Indigenous Health Research Monitoring, June 2022

In this issue:

Just Published

 New scientific publications and articles

Cultural safety

Evaluation of “Ask the specialist”: A cultural education podcast to inspire improved healthcare for Aboriginal peoples in Northern Australia

Kerrigan, V., McGrath, S. Y., Herdman, R. M., Puruntatameri, P., Lee, B., Cass, A., Ralph, A. P., & Hefler, M. (2022): Evaluation of “Ask the Specialist”: A cultural education podcast to inspire improved healthcare for Aboriginal peoples in Northern Australia. Health Sociology Review, 1–19, Online ahead of print. DOI: 10.1080/14461242.2022.2055484
Open access: PDF Evaluation of ‘Ask the Specialist’: a cultural education podcast to inspire improved healthcare for Aboriginal peoples in Northern Australia

Context

For the last fifty years, cultural awareness training has been viewed as a panacea for issues surrounding intercultural relations and health. This type of training has been criticized, however, for a tendency to homogenize Indigenous cultures and reinforce negative stereotypes by emphasizing cultural differences. The authors note a more recent interest in cultural safety, which, in addition to knowledge of Indigenous cultures, requires critical consciousness on the part of employees. This approach was developed to counter anti-Indigenous racism in healthcare.

In Australia’s Northern Territory, Aboriginals represent only 30% of the population yet account for 70% of hospitalizations. Data indicates that current training to raise cultural awareness is poorly received by employees.

The Ask the Specialist: Larraikia, Tiwi and Yolŋu stories to inspire better healthcare pilot project aims to improve the cultural training of physicians. The program comprises a series of podcasts (seven episodes of less than 18 minutes each) in which Specialists—leaders of the Larrakia, Tiwi and Yolŋu peoples—share their experiences of and perspectives on healthcare, followed by group discussion.

Objective

The article’s objective is to explore the impact of the Ask the Specialist podcast on the attitudes and behaviours of physicians at a hospital in Australia’s Northern Territory. Through an exploration of counterstories told by the Specialists, the study examines how this information stimulated the critical thinking required to challenge negative stereotypes and change physicians’ practices.

Methodology

In this research, the concept of critical consciousness links cultural safety with Freirean pedagogy and critical race theory (CRT). The combination of theories offers a paradigm for exploring cultural safety training for healthcare workers. 

To develop the podcast content, physicians were invited to identify problems they face with Aboriginal patients. The Specialists then prepared responses in the form of storytelling based on their own experiences as well as those of their peers.
Sixteen physicians were recruited through one of the coauthors’ networks. One podcast was made available each week, and the participants were asked to provide the research team with weekly reflections by email, audio file or text message. Individual feedback interviews were conducted after the final episode, with voluntary participation.

An inductive narrative analysis of the verbatim transcriptions was conducted using the NVivo 12 software, and the codes were then categorized deductively. The Specialists participated in the data analysis.

What was learned? 

The findings provide evidence that the training, which addresses problems faced by doctors, shares counterstories from Aboriginal individuals and encourages the development of critical consciousness, can change the attitudes and behaviour of healthcare providers.
The participants appreciated the podcast format, as it allowed them to access the information at their convenience. Spreading the episodes over seven weeks allowed for cycles of listening, reflection and action.
Five major areas of critical consciousness learning stood out:

  • Practising culturally safe communication (verbal and nonverbal)
  • Building a rapport with patients
  • Developing awareness of spiritual practices
  • Deconstructing stereotypes
  • Addressing racism

Four main changes in physicians’ behaviour were identified by the analysis:

  • Investing time in building a relationship with the patient
  • Taking time to communicate
  • Working with interpreters
  • Improving the informed consent process

Physicians also recognized that developing the cultural competence of staff reduced self-discharge rates. They reported greater awareness of long-held stereotypes and the everyday nature of racism. Two participants said however that the podcast did not go far enough in addressing racism and the impact of colonialism on health.

