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Relationship building with First Nations and public health: Exploring principles and practices for engagement to improve community health – Review of the Literature

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September 2017

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Contents

Citations

Authors (in alphabetical order)

Project Team

Indigenous Circle

Acknowledgements

The Project Team would like to acknowledge the support and contributions provided by Hilary Gibson-Wood, Research Facilitator from Public Health Ontario.
This research project was supported with funding from Public Health Ontario’s Locally Driven Collaborative Project (LDCP) stream. The views expressed in this report are those of the research team and do not necessarily reflect those of Public Health Ontario.

Contact for More Information

Renée St Onge, Director
Resources, Research, Evaluation and Development Division
Sudbury & District Health Unit
705.522.9200, ext. 510
stonger@sdhu.com

Citation

Relationship Building with First Nations and Public Health Research Team. 2017. Relationship building with First Nations and public health: Exploring principles and practices for engagement to improve community health – Literature Review. Sudbury, ON: Locally Driven Collaborative Projects

Executive Summary

Ontario public health units deliver a broad range of population health programs aimed at improving the health of the population, protecting the health of all, and ensuring everyone has equal opportunities for health. To do this, health units are required to tailor programs and services to the local context and community needs. Thirty-six (36) public health units operate across Ontario, and their catchment areas align with the traditional territories of 133 First Nations. Given its mandate and geographical alignment, public health units and First Nations communities stand to mutually benefit from developing and implementing processes and practices for effective engagement. As such, the overall intent of this research project is to answer the following research question: “What mutually beneficial, respectful, and effective principles and practices of engagement between First Nations communities and public health units in Northeastern Ontario can be identified as an important step in working toward improved opportunities for health for all”. As a first step to answering the research question, the project team conducted a review of both grey and academic literature that explore strategies, approaches, and principles of engagement and collaboration between Indigenous people and public sector agencies in North America and Australia.

Based on findings, there are four principles of Indigenous engagement that emerged. These are respect, trust, self-determination, and commitment. These principles are recommended as exemplifying the underlying philosophy and approach needed to engage successfully and work in meaningful ways with First Nations communities. Within each principle, a number of wise practices were also identified. These wise practices are viewed as specific actions, which can contribute to more successful partnerships with First Nations communities.

The first principle of respect focuses on the need for non-Indigenous people to understand, acknowledge, and appreciate both the history and current context of Indigenous peoples. The literature outlined a number of cultural competency practices that can be seen as a pre-cursor to any engagement activities. Practices that honour the diversity of the unique Indigenous cultures are also recommended. Formal acknowledgment practices, such as workplace signs that identify the traditional owners of the land, further foster this principle.

Trust is another principle that was identified as necessary for establishing and maintaining a mutually beneficial partnership. As many historical and ongoing events have led to considerable distrust by many Indigenous people, for any successful engagement to occur, trust must be a central consideration. Early engagement, working with respected Indigenous members, inclusivity of Indigenous members and genders, and appropriate and ongoing communication are all likely to build trust.

Partnerships with Indigenous peoples have been identified to be more successful if the principle of self-determination is considered and understood. This can be encouraged by ensuring collaborations are driven by Indigenous communities, providing opportunities to build Indigenous workforce capacity, building on the strengths of the Indigenous communities, and having strong Indigenous representation in the decision making process.

The final principle—commitment—is important for sustaining long-term and effective partnerships. Practices that support co-learning and power sharing can foster mutual responsibility. Flexibility with regards to funding structures and timelines are also required to support a fulsome engagement process. As such, progressive leadership is required to do things differently. Additional supporting practices include purposeful Indigenous hiring, ongoing reflection, visible community presence, and ensuring that Indigenous communities validate the findings and that their perspectives are included.

In all, these four principles and their associated practices present a synthesis of findings that have been utilized, suggested, or recommended to engage with Indigenous communities. This is an important foundational first step that provides supportive context and informs the next phases of this project, which include a survey to Ontario public health units, key informant interviews, and gathering information within First Nations communities.

Introduction

Public health units in Ontario are responsible for delivering program and services to improve and protect the health and well-being of the population. They are dedicated to providing equal health opportunities for all. Thirty-six (36) public health units operate across Ontario, and their catchment areas align with the traditional territories of 133 First Nations. The Ministry of Health & Long-Term Care has recently provided further direction to health units to either begin to build and/or further develop relationships with Indigenous communities (Ministry of Health and Long-Term Care, 2017).

Given its mandate and geographical alignment, public health units have an interest in developing processes for guidance on principles and practices that can promote effective engagement with First Nations communities in a respectful and mutually beneficial manner. Little formal guidance is available to public health from the provincial government on the best ways to engage with First Nations. In addition, little is known about the wishes of First Nations with respect to engagement and collaboration specifically with local public health units.

In Northeastern Ontario, there are five public health units whose catchment areas align with the traditional territories of 40 First Nations. This research project intends to identify mutually beneficial, respectful, and effective principles and practices of engagement between First Nations communities and public health units in Northeastern Ontario. This is embedded within an approach that leads to co-creation of the guidance by First Nations communities and public health units. Engagement, for the purposes of this project, is defined as a process of involvement through a respectful relationship.

Broadly speaking and for the purposes of this project, effective engagement is defined as a meaningful, respectful, and mutually beneficial relationship between individuals or groups of people (Anderson-Smith, 2008). More specifically, Indigenous engagement is a sustained process where trust is built by ensuring Indigenous people have the opportunity to actively participate in decision making from the earliest phase. Engagement happens before an issue is even conceptualized and continues through to evaluation, knowledge exchange, and beyond (Hunt, 2013a). It is unique in that it involves process options, strong relationships, and an understanding of each other’s needs, and it must occur in a true intercultural forum (Anderson Smith, 2008).

