Indigenous Health Research Monitoring, July 2024

In this issue :

Just Published

New scientific publications and articles

New publications from INSPQ

Article Summaries: Subject Areas

Cultural safety

Leaving emergency departments without completing treatment among First Nations and non-First Nations patients in Alberta: A mixed-methods study

McLane, P., Bill, L., Healy, B., Barnabe, C., Big Plume, T., Bird, A., Colquhoun, A., Holroyd, B. R., Janvier, K., Louis, E., Rittenbach, K., Curtin, K. D., Fitzpatrick, K. M., Mackey, L., MacLean, D., and Rosychuk, R. J. (2024). Leaving emergency departments without completing treatment among First Nations and non-First Nations patients in Alberta: A mixed-methods study. CMAJ, 196(15), E510–E523.

Context

Since 2018, researchers have been assessing the quality of emergency care received by First Nations’ patients in Alberta, where it has been observed that the number of Indigenous patients leaving emergency departments before being seen or against medical advice is higher than for non Indigenous patients. Research has therefore focused on determining which factors may explain the discrepancy.

Objectives

  • Determine whether the observed difference between First Nations and non-Indigenous patients still exists.
  • Identify influencing factors (diagnosis, visit acuity, geography, patient demographics).
  • Explore the reasons motivating patients to leave without being seen or against medical advice.

Methodology

This mixed-methods research involved a population-based retrospective study using provincial medical administrative data covering the period from April 2012 to March 2017. Multivariable logistic regression models were used to control for demographics, visit characteristics and facility types. Models were evaluated for ten subsets of patients based on five episode disease categories and five specific diagnoses that were preselected by members of Indigenous communities involved in the research.

For the qualitative analysis, a purposive sample of 64 participants was selected. Sharing circles (n = 47) and individual interviews (n = 17) with First Nations patients, directors of Indigenous health institutions and emergency care providers of any background took place between 2019 and 2022.

What was learned?

Quantitative analysis:

  • Out of 11,686,287 patient visits analyzed, more than one million (9.4%) were by a First Nations member. Those visits were deemed less urgent than visits by non-Indigenous patients and took place more often in the evening and in a community hospital.
  • First Nations patients are nearly twice as likely to leave an emergency department without being seen or against medical advice than are non-Indigenous patients. This was observed in all five subsets based on disease and in four of the five diagnosis categories. Geography and patient demographics do not explain the higher risk.
  • A higher number of First Nations patients returned to the emergency department within 72 hours of having left than did their non-Indigenous counterparts, which suggests possible shortcomings in the management and ongoing care of these patients.

Qualitative analysis:

  • First Nations patients cite many of the same reasons as others for their decision to leave: the emergency department environment, the urgency of interactions, the environment not being conducive to rest, etc.
  • Some reasons unique to First Nations patients also emerged: diagnostic questions and case management rooted in anti-Indigenous stereotypes (e.g., hypotheses about substance use), discrimination in providers’ attitudes, racist remarks, etc.
  • Participants mentioned feeling that they had to wait longer than White patients who appeared to be in less urgent need of care. The absence of clear communication about treatment plans was also cited as a reason for leaving the emergency department prematurely.
  • Childcare issues and a fear of Child and Family Services, who apprehend a disproportionate number of First Nations children, were mentioned. First Nations parents and guardians may be especially reluctant to leave their children in the care of friends or family for the duration of a longer hospital stay.

Limitations

Identifiers of First Nations status used in the analysis may underestimate the exact number of First Nations patients. Diagnoses were based on the condition for which a patient made the visit and not the one attributed to them. Finally, a number of variables were dichotomized to produce interpretable models, which may have concealed nonlinear relationships between independent and dependent variables.

Promotion of wellbeing and mental health

Association between poor sleep and mental health issues in Indigenous communities across the globe: A systematic review

Fernandez, D. R., Lee, R., Tran, N., Jabran, D. S., King, S., and McDaid, L. (2024). Association between poor sleep and mental health issues in Indigenous communities across the globe: A systematic review. SLEEP Advances, 5(1).

Context

The impact of intergenerational trauma experienced by Indigenous peoples is reflected in their mental health. Countries with a colonial history, such as Canada, report significantly higher rates of mental health issues and death by suicide among Indigenous peoples compared with their non-Indigenous counterparts. The importance of obtaining quality sleep receives little attention in public health strategies despite studies of non-Indigenous populations establishing an association between insufficient sleep and mental health issues. Little research has been done on the phenomenon in Indigenous peoples.