Limitations

The authors acknowledge certain limitations. In particular, participating doctors may have been favourably disposed to the program from the outset. Since the interviews were conducted between two weeks and three months after listening to the podcasts, it is not possible to determine whether behavioural changes were sustained over time. Finally, given that cultural safety can only be determined by patients, further research is needed to evaluate whether the training improved the patients’ experience and health. A quantitative project looking at self‑discharge rates for patients, which is an indirect measure of cultural safety in healthcare, is currently being planned.

*The podcast is available from the content platforms of Apple, Google and Spotify.

Prevention of infectious and chronic diseases

Ethnographic study of the barriers and facilitators to implementing human papillomavirus (HPV) self-sampling as a primary screening strategy for cervical cancer among Inuit women of Nunavik, Northern Quebec

Gamelin, R., Hébert, M., Tratt, E., & Brassard, P. (2022). Ethnographic study of the barriers and facilitators to implementing human papillomavirus (HPV) self-sampling as a primary screening strategy for cervical cancer among Inuit women of Nunavik, Northern Quebec. International Journal of Circumpolar Health, 81(1), 2032930. DOI: 10.1080/22423982.2022.2032930
Open access: PDF Ethnographic study of the barriers and facilitators to implementing human papillomavirus (HPV) self-sampling as a primary screening strategy for cervical cancer among Inuit women of Nunavik, Northern Quebec

Context

In Nunavik, screening for cervical cancer is based primarily on use of the Papanicolaou test (a cervical smear commonly known as the Pap test), and no recall system is in place to encourage women to participate in screening. About one Inuit woman in four does not undergo a screening test within the recommended timeframe. Consequently, the incidence of cervical cancer is two to three times higher in Inuit women than in the general Canadian population. Cervical cancer is caused by the human papillomavirus (HPV). Early detection of HPV and of abnormal cervical cells remains the best strategy for reducing the rate of cervical cancer. Self-sampling has the potential to overcome certain obstacles related to screening for cervical cancer and to reach more Inuit women.

Objectives

The study aimed to explore facilitators and barriers to the implementation of HPV screening through self-sampling. The data collected will make it possible to incorporate the perspective of Inuit women in implementing the sampling strategy, as well as to maximize the screening rate.

Methodology and data

This article presents data collected from 28 women aged 26 to 78 who participated in individual or group interviews. A semi-structured interview guide was used. Participants were recruited from two Nunavik communities as well as from an urban residential centre reserved exclusively for Nunavik Inuit displaced for medical reasons. Radio announcements and snowball sampling in collaboration with local Inuit women were used for recruitment purposes. Paillé’s grounded theory was used to analyze the data, and a focused ethnographic approach was adopted.

What was learned?

The results indicate the presence of six facilitators for HPV self‑sampling:

  • Acceptability of the self-sampling method: Participants mentioned not having to undress and endure vaginal insertion of the speculum, as well as the rapidity of the technique, as advantages.
  • Information diffusion strategies: Several participants suggested preparing a brochure or video describing the self-sampling technique step by step.
  • Nurse involvement: Women reported wanting to have a nurse present to explain the technique and assist in the event of difficulty during the self-sampling.
  • Being able to choose the sampling method: Some participants were comfortable with self‑sampling but pointed out that others may prefer that a nurse collect the sample. Having a choice appears to be essential.
  • Information about prevention: Participants said that informing the Inuit population about cervical cancer and prevention strategies is important.
  • Feeling concerned about cervical cancer prevention: Participants who felt concerned and informed were more open to using the self-sampling technique.

Four categories of barrier were identified:

  • Not feeling concerned about cervical cancer prevention: Given that HPV is a sexually transmitted infection, some women do not feel at risk (because they do not have sexual relations or have only one partner). Those women tend not to be motivated to undergo screening.
  • Lack of confidence in the ability to perform self-sampling: Some participants have doubts about their ability to self-sample (e.g., because of a lack of knowledge about female genital anatomy).
  • Cross-cultural context of health-care delivery: In Nunavik, a majority of health workers are not Inuit. Ensuring that information is available in Inuktitut and that services are culturally adapted are important strategies to implement.
  • Questioning the effectiveness of self-sampling: Several participants questioned the quality of samples collected by self-sampling in comparison with Pap test samples. It appears necessary to inform Inuit women about the effectiveness of self-sampling.

