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Allostatic load (AL) is an aggregate measure of wear and tear on the body due to the chronic activation of the stress response system. The goal of this study was to examine the association between racially motivated housing discrimination (HD) and AL score within a sample of Indigenous university students. Data for this cross-sectional study were collected from Indigenous adults attending university in a small city in western Canada between 2015 and 2017 (N = 104; mean age = 27.8 years). An item adapted from the Experience of Discrimination Scale was to assess racially motivated HD in the past 12 months. AL was measured as a composite of 7 biomarkers assessing neuroendocrine, cardiovascular, metabolic, and immune system function. Bias-corrected and accelerated bootstrapped linear regression models were used to examine associations adjusting for age, income, parenthood, and other situations in which discrimination had been experienced. Indigenous university students who experienced racially motivated HD in the past year (16.8% of the sample) had an average AL score of approximately 4, which was almost double that of their peers who had not. In an adjusted model, racially motivated HD was associated with a 1.5 point increase in AL score. This model explained 35% of the adjusted variance in AL score, of which racially motivated HD explained 24%. These results suggest Indigenous adults who experienced racially motivated HD in the past year had early and more pronounced wear and tear on neuroendocrine, cardiovascular, metabolic, and immune system functioning in young and middle adulthood than Indigenous peers who did not. These findings combine with others to highlight the need for increased efforts to prevent racially motivated HD in urban centers.

Background: Women face challenges when accessing abortion, including varied legislation and reduced access to services in rural and remote settings. There are limited clinical guidelines in Australia and little information regarding the patient journey, particularly the timeframe between referral to abortion procedure. Legislation reform in the Northern Territory (NT) legalised early medical abortion (EMA) in primary health care, providing an opportunity to review service provision of elective surgical abortion prior to and after these changes., Aims: To review the waiting time to access abortion, percentage eligible for EMA based on ultrasound gestation alone, percentage of Indigenous women accessing abortion in the NT and the effects of the legislation change., Materials and Methods: Retrospective audit-analysed surgical abortion data from 354 patient files who underwent suction curettage of uterus between 2012-2017 in one NT public hospital., Results: Mean wait-time ranged from 20 to 22 days in 2012-2016 and dropped to 15 days in 2017 following the law reform. Sixty-two percent of women waited longer than that in the recommended clinical guidelines. Indigenous women represented approximately 25% of patients accessing surgical abortion services. Average gestation at surgical abortion procedure increased following reform. Prior to reform up to 95% of patients accessing surgical abortion would have been eligible for EMA at time of referral., Conclusions: Results demonstrate potential for changes in service provision of abortion in the NT with increased choice, patient-centred care and reduced waiting times. This audit demonstrated the possibility to move the majority of abortion services into primary health care leading to cost savings., (© 2020 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Background: The burden of acute lower respiratory infection (ALRI) in Indigenous children of Australia's Northern Territory is among the highest globally. No published data exists on the effect of pneumococcal conjugate vaccine (PCV) introduction on ALRIs in this population beyond 2005. The aim of this study was to describe the rates of ALRI admissions to hospital in Indigenous infants in the Northern Territory from 2006 to 2015, across three periods of different PCV use. We hypothesised that broader valency PCVs would be more effective against hospitalisations for pneumonia., Methods: We did a retrospective population-based cohort study of Indigenous infants born in the Northern Territory followed up until age 12 months. Data were from administrative hospital and perinatal datasets. International classification of diseases codes (tenth revision, Australian modification; ICD-10AM) were used to identify respiratory hospitalisations of interest: all-cause ALRI, all-cause pneumonia, bacterial pneumonia, viral pneumonia, influenza-like illness (ILI), respiratory syncytial virus ALRI (RSV-ALRI), and pneumococcal ALRI. Incidence rates were compared between PCV eras (7-valent PCV [PCV7], 2006-09; 10-valent PCV [PCV10], 2009-11; and 13-valent PCV [PCV13], 2011-15) using interrupted time trend analysis and negative binomial regression., Findings: For children born between Jan 1, 2006, and Dec 31, 2015, 4138 ALRI episodes (31% of all hospitalisations) occurred among 2888 (20%) of the 14 594 infants. The overall ALRI hospitalisation rate was 29·7 episodes per 100 child-years. Prominent risk factors associated with ALRI hospitalisation were living in a remote community or the Central desert region, being born preterm or with low birthweight. ALRI rates were lowest in the PCV13 era, in association with a significant reduction in bacterial pneumonia hospitalisations in the PCV13 era compared with the PCV10 (incidence rate ratio 0·68, 95% CI 0·57-0·81) and PCV7 (0·70, 0·60-0·81) eras. In contrast, RSV-ALRI rates were 4·9 episodes per 100 child-years in each era., Interpretation: A 30% reduction in bacterial-coded pneumonia hospitalisations in the Northern Territory during the era of PCV13 immunisation supports its ongoing use in the region. Despite the reduction, one in five Indigenous infants born in the region continue to be hospitalised with an ALRI in their first year of life. Future gains require multifaceted environmental and biomedical approaches., Funding: National Health and Medical Research Council of Australia., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Indigenous populations in Latin America are among the most socially vulnerable groups and their children often suffer severe deprivation in terms of access to proper nutrition, water, and shelter. This study describes the nutritional status of Qom preschoolers in general, and by neighborhood area and family's socioeconomic characteristics in a peri-urban village of Formosa, Argentina. Across-sectional study was carried out between January and December 2016, with 160 Qom children between 2 and 5 years of age. Interviews and anthropometric measures were conducted at the children's homes. Nutritional status was determined by body mass index. The prevalence of excess weight (overweight + obesity) and of stunting were associated with neighborhood area and socioeconomic level. The overall prevalence of stunting was 15.6% and it was found to be higher (25.8%) in areas of relatively lower access to material resources. The overall prevalence of excess weight reached 25%; however, neighborhood areas with greater access to material resources had a significantly higher prevalence of children with excess weight (41.2%). Despite the entire community living under the line of poverty, we found differences in nutritional status by neighborhood areas, suggesting an incipient social stratification and a deepening of inequalities in access to resources.

Obstetric violence has not received the same amount of interest as other forms of violence against women (VAW). We assess the prevalence and factors associated with experiences of obstetric violence (obstetric abuse and violence, and nonconsensual care) among women between 15 and 49 years of age in their latest childbirth within the last 5 years by using the 2016 National Survey on Household Relationship Dynamics. ( N = 24,126 women). A total of 33.3% of Mexican women experienced obstetrical violence in their last childbirth: 23.6% experienced obstetric abuse and violence and 17.1% nonconsensual care. Gender interacts with other social stratification variables. Obstetric violence is an extended practice in health care services. It is a human rights problem that must be prevented and eradicated.

Background: Homelessness is one of the most disabling and precarious living conditions. The objective of this Delphi consensus study was to identify priority needs and at-risk population subgroups among homeless and vulnerably housed people to guide the development of a more responsive and person-centred clinical practice guideline., Methods: We used a literature review and expert working group to produce an initial list of needs and at-risk subgroups of homeless and vulnerably housed populations. We then followed a modified Delphi consensus method, asking expert health professionals, using electronic surveys, and persons with lived experience of homelessness, using oral surveys, to prioritize needs and at-risk sub-populations across Canada. Criteria for ranking included potential for impact, extent of inequities and burden of illness. We set ratings of ≥ 60% to determine consensus over three rounds of surveys., Findings: Eighty four health professionals and 76 persons with lived experience of homelessness participated from across Canada, achieving an overall 73% response rate. The participants identified priority needs including mental health and addiction care, facilitating access to permanent housing, facilitating access to income support and case management/care coordination. Participants also ranked specific homeless sub-populations in need of additional research including: Indigenous Peoples (First Nations, Métis, and Inuit); youth, women and families; people with acquired brain injury, intellectual or physical disabilities; and refugees and other migrants., Interpretation: The inclusion of the perspectives of both expert health professionals and people with lived experience of homelessness provided validity in identifying real-world needs to guide systematic reviews in four key areas according to priority needs, as well as launch a number of working groups to explore how to adapt interventions for specific at-risk populations, to create evidence-based guidelines., Competing Interests: The authors have declared that no competing interests exist.

