Promising Practices to Address Health Inequities  in Aboriginal Mothers, Newborns and Children 

Using Culturally Sensitive and Aligned  Approaches

Deb McNeil, Shivani Rikhy, Jodi Siever, Amy Johnston, Suzanne Tough

Presentation Outline

Background

Synthesis Approach 

Search and Selection

Science and Cultural Appraisal

Identification of Promising Practices

Results 

Key Messages

Why Should We Care?

What Has Been Addressed?

Research Questions:

What programs or activities exist that support Aboriginal 

maternal, reproductive, newborn, child health and well‐

being? 

Specifically,

Which are associated with positive

health/well‐being outcomes?

Which are associated with cultural alignment and sensitivity 

guidelines?

Which represent promising practices?

Research Methods

A Synthesis Review

Systematic 

a literature review with a clearly formulated research question

explicit methods: identify, select, & critically appraise  or evaluate relevant research

Synthesis 

expert panel: Aboriginal Advisory Committee

critical appraisal includes context

Identified promising practices

Search Strategy11 Databases

Medline, PsycINFO, CINAHL, HealthStar, Native Health, ERIC I, 

ERIC II, HealthSource‐Nursing, and Child Abuse, Child Welfare, 

and Adoption

Hand search of included articles

Search Terms

ETHNICITY (Aborigines, Aboriginal, First Nations, Inuit, Metis, American Indian, 

Alaska Native, Torres Strait Islander, Maori, Indian, Eskimo, Indigenous, Native 

American)

CHILDREN (newborn, infant, child, children, youth) 

MATERNAL REPRODUCTIVE (pregnancy, prenatal, maternal, 

maternity, preconception)

COUNTRY OF ORIGIN(Canada, United States, Australia, and New 

Zealand)

Selection Strategy

2 reviewers independently scanned retrieved articles by:

1) title, 2) abstract, 3) full text (respectively) against inclusion/exclusion 

criteria

Inclusion 

Criteria

Identified a program, intervention, service, policy, practice

Included an actionable

component (ex: immunization)

contained substantial representation

from Aboriginal, Métis, Inuit, or First Nations 

populations

Studies published between January 1st, 2005‐

March 31st, 2009, inclusive

Research conducted in Canada, United States, Australia, or New Zealand

Exclusion Criteria

Studies released prior

to January 1st, 2005

Descriptive studies identifying health disparities or poor health outcomes (non‐

actionable)

Case studies, position papers, anecdotal evidence

Program reports associated with marketing materials/products

Programs/practices with no

indication of either outcome or process

Foreign language reports

Note: Some programs/practices published earlier than 2005 were included for review based on the hand search of other included program reports or 

pertinent literature as described above

Evaluating the ScienceQuantitative appraisal18 Factors (Ranking: Low, Mid, High)

selection bias, information bias, and confounding

positive , neutral, or negative outcomes 

Flynn MAT et al. Reducing obesity and related chronic disease risk in children and youth: a synthesis of evidence with 

'best practice‘

recommendations. Obesity Reviews 2006;7(1S):7‐66.

Evaluating the ScienceQualitative appraisal14 Factors (Ranking: Low, Mid, High)

reflexivity, credibility, and transferability

Flynn MAT et al. Reducing obesity and related chronic disease risk in children and youth: a synthesis of evidence 

with 'best practice‘

recommendations. Obesity Reviews 2006;7(1S):7‐66.

Bringing Culture

into the Evaluation

Cultural Safety

Respect for nationality, culture, age, sex, political and religious 

beliefs

Reinforces that each person’s knowledge/reality is valid and 

valuable

Encourages voicing concerns

National Aboriginal Health Organization. Cultural Competency and

Safety: A Guide for Health Care Administrators, Providers and Educators. 2008 www.naho.ca

The patient, consumer, community defines the care or service

Simmons D. Relationship between maternal glycaemia and birth weight in glucose – tolerant women from different ethnic groups in New Zealand. Diabetic Medicine 2007;24 (3):240‐244. date

Conceptual Framework

SOGC Policy  StatementA Guide for Health Professionals 

Working with Aboriginal 

Peoples

Number  100, December 2000

Smylie J. A guide for health professionals working with 

Aboriginal peoples. Society of Obstetricians and 

Gynaecologists of Canada; 2001.