Limitations

The authors point out that since the data was collected from Inuit in Nunavik, the results cannot be generalized to all Indigenous populations. The data was analyzed by non-Indigenous researchers, and the final analysis was not validated by the participants. Finally, voluntary and non-random participation may have affected the discussions in favour of the facilitators.

Promotion of wellbeing and mental health

An interview-based evaluation of an Indigenous traditional spirituality program at an urban American Indian health clinic

Pham T. V., Pomerville A., Burrage R. L., & Gone J. P. (2022). An interview-based evaluation of an Indigenous traditional spirituality program at an urban American Indian health clinic. Transcultural Psychiatry, 1–16. DOI: 10.1177/13634615221076706
Not available through open access.

Context

American Indians suffer from disproportionately high rates of mental health problems, including psychoactive substance abuse, post-traumatic stress disorder and suicide. Conventional therapies do not necessarily meet the specific needs of American First Nations due to a culture mismatch in services and political disempowerment. Traditional spiritual practices are viewed as approaches that can promote health and provide support from community members.
In response to a community needs assessment, the UAITSP (Urban American Indian Traditional Spirituality Program) pilot project developed a 12-week curriculum focused on traditional spirituality. The project was developed in partnership with an urban Indigenous health clinic in Detroit. Based on sweat lodge ceremonies, the program was implemented with 10 members of the community.

Objectives

The article aimed to answer two questions:

  • How do the participants view the feasibility and acceptability of the UAITSP program?
  • What improvements could be made to the program moving forward?

Methodology

A qualitative approach was used. Semi-structured interviews were conducted with 9 of the 10 program participants. A thematic analysis of the data was performed using the NVivo 11 software.

What was learned?

The analysis revealed two main themes.

The impact on personal wellbeing as described in four subthemes:

  • Improvement in psychological and spiritual wellbeing.
  • New meaning attributed to the Indigenous community in Detroit and better cultural cohesion through the creation of new social connections.
  • Increased cultural knowledge, especially in the area of spiritual practices.
  • A desire to continue learning through self-study or by participating in cultural activities, as well as to share personal experiences with other communities.

Suggestions for improving the program that reflect the participants’ desire for it to continue, categorized into four subthemes:

  • A shift to drop-in classes in the interests of a more flexible format would allow participants to cope with the vagaries of everyday life.
  • Classes could cover a wider range of subjects, such as prayers, dance and music.
  • The program could include knowledge-keepers and people with different perspectives, such as former students.
  • The program could be expanded to include intermediate- and advanced-level classes.

Overall, participants reported experiencing benefits from the Indigenous spiritual practices, although the program could be improved through adoption of the above-mentioned changes to the curriculum.

Limitations

The authors mention several limitations to their study:

  • The choice of study design made it impossible to perform a controlled evaluation of the results so as to establish causal relations.
  • The participants’ responses may be biased by various aspects of the study design:
    • The participants selected for the study represent only a subset of the urban American Indian population.
    • Only five participants attended a majority of the program classes (10/12), which may have limited the potential for deeper reflection.
    • The evaluations were completed shortly after the program concluded, which may have positively influenced the results.
    • The potential influence of the interviewers on the participants’ answers also represents a limitation.

Navigating between the two worlds of school and “being on the land”: Arctic Indigenous young people, structural violence, cultural continuity and selfhood

Salusky, I. R., Kral, M., Amarok, B. et Wexler, L. M. (2022) Navigating between two the worlds of school and ‘being on the land’ : Arctic Indigenous young people, structural violence, cultural continuity and selfhood, Journal of Youth Studies, 25:2, 170-192, DOI: 10.1080/13676261.2020.1858040
Not available through open access.

Context

Contemporary life for Indigenous young people in the North American Arctic is shaped by two contexts: school and being on the land. Like all other Indigenous young people, Inupiat and Inuit young people learn to negotiate between local Indigenous traditions and ways of being imposed by the major colonizing societies. Given that suicide rates are high among these young people, understanding the life stories that influence how they face adversity and overcome challenges is clearly pertinent. In this regard, structural violence embedded in practices or policies that limit the potential of one individual or group in favour of another emerges from the discourse of the young people. 