There are multiple components to this project. First, the project team will conduct a review of both academic and grey literature on principles and practices of Indigenous engagement. The second phase, called “Gathering and sharing learnings” consists of the following: (1) an online survey of Ontario public health units, (2) key informant interviews with health agencies that have existing Indigenous-focused strategies, and (3) focus groups or sharing circles involving Northeast Ontario First Nations communities, Tribal Councils, or First Nations regional health service organizations. The intent of this phase is to gather and share learnings about engagement practices as well as the facilitators and barriers to engagement.

Information from both phases will contribute to identifying principles and practices that have worked or would be recommended for mutually beneficial engagement between First Nations and public health. Results will then be actively shared with public health units, First Nations, and others who may have an interest in developing respectful engagement strategies.

This report presents the results from the first phase of the project. The review of the literature includes North American and Australian academic and grey literature that explore strategies, approaches, and principles of engagement and collaboration between Indigenous people and public sector agencies. Academic literature refers to published articles found within peer reviewed journals. Grey literature refers to documents including, but not limited to, reports, working papers, presentations, and project results, that have not been reviewed by peers and can be produced by a wide range of organizations.

Findings from the literature will be foundational to provide supportive context and inform the development of the next phases of this project, which include a survey to Ontario public health units, key informant interviews, and gathering information within First Nations communities.

To ensure that the overall approach to this project includes First Nations voices, the project team includes an Indigenous circle comprised of representatives with expertise, experience, and Indigenous perspectives from communities within Northeastern Ontario. They are responsible for guiding the project team and informing important decisions about the project’s design, direction, and implementation. The project team also includes representation from five Northeastern Ontario public health units as well as Indigenous and non-Indigenous academic scholars.

This research project was supported with funding from Public Health Ontario’s Locally Driven Collaborative Project (LDCP) stream. This is a unique program that aims to facilitate applied research collaboration among health units, and between health units and other stakeholders on identified key public health issues. This specific research project started in early 2017, and both phases will be completed by June 2018.

The terms Indigenous, First Nation(s), Aboriginal, Native American, Anishnaabe, Native, and Indian are used in various instances in this report. While the project team privileges the terms Indigenous and First Nation(s), the other terms are used in instances where we are paraphrasing or citing the literature, so as to remain faithful to the language used in the sources.

Methodology

A literature review of both grey and published literature explored strategies, approaches, and principles of engagement and collaboration between Indigenous people and public sector agencies in the last 10 years in North America and Australia. It is important to note that Australia was purposefully selected for this search given its known work on Indigenous engagement.

This literature search utilized a rapid review process, which enables knowledge synthesis within shorter timeframes. This methodology differs from systematic reviews in that the search strategy is narrowed and a limited number of reviewers are involved (National Collaborating Centre for Methods and Tools, 2017). Although there are limitations to this strategy, it was deemed appropriate for this research project to provide timely foundational knowledge on the research question.

Search Strategy

Published Literature

The search of the published literature was guided by the research question and was carried out by a working group that included an Indigenous academic scholar and three public health sector members with one being of Indigenous ancestry.

The search strategy was developed in Medline and translated into additional academic databases, which were selected for their sociological, health, or cultural scope of coverage. Databases searched include Bibliography of Native North Americans, CINAHL, Medline, PsychInfo, SocIndex. Two bibliographies were compiled—one related to North American and one related to Australian populations, with some duplication between the two.

Indigenous concepts were retrieved through a combination of standard subject headings and through searching terms to identify the cultural group (aborigin* indian Indigenous native tribe or reserve) within proximity to terms in the appropriate geographic setting (America, Canada, provinces, cities etc.). Broad keyword terms were used (amerindian*, eskimo*, first nation, first people, indian, metis and Indigenous) as well as two existing search filters, which identified specific cultural groups (Campbell & Dorgan, 2017; Public Health Ontario, 2017).

Engagement concepts were retrieved through the use of broad subject terms (Community-institutional relations, community participation, community based participatory research), and a broad array of related keywords (engagement, cooperation, participation, partner, collaboration). Additional terms reflecting modalities, cultural values or communication were searched in proximity to community concepts1.

1 Example: (public, citizen, tribe, stakeholders) adj1 (alliance, consult, meeting, outreach, approach, trust, sharing circle, two eyed seeing, dialogue, feedback, input).

The public or community health context was retrieved mostly using subject headings; however, the following important and culturally specific keywords were also used: public health, preventive medicine, intervention, and Indigenous terms for wellness (pimitasiwin and bimaadiziwin).

A total of 2,689 citations were retrieved. The results from the search are outlined in the table below.

DatabaseCitations Extracted Canadian/North AmericanCitations Extracted
Australian
Bibliography of Native North Americans21211
CINAHL15377
Medline1,086384
PsychInfo625242
SocIndex2770
Total Citations2353714
Total after removing duplicates2047642

Additional citations (<10) were also shared by project team members and were added to the list if appropriate.

Grey Literature

The literature review working group met to brainstorm various sources of grey literature pertaining to the research question. The working group initially identified 20 agencies or organizations that involved First Nations/Indigenous engagement or partnerships2. A project team member began searching these 20 agencies’ websites as a starting point and subsequently scanned the bibliographies of relevant reports to then find other places to search. The project team member also searched public health units’ websites for the terms engagement, partnership, cooperation, collaboration, participation, First Nations, Métis, Inuit, First People, Aboriginal, Indian, Tribe, Tribal, Reserve, Reservation. In addition, Google was also used to search the same terms. A second project team member then reviewed the search results to identify documents that were relevant to this project. A total of 62 documents were initially retrieved from the grey literature.