Evaluating Cultural Sensitivity9 Factors

Understanding of Aboriginal culture, history, context, 

medical and other determinants of health, the impact  of colonization, & the availability of cultural training 

for program staff

Evaluating Cultural AlignmentService Delivery

6 Factors

Ability of the service to provide culturally aligned care, 

options available, language preferences, interpreters,

Capacity Building

7 Factors

Developed, implemented, administered and evaluated by 

the community, building local capacity

Identifying Promising Practices

Promising Practices3 Steps

Step 1: Certainty of EffectivenessScience and Outcomes

Step 2: Potential for Population ImpactCultural Sensitivity & AlignmentLogic, Reach (n=>500) and Uptake (>50%)

Step 3: Combining the first two steps in a table

McNeil and Flynn, Methods of defining best practice for population health approaches with obesity 

prevention as an example. Proced. Nutr. Soc. 2006, 65, 403‐411

Elements considered: Potential for Population Impact Certainty of Effectiveness

Step 3: Identification of ‘Promising Practices’

Low Moderate High

High Promising Very Promising Most Promising

Mid Less Promising Promising Very Promising

Low Least Promising Less Promising Promising

Potential for population impact

Cer

tain

ty o

f Ef

fect

iven

ess

Swinburn B., Gill T., & Kumanyika SK. Obesity prevention: a proposed framework for translating evidence into action. Obesity Reviews 2005; 6; 23-33.

RESULTS

Search and Selection ResultsMaternal/Reproductiv

e Child

Maternal Newborn HealthProgram Topic Area Number of Programs/Activities 

(N=21)

Preconception Health 2

Prenatal Care, Labour and Delivery 

Culturally sensitive  care 9

Mental Health  1

Substance Use 3

HIV 2

Labour and Delivery 2

Post Partum Care 1

Total 21

Maternal Newborn Health

IndividualIndividualFamilyFamily

CommunityCommunityCultural

9

Cont

extu

al4

Environmental4Sp

iritua

l

1

Political 0

Curative

0Pr

even

tive

7

Supportive

16

Rehabilitative 0

Promotive 0

Program/Activity Appraisal Rankings

Type of Appraisal Low (n) Mid (n) High (n)

Scientific Qualitative (n=8) 1 6 2

Quantitative (n=13) 5 8 0

Total (n=21)*

Cultural 4 11 3

Total (n=18)* Includes 3 mixed methods studies

Promising Practices

Kreiner M. Delivering diversity: newly regulated midwifery returns to Manitoba Canada, one community at a time. Journal of Midwifery and Women's Health 2009; 54 (1); e1-e10

Jan S., Conaty S., Hecker R., Bartlett M., Delaney S., & Capton T. An holistic economic evaluation of an Aboriginal community- controlled midwifery programmerin Western Sydney. Journal of Health Services Research & Policy 2004 ; 9(1);14-21

Topic Areas in Child Health and WellbeingProgram Topic Area Number of Programs/Activities 

(N=21)

Healthy Lifestyle Promotion 7

Oral Health 3

Mental Health & Substance Abuse 3

Immunization 2

Diabetes 2

Education 2

FASD 1

Telehealth 1

Total 21

Child Health and Wellbeing

IndividualIndividualFamilyFamily

CommunityCommunityCultural

5

Cont

extu

al17

Environmental17Sp

iritua

l

1

Political 0

Curative

0

Prev

entiv

e16

Supportive

15

Rehabilitative 3

Promotive 13

Appraisal Rankings

Type of Appraisal Low (n) Mid (n) High (n)

Scientific Qualitative (n=5) 2 3 0

Quantitative (n=19) 8 10 1

Total (n=24)*

Cultural 10 9 2

Total (n=21)* Includes 3 mixed methods studies

Promising Practice Rankings

Lawrence, HP et al. A 2‐year 

community‐randomized controlled 

trial of fluoride varnish to prevent 

early childhood caries in Aboriginal 

children. Community Dentistry and 

Oral Epidemiology, YEAR 36, 6: 503‐

516

Schinke, SP, Tepavac, L, Cole KC. 

