Indigenous Health Research Monitoring, April 2023

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In this issue:

Just Published

New scientific publications and articles

Article Summaries by Subject Area

Social inequalities and determinants of health

Early childbearing, family support, and staying in school in a Northern Plains American Indian reservation

Peterson, M., Rink, E., Schure, M., Mikkelsen, K., Longtree, H., FireMoon, P. and Johnson, O. (2022). Early childbearing, family support, and staying in school in a Northern Plains American Indian reservation. American Journal of Sexuality Education, 17(4), 510–535.

Not available through open access.

Context

Adolescent pregnancy rates are higher among American Indian and Alaska Natives than in the rest of the population. Early childbearing is associated with adverse socioeconomic and health outcomes, including school dropout. Sexual and reproductive health programs are frequently developed by non-Indigenous people and focus on addressing shortfalls and individual responsibility. Education and intervention methods that take into consideration cultural context of the target population would be more appropriate. Traditionally, children have great value among Northern Plains tribes and are raised collectively by family members. In a context of early childbearing, family support could influence academic persistence.

Objective

Study young people’s perception of family support and belief in their ability to remain in school should they have a child.

Methodology

This three-stage community-based participatory research using mixed methods took place in a reservation community high school in Montana. The first stage was a quantitative analysis of a survey of 212 young people conducted in fall 2019. Secondly, a qualitative component involved having the results validated by seven participants recruited among survey respondents using purposive sampling. Finally, the seven young people were included as study coauthors.

What was learned?

About half of the young people, more females than males, indicated that having a child would make it difficult to stay in school. A greater percentage of female participants (66%) than male participants (46%) also felt that their family would have a negative reaction (disappointment and anger) if they were to announce a pregnancy. A negative perception of family support was associated with reduced confidence in the ability of young people to stay in school. Six themes emerged from the qualitative analysis that nuance the exclusive influence of family support on academic persistence.

  • Gender difference: Parental expectations vary according to gender. Expectations are that young men are naturally more reckless and less involved in their child’s education, whereas young women are expected to act more responsibly and finish their education.
  • Parent communication vs. student observation: A large proportion of students reported being unable to anticipate their parents’ reaction in the case of a pregnancy, suggesting that they may never have discussed that possibility with them. Observing family dynamics might prove a better indicator of family support than a survey.
  • Poverty and drug use: External factors may influence family life and act as barriers to young people staying in school, whether or not they are parents (e.g., drug use in the family, difficult living conditions or the need to care for a sick family member).
  • School support systems: The school system may make graduation more difficult for students facing challenges. However, some students might turn to teachers rather than their parents for support.
  • Childcare: Participants reported that expectations are sometimes quite different from reality. For example, while aunts and grandparents may react positively to the news of the pregnancy and say that they will care for the child, in the end they may not actually be able to help.
  • Partner relationship: The partners’ behaviour often aligns: one parent being motivated to stay in school can make it easier for the other to do likewise.

The results therefore point to several factors to consider in sexual and reproductive health programs: gender-specific interventions, the inclusion of parents, the importance of the school system, and living conditions for young Natives.

Limitations

The COVID-19 pandemic made communication and relationship building with the students more complex. As a result, only seven young women (no male students) participated in the qualitative part of the research. Moreover, the survey measurement tools had already been used in other contexts with First Nations young people but were not specifically designed for them and were not validated. In addition, the results may not be representative of all narratives around adolescent pregnancy, family support and academic persistence in this community.

Indigenous gender and wellness: A scoping review of Canadian research

Tremblay, M., Sydora, B. C., Listener, L. J., Kung, J. Y., Lightning, R., Rabbit, C., Oster, R. T., Kruschke, Z. and Ross, S. (2023). Indigenous gender and wellness: A scoping review of Canadian research. International Journal of Circumpolar Health, 82(1), 2177240.

Open access: PDF

Context

Health disparities between Indigenous and non-Indigenous peoples in Canada are rooted in complex factors related to the persistent effects of colonialism. Gender is also a factor influencing health disparities experienced by Indigenous peoples. Whereas sex can be defined as reflecting a person’s male or female anatomical characteristics, gender includes socially and culturally attributed roles, behaviours, expectations, expressions and identities.

The body of knowledge about the relationship between gender and the wellbeing of Indigenous populations is far from complete. In this study, health and wellbeing are conceived from an Indigenous perspective by focusing on strengths; connections with culture, community and family; and spiritual, emotional, mental and physical balance.

Objective

A scoping review was used to examine scientific data about the relationship between gender and wellbeing in Canadian Indigenous populations, identify topics requiring further study, and suggest directions for future research.

