Indigenous Health Research Monitoring, September 2022

In this issue:

Just Published

 New scientific publications and articles

Cultural safety

Impacts of racism on First Nations patients’ emergency care: results of a thematic analysis of healthcare provider interviews in Alberta, Canada

McLane, P., Mackey, L., Holroyd, B. R., Fitzpatrick, K., Healy, C., Rittenbach, K., Plume, T. B., Bill, L., Bird, A., Healy, B., Janvier, K., Louis, E., & Barnabe, C. (2022). Impacts of racism on First Nations patients' emergency care: results of a thematic analysis of healthcare provider interviews in Alberta, Canada. BMC Health Services Research, 22(1), Article 804
En libre accès ici : PDF

Context

To ensure equitable care for First Nations patients, we need to study how racism and colonialism have impacted healthcare. Moreover, the literature makes it clear that emergency departments are sites of racism. A patient’s state of crisis can itself influence the negative biases of emergency department healthcare providers. Data also shows that First Nations members expect to receive discriminatory treatment. A study of the perceptions of service providers concerning the care received by First Nations patients is therefore relevant.

Objective

This article presents a thematic analysis of interviews with emergency care providers about their perceptions of the care received by First Nations patients.

Methodology

The project respected the principles of ownership, control, access and possession (OCAP), including the involvement of Indigenous communities in Alberta. Theoretical sampling was employed to recruit a variety of healthcare providers according to care type and setting (rural, urban and remote care sites) among the researchers’ professional networks and by snowball sampling in targeted emergency departments. Between November 2019 and March 2020, eleven physicians and five nurses, all working in emergency departments, participated in a telephone interview lasting from 60 to 90 minutes. None of the participants self-identified as Indigenous. The interviews were recorded and transcribed verbatim, then coded to reflect Indigenous ways of knowing and aligned with critical Western paradigms.

What was learned? 

  • The providers reported being aware that First Nations patients are exposed to disrespect through tone and body language, may encounter overt racism, and may also be neglected or not taken seriously. Racism and negative stereotypes towards First Nations are common in emergency departments. Moreover, the organization of emergency services is conducive to racism given that care providers must constantly categorize patients based on perceptions of their need, deservingness and the capacity of the emergency department to assist them. The categorization work (triage) and the allocation of limited emergency resources strengthen colonialism.
  • Participants reported feeling apathy, frustration and even anger when they perceive that their efforts to provide care are not translating into benefit for First Nations patients. Care providers can see that the emergency system is not designed to meet the needs and expectations of First Nations patients, who, in their opinion, fail to understand the nature of emergency services and have expectations for care that do not align with what the provider is able to offer them.
  • The racism and stereotypes expressed reinforce the prejudice that Indigenous peoples are irreversibly damaged, thereby justifying the colonial doctrine of their inferiority and lower value in the allocation of emergency resources. Tenacious stereotypes also reinforce discriminatory practices. For example, the idea that First Nations are abusive in their use of emergency department services places them at a disadvantage in the allocation of emergency resources.
  • Asymmetrical power relations between patients and care providers also influence the decision whether to offer or to refuse care to First Nations patients.
  • Finally, the authors describe the efforts deployed by some providers to combat racism and systemic obstacles to the delivery of care. While they take inspiration from such examples in formulating recommendations for care providers, emergency departments and health systems, they feel that it is unfair to place the responsibility of addressing racism and ongoing colonialism on individual providers.

Limitations

Participation in the study was on a volunteer basis, and the perceptions expressed reflect the opinions of providers who understand racism to be a problem in emergency departments. Those perceptions cannot be generalized to all emergency care providers. Furthermore, the perceptions of First Nations providers may have influenced the results. Since the data does not address specificities of the Métis and Inuit peoples, the participants tended not to make distinctions among the different Indigenous populations.

“I would just like to see more acknowledgement, respect and services for the people who are in between, just Métis people”: Recommendations by Métis women to improve access to health and social services in Victoria, Canada

Monchalin, R., Auger, M., Jones, C., Paul, W., et Loppie, C. (2022). « I would just like to see more acknowledgement, respect and services for the people who are in between, just Métis people »: Recommendations by Métis women to improve access to health and social services in Victoria, Canada. AlterNative: An International Journal of Indigenous Peoples.
En libre accès ici : PDF

Context

The Métis people represent one third of the Indigenous population in Canada and have a distinct social and cultural identity. In British Columbia, where 90,000 Métis live, available data points to shortcomings in access to culturally safe healthcare and social services, i.e., a space where they feel comfortable and secure in being openly Métis. According to the authors, no literature addresses the experience of Métis people with respect to healthcare and social services in the Greater Victoria area.

