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1.  “I have to do what I believe”: Sudanese women’s beliefs and resistance to hegemonic practices at home and during experiences of maternity care in Canada 
Background
Evidence suggests that immigrant women having different ethnocultural backgrounds than those dominant in the host country have difficulty during their access to and reception of maternity care services, but little knowledge exists on how factors such as ethnic group and cultural beliefs intersect and influence health care access and outcomes. Amongst immigrant populations in Canada, refugee women are one of the most vulnerable groups and pregnant women with immediate needs for health care services may be at higher risk of health problems. This paper describes findings from the qualitative dimension of a mixed-methodological study.
Methods
A focused ethnographic approach was conducted in 2010 with Sudanese women living in an urban Canadian city. Focus group interviews were conducted to map out the experiences of these women in maternity care, particularly with respect to the challenges faced when attempting to use health care services.
Results
Twelve women (mean age 36.6 yrs) having experience using maternity services in Canada within the past two years participated. The findings revealed that there are many beliefs that impact upon behaviours and perceptions during the perinatal period. Traditionally, the women mostly avoid anything that they believe could harm themselves or their babies. Pregnancy and delivery were strongly believed to be natural events without need for special attention or intervention. Furthermore, the sub-Saharan culture supports the dominance of the family by males and the ideology of patriarchy. Pregnancy and birth are events reflecting a certain empowerment for women, and the women tend to exert control in ways that may or may not be respected by their husbands. Individual choices are often made to foster self and outward-perceptions of managing one’s affairs with strength.
Conclusion
In today’s multicultural society there is a strong need to avert misunderstandings, and perhaps harm, through facilitating cultural awareness and competency of care rather than misinterpretations of resistance to care.
doi:10.1186/1471-2393-13-51
PMCID: PMC3599128  PMID: 23442448
Canada; Sudanese; Beliefs; Culture; Focused ethnography; Maternity; Refugee; Pregnancy
2.  Immigrant women’s experiences of postpartum depression in Canada: a protocol for systematic review using a narrative synthesis 
Systematic Reviews  2013;2:65.
Background
Literature documents that immigrant women in Canada have a higher prevalence of postpartum depression symptomatology than Canadian-born women. There exists a need to synthesize information on the contextual factors and social determinants of health that influence immigrant women’s reception of and behavior in accessing existing mental health services. Our research question is: what are the ethnoculturally defined patterns of help-seeking behaviors and decision-making and other predictive factors for therapeutic mental health care access and outcomes with respect to postpartum depression for immigrant women in Canada?
Methods/design
Our synthesis incorporates a systematic review using narrative synthesis of reports (peer- and non-peer reviewed) of empirical research and aims to provide stakeholders with perspectives on postpartum mental health care services as experienced by immigrant women. To reach this goal we are using integrated knowledge translation, thus partnering with key stakeholders throughout the planning, implementation and dissemination stages to ensure topic relevancy and impact on future practice and policy. The search and selection strategies draw upon established systematic review methodologies as outlined by the Centre for Reviews and Dissemination and also incorporate guidelines for selection and appraisal of gray literature. Two search phases (a database and a gray literature phase) will identify literature for screening and final selection based on an inclusion/exclusion checklist. Quality appraisal will be performed using the tools produced by the Centre for Evidence Based Management. The narrative synthesis will be informed by Popay et al. (2006) framework using identified tools for each of its four elements. The integrated knowledge translation plan will ensure key messages are delivered in an audience-specific manner to optimize their impact on policy and practice change throughout health service, public health, immigration and community sectors.
Discussion
The narrative synthesis methodology will facilitate understandings and acknowledgement of the broader influences of theoretical and contextual variables, such as race, gender, socio-economic status, pre-migration history and geographical location. Our review aims to have a substantive and sustainable impact on health outcomes, practice, programs and/or policy in the context of postpartum mental health of immigrant women. PROSPERO registration number CRD42012003020.
doi:10.1186/2046-4053-2-65
PMCID: PMC3765819  PMID: 23965183
Narrative synthesis; Immigrant women; Postpartum depression; Maternity care experiences; Canada; Systematic review protocol
3.  A Guide for Health Professionals Working with Aboriginal Peoples: Executive Summary 
Objective
to provide Canadian health professionals with a network of information and recommendations regarding Aboriginal health.
Options
health professionals working with Aboriginal individuals and communities in the area of women’s health care.
Outcomes
improved health status of Aboriginal peoples in Canada.
Appropriateness and accessibility of women’s health services for Aboriginal peoples.
Improved communication and clinical skills of health professionals in the area of Aboriginal health.
Improved quality of relationship between health professionals and Aboriginal individuals and communities.
Improved quality of relationship between health care professionals and Aboriginal individuals and communities.
Evidence
recommendations are based on expert opinion and a review of the literature. Published references were identified by a Medline search of all review articles, randomized clinical control trials, meta-analyses, and practice guidelines from 1966 to February 1999, using the MeSH headings “Indians, North American or Eskimos” and “Health.”* Subsequently published articles were brought to the attention of the authors in the process of writing and reviewing the document. Ancillary and unpublished references were recommended by members of the SOGC Aboriginal Health Issues Committee and the panel of expert reviewers.
Values
information collected was reviewed by the principal author. The social, cultural, political, and historic context of Aboriginal peoples in Canada, systemic barriers regarding the publication of information by Aboriginal authors, the diversity of Aboriginal peoples in Canada, and the need for a culturally appropriate and balanced presentation were carefully considered in addition to more traditional scientific evaluation. The majority of information collected consisted of descriptive health and social information and such evaluation tools as the evidence guidelines of the Canadian Task Force on the Periodic Health exam were not appropriate.