Background: Vulvar cancer is rare and, as a result, is understudied. Treatment is predominantly surgery, irrespective of the type of vulvar cancer, and is associated with physical, emotional and sexual complications. A cluster of human papillomavirus (HPV)-dependent vulvar cancer patients was identified in Arnhem Land Northern Territory (NT), Australia, in which young Indigenous women were diagnosed at 70 times the national incidence rate., Aims: To assess whether women from the Arnhem Land cluster differ from women with vulvar squamous cell carcinoma (VSCC) and vulvar intraepithelial neoplasia (VIN) resident elsewhere in the NT in recurrence after treatment, disease progression and mortality., Materials and Methods: A retrospective cohort study of NT-resident women diagnosed with VIN or invasive vulvar cancer (VSCC) between 1 January 1993 and 30 June 2015 was undertaken. Time to recurrence was assessed using cumulative incidence plots and Fine and Gray competing risk regression models. Mean cumulative count was used to estimate the burden of recurrent events., Results: Indigenous women from Arnhem Land experienced more recurrences after treatment than non-Indigenous women, the cancers recurred faster, and Indigenous women have worse survival at five years., Conclusions: In characterising the epidemiological features of this cluster, we have identified a particularly aggressive form of vulvar cancer. This provides a unique opportunity for elucidating the aetiopathological pathways driving vulvar cancer development that may ultimately lead to preventive and therapeutic targets for this neglected malignancy. Further, these findings have important implications for clinical practice and HPV vaccination policy in the affected population., (© 2019 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Background: Little is known about the influence of toxic exposures on reduced life expectancy in First Nations people in Canada. The Grassy Narrows First Nation community have lived with the consequences of one of the worst environmental disasters in Canadian history. In the early 1960s, 10 000 kg of mercury (Hg) was released into their aquatic ecosystem. Although Hg concentration in fish, their dietary staple, decreased over time, it remains high. We aimed to examine whether elevated Hg exposure over time contributes to premature mortality (younger than 60 years) in this community., Methods: We did longitudinal and case-control analyses with data for individuals of the Grassy Narrows First Nation community. In 2019, the community obtained their historical Hg biomarker data from a government surveillance programme, which was then shared with the authors. A matched-pair approach allowed us to compare longitudinal hair Hg concentration between cases (individuals who died aged younger than 60 years) and controls (individuals who lived beyond 60 years). Matching criteria included year of birth (allowing 2 years either side), sex, and a minimum of four hair Hg concentration measures, of which at least two were in the same year. Analyses included change-point detection, interrupted time series, mixed models, and Cox survival models., Findings: We analysed data collected between Jan 1, 1970, and Jan 31, 1997, for 657 individuals (319 women and 338 men, born between 1884 and 1991) for whom we assembled a retrospective database of yearly measures of hair Hg concentration (n=3603). Hair Hg concentration decreased over time. A subgroup of 222 individuals (107 women and 115 men) reached or could have reached 60 years old by August, 2019. There was an increased risk of dying at a younger age among those with at least one hair Hg measure of 15 μg/g or more (adjusted hazard ratio 1·55, 95% CI 1·11-2·16; p=0·0088). Among the deceased individuals (n=154), longevity decreased by 1 year with every 6·25 μg/g (4·35-14·29) increase in hair Hg concentration. Analyses of 36 matched pairs showed that hair Hg concentration of those who died aged younger than 60 years was 4·7 times higher (3·4-5·9) than controls., Interpretation: The consistent findings between our different analyses support an association between long-term Hg exposure from freshwater fish consumption and premature mortality in this First Nation community. There is a need to do risk-benefit analyses of freshwater fish consumption in environmentally contaminated regions., Funding: Canadian Institutes of Health Research., (Copyright © 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background and Aim: The aim of this study is to identify gastric cancer burden in Indigenous Taiwanese peoples and conduct a project to evaluate how to reduce the disparities most effectively in Indigenous communities., Methods: First, we quantified the health disparities in gastric cancer in Indigenous peoples using data from the cancer registries during the period of 2006-2014. Second, we identified parameters that might be associated with Helicobacter pylori infection or help identify a good eradication strategy., Results: Gastric cancer incidence (24.4 vs 12.3 per 100 000 person-years) and mortality rates (15.8 vs 6.8 per 100 000 person-years) were higher in Indigenous than in non-Indigenous, with 2.19-fold (95% confidence interval [CI]: 2.06-2.33) and 2.47-fold (2.28-2.67) increased risk, respectively. In Indigenous communities, H. pylori infection was more prevalent in Indigenous than in non-Indigenous (59.4% vs 31.5%, P < 0.01). Regression analyses consistently showed that either the mountain or plain Indigenous had 1.89-fold (95% CI: 1.34-2.66) and 1.73-fold (95% CI: 1.24-2.41) increased risk for H. pylori infection, respectively, as compared with non-Indigenous, adjusting for other baseline characteristics. The high infection rates were similarly seen in young, middle-aged, and older adults. Program eradication rates using clarithromycin-based triple therapy were suboptimal (73.7%, 95% CI: 70.0-77.4%); the habits of smoking (1.70-fold, 95% CI: 1.01-2.39) and betel nut chewing (1.54-fold, 95% CI: 0.93-2.16) were associated with the higher risk of treatment failure., Conclusion: Gastric cancer burden is higher in Indigenous Taiwanese peoples than in their non-Indigenous counterparts. Eliminating the prevalent risk factor of H. pylori infection is a top priority to reduce this health disparity., (© 2019 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Objectives: We assess the relationship between distance to a woman's assigned health clinic and obstetric care utilisation., Design: We employ a cross-sectional study design using baseline data from the evaluation of a conditional cash transfer programme to promote greater utilisation of maternal and infant health services. Data were collected between December 2016 and January 2017., Setting: The study is conducted in Ngäbe Buglé, the largest of Panama's three indigenous territories, where maternal mortality is three times the national average., Participants: We analyse a representative sample of 1336 indigenous women with a birth in the 12 months prior to the survey., Primary and Secondary Outcome Measures: Primary outcomes include obstetric care utilisation measures for prenatal, childbirth and postpartum events. Secondary outcomes include reasons for not receiving prenatal care, alarming symptoms, child weight at birth and stillbirths or miscarriages., Results: Compared with women in closest geographic proximity to a health centre (top quintile, Q1), women who lived farthest from a health centre (bottom quintile, Q5) had significantly lower obstetric care utilisation outcomes for critical prenatal, childbirth and postpartum events. Mothers in Q5 were 36 percentage points less likely to have had at least one prenatal care appointment in a hospital, health centre or clinic compared with mothers in Q1 (p<0.01), and 52 percentage points less likely to attend an institutional first appointment (p<0.01). The gap in institutional delivery and postnatal care between mothers in Q1 and Q5 was about 35 percentage points (p<0.01). All utilisation outcomes were negatively correlated with distance, and differences in obstetric care utilisation persisted even when controlling for household wealth, maternal age and maternal education., Conclusion: Distance is an important barrier to obstetric care utilisation, with women in more distant locations suffering significantly lower use of prenatal, childbirth and postpartum care compared with women in closer vicinity to a health establishment. Expanding the supply of healthcare and implementing demand side incentives to promote the use of health services in remote communities are relevant policies to reduce disparities in obstetric care utilisation., Trial Registration Number: AEA Registry (RCT ID AEARCTR-0001751)., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

This article outlines the grassroot level work of Project Sakhi which creates awareness about menstrual hygiene and has set up self-sustaining production units of low-cost sanitary napkins in rural India. The first section of the article focuses on project Sakhi: its genesis, organizational dynamics, and the complementary use of traditional methods such as folk songs and the modern social media marketing strategies to sustain the project. The eco-friendly incinerator - Ashuddhinashak designed by the founder is illustrated. The second section of this paper focuses on an understanding of the founders' perspectives in the context of the challenges they faced working in interior rural India and the perspectives of the key stakeholders such as the women employees, adolescent school girls, and an associated NGO worker. The impact of the project has been discussed in the context of five aspects: health, employment, revenue generation, environmental considerations, and sustainability of the model in the Indian context.

