks, four months, six months, twelve months and eighteen months). Healthcare professionals, specifically midwives and obstetricians, were responsible for explaining the project to parents.

One member of the research team in charge of promoting Aboriginal health was responsible for contacting the community, ensuring their involvement and obtaining their approval for the project. For example, the SMS message was written in collaboration with members of the community.

What was learned? 

A total of 1,141 infants were included in the study, 468 in the intervention group and 673 in the control group. In all, 2,551 SMS reminders were sent at a total cost of AUD637.75. The SMS reminders were intended to be a cost-effective method of improving vaccine coverage. No parent asked to be removed from the list of recipients.

For both groups, the proportion of infants vaccinated on a timely basis decreased with age. That proportion was greater in the intervention group than in the control group for all five milestones. However, the difference was not significant at 12 months. The probability of vaccination was expressed using risk ratios, with the highest difference in probability occurring at the 18-month milestone. At that point, infants in the intervention group were about 30% more likely to be immunized on schedule than those in the control group. A method was also developed for calculating the number of parents needing to receive a reminder to vaccinate one child (a variation on number needed to treat). The smallest number was at the six-month milestone, when an SMS reminder sent to eight parents was associated with one additional vaccinated infant in the intervention group compared with the control group.

The effectiveness of SMS reminders in improving the vaccine coverage rate among children remains dependent on access to technology. In Australia, approximately one Aboriginal in five lives in a remote region where cellphone coverage is not complete

Limitations

The quasi-experimental approach is the main limitation according to the authors. In the region studied, the birthrate among Aboriginals and Torres Strait Islanders would have required an intervention cohort to be followed for three or four years to obtain a sample of sufficient statistical power.

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

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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.