Benefits, costs, and harms
utilization of the information and recommendations by Canadian health professionals will enhance understanding, communication, and clinical skills in the area of Aboriginal health. The resulting enhancement of collaborative relationships between Aboriginal peoples and their women’s health providers may contribute to health services that are more appropriate, effective, efficient, and accessible for Aboriginal peoples in Canada. The educational process may require an initial investment of time from the health professional.
Recommendations
Recommendations were grouped according to four themes: sociocultural context, health concerns, cross-cultural understanding, and Aboriginal health resources. Health professionals are encouraged to learn the appropriate names, demographics, and traditional geographic territories and language groups of the various Aboriginal groups in Canada. In addition, sensitivity to the impact of colonization and current socioeconomic challenges to the health status of Aboriginal peoples is warranted. Health services for Aboriginal peoples should take place as close to home as possible. Governmental obligations and policies regarding determination are recognized. With respect to health concerns, holistic definitions of health, based on Aboriginal perspectives, are put forward. Aboriginal peoples continue to experience a disproportionate burden of health problems. Health professionals are encouraged to become familiar with several key areas of morbidity and mortality. Relationships between Aboriginal peoples and their care providers need to be based on a foundation of mutual respect. Gaps and barriers in the current health care system for Aboriginal peoples are identified. Health professionals are encouraged to work with Aboriginal individuals and communities to address these gaps and barriers. Aboriginal peoples require culturally appropriate health care, including treatment in their own languages when possible. This may require interpreters or Aboriginal health advocates. Health professionals are encouraged to recognize the importance of family and community roles, and to respect traditional medicines and healers. Health professionals can develop their sensitivities towards Aboriginal peoples by participating in workshops, making use of educational resources, and by spending time with Aboriginal peoples in their communities. Aboriginal communities and health professionals are encouraged to support community-based, community-directed health services and health research for Aboriginal peoples. In addition, the education of more Aboriginal health professionals is essential. The need for a preventative approach to health programming in Aboriginal communities is stressed.
Validation
recommendations were reviewed and revised by the SOGC Aboriginal Health Issues Committee, a panel of expert reviewers, and the SOGC Council. In addition, this document was also reviewed and supported by the Assembly of First Nations, Canadian Institute of Child Health, Canadian Paediatric Society, College of Family Physicians of Canada, Congress of Aboriginal Peoples, Federation of Medical Women of Canada, Inuit Tapirisat of Canada, Metis National Council, National Indian and Inuit Community Health Representatives Organization, and Pauktuutit Inuit Women’s Association.
Sponsor
Society of Obstetricians and Gynaecologists of Canada.
PMCID: PMC3653835  PMID: 23682204 CAMSID: cams2752
4.  Aboriginal Health Workers experience multilevel barriers to quitting smoking: a qualitative study 
Introduction
Long-term measures to reduce tobacco consumption in Australia have had differential effects in the population. The prevalence of smoking in Aboriginal peoples is currently more than double that of the non-Aboriginal population. Aboriginal Health Workers are responsible for providing primary health care to Aboriginal clients including smoking cessation programs. However, Aboriginal Health Workers are frequently smokers themselves, and their smoking undermines the smoking cessation services they deliver to Aboriginal clients. An understanding of the barriers to quitting smoking experienced by Aboriginal Health Workers is needed to design culturally relevant smoking cessation programs. Once smoking is reduced in Aboriginal Health Workers, they may then be able to support Aboriginal clients to quit smoking.
Methods
We undertook a fundamental qualitative description study underpinned by social ecological theory. The research was participatory, and academic researchers worked in partnership with personnel from the local Aboriginal health council. The barriers Aboriginal Health Workers experience in relation to quitting smoking were explored in 34 semi-structured interviews (with 23 Aboriginal Health Workers and 11 other health staff) and 3 focus groups (n = 17 participants) with key informants. Content analysis was performed on transcribed text and interview notes.
Results
Aboriginal Health Workers spoke of burdensome stress and grief which made them unable to prioritise quitting smoking. They lacked knowledge about quitting and access to culturally relevant quitting resources. Interpersonal obstacles included a social pressure to smoke, social exclusion when quitting, and few role models. In many workplaces, smoking was part of organisational culture and there were challenges to implementation of Smokefree policy. Respondents identified inadequate funding of tobacco programs and a lack of Smokefree public spaces as policy level barriers. The normalisation of smoking in Aboriginal society was an overarching challenge to quitting.
Conclusions
Aboriginal Health Workers experience multilevel barriers to quitting smoking that include personal, social, cultural and environmental factors. Multidimensional smoking cessation programs are needed that reduce the stress and burden for Aboriginal Health Workers; provide access to culturally relevant quitting resources; and address the prevailing normalisation of smoking in the family, workplace and community.
doi:10.1186/1475-9276-11-27
PMCID: PMC3477099  PMID: 22621767
Aboriginal people, Australia; Health care professionals; Tobacco and health; Smoking cessation; Qualitative research
5.  Access to health care among status Aboriginal people with chronic kidney disease 
Background
Ethnic disparities in access to health care and health outcomes are well documented. It is unclear whether similar differences exist between Aboriginal and non-Aboriginal people with chronic kidney disease in Canada. We determined whether access to care differed between status Aboriginal people (Aboriginal people registered under the federal Indian Act) and non-Aboriginal people with chronic kidney disease.
Methods
We identified 106 511 non-Aboriginal and 1182 Aboriginal patients with chronic kidney disease (estimated glomerular filtration rate less than 60 mL/min/1.73 m2). We compared outcomes, including hospital admissions, that may have been preventable with appropriate outpatient care (ambulatory-care–sensitive conditions) as well as use of specialist services, including visits to nephrologists and general internists.
