Indigenous Health Research Monitoring, January 2022

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Articles summaries

Social inequalities and determinants of health

Families navigating community resources: Understanding and supporting Nunavimmiut families

Fraser, S. L., Parent, V., Weetaltuk, C., & Hunter, J. (2021). Families navigating community resources: Understanding and supporting Nunavimmiut families. International Journal of Circumpolar Health, 80(1), Article 1935594.
Open access: PDF

Context

Community resources include structured services, such as health care and daycare, as well as informal services, such as the support of a cargiver. Families in Nunavik navigate these resources, evaluate the impact of those resources on themselves, and decide which adjustments are necessary in order to make the situation coherent. They select one service over another based on different variables, specifically their understanding of the situation as well as the social and historical context. For this reason, an understanding of the heterogeneity of families’ choices, experiences and needs can help in better adapting services.

Objectives

Explore multidirectional interactions between the family dynamics of Inuit parents (social determinants of health in the immediate family) and community and locally available resources (social determinants of health at the community level).

Methodology and data

This qualitative study analyzed secondary data from research looking at community mobilization, in partnership with community leaders, as a means of supporting family wellbeing. Interviews conducted in 2015 with 14 parents, a majority of whom were women living in a Nunavik community, were accompanied by a brainstorming session with Inuit partners from the community.
The conceptual framework was based on the model of social determinants. Community-level social determinants influence not only existing boundaries between families and the community but also how families use formal and informal services.

What was learned?

The boundaries between the family and the community, as well as between the family and their use of resources, are permeable. This permeability varies over time and is influenced by two factors: the lived experiences of families and social determinants of health.

  • Families adopt various strategies to support their own wellbeing and that of their community. For example, if the community’s needs and expectations rise to the point of being invasive, families withdraw from their social network in order to protect themselves and reduce their exposure to stress factors.
  • Families who have lived through trauma try to deal with those past experiences while also protecting their interpersonal relations. For some families, the healing period involves having to make emotionally complex decisions between protecting the family unit and being present for the community (the extended family). In order to heal themselves and maintain harmonious relations, some families had to limit their interactions with certain community members, despite the repercussions on notions of kinship.
  • In facing complex family choices and having to calculate the repercussions of whether or not to use local resources, it is clear that social determinants of health influence the exposure of families to stress factors and how they choose to deal with them. For this reason, the definition of family and kinship relations within communities evolves over time.

Limitations

The researcher points out that she is not Indigenous and that she has her own culture, worldview and approach to organizing information. Moreover, the authors raise a limitation to generalizing the results: the project includes only one community and a small number of participants (just one man). Finally, since there was just one hour-long meeting with participants, the researcher was not well known to them, which impeded the development of a relationship of trust.


Understanding historical trauma for the holistic care of Indigenous populations: A scoping review

Joo-Castro, L., & Emerson, A. (2021). Understanding historical trauma for the holistic care of Indigenous populations: A scoping review. Journal of Holistic Nursing, 39(3), 285–305.
Not available through open access.

Context

Historical trauma refers to collective suffering and loss in the past that continue to affect populations in the present through intergenerational transmission, i.e., from parent to child. The health indicators of global Indigenous populations are poorer than those of non-Indigenous populations. Moreover, the links between health and historical trauma are still poorly understood, at least in the case of Indigenous populations. Research suggests that historical trauma impacts health by influencing Indigenous peoples’ perception of disease and healing, which in turn impacts health-related behaviour. The study of historical trauma is a complex field that is expanding rapidly through a variety of thematic, geographical and methodological approaches.

Objectives

The purpose of this scoping review was to assess the extent of the literature looking at historical trauma and its impact on Indigenous health. A better understanding of historical trauma and its effects may facilitate the development of holistic and culturally safe care for Indigenous populations.

Methodology and data

The scoping review used the Arksey and O’Malley framework as modified by Levac. Three databases were consulted, and 75 articles published between 1996 and 2020 were included. The analysis, which centred on North American Indigenous peoples, served to summarize trends in purpose, study design and theme that define the current literature on historical trauma.