Objectives

Examine the manner in which structural violence emerges from the stories of Inupiat and Inuit young people concerning two contexts: school and being on the land.

Methodology and data

This qualitative study based in constructivism took place at two sites, one in Alaska and the other in Nunavut. A participatory approach was used, with the perspectives of community members integrated at various stages of the research.

During the summer of 2010, semi-structured interviews were conducted concerning past and present experiences pertaining to school and culture. At the Alaskan community, 20 Inupiat (10 girls and 10 boys) aged 12 to 18 were recruited by word of mouth. At the community in Nunavut, 23 Inuit (12 girls and 11 boys) aged 12 to 19 were recruited at the local school.

A thematic analysis was used to identify how the young people describe and overcome the challenges they face, as well as how their caregivers fit into those challenges. Six themes emerged and were grouped into two categories: school and time spent on the land.

What was learned?

School occupies many hours in the lives of these Indigenous young people, but neither caregivers nor practices and traditions have any role in that context. At the time of the study, school was a place of structural violence for the young people at both sites.

  • While caregivers demonstrate an interest in the academic success of their children, according to the young people they are not directly involved with school, even if their children are experiencing difficulties. The Western structure of school, the organizational hierarchy and the fact that most teachers are white appear to amplify the gap between caregivers and the school environment.
  • The young people experience a dilemma in values pertaining to conflict resolution. If they adopt values that have cultural meaning for them (e.g., confrontation), they will be reprimanded by the school.
  • Not all discussions about school were negative. School is also perceived as enjoyable because of the possibility to socialize with peers and, sometimes, a few teachers. Nonetheless, a gap exists between school life and family life, where Indigenous culture occupies an important place.

On the other hand, time spent on the land reinforces cultural and family strengths through traditional and spiritual activities practised there.

  • The young people pointed out that they go out on the land primarily with family members and Elders and that those occasions provide an opportunity for relationship building. Several participants spoke of their earliest memories being on the land with their family and underscored the importance of those moments.
  • The land represents an opportunity for young people to learn (e.g., gathering, hunting and survival), put their learning to the test and push themselves, all with the attentive guidance of family and Elders. Reciprocal relationships are developed on the land.
  • For the oldest participants, however, opportunities to spend time on the land were more limited because of other responsibilities or because the Elders did not take them anymore.

Limitations

The authors point out the limitations of their convenience sampling. At the Inuit site, young people not attending school were not contacted. For this reason, the participants cannot represent all the different situations of the population studied. Finally, the perspective of the caregivers was not studied.

Culturally adapted approaches to research and intervention

A systematic review of trauma intervention adaptations for Indigenous caregivers and children: Insights and implications for reciprocal collaboration

Richardson, M., Big Eagle, T., & Waters, S. F. (2022). A Systematic Review of Trauma Intervention Adaptations for Indigenous Caregivers and Children: Insights and Implications for Reciprocal Collaboration. Psychological Trauma : Theory, Research, Practice, and Policy. Online ahead of print. DOI: 10.1037/tra0001225
Not available through open access.

Context

Indigenous peoples are at greater risk of being exposed to trauma, as well as to physical and psychological difficulties rooted in past and present colonialism. Exposure to these traumas compromises the healthy development of Indigenous children. Although trauma-focused interventions are increasingly recognized, few such interventions are culturally adapted to the Indigenous context.

Objective

Identify trauma-focused interventions, as well as interventions that can be adapted to trauma, among Indigenous caregivers and children in order to determine where those interventions fit on a cultural adaptation continuum.

Methodology and data

The systematic review took place in September and October 2020, followed by an update in July 2021. The PsycINFO and PubMed/Medline databases were searched. Of 3,749 articles identified by an initial search, 13 met the selection criteria. To qualify, articles needed to address a single intervention focused on trauma affecting Indigenous children and their caregivers, be peer-reviewed and be written in English. The authors grouped the interventions in three categories of cultural adaptation: surface adaptation, deep-structure adaptation and culturally-grounded adaptation.

What was learned?

