"Nothing about us, without us"

This often used expression is the title of a

book by James Charlton (2000) that focused

on disability oppression.

Over the years, this expression has

come to communicate the idea that no
- policy should be decided by any
representative without the full and
An example of one university's progress (UBC) in this area
and recognition of the need for involving indigenous direct participation of members of the
individuals in planning and delivery of programs. group(s) affected by that policy.

Approach to Development of this Unit

AS we set out to develop this module, we conducted a survey of Canadian

pharmacy students june 2020) which indicated a strong motivation to

learn more about Indigenous issues. Many respondents identified a

knowledge gap as a result of insufficient education about these important

issues from grade school through high school, university, and their

current professional program.

We hope to use this platform to engage healthcare students in deepening

their own understanding of Indigenous issues, in order to provide

culturally safe care.

In a participatory design approach, our materials are informed by

Indigenous scholars and resources that have been developed. Over time,

our intention and commitment is to have greater engagement of the

Indigenous community and elders.

back to them at the end.

Match the word to the correct description.

Legally defined in 1982 as including

6 = = Aboriginal \ the Indian, Inuit and Métis people of
Canada

A group of people who first inhabited

Indigenous | aland that was then settled by
another group

Aterm that came into common usage

First Nations \ in the 1970s to replace the word
‘Indian’

Extending the power & dominion of a

Imperialism \ nation especially by direct territorial
acquisitions

To replace the original population of

Settler Colonialism | the colonized territory with a new
society
Major Linguistic Groups

In this map (of what we now call

North America, but what some First

Nations groups called Turtle

Island), we see the thousands of

languages that were spoken by

Indigenous Peoples.
 "Indian": distasteful, but still in use in Canada
The term "Indian" is considered inappropriate by most Indigenous
people. However, there are certain circumstances where it was
used. The major one is the legal term "Indian" from the Indian Act,
1867.

The term is still used as part of the Constitution Act, 1982, despite
First Nations' objections. It is important to note that the term Indian
generally refers only to the First Nations people.

This type of image may be familiar to

you.

Please note the original title of painting.

In some settings, the names are

reversed i.e. Indians Trading with

Champlain.

We know that French explorers and

Champlain Trading with the Indians colonizers traded with Indigenous

Jefferys, Charles William, 1869-1951. peoples, and the colonizers benefited
Library and Archives Canada, Acc. No. 1972-26-1457 greatly from this in many ways.
 Second Term: Aboriginal

The term "Aboriginal" became more

commonly used in Canada when the

Constitution Act (1982) defined

"aboriginal peoples" as a group

consisting of all “Indians, Métis and

Inuit”. This term is still used in

determining identity for the

Canadian Census. ! An Aboriginal encampment, near the Adelaide foothills

Alexander SCHRAMM (1813 - 1864) (Australia)

You may know that the term Born in Berlin. Dead in Adelaide.

"Aboriginal" was used in Australia to

describe the original people of the

land as early as 1789.2

You may know that the term

"Aboriginal" was used in

Australia to describe the

original people of the land as

early as 1789.2
 The term Aboriginal, while still used in Canada,
is also not a preferred term.

The term "Aboriginal" is falling out of use due to sentiments

expressed from the First Peoples.

Some interpret the Latin prefix “ab” to mean “not” or “away from”.
Therefore, aboriginal can mean “not original”.

Another interpretation states that the term derives from the Latin
words 'ab' (from) and 'origine' (origin, beginning), which is far more
suitable.

If you read the article in Footnote #2 above, you will see that there
is a global movement to replace the term "Aboriginal" with the term
"Indigenous".

AUSTRALIA [Senn ee ei Interestingly, one scholar tells us

ee a On he - 4 a that in Australia, some do not want
flora & fauna
to replace Aboriginal with
wna my va
G * AY= 1 ty Indi the the t term Indi
hw fi, naigenous as Indigenous

A 3! 4
refers to the flora and fauna that is

sé Indigenous to the land, and

Stix“
VT Aboriginal implies people.
8 PLANTS BS
 Term 3: Indigenous

The term "Indigenous" has gained

popularity especially as it is an
internationally recognized word. Indigenous

peoples can refer to the Maori of New

Zealand, the Inuit of Canada or other
groups. The generally accepted definition is

"the earliest known inhabitants of a

territory that has been settled by another Spirit Moose by Dwayne Wabegijig
group".

The Indigenous peoples of Canada have come

to mostly prefer this term, when being referred
to as a whole group.
Canada's Indigenous
Indigenous Peoples of Canada
People Canada

©}
©}

©}
Hochelaga Ally
©}

©}
 Acceptable. /~

However, aS we
The name “Canada”
likely comes from
AVOID USE. Implies will learn in the
the Huron-lroquois
possessive, very next video, itis a
word “kanata,”
colonial tone. Sweeping term. It
is better to be
meaning “village” or
“settlement.”
oS specific. 2S

fo)
a societys patterns
path” or for “big
of injustice and
rapids”— also, the
takes
name of an
responsibility for
Indigenous village
Cartier visited that changing these
we now know as patterns. (Bishop,
| 2001) G
Canada has 3 distinct groups of Indigenous peoples:
The First Nations, the Métis and the Inuit.

The First Nations live across the country from the Pacific to the

Atlantic to the Arctic and everywhere in between.

They are the largest group of Indigenous peoples in Canada with

close to 1 million people identifying as being First Nations in Canada
in the 2021 census.

The First Nations people include a wide variety of cultures,

languages and people such as the Néhiyawak (Cree), the
Kanien’keha:ka (Mohawk), the Mi’‘kmaq and the Wet'suweten.

Image: Attributed to A.R. Cogswell. Location unknown. Date: ca. 1890 Reference no.:
Nova Scotia Archives Photo Drawer - Indians - Micmac Camp / negative no. 2485
2

The Métis are a group of people who have a mixed ancestry

composed of Indigenous peoples and European settlers, mainly
French.

Most Métis homeland consists of the Red River Valley in Manitoba

and the Prairies.

Métis is one of the fastest growing groups in Canada. |n 2021,

there were 624,220 Métis living in Canada, up 6.3% from 2016.

Métis have their own unique culture, communities, rights and land
that is different from both First Nations and Inuit.

The language spoken is Michif.

It is important to note that all Métis should be able to draw lineage

to the Red River settlement, i.e. the only new Métis should be

descendants of Métis.
3

The Inuit are the Indigenous peoples living in the circumpolar

region of Canada including:

« Nunavut

Inuvialuit (Northwest Territories and also includes very

northernmost lands in Yukon)

Nunavik (Québec)

-« Nunatsiavut (Labrador)

The Inuit are also present in Greenland, Alaska and Siberia

The term Inuit comes from the Inuktitut word for “people”. The
term Inuk or “person” is therefore applied when only talking about
an individual.

It is not appropriate to say "Inuit people" because that would be

redundant.

The Inuit are the smallest Indigenous group in Canada.

Relative to the Rest of the
Population

According to the 2021 census,

the Indigenous population
comprised 5.0% of the overall
Canadian population.

Land Entitlements

It is estimated the Indigenous

populations have access to 0.2% of
Canada (having had access to 100%
of the land pre-contact).
There is rapid population growth among First Nations people, Métis
and Inuit.

The average age of Indigenous people was 33.6 years in 2021,

compared with 41.8 years for the non-Indigenous population.

The Aboriginal population is also aging. According to population

projections, the proportion of the First Nations, Métis and Inuit
populations 65 years of age and older could more than double by 2036.

There are more than 600 unique First Nations/Indian Bands in Canada.

The First Nations population is growing both on and off reserve; 40.6%
were living on reserve and 59.4% were living off reserve in 2021
whereas 44.2% lived on reserve in 2016, while the rest of the
population lived off reserve.

The Indigenous population living in metropolitan areas is growing.

Over half of First Nations people live in the western provinces (more
than half of First Nations people were living in either British Columbia
(17.7%), Alberta (14.0%), Manitoba (13.4%) or Saskatchewan (11.7%).

The First Nations population doubled in Atlantic Canada (likely due to

increased self-identification).

Ontario has the largest Métis population, while the Métis population
grew at the fastest pace in Quebec (+149.2%) and the Atlantic provinces
(+124.3%).

Almost three-quarters of Inuit live in Inuit Nunangat (known as the

"Arctic",
 Canada is a settler country. Cities like
Toronto are located on Indigenous territory
and are dominated by non-Indigenous
peoples. In 2016, the city of Toronto
reported that only 795 people were able to
speak any Indigenous language."

‘Ref: Stats Can, Census 2016, City of

Toronto, Knowledge of language. Aboriginal

Languages

Turn over the flashcards below for the term's definition.

Settler Imperialism Missionary

Colonialism P Work
a)
o

Settler colonialism: A term used to describe a type of colonialism

which results in the replacement of the Indigenous populations
with the invasive settler culture.
Several countries have experienced settler colonialism including
Canada, the US, Australia and South Africa (especially under
apartheid).
The settlers were mostly white Europeans such as the English,
French, Spanish, Portuguese and the Dutch.
Imperialism: A term used to describe the process in which a
colonial power extends its power over another region inhabited
by others by territorial acquisitions.
 This is generally done militarily but can also be done by
treaties and use of religion.
Click to flip

Missionary work : A process in which members of a religion travel

abroad to spread the reach of the religion by trying to convert
others into their religion.
In Canada, this work was used to convert Indigenous peoples
into Christianity from their Indigenous beliefs.
This work was sometimes forceful (i.e. residential schools) and
sometimes peaceful but resulted in a loss of culture, religion
and language over time for the Indigenous peoples.
 Inappropriate Terminology

We have learned about the origins of a number of terms, and recognized

that they have fallen into disfavour (and for good reason). Despite this,
there are, unfortunately, many examples of derogatory terms that have

been used - and continue to be used - in Canada.