What was learned?

  • In terms of research objectives, the most common ones were: 1) assess the awareness of historical loss (of identity, territory, family, etc.) and the symptoms experienced by the descendants of survivors of historical trauma; 2) understand the psychological symptoms that lead to risky health behaviours, including alcohol consumption, substance abuse and suicide.
  • With respect to research methods, the majority of studies used quantitative research design, of which 27 were observational and 13 experimental.
  • Five themes were identified:
    • Challenges in defining and measuring intergenerational transmission of historical trauma along epigenetic (variations in the expression of genes due to the environment) and social (e.g., parenting practices) pathways
    • Differentiating historical trauma from contemporary trauma and the intersection of the two (e.g., repercussions of the awareness of historical trauma on contemporary experience)
    • Consequences of racism, discrimination and micro-aggressions on health
    • Protection and risk factors, as well as resilience, through enculturation (the transmission of a culture to an individual by the society or group), acculturation (the modification of certain cultural elements through contact with another culture while remaining faithful to both) and assimilation (abandoning aspects of one’s original culture in favour of greater resemblance to a more dominant culture)
    • Interventions and programs that address historical trauma.

Gaps in the literature identified by the authors could guide future research. Understanding the mechanisms of transmission, distinguishing between present and past trauma, and understanding links to physical illness are avenues worth exploring. In addition, epigenetic and transmission theories could be tested, as was done by certain research on descendants of the Holocaust.

Limitations

One limitation identified by the authors is that the literature search, selection and initial analysis were conducted by just one author. On the other hand, the analysis and conclusions were carried out by both authors. The inclusion criterion of physical health caused by historical trauma means that other types of influence (economic, emotional, spiritual, etc.) may have been omitted from the analysis. Furthermore, the focus on Indigenous populations meant that populations of African descent who suffered historical trauma were not included.


Barriers and enablers to older Indigenous people engaging in physical activity—A qualitative systematic review

Gidgup, M. J. R., Kickett, M., Weselman, T., Hill, K., Coombes, J., Ivers, R., Bowser, N., Palacios, V., & Hill, A.-M. (2021). Barriers and enablers to older Indigenous people engaging in physical activity—A qualitative systematic review. Journal of Aging and Physical Activity, 1–13.
Not available through open access.

Context

In Australia, engagement in physical activity among Aboriginal and Torres Strait Islander populations decreases with age, and, in their opinion, many Western physical activity programs are disconnected from their culture and social support system. Sedentariness is associated with a high risk of chronic disease and a shorter life expectancy. The sedentary behaviour of Aboriginal and Torres Strait Islander populations is a repercussion of colonization, with the passage from a nomadic to a sedentary lifestyle being one example of this. Nations were forced off their lands and confined to one place. Forced sedentariness also has adverse consequences on the health of Indigenous peoples in other countries, including Canada. For this reason, studying what influences engagement in physical activity among older Aboriginal individuals could inform the development of programs to increase the probability of their being effective and culturally relevant.

Objectives

Conduct a literature review on barriers and enablers to engaging in physical activity among Indigenous individuals over the age of 40 in Australia and internationally.

Methodology and data

The authors followed the PRISMA guidelines in identifying 4,246 publications in four databases. After removing duplicates and making selections based on specific criteria, 23 articles were included. Following a search of Australian grey literature, one further report was also included. The authors assessed the quality of the articles using an evaluation tool designed by and for Aboriginal and Torres Strait Islander Australians. The data analysis is presented as a descriptive thematic analysis.

What was learned?