2 Social Compass, Closing the Gap Clearinghouse, Toronto Public Health, Waakebiness – Bryce Institute of Indigenous Health, Northeastern Ontario Local Health Integrated Network, BC Public Health Authority, Weeneebayko Area Health Authority, National Collaborating Centre for Aboriginal Health, desLibris (Canadian) grey literature, Carlton University, government documents, First Nations Centre (FNC) -National Aboriginal Health Organization (NAHO), First Nations Aboriginal bodies, University of Alberta, First Nation Inuit Health Branch (FNIHB), Swaby Union of Ontario, Chiefs of Ontario, Assembly of First Nations (AFN), Well Living House, Cancer Care Ontario, Anishnawbe Health Toronto.

Selection of Literature

Published Literature

Retrieved citations were then assessed for inclusion or exclusion in the literature review. The focus of the first phase of the literature review was on citations extracted for Canadian or other North America populations (n= 2,047); however, there were a number that pertained to Australian or New Zealand populations. All 2,047 abstracts were reviewed for potential inclusion.

The assessment of citations for inclusion was based on the following: initiatives where First Nations/Indigenous communities collaborated with mainstream communities, with a focus on collaboration, interaction with public health (or related field), relationships, and partnerships. Excluded were citations that were not specific to First Nations/Indigenous communities, citations about initiatives where First Nations/Indigenous communities were not collaborating with mainstream communities, and  citations that were too program-specific. Also included in a separate listing were citations that mainly referred to community-based participatory action research in First Nations/Indigenous communities.

The initial assessment of citations was carried out by two project team members separately and yielded 131 citations. A second assessment was then carried out by the two project team members to narrow down the list to 71 citations, separate out into “definitely include” (n=33), “possibly include” (n=19), and citations pertaining to research methods (n=19).

Following this, a third project team member with expertise in Indigenous health research assessed the listing and helped narrow down the citations to 61 (22 of which were related to research methods).

Grey Literature

Documents retrieved from the grey literature search were assessed for inclusion into the review of the literature, using very similar criteria to the published literature. The initial list of 62 documents was narrowed down to 26 documents in total.

Summarizing the Literature

The published and grey literature that was retained was subsequently summarized by members of the project team (four members in total, two individuals who are non-Indigenous and two individuals who are Indigenous).

The published literature was summarized using the following headings: purpose of study or research question, type of study design (when applicable), relevant outcomes/findings, and other comments (this may relate to the highlights/lowlights of this article, its rigor/quality, limitations, or anything else relevant to the literature review).

The grey literature was summarized using the following headings: purpose/objective, key findings, and limitations.

Summaries of the literature were then reviewed by members of the project team and key themes were identified. These were used to frame the summary of the literature that is presented in the section that follows.

Strengths and Limitations

This review offers many stren-0gths, including participation and input from Indigenous people, who add an important lens to the review. This review is unique to Ontario public health in that it is there no such review that looks at principles and practices of engagement with First Nations or Indigenous communities. This review obtained a large amount of both grey and academic literature from North America and Australia that will provide great insight into how to engage in a meaningful and mutually beneficial way.

Nevertheless, this review is subject to some limitations. Firstly, it was undertaken using a rapid review process, which streamlines traditional systematic review methods in order to synthesize evidence within a shortened timeframe (Ganann, Ciliska & Thomas, 2010; Hunt, 2013a). Within rapid review studies, accelerating the data extraction process can lead to missing some relevant information (Gannan et al., 2010). Moreover, it has been stated that biases may be introduced due to shortened timeframes for literature searching, article retrieval, and appraisal (Ganann, et al., 2010).

In addition, given the emphasis on decolonizing research within Indigenous communities (Morton Ninomiya & Pollock, 2017; Smylie, 2011), a rapid review would be considered Western-based research, and there may be other Indigenous research methods to consider. As stated, Indigenous people have epistemologically and contextually specific health knowledge and practices that have been historically suppressed and ignored in research practice (Smylie, 2011 from Morton, Ninomiya et al., 2017). The westernized approach would not include any oral narratives that are passed on traditionally. The systematic review done by Morton Ninomiya and Pollock (2017) purposefully included a breadth of grey and non-indexed literature where there tends to be more Indigenous authorship, community engagement, and representation. In addition, their screening and appraisal tools were selected and adapted to meet Indigenous health research principles. This review, while being mindful of these suggested approaches, does not include these and is consequently, somewhat limited in this regard.

Summary of the Literature

Based on the literature reviewed, there are four principles of Indigenous  engagement that emerged that form the basis of the sections that follow. These are respect, trust, self-determination, and commitment. Principles represent goals to strive to achieve and are utilized to guide behaviour to ensure that strategies and actions support the vision and align with the mission (Israel et al., 1998; Wilk & Cook, 2015). Although they are each distinct, it is necessary to view principles integrally, along a continuum (Israel et al., 1998). It should be noted that these four principles were frequently cited in both academic and grey literature, and were viewed as most applicable within the scope of the project.

For engagement with Indigenous people to be meaningful, it requires a number of key elements and actions embedded within a broader set of principles (Wolley et al., 2013). Within each of the four principles, there are numerous “wise” practices that represent activities and approaches that were cited to promote effective engagement with Indigenous people and can contribute to more sustained partnerships. The term “wise” practice is used instead of “best” practice in recognition of the fact that Indigenous knowledge and practice can be used as core sources of information (Well Living House). This challenges the belief that scientific knowledge can only stem from a university or non-Indigenous source (Well Living House).

Deliberate attempts were made to incorporate similar principle-based concepts into one. It is recommended that the principles and practices outlined within this document not be viewed as mutually exclusive, but rather as whole where interconnectedness exists. It is possible that one practice may be a precursor to the next, that multiple practices need to happen simultaneously, and/or that one practice may fit within multiple principles.

