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Analysis

Indigenous-led health care partnerships in Canada

Lindsay Allen, Andrew Hatala, Sabina Ijaz, Elder David Courchene and Elder Burma Bushie
CMAJ March 02, 2020 192 (9) E208-E216; DOI: https://doi.org/10.1503/cmaj.190728
Lindsay Allen
Community Health Sciences (Allen, Hatala), Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Turtle Lodge Central House of Knowledge, Sagkeeng First Nations (Ijaz, Courchene), Fort Alexander, Man.; Giigewigamig First Nation Health Authority (Ijaz, Bushie), Pine Falls, Man.
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Andrew Hatala
Community Health Sciences (Allen, Hatala), Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Turtle Lodge Central House of Knowledge, Sagkeeng First Nations (Ijaz, Courchene), Fort Alexander, Man.; Giigewigamig First Nation Health Authority (Ijaz, Bushie), Pine Falls, Man.
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Sabina Ijaz
Community Health Sciences (Allen, Hatala), Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Turtle Lodge Central House of Knowledge, Sagkeeng First Nations (Ijaz, Courchene), Fort Alexander, Man.; Giigewigamig First Nation Health Authority (Ijaz, Bushie), Pine Falls, Man.
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Elder David Courchene
Community Health Sciences (Allen, Hatala), Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Turtle Lodge Central House of Knowledge, Sagkeeng First Nations (Ijaz, Courchene), Fort Alexander, Man.; Giigewigamig First Nation Health Authority (Ijaz, Bushie), Pine Falls, Man.
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Elder Burma Bushie
Community Health Sciences (Allen, Hatala), Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Turtle Lodge Central House of Knowledge, Sagkeeng First Nations (Ijaz, Courchene), Fort Alexander, Man.; Giigewigamig First Nation Health Authority (Ijaz, Bushie), Pine Falls, Man.
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    Table 1:

    Examples of Canadian Indigenous-led partnerships and health outcomes*

    Location; year of publication; modelType of siteYear establishedServices offered (beyond the biomedical)Types of evidenceHealth outcomes
    Whitehorse General Hospital, Yukon; 2018;17 fully integrated and inter-disciplinaryNorthern urban hospital1993Traditional foods, plant medicines, healing room, Elder’s suite, cultural programs, liaison workersQuality and cultural safety patient surveys, annual reports, websiteQuality and cultural safety improvements unspecified
    Haida Gwaii, BC; 1999;18 integratedDiabetes clinic1994Traditional diet, plant medicines, exercise programChart review, biomedical measurements, focus groups, community-based participatory actionSignificant 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 integratedDrug treatment centres2012Traditional 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 = 526Retention 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 integratedCentres for women who have experienced violence2018Elder-led health promotion circles partnered with nursingLongitudinal 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 integratedIn community2012Women’s heart health group (2 h/wk for 8 wk), Sacred Blanket ceremony, Talking Circle, partnered with nursingMixed-methods pre–post program evaluationMost 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 interdisciplinaryNorthern remote hospital maternity ward and birth centres1990Prenatal, 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 transportFive-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 multidisciplinaryCommunity health access centres on northern reserves1998Traditional healers, Elders and coordinator, home visits, land-based medicines, plant medicines, ceremonies, lifestyle teachings, counselling, chronic illness care, psychiatryRetrospective 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 multidisciplinaryRural hospital2002Traditional 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 sensitivityPatient 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 careConfirmed 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 multidisciplinaryUrban primary health care clinic1993Indigenous-friendly space, culturally appropriate chronic care modelRetrospective cohort pre–post evaluation for intervention data from 2007 to 2012All-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 multidisciplinaryUrban clinic and drop-in centre1993Emergency services, hot lunches, baby supplies, counselling, partnerships with Elders, access to ceremonies and cultural teaching circles for substance-using pregnant womenCase study with participatory observation, 3 focus groups (46 people total) and 25 semistructured interviews with staff, providers, government and community leadersImproved 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 multidisciplinaryPrimary care clinic1990Traditional 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 healersAnnual reports, website, staff reportsQuality and cultural safety improvements unspecified
    Anishnawbe Health Toronto, Ontario; 200628 and 2013;11 multidisciplinary and coordinatedUrban clinic1989Traditional 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 inquiryQuality 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-locatedPrimary care clinic1991Mental health patients had regular contact with an Elder over 6 monthsMixed-methods study designed with Elders advisory council, including quantitative prospective cohortPatients 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 autonomousHealing lodge2002Traditional 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, dialogicalEarly 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.

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    Table 2:

    Examples of international Indigenous-led partnerships and health outcomes*

    Location; year of publication; modelType of siteYear establishedServices offered (beyond the biomedical)Types of evidenceHealth outcomes
    New South Wales, Australia; 2017;34 integratedReproductive and sexual health program2010Strong Family Program includes access to Elders and Indigenous health professionals, yarning circles over 2–3 daysCommunity 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 multidisciplinaryResidential treatment centre for substance use and mental health disordersUnknownCultural, spiritual, traditional healing practices (e.g., sweat lodge, talking circle, smudging), access to healers and spiritual counsellorsNative 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 multidisciplinarySchool-based youth clinic2010Talking 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 multidisciplinaryYouth clinic for severe mental disorders2014Indigenous mental health practitioners provide clinical care, cultural care, information to non-Indigenous providers and coordinate community support in YouthLinks frameworkMixed 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 coordinatedWomen’s centre2018Ten 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 disordersMixed 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 autonomousSuicide and addictions prevention programUnknownCultural interventions at 2 doses (high and low); modules from Yup’ik Qungasvik Toolbox, Elders’ guidance54 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 LifeHigh-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.

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    Table 3:

    Suggestions for health care providers, managers and researchers

    In personal practiceIn public forums and systemsIn 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 organizationsSurvey 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 appointmentsBuild a sense that you belong to the community and care about continuity with your patient base over the yearsAdvance and use Indigenous statistical research methodologies
    Prioritize getting to know your patients, their families, their stories, their preferences and their beliefsPromote community-based participatory action, authentic engagement and relationship-building between people and organizationsPromote 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 resilienceSpeak out in solidarity during professional meetings and public forums to honour and appreciate the medicines of Indigenous PeoplesConduct 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 EldersPost and refer to the United Nations Declaration on the Rights of Indigenous People in terms of health and health careStudy 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 policyDevelop a better understanding of health care and practice across mixed and integrated Indigenous identities
    Hire Indigenous personnelMake 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 specialtiesEnsure 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 eventsCreate 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 communitiesWork 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 wellnessCocreate bicultural policy and procedures manualsUnderstand 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 CourcheneBuild knowledge of Indigenous forms of “evidence” and “efficacy”
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Canadian Medical Association Journal: 192 (9)
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Indigenous-led health care partnerships in Canada
Lindsay Allen, Andrew Hatala, Sabina Ijaz, Elder David Courchene, Elder Burma Bushie
CMAJ Mar 2020, 192 (9) E208-E216; DOI: 10.1503/cmaj.190728

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Indigenous-led health care partnerships in Canada
Lindsay Allen, Andrew Hatala, Sabina Ijaz, Elder David Courchene, Elder Burma Bushie
CMAJ Mar 2020, 192 (9) E208-E216; DOI: 10.1503/cmaj.190728
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    • Why are Indigenous-led partnerships needed in Canada’s health systems?
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