Patches of Equity: Policy and Financing of Indigenous Primary Health Care Providers in Canada, Australia and New Zealand

This thesis investigates how the governments of Canada, Australia and New Zealand balance the ideal of indigenous self-determination with other pressures, such as current trends in public administration and accountability, pressures on the health care system, issues of and sensitivities around minority rights, equity in health and cost-efficiency. It is based on four case studies conducted in Australia and New Zealand. The Canadian material is drawn from both the literature and a period of twelve years working in indigenous-controlled health services. All three governments have made some policy commitments to increased indigenous participation and self-determination, in the pursuit of health gains. The goal is a more responsive health care system. Self-determination is often mentioned. In Australia and New Zealand, the commitment extends to primary, secondary and tertiary care. Canada focuses exclusively on improving the responsiveness of on-reserve primary health care services. The contractual environment in which providers operate bears a highly nuanced resemblance to official policies. Two broad categories of contractual environments have emerged. Indigenous providers who operate in an environment where the funder is an indigenous-specific government authority (First Nations and Australia's new PHCAP program) have access to a relational contractual environment that is advantageous administratively, financially and in terms of comprehensiveness of services. Indigenous providers that secure funding from non-indigenous specific funders (New Zealand, and Australian Aboriginal Health Services) operate in a classic contractual environment where funding is accessed via a multiplicity of fragmented, often proposal-driven, contracts with high administrative costs. Classic contractual environments lead to a patchwork approach to achieving health gains. Indigenous aspirations for self-determination have been partially satisfied with increased opportunities for contracting in health. Although the link between increased indigenous participation and improved outcomes remains to be explored analytically, it is doubtful that classical contractual environments can yield the health gains expected

Contracting in First Nation contexts: pragmatic considerations

APHCRI Conversations was a regular program of presentations held at the Department of Health to facilitate exchange between APHCRI Network researchers and Department policymakers. Topics are developed jointly with the Department of Health and involve a range of speakers from APHCRI, including CRE invited experts, CRE Chief Investigators and stream project Chief Investigator

Points de vue d'acteurs scolaires et d'intervenants communautaires sur les besoins d’élèves immigrants et de leur famille dans des écoles défavorisées à Montréal

Dans une perspective compréhensive,  des acteurs scolaires (enseignants, directeurs) et des intervenants communautaires sont rencontrés dans le but  de croiser les regards sur les défis de l’intervention en milieu scolaire qui conjugue immigration et défavorisation socioéconomique. Aussi, dans un contexte nord-américain où le crédo de la collaboration école-famille-communauté devient prégnant, cette étude est l’occasion de mieux comprendre comment s’articulent les logiques d’intervention entre école et organisme communautaire.Dans une perspective compréhensive,  des acteurs scolaires (enseignants, directeurs) et des intervenants communautaires sont rencontrés dans le but  de croiser les regards sur les défis de l’intervention en milieu scolaire qui conjugue immigration et défavorisation socioéconomique. Aussi, dans un contexte nord-américain où le crédo de la collaboration école-famille-communauté devient prégnant, cette étude est l’occasion de mieux comprendre comment s’articulent les logiques d’intervention entre école et organisme communautaire

Activité dominante négative des protéines p53 mutées

La protéine p53 dispose d’une fonction activatrice de l’expression de nombreux gènes cibles. Le rôle de facteur de transcription joué par la protéine p53 nécessite la formation d’une structure homotétramérique. Les résultats de certaines expérimentations montrent que les monomères p53 mutés ont la capacité de se lier à des monomères p53 sauvages pour constituer des complexes hétérotétramériques. La présence de monomères p53 mutés au sein de ces complexes hétérotétramériques peut avoir pour conséquence immédiate une inactivation des monomères sauvages. Cette capacité de liaison et d’inactivation des p53 mutées à l’égard des p53 sauvages est qualifiée d’« effet dominant négatif ». Plusieurs facteurs enrôlés dans cette activité dominante négative ont été identifiés. La compréhension des fonctions moléculaires complexes qui régissent cette activité constitue un des aspects importants qui permettrait de mieux discerner les mécanismes biologiques en jeu dans la cancérogenèse. Le but de cet article est de mettre en lumière des aspects jusqu’à présent occultés de l’activité dominante négative des protéines p53 mutées. De plus, nous allons souligner comment cette activité contribue à la cancérogenèse induite par les rayons ultraviolets.Tumor suppressor gene inactivation as proposed by the Knudson model implies a sequential inactivation of two alleles of a gene. For example, the first allele is inactivated by a missense mutation, and the second one is inactivated by a deletion or insertion. The alteration of the p53 tumor suppressor gene is far to correspond only to this model. In the great majority of cancers, the mutated allele of p53 coexists with the normal allele. It is well known that the transcriptional activity is one of the most important functions of p53. The p53 protein is active as a tetramer (this complex activates the expression of targeted genes by binding to its consensus DNA sequence called the p53 response element). Experimental evidence shows that wild-type p53 interacts with mutant proteins to form heterotetramers. In association with wild-type proteins, mutant proteins drive the wild-type subunits into a mutant conformation. This association leads to a loss of trans-activating function. The capacity of mutant subunits to form heterotetramers with wild-type subunits and to commit them into a mutant conformation is called « dominant negative effect ». Many p53 mutant proteins possess this dominant negative activity. Recently, several factors, which are implicated in the control of the dominant negative activity of p53 mutants, have been identified. The elucidation of these complex molecular functions, which are implicated in the dominant negative activity of the p53 mutated protein represents an important aspect in the comprehension of the biological mechanisms involved in carcinogenesis

