Janet Smylie

Indigenous health performance measurement systems in Canada, Australia, and New Zealand

The worldwide use of health performance measurement has emerged over the past two decades. Health service managers try to improve effi ciency and outcomes by linking cycles of evaluation to clear and measurable objectives. The World Health Organization (WHO) has defi ned three principal goals for health-care systems as: contributing to good health, responsiveness to the expectations of the population, and fairness of fi nancial contribution. In Canada, Australia, and New Zealand, the extent of Indigenous health disadvantage is well documented. Accordingly, expectations that the development of health performance measurement systems in these nations would give some priority to Indigenous health are reasonable. We discuss here the issues in health performance measurement systems in Indigenous societies within a human rights framework. Our research group examined information systems for Indigenous health in Canada, Australia, and New Zealand, through an extensive, country-specifi c review of both published and unpublished resources, as well as key informant interviews with national, regional, and community health measurement stakeholders. We asked national, regional, and community-level health information specialists and policymakers what health performance measurement systems are used, and how these systems relate to community-based health services and Indigenous peoples’ defi nitions of health. In our thematic analysis, we examined the underlying goals, processes, and contexts of existing Indigenous health measurement systems. We also looked for examples of best practice. Our inquiry identifi ed some advances in the development of Indigenous health performance measurements systems. However, we also identifi ed some important gaps, especially in the development of local and regional information systems and feedback to these systems, as well as in the processes for Indigenous input, including the application of Indigenous-specifi c frame works and indicators. The underlying intent of macro performance measurement systems varies, but includes the fi nancial accountability of programmes and services, political management of programmes, monitoring of the performance of services, and the development of capacity at a programme level. Macro refers to aggregated national or large regional systems. Some key informants felt that despite the often repetitive and lengthy service reporting, feedback processes remained inadequate, especially at community level. For example, our key Canadian informants reported that, in general, data are not compiled and fed back to either the health-care services or to the Indigenous communities from which they came. In New Zealand, key informants indicated that although the national Ministry of Health gathers Māori health data against a long list of indicators, much of those data are not used or fed back to the local level to inform Māori health-care planning and decision-making. Australia now produces a report every 2 years that collates performance data and indicators across a range of Aboriginal and Torres Strait Islander health-care and community service programmes. More importantly, the Australian Federal Health Department, has, since 2001, collaborated with the National Aboriginal Community Controlled Health Organisation on the analysis and publication of performance data from the health-care sector controlled by the Aboriginal community. All three countries have evidence of consultation with Indigenous people in the development of performance measurement systems. In Canada, the Aboriginal Health Reporting Framework process claims to centralise Indigenous consultation. However, the process is clearly driven by federal, provincial, and territorial accountability; is chaired by federal and provincial government representatives; and seeks to identify pan-Indigenous macro-level indicators. In New Zealand, the Ministry of Health held a Viewpoint of community meetings in 2004 to discuss what monitoring framework should be used nationally for Māori health. He Korowai Oranga, the national strategic framework for Māori health, was chosen. This framework can recognise both universal indicators of health such as mortality and disability, and Māori-specifi c indicators such as social determinants, secure cultural identity, and control over one’s destiny. The development of He Korowai Oranga included consultation meetings and written submission as methods of gaining Māori input. In Australia, a collaborative planning strategy has been developed for Aboriginal and Torres Strait Islander health that enables input from Indigenous service stakeholders into all levels and aspects of health system develop ment. Yet, opportunities for input from Indigenous Australian stakeholders outside of health or other community services are few. In all countries, some level of Indigenous involvement in the development of macro health systems has been achieved. Although eff ective consulta tive mechanisms are important, they should not divert attention from the necessity of enabling the development of local measurement systems that are Indigenous-driven. In Canada, several Indigenous groups responded to the gap in local Indigenous health information system Lancet 2006; 367: 2029–31

Health inequity in access to bariatric surgery: a protocol for a systematic review