Just one of the 13 interventions concerned Canadian First Nations, with the rest targeting other Indigenous peoples in the United States, Australia or New Zealand. A majority (eight) of the interventions employed surface adaptation. They used an intervention that had demonstrated effects in another Indigenous community, replacing the original images with other, more culturally appropriate ones. For example, the Triple P-Positive Parenting Program in Australia was adapted by modifying the language level and changing the images and examples of parenting strategies. Only one intervention demonstrated deep-structure adaptation. The Family Spirit intervention program was modified to follow the recommendations of the American Academy of Pediatrics, as well as practices and values specific to the community. Finally, four interventions were based on the culture of the Indigenous community targeted by the intervention. This included the Canadian intervention, which was designed around the strengths of individual participants and was guided by their personal objectives and aspirations.

Limitations

The authors point out several limitations to their study. Firstly, concentrating exclusively on trauma-based interventions targeting Indigenous children and their caregivers limited the number of articles that qualified for selection. Moreover, none of the cultural adaptations of the interventions were validated. For this reason, the authors of the systematic review were unable to address the effect size of the culturally adapted interventions. The results of the interventions were therefore not analyzed. Finally, including only peer-reviewed articles in English limited the selection.

Social inequalities and determinants of health

Be like the running water: Assessing gendered and aged based water insecurity experiences with Six Nations First Nation

Duignan, S., Moffat, T., & Martin-Hill, D. (2022). Be like the running water: Assessing gendered and age-based water insecurity experiences with Six Nations First Nation. Social Science & Medicine, 298, 114864. DOI: 10.1016/j.socscimed.2022.114864
Not available through open access.

Context

In Canada, there is great disparity when it comes to Indigenous peoples accessing a safe and affordable source of water: Indigenous households are 90 times less likely to have running water than are non-Indigenous households. Their experiences with water insecurity are the consequence of colonialization, which resulted in a lack of infrastructure and the dispossession of resources.

Located in southern Ontario, the Six Nations community uses the Grand River as its primary souce of water. The river is polluted by various human activities (including agriculture, residential neighbourhoods and landfill sites). Despite the construction of a water treatment plant in Six Nations in 2014, fewer than one fifth of homes were connected to the plant at the time of publication. For this reason, many homes are faced with issues around contaminated water. Furthermore, the sacred nature of water for this community can be seen in many traditional teachings and ceremonies, and even in their language.

Objective

Evaluate the level of water insecurity and the perceptions pertaining to water access as a function of sex and age in a sample of households in the Six Nations First Nation of the Grand River, Ontario (Canada).

Methodology

A mixed methods approach was used. A survey of the households was used to measure water insecurity experiences using the Household Water Insecurity Experiences (HWISE) scale. The responses were then contextualized with the assistance of personal and semi-directed group interviews.
Between 2019 and 2020, 66 households dispersed throughout the community took part in the survey. A total of 25 participants were interviewed (18 personal interviews and 7 participants in the group discussions). The participants were recruited after taking part in another study on water or through snowball sampling.

Survey data was analyzed with the help of the SPSS software, and a thematic analysis of the interviews was conducted using NVivo.

What was learned?

Results from data collected through the questionnaire indicated a high level of water insecurity (57.5%; n = 38). Overall, participants expressed frustration over the poor quality of drinking water in their community.

Experiences of young people and generational divide

  • The younger participants were likely to pay more for water each month and experience more problems related to water contamination. However, the results do not demonstrate that they actually experience more water insecurity.
  • The interviews revealed a generational divide with respect to the definition of “quality water.” Older participants consider the term to mean water that flows naturally, whereas the younger participants take it to mean clean, accessible water or even bottled water.

Experiences of women

  • The interviews showed that women were more dissatisfied with their drinking water situation because of the water’s quality, source and cost. They face more physical obstacles because of the weight of the containers used to transport water and more psychological obstacles because of their role in the family (caring for children and the elderly) and as knowledge keepers. As a result, they bear additional responsibilities for ensuring the water supply in their household.

Limitations

The authors mention several limitations. Firstly, the small size of the sample and high proportion of women (48/66) limit interpretation of the results. The sample was not representative of the overall community, and a more balanced representation of the genders could have made it possible to address this component in greater depth. Finally, a lack of responses to certain survey questions (e.g., about income) further reduced the size of the sample.

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.