Osteoarthritis (OA), like many other chronic diseases, disproportionately affects Indigenous peoples (O’Brien et al., 2020). A study done in Alberta found that the prevalence of OA in First Nations peoples was double that of non-First Nations people (Barnabe et al., 2015). As the most common cause of disability in older adults, it is a very important issue to address (O’Brien et al., 2020). As I explored the literature on OA and Indigenous groups, two main issues stuck out to me:
There is a serious lack of research in the area of OA within Indigenous groups (O’Brien et al., 2020). We know from population surveys that arthritis is “the most commonly self-reported chronic illness”, however, we have very little data regarding specific forms of arthritis, their prevalence, or the severity of disease among Indigenous Peoples (Barnabe et al., 2015).
The literature shows us that people who find themselves at a socioeconomic disadvantage are at higher risk of OA. First line OA management recommendations from the Osteoarthritis Research Society International (OARSI) include: “Arthritis Education; Structured Land-Based Exercise Programs (Type 1- strengthening and/or cardio and/or balance training/neuromuscular exercise OR Type 2- Mind-body Exercise including Tai Chi or Yoga) with or without Dietary Weight Management” (Bannuru et al., 2019). Below are a few research studies which address these recommendations and link them to socioeconomic status:
We know that obesity is a main risk factor for OA (Assari et al, 2020). Although higher income is typically associated with reduced risk for obesity, this does not hold true for all populations/races. A study showed an inverse relationship between weight and income for White people, but they did not find the same effect for Black people. This study did not look specifically at Indigenous groups, but it brings to light a very important issue: health determinants that we look at as ‘protecting’ or ‘improving’ an individual’s health will not provide benefit universally. The article points out that this is especially important for physicians to be aware of.
People in lower socioeconomic classes are less likely to receive education on managing their OA from their doctors (Reyes & Katz, 2021). They are also less likely to join self-education programs, and they receive less exercise/physical therapy. As I mentioned above, these are two of the main ways in which OA is managed.
To further the above statement, a study in Sweden looked at the socioeconomic status of patients in an OA self-management program and compared it to the general population (Gustafsson et al., 2020). This study found that patients referred to the self-management programs were, on average, in a higher socioeconomic bracket than the general population. This tells us that these types of programs are not reaching groups in lower socioeconomic positions – who likely would benefit from them the most.
So, how can we do better?
We know that Indigenous patients must overcome numerous barriers in order to obtain treatment for arthritis, including "racism encountered in health care setting”, “professional expectations of patients” and “constraints imposed by complex health care systems that are not fully integrated at the municipal, provincial, and federal levels” (Barnabe et al., 2017). An additional key factor in all of this is limited access to specialists who can diagnose and treat these patients.
One approach that has been explored is to offer a Rheumatology outreach clinics on-reserve in conjunction with the on-reserve primary care center (Loyola-Sanchez et al., 2020). This has been done in a Southern Alberta Indigenous community since 2010 – which means we now have plenty of data to observe the impacts of this model. A study looked at the experiences of 32 persons which had either received or provided care through this model, including 14 health providers, 8 administrative staff and 10 Indigenous people with arthritis (Loyola-Sanchez et al., 2020). The research identified an “overarching need: to improve the model’s person-centered approach”. It also highlighted 4 areas for improvement:
“Enhancing patient-provider communication”
“Improving continuity of healthcare services”
“Increasing community awareness about the presence and negative impact of arthritis” and
“Increasing peer connections and support among people living with arthritis”
The University of Calgary interviewed two researchers who feature prominently in research related to arthritis and Indigenous groups in Canada. The article states that “while living in a remote location made it difficult to access specialty care, the bigger issue was that specialist health providers were not recognizing and respecting cultural differences. The unfortunate result of this is a distrust of western health medical doctors, and people choosing to “tough it out” rather than go to see a doctor” (Arthritis Care in Indigenous Communities, 2017).
As was highlighted by Richmond & Cook (2016) “there is great promise in community self-determination in health care and the role of community-led research…”. As I explored literature addressing gaps in OA for Indigenous groups, I found this to be especially true. What I found very interesting was a document published in 1995: the B.C. First Nations Arthritis Self-Management Program. This program was the result of four Indigenous communities approaching The Arthritis Society to see how they could tackle the issue of arthritis in their communities together (First Nations Arthritis Self-Management Program, 1995). The program was based on the already utilized “Arthritis Self-Management Program”, with the incorporation of the cultural beliefs and practices of the Indigenous communities after in-depth discussions with community leaders. The program involved the education and training of community leaders who would then educate their respective community members. Overall, the program found significant improvement in 9 outcome domains: health status, pain, disability, stress, fear, anger, depression, self-efficacy related to symptoms and self-efficacy related to pain. It also found that the relationships between the community and the physicians was improved, and those suffering with arthritis were able to connect with a social network which offered them much needed support. Unfortunately, I was not able to find anything that suggests that this program has been implemented anywhere else, as the trail runs dry after 1995. I find this to be especially unfortunate in light of the fact that it seems this program would effectively address the 4 main gaps I highlighted above!