Introduction and Objective: The epidemiology of infection with hepatitis E virus (HEV) in Tepehuanos (a Mexican ethnic group living in rural areas) is largely unknown. This study aimed to determine the seroprevalence of and risk factors associated with HEV infection in Tepehuanos in Durango, Mexico, and to compare this seroprevalence with that in non-Tepehuanos., Materials and Methods: Through a case-control seroprevalence study, we studied 146 Tepehuanos and 146 age- and gender-matched control subjects of the general population from rural settings. The frequency of anti-HEV IgG antibodies was determined using an enzyme-linked immunoassay. Bivariate and multivariate analyses were used to assess the association between seropositivity and socio-demographic, clinical and behavioral characteristics of the Tepehuanos., Results: IgG antibodies against HEV were found in 5 (3.4%; 95% CI: 1.1-7.8) of 146 Tepehuanos and in 46 (31.5%; 95% CI: 24.1-39.7) of 146 control subjects (OR=0.01; 95% CI: 0.0007-0.20; P<0.000001). Bivariate analysis showed that HEV seropositivity was associated with age, consumption of meat from goat, sheep, boar, turkey and pigeon, and concrete flooring at home. However, these variables were no longer significant when analyzed by logistic regression., Conclusions: This is first study on the epidemiology of HEV exposure in Tepehuanos. We demonstrated serological evidence of HEV infection in this ethnic group. The seroprevalence of HEV exposure in Tepehuanos is low as compared with that found in non-Tepehuano people living in rural Durango. Further studies to determine the risk factors associated with HEV exposure in Tepehuanos are needed., (Copyright © 2019. Published by Elsevier España, S.L.U.)

Objective: Although Indigenous women are exposed to high rates of risk factors for perinatal mental health problems, the magnitude of their risk is not known. This lack of data impedes the development of appropriate screening and treatment protocols, as well as the proper allocation of resources for Indigenous women. The objective of this systematic review and meta-analysis was to compare rates of perinatal mental health problems among Indigenous and non-Indigenous women., Methods: We searched Medline, EMBASE, PsycINFO, CINAHL, and Web of Science from their inceptions until February 2019. Studies were included if they assessed mental health in Indigenous women during pregnancy and/or up to 12 months postpartum., Results: Twenty-six articles met study inclusion criteria and 21 were eligible for meta-analysis. Indigenous identity was associated with higher odds of mental health problems (odds ratio [ OR ] 1.62; 95% confidence interval [CI], 1.25 to 2.11). Odds were higher still when analyses were restricted to problems of greater severity ( OR 1.95; 95% CI, 1.21 to 3.16) and young Indigenous women ( OR 1.86; 95% CI, 1.51 to 2.28)., Conclusion: Indigenous women are at increased risk of mental health problems during the perinatal period, particularly depression, anxiety, and substance misuse. However, resiliency among Indigenous women, cultural teachings, and methodological issues may be affecting estimates. Future research should utilize more representative samples, adapt and validate diagnostic and symptom measures for Indigenous groups, and engage Indigenous actors, leaders, and related allies to help improve the accuracy of estimates, as well as the well-being of Indigenous mothers, their families, and future generations., Trial Registration: PROSPERO-CRD42018108638.

Objective: To investigate whether delayed or no treatment was associated with increased mortality and morbidity risks in people with newly diagnosed epilepsy., Methods: We examined New Zealand hospitalization and antiseizure medication prescription data from 2007-2015. Mortality and hospital-diagnosed morbidities were compared between patients immediately treated after epilepsy diagnosis, treated after a delay, or untreated for the duration of follow-up, adjusted for age, sex, and ethnicity., Results: Three thousand three hundred sixty-six patients (54.7% male, median age = 37.5 years) were included and followed up for a median of 3.39 years. A total of 3123 (92.8%) patients were treated immediately, 125 (3.7%) had delayed treatment, and 118 (3.5%) were untreated. Compared to the general New Zealand population, the cohort had a standardized mortality ratio of 4.60 (95% confidence interval [CI] = 4.24-4.99). Maori patients were less likely to be treated (Holm-Bonferroni adjusted P = .024) and had higher mortality (hazard ratio [HR] = 1.41, 95% CI = 1.08-1.83). There was a trend of increased mortality in the untreated or delayed treatment group compared to the immediate treatment group (HR = 1.36, 95% CI = 0.99-1.87). Hospitalization risk was similar between untreated and immediately treated periods (P = .83). Untreated or delayed treatment patients had higher risk of acute myocardial infarction (HR = 9.64, 95% CI = 1.83-50.8). Maori patients were more likely to develop liver disease (HR = 4.67, 95% CI = 1.32-16.4) and alcohol or drug dependence (HR = 2.55, 95% CI = 1.44-4.51)., Significance: Most epilepsy patients were treated at diagnosis in New Zealand, but Maori patients had lower treatment rates and worse health outcomes. The apparent increased risk of acute myocardial infarction among the untreated or delayed treatment patients warrants further research., (Wiley Periodicals, Inc. © 2020 International League Against Epilepsy.)

Background: Previously, a study conducted by UNICEF found that malnutrition affects approximately 80% of the indigenous children in Guatemala., Objective: Identify prevalence and risk factors for stunted growth in communities surrounding Lake Atitlán, Guatemala., Methods: Height-for-age measurements of children under the age of five, N = 84, determined stunting prevalence and presumed burden of malnutrition in this region of the Guatemalan highlands. Mothers of a subset of this sample, N = 29, were interviewed to assess factors contributing to stunting. Analysis assessed the following risk factors: inadequate nutrition, increased infectious disease risk, high rate self-report illness, inadequate breastfeeding, and inadequate utilization of prenatal care., Findings: The majority of children under the age of five were stunted (65.6%) and likely malnourished. ANOVA analysis showed significant differences in mean height-for-age Z scores (HAZs) between groups with and without adequate nutrition (F = 7.069, p = 0.013), as well has with and without high rates of self-report illness (F = 6.894, p = 0.014). Both groups with inadequate nutrition (mean HAZs = -2.9, 95% CI = [-3.58, -2.24]) and high rates of self-report illness (mean HAZs = -2.8, 95% CI = [-3.13, -2.38]) had mean HAZs that are indicative of stunting. No other risk factors were associated with stunting., Conclusion: These pilot study results offer methods by which to obtain baseline data for assessing nutritional and public health interventions to improve stunting and malnutrition status as well as the health outcomes of children in rural, indigenous communities., Competing Interests: The authors have no competing interests to declare., (Copyright: © 2020 The Author(s).)

Objectives: To analyse incidence of prior emergency department presentations for interpersonal violence and demographics for a series of hospital admissions for interpersonal violence injuries., Design: Retrospective analysis of trauma registry., Setting: A tertiary hospital and primary referral centre for trauma in the Top End of the Northern Territory., Participants: Patients hospitalised from 2010 to 2015 for injuries due to interpersonal violence with an injury severity score > 9., Main Outcome Measures: Patient demographics, injury location, assault mechanism, alleged perpetrator, time/day of event, alcohol involvement, clinical outcome and prior emergency department presentations for interpersonal violence., Results: A total of 248 admissions for patients with Injury Severity Score > 9 due to interpersonal violence were identified. Indigenous females over-represented non-Indigenous females (35.4% vs 5.0%, P < .001). The majority of victims had evidence of alcohol intake at presentation. Victims of single-punch head injuries were mostly male and non-Indigenous, whilst Indigenous persons experienced significantly more blunt and penetrating weapon injuries (66.7% and 68.1%). Forty-three per cent of patients had a preceding emergency department presentation for interpersonal violence; female gender, Indigenous ethnicity, evidence of alcohol intake, and urban location of injury were independent risk factors for prior interpersonal violence presentation., Conclusions: Interpersonal violence is a recurring disease for a just under half of those presenting to a Top End hospital with moderate to severe injuries. Indigenous ethnicity, female gender and evidence of alcohol intake are predictive of prior interpersonal violence presentations. Patient under-reporting and incomplete data may underestimate the true prevalence of interpersonal violence presentations in rural and remote locales., (© 2020 National Rural Health Alliance Inc.)