Methodology

Six databases were consulted using a keyword search in publications as recent as 2021. Studies were included if they dealt explicitly with gender, addressed a topic related to health and wellbeing, adopted an empirical approach and were conducted with Canadian Indigenous populations. Out of 945 articles initially identified, 155 meeting study criteria were selected.

Study characteristics (in terms of gender, age, Indigenous group, living environment, recommendations, etc.) were compiled and analyzed.

What was learned?

Most of the studies reported results pertaining to one Indigenous nation or community. A majority of the samples comprised First Nations, followed by Inuit then Métis, communities. More than half of the articles included women and adults living in a rural area or Indigenous community. Gender-diverse people were rarely included in the articles (18/155).

The topics and data in the selected studies were grouped into five categories:

  1. Physical health: A majority of the articles concerned issues of physical health, including menopause (20 articles), perinatal care (15), HIV (10) or HPV (7). Other articles addressed sexual health (5), diabetes (5), cardiovascular disease (4), cancer (3) or dental health (1).
  2. Social issues: One third of articles addressed social dimensions, specifically using data about social-emotional wellbeing (10 articles), ethnic identity (7) or family violence (5). Some articles referred to intergenerational and historical trauma (4), loss of traditional lifestyles (4), sexual violence (4), parenting (4), housing (2), ageing (2), language (1) or discrimination (1). Gender identity was directly addressed in four articles.
  3. Mental health: One quarter of the articles dealt with mental health, about half of which concentrated on the use of psychoactive substances and gambling (20 articles), while the other half studied mental disorders (17) and suicide (4).
  4. Health policy and perceptions: One fifth of the articles looked at health promotion, healthcare and health policies (18 articles), as well as at perceptions of health and wellbeing (8).
  5. Global health and wellness: These issues were explored in 10 articles and included topics such as food resources (7 articles), use of water and the land (2) and climate change (1).

Several articles recommended that Indigenous cultural realities and knowledge be more integrated into health programs, as well as better documented using strength-based collaborative methodologies.

Limitations

This scoping review was limited to research conducted in Canada. The results may have differed if Indigenous populations in other countries had been included.

In addition, only peer-reviewed articles were included, and the authors acknowledge that this limits the forms of knowledge examined, specifically by excluding work conducted outside the context of university research.

Cultural safety

Cultural safety involves new professional roles: A rapid review of interventions in Australia, the United States, Canada and New Zealand

Tremblay, M.-C., Olivier-D’Avignon, G., Garceau, L., Échaquan, S., Fletcher, C., Leclerc, A.-M., Poitras, M.-E., Neashish, E., Maillet, L. and Paquette, J.-S. (2023). Cultural safety involves new professional roles: A rapid review of interventions in Australia, the United States, Canada and New Zealand. AlterNative: An International Journal of Indigenous Peoples, 19(1), 166–175.

Open access: PDF

Context

In Western-colonized countries, health systems are an extension of the colonial enterprise that reproduces and reinforces the dynamics of power, oppression and exclusion directed at Indigenous peoples. Patients who are the victim of racial discrimination tend to dread interactions with care providers, underutilize healthcare services and underreport their symptoms to health professionals, which contributes to an increase in preventable diseases and more frequent crisis situations.

Cultural safety is described as a decolonizing, transformative and participatory approach in a health system that aims to offer care that recognizes, respects and supports the unique needs, the rights and the identities of Indigenous peoples. That approach is rooted in understanding the power inequities that characterize the health system.

Several definitions of cultural safety place the responsibility for change squarely in the hands of health professionals. That said, the authors contend that reducing health access inequities must involve transforming the health system, with decolonization as a true objective. They believe that such a transformation requires new or radically reimagined professional roles.

Objective

The objective of this rapid synthesis was to obtain an overview of recent scientific literature looking at interventions describing the creation or transformation of professional roles as a strategy for fostering cultural safety in health organizations.

It was part of a broader research project aimed at codeveloping, together with Atikamekw Nehirowisiwok partners, an intervention model advocating for the implementation of cultural safety in the health system.

Methodology

The research strategy was deployed using three databases. A total of 23 articles published between 2010 and 2020 were selected. To be eligible, publications had to report on interventions or strategies aimed at improving cultural safety through the creation of a new professional role or the transformation of an existing role. The studies had to look at interventions impacting the health of Indigenous populations in CANZUS countries.

What was learned? 