AbstractBackgroundBariatric surgery is the only weight-loss treatment available that results in both sustained weight loss and improvements of obesity-related comorbidities. Individuals who meet the eligibility criteria for bariatric surgery are generally older, come from racial or ethnic minorities, are economically disadvantaged, and have low levels of education. However, the population who actually receives bariatric surgery does not reflect the individuals who need it the most. The objective is to conduct a systematic review of the literature exploring the inequities to the access of bariatric surgery.Methods/DesignEMBASE and Medline databases will be searched for observational studies that compared at least one of the PROGRESS-PLUS sociodemographic characteristics of patients eligible for bariatric surgery to those who actually received the procedure. Articles published in the year 1980 to present with no language restrictions will be included. For inclusion, studies must only include adults (≥18xa0years old) who meet National Institutes of Health (NIH) eligibility criteria for bariatric surgery defined as having either (1) a body mass index (BMI) of 40xa0kg/m2 or greater; or (2) BMI of 35xa0kg/m2 or greater with significant weight-related comorbidities. Eligible interventions will include malabsorptive, restrictive, and mixed bariatric procedures.DiscussionThere appears to be inequities in access to bariatric surgery. In order to resolve the health inequity in the treatment of obesity, a synthesis of the literature is needed to explore and identify barriers to accessing bariatric surgery. It is anticipated that the results from this systematic review will have important implications for advancing solutions to minimize inequities in the utilization of bariatric surgery.nhttp://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42013004920.

Birth Outcomes and Infant Mortality by the Degree of Rural Isolation Among First Nations and Non-First Nations in Manitoba, Canada

CONTEXTnIt is unknown whether rural isolation may affect birth outcomes and infant mortality differentially for Indigenous versus non-Indigenous populations. We assessed birth outcomes and infant mortality by the degree of rural isolation among First Nations (North American Indians) and non-First Nations populations in Manitoba, Canada, a setting with universal health insurance.nnnMETHODSnA geocoding-based birth cohort study of 25,143 First Nations and 125,729 non-First Nations live births to Manitoban residents, 1991-2000. Degree of rural isolation was defined by an indicator of urban influence (no, weak, moderate/strong) based on the percentage of the workforce commuting to urban areas.nnnFINDINGSnPreterm birth and low birth weight rates were somewhat lower in all rural areas regardless of the degree of isolation as compared to urban areas for both First Nations and non-First Nations. Infant mortality rates were not significantly different across areas for First Nations (10.7, 9.9, 7.9, and 9.7 per 1,000 in rural areas with no, weak, moderate/strong urban influence, and urban areas, respectively), but rates were significantly lower in less isolated areas for non-First Nations (7.4, 6.0, 5.6, and 4.6 per 1,000, respectively). Adjusted odds ratios showed similar patterns.nnnCONCLUSIONSnLiving in less isolated areas was associated with lower infant mortality only among non-First Nations. First Nations infants do not seem to have similarly benefited from the better health care facilities in urban centers, suggesting a need to improve urban First Nations infant care in meeting the challenges of increasing urban migration.

Understanding the role of Indigenous community participation in Indigenous prenatal and infant-toddler health promotion programs in Canada: A realist review

PURPOSEnStriking disparities in Indigenous maternal-child health outcomes persist in relatively affluent nations such as Canada, despite significant health promotion investments. The aims of this review were two-fold: 1. To identify Indigenous prenatal and infant-toddler health promotion programs in Canada that demonstrate positive impacts on prenatal or child health outcomes. 2. To understand how, why, for which outcomes, and in what contexts Indigenous prenatal and infant-toddler health promotion programs in Canada positively impact Indigenous health and wellbeing.nnnMETHODSnWe systematically searched computerized databases and identified non-indexed reports using key informants. Included literature evaluated a prenatal or child health promoting program intervention in an Indigenous population in Canada. We used realist methods to investigate how, for whom, and in what circumstances programs worked. We developed and appraised the evidence for a middle range theory of Indigenous community investment-ownership-activation as an explanation for program success.nnnFINDINGSnSeventeen articles and six reports describing twenty programs met final inclusion criteria. Program evidence of local Indigenous community investment, community perception of the program as intrinsic (mechanism of community ownership) and high levels of sustained community participation and leadership (community activation) was linked to positive program change across a diverse range of outcomes including: birth outcomes; access to pre- and postnatal care; prenatal street drug use; breast-feeding; dental health; infant nutrition; child development; and child exposure to Indigenous languages and culture.nnnCONCLUSIONSnThese findings demonstrate Indigenous community investment-ownership-activation as an important pathway for success in Indigenous prenatal and infant-toddler health programs.