Results
Aboriginal people were almost twice as likely as non-Aboriginal people to be admitted to hospital for an ambulatory-care–sensitive condition (rate ratio 1.77, 95% confidence interval [CI] 1.46–2.13). Aboriginal people with severe chronic kidney disease (estimated glomerular filtration rate < 30 mL/min/1.73 m2) were 43% less likely than non-Aboriginal people with severe chronic kidney disease to visit a nephrologist (hazard ratio 0.57, 95% CI 0.39–0.83). There was no difference in the likelihood of visiting a general internist (hazard ratio 1.00, 95% CI 0.83–1.21).
Interpretation
Increased rates of hospital admissions for ambulatory-care–sensitive conditions and a reduced likelihood of nephrology visits suggest potential inequities in care among status Aboriginal people with chronic kidney disease. The extent to which this may contribute to the higher rate of kidney failure in this population requires further exploration.
doi:10.1503/cmaj.080063
PMCID: PMC2572655  PMID: 18981441
6.  Identifying barriers and improving communication between cancer service providers and Aboriginal patients and their families: the perspective of service providers 
Background
Aboriginal Australians experience poorer outcomes from cancer compared to the non-Aboriginal population. Some progress has been made in understanding Aboriginal Australians’ perspectives about cancer and their experiences with cancer services. However, little is known of cancer service providers’ (CSPs) thoughts and perceptions regarding Aboriginal patients and their experiences providing optimal cancer care to Aboriginal people. Communication between Aboriginal patients and non-Aboriginal health service providers has been identified as an impediment to good Aboriginal health outcomes. This paper reports on CSPs’ views about the factors impairing communication and offers practical strategies for promoting effective communication with Aboriginal patients in Western Australia (WA).
Methods
A qualitative study involving in-depth interviews with 62 Aboriginal and non-Aboriginal CSPs from across WA was conducted between March 2006 - September 2007 and April-October 2011. CSPs were asked to share their experiences with Aboriginal patients and families experiencing cancer. Thematic analysis was carried out. Our analysis was primarily underpinned by the socio-ecological model, but concepts of Whiteness and privilege, and cultural security also guided our analysis.
Results
CSPs’ lack of knowledge about the needs of Aboriginal people with cancer and Aboriginal patients’ limited understanding of the Western medical system were identified as the two major impediments to communication. For effective patient–provider communication, attention is needed to language, communication style, knowledge and use of medical terminology and cross-cultural differences in the concept of time. Aboriginal marginalization within mainstream society and Aboriginal people’s distrust of the health system were also key issues impacting on communication. Potential solutions to effective Aboriginal patient-provider communication included recruiting more Aboriginal staff, providing appropriate cultural training for CSPs, cancer education for Aboriginal stakeholders, continuity of care, avoiding use of medical jargon, accommodating patients’ psychosocial and logistical needs, and in-service coordination.
Conclusion
Individual CSPs identified challenges in cross-cultural communication and their willingness to accommodate culture-specific needs within the wider health care system including better communication with Aboriginal patients. However, participants’ comments indicated a lack of concerted effort at the system level to address Aboriginal disadvantage in cancer outcomes.
doi:10.1186/1472-6963-13-460
PMCID: PMC3835135  PMID: 24188503
Aboriginal; Indigenous; Cancer; Communication; Health service provider; Cancer service provider
7.  Review of research on aboriginal populations in Canada: relevance to their health needs 
BMJ : British Medical Journal  2003;327(7412):419-422.
Objective To determine if research has adequately examined the health needs of the aboriginal population of Canada.
Design Review.
Study selection Medline search of journal articles published during 1992-2001. The search terms used were “Canada” and various synonyms and categories for Canadian aboriginal people. Each paper was categorised according to the aboriginal group, age-sex group, comparison group, geographic location, and type of research topic (health determinant, health status, or health care).
Results Of 352 citations found, 254 were selected after elimination of those without abstracts, not containing data on Canada, or not focusing on health issues. The proportion of papers does not reflect the demographic composition of aboriginal people in Canada, with severe under-representation of Métis, urban aboriginal people, and First Nations people not living on reserves and over-representation of the Inuit. Children and women received less attention proportional to their share of the population. A few prolific research groups have generated a disproportionate amount of publications from a few communities and regions. 174 papers dealt with health determinants (for example, genetics, diet, and contaminants), 173 with health status, and 75 with health care. Injuries, which account for a third of all deaths, were studied in only 8 papers. None of the health care papers examined rehabilitation.
Conclusion Researchers have not adequately examined several important health needs of the aboriginal population.
PMCID: PMC181255  PMID: 12933728
8.  Dietary intake of vitamin D in a northern Canadian Dené First Nation community 
International Journal of Circumpolar Health  2013;72:10.3402/ijch.v72i0.20723.
Background
Increased awareness of the wide spectrum of activity of vitamin D has focused interest on its role in the health of Canada's Aboriginal peoples, who bear a high burden of both infectious and chronic disease. Cutaneous vitamin D synthesis is limited at northern latitudes, and the transition from nutrient-dense traditional to nutrient-poor market foods has left many Canadian Aboriginal populations food insecure and nutritionally vulnerable.
Objective
The study was undertaken to determine the level of dietary vitamin D in a northern Canadian Aboriginal (Dené) community and to determine the primary food sources of vitamin D.
Design
Cross-sectional study.
Methods
Dietary vitamin D intakes of 46 adult Dené men and women were assessed using a food frequency questionnaire and compared across age, gender, season and body mass index. The adequacy of dietary vitamin D intake was assessed using the 2007 Adequate Intake (AI) and the 2011 Recommended Dietary Allowance (RDA) values for Dietary Reference Intake (DRI).