Respect

Description of the Principle

The principle of respect is a broad principle that encompasses a number elements that may also be termed as honouring, knowing, and understanding. This principle focuses on the need for non-Indigenous people to understand, acknowledge, and appreciate both the history and current context of the Indigenous peoples (Abbott et al., 2014; Bailey & Hunt, 2012; Christopher et al., 2008; Christopher et al., 2011; Graham, 2008; Hunt, 2013a; LaVeaux & Christopher, 2009). This includes recognizing cultural practices, traditions, protocols, values, and views while appreciating that these may be different between and even within communities (Boffa et al., 2011; Chadwick et al., 2014). Because of this diversity, there is no single engagement approach that will work with all Indigenous communities (Anderson-Smith, 2008).

It is highly regarded that non-Indigenous individuals respect the local Indigenous history with non-Indigenous people (Schinke et al., 2013). This history includes, but is not limited to the assimilationist, colonizing, oppressive, and suppressive policies and actions within legal, political, social, economic, and health contexts (Kendall & Barnett, 2015; Mashford Pringle, 2013; Social Compass, 2016).

Respect is also one of the Seven Grandfathers’ Teachings. The Seven Grandfathers’ Teachings—love, respect, honesty, humility, wisdom, truth, and bravery—are a core set of principles shared by many First Nations in the Northeastern Ontario (M. Elliot, personal communication, March 23, 2017).

Wise Practices

The following outlines a summary of themes which emerged within the literature as practices that may support the principle of respect described above.

Cultural competency

A number of articles suggest that non-Indigenous people need to learn about the culture and history of not only Indigenous people broadly, but also that of the specific community with which they are engaging (Abbott et al., 2014; Christopher et al., 2008; LaVeaux & Christopher, 2009). This recommendation is further supported by the Truth and Reconciliation Commission of Canada (2015), which calls on health care professionals to participate in cultural competency training. Since the release of the latter report, there are a number of opportunities to obtain such training within agencies such as the Association of Ontario Health Centres, the Ontario Federation of Indigenous Friendship Centres, Cancer Care Ontario , and Local Health Integration Networks.

According to the literature, the onus to enhance one’s cultural competency rests with the potential partner(ing) agency and/or person seeking to engage with Indigenous people (Tobin et al., 2010). In other words, cultural competency should be considered a pre-cursor to any engagement activities. Training may also take an informal approach, where in one study, Aboriginal patients suggested that their general practitioner (GP) should seek and accept cultural mentorship or advice from local Aboriginal people to enhance their own cultural competency (Abbott et al., 2014). However, it is important to note that participating in cultural competency training does not necessarily lead to full competency. For example, a participant from another study claimed that cultural awareness training may give practitioners a false sense of competency (Kendall & Barnett, 2015). It was further suggested that in order to transfer their knowledge into their practice, health providers must both understand and appreciate the obtained knowledge (Kendall & Barnett, 2015).

Honouring

Part of cultural competency involves acknowledging and honouring Indigenous ways and practices. These ways and practices are often transmitted orally and thus can only be learned by building trusting relationships with Indigenous people from that community (LaVeaux & Christopher, 2009). Honouring Indigenous ways and practices involves understanding and appreciating that some Indigenous communities hold a holistic view concerning health, which differs at times with views shared by non-Indigenous medical practitioners (Kendall & Barnett, 2015). This holistic view of health is premised on the understanding that there is connection between intellectual, spiritual, emotional, physical, and cultural aspects of well-being, and that these are all important for general health (Kendall & Barnett, 2015). Respectful engagement should begin with an understanding and reflection on Indigenous concepts of well-being (Hunt, 2013a).

For example, the North East Local Health Integration Network (LHIN) Aboriginal Health Care Reconciliation Action Plan (2016) integrates the following Seven Grandfathers’ Teachings as their plan’s values:

Similarly, Algoma Public Health (2015) worked with the North Shore Tribal Council on a collaborative project called Mno Bmaadziidaa, which when loosely translated, means The Good Life. This name was developed by the project team by combining concepts from the local Anishinaabe worldview with the mission, vision, values of Algoma Public Health. Within the Anishinaabe worldview, the project team was guided by the Seven Grandfathers’ Teachings, which they have defined as follows:

The purpose of the endeavour was to share, communicate, and explore the development of a relationship framework agreement that would bring more effective public health services to both organizations.

While these are important examples, it should also be noted that while some Northeastern Ontario Anishnaabe communities honour the Seven Grandfathers’ Teachings, not all share this same interpretation and understanding around traditional teachings, values, and concepts. In some instances, while the teachings may be very similar as a foundational  principle or value, the community or group may name and identify them differently. For instance, the Seven Grandfathers’ Teachings may be known in various communities by different names; some communities use courage instead of bravery; and some communities call them Sacred Teachings (Bouchard & Martin, 2009). Thus, an important practice is to learn about, acknowledge, and honour the different ways and practices of each community.

Formal Acknowledgment

Abbott (2014) suggests a number of ways to demonstrate cultural sensitivity. For example, things like workplace signs acknowledging the traditional owners of the land, Indigenous artwork, posters, and signs within a general practitioner’s space have been found to increase Indigenous patients’  feelings of safety (Abbott et al., 2014).

An Aboriginal Health Council in Vancouver, which provides policy direction to Vancouver Costal Health, developed clinical practice protocols. Within \ these protocols, it is suggested that health care providers ought to create supportive environments for a range of traditional practices (Gomes et al., 2014). This could be considered as a means to demonstrate respect for the Indigenous culture by supporting its traditional practices.

Trust

Description of the Principle

The principle of trust can be viewed as a foundation to building a respectful and mutually empowering long-term relationship (Anderson-Smith, 2008; Christopher et al., 2011; University of Manitoba). Trust can be viewed as coming after the previous principle respect, as a trusting relationship cannot be formed if non-Indigenous individuals do not respect and acknowledge Indigenous culture and practices. All principles are interconnected and may even be considered as an outcome of effective engagement.