We chose not to reproduce them here due to their offensive nature but
offer a video that reports on them. Importantly, this video is the result of
one individual student's outstanding commitment to change (please click
on the image to access the video and read more).

[MONTREAL MONTREAL

driving force behing that chang:

READ MORE MONTREAL >
Question 1 Whois considered an “ally’?
comect
ark 1.00048 Selectone
ofi00
_— 3 An individual claiming to be an ally.
a b. Someone from the underrepresented group in question who advocates for equality.
© Someone who recognizes the unearned privilege they receive from society's patterns of injustice and takes responsibility for changing these patterns. W

Quastion 2 What is problematic with the phrase “Canada's Indigenous people”?

corect
ark 1.00048 Selectone
"00
_— 2 timplies possession. ¥
— ’. There is not a problem with using this phrase.
< Indigenous is not the correct term to use.

Geession 3 The name Canadas likely derived from the Huron-Iroquois word “Kanata”. What is one meaning of the word?
comect
ark 1.00048 Selectone
"100
¥ Fag & Tribe
a >. Village W
© Turtle Island

Question ‘According to the 2016 census how many individuals in Canada identified as Aboriginal?
corect
ark 1.00048 Selectone
"00
_— & ~1.7 millionw
— b. ~3.2 million
© ~S5million

Question 5S What is the best definition of the word "Indigenous"?

corect
ark 1.00048 Selectone
of109
trae 3 An alternative word for indian/Aboriginal and the politically correct version.
— ». The earliest known inhabitants of a territory that has been settled by another group. W
© Abroad term used for Canadian Indigenous people, which can be used for Inuit, Metis and First Nations people.

Question 6 Which Indigenous group is the smallest in Canada?

comect
are .000u8 Selectone
"00
P Peg = Inuit w
a » Metis
© First Nations

Question 7 According to the 2016 census there has been a 42.5% increase in the aboriginal population since the last census. which is 4x the growth rate of the non-aboriginal population in the same time frame. What is NOT
Cerect a plausible reason to explain this?
are .000u8
1 Select one:
F Fag
question 3 Changes in self-reported identification.
5. Natural growth which includes increased life expectancy.
© Immigration of indigenous peoples from the United States. W

Question What percentage of Canada do Indigenous people have land entitlement to?
comect
ark .000u8 Selectone
of109
Fig 2 0.2%
question 8 ost
1%

Quesson
comect 9 What should you do when you are unsure how to address an Indigenous person?
ark .000u8 Selectone
of109
_ 3. Always use the term Indigenous to avoid using the wrong term.
a ». Ask them how they self-identify and use the term they share with you. 7
© Assume the Indigenous group they belong to and address them based on that.

Question 10 (On which Indigenous territory is the City of Ottawa located?

comect
Wyare coeur Selectone:
"00
F Fag 2. St6:16, Squamish and Tsleil-Waututh

a ». Plains Cree, Blackfoot / Niitsitapi and Tsuu Tina

© Mohawk, Algonquin, and Anishinabewaki 7
 Insiders’ Insight: Discrimination against Indigenous Peoples
through the Eyes of Health Care Professionals

Lloy Wyliem' and Stephanie McConkey?

Author inf tion Arti tes C ight Li int tion PMC Disclai

Go to:

Abstract

Discrimination in the health care system has a direct negative impact on

health and wellbeing. Experiences of discrimination are considered a
root cause for the health inequalities that exist among Indigenous
peoples. Experiences of discrimination are commonplace, with patients
noting abusive treatment, stereotyping, and a lack of quality in the care
provided, which discourage Indigenous people from accessing care. This
research project examined the perspectives of health care providers and
decision-makers to identify what challenges they see facing Indigenous
patients and families when accessing health services in a large city in
southern Ontario. Discrimination against Indigenous people was
identified as major challenges by respondents, noting that it is
widespread. This paper discusses the three key discrimination
subthemes that were identified, including an unwelcoming environment,
stereotyping and stigma, and practice informed by racism. These findings
point to the conclusion that in order to improve health care access for
Indigenous peoples, we need to go beyond simply making health services
more welcoming and inclusive. Practice norms shaped by biases
informed by discrimination against Indigenous people are widespread
and compromise standards of care. Therefore, the problem needs to be
addressed throughout the health care system as part of a quality
improvement strategy. This will require not only a significant shift in the
attitudes, knowledge, and skills of health care providers, but also the
establishment of accountabilities for health care organizations to ensure
equitable health services for Indigenous peoples.

Keywords: Discrimination, Health services, Indigenous peoples,

Aboriginal people

Go to:

Introduction

Indigenous patients’ experiences of disrespectful treatment by health

care providers remain a significant barrier to health care access [1].
Research shows that discriminatory behavior is still present in the
Canadian health care system today [1-4], and stories of negative
experiences of Indigenous patients are seen in the headlines of Canadian
media [5-7]. In some cases, the lack of consideration for the concerns of
Indigenous patients has resulted in detrimental, if not fatal,
consequences [8].

Indigenous peoples’ narratives about poor treatment by health care

providers draw clear conclusions that racism was a factor in those
interactions. Stories of misdiagnoses of late-stage cancers to assumptions
of drunkenness of patients with acute health episodes demonstrate that
the health concerns of Indigenous people are often disregarded by health
care professionals. The story of Brian Sinclair, who died in the Emergency
Room in 2008, is a case in point. His physician had referred him to the
emergency room as he had a blocked catheter. Health care workers
assumed that Sinclair was a drunk, poor, and homeless Indigenous man
seeking shelter, and therefore, he was never triaged into the system. He
waited 34 h in the waiting room and was pronounced dead when a
physician finally decided to see him [6-8].

This case from over a decade ago demonstrates the significant

consequences of racism and stereotyping on the health outcomes of
Indigenous peoples in Canada. More recent research had demonstrated
that such experiences are not an anomaly. The Canadian health care
system is often a place of negative experiences for Indigenous peoples,
making them reluctant to access services [ 2, 3, 9], and creating
significant barriers to health equity [1-4]. Many Indigenous people have
admitted their reluctance to continue accessing health services after
their experience with discrimination in the health care system. Some
patients avoid services altogether [2, 3, 9], while others prepare to be
mistreated by health care providers prior to accessing services [3]. These
and other instances have been brought forward by Indigenous peoples
and organizations across Canada and have renewed the call for
Indigenous health research to focus on discrimination in health care
systems [3, 10]. The fact that these negative experiences remain so
widespread should be a societal concern, as it demonstrates how our
health care system is failing the most vulnerable. This is not justa
concern about access; it is a matter of life and death, as the case of Brian
Sinclair demonstrates. If Canada is genuinely on a path of reconciliation
in the wake of the recent Truth and Reconciliation Commission in 2015,
the time for change is well overdue.

This study, Engaging for Change, explored the attitudes, knowledge, and
practices of health care providers around working with Indigenous
patients. The purpose of collecting this information was to understand
the current state of these attributes among health care providers, as part
of the information needed to uncover what shapes the experiences of
Indigenous people with health care services in a large city in southern
Ontario. Having knowledge of these attributes can contribute to
informing strategies for changing these norms in ways that will improve
Indigenous peoples’ health care experiences. This paper presents the
findings on health care providers and decision-makers’ perspectives on
discrimination towards Indigenous people in the health care system. By
gaining insight into what care providers think, know, and do in the health
care setting can help identify systemic challenges and identify
opportunities for targeted improvement initiatives to address
discriminatory practices and increase the uptake of culturally safe care.
 Go to:

Background

Research in the USA has extensively examined the relationship between

race and health, demonstrating that people who experience racism have
poorer mental and physical health outcomes [3, 11], therefore
concluding that discrimination is a social determinant of health that has
a significant impact on minority populations [12, 13]. More specifically,
studies on racism in health care have noted that implicit bias of health
care providers result in differential clinical treatments and decisions,
leading to lower quality care for racialized groups [14, 15]. Physicians in
the USA have reinforced that differential treatment based on race does
exist in the health care system, as they acknowledged that they had more
positive associations with their non-racialized patients when compared
to their racialized patients [8, 11].

Discrimination against Indigenous peoples has unique historical roots in

colonialism [16]. As Tuhiwai Smith (1999) has argued, colonialism
required “the imposition of Western authority over all aspects of
indigenous knowledge, languages and cultures” [17]. Indigenous peoples
were subjected to “paternalistic and racist policies and legislation; ...
necessary conditions which had to be met if Indigenous peoples wanted
to become citizens (of their own lands)” [17]. This early subjugation
demanded that Indigenous ways of knowing and being were
characterized as primitive and “savage.” As Henry et al. (2000) have
argued, the colonization of Canada “relied on a belief system that judged
the original inhabitants to be inferior,’ relying on racist ideologies of
Social Darwinism [18]. This constructed inferiority of Indigenous
peoples continues to influence deeply held stereotypes that perpetuate
discrimination against Indigenous peoples today.

