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Background: Indigenous children living in high income countries have a consistently high prevalence of mental health problems. We aimed to identify psychosocial risk and protective factors for mental health in this setting. Methods: A systematic review of studies published between 1996 and 2016 that quantitatively evaluated the association between psychosocial variables and mental health among Indigenous children living in high income countries was conducted. Psychosocial variables were grouped into commonly occurring domains. Individual studies were judged to provide evidence for an association between a domain and either good mental health, poor mental health, or a negligible or inconsistent association. The overall quality of evidence across all studies for each domain was assessed using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) guidelines. Results: Forty-seven papers were eligible (mainland US 30 [64%], Canada 8 [17%], Australia 7 [15%], Hawaii 4 [9%]), including 58,218 participants aged 4-20 years. Most papers were cross-sectional (39, 83%) and measured negative mental health outcomes (41, 87%). Children's negative cohesion with their families and the presence of adverse events appeared the most reliable predictors of increased negative mental health outcomes. Children's substance use, experiences of discrimination, comorbid internalising symptoms, and negative parental behaviour also provided evidence of associations with negative mental health outcomes. Positive family and peer relationships, high self-esteem and optimism were associated with increased positive mental health outcomes. Conclusions: Quantitative research investigating Indigenous children's mental health is largely cross-sectional and focused upon negative outcomes. Indigenous children living in high income countries share many of the same risk and protective factors associated with mental health. The evidence linking children's familial environment, psychological traits, substance use and experiences of discrimination with mental health outcomes highlights key targets for more concerted efforts to develop initiatives to improve the mental health of Indigenous children. [ABSTRACT FROM AUTHOR]

Background: Inequitable access to primary health care (PHC) remains a problem for most western countries. Failure to scale up effective interventions has been due, in part, to a failure to share the logic and essential elements of successful programs. The aim of this paper is to describe what we learned about improving access to PHC for vulnerable groups across multiple sites through use of a common theory-based program logic model and a common evaluation approach. This was the IMPACT initiative. Methods: IMPACT's evaluation used a mixed methods design with longitudinal (pre and post) analysis of six interventions. The analysis for this paper included four of the six sites that met study criteria. These sites were located in Canada (Alberta, Quebec and Ontario) and Australia (New South Wales). Using the overarching logic model, unexpected findings were reviewed, and alternative explanations were considered to understand how the mechanisms of each intervention may have contributed to results. Results: Each site addressed their local access problem with different strategies and from different starting points. All sites observed changes in patient abilities to access PHC and provider access capabilities. The combination of intended and observed consequences for consumers and providers was different at each site, but all sites achieved change in both consumer ability and provider capability, even in interventions where there was no activity targeting provider behaviors. Discussion: The model helped to identify, explore and synthesize intended and unintended consequences of four interventions that appeared to have more differences than similarities. Similar outcomes for different interventions and multiple impacts of each intervention on abilities were observed, implying complex causal pathways. Conclusions: All the interventions were a low-cost incremental attempt to address unmet health care needs of vulnerable populations. Change is possible; sustaining change may be more challenging. Access to PHC requires attention to both patient abilities and provider characteristics. The logic model proved to be a valuable heuristic tool for defining the objectives of the interventions, evaluating their impacts, and learning from the comparison of 'cases'. [ABSTRACT FROM AUTHOR]