Results
Mean daily vitamin D intake was 271.4 IU in winter and 298.3 IU in summer. Forty percent and 47.8% of participants met the vitamin D 1997 AI values in winter and summer, respectively; this dropped to 11.1 and 13.0% in winter and summer using 2011 RDA values. Supplements, milk, and local fish were positively associated with adequate vitamin D intake. Milk and local fish were the major dietary sources of vitamin D.
Conclusions
Dietary intake of vitamin D in the study population was low. Only 2 food sources, fluid milk and fish, provided the majority of dietary vitamin D. Addressing low vitamin D intake in this population requires action aimed at food insecurity present in northern Aboriginal populations.
doi:10.3402/ijch.v72i0.20723
PMCID: PMC3752286  PMID: 23984265
vitamin D; First Nations; indigenous; Aboriginal; diet; nutrition; food security
9.  Examining the gender, ethnicity, and age dimensions of the healthy immigrant effect: Factors in the development of equitable health policy 
This study expands on previous research on the healthy immigrant effect (HIE) in Canada by considering the effects of both immigrant and visible minority status on self-rated health for males and females in mid-(45-64) and later life (65+). The findings reveal a strong HIE among new immigrant middle-aged men, particularly non-Whites. For older men of color the reality is strikingly different: they are disadvantaged in health compared to their Canadian-born counterparts, even when a number of demographic, economic, and lifestyle factors are controlled. Health outcomes for immigrant women are in contrast to that of immigrant men. Among middle-aged women, immigrants, regardless of their ethnicity or number of years since immigration, are much more likely to report poor health compared to the Canadian-born. And, for older women, recent non-white immigrants are more likely to report better health compared to Canadian-born women, although this finding is explained by differences in demographic, economic, and lifestyle factors. Overall, the findings demonstrate the importance of considering the intersections of age, gender, and ethnicity for policymakers in assessing the health of immigrants.
doi:10.1186/1475-9276-11-8
PMCID: PMC3305534  PMID: 22336144
healthy immigrant effect; gender; ethnicity; mid-life; later life; health care policy
10.  A research review: exploring the health of Canada's Aboriginal youth 
International Journal of Circumpolar Health  2012;71:10.3402/ijch.v71i0.18497.
Objective
To compare the current state of health research on Aboriginal and non-Aboriginal youth in Canada.
Design
A search of published academic literature on Canadian Aboriginal youth health, including a comprehensive review of both non-Aboriginal and Aboriginal youth research, was conducted using MEDLINE and summarized.
Methodology
A MEDLINE search was conducted for articles published over a 10-year period (2000–2010). The search was limited to research articles pertaining to Canadian youth, using various synonyms for “Canada,” “youth,” and “Aboriginal.” Each article was coded according to 4 broad categories: Aboriginal identity, geographic location, research topic (health determinants, health status, health care), and the 12 key determinants of health proposed by the Public Health Agency of Canada (PHAC).
Results
Of the 117 articles reviewed, only 34 pertained to Aboriginal youth, while the remaining 83 pertained to non-Aboriginal youth. The results revealed major discrepancies within the current body of research with respect to the geographic representation of Aboriginal youth, with several provinces missing from the literature, including the northern territories. Furthermore, the current research is not reflective of the demographic composition of Aboriginal youth, with an under-representation of Métis and urban Aboriginal youth. Health status of Aboriginal youth has received the most attention, appearing in 79% of the studies reviewed compared with 57% of the non-Aboriginal studies. The number of studies that focus on health determinants and health care is comparable for both groups, with the former accounting for 62 and 64% and the latter comprising 26 and 19% of Aboriginal and non-Aboriginal studies, respectively. However, this review reveals several differences with respect to specific focus on health determinants between the two populations. In non-Aboriginal youth studies, all the 12 key determinants of health of PHAC are explored, whereas in Aboriginal youth studies the health profile remains incomplete and several key determinants and health indicators are neglected.
Conclusions
The current studies are not reflective of the demographic and geographic profiles of Aboriginal youth in Canada, and they have also failed to provide a comprehensive examination of their unique health needs and concerns compared with studies on non-Aboriginal youth.
doi:10.3402/ijch.v71i0.18497
PMCID: PMC3427595  PMID: 22973569
Aboriginal people; health status; determinants of health; youth
11.  HIV Prevalence among Aboriginal British Columbians 
Context
There is considerable concern about the spread of HIV disease among Aboriginal peoples in British Columbia.
Objective
To estimate the number of Aboriginal British Columbians infected with HIV.
Design and setting
A population-based analysis of Aboriginal men and women in British Columbia, Canada from 1980 to 2001.
Participants
Epidemic curves were fit for gay and bisexual men, injection drug users, men and women aged 15 to 49 years and persons over 50 years of age.
Main outcome measures
HIV prevalence for the total Aboriginal population was modeled using the UNAIDS/WHO Estimation and Projection Package (EPP). Monte Carlo simulation was used to estimate potential number infected for select transmission group in 2001.
Results
A total of 170,025 Aboriginals resided in British Columbia in 2001, of whom 69% were 15 years and older. Of these 1,691 (range 1,479 – 1,955) men and women aged 15 years and over were living with HIV with overall prevalence ranging from 1.26% to 1.66%. The majority of the persons infected were men. Injection drug users (range 1,202 – 1,744) and gay and bisexual men (range 145, 232) contributed the greatest number of infections. Few persons infected were from low risk populations.