Discrimination is one of the root causes of the health inequities that exist
between Indigenous and non-Indigenous peoples [19]. Research has
demonstrated that experiences of discrimination is commonplace among
Indigenous peoples, with patients noting abusive treatment,
stereotyping, and a lack of quality in the care provided [1], which
discourage Indigenous people from accessing care [2, 3, 8]. Indigenous
patients have expressed that they are treated like intruders in the health
care system [1], not welcome and provided substandard care. Recent
studies have noted that Indigenous peoples often endure experiences of
racism within the health care system [3, 20]. Furthermore, one study that
examined experiences of Indigenous peoples in the health care system
demonstrated poorer mental, physical, and behavioral health among
those who were subjected to racist treatment, and that 1 in 3
participants experienced a microaggression (a casual derogatory remark
or action) against them by a health care professional [19]. The recent
findings of Allan and Smylie (2015) have demonstrated that the
problems that were identified by researchers over the past 10 to 15 years
have not substantially changed; as the title of their study suggests, First
Peoples continue to get second-class health care [3]:

Growing recognition of the health challenges Indigenous people

experience in Canada through the national dialog about the Truth and
Reconciliation Commission has created a broader sentiment to address
these challenges. The calls to action from the Truth and Reconciliation
Commission [21] provide recommendations for strategies to address
these systemic challenges. In addition, recent mandates from Health
Quality Ontario [22] expect hospitals to have an equity measure, which
has created greater incentives to address the access barriers that
Indigenous people often face in health care. Although more people are
recognizing the health inequities faced by Indigenous people, there are
many gaps in the knowledge, skills, and attitudes of health care providers
to adequately address the problem, including attitudes informed by
anti-Indigenous racism. This opening created by the national dialog in
the wake of the Truth and Reconciliation Commission is an opportunity
to reflect on the anti-Indigenous racism, as it demands attention to the
experiences of Indigenous peoples [23].

Go to:
Research Aims

The purpose of this research project was to examine ways to improve

Indigenous patients’ experiences when accessing health care. Unlike in
British Columbia where the recognition of widespread challenges and
new intergovernmental agreements have put Indigenous health on the
agenda [24, 25], attention to Indigenous peoples’ experiences in health
care seemed absent from the health care dialog in Ontario in 2015.
Compared with the BC experience, where all health authorities have been
mandated to take responsibility for improving First Nations peoples
experiences with their health care organizations [25], there seemed to be
a real lack of concern among health care providers and educators about
Indigenous health equity. Some even stated that equity was not within
the scope of responsibility of hospital services. When raising issues on
Indigenous health inequity, the authors were faced with confused stares
and a declaration that as a hospital, “health equity was not really our job.”

The cases and research presented in the beginning of this paper brought
forward perspectives from Indigenous patients about their experiences
in health care. Rather than choosing to speak with Indigenous patients,
given that others had already brought forward those experiences, this
research chose to initially focus on the perspectives from health care
providers. This research project, Engaging for Change, aimed to
understand if care providers and decision-makers were aware of the
problems and barriers that Indigenous people face regarding health care.
The assumption behind this choice was that a first step in developing a
plan to change practice in health care organizations was to find out if
people working within those organizations were ready to engage in that
change process. Priority health service areas were determined through
discussions with Indigenous health leaders, and included emergency,
diabetes, maternity, cancer, and mental health. Research respondents
were Selected from those service areas.

We carried out a baseline analysis of the current state of cultural

competency and safety skills among health care providers working ina
large city in southern Ontario. Through exploring attitudes, knowledge,
and skills of health care personnel across the five priority health service
areas, this study sought to identify promising practices, challenges, and
gaps in the provision and continuity of health care for Indigenous
peoples. The purpose of this research is to provide an evidence base to
inform improvements in services for Indigenous peoples across hospital-
and community-based health services, by identifying the current
challenges and opportunities for change among health care providers,
decision-makers, and organizations. This paper provides the findings
related to the barriers shaped by discrimination against Indigenous
peoples when they access health care services.

Methods

Priority research areas and topics were identified through a

comprehensive literature review and discussions with community
leaders in Indigenous health in the city and surrounding area. Ethical
approval was granted by the ethics boards of the health sciences center
and the university. A list of participants was developed that included a
selection of service providers and decision-makers in emergency, mental
health, maternity, diabetes, and cancer-related services within the city
and the surrounding area. Interviews and focus groups with health care
workers were carried out once written consent was obtained. Qualitative
one-on-one interviews (n = 21) and focus groups (n = 2) were completed
from August 2015 to June 2016, totaling 25 respondents. Interview and
focus group sessions were approximately 1 to 1.5 hin duration.
Physicians, nurses, social workers, patient navigators, patient experience
specialists, and departmental directors/leaders were interviewed to
understand health care workers’ perspectives and experiences with
Indigenous patients. Semi-structured interviews among participants
included 20 in-depth questions to understand their perspectives of
Indigenous health access barriers, experiences providing care to
Indigenous peoples, and understanding of organizational structures (i.e.,
policies and protocols) for facilitating inclusion of Indigenous-specific
needs. Participants were also asked about their awareness of local
community health services and resources for Indigenous people in the
city and the surrounding area.

For purposes of this study, Indigenous peoples were defined as the First
Nations, Inuit, and Métis peoples of Canada. Interviewees were asked to
reflect on the experiences of their patients they knew or perceived were
Indigenous. Indigenous and Aboriginal will be used interchangeably to
describe the First Nations, Inuit, and Métis peoples of Canada throughout
this paper, to ensure that the respondent quotes are presented verbatim.

All interviews and focus groups were voice recorded, transcribed

verbatim, and coded using NVIVO 10 Software. Discrimination was a
common theme that emerged throughout the analysis, and relevant
quotes were identified across multiple thematic nodes including cultural
barriers for patients, patient/physician relationships, perceived
discrimination by patients, perceived discrimination by care providers,
systemic discrimination, stigma, stereotyping, discriminatory beliefs, and
racism. Quotations were extracted from the data and organized into
subthemes around discrimination. This paper explores attitudes and
practices of discrimination towards Indigenous people as identified by
people working within the health care system in a large city in southern
Ontario.

Go to:

Results

The results from this study demonstrate that experiences of

discrimination are systemic in the health care system. This is not just
from the perspective of Indigenous patients, but also recognized by those
working within the health care system. Respondents expressed that they
have witnessed systemic discrimination and racist practices against
Indigenous people that are influenced by stereotypes, societal
misconceptions, and poor cultural competence of health care workers.
Respondents identified a range of experiences of racist or exclusionary
practices, from the subtler unwelcoming nature of the hospital
environment to more concerning examples of compromised care. The
results are presented along this spectrum, organized into three main
discrimination subthemes, including an unwelcoming environment,
stereotyping and stigma, and practice informed by racism.

Unwelcoming Environment

A common theme among respondents was that health service

organizations are an unwelcoming environment for Indigenous patients
and families. A few respondents acknowledged that Indigenous peoples
may not feel welcome in the health care system due to past negative
experiences with health care organizations and health care workers, or
as a result of their experience with residential schools and Indian
hospitals. These negative experiences are seen to contribute to the
overall hesitancy to access mainstream health services. One health care
leader explained,

I would say that they have a perception that they are perhaps as not well
cared for or as respected when they come in to the facility. Maybe that is a
reluctance for them to come and they seek treatment in other places they
feel more comfortable with (A12L).

A number of respondents noted that there are times when Indigenous

patients come in with expectations of poor treatment, which sets the
stage for a challenging interaction with care providers. One respondent
explained that they (as a physician) sometimes become defensive when
an interaction with an Indigenous patient is not going well. Specifically,
they shared,

I don’t think we are the most welcoming environment. So I think

[Aboriginal patients] come in with a preconceived notion that they are
going to be marginalized or viewed differently or kind of not treated as
well as they should be or viewed differently. I think some Aboriginal people
come with a preconceived notion which on an interaction is not a good way
to start because they are already on the defensive and it puts you on the
defensive. And it can feed on itself (A14P).

When Indigenous patients expect to be treated poorly when they access

health services due to past experiences of discrimination [3], they may
be more likely to question the quality of care they receive. One
respondent provided an example of a time that an Indigenous patient
believed that a regular delay in the emergency room a result of racism:

I remember one lady a long time ago, maybe 12 years ago, she was waiting
in the emergency for a long time and she made a comment out loud about
the wait time and she said that her wait time was discriminatory because
of her Aboriginal status. But the staff was able to explain to her about the
triage system and how it worked and that the wait time was not related to
that at all. It’s hard to know if the patient truly believed that or not, but at
least she appeared to believe it. That is the only thing that I have
experienced and I wouldn't even construe it as negative. I could perceive
that that patient had a negative perspective of how things were going in
the emergency department (A01P).

General frustrations with health care service were also expressed

through accusations of discrimination. Other respondents noted similar
issues where patients expressed concerns of discrimination they felt
were unfounded.

I saw a patient yesterday who has schizophrenia and personality disorder.

Actually his schizophrenia is under excellent control. But he is dissatisfied
with a variety of things, including the level of service. He wants lifts all the
time, and when he doesn’t get them, he gets annoyed. He’s under the public
guardian and trustee to assess managing his finances and all that. So we
were negotiating around that. But often, he gets frustrated and accuses me
of being biased towards him. Brings up residential schools, that this is a
consequence of further insult of the residential school system. It’s a
diversionary issue which doesn’t help with anything... But that is a negative
experience. | think it takes away from the development of relationships.
Unfortunately, that isn’t the only person where I have had that experience
where it comes to a difficulty, this issue is brought up. Sort of a scolding
(H14P).

