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Promising Practices to Address Health Inequities in Aboriginal Mothers, Newborns and Children
Using Culturally Sensitive and Aligned Approaches
Deb McNeil, Shivani Rikhy, Jodi Siever, Amy Johnston, Suzanne Tough
Presentation Outline
Background
Synthesis Approach
Search and Selection
Science and Cultural Appraisal
Identification of Promising Practices
Results
Key Messages
What Has Been Addressed?
Research Questions:
What programs or activities exist that support Aboriginal
maternal, reproductive, newborn, child health and well‐
being?
Specifically,
Which are associated with positive
health/well‐being outcomes?
Which are associated with cultural alignment and sensitivity
guidelines?
Which represent promising practices?
A Synthesis Review
Systematic
a literature review with a clearly formulated research question
explicit methods: identify, select, & critically appraise or evaluate relevant research
Synthesis
expert panel: Aboriginal Advisory Committee
critical appraisal includes context
Identified promising practices
Search Strategy11 Databases
Medline, PsycINFO, CINAHL, HealthStar, Native Health, ERIC I,
ERIC II, HealthSource‐Nursing, and Child Abuse, Child Welfare,
and Adoption
Hand search of included articles
Search Terms
ETHNICITY (Aborigines, Aboriginal, First Nations, Inuit, Metis, American Indian,
Alaska Native, Torres Strait Islander, Maori, Indian, Eskimo, Indigenous, Native
American)
CHILDREN (newborn, infant, child, children, youth)
MATERNAL REPRODUCTIVE (pregnancy, prenatal, maternal,
maternity, preconception)
COUNTRY OF ORIGIN(Canada, United States, Australia, and New
Zealand)
Selection Strategy
2 reviewers independently scanned retrieved articles by:
1) title, 2) abstract, 3) full text (respectively) against inclusion/exclusion
criteria
Inclusion
Criteria
Identified a program, intervention, service, policy, practice
Included an actionable
component (ex: immunization)
contained substantial representation
from Aboriginal, Métis, Inuit, or First Nations
populations
Studies published between January 1st, 2005‐
March 31st, 2009, inclusive
Research conducted in Canada, United States, Australia, or New Zealand
Exclusion Criteria
Studies released prior
to January 1st, 2005
Descriptive studies identifying health disparities or poor health outcomes (non‐
actionable)
Case studies, position papers, anecdotal evidence
Program reports associated with marketing materials/products
Programs/practices with no
indication of either outcome or process
Foreign language reports
Note: Some programs/practices published earlier than 2005 were included for review based on the hand search of other included program reports or
pertinent literature as described above
Evaluating the ScienceQuantitative appraisal18 Factors (Ranking: Low, Mid, High)
selection bias, information bias, and confounding
positive , neutral, or negative outcomes
Flynn MAT et al. Reducing obesity and related chronic disease risk in children and youth: a synthesis of evidence with
'best practice‘
recommendations. Obesity Reviews 2006;7(1S):7‐66.
Evaluating the ScienceQualitative appraisal14 Factors (Ranking: Low, Mid, High)
reflexivity, credibility, and transferability
Flynn MAT et al. Reducing obesity and related chronic disease risk in children and youth: a synthesis of evidence
with 'best practice‘
recommendations. Obesity Reviews 2006;7(1S):7‐66.
Bringing Culture
into the Evaluation
Cultural Safety
Respect for nationality, culture, age, sex, political and religious
beliefs
Reinforces that each person’s knowledge/reality is valid and
valuable
Encourages voicing concerns
National Aboriginal Health Organization. Cultural Competency and
Safety: A Guide for Health Care Administrators, Providers and Educators. 2008 www.naho.ca
The patient, consumer, community defines the care or service
Simmons D. Relationship between maternal glycaemia and birth weight in glucose – tolerant women from different ethnic groups in New Zealand. Diabetic Medicine 2007;24 (3):240‐244. date
Conceptual Framework
SOGC Policy StatementA Guide for Health Professionals
Working with Aboriginal
Peoples
Number 100, December 2000
Smylie J. A guide for health professionals working with
Aboriginal peoples. Society of Obstetricians and
Gynaecologists of Canada; 2001.
Evaluating Cultural Sensitivity9 Factors
Understanding of Aboriginal culture, history, context,
medical and other determinants of health, the impact of colonization, & the availability of cultural training
for program staff
Evaluating Cultural AlignmentService Delivery
6 Factors
Ability of the service to provide culturally aligned care,
options available, language preferences, interpreters,
Capacity Building
7 Factors
Developed, implemented, administered and evaluated by
the community, building local capacity
Promising Practices3 Steps
Step 1: Certainty of EffectivenessScience and Outcomes
Step 2: Potential for Population ImpactCultural Sensitivity & AlignmentLogic, Reach (n=>500) and Uptake (>50%)
Step 3: Combining the first two steps in a table
McNeil and Flynn, Methods of defining best practice for population health approaches with obesity
prevention as an example. Proced. Nutr. Soc. 2006, 65, 403‐411
Elements considered: Potential for Population Impact Certainty of Effectiveness
Step 3: Identification of ‘Promising Practices’
Low Moderate High
High Promising Very Promising Most Promising
Mid Less Promising Promising Very Promising
Low Least Promising Less Promising Promising
Potential for population impact
Cer
tain
ty o
f Ef
fect
iven
ess
Swinburn B., Gill T., & Kumanyika SK. Obesity prevention: a proposed framework for translating evidence into action. Obesity Reviews 2005; 6; 23-33.
