Article Figures & Tables
Tables
Location; year of publication; model Type of site Year established Services offered (beyond the biomedical) Types of evidence Health outcomes Whitehorse General Hospital, Yukon; 2018;17 fully integrated and inter-disciplinary Northern urban hospital 1993 Traditional foods, plant medicines, healing room, Elder’s suite, cultural programs, liaison workers Quality and cultural safety patient surveys, annual reports, website Quality and cultural safety improvements unspecified Haida Gwaii, BC; 1999;18 integrated Diabetes clinic 1994 Traditional diet, plant medicines, exercise program Chart review, biomedical measurements, focus groups, community-based participatory action Significant decrease in total cholesterol (0.45, p = 0.005). Increase in high-density lipoproteins or “good cholesterol” (−0.097, p = 0.05). Six First Nations communities in northwestern Ontario; 2017;19 integrated Drug treatment centres 2012 Traditional healing, traditional counselling, land-based aftercare (e.g., fishing, hunting, memorial walks, community gardening), Elder-run healing sessions (individual and groups) Retrospective cohort study, n = 526 Retention rate = 84%. High rates of negative urine drug screening result. Dramatic reduction in suicides in all 6 communities after onset of program (p = 0.035). At 1 year after onset of buprenorphine–naloxone program, criminal charges decreased by 61.1%, child protection cases decreased by 58.3% and school attendance rates increased by 33.3%. Drug-related medical evacuations to hospital decreased by 30.0%. Two cities in western Canada; 2019;20 integrated Centres for women who have experienced violence 2018 Elder-led health promotion circles partnered with nursing Longitudinal study, pre–post and at 6 months, n = 152. Indigenous women self-report on quality of life and trauma symptoms. Depressive symptoms, social support, personal and interpersonal agency, chronic pain disability. Quality of life and trauma symptoms improved significantly both immediately postintervention and at 6 months. Improvements in 5 of 6 secondary psychological outcomes. Vancouver, BC; 2016;21 integrated In community 2012 Women’s heart health group (2 h/wk for 8 wk), Sacred Blanket ceremony, Talking Circle, partnered with nursing Mixed-methods pre–post program evaluation Most improved diet. Some improved activity level and emotional health. Women reported program as a success because it was both women-centred and appropriate to Indigenous culture. Puvirnituq Hospital and surrounding birth centres in Inukjuak and Salluit, Nunavut; 200422 and 2007;23 fully integrated and interdisciplinary Northern remote hospital maternity ward and birth centres 1990 Prenatal, birth and postpartum services by Inuit midwives (with medical and traditional training) supported by doctors and nurses both on-site and through remote service technology; specialists available by phone, electronic communication and transport Five-year retrospective study including review of birth registrations, antenatal records in Inukjuak and records of evacuations. External evaluation of maternity data with regional cohorts. Since the midwifery program started, evacuations, inductions, cesarean deliveries and episiotomies are drastically reduced. Perinatal mortality equal to Canadian average (0.9%), better than comparable populations, e.g., Northwest Territories (1.9%) and Nunavut (1.1%). Noojmowin Teg Health Centre, Manitoulin Island, Ontario; 200913 and 2013;24 interdisciplinary and multidisciplinary Community health access centres on northern reserves 1998 Traditional healers, Elders and coordinator, home visits, land-based medicines, plant medicines, ceremonies, lifestyle teachings, counselling, chronic illness care, psychiatry Retrospective case study on 10 years of contextualized experience: in-depth interviews and focus groups with 17 providers and 23 clients, and document reviews (e.g., policies and program descriptions). Community-initiated study including 43 semistructured interviews with clients from 7 communities. Faster, better coordinated response times in urgent care and crisis. Integrated care positive for providers and clients. Clinical mental health and traditional services successfully integrated. Meno Ya Win Health Centre, Sioux Lookout, Ontario; 20107 and 2010;25 interdisciplinary and multidisciplinary Rural hospital 2002 Traditional practitioners, foods, plant medicines, ceremonial room, 24/7 language interpreters with expanded roles as advocates, navigators and cultural translators, Elders-in-residence, all staff trained in cultural sensitivity Patient surveys, needs assessments via 4 community consultations, including First Nations Chiefs, spiritual leaders and 50 Elders, site visits to 16 organizations including document reviews and key informant interviews, phenomenological study on end-of-life care Confirmed Elders advisory council is essential in governance and decision-making. Succeeding in providing culturally safe treatment options and advancing integrated care. Significant improvements to end-of-life care and