Another respondent provided a similar case:

We have a gentleman now who is on the transplant list and he is going to

be a challenging transplant because he has a lot of anti-bodies... He’s
questioning if there is any element of discrimination of why he’s not getting
his transplant (A07P).

These examples demonstrate that due to the lack of trust and good
relationships that Indigenous people have with health care providers and
the health system in general, poor communication about processes in
health care can easily be misconstrued.

Although the providers quoted above express that the defensiveness of

their Indigenous patients are unfounded, it is common for the “forces of
colonization to go unrecognized in the health care system” [26]. Despite
this general blindness to institutional oppression, most of the
respondents were clear that the defensiveness among Indigenous
patients was a natural response to the judgmental and often hostile
reception Indigenous people experience in the health care setting. Many
respondents were clear that the hospital environment is indeed
unwelcoming and inflexible in many ways, and particularly for
Indigenous people. As one respondent noted: “we do have challenges
accepting the cultural differences and | hear that from staff” (A22L).
Another respondent expressed that “they have to fit in to this big melting
pot of a system that we have with very little consideration by the
non-Aboriginal population as to what works best for that cultural
population of people. I think that’s a huge thing” (A18L). Of particular
note is that multiple respondents referred to the lack of consideration for
different approaches to health, with a strong conviction of the supremacy
of a western approach. As one respondent noted,
I think that we also do a very poor job of...accepting non-Western medical
therapies, so if anyone talks about naturopathic or holistic healing or
whatever other approaches... whether you say it explicitly or apply it in
your actions, it is really kind of frowned upon and thought of as a lesser
way to care...1 would say that of almost every trainee from the medical
school (A13P).

The ability to ensure that cultural preferences are incorporated into care
is seen as a particular challenge in some areas of hospital services. As
one respondent stated:

I think one of the other barriers is they are intolerant to the welcoming of
other healing practices. You know, you are in the ICU and you
know... everything is so tightly controlled and if you want to add to that,
some other cultural healing practices or have a healer come in, that, I
mean it certainly has happened and it does happen and | think people try,
but it is enormously difficult in such a controlled environment... Once you
are in hospital it is extremely difficult... 1 think particularly challenging in
the ICU, although I have had experiences of having physician and
pharmacy staff getting very involved in trying to support that. But, it is still
with a permission aspect, it is still a very controlled environment and the
control is by our health care system (A20S).

Overall, it was clear that respondents were able to recognize a disconnect

between Indigenous peoples and conventional health care providers,
particularly emphasizing organizational norms that are not open to
adapting to the needs or preferences of Indigenous people. These
examples demonstrate that hospitals and other health care settings are
often an unwelcoming, inflexible environment for Indigenous peoples.
This situation often creates negative expectations, where Indigenous
people anticipate and prepare for negative behaviors from health care
providers prior to accessing services [3]. Furthermore, it is evident that
there are significant communication barriers between health care
workers and Indigenous patients. Although defensiveness was present
among some of the care providers in our study, who emphasized that
they treat everyone the same, more often the attitude among the
respondents was one of uncertainty on how to engage in meaningful
conversations without offending patients. Improving the confidence of
care providers to engage in meaningful and non-judgmental dialog with
Indigenous patients should be an important part of any training to
improve their communication skills. If trust is not gained and
relationships of mutual respect are not built as a first step, negative
interactions continue to perpetuate misunderstandings and an
unwelcoming environment, whether it is intentional or not.

Stereotyping and Stigma

A number of respondents acknowledged their lack of understanding and

knowledge of Indigenous issues, culture, and medicinal practices.
Instead, they noted that views on Indigenous people are informed by
stereotypes perpetuated in the media. One respondent emphasized that
systemic discrimination is a significant issue in the health care system
that shapes health outcomes. They explained,

There has been a lot of stereotyping and bias. To me, that is just one issue
that the report, 'First People, Second Class Treatment’ is that racism has
been identified as something that is a social determinant of health and that
has a very strong influence on outcomes for Indigenous people. I would say
that it’s universal. And not just here. And its everywhere. That is one core
issue (HO6L).

This response suggests that discrimination is a key social determinant of

health for Indigenous people. Health care workers underestimate the
negative consequences and detrimental effects of discrimination on the
health and wellbeing of Indigenous peoples. A respondent shared their
beliefs about how Indigenous patients continue to be stereotyped in the
health care system and acknowledged the lack of cultural consideration
Indigenous patients receive from health care workers, noting that there
are

stereotypes that continue to exist among generations of non Aboriginals as

to what Aboriginal folks’ lifestyles are. Their upbringing, their level of
education; dozens and dozens of these preconceived ideas or assumptions.
Been validated? I don't think they have been validated personally, but
maybe through the media which paints everyone with a very large brush as
you know and probably not doing any justice to the Aboriginal person
(A18L).

This is a very powerful statement that explains how ideas from the past
and current media discourses reinforce common misconceptions about
Indigenous peoples. These misconceptions influence non-Indigenous
people’s behaviour towards and perceptions about Indigenous peoples,
in an overwhelmingly negative way. Another respondent admitted to
widespread “judgment in the system, we judge that they’re idiots when
they’re not (A07P).” A patient support staff also shared feedback they
had received from Indigenous patients regarding their experience using
the health care system. They noted “the themes that we were hearing
from the different experiences were quite negative and they often
involved a level of discrimination, of stereotyping. People who really felt
uncomfortable in their health care setting. And unsupported” (HO6L).

Some staff felt that there were strong tendencies of prejudicial and racist
attitudes among health care providers in this southern Ontario city:

A problem [here] is stigmatization. I find it very conservative, I come from

up north. I mean, I worked on reserve for years and it, | mean it was just a
part of [the town], you didn’t really see that visible minority like you see
here. People just... 1 don’t know; it is just totally different here. I just find the
whole atmosphere different here. In the north, we are just like, here is your
neighbour, and away you go. Here, its just like, “ok, well that person looks
quite different.” So I think that might be a challenge here (H17L).

Although not all health care workers are aware of the frequency or depth
of systemic discrimination that is present in today’s health care system,
respondents noted that discrimination was an issue that needs to be
addressed. As one respondent acknowledged, “I think there is still a lot of
racism and discrimination and | think that is something that they
unfortunately they still face” (AB10P). Another respondent shared:
People stereotype them. ‘oh they are like this, they don’t take care of
themselves’ is kind of the picture I get from other staff...I1 have seen that
personally. It could be a discrimination or lack of understanding,
cross-cultural understanding, how these people are suffering, why and how
we can help them (AH11P).

Negative stereotypes held by health care providers were identified as a

significant problem for Indigenous people accessing health care services.
Respondents felt that these prejudicial beliefs among many of their
fellow health care staff significantly undermined their ability to provide
good care for Indigenous people.

Practice Informed by Racism

Discrimination influences health care providers’ interactions with

patients. Respondents noted that physicians commonly blame
Indigenous individuals for their health status. Care providers are often
unaware of the social determinants of health that have led to poor health
outcomes among racialized populations, partly due to the lack of
research on this area [27]. A respondent identified this lack of knowledge
around the determinants of Indigenous peoples’ health, noting that
“because of things that are more endemic in their populations such as
drug and alcohol abuse, which can be stigmatized but not acknowledged
in terms of why its come about, can be a problem (A09P-FG).” This
respondent clearly stated that many care providers believe that health
issues experienced by Indigenous patients are simply because they do
not take care of themselves. Health care providers often completely
disregard the social determinants of health as explanations for ill health
among Indigenous patients and demonstrate a lack of understanding of
the effects of colonization. They also fail to understand that such negative
historical practices have led to a number of systemic challenges such as
poverty, abuse, and cultural genocide [28], which have a detrimental
effect on Indigenous people’s health and wellbeing. Health care workers
that ignore these systemic challenges are unable to provide adequate
care for Indigenous patients because they do not understand their
specific needs or how to help and support them.
One respondent identified a case where the physician’s reaction to an
Indigenous patient was clearly discriminatory. They felt that “the
response is also informed by racism. Someone else might have the same
behaviour and you wouldn’t get that level of response (A20S-FG).” This
statement suggests that Indigenous peoples face unequal treatment in
the health care system, which may be informed by discrimination and
racist attitudes of health care workers.

One respondent shared that health care workers carry common

preconceived notions and do not take time to understand their
Indigenous patients beyond those common misconceptions. Specifically,
they felt that providers’ attitudes towards their Indigenous patients are
characterized by “not understanding; not taking the time; labelling
(A18L).” Indigenous patients are getting labeled based on discriminatory
stereotypes, which in turn influences the kind of care that they receive
from health care providers.