Objectives

  • Review the state of the literature on sleep and mental health in Indigenous peoples.
  • Study the strength and direction of associations between sleep and mental health.
  • Identify knowledge gaps and make recommendations for future research.

Methodology

A systematic review was conducted of literature published in English. To qualify, studies had to explore the impact of sleep quality on the mental health of Indigenous peoples. The following data were extracted from the selected studies: general information about the study, research objectives, study and participant characteristics, data collection methods, the main results, as well as strengths and limitations of the research. The quality of the studies was evaluated using a standardized tool (Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies). In addition, the research partnership with Indigenous communities was evaluated (e.g., compliance with local protocols and benefits for the community).

What was learned? 

Seven studies (six cross-sectional and one longitudinal) were selected, representing a total of 3,066 Indigenous participants. Study quality was deemed to be moderate in six cases and high in one. The information made available in the studies was insufficient to evaluate the level of Indigenous participation in the research process.

Data were self-reported or supplied by a care provider. All the studies found high levels of poor quality sleep (sleep deprivation, difficulty sleeping, symptoms of insomnia, restless leg syndrome and obstructive sleep apnea). Among adolescents in a North Carolina First Nations community, for instance, more than a quarter (29.3%) reported less than 8 hours of sleep each night.

The results reported in this review suggest an association between sleep and mental health among Indigenous peoples. For example, one study of Australian Indigenous children showed an association between sleep disorders and aggressiveness as well as withdrawn behaviour. On the other hand, going to bed early is associated with a lower risk of behavioural problems. Among First Nations adolescents in the United States, insomnia is associated with symptoms of depression. In the case of adults, a lack of sleep (less than six hours a night) is associated with affective disorders. However, the authors underscore the lack of data to assess causal links between poor sleep and mental health issues.

Limitations

The authors point out that while six of the studies use standardized tools to measure sleep and mental health, such use has not been validated in an Indigenous context. The data collected in these studies therefore may not accurately represent issues around sleep and mental health among the world’s Indigenous peoples. Furthermore, the study samples were not random, which may limit the possibility of generalizing the results. Finally, since Australian spellings were used for certain terms (e.g., apnoea), search results may not have included studies that use American spelling exclusively.

Using latent class analysis to operationalize a wholistic assessment of Inuit health and well-being

Bertheussen, M., Riva, M., Jock, B. W., Fletcher, C., Ayotte, P., Muckle, G., Poliakova, N., and Bélanger, R. (2024). Using latent class analysis to operationalize a wholistic assessment of Inuit health and well being. International Journal of Circumpolar Health, 83(1).

Context

Despite actions taken to decolonize research practices in Indigenous contexts, few studies focus on the practical integration of Indigenous health models. Taking differences between Western and Indigenous health perspectives into consideration is essential, however, in developing programs adapted to the needs of Indigenous populations. In Nunavik, the IQI health model (ilusirsusiarniq, qanuinngisiarniq and inuuqatigiitsianiq) refers to the physical, mental and relational aspects of health based on the Community Component of the Qanuilirpitaa? 2017 health survey.

Objectives

Conduct a secondary analysis of data from the Qanuilirpitaa? 2017 health survey in order to:

  • Operationalize a wholistic health and wellbeing assessment model using latent class analysis
  • Evaluate the model’s validity with the help of questions in the Qanuilirpitaa? 2017 survey pertaining to self-assessed health
  • Explore associations between individual and community determinants and wholistic health

Methodology

Latent class analysis is a quantitative measurement tool that distinguishes different profiles or subgroups within a heterogenous population. In this study, latent class analysis was used to operationalize the IQI health model. Inuit partners lent their expertise and the Nunavik Regional Board of Health and Social Services was consulted at each stage in the process, which are the following:

  • Identify variables based on the IQI model and cluster those variables with the help of Inuit language experts
  • Conduct a latent class analysis of the sample comprising 1,196 participants
  • Assess the face validity of the wholistic health assessment and associations between health and the determinants of health

What was learned? 