Objectives

This article is a call to action to address the lack of access to culturally safe care and services for Métis living in Canada. More specifically, the research aims to explore and understand the experiences of Métis who self-identify as women, two spirit or gender fluid and who live or receive care and services in Victoria.

Methodology and data

Based on earlier research conducted in Toronto, this project and its various phases were led by Indigenous individuals and the community. A Métis Elder provided advice and gave approval concerning the project objectives, recruitment and the interview guide.

Using the Zoom videoconferencing platform, one-hour interviews in the form of a conversation were held with 24 Métis aged 19 or older who self-identify as a woman, two spirit or gender fluid. Ten open-ended questions guided the conversations around various themes, including the Métis identity and experiences with health and social services. The interviews were recorded, transcribed and analyzed.

What was learned?

Five interconnected recommendations aimed at improving access to healthcare for Métis in Victoria emerged from the analysis. The recommendations arise from many overlapping themes addressed in the interviews.

Warm, inviting spaces

  • Relaxing music, warm or neutral colours, and natural lighting are some examples of this. Accessibility for people living with a disability is also a concern. Displaying the works of Indigenous artists contributes to making a space more welcoming. However, participants emphasized that health and social services in Victoria need to do more than just improve the physical environment.

Cultural safety training specific to the Métis

  • Providing cultural safety training specific to the unique experiences of Métis, rather adopting than a pan‑Indigenous approach, would be more relevant to patients. Moreover, an evaluation process (e.g., a suggestion box) should be added so that patients can provide feedback about the services they receive.

Clinics for Indigenous patients

  • Sharing the space with other Indigenous persons improves the comfort level. For example, seeing other Indigenous individuals in the waiting room puts some patients more at ease. That said, clinics need to be clear about eligibility for services.

Integrated global services

  • Services need to address health and wellbeing holistically by recognizing the connection between a person’s physical, emotional, spiritual and mental welfare. In addition, offering integrated services means that each provider considers the patient’s overall health in collaboration with other providers.

Nonjudgmental service providers

  • During the interviews, the two aspects most frequently mentioned as desirable were nonjudgmental interactions and service providers who listen to patients’ needs. Participants want their life experiences to be acknowledged. They also prefer transparent and reassuring service providers who establish visual contact, are sensitive to trauma and ask for consent.

Limitations

Participants were recruited exclusively from a Facebook group. The recommendations may not represent the concerns of the entire Métis community. Due to COVID-19, only subjects with a telephone or computer were able to participate.

Promotion of wellbeing and mental health

“We’re Home Now”: How a Rehousing Intervention Shapes the Mental Well-Being of Inuit Adults in Nunavut, Canada

Perreault, K., Lapalme, J., Potvin, L., & Riva, M. (2022). « We’re Home Now »: How a Rehousing Intervention Shapes the Mental Well-Being of Inuit Adults in Nunavut, Canada. International Journal of Environmental Research and Public Health, 19(11), Article 6432.
En libre accès ici : PDF

Context

In 2016, 40% of Inuit were considered to have an urgent need for housing, compared with 10% of non‑Indigenous Canadians. This issue is related to the federal government having forced Inuit to relocate and settle in permanent communities between 1950 and 1960.

Many challenges pertaining to the delivery of new housing have amplified the problem, including the high cost of construction materials, a short construction season and dependence on funding from the federal and provincial governments. In Nunavut, the wait time for social housing is about three to six years. Housing allocation is based on a system of points based on criteria such as overcrowding, social problems, health issues pertaining to housing and the number of dependent children.

In Inuit culture, health is generally approached from an ecocentric perspective that accords central importance to places and relationships. Experiences related to housing conditions and their repercussions on mental wellbeing have rarely been explored in the literature from the Inuit perspective.

Objective

This article explores the experiences of Inuit adults who have been relocated to new housing or are still on a waiting list for housing, as well as the perceived impacts on their mental wellbeing.

Methodology and data

The framework project for this study was developed in collaboration with organizations in Nunavut and Nunavik.

Data collection took place in 2018 in a community where housing needs were deemed to be critical. Participants were selected using targeted sampling methods, including door-to-door solicitation and radio advertising and through snowball sampling. Of the 25 participants (8 men and 17 women), 11 had been rehoused and 14 were still on a waiting list.

A thematic analysis was conducted. The authors employed Giddens’ notion of ontological security to analyze how personal experiences influenced the perceived wellbeing of Inuit adults.

What was learned?