Preventing substance abuse among 

Native American youth: three‐year 

results. Addictive Behavior. 

2000;25(3):387‐97.

Key Messages

Culturally aligned and sensitive community‐centered midwifery practice 

is promising in reducing birth outcome disparities.

The meaning of risk can be different between providers and individuals and 

their communities. These differences in understanding can result

in 

diminished choice of labour and delivery options, potentially contributing  to 

culturally unsafe  care

Given the importance of spirituality

and holistic health for Aboriginal 

peoples, an opportunity exists to address the contribution of spirituality in 

health and wellbeing. 

Key Messages

A variety of well‐documented disparities, such as unwanted pregnancy and 

infant mortality, have not been  well addressed through programming and 

research.

There is a gap in (reporting of research) conducted in rural communities, 

which presents an opportunity for  future programming and research .

High quality research is needed; as demonstrated by the four  very promising 

programs, science does not have to be a trade‐off for cultural sensitivity; 

it is possible to  have both. 

Canada is a leader in culturally sensitive intervention research. Persistent 

health disparities  may be reduced by adopting culturally sensitive and aligned 

promising practices.

Acknowledgements

Alberta Centre for Child, Family, & Community Research and Health Canada‐

financial support

Aboriginal Advisory Committee of the Alberta Centre for Child, Family, & 

Community Research

development of a tool to assess cultural sensitivity and alignment for 

research reports. 

Mary Goitom, Courtney Crockett, Patrick O’Connell, and Sarah Horn‐

ongoing support and insight into research process and findings

Content experts contacted for input on emerging issues in Aboriginal health

Contact information: Debbie.McNeil@albertahealthservices.ca

Cultural Understanding

9 factors were evaluated: understanding of Aboriginal  culture, history, and context

Capacity Building

7 factors related to: efforts to build local capacity, also 

included items focused on whether the program/practice  and research was community based

Service Delivery

6 factors were assessed: ability of the service 

to provide culturally aligned care, including  language preferences

Step 1: ‘Certainty of Effectiveness’

Elements considered:

Science

Study outcomes 

Negative

Neutral Positive Unknown

High

Low Mid High Mid

Mid

Low Low Mid Low

Low Low Low Low Low 

Scie

nce

Outcomes

Step 2: ‘Potential for Population Impact’

Elements considered:

Cultural assessment

3 study characteristics: Logic,

Reach

(n>500), Uptake

(≥

50%)

0/3 1/3 2/3 3/3

High Low Mid Mid High

Mid Low Low Mid High

Low Low Low Low Mid

Low (Zero score)

Low Low Low Mid

Number of Study Characteristics out of Three

Cu

ltu

ral A

sses

smen

t

SOGC Guidelines

Sociocultural

Context

Understanding: groups, demographics, languages, colonization, socio‐

demographics, services close to home, governmental obligations, self 

determination

Health Concerns 

Appreciate  holistic definitions of health, degree of ill health

unacceptable, 

work with communities, not stereotype

Cross‐Cultural Understanding

Recognise: need for relationships to be based on mutual respect,

system gaps 

and barriers, proactive to address gaps, care culturally appropriate, treatment 

in own language, use cultural interpreters and advocates, importance of family 

and community roles, integration of traditional medicine, increase personal 

sensitivity, get to know communities

Aboriginal Health Resources

Support: community directed programming and participatory research, 

education of Aboriginal health professionals, preventive health programming

Smylie

J. A guide for health professionals working with Aboriginal peoples. Society of Obstetricians and 

Gynaecologists

of Canada; 2001.