culturally responsive care. Unnamed clinic, Vancouver Native Health Society, BC; 2016;26 multidisciplinary Urban primary health care clinic 1993 Indigenous-friendly space, culturally appropriate chronic care model Retrospective cohort pre–post evaluation for intervention data from 2007 to 2012 All-cause mortality rates were significantly reduced from 10.00 per 100 person years in exposed group to 5.00 per 100 person years (p = 0.023). HIV-cause mortality rates were significantly reduced from 5.56 per 100 person years to 1.80 per person years (p = 0.005) between 2007 and 2012. Sheway, Vancouver Native Health Society, Vancouver Downtown Eastside, BC; 2003;14 multidisciplinary Urban clinic and drop-in centre 1993 Emergency services, hot lunches, baby supplies, counselling, partnerships with Elders, access to ceremonies and cultural teaching circles for substance-using pregnant women Case study with participatory observation, 3 focus groups (46 people total) and 25 semistructured interviews with staff, providers, government and community leaders Improved access to prenatal care, maternal nutrition and infant birth weights (from 33% to 24% low birth weight in first 5 yr). Reduced isolation, substance use, fetal alcohol syndrome, neonatal abstinence syndrome and child apprehensions (from 100% to 42% in first 5 yr). Improved interpersonal and problem-solving skills. Anishnawbe Mushkiki Aboriginal Health Centre, Thunder Bay, Ontario; 2019;27 multidisciplinary Primary care clinic 1990 Traditional healing program includes ceremonies (e.g., feasts, sweat lodge, naming and grieving), cultural teachings (e.g., medicine wheel, seven grandfathers, clan, parenting, women’s, sacred medicines), traditional wellness coordinator, access to Elders and traditional healers Annual reports, website, staff reports Quality and cultural safety improvements unspecified Anishnawbe Health Toronto, Ontario; 200628 and 2013;11 multidisciplinary and coordinated Urban clinic 1989 Traditional family services, Elders, healers, counsellors, teaching circles and ceremonies (e.g., naming, shake tent, pipe, full moon, clan feasts and vision quests) Mixed methods using 42 intake questionnaires, 12 interviews participatory observation and narrative inquiry Quality and cultural safety improvements unspecified. Thematic analysis summary: identity reclamation is crucial step in healing Indigenous psyche, and mental health services must be culturally relevant and trauma-informed. Unnamed inner-city clinic, western Canada; 2019;29 coordinated and co-located Primary care clinic 1991 Mental health patients had regular contact with an Elder over 6 months Mixed-methods study designed with Elders advisory council, including quantitative prospective cohort Patients who at study onset reported moderate to severe depression (Patient Health Questionnaire score of 10 or greater) and high risk for suicide (Revised Suicide Behaviours Questionnaire score of 7 or greater) improved by 5 points (p = 0.001) and 2 points (p = 0.005), respectively. Emergency department mental health visits decreased by 56% for the total sample population, for a year on either side of the intervention. Turtle Lodge and Giigewigamig Traditional Healing Center, Sagkeeng First Nation, Manitoba; 2019;9 autonomous Healing lodge 2002 Traditional healers, Elders, cultural teachings, ceremonies, round tables, land-based activities, sacred gathering place. “Medicine Mondays” held at the sacred fire and sweat lodge onsite at hospital. Referrals from doctors to traditional healers. Descriptive, analysis, dialogical Early evidence emerging from conversations with patients, families and Elders show improved access to culturally safe care and holistic health outcomes. Elders at Giigewigamig also take the lead at building partnerships with doctors and hospital staff through regular invitations to learn about local medicines and experience traditional healing ceremonies. ↵* In this analysis, we reviewed qualitative, quantitative and mixed-methods research. Although Indigenous-led statistics is an emerging area, literature on traditional Indigenous knowledge is largely qualitative to date; thus, we included studies involving interviews, focus groups and community-based participatory processes alongside quantitative studies. Literature searches through medical and social science databases, academic journal articles, published theses and relevant grey literature (e.g., websites, annual reports, organizational statements) from Indigenous organizations, health care facilities and health research institutions were conducted. About 150 articles were reviewed by selecting for relevancy, analyzing for themes and synthesizing for succinctness. These 14 examples were chosen for the strength of the partnerships outlined, the clarity of evidence presented, and the degree to which Indigenous communities or traditional Indigenous knowledge was central to or leading the research and clinical process. We worked together as a team inclusive of Indigenous Elders, a physician and scholars in discussion, in ceremony and in the writing process.