Lastly, I wanted to share an editorial released in July 2020 titled “Tackling the Burden of Osteoarthritis as a Health Care Opportunity in Indigenous Communities – A Call to Action” (O’Brien et al., 2020). This editorial explains why addressing OA in Indigenous communities is so important, how it relates to the overall burden of chronic disease in Indigenous populations, what the research shows, where the gaps are, and most importantly, a call to action. Below is a table from the report which provides a great summary:
(O’Brien et al., 2020)
I would love to hear your thoughts on this topic!
References:
Arthritis care in Indigenous Communities. (2017, March 1). News. https://www.ucalgary.ca/news/arthritis-care-indigenous-communities
Assari, S., Bazargan, M., & Chalian, M. (2020). The Unequal Effect of Income on Risk of Overweight/Obesity of Whites and Blacks with Knee Osteoarthritis: The Osteoarthritis Initiative. Journal of Racial and Ethnic Health Disparities, 7(4), 776–784. https://doi.org/10.1007/s40615-020-00719-5
Bannuru, R. R., Osani, M. C., Vaysbrot, E. E., Arden, N. K., Bennell, K., Bierma-Zeinstra, S. M. A., Kraus, V. B., Lohmander, L. S., Abbott, J. H., Bhandari, M., Blanco, F. J., Espinosa, R., Haugen, I. K., Lin, J., Mandl, L. A., Moilanen, E., Nakamura, N., Snyder-Mackler, L., Trojian, T., … McAlindon, T. E. (2019). OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis and Cartilage, 27(11), 1578–1589. https://doi.org/10.1016/j.joca.2019.06.011
Barnabe, C., Hemmelgarn, B., Jones, C. A., Peschken, C. A., Voaklander, D., Joseph, L., Bernatsky, S., Esdaile, J. M., & Marshall, D. A. (2015). Imbalance of Prevalence and Specialty Care for Osteoarthritis for First Nations People in Alberta, Canada. The Journal of Rheumatology, 42(2), 323–328. https://doi.org/10.3899/jrheum.140551
Barnabe, C., Lockerbie, S., Erasmus, E., & Crowshoe, L. (2017). Facilitated access to an integrated model of care for arthritis in an urban Aboriginal population. Canadian Family Physician, 63(9), 699–706. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5597017/
FIRST NATIONS ARTHRITIS SELF-MANAGEMENT PROGRAM. (1995). 111.
Loyola-Sanchez, A., Pelaez-Ballestas, I., Crowshoe, L., Lacaille, D., Henderson, R., Rame, A., Linkert, T., White, T., & Barnabe, C. (2020). “There are still a lot of things that I need”: A qualitative study exploring opportunities to improve the health services of First Nations People with arthritis seen at an on-reserve outreach rheumatology clinic. BMC Health Services Research, 20(1), 1076. https://doi.org/10.1186/s12913-020-05909-9
Gustafsson, K., Kvist, J., Eriksson, M., Dahlberg, L. E., & Rolfson, O. (2020). Socioeconomic status of patients in a Swedish national self-management program for osteoarthritis compared with the general population—A descriptive observational study. BMC Musculoskeletal Disorders, 21(1), 10. https://doi.org/10.1186/s12891-019-3016-z
O’Brien, P., Bunzli, S., Lin, I., Gunatillake, T., Bessarab, D., Coffin, J., Garvey, G., Dowsey, M., & Choong, P. (2020). Tackling the Burden of Osteoarthritis as a Health Care Opportunity in Indigenous Communities—A Call to Action. Journal of Clinical Medicine, 9(8), 2393. https://doi.org/10.3390/jcm9082393
Reyes, A. M., & Katz, J. N. (2021). Racial/Ethnic and Socioeconomic Disparities in Osteoarthritis Management. Rheumatic Disease Clinics of North America, 47(1), 21–40. https://doi.org/10.1016/j.rdc.2020.09.006
Richmond, C. A. M., & Cook, C. (2016). Creating conditions for Canadian aboriginal health equity: The promise of healthy public policy. Public Health Reviews, 37(1), 2. https://doi.org/10.1186/s40985-016-0016-5
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