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Integration of genomic technology into healthcare settings establishes new capabilities to predict disease susceptibility and optimize treatment regimes. Yet, Indigenous peoples remain starkly underrepresented in genetic and clinical health research and are unlikely to benefit from such efforts. To foster collaboration with Indigenous communities, we propose six principles for ethical engagement in genomic research: understand existing regulations, foster collaboration, build cultural competency, improve research transparency, support capacity building, and disseminate research findings. Inclusion of underrepresented communities in genomic research has the potential to expand our understanding of genomic influences on health and improve clinical approaches for all populations. Indigenous peoples are still underrepresented in genetic research. Here, the authors propose an ethical framework consisting of six major principles that encourages researchers and Indigenous communities to build strong and equal partnerships to increase trust, engagement and diversity in genomic studies.

Background Structural violence shapes the health of Indigenous peoples globally, and is deeply embedded in history, individual and institutional racism, and inequitable social policies and practices. Many Indigenous communities have flourished, however, the impact of colonialism continues to have profound health effects for Indigenous peoples in Canada and internationally. Despite increasing evidence of health status inequities affecting Indigenous populations, health services often fail to address health and social inequities as routine aspects of health care delivery. In this paper, we discuss an evidence-based framework and specific strategies for promoting health care equity for Indigenous populations. Methods Using an ethnographic design and mixed methods, this study was conducted at two Urban Aboriginal Health Centres located in two inner cities in Canada, which serve a combined patient population of 5,500. Data collection included in-depth interviews with a total of 114 patients and staff ( n  = 73 patients; n  = 41 staff), and over 900 h of participant observation focused on staff members’ interactions and patterns of relating with patients. Results Four key dimensions of equity-oriented health services are foundational to supporting the health and well-being of Indigenous peoples: inequity-responsive care, culturally safe care, trauma- and violence-informed care, and contextually tailored care. Partnerships with Indigenous leaders, agencies, and communities are required to operationalize and tailor these key dimensions to local contexts. We discuss 10 strategies that intersect to optimize effectiveness of health care services for Indigenous peoples, and provide examples of how they can be implemented in a variety of health care settings. Conclusions While the key dimensions of equity-oriented care and 10 strategies may be most optimally operationalized in the context of interdisciplinary teamwork, they also serve as health equity guidelines for organizations and providers working in various settings, including individual primary care practices. These strategies provide a basis for organizational-level interventions to promote the provision of more equitable, responsive, and respectful PHC services for Indigenous populations. Given the similarities in colonizing processes and Indigenous peoples’ experiences of such processes in many countries, these strategies have international applicability.

Background Addressing health workforce cultural competence is a common approach to improving health service quality for culturally and ethnically diverse groups. Research evidence in this area is primarily focused on cultural competency training and its effects on practitioners’ knowledge, attitudes, skills and behaviour. While improvements in measures of healthcare practitioner cultural competency and other healthcare outcomes have been reported, there are concerns around evidence strength and quality. This scoping review reports on the intervention strategies, outcomes, and measures of included studies with the purpose of informing the implementation and evaluation of future interventions to improve health workforce cultural competence. Methods This systematic scoping review was completed as part of a larger systematic literature search conducted on cultural competence intervention evaluations in health care in Canada, the United States, Australia and New Zealand published from 2006 to 2015. Overall, 64 studies on cultural competency interventions were found, with 16 aimed directly at the health workforce. Results There was significant heterogeneity in workforce intervention strategies, measures and outcomes reported across studies making comparisons of intervention effects difficult. The two main workforce intervention strategies identified were cultural competency training and other professional development interventions including other training and mentoring. Positive outcomes were commonly reported for improved practitioner knowledge (9/16), skills (7/16), and attitudes/beliefs (5/16). Although health care (6/16) and health (2/16) outcomes were reported in some studies there was very limited evidence of positive intervention impacts. Only four studies utilised existing validated measurement tools to assess intervention outcomes. Conclusion Training and development of the health workforce remain a principle strategy towards the goal of improved cultural competence in health services and systems. Diverse approaches are available to increase health workforce cultural competence. However, the effects of interventions beyond practitioner knowledge and attitudes remains unclear. Assessment of practitioner behavioural outcomes as well as measures of intervention impact on healthcare and health outcomes are needed to build a stronger evidence base.