There are a number of historical events that significantly contributed to the root of distrust by many Indigenous people, some of which are documented within the Truth and Reconciliation report (Christopher et al., 2008; Truth and Reconciliation Commission of Canada). Christopher et al. (2008) also discuss the adverse experiences of Indigenous people with researchers and the government, while noting that research has historically been done ont rather than with Indigenous people. As such, it is important to recognize and acknowledge these roots of distrust, while also taking steps towards rebuilding this trust. The development of a trusting relationship is key to engagement success (Hunt, 2013a).

Wise Practices

The following outlines a summary of themes that emerged within the literature as practices that may support the principle of trust described above.

Engage Early

Reaching out and engaging with the community should be viewed as a non-negotiable component of any health-related endeavour with Indigenous communities. A great deal of the grey and academic literature supports the notion that engaging early in this process, before the start of any project, is an effective strategy for reducing distrust and increasing trust and participation (Chadwick et al. 2014; Christopher et al., 2008; Christopher et al., 2011; Hunt, 2013a; Loppie, 2007; Ministry of Aboriginal Relations and Reconciliation, 2016; Ministry of Community, Sport and Cultural Development, 2014; Social Compass, 2016; University of Manitoba; Zehbe et al., 2012). As such, there needs to be early dialogue between Indigenous partners and those external to that community to learn about each other (Maar et al., 2015).

Furthermore, research highlights that not only starting early, but starting slowly is a strong indicator for future success (Blignault et al., 2016). It has been claimed that building an effective and trusting partnership between numerous organizations takes significant time and is something that should not be rushed (Green et al., 2014). While this may seem like a large undertaking, finding effective ways to collaborate on smaller projects can be efficacious in building relationships for future and potentially larger projects (Christopher et al., 2011; Zehbe et al., 2012). Notably, a benefit of early engagement is the promotion of participatory processes that are based on Indigenous aspirations and priorities (Matloub et al., 2009). If a health related endeavour does not begin early and slowly, it has been reported that it may lead to a consultative rather than collaborative process, thus fostering central decision making, passivity, and consultation fatigue, thereby reducing trust (Hunt, 2013a; Social Compass, 2016).

Connect with respected Indigenous members

Elders are respected Indigenous members and can help support research and engagement processes (Gomes et al., 2014; Weston et al., 2009). For instance, the Toronto Health Strategy Advisory Circle meetings are opened and closed in a traditional way by an Elder (Toronto’s First Indigenous Health Strategy, 2016). Christopher et al. (2011) suggest that key respected Indigenous community members were pivotal in helping to gain project approvals by their local tribal council. These individuals are described as well-respected Indigenous members of the community who either hold formal or informal influence and power within the culture (Israel et al, 1998; The Homeless Hub). They therefore play an essential role in building bridges between researchers and the community. These well-respected Indigenous individuals may be Elders, community members, or tribal government officials (Gomes et al., 2014; LaVeaux & Christopher, 2009). They can enhance community participation, provide support in the presence of governance turnover, and provide insight into culturally appropriate protocols throughout a project (LaVeaux & Christopher, 2009; Weaver, 1999). It is valuable to reach out to and involve these respected Indigenous community members with pre-existing trusting relationships, as they may also have insight into appropriate contact approaches to their community (Israel, 1998).

Be inclusive of Indigenous people

Anyone wishing to engage with Indigenous communities must include Indigenous people in all aspects of that work. In contrast, one-off consultations that do not include Indigenous people in their design, implementation, and decision-making processes will fail to meet Indigenous aspirations and ultimately reduce trust (Hunt, 2013a; Social Compass, 2016).

The development of a community advisory board has been cited as a critical component to building trust (Christopher et al., 2011) and to encourage a mutually respectful environment in order to promote inclusivity (Singer et al., 2015). It is suggested that such boards include Indigenous community members, key informants, and agencies from community, as well as members from a variety of backgrounds (e.g. health, research, culture) depending on specific project needs (Boffa et al., 2011; Christopher et al., 2011). Community advisory board meetings should be held regularly and be focused on staff members’ opportunity to interact and build trusting relationships (Taylor et al., 2011). Board roles will vary, but may include guiding, advising, and providing general project oversight on its design, incentives, etc. throughout all project phases (Boffa et al., 2011; Christopher et al., 2011). One collaboration reported giving the partnership an Aboriginal name in order to endorse feelings of inclusivity and trust (Taylor et al., 2011).

Be inclusive of youth and respectful of gender balance

Balance is another key tenet in most First Nations cultures. In engagement practices, this relates to equal respect accorded to men and women. Historically, amongst many Indigenous groups, leaders and healers could be either men or women in the community (Deiter & Otway, 2001). This equality in the community stems from an understanding that each individual carries out an important role and holds respective responsibilities in survival, sustenance and raising the family, and helping the community and Mother Earth. These traditional roles help achieve and maintain balance. (Caibaiosai, 2008).

It is also important to honour and include the views across generations, including youth and Elders. As an example, the Toronto Indigenous Health Advisory Circle is structured to include both youth and Elders according to community recommendations. “The best way for the circle to work together is through a harmonized approach. This means that all meetings and the ways we work together are guided by Elders and involve youth. It is intergenerational, involves healers and different ways of knowing.” (p.8 L. Monib, Health Equity Specialist, Circle Secretariat, Toronto Public Health).