Introduction: Healthcare organisations serve clients from diverse Indigenous and other ethnic and racial groups on a daily basis, and require appropriate client-centred systems and services for provision of optimal healthcare. Despite advocacy for systems-level approaches to cultural competence, the primary focus in the literature remains on competency strategies aimed at health promotion initiatives, workforce development and student education. This paper aims to bridge the gap in available evidence about systems approaches to cultural competence by systematically mapping key concepts, types of evidence, and gaps in research. Methods: A literature search was completed as part of a larger systematic search of evaluations and measures of cultural competence interventions in health care in Canada, the United States, Australia and New Zealand. Seventeen peer-reviewed databases, 13 websites and clearinghouses, and 11 literature reviews were searched from 2002 to 2015. Overall, 109 studies were found, with 15 evaluating systems-level interventions or describing measurements. Thematic analysis was used to identify key implementation principles, intervention strategies and outcomes reported. Results: Twelve intervention and three measurement studies met our inclusion criteria. Key principles for implementing systems approaches were: user engagement, organisational readiness, and delivery across multiple sites. Two key types of intervention strategies to embed cultural competence within health systems were: audit and quality improvement approaches and service-level policies or strategies. Outcomes were found for organisational systems, the client/practitioner encounter, health, and at national policy level. Discussion and implications: We could not determine the overall effectiveness of systems-level interventions to reform health systems because interventions were context-specific, there were too few comparative studies and studies did not use the same outcome measures. However, examined together, the intervention and measurement principles, strategies and outcomes provide a preliminary framework for implementation and evaluation of systems-level interventions to improve cultural competence. Identified gaps in the literature included a need for cost and effectiveness studies of systems approaches and explication of the effects of cultural competence on client experience. Further research is needed to explore the extent to which cultural competence improves health outcomes and reduces ethnic and racially-based healthcare disparities. [ABSTRACT FROM AUTHOR]

Background: Racism in the healthcare system has become a burgeoning focus in health policy-making and research. Existing research has shown both interpersonal and structural forms of racism limiting access to quality healthcare for racialised healthcare users. Nevertheless, little is known about the specifics of racism in the inpatient sector, specifically hospitals and rehabilitation facilities. The aim of this scoping review is therefore to map the evidence on racial discrimination experienced by people receiving treatment in inpatient settings (hospitals and rehabilitation facilities) or their caregivers in high-income countries, focusing specifically on whether intersectional axes of discrimination have been taken into account when describing these experiences. Methods: Based on the conceptual framework developed by Arksey and O'Malley, this scoping review surveyed existing research on racism and racial discrimination in inpatient care in high-income countries published between 2013 and 2023. The software Rayyan was used to support the screening process while MAXQDA was used for thematic coding. Results: Forty-seven articles were included in this review. Specifics of the inpatient sector included different hospitalisation, admission and referral rates within and across hospitals; the threat of racial discrimination from other healthcare users; and the spatial segregation of healthcare users according to ethnic, religious or racialised criteria. While most articles described some interactions between race and other social categories in the sample composition, the framework of intersectionality was rarely considered explicitly during analysis. Discussion: While the USA continue to predominate in discussions, other high-income countries including Canada, Australia and the UK also examine racism in their own healthcare systems. Absent from the literature are studies from a wider range of European countries as well as of racialised and disadvantaged groups other than refugees or recent immigrants. Research in this area would also benefit from an engagement with approaches to intersectionality in public health to produce a more nuanced understanding of the interactions of racism with other axes of discrimination. As inpatient care exhibits a range of specific structures, future research and policy-making ought to consider these specifics to develop targeted interventions, including training for non-clinical staff and robust, transparent and accessible complaint procedures. [ABSTRACT FROM AUTHOR]

Background: Perceived financial security impacts physical, mental, and social health and overall wellbeing at community and population levels. Public health action on this dynamic is even more critical now that the COVID-19 pandemic has exacerbated financial strain and reduced financial wellbeing. Yet, public health literature on this topic is limited. Initiatives targeting financial strain and financial wellbeing and their deterministic effects on equity in health and living conditions are missing. Our research-practice collaborative project addresses this gap in knowledge and intervention through an action-oriented public health framework for initiatives targeting financial strain and wellbeing. Methods: The Framework was developed using a multi-step methodology that involved review of theoretical and empirical evidence alongside input from a panel of experts from Australia and Canada. In an integrated knowledge translation approach, academics (n = 14) and a diverse group of experts from government and non-profit sectors (n = 22) were engaged throughout the project via workshops, one-on-one dialogues, and questionnaires. Results: The validated Framework provides organizations and governments with guidance for the design, implementation, and assessment of diverse financial wellbeing- and financial strain-related initiatives. It presents 17 priority actionable areas (i.e., entry points for action) likely to have long-lasting, positive effects on people's financial circumstances, contributing to improved financial wellbeing and health. The 17 entry points relate to five domains: Government (All Levels), Organizational & Political Culture, Socioeconomic & Political Context, Social & Cultural Circumstances, and Life Circumstances. Conclusions: The Framework reveals the intersectionality of root causes and consequences of financial strain and poor financial wellbeing, while also reinforcing the need for tailored actions to promote socioeconomic and health equity for all people. The dynamic, systemic interplay of the entry points illustrated in the Framework suggest opportunities for multi-sectoral, collaborative action across government and organizations towards systems change and the prevention of unintended negative impacts of initiatives. [ABSTRACT FROM AUTHOR]