Refuge creation

  • The creation of a refuge was explicitly mentioned and associated with wellbeing by almost all participants. Several of them identified housing as a family space that should represent stability and security. Situations of forced cohabitation, however, can lead to family tensions. Participants on a waiting list reported experiences of instability, homelessness and eviction.

Self-determination and increased control

  • Participants on a waiting list reported having very little control over their housing situation. Especially in the case of mothers and young women, the lack of access to housing can prevent them from living with their child or partner. Participants also indicated that overcrowding can limit social support due to the lack of housing.

    Furthermore, water supply shortages lead to rationing and continual negotiations among all residents in the unit, which can result in tension and aggression.

Improved family dynamics and identity repair

  • Participants associate access to new housing with the opportunity to make choices at important stages in their life, such as starting a family, which was identified as a source of pride. Rehousing can also contribute positively to family dynamics by improving communication, which is associated with a better sense of self.

Limitations

The study emphasizes subjective experiences around housing and wellbeing, especially with respect to mental health. However, research partners also pointed out that poor housing conditions also impact physical health. The connection between housing and infectious diseases, such as tuberculosis and, more recently, COVID-19, are known but not documented in the study.

Parent-Child Separations and Mental Health among First Nations and Métis Peoples in Canada: Links to Intergenerational Residential School Attendance

McQuaid, R. J., Schwartz, F. D., Blackstock, C., Matheson, K., Anisman, H., & Bombay, A. (2022). Parent-Child Separations and Mental Health among First Nations and Métis Peoples in Canada: Links to Intergenerational Residential School Attendance. International Journal of Environmental Research and Public Health, 19(11), Article 6877.
En libre accès ici : PDF

Context

In Canada, First Nations children are at least 17 times more likely to be removed from their family and placed in the child welfare system than are non-Indigenous children. The social inequalities experienced by Indigenous peoples are rooted in a history of colonial practices in Canada aimed at assimilation. The system of Indigenous residential schools resulted in a multigenerational cycle of family disruptions documented among the children and grandchildren of survivors. Those younger generations tend to report high levels of psychological distress, substance abuse and health problems. Adult Indigenous individuals with a history of having been placed with the child welfare system (foster home, group home, kinship care or adoption) are also more likely to present psychosocial and mental health problems.

Objective

The study aimed to explore the effects of parent-child separation in two different samples—one comprising young people and the other adults—by associating intergenerational exposure to Indigenous residential schools with exposure to the child welfare system, as well as the consequences on mental health.

Methodology and data

The study used a cross-sectional quantitative methodology.

For the sample of young people, data from the youth-specific 2015–2016 First Nations Regional Health Survey (RHS) was analyzed. In total, 4,968 (weighted = 47,918) young people aged 12 to 17 living in First Nations communities across Canada were included. The family history of Indigenous residential schools was determined by asking participants if one of their parents or grandparents attended a residential school. Psychological distress was measured using the Kessler scale, which evaluates symptoms of anxiety and depression over the last month.

For the sample of adults, 433 participants aged 18 or older (24% Métis and 76% First Nations) were recruited through flyers posted in Indigenous community and health centres and with the help of electronic mailing lists. Participants were interviewed about their parents’ and grandparents’ history with Indigenous residential schools. Experience with the child welfare system was determined by asking participants if they had spent time in a foster home or group home and who their primary guardians were during childhood. The Beck depression inventory was used to measure symptoms of depression.

Cross tabulations, binary logistic regressions and an analysis of covariance (ANCOVA) were conducted for both samples.

What was learned?

Data for the young people shows that those with a parent or grandparent who attended an Indigenous residential school present significantly higher psychological distress scores than do those without a family residential school history. Distress levels were also higher in young people who did not live with either biological parent compared with those who lived with at least one parent.

Data for the adults showed that those with a parent or grandparent who attended an Indigenous residential school were significantly more likely to have been exposed to the child welfare system than those without a family residential school history. Adults with a family residential school history and those who spent time in the child welfare system had higher depression scores.

The results for both groups underscore that the cycle of parent-child separation among First Nations and Métis peoples in Canada still continues today and is associated with vestiges of the Indigenous residential school system.

Limitations

The authors point out that data for the young people is limited by the RHS survey questions and that the reasons for the separation from the biological parents was not documented. Likewise, since the RHS concentrated on young people currently living in First Nations communities, the analyses do not include young people living away from their community. Some young people living in foster homes may therefore not have been reached.

Data for the adults is limited in that the sample is not representative. Participants were deemed to have been personally exposed to the child welfare system if they named an adoptive parent as the primary caregiver or if they spent time in a foster home or group home, even though those experiences may be quite different.

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