Use appropriate communication approaches

Another practice that helps develop trust between Indigenous and non Indigenous individuals is proper communication (Taylor et al., 2011). At the forefront of successful communication strategies is the utilization of open and respectful communication styles (Green et al., 2014; Miller et al., 2015). Some research has highlighted that hasty and professional communication styles, often filled with excessive jargon, can lead to feelings of disengagement and discontent by the Indigenous individuals (Kendall & Barnett, 2015; Social Compass, 2016). Furthermore, throughout all stages of the project, from development to knowledge translation, acceptable communication must be held to a high regard (Jacklin & Kinoshameg, 2008). This includes being prepared to listen and allow time for meaningful discussion (Ministry of Community, Sport and Cultural Development, 2014).

In order to foster trust, face-to-face dialogue has been suggested to be an effective approach (Federation of Canadian Municipalities; Maar et al., 2011; Maar et al., 2015; Matloub et al., 2009; Zehbe et al., 2012). This may take the form of community visits, meet and greet sessions, informal interactions, and meetings (Hartman, 2017; Christopher et al., 2011; Zehbe et al., 2012). One project director reports finding it beneficial to be on-site for three-quarters of the time (Christopher et al., 2011). Another source highlights how a research team embraced a learning opportunity that was provided to them during the face-to-face meetings which were relaxed, informal, and friendly (Zehbe et al, 2012).

In addition to communication styles, being upfront and honest about expectations, intentions, resources, or any limitations are key to building trust (Christopher et al., 2011; Hunt, 2013a; Ministry of Community, Sport and Cultural Development, 2014). This can be done by providing ongoing project updates, sharing results, and reporting back to the Indigenous community (Christopher et al., 2011). This can be done in the form of emails, phone calls, mail outs, posters, and routine meetings (Christopher et al., 2011; Hartman, 2017). Doing this demonstrates commitment to the partnership and, in the case of research, can show the community that their responses were heard and utilized (LaVeaux & Christopher, 2009).

Self-Determination

Description of the Principle

The principle of self-determination acknowledges the inherent rights of Indigenous people to freely determine their own pathways and to make decisions about all aspects of their communities and livelihoods (Chadwick et al., 2014; Chiefs of Ontario; Mashford-Pringle, 2014). Self-determination supports cultural preservation and development, while ensuring that sovereignty is respected in a way that provides clear benefits to Indigenous people and communities (Gomes et al., 2014; Schnarch, 2004).

Although formal aspects of self-determination are linked to governmental, legal, and jurisdictional structures, there are many additional informal opportunities that can also support this principle (Baydala et al., 2015; Chiefs of Ontario; Schnarch, 2004). Those engaging with Indigenous people are more likely to be successful if they operate within a framework where self-determination is acknowledged, understood, and honoured (Bailey & Hunt, 2012; Hunt, 2012). The principle of self-determination has informed every step in the creation of A Reclamation of Well-Being: Visioning a Thriving and Healthy Urban Indigenous Community, Toronto’s first Indigenous Health Strategy, 2016 – 2021. Their strategy is entitled Indigenous Health in Indigenous Hands (Toronto’s First Indigenous Health Strategy, 2016) to reflect this important principle.

Wise Practices

The following outlines a summary of themes that emerged within the literature as practices that may support the principle of self-determination described above.

Indigenous-driven

An important aspect of self-determination relates to a need for the partnerships to be beneficial and Indigenous-driven. In considering undertaking any project, it is Indigenous peoples’ right of self-determination to prohibit projects that do not benefit their community (LaVeaux & Christopher, 2009). Research with Indigenous or Aboriginal communities in Australia and other regions further noted that partnerships with Aboriginal people operate within a framework of Aboriginal self-determination (Bailey & Hunt 2012; Burton, 2012; Raymond et al., 2012) or Aboriginal decision making, with Indigenous driven priorities (Bauman & Smyth 2007; Rockloff & Lockie, 2006). For example, when the process of the research agenda used settings that were controlled and driven by Aboriginal people, it built the capacity for everyone through all stages of the research process. (Couzos et al., 2005; Hunt, 2013b; Salisbury 1998).

Building capacity

One way to support self-determination, trust, and engagement as a whole is through the provision of training opportunities for Indigenous community members (Hunt, 2012; Taylor & Thompson, 2011; Zehbe et al., 2012). This has a reciprocal benefit to the community and demonstrates a commitment to building capacity within the local Indigenous workforce (Singer et al., 2015). One research project did exactly this by hiring a Community-Based Research Assistant, who not only helped to involve the community in the project, but also helped build capacity within that community (Zehbe et al., 2012).

Strength-based approach

Indigenous people have expressed that they do not want to be defined by their deficits, but rather wish to be part of a process that allows them to discover their strengths (Allen et al., 2014). As each Indigenous community is different, it can be propositioned that there are equally as many unique  strengths and priorities of each community (Blignault et al., 2016). Tobin et  al. (2010) point out that any engagement process should begin by  recognizing the strengths and resiliency within the Indigenous communities. This strength-based approach implies a conscious effort to build from a community’s assets, achievements, and structures that can enable health improvements (Israel et al., 1998). Showing respect for the culture, protocols, and ways of knowing of First Nations is the basis for any examination or intervention that outsiders may bring to bear on a community. From this starting point, it becomes possible to recognize and work with the strengths of communities, rather than seeing only problems and shortcomings. (Tobin et al., 2010).

Protocol development

Those seeking to engage with Indigenous communities should be required to follow de-centralized decision-making processes or Indigenous-based protocols, which acknowledges historical and contemporary power dynamics and differentials and considers these structures within particular communities (Social Compass, 2016). This supports self-determination, since it ensures Indigenous communities shape and determine what is best for their people.

A practice that has been suggested to strengthen the relationship between Indigenous and non-Indigenous partners is to engage with and constantly practice the mutually established protocol, not simply to just acknowledge it (Gomes et al., 2014). Hence, Indigenous community-based protocols may need to be developed and followed in order for a project to move forward and be approved by the Indigenous community. These protocols can outline how to work together, roles, processes, approvals, and practice standards, and can take the form of Chief and Council resolutions and written agreements (Christopher et al., 2011).