The vast majority of comments about the practices informed by

discriminatory attitudes spoke about the hesitation to prescribe pain
medication. Respondents reported incidences where they witnessed care
providers’ reluctance to prescribe pain medications due to common
misconceptions about Indigenous peoples as drug abusers. One
respondent acknowledged the general lack of standards for pain
medication prescriptions, based both on poor training and perceptions
about Indigenous peoples and addiction:

It’s my bias and I put it out there... My perception is that it’s a bigger issue
with the use of narcotics and I think to be honest, we’re poorly trained... I’m
not a social worker, I know nothing of past and dealing with emotions and
pain from bad experiences from the past, other than I realize it’s an issue. I
don’t delve into that because you wouldn't want me to. Probably get myself
into a black hole that I couldn't get out of: We do have a social
worker...and | think they’re better trained at that. I think there’s a whole
lot of stuff that doesn’t get unpacked and where that leads to pain and blah
blah, that’s too much for me. That’s an excuse and it’s too much for me to
really carry on about because I’m not trained to do those
conversations... We're either giving too much or not enough, and mine is
probably not enough. | don’t prescribe narcotics unless I have some kind of
clear guideline and it can be very clear, including screening urine (AO7P).

The respondent acknowledged their assumption that Indigenous peoples

are drug seekers, using emotional pain as an excuse. Although these
assumptions informed by stereotypes led to possible under prescribing
of pain medications, the respondent noted that better training is needed
to ensure the safe use of narcotics for pain management among all
patients.

Another respondent acknowledged that there is a system-wide belief

that Indigenous peoples misuse pain medications, and as a result,
Indigenous peoples are not provided adequate pain medication. One
physician noted,

I would think there are, that on our side some frequency of notions that
they are all drug seekers. Which clearly isn’t true. But | think that if you
lined up 10 patients with the same condition and how much pain meds
would you give this person if they were Aboriginal, I would bet less, because
the fear would be that they are there looking for pain meds to abuse or sell
(A04P).

A patient support worker acknowledged that racism and discrimination

are evident in the health care system surrounding pain medications.
They explained that the assumption that Indigenous people are drug
abusers was widespread:

Ina lot of the charts, there is always something written, suspect abuse,
suspect abuse, suspect abuse...1 thought, is everyone suspected of alcohol
abuse and drug abuse?...A lot of the advocating thatI do is, they need pain
meds, they need pain meds, they need pain meds. It seems like the
physicians or the medical staff seem reluctant to give it them. I have even
had people who were diagnosed with cancer throughout their bones
and...it’s the most excruciating form of cancer and this particular patient
was prescribed Percocets...1 thought Percocets were for more of a sore
back or you tore a ligament or something. But not for bone cancer. So she
was taking like 10 of them a day, 10 or 12 a day. Isn’t that too many pills?
Can't you give her something else that is going to work more effectively
than taking 3 or 4 percocets, 4 or 3 times a day? (H05S).

This response suggests that the stereotypes that care providers have
about Indigenous people influences their clinical decision making.
Indigenous people are regularly being labeled as drug abusers, without
an open conversation with the patient and without taking their medical
history into consideration. Indigenous peoples are being denied access to
necessary pain medications as a result. This is a clear example of the link
between discrimination and the provision of inadequate care for
Indigenous peoples.

Go to:

Discussion

This study has demonstrated a range of challenges that Indigenous

people face that stem from discriminatory attitudes and behaviors of
staff in the health care system. The health care providers that shared
their experiences and insights with us were forthright that
discrimination shaped the experiences of all Indigenous people accessing
care in their organizations. The lack of a welcoming environment leads to
misunderstandings when there are legitimate service delays and
complications. It also sets the stage for poor interactions, preventing
positive relationship and trust building between Indigenous patients and
families with health care providers. This unwelcoming environment was
also seen as a Significant reason why Indigenous people avoid accessing
mainstream health care services. The unwelcoming nature of health
services is created by the assumptions that health care providers make
based on stereotypes formulated through a racist discourse played out in
the media again and again. These poor attitudes in turn shape the care
and treatment decisions made by health care providers. Some care
providers were aware of this bias, while others noted that these attitudes
were so normalized in the system that many people are unaware of the
problem.

Discrimination can be seen as preventing access to health services, which

research has shown results in a high number of Indigenous patients
receiving late diagnoses. Many times these patients are provideda
disease diagnosis at a stage that is untreatable [14]. This is a significant
problem that worsens the health status of a population group that is
already suffering a considerably higher burden of disease across a range
of health conditions [2]. This demonstrates that the Canadian health care
system we tout as universally accessible, is actually perpetuating access
barriers for Indigenous peoples. Attitudes based on stereotypes and
stigmatization of Indigenous people are shaping practice in ways that
compromise care for this entire population.

Although we know that care providers often underestimate the

challenges faced by Indigenous peoples in health care [16], this study
shows that it is such a widespread concern that even people who state
they are unaware of many of the challenges Indigenous people face
witness widespread discrimination within their own organizations [29].
Therefore, to improve health care access for Indigenous peoples, there
are a range of issues that need to addressed, including discrimination
and lack of knowledge about Indigenous peoples that lead to negative
stereotyping. This demonstrates that the challenges in accessing
appropriate and necessary health services for Indigenous peoples are
uniquely shaped by discrimination that is manifested in a myriad of ways
when an Indigenous person walks into a health care facility. This study
validates these concerns that have been brought forward by Indigenous
patients and families, as it demonstrates that people working within the
system know that experiences of discrimination are commonplace and
therefore require a system-wide response.

This study has shown that there are serious concerns that health care
practices are being shaped by prejudice against Indigenous people,
rather than by evidence-based, patient-centered care, which is a common
mandate of health care organizations. Health service organizations need
to address the discriminatory bias that their staff bring to interactions
with Indigenous patients and families. This includes developing ways to
rewrite the narrative, based on respectful relationships with Indigenous
peoples and communities. Such relationships would require health care
professionals to be open and non-judgmental about Indigenous patients’
health conditions and health care preferences, rather than just simply
making assumptions and imposing the health care practices of
mainstream services [1, 9, 30]. Unless discrimination is taken on
systemically through the development of protocols based on principles of
cultural safety that ensure respectful engagement with all patients and
families, health care organizations will continue to perpetuate access
barriers for Indigenous people.

To address this violation of Indigenous peoples’ rights to accessible

health care, health facilities need to ensure that practices are based on
respectful interactions with Indigenous patients and families, which
ensure quality care that attends to their specific needs, while meeting
high standards of practice. Providing a safe and welcoming environment
for Indigenous peoples is key for working through past traumas resulting
from colonial practices and to redress negative experiences with health
care. This requires a significant shift in the attitudes, knowledge, and
practice of health care providers who work with Indigenous peoples. In
line with the recommendations of the Truth and Reconciliation
Commission (2015), this training needs to be taken up by the educational
institutions who train future health care providers, specifically to ensure
that students are enrolled in a course that addresses Indigenous health
issues. What this paper has demonstrated is that although background
training may be valuable, the organizational culture within health care
institutions carries a strong weight of the past, normalizing colonial
practices that reinforce the inferiority of Indigenous peoples and
practices. Effectively challenging and changing this deep-seated
organizational culture within health care institutions will require
ongoing training and vigilance to ensure new norms of equity and
characterize the ethos of our health care institutions.
Acknowledgements

We extend our appreciation to the people we interviewed and to Danielle

Alcock, Jasmine Fournier, and Bimadoshka Pucan for research assistance.

Go to:

Funding

This study was funded by a Phoenix Fellowship from Associated Medical

Services.

Go to:

Compliance with Ethical Standards

All procedures performed in this study involving human participants

were in accordance with the ethical standards of the Health Sciences
Research Ethics Board of the University, the health sciences research
institute ethics board, and the Tri-Agency Framework on Responsible
Conduct of Research, and with the 1964 Helsinki declaration and its later
amendments or comparable ethical standards. Informed consent was
obtained from all individual participants included in the study.

Conflict of Interest

The authors declare that they have no conflict of interest.

 Go to:

Contributor Information

Lloy Wylie, Phone: 1-519-661-2111 x 86309, Email: ac.owu@2Zeilywl.

Stephanie McConkey, Email: ac.owu@knoccms.

 First Nations, Inuit and Métis Peoples Living in Urban Areas
of Canada and Their Access to Healthcare: A Systematic
Review

Simon Graham,’ Nicole M. Muir,? Jocelyn W. Formsma,? and Janet Smylie**

Florian Steger, Academic Editor and Marcin Orzechowski, Academic Editor

Author information Article notes Copyright and License information PMC Disclaimer

Associated Data

Supplementary Materials

Data Availability Statement

Abstract

In Canada, approximately 52% of First Nations, Inuit and Métis

(Indigenous) peoples live in urban areas. Although urban areas have
some of the best health services in the world, little is known about the
barriers or facilitators Indigenous peoples face when accessing these
services. This review aims to fill these gaps in knowledge. Embase,
Medline and Web of Science were searched from 1 January 1981 to 30
April 2020. A total of 41 studies identified barriers or facilitators of
health service access for Indigenous peoples in urban areas. Barriers
included difficult communication with health professionals, medication
issues, dismissal by healthcare staff, wait times, mistrust and avoidance
of healthcare, racial discrimination, poverty and transportation issues.
Facilitators included access to culture, traditional healing, Indigenous-led
health services and cultural safety. Policies and programs that remove
barriers and implement the facilitators could improve health service
access for Indigenous peoples living in urban and related homelands in
Canada.

Keywords: Indigenous, barriers, facilitators, discrimination, culture,

healthcare

1. Introduction

1.1. First Nations, Inuit and Métis Peoples

First Nations, Inuit and Métis (Indigenous) peoples are the recognized
Indigenous peoples in Canada [1]. Each has their own colonial history,
and there is diversity and relatedness within and between these distinct
peoples [1].