Conclusion
More than 1 in every 100 Aboriginals aged 15 years and over was living with HIV in 2001. Culturally appropriate approaches are needed to tailor effective HIV interventions to this community.
doi:10.1186/1477-7517-2-26
PMCID: PMC1368971  PMID: 16375771
12.  Survivors of sexual abuse: clinical, lifestyle and reproductive consequences 
BACKGROUND: In recent years, an increase in the prevalence of sexual abuse of women has been reported in Canada and elsewhere. However, there are few empirical data on the extent of the problem in Canadian aboriginal populations. The authors investigated the presence of a reported history of sexual abuse and other health determinants in a sample of women attending a community health centre with a substantial aboriginal population. This allowed determination of whether reported sexual abuse and its associated demographic and health-related effects were different for aboriginal and non-aboriginal women. METHODS: A sample of 1696 women was selected from women attending a community health centre in a predominantly low-income inner-city area of Winnipeg for a cross-sectional survey designed to study the association between sexual behavior and cervical infections. The survey was conducted between November 1992 and March 1995 and involved a clinical examination, laboratory tests and an interviewer-administered questionnaire. A substudy was conducted among 1003 women who were asked 2 questions about sexual abuse. RESULTS: The overall response rate for the main study was 87%. Of the 1003 women who were asked the questions about sexual abuse, 843 (84.0%) responded. Among the respondents, 368 (43.6%) were aboriginal. Overall, 308 (36.5%) of the respondents reported having been sexually abused, 74.0% of the incidents having occurred during childhood. The prevalence was higher among aboriginal women than among non-aboriginal women (44.8% v. 30.1%, p < 0.001). Women who had been sexually abused were younger when they first had sexual intercourse, they had multiple partners, and they had a history of sexually transmitted diseases. In addition, non-aboriginal women who had been sexually abused were more likely than those who had not been abused to have been separated or divorced, unemployed and multiparous and to have used an intrauterine device rather than oral contraceptives. Aboriginal women who had been sexually abused were more likely than those who had not been abused to have been separated or divorced, unemployed and multiparous and to have used an intrauterine device rather than oral contraceptives. Aboriginal women who had been sexually abused were more likely than those who had not been abused to have had abnormal Papanicolaou smears. The proportion of smokers was higher among the abused women than among the non-abused women in both ethnic groups. INTERPRETATION: A history of sexual abuse was associated with other clinical, lifestyle and reproductive factors. This suggests that sexual abuse may be associated with subsequent health behaviors, beyond specific physical and psychosocial disorders. Aboriginal and non-aboriginal women who have suffered sexual abuse showed substantial differences in their subsequent health and health-related behaviours.
PMCID: PMC1229591  PMID: 9732710
13.  Shared decision-making and health for First Nations, Métis and Inuit women: a study protocol 
Background
Little is known about shared decision-making (SDM) with Métis, First Nations and Inuit women (“Aboriginal women”). SDM is a collaborative process that engages health care professional(s) and the client in making health decisions and is fundamental for informed consent and patient-centred care. The objective of this study is to explore Aboriginal women’s health and social decision-making needs and to engage Aboriginal women in culturally adapting an SDM approach.
Methods
Using participatory research principles and guided by a postcolonial theoretical lens, the proposed mixed methods research will involve three phases. Phase I is an international systematic review of the effectiveness of interventions for Aboriginal peoples’ health decision-making. Developed following dialogue with key stakeholders, proposed methods are guided by the Cochrane handbook and include a comprehensive search, screening by two independent researchers, and synthesis of findings. Phases II and III will be conducted in collaboration with Minwaashin Lodge and engage an urban Aboriginal community of women in an interpretive descriptive qualitative study. In Phase II, 10 to 13 Aboriginal women will be interviewed to explore their health/social decision-making experiences. The interview guide is based on the Ottawa Decision Support Framework and previous decisional needs assessments, and as appropriate may be adapted to findings from the systematic review. Digitally-recorded interviews will be transcribed verbatim and analyzed inductively to identify participant decision-making approaches and needs when making health/social decisions. In Phase III, there will be cultural adaptation of an SDM facilitation tool, the Ottawa Personal Decision Guide, by two focus groups consisting of five to seven Aboriginal women. The culturally adapted guide will undergo usability testing through individual interviews with five to six women who are about to make a health/social decision. Focus groups and individual interviews will be digitally-recorded, transcribed verbatim, and analyzed inductively to identify the adaptation required and usability of the adapted decision guide.
Discussion
Findings from this research will produce a culturally sensitive intervention to facilitate SDM within a population of urban Aboriginal women, which can subsequently be evaluated to determine impacts on narrowing health/social decision-making inequities.
doi:10.1186/1472-6947-12-146
PMCID: PMC3541952  PMID: 23249503
First Nations; Inuit and Métis women; Shared decision-making; Equity; Health equity; Participatory research principles; Cultural adaption
14.  Aboriginal Families Study: a population-based study keeping community and policy goals in mind right from the start 
Background
Australian Aboriginal and Torres Strait Islander women are between two to five times more likely to die in childbirth than non-Aboriginal women, and two to three times more likely to have a low birthweight infant. Babies with a low birthweight are more likely to have chronic health problems in adult life. Currently, there is limited research evidence regarding effective interventions to inform new initiatives to strengthen antenatal care for Aboriginal families.
Method/Design
The Aboriginal Families Study is a cross sectional population-based study investigating the views and experiences of Aboriginal and non-Aboriginal women having an Aboriginal baby in the state of South Australia over a 2-year period. The primary aims are to compare the experiences and views of women attending standard models of antenatal care with those accessing care via Aboriginal Family Birthing Program services which include Aboriginal Maternal Infant Care (AMIC) Workers as members of the clinical team; to assess factors associated with early and continuing engagement with antenatal care; and to use the information to inform strengthening of services for Aboriginal families. Women living in urban, regional and remote areas of South Australia have been invited to take part in the study by completing a structured interview or, if preferred, a self-administered questionnaire, when their baby is between 4–12 months old.