Some communities may also have formal protocols to be followed such as obtaining approval from Chief and Council (or Band leadership) and community meetings to provide project overviews (Tobin et al., 2010; Hartman, 2017). It is therefore important to know and understand these protocols to ensure they are followed throughout any engagement processes.

Commitment

Description of the Principle

Indigenous engagement must be seen as a long-term engagement process that takes time and commitment (Israel, 1998). The process must be deliberate and adaptive, facilitated by people committed to Indigenous empowerment, priority setting, and decision making. Governments need to be responsive to Indigenous priorities (Gilligan 2006; Hunt, 2013b; Smyth et al. 2004).

Overall, the principle of commitment supports prosperous engagements, if appropriate practices are in place. An example of these practices is exploring working in a more culturally appropriate manner (Taylor et al., 2013); this can encourage and reinforce participation from Indigenous communities.

Wise Practices

The following outlines a summary of themes that emerged within the literature as practices that may support the principle of commitment described above.

Mutual sharing

Given that engaging partnerships can accomplish more work than what either party could have accomplished alone (Bainbridge et al., 2015), this partnership must be reciprocal, genuine, and mutually beneficial (Jacklin & Kinoshameg, 2008; Maar et al., 2015; Social Compass, 2016). It has been stated by the Royal Commission on Aboriginal Peoples (RCAP) that for renewed relationships to occur between Aboriginal and non-Aboriginal individuals, mutual responsibility is key (Royal Commission on Aboriginal Peoples, 1996). Not only do non-Indigenous individuals need to learn more about the history, culture, traditions, and stories of Indigenous people through this sharing, but the process of co-learning also supports the learning of the Indigenous people who can then expand their knowledge of those external to their community (Maar et al., 2015). This may be done through reciprocal training, orientation, and/or knowledge sharing activities. Some studies have suggested integrating a two-way knowledge exchange event focused on educating both Indigenous and non-Indigenous individuals (Gomes et al., 2014; University of Manitoba). These empowering processes can serve to open the dialogue towards bridging Indigenous and public health approaches within a true intercultural forum where both are able to participate according to their interest and capacity (Anderson-Smith, 2008; LaVeaux & Christopher, 2009).

Engagement cannot be unilateral, and sincere attempts must be made to share the power (Hunt, 2013a). The Toronto Indigenous Health Strategy Advisory Circle (TIHAC) is guided by the concept of harmonized governance. This refers to the blending of traditional Indigenous ways of being with the western system (Toronto’s First Indigenous Health Strategy, 2016). It is especially important for non-Indigenous individuals to acknowledge when power inequalities are present and how these may shape Indigenous engagement and participation (Hunt, 2013a; Hunt, 2013b; Israel et al., 1998; National Aboriginal Health Organization; Social Compass, 2016). One strategy that which aims to reduce these inequalities is the development of mutual accountability agreements to enable shared responsibility, accountability, and stewardship (Hunt, 2013a; Maar et al., 2015). Others encourage equal participation in the planning of current endeavours in order to balance the sharing of power (Taylor & Thompson, 2011).

Furthermore, other resources suggest that when dealing with power inequalities, active collaboration, and negotiation can be used to formulate success in sharing power in an effective manner (Hunt, 2013b). An Australian-based report on engagement between non-government and Indigenous organizations outlines that genuine efforts to share power, including agreed conflict resolution processes and transparency about decision making are needed. Agreements should spell out mutual benefits for each party (Carter 2010; Duffy et al., 2013; Matloub et al., 2009). In sum, engagement is about sharing knowledge, power, and efforts equally so both can mutually benefit.

Responsive funding

Flexible funding arrangements are needed to support engagement with Indigenous communities both in terms of time and activities (Boffa et al., 2011; Hunt, 2013a; Toronto’s First Indigenous Health Strategy, 2016; University of Manitoba). As previously noted, engagement is a long-term process which in itself entails a responsive funding structure. One study outlined challenges related to traditional funding deadlines, where additional time was needed to engage with Indigenous communities. In turn, this additional time delayed project activities, and the project did not meet agency funding timelines. Although they were able to obtain approval for a project extension, it nonetheless demonstrated that additional investment and some leniency may be required to support a fulsome engagement process (Boffa et al., 2011). Baeza and Lewis (2010) state that the relationship between Aboriginal and non-Aboriginal organizations requires appropriate funding so that the Aboriginal controlled health sector has the capacity to effectively engage with the mainstream health sector. Watanabe-Galloway (2014) states that a key component that contributed to successful collaboration among partners was the transparency of the budget.

Agencies who want to work with Indigenous populations will additionally require funds dedicated to respecting and honouring Indigenous protocols and traditions. This can take the form of Elder honouraria, physical gifts to an Indigenous person sharing knowledge, and traditional tobacco for use during prayers (Boffa et al., 2011).

Ongoing reflection

To nurture and sustain a relationship, it is suggested to incorporate a process of continued reflection. This critical analysis can act as a checkpoint to scrutinize the partnership with regards to the balance of power and ensure that opportunities are meaningful and that members are equally respected (IPAC, 2010). Christopher et al. (2008) suggest that the impetus also needs to be placed on the need to acknowledge our own history, background, and values with the goal of continuously working towards more self-understanding. It can be expected that Indigenous individuals might have skepticism with regard to research and health care practitioners (Schinke et al., 2013), thus these feelings should be recognized and processed for successful engagement to continue (Social Compass, 2016). This process could also require some to accept new viewpoints and possibly leaving their expert position within a topic area (LaVeaux & Christopher, 2009).

