"All my relations": experiences and perceptions of Indigenous patients connecting with Indigenous Elders in an inner city primary care partnership for mental health and well-being

Inuit youth health and wellbeing programming in Canada

Inuit youth face challenges in maintaining their wellbeing, stemming from continued impacts of colonisation. Recent work documented that urban centres, such as Winnipeg Canada, have large Inuit populations comprised of a high proportion of youth. However, youth lack culturally appropriate health and wellbeing services. This review aimed to scan peer-reviewed and grey literature on Inuit youth health and wellbeing programming in Canada. This review is to serve as an initial phase in the development of Inuit-centric youth programming for the Qanuinngitsiarutiksait program of research. Findings will support further work of this program of research, including the development of culturally congruent Inuit-youth centric programming in Winnipeg. We conducted an environmental scan and used an assessment criteria to assess the effectiveness of the identified programs. Results showed that identified programs had Inuit involvement in creation framing programming through Inuit knowledge and mostly informed by the culture as treatment approach. Evaluation of programs was diffcult to locate, and it was hard to discren between programming, pilots or explorative studies. Despite the growing urban population, more non-urban programming was found. Overall, research contributes to the development of effective strategies to enhance the health and wellbeing of Inuit youth living in Canada.

Truth and Reconcilition Commissions and Health Care System Responses for Indigenous Peoples: A Scoping Review

Grounded in human rights approaches, truth and reconciliation commissions (TRCs) explore an event or process that did widespread and systematic intentional harm to a group of people. Health as a fundamental right is an important component addressed by TRCs. Yet despite TRCs often having recommendations for health care systems, it is unknown how well these recommendations are being translated within health care settings. Therefore, the overarching purpose of our scoping review was to identify academic articles that discussed health care system discourse or responses to TRCs in the context of Indigenous Peoples. Our thematic analysis of the included articles identified three main themes for health care system responses to TRCs: (1) the acknowledgment of multiple ways of knowing, being, and doing in health systems; (2) current interventions as responses within health systems; and (3) suggestions for change within health systems. Although a TRC may create a specific road map and mandate for health care systems, we found considerable variability in the uptake of these actions across institutions. Concerted efforts within and around health care systems and across sectors are therefore necessary to achieve large-scale, meaningful change for Indigenous Peoples post-TRCs and to maintain accountability as a foundational human rights principle.

'God is the one who give child': An abductive analysis of barriers to postnatal care using the Health Equity Implementation Framework

Background

Postnatal care is recommended as a means of preventing maternal mortality during the postpartum period, but many women in low- and middle-income countries (LMICs) do not access care during this period. We set out to examine sociocultural preferences that have been portrayed as barriers to care.

Methods

We performed an abductive analysis of 63 semi-structured interviews with women who had recently given birth in three regions of Ethiopia using the Health Equity Implementation Framework (HEIF) and an inductive-deductive codebook to understand why women in Ethiopia do not use recommended postnatal care.

Results

We found that, in many cases, health providers do not consider women's cultural safety a primary need, but rather as a barrier to care. However, women's perceived refusal to participate in postnatal visits was, for many, an expression of agency and asserting their needs for cultural safety.

Trial registration

n/a.

Conclusions

We propose adding cultural safety to HEIF as a process outcome, so that implementers consider cultural needs in a dynamic manner that does not ask patients to choose between meeting their cultural needs and receiving necessary health care during the postnatal period.