Location; year of publication; model Type of site Year established Services offered (beyond the biomedical) Types of evidence Health outcomes New South Wales, Australia; 2017;34 integrated Reproductive and sexual health program 2010 Strong Family Program includes access to Elders and Indigenous health professionals, yarning circles over 2–3 days Community engagement, focus groups, pre–post surveys. Indigenous youth and adults (n = 76). Knowledge and attitude scores improved 5% points on average. Participants aged 13–20 years had greatest increase in knowledge (p = 0.034); participants aged 20–78 had greatest increase in positive attitudes (p = 0.001). Unnamed, US; 2015;35 interdisciplinary and multidisciplinary Residential treatment centre for substance use and mental health disorders Unknown Cultural, spiritual, traditional healing practices (e.g., sweat lodge, talking circle, smudging), access to healers and spiritual counsellors Native American and Alaskan Native youth (n = 229). Youth Outcome Questionnaire Self Report. Pre–post group matched. 96% improved or recovered (using clinically significant change criteria). None deteriorated (compare with the 15%–24% standard in similar settings). Large effect size found with the Cohen criteria. Rural Oklahoma, US; 2015;36 multidisciplinary School-based youth clinic 2010 Talking circle intervention, 30-minute sessions 2–3 times per week for 8.5 weeks (10 hr) Native American Indian Plains at-risk youth (n = 44). Pre–post questionnaires (Native Self-Reliance, Global Appraisal of Individual Needs — Quick) One-tailed, paired sample t tests showed significant increase in self-reliance, from 86.227 to 92.204 (t43 = −2.580, p = 0.007) and decrease in substance abuse and use, from 2.265 to 1.265 (t33 = 1.844, p = 0.007). Perth, Western Australia; 2018;37 multidisciplinary Youth clinic for severe mental disorders 2014 Indigenous mental health practitioners provide clinical care, cultural care, information to non-Indigenous providers and coordinate community support in YouthLinks framework Mixed methods. Aboriginal youth (n = 40). Outcome Rating Scale and Session Rating Scale over 2 years. 65% improved (35% achieved clinical recovery, 30% achieved clinical cut-off by last session), 25% showed no change and 10% deteriorated. Therapeutic bond with practitioner had stronger effect compared with non-Indigenous populations. Five Mam and 3 K’iche’ communities near Quetzaltenango City, Guatemala; 2019;38 coordinated Women’s centre 2018 Ten 6-hour sessions co-designed and facilitated by Indigenous health workers using traditional teachings, art, therapies and skill development for women at risk for perinatal mental disorders Mixed methods. Randomized parallel groups, women (n = 84) (12 per community in 7 communities) in intervention group, plus 71 in control group. Measured maternal psychosocial distress, well-being (Mental Health Continuum — Short Form), self-efficacy, and engagement in early infant stimulation activities. In-depth interviews to gauge feasibility and acceptance. Postintervention (1 mo), compared with control group, treatment group experienced increased well-being (p = 0.008) and self-care self-efficacy (p = 0.049). Attending more sessions led to improved well-being (p = 0.007), self-care (p = 0.014), infant-care self-efficacy (p = 0.043) and early infant stimulation (p = 0.019) scores. Two Yup’ik communities in Southwest Alaska; 2018;39 autonomous Suicide and addictions prevention program Unknown Cultural interventions at 2 doses (high and low); modules from Yup’ik Qungasvik Toolbox, Elders’ guidance 54 youth participated through analysis stage in community 1 (treatment arm); 74 youth participated in community 2 (comparison arm). Measurement tools: Multicultural Mastery Scale, Brief Family Relationship Scale, Youth Community Protective Factors, American Drug and Alcohol Survey, Reflective Process and Reasons for Life High-dose intervention produced greater impact on Reasons for Life (d = 0.28, p < 0.05), increasing suicide protection in the treatment arm. Analyses found significant growth over time within community 1, but not community 2, on Reasons for Life (d = 0.43, p < 0.05). ↵* This analysis involved literature searches through medical and social science databases, academic journal articles, published theses, and relevant grey literature (e.g., websites, annual reports, organizational statements) from Indigenous organizations, health care facilities, and health research institutions were conducted. These 6 key examples were chosen due to the strength of the partnerships outlined, the clarity of quantitative evidence presented, the recency, and the degree to which Indigenous communities or traditional Indigenous knowledge was central to or leading the research and clinical process to demonstrate the spectrum of models.