Access to food has been determined to be a factor that strongly influences the dietary intake and eating habit of indigenous people ( Orang Asli , OA). This study explored food acquisition and the barriers in obtaining traditional and market foods among the Jahai subtribe (within the Negrito ethnic group) via a qualitative approach. Twenty-eight OA (14 males and 14 females) from Gerik, Perak, Malaysia participated in four focus group discussions (FGDs; two male-only and two female-only groups; seven informants in each FGD). Thematic analysis was adopted to analyse the gathered data. The results found that the Jahai applied both modern (buying and receiving food assistance) and traditional (gathering, farming, fishing, and hunting) methods in obtaining food. The barriers they faced in gathering sufficient food supply included low purchasing power, high demand for food, high transport costs, depletion of food supplies in their surroundings, threats from wild animals on the farm and during food searching activities, and food sharing. Food preparation methods practiced by the OA include roasting and grilling, frying, simmering ( gulai ), and boiling. In conclusion, this study enhances our understanding of the dietary behaviour of the Jahai subtribe and highlights restricted food access among the OA, which demands urgent attention.

India's Adivasi scheduled tribe population is disproportionately affected by undernutrition and anemia, thereby prevailing in the poorest wealth deciles denominated as socially and economically vulnerable. This study was designed to assess the extent of child undernutrition (conventional and composite index of anthropometric failure (CIAF) classification), as well as the burden of anemia in children and its independent nutrition specific and sensitive drivers, moreover to reflect the living conditions of Santal Adivasis. The research survey was conducted in 21 Santal villages, Birbhum District, West Bengal, in 2015. An overall 307 children (aged 6-39 months) and their mothers ( n = 288) were assessed for their hemoglobin (Hb) levels (HemoCue Hb201+) and anthropometric indices such as height/length, weight and mid-upper arm circumference (MUAC). Moreover, socio-demographic household characteristics were surveyed. The study confirmed Adivasi children lagging behind national average with a high prevalence of undernutrition (height-for-age z-score (HAZ) 51.9%, weight-for-age z-score (WAZ) 49.2%, weight-for-height z-score WHZ 19.0% and CIAF 61.6%) and of moderate and severe anemia (Hb < 10 g/dL, 73.3% altogether). Child's age <24 months, low WAZ scores, morbidity (any fever, diarrhea or respiratory infection) on the checkup day or during previous week, low maternal Hb level, and lack of dietary diversification were identified as predictors for anemia, thereby warrant targeted interventions to decrease the high anemia rates assessed in the study site.

Background: There remains a lack of information and understanding of the prevalence and incidence of Alzheimer's disease and related dementia in Indigenous populations. Little evidence available suggests that Indigenous peoples may have disproportionately high rates of Alzheimer's disease and related dementia (ADRD)., Objective: Given this information, this study systematically explores what risk factors may be associated with ADRD in Indigenous populations., Methods: A search of all published literature was conducted in October 2016, March 2018, and July 2019 using Medline, Embase, and PsychINFO. Subject headings explored were inclusive of all terms related to Indigenous persons, dementia, and risk. All relevant words, phrases, and combinations were used. To be included in this systematic review, articles had to display an association of a risk factor and ADRD. Only studies that reported a quantifiable measure of risk, involved human subjects, and were published in English were included., Results: Of 237 articles originally identified through database searches, 45 were duplicates and 179 did not meet a priori inclusion criteria, resulting in 13 studies eligible for inclusion in this systematic review., Conclusion: The large number of potentially modifiable risk factors reported relative to non-modifiable risk factors illustrates the importance of socioeconomic context in the pathogenesis of ADRD in Indigenous populations. The tendency to prioritize genetic over social explanations when encountering disproportionately high disease rates in Indigenous populations can distract from modifiable proximal, intermediate, and distal determinants of health.

Objective: to describe the profile and incidence of malaria cases among indigenous and non-indigenous people on the Brazil-French Guiana border, between 2007 and 2016., Methods: this is a descriptive study based on analysis of cases notified on the Malaria Epidemiological Surveillance Information System (SIVEP-Malaria), organized using Tableau 10.3., Results: a total of 21,729 cases were notified in the period; the highest annual number of notifications was 3,637 (16.7%) in 2009, 1,956 (53.8%) of which related to indigenous people, representing annual parasite incidence (API) of 261/1,000; higher risk of infection was found in the Kumenê base area (API between 13 and 534/1,000) and the Manga base area (API between 55 and 448/1,000); children accounted for 20.0 to 40.0% of notified cases, while pregnant women accounted for 2.0% among non-indigenous people and 1.0% among the indigenous., Conclusion: malaria case distribution was unequal between indigenous and non-indigenous people, with greater occurrence among the indigenous.

Backround: The availability of contraband cigarettes provides incentives for price-sensitive smokers to reduce their monetary costs of smoking. The objectives of this study were to examine whether Canadian smokers' geographic proximity to First Nations reserves and attempts to quit smoking influenced the likelihood of purchasing lower-cost cigarettes from reserves., Methods: Data were from the International Tobacco Control (ITC) Canada Survey, a prospective survey of Canadian adult smokers conducted from 2002 to 2014 using telephone and online interviewing methods. Analysis was restricted to smokers from Ontario (n=2105) and Quebec (n=1427) participating in at least one survey wave. Smokers' postal codes were used to calculate distance to the nearest reserve. Weighted logistic generalised estimating equations (GEE) regression examined the linear relationship between distance and the log odds of last purchasing cigarettes on reserve in each province. GEE models also examined the relationship between past-year quit attempts and the log odds of on-reserve purchasing., Results: Controlling for other factors, from 2002-2014, smokers from Ontario who lived 10 km closer to reserves than otherwise similar smokers had significantly higher odds of last purchasing on reserve (OR ranged from 1.16 to 1.65). Distance had little effect on smokers' purchasing behaviours in Quebec. Moreover, in Ontario, for every 10 km increase in distance, smokers who did not try to quit had significantly greater odds of purchasing from a reserve than smokers who tried to quit (p=0.002)., Conclusion: In order for tobacco taxation policies to achieve their maximal benefit, governments must limit potential sources of lower-cost cigarettes. Collaborative governance arrangements can ensure tobacco products sold on reserve to non-Indigenous people are appropriately taxed while allowing First Nations communities to keep the revenue generated by such taxes., (Copyright © 2019 The Author(s). Published by Elsevier B.V. All rights reserved.)

Currently, 1 in 3 Canadian seniors meet the criteria for successful aging, which include low probability of disease and disability, high cognitive and physical ability and active engagement in life. The sociodemographic characteristic of living alone can identify high-risk seniors, due to its association with lower social support and interactions, thus increasing susceptibility to negative health outcomes in older age. However, limited data exists on the living arrangements of Canadian seniors. In this analysis, we present sociodemographic characteristics and measures of health and social well-being of seniors by living arrangement. This information should be used to identify and support vulnerable seniors and increase the prevalence of healthy aging among Canadians., Competing Interests: The authors have no conflicts of interest to disclose. This research did not receive any funding.

Background: Among Organisation for Economic Co-operation and Development [OECD] countries, Australians with disabilities are most at risk of experiencing poverty. Employment equity is essential for wellbeing, health and social inclusion. Reported differences in income level between people with and without disabilities vary widely between 0 to 47% depending on productivity assumptions. Contradictory to these assumptions, empirical research has demonstrated that people with disabilities often have equivalent skills, superior loyalty and lower absentee rates., Objective: To investigate if there is a significant difference in the annual remuneration, hours worked and age-related career trajectory of graduates with and without disabilities., Methods: Descriptive statistics and regression analysis were used to identify employment equity between graduates with and without disabilities in the 2011 Australian Census., Results: Graduates with disabilities received a mean weekly income that was 53% of the income of graduates without disabilities and 85% of the mean hourly income. Female graduates with disabilities received the lowest mean income of all subgroups at 35% of the mean weekly income of male graduates without disabilitiesCONCLUSION:This corroborates previous research that reports people with disabilities have difficulty obtaining employment, experience insecure employment and have fewer career and promotional opportunities. The income gaps were significantly greater than gaps previously reported.