  • Of the 81 questions preselected from the Qanuilirpitaa? 2017 survey, 21 key indicators were retained as best representing the foundational concepts of the IQI model.
  • Three health profiles were developed: excellent, good and fair. The three sample subgroups show high class homogeneity and also confirm the wholistic nature of Inuit health, given that several indicators are found in the three profiles.
  • All three profiles had positive responses to questions about spirituality, observing and learning Inuit practices while growing up, and sharing and receiving food.
  • Nunavimmiut aged 31 to 54 and 55 or older are more likely to be in excellent or good health, as are those who have participated in cultural, community or sports activities or done volunteer work. Furthermore, individuals in a relationship are more likely to have an excellent or good health profile.
  • Women and young people have a greater probability of being in the fair health profile, which also presents lower levels of community cohesion, family relationships and emotional support.

Limitations

The Qanuilirpitaa? 2017 health survey does not necessarily contain questions that accurately reflect the IQI model, which was developed at a later date. Due to the interconnectivity of concepts in the IQI model, few questions correspond to a single concept. The latent class analysis tool serves to simplify the results, given that any one person may present characteristics of several subgroups simultaneously.

Early childhood and childhood development

Preconception health of Indigenous peoples in Australia, Canada, New Zealand, and the United States: A scoping review

Walker, C., Begum, T., Boyle, J. A., Ward, J., and Barzi, F. (2024). Preconception health of Indigenous peoples in Australia, Canada, New Zealand, and the United States: A scoping review. International Journal of Environmental Research and Public Health, 21(3).

Context

The health and behaviours of women and men prior to conception can influence fertility as well as health outcomes for pregnant women and their unborn child. The first few weeks of pregnancy are especially critical as many women are not aware of being pregnant and may have behaviours that are harmful to the foetus. This is the reason behind preconception care (counselling and interventions targeting women and their partners). The importance of the preconception period in the fight against health inequities is an emerging topic and one that is relevant to explore in Indigenous populations.

Objective

Understand the scope and nature of preconception health knowledge among Indigenous peoples in Australia, Canada, New Zealand and the United States.

Methodology

A scoping review was conducted as per the Johanna Briggs Institute methodology and PRISMA. Quantitative (experimental, quasi-experimental and observational) and qualitative research studies published in English in peer-reviewed journals between 2010 and June 25, 2023, were included in the search. To qualify for selection, a study had to focus on one or more of the following: risk factors during the preconception period; levers and barriers to accessing preconception care; the design, implementation and evaluation of interventions; Indigenous peoples’ and health professionals’ understanding and awareness of preconception health. An inductive content analysis was conducted on the qualitative data.

What was learned? 

A total of 57 studies were selected, with the majority from the United States (n = 36) and Australia (n = 13). The study population primarily comprised women of any age (n = 46). Only three studies included men. It should be pointed out that risk factors, such as smoking, can impact reproductive health and that the partner’s lifestyle can influence that of the women. The authors suggest that further research should be done into men’s knowledge of and attitudes about preconception health. Furthermore, the authors were unable to determine the geographic context (rural or urban) of the sample population in 14 of the selected studies. Geographic specificities therefore comprise a shortcoming in the literature that needs to be addressed.

Of the selected studies, 27 report associations between risk factors (body mass index, drinking, diet, diabetes) during the preconception period and health outcomes for the mother and child. In general, these studies show an association between a higher body mass index and diabetes (gestational and postnatal), hypertension, delivery by caesarean section, and lower birth weight. Data concerning other risk factors were more fragmented.

What is more, 26 studies looked at conception and the implementation and evaluation of interventions. A majority of these studies focused on one risk factor at a time, primarily drinking and folic acid intake. For the most part, the qualitative data collected pertained to conception as well as the implementation and evaluation of interventions: the role of the family, community and culture; the importance of factual content on preconception health risks and of a strength-based approach; and the need to reach out to teenagers. The authors issue a reminder about the relevance of offering Indigenous populations interventions that address multiple risk factors in a holistic and culturally appropriate manner.

Limitations

The authors identify several limitations of their approach, including the absence of research from the grey literature. Some preconception health interventions may not have been taken into account. In addition, the broad inclusion criteria led to discrepancies among reviewers, which necessitated discussion and the expertise of a third person. Studies that combined preconception and pregnancy risk factors were not selected. This resulted in the exclusion of articles about key risk factors for the health of mothers and children, such as psychoactive substance use before, during and after pregnancy. Finally, studies presenting observational data but no association analyses were excluded even though this type of data can help in understanding the issue.

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 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.