Educating for Indigenous health equity: An international consensus statement

The determinants of health inequities between Indigenous and non-Indigenous populations include factors amenable to medical education’s influence, for example, the competence of the medical workforce to provide effective and equitable care to Indigenous populations. Medical education institutions have an important role to play in eliminating these inequities. However, there is evidence that medical education is not adequately fulfilling this role, and in fact may be complicit in perpetuating inequities. This article seeks to examine the factors underpinning medical education’s role in Indigenous health inequity, in order to inform interventions to address these factors. The authors developed a consensus statement that synthesizes evidence from research, evaluation, and the collective experience of an international research collaboration including experts in Indigenous medical education. The statement describes foundational processes that limit Indigenous health development in medical education and articulates key principles that can be applied at multiple levels to advance Indigenous health equity. The authors recognize colonization, racism, and privilege as fundamental determinants of Indigenous health that are also deeply embedded in Western medical education. In order to contribute effectively to Indigenous health development, medical education institutions must engage in decolonization processes and address racism and privilege at curricular and institutional levels. Indigenous health curricula must be formalized and comprehensive, and must be consistently reinforced in all educational environments. Institutions’ responsibilities extend to advocacy for health system and broader societal reform to reduce and eliminate health inequities. These activities must be adequately resourced and underpinned by investment in infrastructure and Indigenous leadership

Indigenous health: designing a clinical orientation program valued by learners

Abstract Background Indigenous health programs are seen as a curriculum response to addressing health disparities and social accountability. Several interrelated teaching approaches to cultural competency curricula have been recommended, however evidence of the impact of these on learner outcomes including engagement and self-reported competencies is limited. We aimed to explore undergraduate medical student perspectives of an indigenous health orientation program to inform curriculum strategies that promote learning and development of clinical skills. Methods We analyzed quantitative and qualitative student evaluations (n = 602) of a three-day immersed indigenous health orientation program between 2006 and 2014 based on Likert-scale responses and open-text comments. We conducted a thematic analysis of narrative student experiences (n = 426). Results Overall, 509 of 551 respondents (92%) rated the indigenous health orientation program as extremely or highly valuable and most (87%) reported that the course strongly increased their interest in indigenous health. The features of the clinical course that enhanced value for learners included situated learning (learning environment; learning context); teaching qualities (enthusiasm and passion for Māori health; role-modelling); curriculum content (re-presenting Māori history; exploring Māori beliefs, values and practices; using a Māori health framework in clinical practice); teaching methodologies (multiple teaching methods; simulated patient interview); and building relationships with peers (getting to know the student cohort; developing professional working relationships). Conclusions Undergraduate medical students valued an indigenous health program delivered in an authentic indigenous environment and that explicitly reframed historical notions of indigenous health to contextualize learning. Content relevant to clinical practice, faculty knowledge, and strengthened peer interactions combined to build learner confidence and self-reported indigenous health competencies. These findings suggest empirical evidence to support a curriculum approach to indigenous health teaching that enhances clinical learning

Inequity in dialysis related practices and outcomes in Aotearoa/New Zealand: a Kaupapa Māori analysis

Abstract Background In Aotearoa/New Zealand, Māori, as the indigenous people, experience chronic kidney disease at three times the rate of non-Māori, non-Pacific New Zealanders. Māori commence dialysis treatment for end-stage kidney disease at three times the rate of New Zealand European adults. To examine for evidence of inequity in dialysis-related incidence, treatment practices, and survival according to indigeneity in Aotearoa/New Zealand, utilising a Kaupapa Māori approach. Methods We conducted a retrospective cohort study involving adults who commenced treatment for end-stage kidney disease in Aotearoa/New Zealand between 2002 and 2011. We extracted data from the Australian and New Zealand Dialysis and Transplant Registry (ANZDATA) linked to the New Zealand National Health Index (NHI). Propensity score methods were used to assemble a cohort of 1039 Māori patients matched 1:1 on clinical and socio-demographic characteristics with a cohort of 1026 non-Māori patients. We compared incidence of end-stage kidney disease and treatment practices. Differences in the risks of all-cause mortality during treatment between propensity-matched cohorts were estimated using Cox proportional hazards and generalised linear models. Results Non-Māori patients were older, more frequently lived in urban areas (83% versus 67% [standardised difference 0.38]) and bore less socioeconomic deprivation (36% living in highest decile areas versus 14% [0.53]). Fewer non-Māori patients had diabetes (35% versus 69%, [− 0.72]) as a cause of kidney failure. Non-Māori patients were more frequently treated with peritoneal dialysis (34% versus 29% [0.11]), received a pre-emptive kidney transplant (4% vs 1% [0.19]), and were referred to specialist care < 3 months before treatment (25% vs 19% [0.15]) than Māori patients. Fewer non-Māori started dialysis with a non-tunnelled dialysis vascular catheter (43% versus 47% [− 0.08]). The indigenous-age standardised incidence rate ratio for non-Māori commencing renal replacement therapy in 2011 was 0.50 (95% CI, 0.40–0.61) compared with Māori. Propensity score matching generated cohorts with similar characteristics, although non-Māori less frequently started dialysis with a non-tunnelled venous catheter (30% versus 47% [− 0.35]) or lived remotely (3% versus 14% [− 0.50]). In matched cohorts, non-Māori experienced lower all-cause mortality at 5 yr. after commencement of treatment (risk ratio 0.78, 95% CI 0.72–0.84). New Zealand European patients experienced lower mortality than Māori patients in indigenous age-standardised analyses (age-standardised mortality rate ratio 0.58, 95% CI 0.51–0.67). Conclusions Non-Māori patients are treated with temporary dialysis vascular access less often than Māori, and experience longer life expectancy with dialysis, even when socioeconomic, demographic, and geographical factors are equivalent. Based on these disparities, health services should monitor and address inequitable treatment practices and outcomes in end-stage kidney disease care

Medical education to improve Māori health

Medical education in Aotearoa/New Zealand has a critical role to play in producing a health professional workforce that is prepared to meet the challenge of addressing Māori health. While cultural competence is an important aspect of this, we argue that Māori health is an educational domain in its own right with distinct learning objectives and educational approaches. An emerging consensus as to the optimal graduate outcomes and key components of a Māori health curriculum is supported by a growing international evidence base in indigenous health education. Several significant challenges exist, many of which can be overcome by reorienting institutional systems, structures and processes to support effective Māori health teaching and learning. We recommend a combination of immersed, integrated and independent teaching and learning approaches in order to promote high-quality outcomes

A proposed hauora Māori clinical guide for psychologists: Using the hui process and meihana model in clinical assessment and formulation

This paper documents a joint initiative of clinical practice educators from four tertiary institutions and their engagement in the design and development of a proposed Hauora Māori Clinical Guide for Psychologists, which outlines how to apply the Hui Process and Meihana Model to applied psychology. It describes the ability for this proposed Hauora Maori Clinical Guide for Psychologists to assist clinicians, professional psychology training programmes and institutions in meeting the expectations of the Health Practitioners Act and The New Zealand Psychologists Board’s (NZPB) Standards and Procedures document. It presents how this proposed guide can support the implementation of clinical and cultural competence and the Code of Ethics for Psychologists Working in New Zealand. It also provides an opportunity for the psychology profession to demonstrate responsivity to Te Tiriti o Waitangi obligations