In personal practice In public forums and systems In research Reflect on your own biases. Commit to professional development for yourself and your team in cultural safety, awareness of the Truth and Reconciliation Commission of Canada’s Calls to Action, and antioppressive, antiracist training. Go to ceremonies and community events to connect with Indigenous Peoples, communities and organizations Survey current knowledge and attitudes of health care providers, traditional practitioners and patients across the country Greet people in their traditional language at the start of appointments Build a sense that you belong to the community and care about continuity with your patient base over the years Advance and use Indigenous statistical research methodologies Prioritize getting to know your patients, their families, their stories, their preferences and their beliefs Promote community-based participatory action, authentic engagement and relationship-building between people and organizations Promote and build competence in the use of Indigenous research methodologies In appointments, acknowledge socio-historic injustices (e.g., colonization, residential schools and ongoing racism) affecting health, while celebrating strengths and resilience Speak out in solidarity during professional meetings and public forums to honour and appreciate the medicines of Indigenous Peoples Conduct systematic or scoping reviews of traditional–Western medicine partnerships in Canada and internationally Inquire about (and be open-minded to) patient disclosure of traditional medicine use or consultations with healers and Elders Post and refer to the United Nations Declaration on the Rights of Indigenous People in terms of health and health care Study how to protect Indigenous medicines, healing practices and knowledge in their full integrity Initiate a personal relationship with an Elder and be open to other ways of knowing and forms of “evidence” Use the Truth and Reconciliation Commission of Canada’s Calls to Action, the Calls to Justice of the Missing and Murdered Indigenous Women and Girls Report, and any provincial acts (e.g., Manitoba’s The Path to Reconciliation Act) to promote system changes on all levels of policy Develop a better understanding of health care and practice across mixed and integrated Indigenous identities Hire Indigenous personnel Make Indigenous-friendly spaces with visual indications of welcome (e.g., plaques, art-work and Truth and Reconciliation Commission of Canada commemorations) Work alongside and train Indigenous community members as researchers Get to know your local traditional practitioners and their specialties Ensure safe spaces (e.g., ceremony rooms and smudge-friendly spaces) in hospitals and clinics. Seek partnerships with local Indigenous Knowledge Keepers to provide cultural education for staff. Build knowledge of how different models of Indigenous-led health partnerships can respond to context-specific service needs Treat patients by connecting them with local resources and traditional cultural events Create partnerships with Indigenous Elder-led organizations. Develop Elder advisory committees in organizations that do not have them already. Consult in organizations that do. Consult with Indigenous Knowledge Keepers on using the Medicine Wheel framework in health services and systems Consult with Elders, refer patients to traditional practitioners, support the work they do in communities Work with Elder advisory committees to discern culturally appropriate systems (e.g., fair compensation, patient safety standards, scope of practice, role profiles, record keeping and record sharing) Learn about and advance a “two-eyed seeing” framework for practice and evidence-based research Respect various Medicine Wheel teachings as holistic conceptual models of health and wellness Cocreate bicultural policy and procedures manuals Understand proper cultural protocols, engagement practices and self-determination in health policy research and development Value traditional medicine equally with biomedicine “Get out of the box and back into the circle” — Elder Dr. David Courchene Build knowledge of Indigenous forms of “evidence” and “efficacy”