Community leadership appears to be a key factor for program success. With respect to structure, programs that are designed in accordance with Aboriginal worldviews and meet the needs of local Aboriginal populations act as an enabler. For example, programs that provide time for group discussion in the form of a sharing circle or include traditional activities stand out in the authors’ analyses. Furthermore, family and community support are an important factor in the studies. Family members may be present to provide support and encouragement during the physical activity, or a peer caregiver can provide guidance. Relationships with program implementation managers also influence program compliance. In addition, the high cost of a program and a lack of transportation to where the activities take place are considered barriers. Finally, participants’ motivation acts as an enabler for those who have a strong desire to improve their physical condition but as a barrier to overcome for participants who are ashamed of their physical condition.

The results described above encompass three overarching analytical themes:

  • Cultural safety and security is an important aspect, specifically the development of physical activity programs that are led by Aboriginal communities and incorporate their values. For example, successful programs reflect an understanding of the community’s infrastructure needs and how people should be welcomed.
  • Distrust arising from a history of colonialism acts as a negative influence on Aboriginal perceptions of advice or recommendations concerning physical activity. Adopting a decolonizing approach, for example by designing programs that focus on Aboriginal perspectives and knowledge, is recommended. Indeed, the authors point out that many Aboriginal communities do not see physical activity as an individual pursuit. They feel that the entire family should be involved, which is quite the opposite of modifying an individual’s behaviour, as is sometimes the goal in physical activity programs.
  • Effective programs take social determinants of health into consideration, including program cost and transportation. When these are not incorporated into planning, they become factors for demotivation and disengagement. Parenting responsibilities, feelings of isolation, and a lack of infrastructure and support from outside the community also make it more difficult to change behaviour.

Limitations

The authors point out that evaluating the quality of all the articles, independent of their source, with a tool designed in the Australian context is a limitation. They mention, however, that some features of the tool are relevant, given that Aboriginal epistemologies, values and principles are front and centre. They describe the studies included as being variable, specifically because not all of them involved Aboriginal individuals in the research.


Health consequences of child removal among Indigenous and non-Indigenous sex workers: Examining trajectories, mechanisms and resiliencies

Kenny, K. S., Krüsi, A., Barrington, C., Ranville, F., Green, S. L., Bingham, B., Abrahams, R., & Shannon, K. (2021). Health consequences of child removal among Indigenous and non‐Indigenous sex workers: Examining trajectories, mechanisms and resilienciesSociology of Health & Illness, 43(8), 1903–1920.
Not available through open access.

Context

Mothers who are sex workers tend to accumulate many factors of stigma (e.g., poverty and substance abuse), which expose them to a greater probability that the child protection system will intervene in the family. It is common to find intergenerational transmission of child removal among sex workers, especially in the case of Indigenous women. Moreover, Indigenous women are overrepresented in sex work across Canada. There is a link between child removal and several threats to the mother’s health. While a large body of research has studied the impact of removal from the home on the child’s health, little attention has been given to the health outcomes of this experience on the mother.

Objectives

The study aimed to achieve a better understanding of the impacts of child removal by the child protection system on mothers who are sex workers by examining health impacts. The study also aimed to explore the mechanisms underlying the relationship between removing children and the negative health impact on sex worker mothers.

Methodology

The article presents data collected by a prospective cohort study of a sample of female sex workers in Vancouver, Canada. Semi-structured interviews were conducted with 31 women aged 27 to 56 who had had a child removed by the child protection system. Among the women, 19 (61%) identified as Indigenous (First Nations or Métis). All of the participants reported living in conditions of extreme poverty. The interview guide was developed by Indigenous and non‑Indigenous researchers with the assistance of feedback from collaborators in the sex worker community. The thematic analysis was based on a qualitative approach.

What was learned?

