For demographic reasons and as a result of a number of high profile health incidents in recent years, much of the health research and policy focus is on the younger cohorts of Aboriginal peoples in Canada. A critical examination of recent demographic trends reveals, however, that older cohorts of the Aboriginal population are increasing at a faster rate than younger cohorts, primarily due to improvements in life expectancy and declining fertility rates. Yet, there are surprisingly few health studies that have recognized the aging of the Aboriginal population. The overall goal of this paper is to examine differences in health status, use of conventional health care and traditional approaches to healing between older and younger cohorts of the Aboriginal population as well as to examine the importance of age as a determinant of health and health care use. Using data from the 2001 Statistics Canada Aboriginal Peoples Survey and contingency tables and logistic regression, the results demonstrate that older Aboriginal people face unique challenges - e.g. loss of traditional approaches to healing, geographic isolation, identity politics, constitutional and legal divisions within the Aboriginal community - with respect to their health and access to health services. These outcomes result from a colonial past and contemporary policies that affect all Aboriginal people.
The debate on health care reform in the United States has been greatly influenced by various national studies showing a strong relationship between lack of public or private health care coverage and inadequate access to health services. There is also much concern about deficiencies in the availability and delivery of services to certain population groups--especially for those living in the most remote and sparsely populated areas of the country. However, national studies have generally not demonstrated that the use of health services is strongly associated with urban/rural residence or the supply of medical providers. In this study, we show that national studies can obscure the problems of certain population groups including American Indians and Alaska Natives. Using data from the 1987 National Medical Expenditure Survey, the findings show that the availability of medical providers as well as place of residence were strongly associated with the use of health care by American Indians and Alaska Natives. Although American Indians and Alaska Natives included in this study were eligible to receive health care free of charge from the Indian Health Service (IHS), financial factors were also significantly associated with use due to the use of services other than those provided or sponsored by IHS. Also, the results show that while geographic and supply factors have only modest effects on the average travel time to medical providers for the U.S. population as a whole, travel times are dramatically longer for American Indians and Alaska Natives living in rural areas and where there are few medical providers. In addition, there appear to be fewer hospitalizations in areas where there are IHS outpatient services. We conclude by discussing the need for health care reform to take into account the diversity of a large country such as the U.S., and the special needs of population groups that are usually not adequately represented in national studies.
The Indian Health Service (IHS) is unique among U.S. private and public health programs in that free comprehensive health services are provided to eligible American Indians and Alaska Natives regardless of their ability to pay. However, resource limitations may compel some eligible persons to go outside of the IHS system to receive health care. Although IHS eligibles have comparatively low rates of private or public health care coverage, and much of this population lives in underserved areas, over half of IHS-eligible persons had some type of out-of-plan use in 1987. Furthermore, services received through private providers appear to supplement those received through IHS-sponsored providers. Overall, persons who use both IHS and non-IHS providers have higher levels of health care use than do those who rely exclusively on the IHS.
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.
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 m(2)). 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.
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
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In this article, we discuss findings from an ethnographic study in which we explored experiences of access to primary care services from the perspective of Aboriginal people seeking care at an emergency department (ED) located in a large Canadian city. Data were collected over 20 months of immersion in the ED, and included participant observation and in-depth interviews with 44 patients triaged as stable and nonurgent, most of whom were living in poverty and residing in the inner city. Three themes in the findings are discussed: (a) anticipating providers' assumptions; (b) seeking help for chronic pain; and (c) use of the ED as a reflection of social suffering. Implications of these findings are discussed in relation to the role of the ED as well as the broader primary care sector in responding to the needs of patients affected by poverty, racialization, and other forms of disadvantage.
For uninsured American Indians and Alaskan Natives (AIAN) diagnosed with cancer, prompt enrollment in Medicaid may speed access to treatment and improve survival. We hypothesized that AIANs who were eligible for the Indian Health Service Care System (IHSCS) at cancer diagnosis may be enrolled in Medicaid sooner than other AIANs.
Using Washington, Oregon, and California State Cancer Registries, we identified AIANs with a primary diagnosis of lung, breast, colorectal, cervical, ovarian, stomach, or prostate cancer between 2001 and 2007. Among AIANs enrolled in Medicaid within 365 days of a cancer diagnosis, we linked cancer registry records with Medicaid enrollment data and used a multivariate logistic regression model to compare the odds of delayed Medicaid enrollment between those with (n = 223) and without (n = 177) IHSCS eligibility.
