Essential Elements for Advancing Cultural Humility through a Community-Based Physical Therapy Practicum in a Métis Community

Identifying Relevant Content to Inform a Comprehensive Indigenous Health Curriculum: A Scoping Review

Purpose

To identify the entry-level curricular content related to Indigenous health recommended for entry-level physiotherapy (PT) programs in Canada and other similar countries.

Methods

Design: Scoping review. Procedures: Four electronic databases were searched using the terms physiotherapy, Indigenous health, entry-level curriculum, and their derivatives. Grey literature sources were hand searched and included Canadian PT professional documents, PT Program websites, Truth and Reconciliation Commission (TRC) sources, and a Google search. Data related to curriculum characteristics, methods of delivery, and barriers and facilitators to implementation were extracted from relevant references. Stakeholders reviewed study findings.

Results

Forty-five documents were included. Documents focused on Indigenous peoples in Canada, Aboriginal and Torres Strait Islanders in Australia, and Māori in New Zealand. Canadian PT programs appeared to rely on passive teaching methods while programs in Australia and New Zealand emphasized the importance of partnering and engaging with Indigenous people. Barriers to incorporating indigenous health curriculum included an overcrowded curriculum and difficulty establishing relevance of Indigenous content (i.e., meaning).

Conclusions

Similarities and differences were found between curricula content and approaches to teaching IH in Canada and the other countries reviewed. Strategies to promote greater engagement of Indigenous people in the development and teaching of IH is recommended.

Health Equity and Policy Considerations for Pediatric and Adult Congenital Heart Disease Care among Minoritized Populations in the United States

Achieving health equity in populations with congenital heart disease (CHD) requires recognizing existing disparities throughout the lifespan that negatively and disproportionately impact specific groups of individuals. These disparities occur at individual, institutional, or system levels and often result in increased morbidity and mortality for marginalized or racially minoritized populations (population subgroups (e.g., ethnic, racial, social, religious) with differential power compared to those deemed to hold the majority power in the population). Creating actionable strategies and solutions to address these health disparities in patients with CHD requires critically examining multilevel factors and health policies that continue to drive health inequities, including varying social determinants of health (SDOH), systemic inequities, and structural racism. In this comprehensive review article, we focus on health equity solutions and health policy considerations for minoritized and marginalized populations with CHD throughout their lifespan in the United States. We review unique challenges that these populations may face and strategies for mitigating disparities in lifelong CHD care. We assess ways to deliver culturally competent CHD care and to help lower-health-literacy populations navigate CHD care. Finally, we review system-level health policies that impact reimbursement and research funding, as well as institutional policies that impact leadership diversity and representation in the workforce.

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.

Critical physiotherapy: a ten-year retrospective

Critical physiotherapy has been a rapidly expanding field over the last decade and could now justifiably be called a professional sub-discipline. In this paper we define three different but somewhat interconnected critical positions that have emerged over the last decade that share a critique of physiotherapy's historical approach to health and illness, while also diverging in the possibilities for new forms of practice and thinking. These three positions broadly align with three distinctive philosophies: approaches that emphasize lived experience, social theory, and a range of philosophies increasingly referred to as the "posts". In this paper we discuss the origins of these approaches, exploring the ways they critique contemporary physiotherapy thinking and practice. We offer an overview of the key principles of each approach and, for each in turn, suggest readings from key authors. We conclude each section by discussing the limits of these various approaches, but also indicate ways in which they might inform future thinking and practice. We end the paper by arguing that the various approaches that now fall under the rubric of critical physiotherapy represent some of the most exciting and opportune ways we might (re)think the future for the physiotherapy profession and the physical therapies more generally.

Beliefs around the causes of inequities and intergroup attitudes among health professional students before and after a course related to Indigenous Peoples and colonialism

BACKGROUND

Addressing the Truth and Reconciliation Calls to Action on including anti-racism and cultural competency education is acknowledged within many health professional programs. However, little is known about the effects of a course related to Indigenous Peoples and colonialism on learners' beliefs about the causes of inequities and intergroup attitudes.