Discussion
Having a baby is an important life event in all families and in all cultures. How supported women feel during pregnancy, how women and families are welcomed by services, how safe they feel coming in to hospitals to give birth, and what happens to families during a hospital stay and in the early months after the birth of a new baby are important social determinants of maternal, newborn and child health outcomes. The Aboriginal Families Study builds on consultation with Aboriginal communities across South Australia. The project has been implemented with guidance from an Aboriginal Advisory Group keeping community and policy goals in mind right from the start. The results of the study will provide a unique resource to inform quality improvement and strengthening of services for Aboriginal families.
doi:10.1186/1475-9276-12-41
PMCID: PMC3689616  PMID: 23767813
Antenatal care; Health inequalities; Indigenous health; Maternal health; Participatory research; Perinatal health outcomes
15.  “We Are Not Being Heard”: Aboriginal Perspectives on Traditional Foods Access and Food Security 
Aboriginal peoples are among the most food insecure groups in Canada, yet their perspectives and knowledge are often sidelined in mainstream food security debates. In order to create food security for all, Aboriginal perspectives must be included in food security research and discourse. This project demonstrates a process in which Aboriginal and non-Aboriginal partners engaged in a culturally appropriate and respectful collaboration, assessing the challenges and barriers to traditional foods access in the urban environment of Vancouver, BC, Canada. The findings highlight local, national, and international actions required to increase access to traditional foods as a means of achieving food security for all people. The paper underscores the interconnectedness of local and global food security issues and highlights challenges as well as solutions with potential to improve food security of both Aboriginal and non-Aboriginal peoples alike.
doi:10.1155/2012/130945
PMCID: PMC3549364  PMID: 23346118
16.  Diversity Considerations for Promoting Early Childhood Oral Health: A Pilot Study 
Objectives. Several groups in Manitoba, Canada, experience early childhood caries (ECC), including Aboriginal, immigrant, and refugee children and those from select rural regions. The purpose of this pilot study was to explore the views of parents and caregivers from four cultural groups on early childhood oral health and ECC. Methods. A qualitative descriptive study design using focus groups recruited parents and caregivers from four cultural groups. Discussions were documented, audio-recorded, transcribed, and then analyzed for content based on themes. Results. Parents and caregivers identified several potential barriers to good oral health practice, including child's temperament, finances, and inability to control sugar intake. Both religion and genetics were found to influence perceptions of oral health. Misconceptions regarding breastfeeding and bottle use were present. One-on-one discussions, parental networks, and using laypeople from similar backgrounds were suggested methods to promote oral health. The immigrant and refugee participants placed emphasis on the use of visuals for those with language barriers while Hutterite participants suggested a health-education approach. Conclusions. These pilot study findings provide initial insight into the oral health-related knowledge and beliefs of these groups. This will help to inform planning of ECC prevention and research strategies, which can be tailored to specific populations.
doi:10.1155/2014/175084
PMCID: PMC3928864  PMID: 24624141
17.  Policy silences: why Canada needs a National First Nations, Inuit and Métis health policy 
International Journal of Circumpolar Health  2013;72:10.3402/ijch.v72i0.22690.
Objectives
Despite attempts, policy silences continue to create barriers to addressing the healthcare needs of First Nations, Inuit and Métis. The purpose of this article is to answer the question, if what we have in Canada is an Aboriginal health policy patchwork that fails to address inequities, then what would a Healthy Aboriginal Health Policy framework look like?
Methods
The data collected included federal, provincial and territorial health policies and legislation that contain Aboriginal, First Nation, Inuit and/or Métis-specific provisions available on the internet. Key websites included the Parliamentary Library, federal, provincial and territorial health and Aboriginal websites, as well as the Department of Justice Canada, Statistics Canada and the Aboriginal Canada Portal.
Results
The Indian Act gives the Governor in Council the authority to make health regulations. The First Nations and Inuit Health Branch (FNIHB) of Health Canada historically provided health services to First Nations and Inuit, as a matter of policy. FNIHB's policies are few, and apply only to Status Indians and Inuit. Health legislation in 2 territories and 4 provinces contain no provision to clarify their responsibilities. In provinces where provisions exist, they broadly focus on jurisdiction. Few Aboriginal-specific policies and policy frameworks exist. Generally, these apply to some Aboriginal peoples and exclude others.
Conclusion
Although some Aboriginal-specific provisions exist in some legislation, and some policies are in place, significant gaps and jurisdictional ambiguities remain. This policy patchwork perpetuates confusion. A national First Nation, Inuit and Métis policy framework is needed to address this issue.
doi:10.3402/ijch.v72i0.22690
PMCID: PMC3875351  PMID: 24380077
indigenous populations; health services; indigenous; health policy; legislation; Canada
18.  Residents' exposure to aboriginal health issues. Survey of family medicine programs in Canada. 
Canadian Family Physician  1999;45:325-330.
OBJECTIVE: To determine whether Canadian family medicine residency programs currently have objectives, staff, and clinical experiences for adequately exposing residents to aboriginal health issues. DESIGN: A one-page questionnaire was developed to survey the details of teaching about and exposure to aboriginal health issues. SETTING: Family medicine programs in Canada. PARTICIPANTS: All Canadian family medicine program directors in the 18 programs (16 at universities and two satellite programs) were surveyed between October 1997 and March 1998. MAIN OUTCOME MEASURES: Whether programs had teaching objectives for exposing residents to aboriginal health issues, whether they had resource people available, what elective and core experiences in aboriginal health were offered, and what types of experiences were available. RESULTS: Response rate was 100%. No programs had formal, written curriculum objectives for residency training in aboriginal health issues, although some were considering them. Some programs, however, had objectives for specific weekend or day sessions. No programs had a strategy for encouraging enrollment of residents of aboriginal origin. Eleven programs had at least one resource person with experience in aboriginal health issues, and 12 had access to community-based aboriginal groups. Core experiences were all weekend seminars or retreats. Elective experiences in aboriginal health were available in 16 programs, and 11 programs were active on reserves. CONCLUSIONS: Many Canadian family medicine programs give residents some exposure to aboriginal health issues, but most need more expertise and direction on these issues. Some programs have unique approaches to teaching aboriginal health care that could be shared. Formalized objectives derived in collaboration with other family medicine programs and aboriginal groups could substantially improve the quality of education in aboriginal health care in Canada.