Three types of professional role that could foster cultural safety emerged:

  1. Supporting Indigenous people’s access to and navigation of the healthcare system: Thirteen interventions are based on the role of a peer facilitator. Often a community member who speaks the language and is familiar with social codes, the facilitator helps Indigenous patients and their families overcome systemic and organizational obstacles to accessing care (e.g., service navigators or a community agent).
    • The authors note that this type of role is criticized for being unidirectional: the patient is assisted in adapting to services without actually action being taken to remove barriers to access. Moreover, a large pool of navigators is needed in urban settings in order to represent the wide diversity of Indigenous patients.
  2. Providing a new or improved service offering that meets the needs of Indigenous peoples: Two interventions cite examples of a professional whose role was expanded or created (an Indigenous Elder providing spiritual advice and a traditional health practice offering).
    • These interventions take into consideration the holistic needs and situation of patients. However, the authors warn that these “added” services cannot be an end in and of themselves and need to be accompanied by changes in values, organizational practices and health policies.
  3. Building capacity to provide culturally safe healthcare: Three studies report interventions in which professional roles focus on the organization and its employees, rather than on patients (e.g., a consultant who acts as a cultural mentor and provides training at the workplace).
    • These interventions are rooted in social justice ideals and collaborative governance models.
    • They require organizational openness and commitment in favour of cultural safety, which can create friction with other conflicting priorities.
  4. Mixed interventions: Five studies looked at interventions involving all three types of professional role mentioned above in order to act across the various organizational levels (e.g., a mobile multidisciplinary team of community agents equipped with portable diagnostic tools in order to direct people to the appropriate services).
    • No one of the three types of role is sufficient on its own, but together they can form a more integrated approach to cultural safety.

Limitations

Many of the articles included in the review are descriptive in nature and did not report on the effects of the interventions. As a result, the effectiveness of the various roles promoting cultural safety could not be evaluated. Also, the decision to deliberately select recent publications about Indigenous populations in CANZUS countries excluded studies that may address power dynamics impacting access to healthcare by other marginalized populations.

Qanuilirpitaa? 2017

Publications in the Special Issue of the Canadian Journal of Public Health dedicated to Nunavimmiut health

Promotion of wellbeing and mental health

The psychosocial dimension of housing in Nunavik: Does social support vary with household crowding?

Simard, C.-O., Riva, M., Dufresne, P., Perreault, K., Muckle, G., Poliakova, N., Desrochers-Couture, M., Fletcher, C., Moisan, C., Fraser, S., Bélanger, R., Courtemanche, Y. and Bignami, S. (2022). The psychosocial dimension of housing in Nunavik: Does social support vary with household crowding? Canadian Journal of Public Health, 1–10.

Open access: PDF

Context

In Nunavik, data points to the impact of overcrowded households on the mental health of Inuit, for whom social relations are critical to the wellbeing of individuals and communities. For them, housing is an important health determinant because of its influence on family relations and cultural identity, which in turn is an integral part of their sense of belonging.

The erosion of social support may explain how overcrowded housing affects mental health. Overcrowding leads to adverse interactions and tension within households, resulting in isolation.

Objective

Evaluate whether overcrowded housing is associated with lower levels of perceived social support among Inuit living in Nunavik and whether the association varies with sex and age.

Methodology

The data used came from Qanuilirpitaa?, the 2017 Nunavik Health Survey. A perceived social support index was derived from answers to five questions related to three different components of social support: positive interaction, emotional support, and love and affection. Overcrowded housing was measured with the help of a dichotomous variable generated from the number of residents per room, with a threshold of more than one person per room as the definition of an overcrowded household.

The associations were measured using linear and logistic regression models by adjusting the sociodemographic and economic covariables. The analyses were stratified by sex and age (16 to 29 years, 30 to 54 years and 55 years or older). A committee composed of Nunavimmiut and representatives of Inuit organizations was involved in interpreting the results.

What was learned?

In keeping with earlier studies, people living in overcrowded households reported lower levels of social support independent of the sociodemographic and economic covariables.

For the different components of social support, the probability of feeling affection and love was almost two times lower for participants living in an overcrowded household than for participants not living in such housing.

The association between overcrowding and perceived social support varied according to sex and age group. Unlike the results of an earlier study conducted in Greenland, overcrowding in Nunavik is negatively associated with social support for men, but not women.

These results appear to be culturally relevant, given that social support and meaningful social relations are key health factors for the Inuit.

Limitations

The authors report that the proportion of individuals living in an overcrowded household in their sample is lower than in the Canadian 2016 Census for the same region. The association between overcrowded housing and social support may have been underestimated.

Given that the data is self-reported, the results may express differences between perceived and actual social support. For this reason, the results broken down by sex may describe differences in perceived social support rather than actual differences.

Since the data comes from a cross-sectional survey, a reverse causality may exist, i.e., individuals with a lower perception of social support may have ended up living in overcrowded households.