Indigenous Health Research Monitoring, October 2023

In this issue:

Just Published

New scientific publications and articles

Article Summaries: Subject Areas

Culturally adapted approaches to research and intervention

Nehiyawak (Cree) women’s strategies for aging well: Community-based participatory research in Maskwacîs, Alberta, Canada, by the Sohkitehew (Strong Heart) group

Listener, L., Ross, S., Oster, R., Graham, B., Heckman, S., and Voyageur, C. (2023). Nehiyawak (Cree) women’s strategies for aging well: Community-based participatory research in Maskwacîs, Alberta, Canada, by the Sohkitehew (Strong Heart) group. BMC Women’s Health, 23(1), Article 341.

Context

Women have held—and continue to hold—an important position in Nehiyawak/Cree communities as the ones who preserve and share traditional knowledge. Past and current colonial policies have negatively affected the intergenerational transmission of knowledge and, consequently, the wellbeing of women. Wellbeing which is viewed holistically as a balance of one’s physical, mental, emotional and spiritual dimensions, is critical not only to women individually but also for the revitalization of families and communities. Although ageing is a barrier to women achieving and maintaining wellbeing, the subject is rarely addressed other than by those who are directly impacted, hence the relevance of conducting research in this area.

Objectives

Bring together members of the Nehiyawak/Cree community to develop a mutual understanding of what it means for women to age well.

Explore and describe means of achieving and maintaining wellbeing during ageing and share the resulting information.

Methodology

This community-based participatory research project aimed to build bridges between the community and researchers by developing mutual trust. A strength-based approach focused on identifying and supporting various strengths, motivations and protection factors was used. Originally created to organize awareness-raising activities around menopause, the research group collaborated closely with an advisory committee composed of seven Elders women, who expressed their needs in this area.

A group of 36 community members of all ages and genders was formed in order to create three sharing circles—a traditional method of communication in which everyone involved is treated equally and with respect. All of the participants’ comments were recorded on a flipchart in plain view, on which precisions and clarifications were added. A qualitative analysis of transcriptions of the recorded notes was conducted.

What was learned? 

Participants’ perceptions were organized around the four dimensions of wellbeing supported by the Medicine Wheel. For each dimension, data emerged pertaining to three wellbeing themes: 1) culture/tradition, 2) self-care and 3) family/intergenerational considerations. The results presented were based on the themes, always bearing in mind the need for balance among the different dimensions.

  • Physical: The importance of mobility, remaining active and choosing enjoyable physical activities not viewed as a chore, such as walking or gardening, emerged from the sharing circles. Community members reported being especially concerned by certain harmful lifestyles of family members, such as eating habits. In addition, women should have easy access to health information so they can determine whether the changes they experience during ageing are normal.
  • Mental: Honesty and openness are critical to obtaining appropriate assistance when things are not going well. Community members reported that keeping busy is essential to caring for their mental health. This applies to both traditional activities (such as powwows, sweat lodges and crafts) and nontraditional activities (puzzles, board games and yoga, for example).
  • Emotional: Showing empathy, compassion and patience with oneself and others is a sign of emotional wellness. Childhood is a key period for developing skills to deal with emotions, ranging from understanding to expressing them.
  • Spiritual: Spiritual wellbeing is an integral part of daily life. The participants believe that traditional values (such as unconditional love and sharing) need to be transmitted from Elders to children. Prayer and cultural celebrations are ways that this might be accomplished.

Limitations

The authors note that generalizing the results to other Indigenous communities is difficult. In addition, the sharing circles met during the day, which may be a barrier to participation for some people. Moreover, the presence of men in the circles may have limited the scope and depth of subjects addressed. Despite those limitations, the authors suggest that the methodology could be used elsewhere to generate context-specific data.

Social inequalities and determinants of health

Examining pathways from food insecurity to safer sex efficacy among northern Indigenous adolescents in the Northwest Territories, Canada

Logie, C. H., Lys, C., Sokolovic, N., Malama, K., Mackay, K. I., McNamee, C., Lad, A., and Kanbari, A. (2023). Examining pathways from food insecurity to safer sex efficacy among northern and Indigenous adolescents in the Northwest Territories, Canada. International Journal of Behavioral Medicine, 1–13.
Not available through open access.