Background: Mobile clinics have been used to deliver primary health care to populations that otherwise experience difficulty in accessing services. Indigenous populations in Australia, Canada, New Zealand, and the United States experience greater health inequities than non-Indigenous populations. There is increasing support for Indigenous-governed and culturally accessible primary health care services which meet the needs of Indigenous populations. There is some support for primary health care mobile clinics implemented specifically for Indigenous populations to improve health service accessibility. The purpose of this review is to scope the literature for evidence of mobile primary health care clinics implemented specifically for Indigenous populations in Australia, Canada, New Zealand, and the United States. Methods: This review was undertaken using the Joanna Brigg Institute (JBI) scoping review methodology. Review objectives, inclusion criteria and methods were specified in advance and documented in a published protocol. The search included five academic databases and an extensive search of the grey literature. Results: The search resulted in 1350 unique citations, with 91 of these citations retrieved from the grey literature and targeted organisational websites. Title, abstract and full-text screening was conducted independently by two reviewers, with 123 citations undergoing full text review. Of these, 39 citations discussing 25 mobile clinics, met the inclusion criteria. An additional 14 citations were snowballed from a review of the reference lists of included citations. Of these 25 mobile clinics, the majority were implemented in Australia (n = 14), followed by United States (n = 6) and Canada (n = 5). No primary health mobile clinics specifically for Indigenous people in New Zealand were retrieved. There was a pattern of declining locations serviced by mobile clinics with an increasing population. Furthermore, only 13 mobile clinics had some form of evaluation. Conclusions: This review identifies geographical gaps in the implementation of primary health care mobile clinics for Indigenous populations in Australia, Canada, New Zealand, and the United States. There is a paucity of evaluations supporting the use of mobile clinics for Indigenous populations and a need for organisations implementing mobile clinics specifically for Indigenous populations to share their experiences. Engaging with the perspectives of Indigenous people accessing mobile clinic services is imperative to future evaluations. Registration: The protocol for this review has been peer-reviewed and published in JBI Evidence Synthesis (doi: 10.11124/JBISRIR-D-19-00057). [ABSTRACT FROM AUTHOR]

Objective: This narrative review aimed to identify and categorize the barriers and facilitators to the provision of brief intervention and behavioral change programs that target several risk behaviors among the Indigenous populations of Australia, Canada, and New Zealand. Methods: A systematic database search was conducted of six databases including PubMeD, Embase, CINAHL, HealthStar, PsycINFO, and Web of Science. Thematic analysis was utilized to analyze qualitative data extracted from the included studies, and a narrative approach was employed to synthesize the common themes that emerged. The quality of studies was assessed in accordance with the Joanna Briggs Institute's guidelines and using the software SUMARI – The System for the Unified Management, Assessment and Review of Information. Results: Nine studies were included. The studies were classified at three intervention levels: (1) individual-based brief interventions, (2) family-based interventions, and (3) community-based-interventions. Across the studies, selection of the intervention level was associated with Indigenous priorities and preferences, and approaches with Indigenous collaboration were supported. Barriers and facilitators were grouped under four major categories representing the common themes: (1) characteristics of design, development, and delivery, (2) patient/provider relationship, (3) environmental factors, and (4) organizational capacity and workplace-related factors. Several sub-themes also emerged under the above-mentioned categories including level of intervention, Indigenous leadership and participation, cultural appropriateness, social and economic barriers, and design elements. Conclusion: To improve the effectiveness of multiple health behavior change interventions among Indigenous populations, collaborative approaches that target different intervention levels are beneficial. Further research to bridge the knowledge gap in this topic will help to improve the quality of preventive health strategies to achieve better outcomes at all levels, and will improve intervention implementation from development and delivery fidelity, to acceptability and sustainability. [ABSTRACT FROM AUTHOR]