Introduction In the field of health, numerous frameworks have emerged that advance understandings of the differential impacts of health policies to produce inclusive and socially just health outcomes. In this paper, we present the development of an important contribution to these efforts – an Intersectionality-Based Policy Analysis (IBPA) Framework. Methods Developed over the course of two years in consultation with key stakeholders and drawing on best and promising practices of other equity-informed approaches, this participatory and iterative IBPA Framework provides guidance and direction for researchers, civil society, public health professionals and policy actors seeking to address the challenges of health inequities across diverse populations. Importantly, we present the application of the IBPA Framework in seven priority health-related policy case studies. Results The analysis of each case study is focused on explaining how IBPA: 1) provides an innovative structure for critical policy analysis; 2) captures the different dimensions of policy contexts including history, politics, everyday lived experiences, diverse knowledges and intersecting social locations; and 3) generates transformative insights, knowledge, policy solutions and actions that cannot be gleaned from other equity-focused policy frameworks. Conclusion The aim of this paper is to inspire a range of policy actors to recognize the potential of IBPA to foreground the complex contexts of health and social problems, and ultimately to transform how policy analysis is undertaken.

Background The capacity of the Indigenous primary healthcare (PHC) sector to continue playing a crucial role in meeting the health needs of Aboriginal and Torres Strait Islander Australians is in large part reliant on the skills, motivation and experience of its workforce. While exhibiting many workforce strengths, the sector faces significant challenges in building and maintaining a strong and stable workforce. Drawing on data from one Aboriginal Community Controlled Health Service (ACCHS), this study reports what is working well and what could be improved to strengthen the Indigenous PHC sector workforce. Methods Using grounded theory methods, interviews with 17 ACCHS staff from a range of organisational positions were transcribed, coded and analysed. This paper focuses on the strategies identified that contribute towards strengthening the Indigenous PHC workforce. Results Four overarching strategies for Indigenous PHC workforce strengthening were identified. These were Strengthening Workforce Stability, Having Strong Leadership, Growing Capacity, and Working Well Together . A range of enabling factors at the macro, community, organisational and individual levels were also identified. Conclusion Indigenous PHC services are already implementing many important workforce-development strategies that are having a positive impact on the sector. There are also several persistent challenges which need to be addressed through action at organisational and structural levels. Approaches to workforce strengthening in Indigenous PHC should be tailored to local needs to ensure they address the unique workforce challenges experienced in different contexts.

The individualistic and colonial foundations of neoliberal socio-political ideologies are embedded throughout Australian health systems, services, and discourses. Not only does neoliberalism undermine Aboriginal and Torres Strait Islander collectivist values by emphasizing personal autonomy, but it has significant implications for Aboriginal and Torres Strait Islander health. Aboriginal Community Controlled Health Services (ACCHS) operate within Community-oriented holistic understandings of well-being that contradict neoliberal values that Western health services operate within. Therefore, this paper aims to explore the role of ACCHS in resisting the pervasive nature of neoliberalism through the prioritization of self-determination for Aboriginal and Torres Strait Islander Peoples. Utilizing a critical evaluative commentary, we reflect on Aboriginal political leadership and advocacy during the 1970s and 1980s and the development of neoliberalism in Australia in the context of ACCHS. Community controlled primary health services across Australia are the only remaining government-funded and Aboriginal-controlled organizations. Not only do ACCHS models resist neoliberal ideologies of reduced public expenditure and dominant individualistic models of care, but they also incontrovertibly strengthen individual and Community health. ACCHS remain the gold standard model by ensuring Aboriginal and Torres Strait Islander rights to the self-determination of health in accordance with the United Nations Declaration of the Rights of Indigenous Peoples.

Our scoping review sought to consider how Etuaptmumk or Two-Eyed Seeing is described in Indigenous health research and to compare descriptions of Two-Eyed Seeing between original authors (Elders Albert and Murdena Marshall, and Dr. Cheryl Bartlett) and new authors. Using the JBI scoping review methodology and qualitative thematic coding, we identified seven categories describing the meaning of Two-Eyed Seeing from 80 articles: guide for life, responsibility for the greater good and future generations, co-learning journey, multiple or diverse perspectives, spirit, decolonization and self-determination, and humans being part of ecosystems. We discuss inconsistencies between the original and new authors, important observations across the thematic categories, and our reflections from the review process. We intend to contribute to a wider dialogue about how Two-Eyed Seeing is understood in Indigenous health research and to encourage thoughtful and rich descriptions of the guiding principle.