The results served to identify four trajectories through which child removal influences the health of sex worker mothers:

  • Severe mental distress: All of the Indigenous and non-Indigenous participants reported experiencing severe mental distress after being separated from their children (i.e., depression, sadness, anger, and suicidal ideation and attempts). Several reported turning to drugs and alcohol as a strategy for coping with the distress. Drug use was identified as generating health issues such as weight loss, insomnia and a greater risk of overdose. Several Indigenous participants indicated that traumatic memories resurfaced of their own experience of having been removed from their family as a child.
  • Poverty: A worsening of poverty was mentioned by several participants, and this affected Indigenous women at a higher rate. Both Indigenous and non-Indigenous participants reported that the removal of their children could result in losing access to subsidized housing, leaving them homeless and even more dependent on their income from sex work. This intersection between poverty, homelessness and greater involvement in sex work exacerbated the harmful consequences on participants’ health and was associated with a greater risk of being subject to violence.
  • Social isolation and displacement: The narratives of Indigenous and non-Indigenous women include greater social isolation following the removal of their children. For some, and more commonly for the Indigenous participants, the loss of their children led to a loss of their social ties. This could be a result of self-imposed isolation motivated by feelings of shame and guilt, or else isolation due to conjugal violence that worsened following the removal of the children. No participants reported feeling supported by health and social services providers. Isolation and a lack of support damaged the health of these women by undermining their coping capacities and reducing access to resources.
  • Caretaking and family regeneration: Indigenous and non-Indigenous participants provided insight into certain strategies for taking care of themselves and maintaining or renewing the relationship with their children, for example, by becoming very involved with their grandchildren. They consider in-person access to their children to be essential and described it as an important source of motivation in reinforcing the women’s intentions to move towards better living conditions. Spiritual and cultural practices were also a critical component of healing for the Indigenous participants.

Limitations

The authors did not address limitations to their study.


Cultural safety

The KAIROS Blanket Exercise: Engaging Indigenous ways of knowing to foster critical consciousness in medical education

Herzog, L. S., Wright, S. R., Pennington, J. J., et Richardson, L. (2021). The KAIROS Blanket Exercise: Engaging Indigenous ways of knowing to foster critical consciousness in medical education. Medical Teacher, 43(12), 1437–1443.
Not available through open access.

Context

Fostering the critical consciousness of future physicians is an important way to work towards culturally safe care and reduce health disparities between Indigenous and non-Indigenous peoples. Medical education points to the existence of social determinants of health without necessarily calling into question their source, thereby perpetuating the notion that inequities are inevitable. The theory of critical consciousness suggests mindful awareness of the power dynamics between ourselves and others as a way to create a better understanding of the social roots of inequities in health and empower learners to engage in social action to reduce them. The application of the concept of critical consciousness in medical education has rarely been described in the literature.

Objectives

Evaluate the KAIROS Blanket Exercise intended to foster critical consciousness in medical students by verifying whether the exercise changed their initial perspective, values and assumptions.

Methodology and data

Two hundred and thirteen second-year medical students at the University of Toronto participated in an immersive activity followed by a discussion period in the form of a talking circle. This Indigenous methodology encourages dialogue and sharing in a safe, non-hierarchical environment. The activities took place in six sessions over two days, led by an expert from the KAIROS organization. Eighty-one percent of the students (174) agreed to provide a written evaluation including both closed- and open-ended questions. The content of the evaluation incorporated Indigenous knowledge through close collaboration between the Indigenous and non‑Indigenous members of the research team, as well as the input of a Cree Elder from the local territory. Using a deductive approach, the evaluation focused on concepts of cultural safety and critical consciousness. Quantitative data was evaluated using a 5-point Likert scale. The qualitative analysis was conducted with the assistance of NVivo 12.

What was learned?

Creating space for dialogue: The participants were encouraged to share their feelings about and experience with the exercise and to open themselves to the experiences and points of view of others. The authors insist on a distinction between dialogue and discussion. Discussion is part of the educational model wherein information is transmitted from the teacher to the learner, who is a passive receptor. It values authority of content and is motivated by achieving practical goals and finding solutions. Dialogue asks all participants to share their feelings and lived experience. Authority of content is thus shared. Without actually generating a solution, participants develop their understanding and openness to new perspectives in a spirit of humility.

Shedding light on the sociopolitical and historical context of Indigenous peoples: Participants confirmed having a better understanding of the history of colonization and its repercussions on Indigenous peoples, which refined their understanding of current problems.

