Arthritis care in Indigenous Communities

When a patient is diagnosed with a chronic condition like rheumatoid arthritis, health care immediately becomes more complex. Suddenly there are appointments with specialists and physiotherapists, lab tests, x-rays and visits to the pharmacy. Coordinating all these health services can be overwhelming, but add a remote location and cultural differences to the mix, and it becomes extremely difficult for patients to receive the care they need. This is especially evident for arthritis patients living in Indigenous communities across Alberta.

“In this world, unfortunately, medicine works in silos,” says Adalberto Loyola Sanchez, a physician and postdoctoral fellow in the McCaig Institute. “Services are very fragmented, even in urban settings,” he says. “Coordinating access to health services is even more challenging in Indigenous communities due to adverse socio-economic factors.” Loyola Sanchez and his supervisor, rheumatologist Cheryl Barnabe are working to improve arthritis care for those living on Alberta reserves.

Rheumatoid arthritis (RA), an autoimmune disease that causes painful inflammation and damage to joints, is three times more common among First Nations people than other Albertans. Having access to a rheumatologist and related support services is vitally important because RA can often be treated successfully if caught early. However, after looking at provincial health information, Barnabe noticed that First Nations patients with RA and osteoarthritis were often receiving care for their condition from their family physician rather than a specialist. They were also 1/3 less likely than non-First Nations Albertans to get orthopaedic surgeries for osteoarthritis. So she asked the question, “why?”

Identifying the barriers 

Barnabe, who herself is of Métis heritage, travels monthly to the Tsuut’Ina, Siksika and Blood reserves to provide rheumatology care. Through her work on the Siksika reserve, and in coordination with Siksika Health Services, she and Loyola Sanchez embarked on a study to identify the barriers to receiving arthritis care for patients from that community.

Through interviews with health care workers, patients and their families. They found 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. “People were deciding to “tough out” their arthritis because they didn’t trust the western health system,” says Barnabe. “This had to do with frank episodes of stereotyping and racism that had occurred in the health system when they came to specialty care.”

In addition, even though specialists were visiting the community, there were still important areas of arthritis management not being met. With the help of an advisory committee comprised of community leaders, patients and healthcare workers, Loyola Sanchez determined four things that could improve arthritis care:

• Coordination of services. Even in a small centre, there are many different departments – clinical services, community health, home care, rehabilitation services for example. These departments need to enhance the development of coordinated care plans to meet patient needs.
• Physician awareness and advocacy for needed services. As the physicians that practice at Siksika do not live in the community, there is a gap in understanding what is needed for access to services and disease education.
• Support for patients to explore traditional medicine options. Many patients feel threatened by western medicine, however community knowledge of traditional medicine is dwindling. Patients feel caught in the middle of two cultures.
• An arthritis patient support system within the community. Patients feel disconnected from other people with the same health issues. They would like to connect with others for support.

Implementing change

With the help of the advisory committee, it was decided that a case manager with cultural knowledge was needed at the Siksika Health Centre to coordinate services for patients living with RA. “We determined that seeing a physician once a month is not enough. There needs to be someone with cultural knowledge from the community to coordinate services – medications, appointments, rehabilitation services.” They recently recruited a community member to fill the position, and will do an evaluation to see if arthritis outcomes and satisfaction with care improves.

Cheryl Barnabe is an associate professor in the University of Calgary’s Cumming School of Medicine and a member of the McCaig Institute and the O’Brien Institute for Public Health.

Adalberto Loyola Sanchez is a researcher with Dr. Barnabe’s team, and a physiatrist with the Mayan Municipality of Chankom in Yucatan, Mexico. He recently received the prestigious Banting Postdoctoral Fellowship.