Unmasking health determinants and health outcomes for urban First Nations using respondent-driven sampling

Objective Population-based health information on urban Aboriginal populations in Canada is limited due to challenges with the identification of Aboriginal persons in existing health data sets. The main objective of the Our Health Counts (OHC) project was to work in partnership with Aboriginal stakeholders to generate a culturally relevant, representative baseline health data set for three urban Aboriginal communities in Ontario, Canada. Design Respondent-driven sampling (RDS). Setting Hamilton, Ontario, Canada. Participants The OHC study, in partnership with the De dwa da dehs ney >s Aboriginal Health Access Centre (DAHC), recruited 554 First Nations adults living in Hamilton using RDS. Results Among First Nations adults living in Hamilton, 78% earned less than

Cardiovascular disease medication health literacy among Indigenous peoples: design and protocol of an intervention trial in Indigenous primary care services

20u2005000 per year and 70% lived in the lowest income quartile neighbourhoods. Mobility and crowded living conditions were also highly prevalent. Common chronic diseases included arthritis, hypertension, diabetes and chronic obstructive pulmonary disease and rates of emergency room access were elevated. Conclusions RDS is an effective sampling method in urban Aboriginal contexts as it builds on existing social networks and successfully identified a population-based cohort. The findings illustrate striking disparities in health determinants and health outcomes between urban First Nations individuals and the general population which have important implications for health services delivery, programming and policy development.

Aboriginal infant mortality rate in Canada

BackgroundCardiovascular diseases (CVD) are leading causes of mortality and morbidity among Indigenous people in New Zealand, Australia and Canada and are a major driver of the inequities in life expectancy between Indigenous and non-Indigenous people in these countries. Evidence-based pharmaceutical management of CVD can significantly reduce mortality and morbidity for persons diagnosed with CVD or for those at intermediate or high risk of CVD. Health literacy has been identified as a major barrier in the communication and implementation of appropriate pharmaceutical management plans for CVD. Addressing health literacy is particularly relevant in Indigenous populations where there are unique health and adult literacy challenges.Methods/designThis study will examine the effect of a customized, structured CVD medication programme, delivered by health professionals, on the health literacy of Indigenous people with, or at risk, of CVD. Primary outcomes are patient’s knowledge about CVD medications; secondary outcomes examine changes in health literacy skills and practices. The study will employ a multi-site pre-post design with multiple measurement points to assess intervention efficacy. Participants will be recruited from four Indigenous primary care services in Australia, Canada and New Zealand. Three educational sessions will be delivered over four weeks. A tablet application will support the education sessions and produce a customized pill card for each participant. Participants will be provided with written information about CVD medications. Medication knowledge scores, and specific health literacy skills and practices will be assessed before and after the three sessions. Statistical analyses will identify significant changes in outcomes over each session, and from the pre-session one to post-session three time points.DiscussionThis study will make an important contribution to understanding the effect of a structured primary care-based intervention on CVD health literacy in Indigenous populations. The study also illustrates the incorporation of Indigenous health research principles and processes in clinical trials and provides insights that may be useful in other contexts.Trial registrationAustralian and New Zealand Clinical Trials Register (ACTRN12612001309875; date of registration 18/12/2012).

Evaluation of the acceptability of a CD-Rom as a health promotion tool for Inuit in Ottawa

1reports that “For Aboriginal people as a whole, infant mortality is almost 20% higher than among inhabitants in the rest of Canada”. This fi gure is substantially lower than the disparities between Aboriginal and non-Aboriginal infant mortality in Canada that have been cited in recent reviews. 2,3 Inconsistent or absent identifi cation of Aboriginal people in Canadian health information systems precludes the calculation of pan-Canadian Aboriginal infant mortality rates. However, peer-reviewed studies have revealed infant mortality rates that are 190% higher for First Nations compared with non-First-Nations 4

Together we can make a difference

Background There are few health promotion tools for urban Inuit, and there is a specific dearth of evaluations on such tools. Objective The current study used a community-specific approach in the evaluation of a health promotion tool, based on an urban Inuit communitys preferences of health knowledge sources and distribution strategies. In partnership with the Tungasuvvingat Inuit Family Health Team in Ottawa, a CD-Rom was developed featuring an Inuk Elder presenting prenatal health messages in both Inuktitut and English. Also, relevant evaluation materials were developed. Design Using a mixed methods approach, 40 participants completed interviews prior to viewing the CD-Rom and participated in a focus group at follow-up. Questionnaires were also completed pre- and post-viewing to assess changes between expectations and reactions in order to document acceptability. Results Significant increases were found on satisfaction, acceptability of medium and relevance of content ratings. Qualitative findings also included (a) interest, uncertainty and conditional interest prior to viewing; and (b) positive evaluations of the CD-Rom. Conclusions This suggests that CD-Rom technology has the potential for health promotion for urban Inuit, and the community-specific evaluation approach yielded useful information.