Traditional consumption of edible mushrooms is supported by ethnomycological studies worldwide. However, the potential impact of mushroom consumption on the nutritional and health status of remote rural communities has not yet been studied. We carried out these initial standard studies in the indigenous peasant community of Benito Juarez, Oaxaca, Mexico. Participant adults (45) were grouped as follows: optimal body mass index (BMI: 17.8%), overweight (48.9%), obesity type I (24.5%), obesity type II (4.4%), and obesity type III (4.4%). A high proportion of women (90.3%) and men (64.3%) had a high risk of cardiovascular disease (WHI: waist/hip index). Most women (93.6%) and men (57.1%) showed abdominal obesity. In biochemical parameters, subjects had hypertriglyceridemia (75.6%), hypercholesterolemia (26.7%), hyperglycemia (53.3%), and hypertension (46.7%). There was an excessive intake in the diet of energy, proteins, carbohydrates, sugar, and lipids, as well as a deficiency in the consumption of several vitamins and minerals. A high frequency of mushroom consumption (> 3 times per week) was significantly correlated to lower energy, lipids, saturated fatty acids (SFA), and sodium intake, as well as to higher intake of cobalamin and zinc. The levels of triglycerides and diastolic blood pressure were significantly lower in adults consuming edible mushrooms every day. Total cholesterol also tended to be lower. These associations allow to promote healthier diets in remote indigenous communities by keeping or increasing the consumption of edible mushrooms, either wild or cultivated. Edible mushrooms can play a more important role in community nutrition and health, considering their unique functional and medicinal properties.

Objectives: to assess the attributes of Primary Health Care from the perspective of health professionals, comparing services in the Special Indigenous Health District and the Municipal Health Offices., Methods: a cross-sectional study in the Upper Rio Negro region, State of Amazonas, with 116 professionals. The data were collected through the Primary Care Assessment Tool. Scores were categorized (≥ 6.6) - strong orientation and (<6.6) - low orientation. The chi-square and maximum likelihood test for crossover analysis. The comparison between professionals the Kruskal-Wallis Test., Results: a higher overall score was observed in the Indigenous Health District (7.2). The same trend was observed individually in the essential and derived attributes., Conclusions: this work may support strategies that positively impact the management model and work processes from the perspective of strengthening the primary care offered to the population from Rio Negro.

The purpose of this correspondence is to express our disappointment with the coverage of the BMC Public Health supplement: Vol 19 (4) titled "Health and Nutritional Issues Among Low Income Population in Malaysia", which neglected to include the fundamental health and nutrition issues that are adversely affecting the lives and livelihood of the indigenous peoples. The Supplement comprised 21 papers. Two of these papers included indigenous peoples as study subjects. These two papers addressed peripheral, albeit important health issues, namely visual impairment and quality of life, and not the persistent and rising health concerns impacting this population. We will provide evidence from research and reports to justify our critique that the Supplement missed the opportunity to spotlight on the serious extent of the health and nutritional deprivations of the indigenous peoples of Malaysia. As researchers of the indigenous peoples, we ought to lend our voice to the "silenced minority" by highlighting their plight in the media including scientific journals.

Alphaviruses (Togaviridae, Alphavirus ) are arthropod-borne single-stranded RNA pathogens that cause febrile and neurologic disease in much of Latin America. However, many features of Alphavirus epidemiology remain unknown. In 2011, we undertook a cross-sectional study in Nueva Esperanza, an indigenous community in the Peruvian Amazon. Here, we present the first serologic evidence of Mayaro (MAYV), Venezuelan equine encephalitis (VEE) complex alphavirus, Una (UNAV), and Madariaga (MADV) viruses reported in humans (24%, 16%, 13%, and 1.5%, respectively) from an Amazonian indigenous community in Peru. Hunting activity and cohabiting with hunters were the main risk factors for Mayaro seroconversion, but only hunting was associated with UNAV seropositivity. Our results suggest that alphavirus infection in this region is common, but we highlight the high UNAV seroprevalence found and corroborate the low MADV prevalence reported in this region. Furthermore, MAYV-neutralizing antibodies were also detected in stored samples from wild animals (18%) hunted by Nueva Esperanza inhabitants and another mestizo community located close to Iquitos. Further serological surveys of VEE complex alphaviruses, UNAV, and MADV in wild animals and assessing the ability of the MAYV seropositive species to transmit the virus will be relevant.

The aim of this parasitological study is examining contemporary (the late 20th century) specimens of the arctic or subarctic areas in Western Siberia and comparing them with the information acquired from archaeological samples from the same area. In the contemporary specimens, we observed the parasite eggs of 3 different species: Opisthochis felineus, Ascaris lumbricoides, and Enterobius vermicularis. Meanwhile, in archaeoparasitological results of Vesakoyakha, Kikki-Akki, and Nyamboyto I burial grounds, the eggs of Diphyllobothrium and Taenia spp. were found while no nematode (soil-transmitted) eggs were observed in the same samples. In this study, we concluded helminth infection pattern among the arctic and subarctic peoples of Western Siberia throughout history as follows: the raw fish-eating tradition did not undergo radical change in the area at least since the 18th century; and A. lumbricoides or E. vermicularis did not infect the inhabitants of this area before 20th century. With respect to the Western Siberia, we caught glimpse of the parasite infection pattern prevalent therein via investigations on contemporary and archaeoparasitological specimens.

Background: Gambling is a behaviour engaged in by millions of people worldwide; for some, gambling can become a severely maladaptive behaviour, and previous research has identified a wide range of psychosocial risk factors that can be considered important for the development and maintenance of disordered gambling. Although risk factors have been identified, the homogeneity of risk factors across specific groups thought to be vulnerable to disordered gambling is to date, unexplored., Methods: To address this, the current review sought to conduct a systematic overview of literature relating to seven vulnerable groups: young people and adolescents, older adults, women, veterans, indigenous peoples, prisoners, and low socio-economic/income groups., Results: Multiple risk factors associated with disordered gambling were identified; some appeared consistently across most groups, including being male, co-morbid mental and physical health conditions, substance use disorders, accessibility and availability of gambling, form and mode of gambling, and experience of trauma. Further risk factors were identified that were specific to each vulnerable group., Conclusion: Within the general population, certain groups are more vulnerable to disordered gambling. Although some risk factors are consistent across groups, some risk factors appear to be group specific. It is clear that there is no homogenous pathway in to disordered gambling, and that social, developmental, environmental and demographic characteristics can all interact to influence an individual's relationship with gambling., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

'Imi Ho'ola is a program for those seeking to heal. Since 1973, 'Imi Ho'ola has provided educational opportunities to students from underrepresented populations in medicine and has demonstrated its success as a pathway for Native Hawaiians and other Pacific Islanders into the University of Hawai'i John A. Burns School of Medicine (JABSOM). The program's student-centered, individualized, and team-based approach offers participants the opportunity to develop effective learning and study skills while solidifying students' foundation in the basic sciences and humanities. 'Imi Ho'ola is an educational model that has had a longstanding impact on the diversity within JABSOM and has contributed to the success of indigenous students in medicine., Competing Interests: None of the authors identify a conflict of interest., (©Copyright 2019 by University Health Partners of Hawai‘i (UHP Hawai‘i).)

Background: Historical, colonial, and racist policies continue to influence the health of Indigenous people, and they continue to have higher rates of chronic diseases and reduced life expectancy compared with non-Indigenous people. We determined factors accounting for variations in cardiovascular risk factors among First Nations communities in Canada., Methods: Men and women (n=1302) aged 18 years or older from eight First Nations communities participated in a population-based study. Questionnaires, physical measures, blood samples, MRI of preclinical vascular disease, and community audits were collected. In this cross-sectional analysis, the main outcome was the INTERHEART risk score, a measure of cardiovascular risk factor burden. A multivariable model was developed to explain the variations in INTERHEART risk score among communities. The secondary outcome was MRI-detected carotid wall volume, a measure of subclinical atherosclerosis., Findings: The mean INTERHEART risk score of all communities was 17·2 (SE 0·2), and more than 85% of individuals had a risk score in the moderate to high risk range. Subclinical atherosclerosis increased significantly across risk score categories (p<0·0001). Socioeconomic advantage (-1·4 score, 95% CI -2·5 to -0·3; p=0·01), trust between neighbours (-0·7, -1·2 to -0·3; p=0·003), higher education level (-1·9, -2·9 to -0·8, p<0·001), and higher social support (-1·1, -2·0 to -0·2; p=0·02) were independently associated with a lower INTERHEART risk score; difficulty accessing routine health care (2·2, 0·3 to 4·1, p=0·02), taking prescription medication (3·5, 2·8 to 4·3; p<0·001), and inability to afford prescription medications (1·5, 0·5 to 2·6; p=0·003) were associated with a higher INTERHEART risk score. Collectively, these factors explained 28% variation in the cardiac risk score among communities. Communities with higher socioeconomic advantage and greater trust, and individuals with higher education and social support, had a lower INTERHEART risk score. Communities with difficulty accessing health care, and individuals taking or unable to afford prescription medications, had a higher INTERHEART risk score., Interpretation: Cardiac risk factors are lower in communities with high socioeconomic advantage, greater trust, social support and educational opportunities, and higher where it is difficult to access health care or afford prescription medications. Strategies to optimise the protective factors and reduce barriers to health care in First Nations communities might contribute to improved health and wellbeing., Funding: Heart and Stroke Foundation of Canada, Canadian Partnership Against Cancer, Canadian Institutes for Health Research., (Copyright © 2019 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