Engaging in critical thinking: A majority of participants responded positively to the statement that the exercise had changed how they perceive people who come from a different background. They felt better equipped to recognize their own biases and privileges, as well as the benefits of this recognition in delivering more equitable care. For the students, reflecting on their role in care relationships and in the movement towards equity may motivate them to take social action.

Working towards social action: A majority of students responded positively to the statement concerning improvement in their sense of being able to create a culturally safe environment when interacting with Indigenous patients.

The authors support introducing critical pedagogies into educational programs addressing cultural safety, as this provides students with the possibility of challenging the status quo and engaging in social change for greater health equity. They also suggest reorienting problem-based learning in medical education towards learning where students critically examine the conditions responsible for these issues.

Limitations

The authors express certain tensions around the use of non-Indigenous theoretical frameworks and methodologies for understanding Indigenous health issues. That said, they prioritized Indigenous knowledge in the evaluation content and applied the core principle of wise practice, by remaining sensitive to the local context. In addition, the study is based on an isolated activity in one institution, which limits the ability to generalize the results. Finally, since the results depend on a cursory evaluation of attitudes that are self-reported by participants, the possibility of drawing causal conclusions is limited.


Culturally adapted research methods

“Sewing is part of our tradition”: A case study of sewing as a strategy for arts-based inquiry in health research with Inuit women

Brubacher, L. J., Dewey, C. E., Tatty, N., Healey Akearok, G. K., Cunsolo, A., Humphries, S., et Harper, S. L. (2021). “Sewing Is Part of Our Tradition”: A case study of sewing as a strategy for arts-based inquiry in health research with Inuit women. Qualitative Health Research, 31(14), 2602­–2616.
Open access: PDF

Context

Sewing, which is rooted in Inuit tradition, could prove to be a relevant data-collection strategy for arts-based research. This type of strategy is increasingly recognized and recommended in populations with artistic traditions, such as the Inuit, as it facilitates dialogue and enhances the quality of the data collected.

Objective

Based on a participatory approach, the study aimed to analyze and evaluate the methodological value and potential of sewing as a data collection strategy, as well as to share the lessons learned with researchers interested in using this strategy.

Methodology and data

Exploring sewing as an arts-based study strategy was part of a project looking at experiences of childbirth among Inuit women living in the Nunavut city of Iqaluit. Five discussion groups involving pregnant women (N = 19) in the form of sewing sessions of less than three hours took place in English and Inuktitut. Open-ended conversational questions were asked in order to foster a climate of trust. Information about their experiences of childbirth, their point of view concerning the sewing sessions and the data collection method emerged organically during the sessions. A thematic analysis comparing observational notes with transcripts of recordings was then carried out based on three concepts drawn from the literature: relationality and kinship, voicing and storytelling, and knowing (and sharing) arising from “doing.”

What was learned?

Compared with the use of a structured interview guide, sewing encouraged more flexible dialogue in discussion groups. This enabled participants to create a comfortable space for expressing themselves, telling stories, sharing and building relationships. Sewing, which has been described as specific to Inuit territories and even the Inuit themselves, is an applied experience of Inuit knowledge and tradition. The participants were receptive to the stories of others, offering mutual support around the experience of pregnancy while sharing sewing tips at the same time.

Two major lessons were learned by the researchers. The first concerns the importance of the partnership between Inuit and non-Inuit researchers and the position that must be accorded Inuit researchers in guiding the discussion, as well as in reformulating, refining and culturally adapting the questions in the interview guide. The second lesson pertains to rebalancing power relationships between Inuit and non-Inuit, especially in allowing participants to choose the language they spoke during discussion groups and in non-Inuit researchers adopting the role of “learner.”

Limitations

The authors did not address limitations to their study.


The inclusion of articles presented in this monitoring newsletter does not represent their endorsement by the Institut. Professional judgment remains essential in assessing the value of these articles for your work. You can also consult the Methodology for Indigenous Health Research Monitoring.