Background: Despite significant investments to support primary care internationally, income-based inequities in access to quality health care are present in many high-income countries. This study aims to determine whether low- and middle-income groups are more likely to report poor quality of primary care (PC) than high-income groups cross-nationally. Methods: The 2011 Commonwealth Fund Telephone Survey of Sicker Adults is a cross-sectional study across eleven countries. Respondents were recruited from randomly selected households. We used data from surveys conducted in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, the United Kingdom, and the United States. We identified all questions relating to primary care performance, and categorized these into five dimensions: 1) access to care, 2) coordination 3) patient-centered care, and 4) technical quality of care. We used logistic regression with low and middle-income as the comparison groups and high-income as the referent. Results: Fourteen thousand two hundred sixty-two respondents provided income data. Countries varied considerably in their extent of income disparity. Overall, 24.7% were categorized as low- and 13.9% as high-income. The odds of reporting poor access to care were higher for low- and middle-income than high-income respondents in Canada, New Zealand and the US. Similar results were found for Sweden and Norway on coordination; the opposite trend favoring the low- and middle-income groups was found in New Zealand, United Kingdom, and the United States. The odds of reporting poor patient-centered care were higher for low-income than high-income respondents in the Netherlands, Norway, and the US; in Australia, this was true for low- and middle-income respondents. On technical quality of care, the odds of reporting poor care were higher for the low- and middle-income comparisons in Canada and Norway; in Germany, the odds were higher for low-income respondents only. The odds of reporting poor technical quality of care were higher for high-income than low-income respondents in the Netherlands. Conclusion: Inequities in quality PC for low and middle income groups exist on at least one dimension in all countries, including some that in theory provide universal access. More research is needed to fully understand equity in the PC sector. [ABSTRACT FROM AUTHOR]

Background: Disparities in access to primary care (PC) have been demonstrated within and between health systems. However, few studies have assessed the factors associated with multiple barriers to access occurring along the care-seeking process in different healthcare systems. Methods: In this secondary analysis of the 2016 Commonwealth Fund International Health Policy Survey of Adults, access was represented through participant responses to questions relating to access barriers either before or after reaching the PC practice in 11 countries (Australia, Canada, France, Germany, Norway, the Netherlands, New Zealand, Sweden, Switzerland, the United Kingdom, and United States). The number of respondents in each country ranged from 1000 to 7000 and the response rates ranged from 11% to 47%. We used multivariable logistic regression models within each of eleven countries to identify disparities in response to the access barriers by age, sex, immigrant status, income and the presence of chronic conditions. Results: Overall, one in five adults (21%) experienced multiple barriers before reaching PC practices. After reaching care, an average of 16% of adults had two or more barriers. There was a sixfold difference between nations in the experience of these barriers to access. Vulnerable groups experiencing multiple barriers were relatively consistent across countries. People with lower income were more likely to experience multiple barriers, particularly before reaching primary care practices. Respondents with mental health problems and those born outside the country displayed substantial vulnerability in terms of barriers after reaching care. Conclusion: A greater understanding of the multiple barriers to access to PC across the stages of the care-seeking process may help to inform planning and performance monitoring of disparities in access. Variation across countries may reveal organisational and system drivers of access, and inform efforts to improve access to PC for vulnerable groups. The cumulative nature of these barriers remains to be assessed. [ABSTRACT FROM AUTHOR]