METHODS

A total of 335 learners across three course cohorts (in 2019, 2020, 2022) of health professional programs (e.g., Dentistry/Dental Hygiene, Medicine, Nursing, and Pharmacy) at a Canadian university completed a survey prior to and 3 months following an educational intervention. The survey assessed gender, age, cultural identity, political ideology, and health professional program along with learners' causal beliefs, blaming attitudes, support for social action and perceived professional responsibility to address inequities. Pre-post changes were assessed using mixed measures (Cohort x Time of measurement) analyses of variance, and demographic predictors of change were determined using multiple regression analyses. Pearson correlations were conducted to assess the relationship between the main outcome variables.

RESULTS

Only one cohort of learners reported change following the intervention, indicating greater awareness of the effects of historical aspects of colonialism on Indigenous Peoples inequities, but unexpectedly, expressed stronger blaming attitudes and less support for government social action and policy at the end of the course. When controlling for demographic variables, the strongest predictors of blaming attitudes towards Indigenous Peoples and lower support for government action were gender and health professional program. There was a negative correlation between historical factors and blaming attitudes suggesting that learners who were less willing to recognize the role of historical factors on health inequities were more likely to express blaming attitudes. Further, stronger support for government action or policies to address such inequities was associated with greater recognition of the causal effects of historical factors, and learners were less likely to express blaming attitudes.

CONCLUSION

The findings with respect to blaming attitudes and lower support for government social action and policies suggested that educational interventions can have unexpected negative effects. As such, implementation of content to address the Truth and Reconciliation Commissions Calls to Action should be accompanied by rigorous research and evaluation that explore how attitudes are transformed across the health professional education journey to monitor intended and unintended effects.

Actualizing Cultural Humility: An Exploratory Study of Veterinary Students' Participation in a Northern Community Health Rotation

Rotations in diverse, marginalized communities may offer health care students opportunities to develop cultural humility through different clinical experiences and activities. Through the actualization of cultural humility, veterinarians may offer accessible, affordable, culturally proficient, high-quality care to all their patients with a better understanding of how cultural differences affect the animal patient's health, well-being, and care. The purpose of this study was to explore whether participation in a community rotation in remote northern Indigenous communities promotes cultural humility among final-year veterinary students. Small groups of University of Calgary veterinary students travel annually to the Sahtu Settlement Area of the Northwest Territories, Canada, to participate in the Northern Community Health Rotation (NCHR). During the 4-week rotation, students spend 2.5 weeks providing veterinary services to domestic animals in five communities in the Sahtu. Eleven veterinary students who attended the NCHR between 2015 and 2020 answered exploratory open-ended questions in an online survey. Responses highlight areas of learning that contributed to their development of cultural humility. The rotation appears successful in increasing students' confidence working with people from diverse cultures, offering students opportunities to implement a client-centered approach, and advancing their capacity to recognize and challenge their preconceived biases about Indigenous cultures and animal ownership. These experiences are important to the acquisition of cultural humility for veterinary care providers.

Student Veterinarian Perceptions of Community-Based Primary Care Veterinary Clinics in Indigenous Communities in Southern Ontario, Canada

Community-based primary care veterinary clinics represent an opportunity to benefit multiple populations. Student veterinarians are afforded the opportunity to build technical and non-technical professional skills, while underserved communities are provided with access to companion animal care. The Ontario Veterinary College (OVC), as with many other veterinary colleges across Canada and the United States, has hosted community-based primary care veterinary clinics, including in local Indigenous communities. As these clinics continue and grow, it is critical to evaluate their operation to ensure that they align with community goals and values, adequately support student learning, and do not perpetuate racism and implicit bias. The objective of this study was to explore the perceptions of student veterinarians who had volunteered at community-based primary care veterinary clinics in First Nations communities in southern Ontario, Canada. We used an online survey that consisted of multiple choice and short answer questions focused on motivating factors for involvement, supports available before and during the clinics, exposure to Indigenous cultures, and the challenges and rewards associated with volunteering. Forty-one student veterinarians from OVC completed the survey in January 2020. Most students were motivated to volunteer to make a positive difference in the lives of people and animals and improve their clinical skills. In general, respondents felt adequately prepared for and supported during their experiences but did recommend additional pre-departure instructions on roles and responsibilities. Participants were ambivalent as to whether they had learned about Indigenous culture, with several strongly recommending more cultural sensitivity training. Most students found their experiences rewarding because of the gratitude expressed by clients and the feeling that they had made a difference. We reflect on the potential benefits and challenges of community-based primary care veterinary clinics in light of student responses.