A scoping review of frameworks utilized in the design and evaluation of courses in health professional programs to address the role of historical and ongoing colonialism in the health outcomes of Indigenous Peoples

Indigenous education curriculum has been implemented in health professional programs as a potential solution to addressing commonly held false beliefs, as well as negative social attitudes and behaviours. As such it is important to map and analyze the current literature on educational initiatives that teach about historical and ongoing colonialism as a determinant of health to identify commonly used theoretical frameworks and outcomes assessed, as well as the intended and unintended short- and long-term outcomes on health professional learner's beliefs, attitudes and behaviours. This scoping review follows the framework by (Peters et al., JBI Evidence Synthesis 18:2119-2126, 2020). Six databases (MEDLINE, CINAHL, PsychInfo, Sociological Abstracts, ERIC, and ProQuest Dissertations and Theses) were searched with grey literature included through hand-searching of Indigenous journals and citation searching for papers published up until 2022 based on an established search criterion. Two reviewers independently screened articles. In total, 2731 records were identified and screened; full text was assessed for 72 articles; 14 articles were identified as meeting all the inclusion criteria and included in the final review. Commonly- used theoretical frameworks were transformative learning and cultural safety, with a variety of evaluation tools used and post-intervention outcomes measured across the studies (e.g., knowledge, beliefs, attitudes, behaviour and general learner feedback). Indigenous education interventions require longitudinal evaluation studies to address shortcomings in the design and evaluation of outcomes associated with teaching about colonialism as a structural determinant of health. It is critical that we identify and monitor the intended and unintended consequences of such curriculum as we look to develop solutions to changing health professional learners' false beliefs and attitudes, in hopes to inform their future care practices.

Core components of an anti-racist approach among health professions educators: an integrative review

Objectives

This integrative literature review aimed to identify the core elements of an anti-racist approach among health professions educators.

Methods

We searched five databases CINAHL (EBSCOhost), ERIC (ProQuest Dissertations & Thesis Global), EMBASE (Ovid), MEDLINE (Ovid), and Web of Science (Social Sciences Citation Index, Citation Index Expanded) in March 2021. The search strategy combined concepts related to anti-racist pedagogies in the context of health professions education by educators in any capacity. From 1,755 results, we selected 249 manuscripts published in English or French between 2008 and 2021 based on titles and abstracts. After reviewing the full texts, we selected the 48 most relevant sources. We extracted data regarding knowledge, skills, and attitudes in reference to anti-racist approaches or surrogate terms. Within each category, we grouped similar data using a conceptual map.

Results

Analysis of the selected sources revealed that, for health professions educators, engaging in an anti-racist pedagogical approach requires more than incorporating racialized perspectives and content into the classroom. It rather rests on three interrelated components: developing a critical understanding of power relationships, moving toward a critical consciousness, and taking action at individual and organizational levels.

Conclusions

This review sheds light on knowledge, attitudes and skills that educators must deploy to adopt an anti-racist approach competently. This approach is a learned, intentional, and strategic effort in which health professions educators incorporate anti-racism into their teaching and apply anti-racist values to their various spheres of influence. This ongoing process strives for institutional and structural changes and requires whole-system actions.

Linking Heart Health and Mental Wellbeing: Centering Indigenous Perspectives from across Canada

Indigenous peoples have thrived since time immemorial across North America; however, over the past three to four generations there has been a marked increase in health disparities amongst Indigenous peoples versus the general population. Heart disease and mental health issues have been well documented and appear to be interrelated within Indigenous peoples across Canada. However, Western medicine has yet to clearly identify the reasons for the increased prevalence of heart disease and mental health issues and their relationship. In this narrative review, we discuss how Indigenous perspectives of health and wholistic wellness may provide greater insight into the connection between heart disease and mental wellbeing within Indigenous peoples and communities across Canada. We argue that colonization (and its institutions, such as the Indian Residential School system) and a failure to include or acknowledge traditional Indigenous health and wellness practices and beliefs within Western medicine have accelerated these health disparities within Indigenous peoples. We summarize some of the many Indigenous cultural perspectives and wholistic approaches to heart health and mental wellbeing. Lastly, we provide recommendations that support and wholistic perspective and Indigenous peoples on their journey of heart health and mental wellbeing.