PMCID: PMC2328292  PMID: 10065306
19.  Acculturation and Nutritional Health of Immigrants in Canada: A Scoping Review 
Although recent immigrants to Canada are healthier than Canadian born (i.e., the Healthy Immigrant Effect), they experience a deterioration in their health status which is partly due to transitions in dietary habits. Since pathways to these transitions are under-documented, this scoping review aims to identify knowledge gaps and research priorities related to immigrant nutritional health. A total of 49 articles were retrieved and reviewed using electronic databases and a stakeholder consultation was undertaken to consolidate findings. Overall, research tends to confirm the Healthy Immigrant Effect and suggests that significant knowledge gaps in nutritional health persist, thereby creating a barrier to the advancement of health promotion and the achievement of maximum health equity. Five research priorities were identified including (1) risks and benefits associated with traditional/ethnic foods; (2) access and outreach to immigrants; (3) mechanisms and coping strategies for food security; (4) mechanisms of food choice in immigrant families; and (5) health promotion strategies that work for immigrant populations.
Electronic supplementary material
The online version of this article (doi:10.1007/s10903-013-9823-7) contains supplementary material, which is available to authorized users.
doi:10.1007/s10903-013-9823-7
PMCID: PMC3895180  PMID: 23595263
Dietary acculturation; Immigrant health; Canada; Nutrition
20.  Evaluation of evidence-based literature and formulation of recommendations for the clinical preventive guidelines for immigrants and refugees in Canada 
Background:
This article describes the evidence review and guideline development method developed for the Clinical Preventive Guidelines for Immigrants and Refugees in Canada by the Canadian Collaboration for Immigrant and Refugee Health Guideline Committee.
Methods:
The Appraisal of Guidelines for Research and Evaluation (AGREE) best-practice framework was combined with the recently developed Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to produce evidence-based clinical guidelines for immigrants and refugees in Canada.
Results:
A systematic approach was designed to produce the evidence reviews and apply the GRADE approach, including building on evidence from previous systematic reviews, searching for and comparing evidence between general and specific immigrant populations, and applying the GRADE criteria for making recommendations. This method was used for priority health conditions that had been selected by practitioners caring for immigrants and refugees in Canada.
Interpretation:
This article outlines the 14-step method that was defined to standardize the guideline development process for each priority health condition.
doi:10.1503/cmaj.090289
PMCID: PMC3168669  PMID: 20573711
21.  Access to Primary and Preventive Care among Foreign-Born Adults in Canada and the United States 
Health Services Research  2010;45(6 Pt 1):1693-1719.
Objective
To conduct cross-country comparisons and assess the effect of foreign birth on access to primary and preventive care in Canada and the United States.
Data Sources
Secondary data from the 2002 to 2003 Joint Canada–United States Survey of Health.
Study Design
Descriptive and comparative analyses were conducted, and logistic regression models were used to assess the effect of immigrant status and country of residence on access to care. Outcomes included measures of health care systems and processes, utilization, and patient perceptions.
Principal Findings
In adjusted analyses, immigrants in Canada fared worse than nonimmigrants regarding having timely Pap tests; in the United States, immigrants fared worse for having a regular doctor and an annual consultation with a health professional. Immigrants in Canada had better access to care than immigrants in the United States; most of these differences were explained by differences in socioeconomic status and insurance coverage across the two countries. However, U.S. immigrants were more likely to have timely Pap tests than Canadian immigrants, even after adjusting for potential confounders.
Conclusions
In both countries, foreign-born populations had worse access to care than their native-born counterparts for some indicators but not others. However, few differences in access to care were found when direct cross-country comparisons were made between immigrants in Canada versus the United States, after accounting for sociodemographic differences.
doi:10.1111/j.1475-6773.2010.01163.x
PMCID: PMC3026954  PMID: 20819107
Access to health care; primary care; immigrants; Canada; United States
22.  Immigrant women’s experiences of maternity-care services in Canada: a protocol for systematic review using a narrative synthesis 
Systematic Reviews  2012;1:27.
Background
Canada’s diverse society and statutory commitment to multiculturalism means that the synthesis of knowledge related to the health care experiences of immigrants is essential to realize the health potential for future Canadians. Although concerns about the maternity experiences of immigrants in Canada are relatively new, recent national guidelines explicitly call for tailoring of services to user needs. We are therefore assessing the experiences of immigrant women in Canada accessing maternity-care services. We are focusing on: 1) accessibility and acceptability (as an important dimension of access) to maternity-care services as perceived and experienced by immigrant women, and 2) the birth and postnatal outcomes of these women.