Context

Indigenous peoples comprise half the population in Canada’s Northwest Territories and are more likely to experience food insecurity compared with the non-Indigenous population. The region also faces sexual health disparities, with chlamydia and gonorrhea rates five and ten times the national rates, respectively.

The connection between food insecurity and exposure to sexually transmitted and bloodborne infections (STBBI) is the result of several behavioural and mental health pathways: depression, substance abuse, increased transactional sex in exchange for food, and a reduced ability to negotiate condom use due to socioeconomic relationship imbalances.

Safer sex efficacy—the ability to navigate sexual decision-making and condom use—may also explain the association between food insecurity and exposure to STBBIs.

Objective

Examine: 1) the direct pathway between food insecurity and safer sex efficacy and 2) the indirect pathways between food insecurity and safer sex efficacy through resilience, depression and relationship power inequity among adolescents in the Northwest Territories.

Methodology

This community-based research was conducted in collaboration with an Indigenous organization promoting sexual health. High school students were invited to a workshop on sexual health, for which standardized questionnaires were self-completed in advance.

Logistic regressions were performed to assess sociodemographic factors associated with food insecurity. Structural equation modelling was then conducted to measure the direct pathways between food insecurity and safer sex efficacy, as well as indirect mediation pathways through resilience, depression and relationship power inequity.

Specifically, condom use self-efficacy (e.g., trust in one’s ability to negotiate condom use) and situational safer sex self-efficacy (e.g., under pressure from the partner) were evaluated.

What was learned? 

The sample included 410 adolescents aged 13 to 18, of whom 79% were Indigenous. The participants identifying as female or nonbinary were at greater risk of suffering from food insecurity (57% and 50%, respectively), compared with males (33%). The rate of food insecurity was higher among Indigenous (48%) than non-Indigenous (34%) participants.

According to logistic regression models, young people facing food insecurity are more likely to report few sources of resilience, experience symptoms of depression and experience relationship power inequity (e.g., receive psychological aggression from their intimate partners or direct psychological aggression towards their partners).

According to structural equation modelling, a direct pathway can be seen between food insecurity and condom self-use efficacy through resilience and depression. Moreover, an indirect pathway exists between food insecurity and situational safer sex self-efficacy through the intermediary of resilience. In other words, food insecurity leads to problems with resilience and depression, which in turn affect safer sex efficacy.

Structural equation modelling established no association between relationship power inequity and food insecurity or safer sex efficacy.

The results support the relevance of developing systemic interventions to fight food insecurity focused on resilience as well as on sexual and mental health, over and above strategies aimed solely at changing individual behaviour.

Limitations

This study is limited by its nonprobability sampling method and cross-sectional design, which restricts the possibility of generalizing the results and inferring causal relations. Similarly, safe sex practices are subject to social desirability bias, which can influence participants’ responses. Another limitation is that no overall measurement of socioeconomic status, such as the parents’ income, was included.

Promotion of wellbeing and mental health

Impact on community members of a culturally appropriate adaptation of a social and well-being intervention in an Aboriginal community

Anwar-McHenry, J., Murray, L., Drane, C. F., Owen, J., Nicholas, A., and Donovan, R. J. (2022). Impact on community members of a culturally appropriate adaptation of a social and emotional well-being intervention in an Aboriginal community. Journal of Public Mental Health, 21(2), 108–118.
Not available through open access.

Context

Aboriginals and Torres Strait Islanders in Australia report a generally more precarious mental health status than do non-Aboriginal populations. Studies show that culturally adapted services are more effective in promoting mental health. In this regard, the Act-Belong-Commit campaign promoting overall mental health was adapted to the social and cultural situation of the Aboriginal community of Roebourne in Western Australia. The town has a population of about 1,000, 75% of whom identify as Aboriginal or Torres Strait Islander.

The campaign encourages building positive mental health by remaining physically, mentally, spiritually and socially active—a positive mental health vision consistent with that of the community. A local group of Aboriginal consultants was responsible for the cultural adaptation of the campaign by organizing discussions with Elders, organization representatives, and community members. A slogan and logo were also created for the community.