Among AIANs who enrolled in Medicaid during the year following their cancer diagnosis, approximately 32% enrolled >1 month following diagnosis. Comparing those without IHSCS eligibility to those with IHSCS eligibility, the adjusted odds ratio (OR) for moderately late Medicaid enrollment (between 1 and 6 months after diagnosis) relative to early Medicaid enrollment (=1 month after diagnosis) was 1.10 [95% confidence interval (CI), 0.62-1.95] and for very late Medicaid enrollment (>6 months to 12 months after diagnosis), OR was 1.14 (CI, 0.54-2.43).
IHSCS eligibility at the time of diagnosis does not seem to facilitate early Medicaid enrollment.
Because cancer survival rates in AIANs are among the lowest of any racial group, additional research is needed to identify factors that improve access to care in AIANs.
In a pandemic situation, resources in intensive care units may be stretched to the breaking point, and critical care triage may become necessary. In such a situation, I argue that a patient's combined vulnerability to illness and social disadvantage should be a justification for giving that patient some priority for critical care. In this article I present an example of a critical care triage protocol that recognizes the moral relevance of vulnerability to illness and social disadvantage, from the Canadian province of Newfoundland and Labrador.
Abstract: As health care disparities become more evident in our multicultural nation, culture sensitive health research needs to be a priority in order for good health care to take place. This article will explore the literature related to acculturation stress and mental health disparities among the Mayan population. Literatures of similar but distinct groups are included due to the limited amount of research of the Mayan population. Using Leiniger's Transcultural nursing theory, these findings suggest that nurses have a large gap to fill to address the mental health disparities of specific cultural groups like the indigenous Maya, thereby satisfying their nursing obligations.
Actinic prurigo, an idiopathic familial photodermatosis, has been described in Amerindians in Manitoba, Canada, as well as in the United States, Mexico, and South America.
Our purpose was to describe the clinical features and prognosis of actinic prurigo in Amerindians in Saskatchewan, Canada.
Clinical examinations, questionnaires, phototesting, and laboratory tests were used.
We present a series of 93 Amerindian patients. The face is the most commonly involved area. A hereditary tendency, cheilitis, and pruritus are prominent features. One third of patients report some lesions, often minor, during the winter. The majority of patients phototested were sensitive to ultraviolet A light.
We find the age of onset of actinic prurigo to be the most important feature in determining the type of eruption and the prognosis for the patient. In general the younger ages of onset (up to 20 years of age) are associated with cheilitis and more acute eruptions and are more likely to improve over 5 years. Those who develop actinic prurigo as adults (21 years of age and older) tend to have a milder and more persistent dermatosis.
Comment In: J Am Acad Dermatol. 1997 Mar;36(3 Pt 1):504-59091504
Research that has examined Aboriginal children's hospitalization rates at the national level has been limited to analyses of areas with large percentages of Aboriginal residents, rather than of Aboriginal individuals. This study uses linked census and administrative data to describe hospitalization patterns among children and youth aged 0 to 19, by Aboriginal identity, for all provinces and territories except Quebec.
The 2006 Census was linked to the 2006/2007-to-2008/2009 Discharge Abstract Database, which contains hospital records from all acute care facilities (except Quebec). Hospital records were examined by Aboriginal identity, as reported to the census, according to International Classification of Diseases chapters based on "the most responsible diagnosis." Age-standardized hospitalization rates (ASHRs) were calculated per 100,000 population, and age-standardized rate ratios (RRs) were calculated for Aboriginal groups relative to non-Aboriginal people.
ASHRs were consistently higher among Aboriginal children and youth relative to their non-Aboriginal counterparts; rates for children aged 0 to 9 were 1.4 to 1.8 times higher; for youth aged 10 to 19, 2.0 to 3.8 times higher. For all children aged 0 to 9, the leading cause of hospitalization was "diseases of the respiratory system," but RRs for Aboriginal children ranged from 1.7 to 2.5, compared with non-Aboriginal children. Disparities between Aboriginal and non-Aboriginal 10- to 19-year-olds were pronounced for injuries due to assaults (RRs from 4.8 to 10.0), self-inflicted injuries (RRs from 2.7 to 14.2), and pregnancy, childbirth and the puerperium (RRs from 4.1 to 9.8).
Additional research is needed to examine reasons for the disparities in hospitalization rates between Aboriginal and non-Aboriginal children and youth.