Integrating Indigenous healing practices within collaborative care models in primary healthcare in Canada: a rapid scoping review

OBJECTIVES

In November 2020, a series of reports, In Plain Sight, described widespread Indigenous-specific stereotyping, racism and discrimination limiting access to medical treatment and negatively impacting the health and wellness of Indigenous Peoples in British Columbia, Canada. To address the health inequalities experienced by Indigenous peoples, Indigenous healing practices must be integrated within the delivery of care. This rapid scoping review aimed to identify and synthesise strategies used to integrate Indigenous healing practices within collaborative care models available in community-based primary healthcare, delivered by regulated health professionals in Canada.

ELIGIBILITY CRITERIA

We included quantitative, qualitative and mixed-methods studies conducted in community-based primary healthcare practices that used strategies to integrate Indigenous healing practices within collaborative care models.

SOURCES OF EVIDENCE

We searched MEDLINE, Embase, Indigenous Studies Portal, Informit Indigenous Collection and Native Health Database for studies published from 2015 to 2021.

CHARTING METHODS

Our data extraction used three frameworks to categorise the findings. These frameworks defined elements of integrated healthcare (ie, functional, organisational, normative and professional), culturally appropriate primary healthcare and the extent of community engagement. We narratively summarised the included study characteristics.

RESULTS

We identified 2573 citations and included 31 in our review. Thirty-nine per cent of reported strategies used functional integration (n=12), 26% organisational (n=8), 19% normative (n=6) and 16% professional (n=5). Eighteen studies (58%) integrated all characteristics of culturally appropriate Indigenous healing practices into primary healthcare. Twenty-four studies (77%) involved Indigenous leadership or collaboration at each phase of the study and, seven (23%) included consultation only or the level of engagement was unclear.

CONCLUSIONS

We found that collaborative and Indigenous-led strategies were more likely to facilitate and implement the integration of Indigenous healing practices. Commonalities across strategies included community engagement, elder support or Indigenous ceremony or traditions. However, we did not evaluate the effectiveness of these strategies.

Culturally safe interventions in primary care for the management of chronic diseases of urban Indigenous People: a scoping review

Objectives

Chronic conditions represent an important source of major health issues among Indigenous People. The same applies to those, who live off-reserve and in urban areas. However, very few healthcare services are considered culturally safe, resulting in some avoidance of the public healthcare system. Our goal was to review the literature on culturally safe practices available to urban Indigenous People who suffer from chronic diseases.

Design

We conducted a scoping review to determine what culturally safe healthcare services are currently offered for the management of chronic conditions in urban Indigenous populations, to contribute to a tailored, holistic and safe space in mainstream healthcare systems.

Eligibility criteria

Peer-reviewed original research articles had to be published by 27 October 2020, in English or French.

Information source: In October 2020, we searched five academic databases (EBSCO, PsycArticles, SocINDEX, MEDLINE and PsycINFO) and also reviewed grey literature and the websites of organisations or governments. The data were extracted and collected in an EXCEL spreadsheet. Two reviewers independently screened 326 titles and abstracts, followed by an independent evaluation of 48 full text articles. A total of 19 studies were included in this scoping review, as well as 5 websites/documents from the grey literature.

Results

In total, 19 studies were included in our analysis. We found that Elders, family and the assistance of an interpreter are crucial elements to include to make urban Indigenous feel safe when they seek healthcare services. With this scoping review, we report interventions that are successful in terms of healthcare delivery for this population. Our findings provide insight on what services should be in place in mainstream healthcare settings to create a culturally safe experience for urban Indigenous People.

Conclusions

In recent years, there appears to be a growing awareness of the need to provide culturally safe health services. This scoping review identified multiple strategies to promote cultural safety in this context, as well as barriers and facilitators to their implementation. These elements, which have been extensively documented in the literature, should be included in the chronic diseases management interventions to be developed by urban and primary care settings.