Objective

Analyze the impact of the cultural adaptation of the Act-Belong-Commit campaign on the mental health and social wellbeing of members of the Roebourne community.

Methodology

Aboriginal respondents were surveyed concerning the impact of the campaign on their lifestyle. The survey questions were adapted from a questionnaire used to measure the outcomes of a mental health promotion campaign within the general population. Research results were shared within the community by local organizations working in the area of mental health and by project stakeholders.

What was learned?

A total of 31 indigenous adult responded to the survey. A majority of the participants (80%) were female, two thirds of whom were over 40 years of age. All of the people surveyed were familiar with the slogan, the logo or program activities.

Generally speaking, respondents indicated that the campaign had a beneficial effect on the community, especially by encouraging participation in various activities that they would not otherwise have attended.

A total of 25 individuals (81%) said they had attempted to take action to improve their social and emotional wellbeing. They reported being involved in events and in the community, visiting family members, conversing with people and helping others.

Nearly three quarters (74%) of those surveyed reported having attempted to take actions to improve the social and emotional wellbeing of family and friends, and close to half (48%) said that they had supported the wellbeing of the community. Actions mentioned included cooperating in organizing events, encouraging healthy habits and educating others about these actions.

Overall, the data collected shows that the people surveyed had a good understanding of the campaign messages and were able to put them into practice in their own lives.

Limitations

The sample was not random, which may have led to selection bias and could explain the low rate of participation by men. Likewise, given that the participants were recruited in a public setting, they may have had greater exposure to campaign posters and been more familiar with the campaign.

Indigenous women’s experiences of lateral violence: A systematic literature review

Jaber, L., Stirbys, C., Scott, J., and Foong, E. (2023). Indigenous women’s experiences of lateral violence: A systematic literature review. Trauma, Violence, & Abuse, 24(3), 1763–1776.

Context

Lateral violence is defined as aggression perpetuated within systematically oppressed groups. It takes the form of dehumanizing beliefs, values and acts. Common behavioural manifestations of lateral violence include bullying, gossiping, shaming, intimidation and sabotaging. Perceptions of toxicity within communities act as barriers to the continuity of Indigenous cultures by fostering assimilation.

Objective

Synthesize data about lateral violence in an Indigenous context, with particular attention to the experiences of women, using intersectionality theory and post-colonial theory.

Methodology

This systematic review follows the PRISMA-P protocol. Qualitative and quantitative peer-reviewed studies had to contain primary data and have been published in English between 2000 and 2021. Sample groups had to include Indigenous women. The search was conducted in four phases: 1) five academic databases, 2) Google scholar, 3) 23 periodicals dedicated to Indigenous issues, and 4) the snowball sampling method. A total of 10 articles, mostly qualitative, were selected and analyzed using NVivo 1.0.

What was learned? 

  • Prevalence, forms and outcomes of lateral violence: According to the studies selected, lateral violence is widespread in Indigenous communities, largely concealed and associated with harmful experiences.
  • Awareness and terminology: Using the term “lateral violence” can open a discussion around difficult experiences. Knowing that a term exists to describe structural roots can bring relief, empowerment and hope for social change. Participants recommended using contrasting positive terms, such as “lateral love” and “lateral healing.”
  • Impact on the social fabric of communities: Lateral violence has devastating effects on community relationships. The subject may be difficult, controversial and taboo, and any one person may be both the victim and author of such violence. As many people have experienced, incidents may be repressed, normalized or doubted. Reactions triggered may include self‑protection and survival reflexes such as withdrawal, avoidance, cognitive reinterpretation and denial. The effects may dissuade some Indigenous individuals from claiming status or attempting to connect with their culture and heritage.
  • Institutions and workplaces: The lack of resources available to Indigenous peoples in university settings, for example, may lead to competition between groups and drive conflict. Policies against bullying and harassment can, however, reduce such outcomes. With respect to the workplace, some studies point to the benefits of training to raise awareness and increase cultural competency.
  • Doubts cast on the authenticity of the Indigenous identity: The studies point to victims holding internal racist beliefs and negative stereotypes of Indigenous people. Conflicts are rooted in a perception of “true” indigeneity based on colonial classifications such as appearance, skin colour, blood quantum, place of residence (urban versus on reserve), level of involvement in cultural practices, or adherence to non-Indigenous or white values. A strong sense of Indigenous identity may, however, act as a protection factor for some. Gender identity and violence perpetrated by non-Indigenous peoples was taken into consideration.
  • Resilience, resistance and interventions: To reduce lateral violence, the authors recommend greater awareness of the role colonial practices have in perpetuating the oppression of Indigenous peoples. Giving lateral violence a name, raising awareness and educating people about the underlying mechanisms are all important steps in the process of healing and of Indigenous belonging.