Maternal Newborn HealthProgram Topic Area Number of Programs/Activities
(N=21)
Preconception Health 2
Prenatal Care, Labour and Delivery
Culturally sensitive care 9
Mental Health 1
Substance Use 3
HIV 2
Labour and Delivery 2
Post Partum Care 1
Total 21
Maternal Newborn Health
IndividualIndividualFamilyFamily
CommunityCommunityCultural
9
Cont
extu
al4
Environmental4Sp
iritua
l
1
Political 0
Curative
0Pr
even
tive
7
Supportive
16
Rehabilitative 0
Promotive 0
Program/Activity Appraisal Rankings
Type of Appraisal Low (n) Mid (n) High (n)
Scientific Qualitative (n=8) 1 6 2
Quantitative (n=13) 5 8 0
Total (n=21)*
Cultural 4 11 3
Total (n=18)* Includes 3 mixed methods studies
Promising Practices
Kreiner M. Delivering diversity: newly regulated midwifery returns to Manitoba Canada, one community at a time. Journal of Midwifery and Women's Health 2009; 54 (1); e1-e10
Jan S., Conaty S., Hecker R., Bartlett M., Delaney S., & Capton T. An holistic economic evaluation of an Aboriginal community- controlled midwifery programmerin Western Sydney. Journal of Health Services Research & Policy 2004 ; 9(1);14-21
Topic Areas in Child Health and WellbeingProgram Topic Area Number of Programs/Activities
(N=21)
Healthy Lifestyle Promotion 7
Oral Health 3
Mental Health & Substance Abuse 3
Immunization 2
Diabetes 2
Education 2
FASD 1
Telehealth 1
Total 21
Child Health and Wellbeing
IndividualIndividualFamilyFamily
CommunityCommunityCultural
5
Cont
extu
al17
Environmental17Sp
iritua
l
1
Political 0
Curative
0
Prev
entiv
e16
Supportive
15
Rehabilitative 3
Promotive 13
Appraisal Rankings
Type of Appraisal Low (n) Mid (n) High (n)
Scientific Qualitative (n=5) 2 3 0
Quantitative (n=19) 8 10 1
Total (n=24)*
Cultural 10 9 2
Total (n=21)* Includes 3 mixed methods studies
Promising Practice Rankings
Lawrence, HP et al. A 2‐year
community‐randomized controlled
trial of fluoride varnish to prevent
early childhood caries in Aboriginal
children. Community Dentistry and
Oral Epidemiology, YEAR 36, 6: 503‐
516
Schinke, SP, Tepavac, L, Cole KC.
Preventing substance abuse among
Native American youth: three‐year
results. Addictive Behavior.
2000;25(3):387‐97.
Key Messages
Culturally aligned and sensitive community‐centered midwifery practice
is promising in reducing birth outcome disparities.
The meaning of risk can be different between providers and individuals and
their communities. These differences in understanding can result
in
diminished choice of labour and delivery options, potentially contributing to
culturally unsafe care
Given the importance of spirituality
and holistic health for Aboriginal
peoples, an opportunity exists to address the contribution of spirituality in
health and wellbeing.
Key Messages
A variety of well‐documented disparities, such as unwanted pregnancy and
infant mortality, have not been well addressed through programming and
research.
There is a gap in (reporting of research) conducted in rural communities,
which presents an opportunity for future programming and research .
High quality research is needed; as demonstrated by the four very promising
programs, science does not have to be a trade‐off for cultural sensitivity;
it is possible to have both.
Canada is a leader in culturally sensitive intervention research. Persistent
health disparities may be reduced by adopting culturally sensitive and aligned
promising practices.
Acknowledgements
Alberta Centre for Child, Family, & Community Research and Health Canada‐
financial support
Aboriginal Advisory Committee of the Alberta Centre for Child, Family, &
Community Research
development of a tool to assess cultural sensitivity and alignment for
research reports.
Mary Goitom, Courtney Crockett, Patrick O’Connell, and Sarah Horn‐
ongoing support and insight into research process and findings
Content experts contacted for input on emerging issues in Aboriginal health
Contact information: [email protected]
Cultural Understanding
9 factors were evaluated: understanding of Aboriginal culture, history, and context
Capacity Building
7 factors related to: efforts to build local capacity, also
included items focused on whether the program/practice and research was community based
Service Delivery
6 factors were assessed: ability of the service
to provide culturally aligned care, including language preferences
Step 1: ‘Certainty of Effectiveness’
Elements considered:
Science
Study outcomes
Negative
Neutral Positive Unknown
High
Low Mid High Mid
Mid
Low Low Mid Low
Low Low Low Low Low
Scie
nce
Outcomes
Step 2: ‘Potential for Population Impact’
Elements considered:
Cultural assessment
3 study characteristics: Logic,
Reach
(n>500), Uptake
(≥
50%)
0/3 1/3 2/3 3/3
High Low Mid Mid High
Mid Low Low Mid High
Low Low Low Low Mid
Low (Zero score)
Low Low Low Mid
Number of Study Characteristics out of Three
Cu
ltu
ral A
sses
smen
t
SOGC Guidelines
Sociocultural
Context
Understanding: groups, demographics, languages, colonization, socio‐
demographics, services close to home, governmental obligations, self
determination
Health Concerns
Appreciate holistic definitions of health, degree of ill health
unacceptable,
work with communities, not stereotype
Cross‐Cultural Understanding
Recognise: need for relationships to be based on mutual respect,
system gaps
and barriers, proactive to address gaps, care culturally appropriate, treatment
in own language, use cultural interpreters and advocates, importance of family
and community roles, integration of traditional medicine, increase personal
sensitivity, get to know communities
Aboriginal Health Resources
Support: community directed programming and participatory research,
education of Aboriginal health professionals, preventive health programming
Smylie
J. A guide for health professionals working with Aboriginal peoples. Society of Obstetricians and
Gynaecologists
of Canada; 2001.