American Indian, Alaska Native (AIAN) and Native Hawaiian and other Pacific Islander (NHPI) faculty, are substantially under-represented (<1%) at US medical schools. The Oregon Health & Science University's Northwest Native American Center of Excellence and The University of Hawai'i Native Hawaiian Center of Excellence have created an Indigenous Faculty Forum (IFF), a one-day structured course with flanking social activities, specifically designed to meet the unique needs of AIAN and NHPI academic faculty. It provided: (1) Indigenous space, (2) skill building, (3) networking, and (4) ongoing mentorship, each of which were included to specifically mitigate isolation and tokenism that negatively affects promotion and advancement. Two Forums have been conducted, first in Portland, OR in 2017 and the second in Hilo, Hawai'i in 2018. Nine of eighteen AIAN faculty in the three-state region (CA, OR, WA) attended IFF Session #1, representing 50% of known AIAN faculty in this region. Thirty-four Indigenous faculty from around the world attended IFF Session #2, with twenty-nine completing program evaluations. Respondents were predominantly female (81.6%), under age 44 (52.7%), and either instructors or assistant professors (52.6%). In terms of career choice, both sessions included primary care physicians as the most represented group (55.6% at Session #1 and 62.1% at Session #2). Increasing Indigenous faculty representation in US medical schools, while simultaneously fostering their career advancement and meaning in work, is vitally important. We have begun the work needed to address this problem and look forward to conducting more efforts, including longitudinal evaluation designs to study effectiveness., Competing Interests: None of the authors identify a conflict of interest., (©Copyright 2019 by University Health Partners of Hawai‘i (UHP Hawai‘i).)

The 2018 Pacific Region Indigenous Doctors Congress (PRIDoC) conference featured a student track curriculum that was developed by students at the John A. Burns School of Medicine. Activities were designed around the student track theme, ho'oku'ikahi, meaning "unity" or "unify," as well as the overarching conference theme 'Oi Ola Wai Honua meaning "life is better while the earth has water." Following the conference, surveys were distributed among the trainees who had participated in the student track. The survey feedback was used to evaluate the student track curriculum, as well as its execution. Learning objectives developed for the Student Track were (1) to build formal professional networks, (2) to build a knowledge economy with shared knowledge among participants, and (3) to engage in cultural experiences. Analysis of qualitative data suggest that all learning objectives were satisfactorily fulfilled through planned conference activities. The data will be used to facilitate student tracks at future PRIDoC conferences. The student track at PRIDoC aims to establish and contribute to an ever-growing international network of indigenous students that will extend into professional practice., Competing Interests: None of the authors identify any conflict of interest., (©Copyright 2019 by University Health Partners of Hawai‘i (UHP Hawai‘i).)

Background: There is scant information on sexually transmitted infection (STI) prevalence and risk factors among Latin American indigenous populations. We investigated STI prevalence and risk factors among adolescents of the Comarca Ngäbe-Buglé indigenous region of Panama., Methods: A population-based cross-sectional study was conducted among school-going adolescents aged 14 to 19 years. Eligible consenting participants self-completed a questionnaire and provided blood and urine samples. Female participants provided additional self-administered genital swabs. Seroprevalences of human immunodeficiency virus (HIV), syphilis, hepatitis B (HBsAg, anti-HBc), and herpes simplex virus type 2 (HSV-2) were determined in all participants; genital Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) by PCR among participants who reported sexual experience or were seropositive for HIV/syphilis/HSV2/HBsAg; high-risk human papillomavirus (HPV) by qualitative DNA assay and bacterial vaginosis (BV) by Gram-stain among female participants. Risk factors were identified by estimating adjusted odds ratios (AOR) using random-effects logistic regression., Results: We enrolled 700 participants (median age, 17 years [female participants]; 18 years [male participants]) from 20 schools. Sexual experience was reported by 536 participants (76.6%). The HIV/STI prevalences among females and males were: HIV 0.4% and 1.0%, high-titer active syphilis 1.3% and 6.6%, HSV-2 16.1% and 16.1%, HBsAg 1.3% and 1.4%, anti-HBc 3.2% and 1.4%, NG 1.8% and 1.7%, CT 17.5% and 10.7%; among females: BV 42.9% and HPV 33.2%. CT was independently associated with being female (AOR, 2.02; 95% confidence interval [CI], 1.20-3.41); high-titer active syphilis with being male (AOR, 4.51; 95% CI, 1.17-17.40). Bacterial vaginosis was associated with sexual behavior (≥3 lifetime sex partners: AOR, 3.81; 95% CI, 1.29-11.26), HPV with sexual experience (AOR, 4.05; 95% CI, 1.62-10.09)., Conclusions: School-going indigenous adolescents in rural Panama have substantial STI burden. Targeted STI screening is required.

Background: New Zealand (NZ) has an ethnically diverse population. International studies have demonstrated significant differences in health equity by ethnicity; however, there is limited evidence in the context of out-of-hospital cardiac arrest in NZ. We investigated whether heath disparities in incidence and outcome of out-of-hospital cardiac arrest exist between NZ ethnic groups., Method: A retrospective observational study was conducted using NZ cardiac arrest registry data for a 2-year period. Ethnic cohorts investigated were the indigenous Māori population, Pacific Peoples and European/Others. Incidence rates, population characteristics and outcomes (Return of Spontaneous Circulation sustained to hospital handover and thirty-day survival) were compared., Results: Age-adjusted incidence rates per 100,000 person-years were higher in Māori (144.4) and Pacific Peoples (113.5) compared to European/Others (93.8). Return of spontaneous circulation sustained to hospital handover was significantly lower in Māori (adjusted OR 0.74, 95% CI 0.64-0.87, p < 0.001). Survival to thirty-days was lower for both Māori (adjusted OR 0.61, 95% CI 0.48-0.78, p < 0.001) and Pacific Peoples (adjusted OR 0.52, 95% CI 0.37-0.72, p < 0.001). A higher proportion of events occurred in all age groups below 65 years old in Māori and Pacific Peoples (p < 0.001), and a higher proportion of events occurred among women in Māori and Pacific Peoples (p < 0.001)., Conclusions: There are significant differences in health equity by ethnicity. Both Māori and Pacific Peoples have higher incidence of out-of-hospital cardiac arrest and at a younger age. Māori and Pacific Peoples have lower rates of survival to thirty-days. Our results provide impetus for targeted health strategies for at-risk ethnic populations., (Copyright © 2019 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: Rates of cardiovascular disease among people with diabetes have declined over the last 20-30 years. To determine whether First Nations people have experienced similar declines, we compared time trends in rates of cardiac event and disease management among First Nations people with diabetes and other people with diabetes in Ontario, Canada., Methods: We conducted a retrospective cohort study of patients aged 20 to 105 years with diabetes between 1996 and 2015, using linked health administrative databases. Outcomes compared were the annual incidence of each admission to hospital for myocardial infarction and heart failure, and death owing to ischemic heart disease. Management indicators were coronary revascularization and prescription rates for cardioprotective medications. Overall rates and annual percent changes were compared using Poisson regression., Results: Incidence rates for all cardiac outcomes decreased over the study period. The greatest relative annual decline among First Nations men and women were observed in ischemic heart disease death (4.4%, 95% confidence interval [CI] 3.0 to 5.9) and heart failure (5.4%, 95% CI 4.5 to 6.4), respectively. Among other men and women, the greatest annual declines were seen in ischemic heart disease death (6.3%, 95% CI 6.1 to 6.5 and 7.3%, 95% CI 7.1 to 7.6, respectively). However, all absolute cardiac event rates were higher among First Nations people ( p < 0.001). Coronary artery revascularization procedures and prescriptions for cardioprotective medications increased among First Nations people, while only prescriptions increased among other people., Interpretation: Over the last 20 years, the incidence of cardiac events has declined among First Nations people with diabetes, but remains higher than other people with diabetes in Ontario. For continued reductions in incidence, future efforts need to recognize First Nations people's unique social and cultural determinants of health., Competing Interests: Competing interests: Michael Green received grant funding from the Ontario Strategy for Patient-Oriented Research (SPOR) Support Unit, which is jointly funded by the Canadian Institutes of Health Research (CIHR) and the Province of Ontario specific to this work. Dr. Green receives grant funding for other related work from both CIHR and the Ontario Ministry of Health and Long-Term Care (MOHLTC). Dr. Green has received funding from Health Canada’s First Nations and Inuit Health Branch for consulting work related to the application of Jordan’s Principle in Ontario. Jack Tu and Douglas Lee received a grant from CIHR, during the conduct of the study. No other competing interests were declared., (© 2019 Joule Inc. or its licensors.)