Identifying priorities, directions and a vision for Indigenous mental health using a collaborative and consensus-based facilitation approach

Background

Mental health disparities between Indigenous and non-Indigenous people in Canada are related to underlying economic, social, and political inequities that are legacies of colonization and the oppression of Indigenous cultures. It also widely acknowledged that mental health services currently available may not be culturally appropriate in supporting the health needs of Indigenous Canadians. A two-day Indigenous mental health forum examined mental health needs and gaps among Indigenous communities across the Regional Municipality of Wood Buffalo (RMWB) on Treaty 8 territory, in northern Alberta, Canada. This paper outlines the insights generated by stakeholder engagement at the forum to identify and prioritize directions for Indigenous mental health and build a vision and strategy for improving mental health services and programs for the region’s diverse Indigenous population.

Methods

We applied a modified nominal group technique (NGT) consensus method embedded within Indigenous knowledge to determine key priorities and directions for Indigenous-focused mental health and synthesize information from discussions that occurred at the forum. Following the NGT, a participatory community visioning exercise was conducted with participants to develop a vision, guiding principles, and components of an action plan for an Indigenous mental health strategy for the RMWB.

Results

Four key themes for setting priorities and directions for Indigenous mental health emerged from roundtable group discussions: 1) understand the realities of mental health experiences for Indigenous peoples, 2) design a holistic and culturally rooted mental health system, 3) foster cross-sectoral engagement and collaboration on mental health service delivery, and 4) focus on children and youth. The community visioning exercise helped stakeholders to visualize a direction or path forward for addressing existing gaps in the mental health system and opportunities for strengthening Indigenous mental health in the region.

Conclusions

Forum participants described mental health and well-being around holistic concepts of social and emotional well-being. Addressing Indigenous mental health and wellness involves multi-sectoral action in various settings including community and school through programs, policies, and other interventions that promote mental health for all Indigenous peoples, as well as for those at greater risk such as children and youth.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07682-3.

Association between intergenerational solidarity involving elders and mental health of Indigenous people living off reserve

Background

Indigenous elders play an important role in transmitting knowledge, values and practices, hence fostering identity-building through intergenerational solidarity. We aimed to verify the association between intergenerational solidarity involving Indigenous elders and mental health of Indigenous people living off reserve.

Methods

We carried secondary analyses of data for a subsample from the cross-sectional 2012 Aboriginal Peoples Survey (total sample: n = 28,410 Indigenous persons aged ≥6 years old living off reserve; subsample: n = 13,020 aged 18–44 years old). Controlling for age as well as material and social deprivation, we used logistic regressions to verify the association between intergenerational solidarity (proxied as time spent with an elder and potential of turning to an elder or grandparent for support in times of need) and mental health (perceived mental health, mood disorders, anxiety, suicidal thoughts and attempts).

Results

About 39 and 9% of the respondents respectively reported having spent time with an elder and would have turned to an elder or grandparent for support in times of need. Women who would not turn to an elder or grandparent for support in times of need were more likely to report fair or poor perceived mental health (OR = 1.69, p = 0.03). Men not spending time with an elder were more likely to experience mood disorders (OR = 1.66, p = 0.004). Women who would not turn to an elder or grandparent for support in times of need were more likely to experience anxiety disorders (OR = 1.57, p = 0.04). Women not spending time with an elder or who would not turn to an elder or grandparent for support in times of need were respectively more likely to have suicidal thoughts (OR = 1.62, p = 0.04) or to have attempted suicide (OR = 3.38, p = 0.04).

Conclusion

Intergenerational solidarity is associated with better mental health outcomes of Indigenous people living off reserve. These results could guide policies and practices that aim to enhance mental health and wellness in Indigenous populations.