Background Indigenous peoples have worse health than non-Indigenous, are over-represented amongst the poor and disadvantaged, have lower life expectancies, and success in improving disparities is limited. To address this, research usually focuses on disadvantaged and marginalised groups, offering only partial understanding of influences underpinning slow progress. Critical analysis is also required of those with the power to perpetuate or improve health inequities. In this paper, using Australia as a case example, we explore the effects of ‘White’, Anglo-Australian cultural dominance in health service delivery to Indigenous Australians. We address the issue using race as an organising principle, underpinned by relations of power. Methods Interviews with non-Indigenous medical practitioners in Western Australia with extensive experience in Indigenous health encouraged reflection and articulation of their insights into factors promoting or impeding quality health care to Indigenous Australians. Interviews were audio-taped and transcribed. An inductive, exploratory analysis identified key themes that were reviewed and interrogated in light of existing literature on health care to Indigenous people, race and disadvantage. The researchers’ past experience, knowledge and understanding of health care and Indigenous health assisted with data interpretation. Informal discussions were also held with colleagues working professionally in Indigenous policy, practice and community settings. Results Racism emerged as a key issue, leading us to more deeply interrogate the role ‘Whiteness’ plays in Indigenous health care. While Whiteness can refer to skin colour, it also represents a racialized social structure where Indigenous knowledge, beliefs and values are subjugated to the dominant western biomedical model in policy and practice. Racism towards Indigenous patients in health services was institutional and interpersonal. Internalised racism was manifest when Indigenous patients incorporated racist attitudes and beliefs into their lived experience, lowering expectations and their sense of self-worth. Conclusions Current health policies and practices favour standardised care where the voice of those who are marginalised is often absent. Examining the effectiveness of such models in reducing health disparities requires health providers to critically reflect on whether policies and practices promote or compromise Indigenous health and wellbeing - an important step in changing the discourse that places Indigenous people at the centre of the problem.

Background Public insurance reforms of the past two decades have failed to substantively address the healthcare needs of American Indians in general, let alone the particular needs of American Indian elders, ages 55 years and older. Historically, this population is more likely to be uninsured and to suffer from greater morbidities, poorer health outcomes and quality of life, and lower life expectancies compared to all other United States aging populations, representing a neglected group within the healthcare system. Despite the pervasive belief that the Indian Health Service will address all their health-related needs, American Indian elders are negatively affected by gaps in insurance and lack of access to health care. While the 2010 Patient Protection and Affordable Care Act included provisions to ameliorate disparities for American Indians, its future is uncertain. In this context, American Indian elders with variable health literacy must navigate a complex and unstable healthcare system, regardless of where they seek care. Methods This community-driven study features a mixed-method, participatory design to examine help-seeking behavior and healthcare experiences of American Indian elders in New Mexico, in order to develop and evaluate a tailored intervention to enhance knowledge of, access to, and use of insurance and available services to reduce healthcare disparities. This study includes qualitative and quantitative interviews combined with concept mapping and focus groups with American Indian elders and other key stakeholders. Discussion The information gathered will generate new practical knowledge, grounded in actual perspectives of American Indian elders and other relevant stakeholders, to improve healthcare practices and policies for a population that has been largely excluded from national and state discussions of healthcare reform. Study data will inform development and evaluation of culturally tailored programming to enhance understanding and facilitate negotiation of the changing landscape of health care by American Indian elders. This work will fill a gap in research on public insurance initiatives, which do not typically focus on this population, and will offer a replicable model for enhancing the effects of such initiatives on other underserved groups affected by healthcare inequities. Trial registration This protocol does not include the collection of health outcome data. Clinicaltrials.gov, NCT03550404 . Registered June 6, 2018.

Mental health inequities between Indigenous and non-Indigenous populations are well documented. There is growing recognition of the role that culturally safety plays in achieving equitable outcomes. However, a clear understanding of the key characteristics of culturally safe mental health care is currently lacking. This protocol outlines a qualitative systematic review that aims to identify the key characteristics of culturally safe mental health care for Aboriginal and Torres Strait Islander peoples, at the individual, service, and systems level. This knowledge will improve the cultural safety of mental health care provided to Indigenous peoples, with a focus on Aboriginal and Torres Strait Islander peoples in Australia. Through a review of academic, grey, and cultural literature, we will identify the key characteristics of culturally safe mental health care for Aboriginal and Torres Strait Islander peoples in Australia. We will consider the characteristics of culturally safe care at the individual practitioner, service, and systems levels. CRD42021258724.