Methods
The aim of this study is to use a narrative synthesis, incorporating both a systematic review using narrative synthesis of reports of empirical research (qualitative, quantitative, and mixed-method designs), and a literature review of non-empirically based reports, both of which include ‘grey’ literature. The study aims to provide stakeholders with perspectives on maternity-care services as experienced by immigrant women. To achieve this, we are using integrated knowledge translation, partnering with key stakeholders to ensure topic relevancy and to tailor recommendations for effective translation into future policy and practice/programming. Two search phases and a three-stage selection process are being conducted (database search retrieved 1487 hits excluding duplicates) to provide evidence to contribute jointly to both the narrative synthesis and the non-empirical literature review. The narrative synthesis will be informed by the previous framework published in 2006 by Popay et al., using identified tools for each of its four elements. The non-empirical literature review will build upon the narrative-synthesis findings and/or identify omissions or gaps in the empirical research literature. The integrated knowledge translation plan will ensure that key messages are delivered in an audience-specific manner to optimize their effect on policy and practice change throughout the health service, and the public health, immigration and community sectors.
Discussion
Narrative-synthesis methods of systematic review facilitate understanding and acknowledgement of the broader influences of theoretical and contextual variables, such as race, gender, socioeconomic status, and geographical location. They also enable understanding of the shaping of differences between reported outcomes and study designs related to childbearing populations, and the development and implementation of maternity services and health interventions across diverse settings.
PROSPERO registration
Number 2185.
doi:10.1186/2046-4053-1-27
PMCID: PMC3433387  PMID: 22651573
Narrative synthesis; Immigrant women; Maternity-care experiences; Canada; Study protocol; Mixed research design review
23.  Cultural repertoires and food-related household technology within colonia households under conditions of material hardship 
Introduction
Mexican-origin women in the U.S. living in colonias (new-destination Mexican-immigrant communities) along the Texas-Mexico border suffer from a high incidence of food insecurity and diet-related chronic disease. Understanding environmental factors that influence food-related behaviors among this population will be important to improving the well-being of colonia households. This article focuses on cultural repertoires that enable food choice and the everyday uses of technology in food-related practice by Mexican-immigrant women in colonia households under conditions of material hardship. Findings are presented within a conceptual framework informed by concepts drawn from sociological accounts of technology, food choice, culture, and material hardship.
Methods
Field notes were provided by teams of promotora-researchers (indigenous community health workers) and public-health professionals trained as participant observers. They conducted observations on three separate occasions (two half-days during the week and one weekend day) within eight family residences located in colonias near the towns of Alton and San Carlos, Texas. English observations were coded inductively and early observations stressed the importance of technology and material hardship in food-related behavior. These observations were further explored and coded using the qualitative data package Atlas.ti.
Results
Technology included kitchen implements used in standard and adapted configurations and household infrastructure. Residents employed tools across a range of food-related activities identified as forms of food acquisition, storage, preparation, serving, feeding and eating, cleaning, and waste processing. Material hardships included the quality, quantity, acceptability, and uncertainty dimensions of food insecurity, and insufficient consumption of housing, clothing and medical care. Cultural repertoires for coping with material hardship included reliance on inexpensive staple foods and dishes, and conventional and innovative technological practices. These repertoires expressed the creative agency of women colonia residents. Food-related practices were constrained by climate, animal and insect pests, women’s gender roles, limitations in neighborhood and household infrastructure, and economic and material resources.
Conclusions
This research points to the importance of socioeconomic and structural factors such as gender roles, economic poverty and material hardship as constraints on food choice and food-related behavior. In turn, it emphasizes the innovative practices employed by women residents of colonias to prepare meals under these constraints.
doi:10.1186/1475-9276-11-25
PMCID: PMC3442973  PMID: 22587790
24.  The health of Inuit children under age 6 in Canada 
International Journal of Circumpolar Health  2012;71:10.3402/ijch.v71i0.18580.
Objectives
Previous research has suggested that Inuit children experience poor health as compared to their non-Aboriginal counterparts, although social determinants such as family and social conditions, lifestyle or behaviour, and cultural factors may be at play. The purpose of the current study was to examine the parent-reported health of Inuit children under 6 years of age living in Canada.
Study design and methods
Data from the 2006 Aboriginal Children's Survey were used to examine measures of Inuit child health as rated by parents including child health, limitations to physical activity, chronic conditions, ear infections, and dental problems. Associations between social determinants of health and parent-rated Inuit child health were also explored.
Results
Most Inuit children under age 6 were reported by their parents or guardians to be in excellent or very good health. The most common chronic conditions identified were asthma, speech and language difficulties, allergies, lactose intolerance, and hearing impairment. Several social determinants of health were associated with child health, including parental education, household income, breastfeeding, and perceived housing conditions.
Conclusions
The findings show that social determinants of health, including both socio-economic and household characteristics, are associated with Inuit child health.
doi:10.3402/ijch.v71i0.18580
PMCID: PMC3417691  PMID: 22973565
children; Inuit; social determinants of health
25.  The creation of the expected Aboriginal woman drug offender in Canada: Exploring relations between victimization, punishment, and cultural identity 
This article illustrates how the Aboriginal female drug user is responded to as an expected offender based on the intersection of her gender, race, and class. Drawing on the findings of a national Canadian study documenting the lived experiences of First Nations, Métis, and Inuit female drug users, we argue that the strengthening of cultural identity can potentially disrupt this expected status at both the individual and social system levels. Within the framework of critical victimology, the challenge then becomes to translate this understanding into praxis. In response, we suggest advancing women’s agency at the individual level in the face of disempowering images and practices related to the offender, the victim, and Aboriginality. For change at the system level, we return to Christie’s notion of the need to dismantle the stereotypical construction of the Aboriginal female drug user. We illustrate both levels of change with an innovative form of knowledge sharing, which aims to evoke transformation with respect to individual and socially constructed conceptualizations of identity.
doi:10.1177/0269758012447215
PMCID: PMC4006816  PMID: 24795492 CAMSID: cams2785
criminalization; cultural identity; drug offender; punishment; victimology

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