Health professional perspectives on translation of cultural safety concepts into practice: A scoping study

People from unique and diverse populations, (i.e., social groupings excluded by the dominant majority by, for example, ethnicity, gender, age, sexual orientation, disability or even rurality), experience dissimilar health outcomes. Members of such populations who have long-term health conditions experience further health disparities through inefficient management and treatment. This remains a significant hindrance to achieving equity in health outcomes. Being responsive and acting upon the cultural needs of unique and diverse populations within health services is pivotal in addressing health disparities. Despite provision of professional training to health professionals, cultural competency remains an elusive goal. This scoping study summarized available literature about what helped health professionals translate cultural safety concepts into practice. We searched electronic databases using MeSH terms and keywords for English language articles and reference lists of potentially included studies. Quality appraisal was undertaken using Joanna Briggs Institute critical appraisal tools. Data were charted, with a descriptive numerical summary and thematic analysis of study findings undertaken. Twelve qualitative studies with n = 206 participants were included. Learning through and from direct experience, and the individual qualities of professionals (i.e., individual capacity for relational skills and intentionality of engagement with one's own values and biases) facilitated translation of cultural safety concepts into practice. Also important was the need for cultural training interventions to address both issues of content and process within course design. Doing this would take into consideration the benefits that can come from learning as a part of a collective. In each of these themes was evidence of how health professionals needed the ability to manage emotional discomfort as part of the process of learning. A dearth of information exists exploring professionals' perspectives on translating cultural safety concepts into practice. There may be merit in designing educational interventions that look beyond the classroom. We also suggest that nurturing people's relational skills likely holds benefits to growing culturally safe practice as does increasing health professional's capacity to sit with the discomfort that occurs when paying attention to one's own and others values and biases.

Challenging Health Service Delivery Models to Improve Access to Physical Therapy in Rural, Remote and Northern Communities

Effective rural, remote and northern physical therapy services are an important component of health care. Providing these services with limited financial and human resources can present many challenges. Indigenous communities also have unique needs that must be considered when providing health care. Most current service delivery models are based in Western medicine practices and most often, do not account for the local, political, cultural and spiritual needs of communities. In this perspective article, I discuss the challenges of providing these services in rural Yukon to many small First Nation communities. Relationship building is paramount to effective and meaningful health care programs, and this means a change in current practice approaches. We need to challenge the delivery models and be open to other ways of knowing, beyond the Western biomedical approach that is the foundation of our profession. It is imperative that physical therapists, health care providers and funders seek new and innovative ways to provide services to the rural, remote and northern communities while ensuring a culturally humble approach.

Reflexive Practice as an Approach to Improve Healthcare Delivery for Indigenous Peoples: A Systematic Critical Synthesis and Exploration of the Cultural Safety Education Literature

Cultural safety is increasingly being taught in tertiary programmes of study for health professionals. Reflexivity is a key skill required to engage in culturally safe practice, however, there is currently limited literature examining how reflexivity is taught or assessed within cultural safety curricula. A systematic review of the literature up until November 2021 was conducted, examining educational interventions which aimed to produce culturally safe learners. Studies were limited to those with a focus on Indigenous health and delivered in Australia, Aotearoa New Zealand, Canada, and the United States. A total of 46 documents describing 43 different educational interventions were identified. We found that definitions and conceptualisations of reflexivity varied considerably, resulting in a lack of conceptual clarity. Reflexive catalysts were the primary pedagogical approaches used, where objects, people, or Indigenous pedagogies provided a counterpoint to learners’ knowledges and experiences. Information regarding assessment methods was limited but indicates that the focus of existing programmes has been on changes in learner knowledge and attitudes rather than the ability to engage in reflexivity. The results demonstrate a need for greater conceptual clarity regarding reflexivity as it relates to cultural safety, and to develop methods of assessment that focus on process rather than outcomes.