The Efficacy of a Health Promotion Intervention for Indigenous Women: Reclaiming Our Spirits

Indigenous women globally are subjected to high rates of multiple forms of violence, including intimate partner violence (IPV), yet there is often a mismatch between available services and Indigenous women's needs and there are few evidence-based interventions specifically designed for this group. Building on an IPV-specific intervention (Intervention for Health Enhancement After Leaving [iHEAL]), "Reclaiming Our Spirits" (ROS) is a health promotion intervention developed to address this gap. Offered over 6 to 8 months in a partnership between nurses and Indigenous Elders, nurses worked individually with women focusing on six areas for health promotion and integrated health-related workshops within weekly Circles led by an Indigenous Elder. The efficacy of ROS in improving women's quality of life and health was examined in a community sample of 152 Indigenous women living in highly marginalizing conditions in two Canadian cities. Participants completed standard self-report measures of primary (quality of life, trauma symptoms) and secondary outcomes (depressive symptoms, social support, mastery, personal agency, interpersonal agency, chronic pain disability) at three points: preintervention (T1), postintervention (T2), and 6 months later (T3). In an intention-to-treat (ITT) analysis, Generalized Estimating Equations (GEE) were used to examine hypothesized changes in outcomes over time. As hypothesized, women's quality of life and trauma symptoms improved significantly pre- to postintervention and these changes were maintained 6 months later. Similar patterns of improvement were noted for five of six secondary outcomes, although improvements in interpersonal agency were not maintained at T3. Chronic pain disability did not change over time. Within a context of extreme poverty, structural violence, and high levels of trauma and substance use, some women enrolled but were unable to participate. Despite the challenging circumstances in the women's lives, these findings suggest that this intervention has promise and can be effectively tailored to the specific needs of Indigenous women.

Beyond deficit: 'strengths-based approaches' in Indigenous health research

Health research concerning Indigenous peoples has been strongly characterised by deficit discourse-a 'mode of thinking' that is overly focused on risk behaviours and problems. Strengths-based approaches offer a different perspective by promoting a set of values that recognise the capacities and capabilities of Indigenous peoples. In this article, we seek to understand the conceptual basis of strengths-based approaches as currently presented in health research. We propose that three main approaches exist: 'resilience' approaches concerned with the personal skills of individuals; 'social-ecological' approaches, which focus on the individual, community and structural aspects of a person's environment; and 'sociocultural' approaches, which view 'strengths' as social relations, collective identities and practices. We suggest that neither 'resilience' nor 'social-ecological' approaches sufficiently problematise deficit discourse because they remain largely informed by Western concepts of individualised rationality and, as a result, rest on logics that support notions of absence and deficit. In contrast, sociocultural approaches tend to view 'strengths' not as qualities possessed by individuals, but as the structure and character of social relations, collective practices and identities. As such, they are better able to capture Indigenous ways of knowing and being and provide a stronger basis on which to build meaningful interventions.

Integrating equity and social justice for indigenous peoples in undergraduate health professions education in Canada: a framework from a critical review of literature

Understanding how to create structural change by actively counteracting racialized ways of interacting with Indigenous peoples at an individual and organizational level within health care systems and health professions education is essential for creating a more inclusive, equitable, and healthier society. In health professions education, the primary means of teaching about health inequities has been to frame them as stemming from culturally or ethnically based issues. While attention to culturally specific practices can be valuable to health and healing in some contexts, education that solely focuses on Indigenous cultures risks perpetuating cultural stereotypes and othering, rather than focusing on how Eurocentric systems continue to exert oppressive effects on Indigenous peoples. We present an organizational transformation framework grounded in equitable partnerships from a comprehensive critical review of the literature on the integration of equity and social justice in undergraduate health professions education with a focus on Indigenous health. We did a thematic analysis of the results and discussions presented in the 26 selected articles to identify promising practices and challenges associated with the integration of equity and social justice in undergraduate health professions education. The framework resulting from this analysis is composed of three interrelated components: 1) adopt critical pedagogical approaches that promote Indigenous epistemologies; 2) partner with Indigenous students, educators and communities; 3) engage educators in critical pedagogical approaches and health equity issues. This framework could guide the development of contextually tailored interventions that contribute to decolonizing health professions education.