Introduction and Aims: Liquor permits were once used throughout Scandinavia and North America for managing alcohol, but largely disappeared in the late 20th century. Today, they are used in some Indigenous communities in Nunavut, Canada and the Northern Territory, Australia. This paper examines the extent to which liquor permits: (i) contribute to reducing alcohol-related harms in Indigenous communities; and (ii) offer a viable mechanism for managing alcohol in Indigenous communities., Design and Methods: The study draws on published and unpublished international literature on liquor permit systems in Indigenous communities, and on field visits to northern territory (NT) communities., Results: Apart from one anecdotal report, the study found no evidence that liquor permit systems in Nunavut communities have reduced alcohol-related problems. In the NT, they have reduced alcohol-related harms in some communities. However, management of liquor permit systems generates significant administrative demands in communities., Discussion and Conclusions: Effectiveness of liquor permit systems is a product of five factors: permits themselves; agencies and procedures for issuing and managing permits; agencies and procedures for supplying liquor; enforcement of permit conditions, and the presence of other agencies-legal and illegal-affecting supply and consumption of liquor. Liquor permits continue to be valued by some Indigenous communities for managing alcohol. This study suggests that they can do so provided: (i) agencies administering permits have adequate support; (ii) controls over non-legal purchasing and consumption of liquor are effective, and (iii) the permit system is viewed in the community as legitimate, equitable and transparent., (© 2019 The Authors Drug and Alcohol Review published by John Wiley & Sons Australia, Ltd on behalf of Australasian Professional Society on Alcohol and other Drugs.)

Background: With an increasing number of women attending antenatal care for the recommended number of contacts, focus now must be placed on the quality and utility of care; without understanding adherence, the true contribution of antenatal care to improved maternal health outcomes is difficult to determine., Objective: This research explored the practicality of antenatal care recommendations for women and the factors which facilitate or hinder adherence and shape the overall utility of care., Design: Qualitative data were collected using a community-centred approach by means of focus group discussions with women and key informant interviews with healthcare providers throughout May and June of 2017. Data were analysed via thematic analysis guided by an essentialist/realist paradigm., Setting: Kanungu District, Uganda; a district in southwestern Uganda., Participants: A convenience sample of 38 Indigenous Batwa and non-Indigenous Bakiga women from four matched communities and three healthcare providers., Findings: A number of barriers to antenatal care adherence were identified which included a lack of monetary and material resources, a lack of a shared understanding and perceived value of care, and gender and position-based power dynamics, all of which were compounded by previous experiences with antenatal care. The factors identified which influenced adherence were highly complex and non-linear, affected by individual, community, health centre, and health system-level factors. Promotion of spousal involvement in antenatal care had different effects based on pre-existing individual levels of spousal support, either improving or hindering adherence. A lack of resources created a double burden for women through which maternal health was jeopardized by the inability to adhere to antenatal care recommendations and the poor quality patient-provider relationships which resulted and deterred future antenatal care attendance., Key Conclusions and Implications for Practice: The capacity to avail oneself of antenatal care varied significantly for women based on their socio-economic status, levels of autonomy, and spousal support. Strategies to improve antenatal care need to focus on health equity to ensure care has a high degree of utility for all women. The interconnectedness of care and those who deliver care necessitates healthcare providers to develop strong patient-provider relationships through their attitudes, behaviours, and the delivery of equitable care. In light of a historical emphasis on attendance, this research highlights the significance of improving the quality and utility of antenatal care, inclusive of Indigenous perspectives, to deliver high-value care., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Diversity initiatives are being implemented widely within academia and society more broadly; however, the School of Nursing (SoN) at Dalhousie University in Halifax, Nova Scotia, Canada, is taking an innovative approach. Faculty members recognized the need to support students at the graduate and undergraduate levels from Black, Indigenous, LGBTQ2S (Lesbian, Gay, Bisexual, Transgender, Queer, and Two-Spirit), and International communities in a student-led initiative with the mission to promote diversity, inclusion, and equity within the SoN. This coalition seeks to offer students who are often rendered invisible within the academy and society more broadly in relation to dominant cultures and normative expectations an opportunity to build relationships and expose shared histories of oppression in such a way that issues of social justice are uncovered. In response to nursing students and faculty who self-identify as members of dominant groups and who sought inclusion as allies, the leaders of the student community groups recognized a need to develop a position statement on allyship. The collaboration that transpired between the four groups of communities to develop the position statement led to the formation of the Student Equity Coalition. This article begins with the authors' definition of allyship, followed by a description of the context in which this unique initiative is taking place, the rationale behind developing a shared position statement on allyship, and the significance of this work in positioning and supporting nursing students of minority status as emerging nurse leaders., (© Copyright 2019 Creative Health Care Management.)

Objectives: Canada's Indian Residential School (IRS) system aimed to annihilate Indigenous culture among Indigenous children. Negative health impacts have been documented not only among survivors but also among their descendants. Reconnection with culture has been promoted as a means to recovery for people affected by this historical trauma. This study aimed to assess whether cultural connectedness has a specific protective effect on mental health among the descendants of IRS survivors., Study Design: Cross-sectional survey., Methods: A randomly selected cross section of Anishinabe people, aged 18-39 years, from one community were invited to complete a brief questionnaire. Associations were calculated between IRS attendance, cultural connectedness, and mental health., Results: A total of 147 people participated. Among participants without a family history of IRS attendance, cultural connectedness was not significantly associated with improved mental health. Among participants with a family history of IRS attendance, a high level of cultural connectedness was significantly associated with a 31% greater probability of reporting high mental health and mental health status similar to those with no family history of IRS attendance., Conclusions: Cultural connectedness appears to act as a strong and specific protective factor against the intergenerational effects of IRS on the mental health of Anishinabe young adults, providing epidemiological support for the notion of 'culture as treatment.', (Copyright © 2018 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.)

Background: Many studies have shown the impact of heat and cold on total and age-specific mortality, but knowledge gaps remain regarding weather vulnerability of very young infants. This study assessed the association of temperature extremes with perinatal mortality (stillbirths and deaths in the first week of life), among two ethnic groups in pre-industrial northern Sweden., Methods: We used population data of indigenous Sami and non-Sami in selected parishes of northern Sweden, 1800-1895, and monthly temperature data. Multiple logistic regression models were conducted to estimate the association of cold (<10th percentile of temperature) and warmth (>90th percentile) in the month of birth with perinatal mortality, adjusted for cold and warmth in the month prior birth and period, stratified by season and ethnicity., Results: Perinatal mortality was slightly higher in Sami than in non-Sami (46 vs. 42 / 1000 live and stillbirths), but showed large variations across the region and over time. Both groups saw the highest perinatal mortality in autumn. For Sami, winter was a high-risk time as well, while for non-Sami, seasonality was less distinct. We found an association between exposure to cold and perinatal mortality among winter-born Sami [Odds ratio (OR) 1.91, 95% confidence interval (CI) 1.26-2.92, compared to moderate temperature], while there was little effect of cold or warmth during other seasons. Non-Sami, meanwhile, were affected in summer by warmth (OR 0.20, CI 0.05-0.81), and in autumn by cold (OR 0.39, CI 0.19-0.82)., Conclusions: In this pre-industrial, subarctic setting, the indigenous Sami's perinatal mortality was influenced by extreme cold in winter, while non-Sami seemed to benefit from high temperature in summer and low temperature in autumn. Climate vulnerability of these two ethnic groups sharing the same environment was shaped by their specific lifestyles and living conditions., Competing Interests: The authors have declared that no competing interests exist.