Indigenous hiring practices

The Truth and Reconciliation Commission of Canada (2015) calls for an increase in the number of Aboriginal professionals working in the health care field. Chadwick et al. (2014) outlined that they purposefully hired a Native American coordinator as part of their research project. This role was vital to fostering relationships between their agency and the tribal communities to maintain open communication. The position also ensured that Native American interests were represented throughout their project. In the end, the authors discussed the positive contributions of this position to resolving potential barriers and alleviating many concerns. Mentorship by Indigenous people with non-Indigenous staff is another practice that was found to support culturally competent medical practice (Abbott et al., 2014).

Community presence

Indigenous people are aware when strangers are in their community. Those seeking to engage must therefore work towards having an authentic presence within that community (Christopher et al., 2008). This could take the form of attending community-based social and cultural events or making arrangements to work from that community on certain days. This helps to demonstrate a broader community interest rather than a unilateral project gain and can also help to learn more about Indigenous people (Christopher et al., 2008).

Progressive leadership

Those seeking to engage with Indigenous people require leadership that is strategic, collegial, not risk-adverse, and not “turf-bound” (Social Compass, 2016). This type of leadership needs to be accountable to the engagement policies and frameworks that are promoted and committed to doing things differently without the context of bureaucratic silos (Social Compass, 2016). This is reflective of a participatory governance model where power is shared, innovation is supported, and meaningful participation strategies are utilized.

This could be a shift for some government-based organizations that typically work within short timelines, focus on fixing problems, follow a business as usual model, require control, and are report-heavy (Social Compass, 2016). Such change in organizational culture can be challenging, but is needed to meaningfully and effectively engage with Indigenous people.

A progressive leader working with Indigenous partners will avoid authoritative decision making or imposed solutions. Rather, it is recommended to look for ways to build consensus amongst the group to make decisions more legitimate (Federation of Canadian Municipalities). According to one article, An Indigenous model works from the ground up, reversing the top-down application of Western science to classic public health that too often results in programs that are outside-in and community placed rather than community-based (Chino & DeBruyn, 2006).

Flexible timeframes

It is emphasized that engaging with Indigenous people and communities will require extra time (Boffa et al., 2011; Chadwick et al., 2014; Christopher et al. 2011, Hunt, 2013a; Matloub & Waukau, 2009; University of Manitoba). Time is needed to develop a trusting relationship which includes getting to know the community, the people, and the history of the community (Hunt, 2013b; Matloub et al., 2009). This can be challenging for some who typically work within controlled and tight timelines. Zehbe et al. (2012) utilized an iterative approach to engaging with First Nations communities that was done over approximately two years. The authors noted that although this time was needed to engage and was beneficial to the development of their research project, the structures of Western academia and funding opportunities do not support such time and resource intensive activities. Another study devoted their first project year to relationship building and face-to-face meetings, which proved beneficial to obtain project approvals in their second year (Matloub et al., 2009). This again demonstrates the need to build in time for relationship and trust building.

It is also understood that Indigenous communities themselves may have competing priorities and limited resources that may take precedence (Chadwick et al., 2014). One author cited an instance where the community was at a standstill for a funeral of one of its members (Christopher et al., 2011). Sharing power and honouring a community’s self-determination will also likely involve multiple reviews, consultations, and approvals that will ultimately take time to realize (Chadwick et al., 2014).

Indigenous validation

Information gained about the Indigenous community requires validation to  provide an Indigenous perspective and interpretation of findings (Mazloum & Waukau, 2009). Although this notion is typically applied to research based engagement, this validation process could also inform many other engagement activities. A primary benefit of engaging in this validation process is to obtain a more holistic view from multiple diverse perspectives. Furthermore, any outcomes or implications from the results are more accurate, as it has been confirmed and modified by Indigenous individuals.

Summary

Four principles emerged in the reviewed literature (respect, trust, self determination, and commitment). These principles are recommended to be goals for future behaviour to engage successfully with Indigenous individuals and First Nations communities. Within each principle, a number of wise practices were also identified. These wise practices are viewed as more specific actions than the principles, which can contribute to more successful partnerships with First Nations communities. The results from this literature review will be used as the foundation to guide the gathering and learning process for this larger project.

Conclusion

This review of literature yielded important findings to provide further context to the area of Indigenous engagement. Although this search did not find any principles and practices within the specific context of Ontario public health, it did outline a number of themes that were presented as principles and linked to wise practices. The review team was challenged to find literature that detailed engagement processes per se, as much of the literature focused solely on the outcomes from engagement (i.e. new program). However, this was not the case for a number of articles utilizing Indigenous community-based research (CBR) methodology. These often followed Indigenous-driven ethical guidelines and/or protocols which in turn enrichened the engagement process. And, many CBR articles did discuss how they engaged with Indigenous communities.

It is important to note that the content of this review should not be used as a directive to engaging with Indigenous communities. Rather, it presents a synthesis of findings that are cited within the literature as principles and practices that have been utilized, suggested, and/or recommended to engage with Indigenous communities. It likely that many synergistic components of engagement are needed to build and develop mutually trusting and respectful relationships with Indigenous communities.

Moving forward, findings from this review will be utilized in future phases of the broader research project. This involves a survey to Ontario public health units who will be asked, among other things, about their use of the engagement practices found within this summary of literature. They will also be asked about their perception of successful practices and lessons learned from previous engagement with First Nations communities. The information from the literature review and the public health unit survey will then be used to further explore practices and principles of engagement with 5 to 6 First Nations communities from Northeastern Ontario. As a whole, this cumulative data gathering process will be used to develop guidance in the form of principles, strategies, and practices that are valuable and recommended as a basis for good engagement between public health units and First Nations communities.

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This item was last modified on May 14, 2024