Volume 150, February 2016, Pages 128–143
Open Access
Highlights
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- We identify successful indigenous child health promotion programs in Canada.
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- We apply realist methods to study how, why and in what contexts programs work.
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- We demonstrate a new pathway linking indigenous ownership to program success.
Abstract
Purpose
Striking
disparities in Indigenous maternal-child health outcomes persist in
relatively affluent nations such as Canada, despite significant health
promotion investments. The aims of this review were two-fold: 1. To
identify Indigenous prenatal and infant-toddler health promotion
programs in Canada that demonstrate positive impacts on prenatal or
child health outcomes. 2. To understand how, why, for which outcomes,
and in what contexts Indigenous prenatal and infant-toddler health
promotion programs in Canada positively impact Indigenous health and
wellbeing.
Methods
We
systematically searched computerized databases and identified
non-indexed reports using key informants. Included literature evaluated a
prenatal or child health promoting program intervention in an
Indigenous population in Canada. We used realist methods to investigate
how, for whom, and in what circumstances programs worked. We developed
and appraised the evidence for a middle range theory of Indigenous
community investment-ownership-activation as an explanation for program
success.
Findings
Seventeen
articles and six reports describing twenty programs met final inclusion
criteria. Program evidence of local Indigenous community investment,
community perception of the program as intrinsic (mechanism of community
ownership) and high levels of sustained community participation and
leadership (community activation) was linked to positive program change
across a diverse range of outcomes including: birth outcomes; access to
pre- and postnatal care; prenatal street drug use; breast-feeding;
dental health; infant nutrition; child development; and child exposure
to Indigenous languages and culture.
Conclusions
These
findings demonstrate Indigenous community
investment-ownership-activation as an important pathway for success in
Indigenous prenatal and infant-toddler health programs.
Keywords
- Indigenous;
- Prenatal health promotion;
- Child health promotion;
- Program evaluation;
- Realist review
1. Introduction
As
a relatively affluent country, Canada is well positioned to respond to
the striking health inequities experienced by its growing population of
Indigenous infants and children (Postl et al., 2010, Smylie, 2014 and Unicef, 2009).
Investments in prenatal and infant-toddler health promoting programs
have been demonstrated to improve maternal, infant and child health
outcomes (Anderson et al., 2003, Chung et al., 2008 and World Health Organization, 2014), some even when they are rooted in population specific disparities in the social determinants of health (Anderson et al., 2003 and Dyson et al., 2014) which is certainly the case for Indigenous children in Canada (Anderson et al., 2003, Dyson et al., 2014, Findlay and Janz, 2012, Loppie Reading and Wien, 2009 and McNeil et al., 2009).
Numerous Indigenous specific and mainstream programs with significant
Indigenous participation currently exist and are funded through
investments at the federal, provincial/territorial, and municipal levels
(Aboriginal Affairs, 2013a, Aboriginal Affairs, 2013b and Human Resources and Skills Development Canada, 2010).
Despite
this marked health inequity and sizeable program response, there is a
gap in the literature that systematically identifies, documents and
evaluates the effectiveness of Indigenous prenatal and infant-toddler
health promotion programs in Canada (Health Council of Canada, 2011, McNeil et al., 2009 and Smylie and Adomako, 2009).
Evidence indicates that health promoting approaches effective in
non-Indigenous contexts will not necessarily be effective in Indigenous
contexts and point towards a need for messaging and approaches that
reflect local Indigenous systems of health knowledge and practice (Health Council of Canada, 2011, McNeil et al., 2009 and Tipene-Leach et al., 2010).
A synthesis of the evidence regarding program effectiveness specific to
Indigenous contexts is therefore urgently required. In addition to the
classic review of program effectiveness, a realist inquiry into how, why
and in what contexts programs are working is also extremely relevant
for ongoing policy and practice.
Approaches
to evidence synthesis based on realism encompass a number of features
which align well with existing scholarship bridging the domains of
Indigenous knowledge and public health. While Indigenous and modern
public health evidence assessment share a reliance on empirical
observations of outcomes, there are significant differences in
Indigenous and public health knowledge systems and assumptions, which
can lead to faulty underlying theory if not attended to. For example,
Indigenous hypothesis testing is almost always specific to a local
socio-ecologic context (Youngblood Henderson, 2000)
and classic biomedical hypothesis tests purposefully seek a distancing
from context in a positivist quest for generalizability. Realist
approaches to evidence synthesis provide an opportunity to bridge these
tensions by allowing for the explicit formulation of testable theories (Pawson et al., 2005 and Wong et al., 2013a)
which can be constructed in alignment with Indigenous knowledge systems
and assumptions. Realist reviews involve a theory-driven approach which
seeks to uncover key program mechanisms and contextual factors that are
linked to program success (or failure) (Pawson et al., 2005 and Wong et al., 2013a).
Such an approach guards against the non-explicit application of faulty
Eurocentric theory, which is a common Indigenous critique of mainstream
evidence synthesis (Smith, 2012 and Smylie et al., 2011).
Both
Indigenous and realist knowledge theorists describe a complex and
inter-related reality, of which humans impartially know and describe –
but with focus and rigour can come to know and describe better (Battiste and Youngblood Henderson, 2000 and Kirst and O'Campo, 2012).
The explanatory nature of realist review was also deemed desirable by
our front line Indigenous prenatal and infant-toddler health promotion
program and service provider knowledge user partners as it would support
successful adaptation of best practices to local settings.