Objectives: This study looked at observed crude prevalence/incidence of multiple sclerosis (MS) and neuromyelitis optica spectrum disorder (NMOSD) in Malaysia and identified any inter-ethnic differences for MS/NMOSD., Methods: This was a nationwide tertiary hospital-based retrospective cross-sectional study using the capture-recapture method. It looked at the estimated crude prevalence of confirmed MS and NMOSD and annual incidence on 29 December 2017. Recapture of data was done between February and March 2018 on 1 March 2018. Public and referring private institutions were accessed., Results: The survey identified 767 MS and 545 NMOSD subjects, with crude prevalence rates of 2.73 per 100,000 (95% confidence interval (CI): 2.53; 2.92 per 100,000 population) and 1.94 per 100,000 (95% CI: 1.77; 2.10 per 100,000 population) with observed crude annual incidence of 0.55 (95% CI: 0.43; 0.58) for MS and 0.39 per 100,000 (95% CI: 0.35; 0.47) for NMOSD. The MS:NMOSD ratios were 1.4:1.0. The capture-recapture method revealed 913 MS (95% CI: 910; 915.9) and 580 (95% CI: 578.8; 581.2) NMOSD with prevalence per 100,000 of 3.26 (95% CI: 3.05; 3.47) and 2.07 (95% CI: 1.90; 2.24), respectively. In the MS group, 59.4% were Malay, 16.6% Chinese, 20.5% Indian, and 3.5% were from indigenous groups. In the NMOSD group, 47.3% were Malay, 46.9% Chinese, 3.5% Indian, and 2.3% were from other indigenous groups. The ratio of NMOSD to MS among the Chinese was 2:1, but the ratio of MS to NMOSD among the Malays was 1.8:1, and that in Indians was 8.3:1., Conclusion: There is a modest increase in the prevalence of MS and NMOSD in Malaysia with inter-ethnic differences for MS/NMOSD.

Objective : Asthma and allergic diseases are poorly described in rural areas. The objective of this study was, therefore, to determine the prevalence of wheezing, asthma, and other allergic disorders among children living in regional and rural Tasmania. Methodology : Data from a cross-sectional survey using standardized questionnaires of asthma, allergic conditions and food allergies were collected from 39 primary schools across North West Tasmania. We enrolled 1075 children between 6 and 8 years. The main outcomes were prevalences of wheezing, asthma, and other allergic disorders further stratified by sex and indigenous status. Results : Baseline characteristics were as follows: median age 8.1 years (IQR: 7.6, 8.7) with equal sex distribution, most (80.1%) attended public schools and 11.0% identified as indigenous. We report prevalences of current wheezing (22.7%), allergic rhinoconjunctivitis (16.3%) and atopic eczema (16.6%), with higher prevalences among boys (except eczema). Food allergies were reported in 8.6% and food-related anaphylaxis in 1.6% of the sample. Indigenous children had significantly higher prevalence of current wheezing (indigenous 31.1% versus non-indigenous 21.6%; p  = 0.02). Further, children with current wheezing and no asthma diagnosis, had similar prevalence of other atopic diseases (hayfever 31.4%, eczema 44.0%, and food reaction 23.2%) compared with diagnosed asthmatics, although likely shared the illness. Conclusions : Childhood asthma is more prevalent in regional Tasmania compared with national estimates, especially among indigenous children. This appears not to be driven by an allergic response. Also, a significant proportion of children are likely to have undiagnosed asthma which has implications for rural health service delivery.

Objective: This systematic review synthesized and evaluated the evidence on the prevalence of postpartum mental health disorders in Indigenous women., Methods: Comprehensive searches of biomedical electronic databases including Medline, EMBASE, PsychINFO, CINAHL, and Web of Science were performed for peer-reviewed literature published from 1990 to September 2018. The search strategy included terms related to the postpartum period, mental health disorders, and Indigenous ancestry. Epidemiological observational studies that evaluated the prevalence of mental health disorders in the postpartum and included Indigenous women from Australia, Canada, New Zealand, and the United States were included. Two independent reviewers screened and evaluated the risk of bias of included studies. A narrative synthesis of study results was conducted. Prevalence estimates from homogeneous studies were pooled in a random-effects meta-analysis (Canadian Task Force Classification II-2)., Results: A total of 2297 references were initially identified, of which six studies were included in the review. All included studies evaluated the prevalence of postpartum depression (PPD) and were of moderate or low risk of bias. Other postpartum mental health disorders were not evaluated. Overall, Indigenous women had 87% increased odds of PPD compared with Caucasian groups of women (odds ratio 1.87; 95% confidence interval 1.14-3.09). Substantial heterogeneity across prevalence estimates was observed., Conclusion: Limited evidence suggests a greater burden of PPD affecting Indigenous women. There is insufficient evidence informing the prevalence of other postpartum mental health disorders in Indigenous women. More epidemiological research in this area is essential to provide accurate and reliable prevalence estimates of postpartum mental health disorders among Indigenous women., (Copyright © 2019 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.)

The Pacific region, also referred to as Oceania, is a geographically widespread region populated by people of diverse cultures and ethnicities. Indigenous people in the region (Melanesians, Polynesians, Micronesians, Papuans, and Indigenous Australians) are over-represented on national, regional, and global scales for the burden of infectious and non-communicable diseases. Although social and environmental factors such as poverty, education, and access to health-care are assumed to be major drivers of this disease burden, there is also developing evidence that genetic and microbiotic factors should also be considered. To date, studies investigating genetic and/or microbiotic links with vulnerabilities to infectious and non-communicable diseases have mostly focused on populations in Europe, Asia, and USA, with uncertain associations for other populations such as indigenous communities in Oceania. Recent developments in personalized medicine have shown that identifying ethnicity-linked genetic vulnerabilities can be important for medical management. Although our understanding of the impacts of the gut microbiome on health is still in the early stages, it is likely that equivalent vulnerabilities will also be identified through the interaction between gut microbiome composition and function with pathogens and the host immune system. As rapid economic, dietary, and cultural changes occur throughout Oceania it becomes increasingly important that further research is conducted within indigenous populations to address the double burden of high rates of infectious diseases and rapidly rising non-communicable diseases so that comprehensive development goals can be planned. In this article, we review the current knowledge on the impact of nutrition, genetics, and the gut microbiome on infectious diseases in indigenous people of the Pacific region., (Copyright © 2019 Horwood, Tarantola, Goarant, Matsui, Klement, Umezaki, Navarro and Greenhill.)

Background: The health status and needs of indigenous populations of Australia, Canada and New Zealand are often compared because of the shared experience of colonisation. One enduring impact has been a disproportionately high rate of commercial tobacco use compared with non-indigenous populations. All three countries have ratified the WHO Framework Convention on Tobacco Control (FCTC), which acknowledges the harm caused to indigenous peoples by tobacco., Aim and Objectives: We evaluated and compared reporting on FCTC progress related to indigenous peoples by Australia, Canada and New Zealand as States Parties. The critiqued data included disparities in smoking prevalence between indigenous and non-indigenous peoples; extent of indigenous participation in tobacco control development, implementation and evaluation; and what indigenous commercial tobacco reduction interventions were delivered and evaluated., Data Sources: We searched FCTC: (1) Global Progress Reports for information regarding indigenous peoples in Australia, Canada and New Zealand; and (2) country-specific reports from Australia, Canada and New Zealand between 2007 and 2016., Study Selection: Two of the authors independently reviewed the FCTC Global and respective Country Reports, identifying where indigenous search terms appeared., Data Extraction: All data associated with the identified search terms were extracted, and content analysis was applied., Results: It is difficult to determine if or what progress has been made to reduce commercial tobacco use by the three States Parties as part of their commitments under FCTC reporting systems. There is some evidence that progress is being made towards reducing indigenous commercial tobacco use, including the implementation of indigenous-focused initiatives. However, there are significant gaps and inconsistencies in reporting. Strengthening FCTC reporting instruments to include standardised indigenous-specific data will help to realise the FCTC Guiding Principles by holding States Parties to account and building momentum for reducing the high prevalence of commercial tobacco use among indigenous peoples., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)