1.2. The Migration of Indigenous People to Urban Areas

Indigenous peoples in Canada are becoming more urbanized, with the

2016 census highlighting that 52% of First Nations, 62.6% of Métis and
56.2% of Inuit peoples lived in urban areas [2]. From 2006 to 2016, the
estimated number of Indigenous peoples living in urban areas increased
by 59.7% [2].

Métis people have been living in and migrating to Canadian cities since
the founding days of the Métis nation [3]. In 1951, amendments to the
Indian Act repealed a law that limited the free movement of First Nations
peoples off reserves, resulting in the migration of First Nations people to
urban areas [4]. The Indian Act also contributed to First Nations
women’s migration to cities because if a First Nations woman with status
(formally recognised as a First Nations woman) married a non-status
man, she would lose her status and therefore be unable to live on
reserve; which forced many First Nations women to move to urban areas
[5]. The federal government began to actively implement polices of Inuit
relocation from traditional territories to permanent settlements in the
Nunangat or southern urban centres during WWII [3,4,5]. Food
insecurity and access to health care, housing, employment, and education
have prompted the ongoing migration of Inuit people to urban centres
[3,6].

1.3. Access to Health Services in Urban Areas of Canada

Compared to remote areas of Canada, urban centres have a higher per

capita density of primary healthcare, mental health, social support and
specialist health services. Despite this urban concentration of services,
Indigenous peoples living in urban areas do not necessarily have better
health care experiences and treatment outcomes compared to First
Nations people living on reserves or Inuit people living on Nunangat. The
First Nations Regional Health Survey (RHS) found that 21.3% of First
Nations people living on-reserve reported not having a primary health
care provider, and 9.6% reported unmet health needs in the previous 12
months [7]. In the urban city of Toronto, 37.4% of Indigenous people
reported not having a primary health care provider, and 28.0% reported
having unmet healthcare needs in the previous 12 months [8]. This
highlights that some Indigenous peoples living in urban areas, despite
living closer to a range of health services, are having difficulty accessing
health care services or are choosing not to access these services.

1.4. Aim

This study aims to highlight the barriers Indigenous people experience

and the facilitators that could improve access to health services among
Indigenous peoples living in urban areas of Canada.

Go to:
2. Materials and Methods

2.1. Conducting the Review

This systematic review was conducted according to the Preferred

Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA
Statement [9] but is not registered with the International Prospective
Register of Systematic Reviews (PROSPERO). The primary research
question was the following: What are the barriers to and facilitators of
access to health services for First Nations, Inuit and Métis peoples living
in urban areas of Canada?

2.2. Search Strategy

We searched the electronic databases Embase, Medline and Web of

Science from 1 January 1981 to 30 April 2020 using the following MeSH
terms and variations:

1. (First Nations OR Inuit OR Métis OR Indigenous OR Aboriginal OR

Native) AND
2. (Canada) AND
3. (Urban OR urbanized OR city OR cities OR metropolitan) AND
4. (clinic OR medical OR doctor OR nurse OR physician OR primary
health service OR mental health OR hospital OR drug use services)
AND
5. (access OR accessing)

2.3. Inclusion Criteria

Reference lists of included studies were examined for additional studies.

We also searched for relevant grey literature including government or
community reports using Google. Studies were included if they had a
focus on First Nations (status or non-status), Inuit or Métis peoples who
lived in urban areas of Canada and provided information about barriers
or facilitators to accessing health services. Studies that reported
combined results of Indigenous people living in urban and rural/remote
settings were included if there was content specific to urban health care.

2.4. Exclusion Criteria

Studies were excluded if they were guidelines, reviews, opinion pieces,

notin English, contained no Indigenous specific results, or the full paper
could not be accessed electronically or through author communication. If
a study met the inclusion criteria but it did not specify the distinct
Indigenous nations included in the study (i.e., First Nations, Inuit or
Métis) then the authors labelled the study population as ‘Indigenous’,
recognizing that pan-Indigenous approaches that combine distinct
Indigenous populations have limitations. In alignment with Statistics
Canada, urban areas were defined as a population of >1000 anda
population density of >400 persons/km [10].

2.5. Data Extraction

The first author reviewed each study using Covidence software [11] and
removed studies that did not meet inclusion criteria. The first and second
authors then worked together to reach consensus on the included
studies. Data extraction was conducted by the first author and inserted
into an excel spreadsheet [12]. The following information was extracted:
author, year the study was published, years the study was conducted, city
and province, Indigenous group (First Nations, Inuit, Métis), study
design, how the sample was chosen, sample size, population group
(adults, youth, Elders), type of health service (general practitioner,
emergency department of a hospital, substance use service, dental clinic,
etc.), incentives provided (cash, gift cards), aim of the study, barriers to
health service access and facilitators to health service access.

2.6. Ethics
This study did not seek ethics approval because it used publicly available
studies and government and community reports. It was reviewed and
approved by the board of an Indigenous organization of which the third
author is a senior staff member.

3. Results

3.1. Overview of Included Studies

Overall, 41 studies met the inclusion criteria (Figure 1 and Table 1)

[13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,3
6,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53].
 Studies identified by databases and other sources:

1. Medline (n=134)
2. Web of Science (n=41)
3. Embase (n=211)
4, Grey literature (n=17)
5. Reference lists (n=1)

|!
Total number of studies (n=404)

> Number of duplicates removed (n=126)

¥
Studies screened (n=278)

¥.

Studies from reference lists of above studies (n=1)

Studies screened (n=279)

Studies removed (n=238)

Reasons:
1. Areview or guideline (n=36)
2. Not Indigenous people (n=70)
> 3. Not about barriers or access (n=48)
4. Not in Canada (n=5)
5. Not urban (n=79)

Studies included (n=41)

\
! ¥ f
Qualitative Quantitative Mixed-methods
{n=25) (n=13) {n=3)

Figure 1
Flow diagram of included studies.
Table 1
Studies examining health service access among First Nations, Inuit and Métis peoples living
in urban areas of Canada.
Author, Indigeno Study Health Incentive
Participa Sample .
Year Location us Design, Service s
nts Size .
Published Group * Methods Focus ® Provided

Aboriginal ;
First ;
Health ; ; Primary
; Nations, Quantitat
Access Ontario ; Adults 50,000 ; health = Not Stated
Inuit, ive ;
Centres, ; services
Métis
2015 [14]

Aboriginal ;
First ;
Health ; ; Primary
; Nations, Quantitat
Access Ontario ; Adults 50,000 ; health = Not stated
Inuit, ive ;
Centres, ; services
Métis
2016 [13]

First Family
Nations members
Vancouver (status), or carers
Auger et out Tatts ;
, First of Qualitati Diabetic $35 gift
al., 2016 . ; ; 35 ;
British Nations Indigenou ve patients card
[36] Columbia
. (non-stat s people
us), with type
Métis 2 diabetes

Auger, Vancouver 23 Qualitati Mental — $25 gift

Métis women 33
2019 [25] ve health card
>
and 10
Author, Indigeno Study Health Incentive
Participa Sample . .
Year Location us Design, Service s
nts Size .
Published Group * Methods Focus # Provided

British men
Columbia accessing
mental
health
services

Primary
health
Barnabe et ; ; services at
Calgary, First Quantitat None
al., 2017 ; Adults 38 ; the Elbow ;
Alberta Nations ive ; provided
[46] River
Health
Lodge

$20 plus
$10 for
Beckett et ; ; . . .
Hamilton, First Quantitat Diabetic each
al., 2018 ; ; Adults 524 ; ;
Ontario Nations ive patients person
[49]
they
recruit

Primary

Benoi Vancouver health An

enoit et .
First Adult Qualitati SVS AL honorariu
al., 2003 61 the
su] British Nations women ve m was
-_ Columbia Vancouver provided
Native
Health
Author, Indigeno Study Health Incentive
Participa Sample .
Year Location us Design, Service s
nts Size
Published Group * Methods Focus * Provided

Society
(VNHS)
and Shewa

Toronto ; Women
; First _
Benoit et and ; living ;
Nations, ; Mixed ;
al., 2019 Thunder ; with and 90 Multiple Not stated
Inuit, ; methods
[50] Bay, ; without
Métis
Ontario HIV

Patients
; of the
First
; emergence
Nations, Emergenc
Vancouver ; y
Browne et Métis, ;
departme Quantitat None
al., 2011 . non-statu ; department ;
British nt (ED) ive provided
[52] ; s ofa
Columbia ; and ED ;
Indigeno hospital
staff. 44
us people ;
patients,
38 staff.