The Path to Eldership: Results from a Contemporary Indigenous Australian Community

BACKGROUND AND OBJECTIVES

Traditionally, Elders have held a unique social position within Indigenous Australian communities. This study aimed to identify the characteristics of Indigenous Elders that distinguish them from other people in their community.

RESEARCH DESIGN AND METHODS

Using a community-based participatory research approach, the study was conducted in a regional Indigenous community in Southeast Queensland. The design and data collection methods were informed through a community forum, known as a 'Yarning Circle'. One-on-one semi-structured interviews and focus groups with community members were carried out by Indigenous researchers. Data were analysed in NVivo software, using thematic analysis (TA), with themes derived directly from data.

RESULTS

Fifty individuals participated in the study. The participants' median age was 45 years (range 18-76 years) and 31 (62%) were female. TA identified three overarching themes related to Elders' attributes: (1) distinguishing characteristics of Elders (sub-themes of respect, leadership, reciprocity, life experience, approachability, connection to traditional culture, transmitting knowledge through generations): (2) how one becomes an Elder (earnt eldership, permanency of eldership, mentors and role models, age); and (3) threats to Elders' influence (intergenerational gap, community disconnect, and cultural trauma).

DISCUSSION AND IMPLICATIONS

Our results build a greater understanding of the contemporary role of Indigenous Australian Elders, which will inform the development of future interventions directed at strengthening Elders' role in their communities.

Partnering with Indigenous Elders in primary care improves mental health outcomes of inner-city Indigenous patients: Prospective cohort study

OBJECTIVE

To determine whether including Indigenous Elders as part of routine primary care improves depressive symptoms and suicidal ideation in Indigenous patients.

DESIGN

Prospective cohort study with quantitative measures at baseline and 1, 3, and 6 months postintervention, along with emergency department (ED) utilization rates before and after the intervention.

SETTING

Western Canadian inner-city primary care clinic.

PARTICIPANTS

A total of 45 people who were older than age 18, who self-identified as Indigenous, and who had no previous visits with the clinic-based Indigenous Elders program.

INTERVENTION

Participants met with an Indigenous Elder as part of individual or group cultural sessions over the 6-month study period.

MAIN OUTCOME MEASURES

Changes in depressive symptoms, measured with the PHQ-9 (Patient Health Questionnaire), following Indigenous patients' encounters with Indigenous Elders. Secondary outcomes included changes in suicide risk (measured with the SBQ-R [Suicidal Behaviors Questionnaire-Revised]) and ED use.

RESULTS

Characteristics among those who consented to participate were as follows: 71% were female; mean age was 49 years; 31% had attended residential or Indian day school; and 64% had direct experience in the foster care system. At baseline 28 participants had moderate to severe depressive symptoms (PHQ-9 score of ≥ 10). There was a 5-point decrease that was sustained over a 6-month period (P = .001). Fourteen participants had an above-average suicide risk score at baseline (SBQ-R score of ≥ 7), and there was a 2-point decrease in suicide risk that was sustained over a 6-month period (P = .005). For all participants there was a 56% reduction in mental health-related ED visits (80 vs 35) when comparing the 12 months before and after enrolment.

CONCLUSION

Encounters with Indigenous Elders, as part of routine primary care, were associated with a clinically and statistically significant reduction in depressive symptoms and suicide risk among Indigenous patients. Emergency department use decreased, which might reduce crisis-oriented mental health care costs. Further expansion and evaluation of the role of Indigenous Elders as part of routine primary care is warranted.

Indigenous health disparities: a challenge and an opportunity

Summary

Clinical Indigenous health research is sparse and often not patient-centred. Despite a broad acknowledgement that Indigenous patients have unique clinical considerations, specific interventional research in Indigenous health is lacking.

Indigenous health disparities: a challenge and an opportunity

Summary

Clinical Indigenous health research is sparse and often not patient-centred. Despite a broad acknowledgement that Indigenous patients have unique clinical considerations, specific interventional research in Indigenous health is lacking.