Limitations

The small sample size may limit generalizability of the findings and account for potential selection and recruitment bias. The authors point out, however, that in qualitative studies, the saturation of results overrides the small sample size.

Cultural safety

First Nations, Inuit and Métis peoples living in urban areas of Canada and their access to healthcare: A systematic review

Graham, S., Muir, N. M., Formsma, J. W., and Smylie, J. (2023). First Nations, Inuit and Métis peoples living in urban areas of Canada and their access to healthcare: A systematic review. International Journal of Environmental Research and Public Health, 20(11), Article 5956.

Context

According to the 2016 Canadian Census, 52% of First Nations, 56% of Inuit and 63% of Métis live in urban areas. Reasons for living in a city include access to healthcare, education, jobs and housing.

Despite a higher concentration of health services in Canadian cities, Indigenous populations experience difficulty in accessing those services or choose not to use them, which can mean waiting until they are very sick before seeking assistance.

Objective

To gain an understanding of this social phenomenon, the four Indigenous authors of this study sought to bring to light positive and negative factors affecting access to health services by Indigenous populations living in urban areas.

Methodology

A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) model. The Embase, Medline and Web of Science databases were searched for scientific data published between January 1, 1981, and April 30, 2020. Searches were also conducted in the grey literature and in study references using the snowball method.

To qualify for selection, the research had to concern First Nations, Inuit or Métis populations living in a Canadian urban centre and provide information about positive or negative factors influencing access to health services.

What was learned? 

A total of 41 studies were selected. With the exception of one study describing the perspectives of non-Indigenous health professionals, all the studies presented the experiences of Indigenous populations in accessing health services.

Seven categories of barrier were identified:

  • Difficulty in communicating with health professionals (e.g., failure to listen to the patient or to take them seriously)
  • Medication issues (e.g., refusal to provide medications to drug users)
  • Dismissal or discharge by medical department staff (e.g., being involuntary discharged from the hospital)
  • Wait times (e.g., long wait times for an appointment, to see a health professional or to receive medical test results)
  • Mistrust and avoidance of health services (e.g., scepticism about the treatment provided)
  • Racial discrimination (e.g., defensive attitude on the part of a health professional)
  • Poverty and transportation issues (e.g., inability to pay for public transit)

Four positive factors were identified:

  • Access to culture (e.g., participation in ceremonies or the ability to speak an Indigenous language)
  • Traditional healing (e.g., personal relationship with traditional healers)
  • Indigenous-led and run health services (e.g., active presence by clinic staff in the community)
  • Support in meeting various needs (e.g., food and transportation)

These positive factors could serve to reduce the identified barriers. The authors conclude that urban Indigenous populations in Canada face barriers to accessing healthcare. Interactions between Indigenous patients and health professionals are especially affected by existing discrimination within health services. To promote the identified positive factors, the authors believe that it is necessary to provide training in cultural safety, as well as to evaluate training that is currently available.

Limitations

Of the 41 studies selected, the 13 quantitative studies included in this research do not include sufficient details about the positive and negative factors impacting access to health services.

If you are experiencing emotional distress, you can call the Hope for Wellness Help Line (1‑855‑242‑3310) or chat online. This service is available 24/7 for Indigenous people in Canada.

For other available services, see the list of helplines by region (regional support lines).

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.