Emergenc
Cameronet Edmonton First “borigina Oualitat y
: uahitati
al., 2014 , Nations, I patients 19 department Not stated
: ve
[53] Alberta Métis m ofa
hospital hospital
Author, Indigeno Study Health Incentive
Participa Sample . .
Year Location us Design, Service s
nts Size
Published Group * Methods Focus # Provided

and their
families

Vancouver HIV
, Victoria, testing and
Carter et ; ; Women —
Prince First _ Qualitati treatment
al., 2014 ; living 28 ; Not stated
George, Nations ; ve services
[15] with HIV
British and
Columbia hospitals

Mothers
where
; apprehens
First ;
Denisonet Northern ; ion of —
. Nations, ; Qualitati ;
al., 2014 British ; their 9 Hospital Not stated
; Inuit, ; ve
[16] Columbia ; children
Métis oo
is being
threatene
d

Vancouver

First
Environics Edmonton . ae
Nations, Qualitati ;
Institute, ? imu; Adults 2614 Multiple Not stated
nuit, ve
2010 [17] Calgary, -
Regina, Métis

Saskatoon

>
Author, Indigeno Study Health Incentive
Participa Sample .
Year Location us Design, Service s
nts Size .
Published Group * Methods Focus * Provided

Winnipeg,
Thunder
Bay,

Montreal,

Toronto,

Halifax
and
Ottawa

$20 to
participate
Firestone et ; ; ; Primary _ plus $10
Hamilton, First Quantitat
al., 2014 ; ; Adults 554 ; health care foreach
Ontario Nations ive ;
[19] services person

they
recruited

$20 to
participate
Firestone et ; ; ; plus $10
Hamilton, First Quantitat Mental
al., 2015 Adults 554 ; for each
Ontario =‘ Nations ive health
[18] person
they
recruited
Author, Indigeno Study Health Incentive
Participa Sample .
Year Location us Design, Service s
nts Size
Published Group * Methods Focus * Provided

Drug,

Vancouver alcohol
Goodman et ; ——
First Qualitati and
al., 2017 . ; Adults 30 Not stated
British Nations ve substance
[20] ;
Columbia use
services

Young ;
Goodmanet ; _. Primary
Winnipeg, —- First people Qualitati None
al., 2019 ; ; 8 health ;
Manitoba Nations (15-25 ve ; provided
[21] services
years)

Health First Pregnant Maternal,

Council of Multiple Nations, women Not Qualitati post natal Not
Canada, provinces Inuit, and reported ve and child —_ reported
2003 [22] Métis mothers health

Saskatoon

Health Winnipeg. First on

as rimary
Council of Edmonton Nations, Qualitati Not
; Adults 160 health
Canada, ? Inuit, ve ; reported
services
2012 [24] Vancouver — wrétis

Toronto,

Montreal,
Author, Indigeno Study Health Incentive
Participa Sample
Year Location us Design, Service s
nts Size
Published Group * Methods Focus ? Provided

and
St. John’s

Vancouver

Winnipeg,
Health Ottawa, First ;
, , , _,, Primary
Council of Iqaluit, Nations, Not Qualitati Not
; ; Elders health
Canada, Inuvik, Inuit, reported ve ; reported
services
2013 [23] and Métis

Happy
Valley-Go
ose Bay

Maternal
Heaman et — ; — $20
Winnipeg, —- First Pregnant Qualitati and
al., 2015 ; ; 26 grocery
Manitoba nations women ve prenatal ;
[27] gift card
care

24
postpartu
m Maternal
Heaman,
_
Winnipeg,
.
First women,
a
Qualitati and
$20
; ; 24 grocery
2018 [26] Manitoba nations 30 ve prenatal ;
gift card
healthcar care
e
providers
Author, Indigeno Study Health Incentive
Participa Sample .
Year Location us Design, Service s
nts Size
Published Group * Methods Focus # Provided

Kelowna, ; ——
Hole et al., . First Qualitati ;
British ; Adults 28 Hospital Not stated
2015 [28] ; Nations ve
Columbia

$20 to
participate
Kitching et ; ; Primary __ plus $10
Toronto, First Quantitat
al., 2020 ; ; Adults 836 ; health for each
Ontario Nations ive ;
[29] service person

they
recruited

Lawrence et ; First ;
Ontario, Pregnant Quantitat Dental
al., 2016 ; Nations, 541 ; ; Not stated
Manitoba ; women ive services
[30] Métis

Patients Rheumatol
Loyola-San ; ; es
Southern Indigeno needing Qualitati ogy
chez et al., 13 . Not stated
Alberta us Arthritis ve arthritis
2020 [31] .
services practices

1059
(623
McCaskill ; ; ;
Toronto, First surveys Mixed ; $5 gift
et al., 2011 Adults Multiple
Ontario Nations and 436 methods card
[32]
intervie

ws)
Author, Indigeno Study Health Incentive
Participa Sample .
Year Location us Design, Service s
nts Size .
Published Group * Methods Focus # Provided

Participan
ts were
provided
witha
small
Vancouver
token of
, appreciati
Edmonton
441 on (no
_— (413 HIV further
; Winnipeg, _ Youth ; ; ;
Mill et al., Aborigin surveys Mixed _ testing and info
Ottawa, 15-30 ;
2008 [33] and28 methods manageme provided).
Toronto, years) ; oo,
intervie nt Participati
Montreal,
ws) ng
Halifax, Lo.
organizati
Labrador,
. ons
Inuvik .
received a
small
compensa
tion for
staff time.

Prince .
Nelson et ; _. Primary
George, First Qualitati
al., 2018 . ; Adults 50 health care Not stated
British Nations ve ;
[34] service
Columbia
Author, Indigeno Study Health Incentive
Participa Sample .
Year Location us Design, Service s
nts Size .
Published Group * Methods Focus ? Provided

Cash $20
per hour,
travel
expenses
Saskatoon
HIV $20,
; and .
Nowgesic ; ; _, treatment — childcare
Prince First Qualitati
et al., 2015 ; Adults 20 and expenses
Albert, Nations ve
[35] manageme $40,a
Saskatche
nt small
wan
tobacco
bundle, an
Indigenou
s gift

$20 to
. participate
First
O’Brien et plus $10
London, Nations, Not Quantitat
al., 2016 ; ; Adults ; Any type foreach
Ontario Inuit, stated ive
[37] ; person
Métis
they
recruited

> Vancouver First People

earce et F
12019 , Prince Nations, Who use 45 Qualitati Hepatitis Cash
al, Wen ; as
Bs] George, Inuit, illicit ve C clinics
Sudbury, Métis drugs and
Regina, are
Author, Indigeno Study Health Incentive
Participa Sample
Year Location us Design, Service s
nts Size
Published Group * Methods Focus * Provided

Saskatche accessing
wan hepatitis
Cc
treatment

$25 for
First each
; Kelowna, ; es ;
Schill et al., Nations, Qualitati Mental sharing
British ; Elders 9 ;
2019 [39] ; Inuit, ve health circle the
Columbia
Métis elders
attended

First
Smylie et ; ; Adults ;
Hamilton, Nations, Quantitat
al., 2011 ; ; and 790 ; Any type $10
Ontario Inuit, ; ive
[41] children
Métis

Vancouver First Mental

Syme et al., , Nations, Qualitati health and
. Adults 60 _ $30 each
2011 [40] British Inuit, ve addictions
Columbia Métis services

Emergenc
Vancouver
. er y
Tang et al., , Indigeno Qualitati
. Adults 34 department Not stated
2015 [42] British us ve
; ofa
Columbia
hospital
Author, Indigeno Study Health Incentive
Participa Sample .
Year Location us Design, Service s
nts Size .
Published Group * Methods Focus # Provided

$10 to
participate
Tungasuvwvi ; plus $10
; Ottawa, ; Quantitat
ngat Inuit, ; Tnuit Adults 345 ; Any type foreach
Ontario ive
2017 [43] person

they
recruited

Services
First for
Van Herk et ; ——
Ottawa, Nations, Qualitati women,
al., 2012 ; Adults 26 ; Not stated
Ontario Inuit, ve social
[44] ;
Métis services
for all

$20 to
; participate
First
Well Living plus $10
Toronto, Nations, Not Quantitat
House, ; ; Adults ; Any type foreach
Ontario Inuit, stated ive
2016 [45] ; person
Métis
they
recruited

Wright et ; First __ . Primary

Hamilton, ; Pregnant Qualitati
al., 2019 ; Nations, 19 health Not stated
Ontario women ve
[47] Métis services
Author, Indigeno Study Health Incentive
Participa Sample
Year Location us Design, Service s
nts Size
Published Group * Methods Focus ? Provided

Urban city ——‘ First

; ; ; Health _. Primary
Wylie et al., in Nations, Qualitati
; care 25 health = Not stated
2019 [48] — southern Inuit, ; ve ;
providers services
Ontario Métis

Open in a separate window

4—Jndigenous group: the Indigenous group reported by each study is used; if the study did
not report a specific group, it was labelled as ‘Indigenous’. *—Health service type:
Emergency department of a hospital, mental health service, primary health care service,
dental services, addiction and substance use services, maternal health.

3.2. Barriers of Accessing Health Services

Barriers of accessing health care services for Indigenous peoples living in

urban areas included difficult communication with health professionals,
medication issues, dismissal by healthcare staff, wait times, mistrust and
avoidance of healthcare, racial discrimination, poverty and
transportation issues (Table 2 and Supplementary Table $1).