Public administration reform for Aboriginal affairs: an institutionalist analysis

Persistent underperformance of public policy and program implementation in Aboriginal affairs is widely recognised. We analysed the results of two case studies of attempted reforms in public administration of Aboriginal primary health care in the Northern Territory, using a framework based on the institutionalist and systemic racism literatures, with the aim of better understanding the sources of implementation failure. Implementation of the agreed reforms was unsuccessful. Contributing factors were as follows: strong recognition of the need for change was not sustained; the seeds of change, present in the form of alternative practices, were not built on; there was a notable absence of sustained political/bureaucratic authorisation; and, interacting with all of these, systemic racism had important consequences and implications. Our framework was useful for making sense of the results. It is clear that reforms in Aboriginal affairs will require government authorities to engage with organisations and communities. We conclude that there are four requirements for improved implementation success: clear recognition of the need for change in 'business as usual'; sustainable commitment and authorisation; the building of alternative structures and methods to enable effective power sharing (consistent with the requirements of parliamentary democracy); and addressing the impact of systemic racism on decision-making, relationships, and risk management

Acting as a Change Agent

Background: Acting as a change agent (CA) is a key role for Health and Social Services (HSS) professionals. It involves working collaboratively with actors across and outside the HSS system and influencing decision-makers. However, this role requires specific skills that HSS professionals generally feel that they have not mastered. The overarching goal of this research partnership is to explore the development of CA skills by HSS professionals using a customized training program. Methods/Design: Through a research partnership, 128 HSS professionals will receive 7 hours of training using a professional co-development approach and a checklist. The immediate and medium-term effects of the training on their skills development will be evaluated with a self-administered questionnaire before and immediately following the training and again nine months later. The data will be analyzed using descriptive and inferential statistics. Discussion: This study will shed light on the effects of a customized training program on CA skills development. It will also have three main benefits: (1) development of an easy-to-reuse CA training program and checklist; (2) partner’s ownership of these products through close involvement; and (3) development of a sustainable partnership between a team of researchers and a recognized organization with an extensive HSS network

A Decolonizing Approach in Population Health Research: Examining the Association between the federal maternal evacuation policy on Maternal and Child outcomes in First Nation (FN) Communities in Manitoba.

Objectives Responding to the Truth and Reconciliation Commission of Canada’s (TRC) Call to Action #19 to close the gap in maternal/child outcomes, the goal of this study was to provide a baseline for select outcomes and demonstrate how an Indigenous/decolonizing framework can be applied to population health research involving Indigenous people. Approach This retrospective cohort study was embedded within a decolonizing and Indigenous framework. Data extracted from administrative data housed at the Manitoba Centre for Health Policy was utilized to create a cohort of low-risk women residing in FN communities delivering a baby between 2005-2015. Two groups of mother/child dyads were compared: those evacuated for birth and those who were not required to leave home. Data were analyzed to assess the association between the evacuation policy on health outcomes. Results Decolonizing and Indigenous frameworks are feasible, essential, and necessary in population health research involving Indigenous people. This methodology does not detract from scientific rigor. In keeping with Indigenous methodology, Knowledge Keepers and a Grandmother Advisor informed the research from the onset, including insightful dialogue about the study findings. Using such an approach, this study generated evidence that the present-day OFC policy continues to harm Indigenous women, families, and communities. The OFC policy is associated with increased odds of inadequate PNC (OR 1.64 1.51, 1.79 CI) and small for gestational age births (OR 1.25 1.02, 1.50 CI) and decreased breastfeeding initiation (OR 0.55 0.50, 0.61 CI) and maternal psychological distress diagnoses (OR .43 0.36, 0.51), after adjusting for various confounders. Conclusion This study documented a journey of an Anishinaabekwe in the space where western and Indigenous methodologies met. In answering the TRC call to improve maternal and infant outcomes, epidemiological and population health research requires epistemological frameworks that adequately incorporate the voices and realities of Indigenous people's lives while remaining scientifically rigorous