Table 2
Barriers and facilitators of accessing health services among First Nations, Métis and Inuit
peoples living in urban areas of Canada.
Facilitators to Accessing
Author, Year _ Barriers to Accessing Health Care
Health Care

Aboriginal e Holistic wellbeing

Health Access e Culture as treatment
Centres, 2015 e Not the focus of this study e Indigenous community
[14] led and run primary
health services
 Facilitators to Accessing
Author, Year _ Barriers to Accessing Health Care
Health Care

e Indigenous knowledge
of the life cycle
Aboriginal e Indigenous concept of
holistic health
Health Access e The continuity of care
Centres, 2016 Not the focus of this study from health promotion
and prevention to
U3] rehabilitation
e Integrating western
medicine with traditional
healers
e High value of traditional
healing that is based on
Auger et al., Racism relationships
2016 [36] Discrimination e Increase in owning their
Mistrust own health and knowing
about other options for
health

Increased access to culturall * Wellness was understood

Auger, 2019 y as a whole, including
responsive health care spanning mental. emotional
[25] both Western and traditional ne °
systems spiritual and physical
y health
e No discrimination
Barnabe et al., Long waiting periods * Easy to access the
2017 [46] Transportation issues service
Language e Good communication
with patients
Not having NIHB insurance
Beckett et al., Long waiting lists
Income e Not the focus of this
2018 [49] study
Poverty
Not culturally appropriate
Benoit et al., Difficult communication e Good communication
2003 [51] Poverty e Holistic wellbeing
No traditional healers
approach
 Facilitators — to Accessing
Author, Year _ Barriers to Accessing Health Care
Health Care

e Indigenous health
services
Racism, negative stereotypes and
judgements
Sixties Scoop
Benoit et al., The Indian Act
2019 [50] Indian Residential Schools ° sed focus of this
Inadequate health services
Socio-economic insecurity
A lack of recognition of
Indigenous knowledge systems
Browne et al., Caring about the person
Discrimination
2011 [52] Difficult communication with staff
Holistic wellbeing
approach
Limited access to specialized care

Cameron et al., Long waiting times Good communication

2014 [53] Barriers in the communication and with health professionals
~ understanding of medical jargon e Having a family member
Barriers in the interaction with go with you
health care professionals
Carter et al.,
. oo. , e Not the focus of this
2014 [15] Racism, discrimination study

Denison et al.,
. oo. , e Not the focus of this
2014 [16] Racism, discrimination study

Environics

Institute, 2010 Traditional healing, easy

Not the focus of this study
access to services
[17]
 Facilitators — to Accessing
Author, Year Barriers to Accessing Health Care
Health Care

Transportation
Doctor not being available
Firestone et al.,
Low income and poverty
e Not the focus of this
2014 [19] Services not covered by study
Non-Insured Health Benefits
Lack of trust in healthcare
provider
Firestone et al.,
Discrimination e Not the focus of this
2015 [18] study

Goodman et al., Participants’ experienced medical ¢ Good communication

5017 20 dismissal often which resulted in
[20] disengagement from care or delay
in care
Residential mobility
Goodman et al., Racism negatively influenced the
types of social support and
2019 [21] relationships formed
with health professionals
e Holistic wellbeing
approaches
.
e Culturally based services

Improved access to
health-promoting social programs
Health Council
of e Traditional healing
Canada, 2003 Not the focus of this study e Indigenous
; community-based
[22] services

Health Council
of e Welcoming
Canada, 2012 Not the focus of this study e Feeling culturally safe
[24] e Feeling like you belong

Health Council Isolation e Consulting with and

building equal
of Poverty partnerships with First
 Facilitators — to Accessing
Author, Year Barriers to Accessing Health Care
Health Care

Canada, 2013 Nations, Inuit and Métis

[23]
Transportation
Childcare
Heaman et al., Could not afford transportation to
get to prenatal appointments
2015 [27|
Long periods in a waiting room
Negative personality of PNC staff,
such as being rude or abrasive,
distracted, or not caring
A better understanding of other
programs arising from their
involvement
Heaman, 2018
Improved communication
[26] Benefits of teamwork
Positive changes in service
delivery (e.g., more accessible,
convenient)
peoples
e Dedicated Indigenous
health centres and case
managers
e Whole of community
programs to assist
seniors and elders, ¢.g.,
Peter Ballantyne Cree
Nation, Kahnawake
Shakotiia’takenhas
Community Services,
Saanich First Nations
Adults Care Society
e Increased use of
Telehealth
e Acknowledging and
integrating traditional
culture into care services
e Transportation assistance
e Convenient location of
services
e Positive care provider
qualities
e Women were motivated
to attend prenatal care to
gain knowledge and
skills and to have a
healthy baby
e Convenient
e Good communication
 Facilitators to Accessing
Author, Year _ Barriers to Accessing Health Care
Health Care

Positive culturally safe

experiences, were
described as
Hole et al., e Structural violence that reproduces interpersonal
2015 [28] experiences of institutional trauma interactions with
in hospital feelings, being visible,
being heard, being
respected, treatment as a
“human being”
Kitching et al., ;
2020 [29] e Racism and discrimination Not the focus of this
study

Lawrence et al., ;
2016 [30] e Racism, discrimination Not the focus of this
— ° study

Increasing
patient—provider trust.
Patients’ narratives
Loyola-Sanchez identified that
Good relationships with health
et al., 2020 [31] patient—provider trust
providers
could be fostered by an
environment that is safe,
collaborative, and
professional
McCaskill et
Indigenous led and run
al., 2011 [32] Discrimination, Racism
services

Mill et al., 2008 Indigenous culturally

[33] Discrimination based services, holistic
wellbeing

Nelson et al., Lack of quality of care

Not the focus of this
2018 [34] Long wait times
study
Racism and discrimination
 Facilitators to Accessing
Author, Year Barriers to Accessing Health Care
Health Care

Nowgesic et al., Accessing antiretroviral therapy

within the context of living with a e Not the focus of this
2015 [35] substance use disorder was an study
overarching theme
Inability to obtain or afford
O’Brien et al., transportation
e Not the focus of this
2016 [37| Poverty
study
Lack of trust in health care
providers
First: treatment providers must
understand and accept colonization
as a determinant of health and
wellness among hepatitis C
affected Indigenous people,
including ongoing cycles of child
apprehension and discrimination
within the healthcare system e Good communication
Pearce et al., Second: consistently safe attitudes e Respectful relationships
and actions create trust within
2019 [38] hepatitis C treatment e Trust

provider—patient relationships and e Holistic wellbeing

open opportunities for engagement approaches
into care
Third: treatment providers who
identify, build and strengthen
circles of care will have greater
success engaging hepatitis C
affected Indigenous people who
have used drugs into care
Transportation to cultural activities
outside urban centres such as
medicine picking
Schill et al., The importance of urban
e Not the focus of this
2019 [39] organizations (such as Aboriginal
Friendship Centres) in developing study
social support networks
The role of discrimination and
racism
 Facilitators — to Accessing
Author, Year Barriers to Accessing Health Care
Health Care

Inequitable care as barriers to

accessing services in urban centres
Poverty
Discrimination
Doctor not available in my area
Nurse not available
Lack of trust in the health care
provider
Waiting list too long
Smylie et al.,
Unable to organize transportation e Access to traditional
2011 [41]
Difficult to get traditional care medicine
Health care not covered by
Non-Insured Health Benefits
(NIHB)
Prior approval for services under
NIHB was denied
Could not afford childcare costs
Felt health care provided was not
culturally appropriate
Three intersecting issues that
impact access to Methadone
Maintenance Treatment
Syme et al.,
Stigma and prejudice e Not the focus of this
2011 [40] study
Social and structural constraints
influencing enactment of peoples’
agency
Homelessness
Tang et al., Racism
e Not the focus of this
2015 [42] Discrimination
study
Long waiting times
Tungasuvvingat No traditional medicine
e Not the focus of this
Inuit, 2017 [43] Cannot understand what the health
study
provider was saying
 Facilitators to Accessing
Author, Year _ Barriers to Accessing Health Care
Health Care

e Not comfortable with health

provider
e Costs
e Cannot afford transportation
e Health services not available after
hours
e Safe spaces and safe
relational places
Van Herk et al., e Belonging and
2012 [44] e Not the focus of this study community
e Engaging the five senses
e Service provider attitude
and commitment
Well Living
House, 2016 e Stigma and discrimination e Not the focus of this
[45] e Poverty study

e Mothers described four

organizational policies
that influenced their
experiences of using
primary care for their
infants, including:
e (a)
Wright et al., Unwelcomine clini flexible
2019 [47] e Unwelcoming clinics ‘
appointments
e Poverty ° (b)

alternative
options for care
e (©)
welcoming
receptionists
e (d)
 Facilitators to Accessing
Author, Year _ Barriers to Accessing Health Care
Health Care

welcoming
spaces
e ()
multi-service
clinics
Wylie et al., e Unwelcoming environment
. . e Not the focus of this
2019 [48] e Stereotyping and stigma
study
e Practice informed by racism
Open in a separate window

3.2.1. Difficult Communication with Health Care Professionals

Difficult communication with hospital staff was highlighted as a barrier

[28,37,41,43,52,53]. Participants gave examples of when they were in
medical facilities and not listened to, not believed or spoken to ina
condescending manner [28,35,42]. Some participants spoke of not
understanding what the healthcare providers were saying to them. When
a family member accompanied one participant to the hospital, the
participant said the following:

This time it was not as bad because my daughter came with me. Ifelt | was
treated alright... | felt this time around the staff treated me good and this
time I understand as the doctor talked slow to me and when I don't
understand the question I asked him to explain it to me better. I feel more
comfortable now.

[53]

One participant who was pregnant felt she did not have time to ask
questions and said the following:
The doctor himself is so abrasive—flies into the room, does what he needs
to do ... it doesn’t really seem like he cares, and he is out the door and on to
the next patient. ... I feel so rushed that I don’t actually get to talk about
things that are pertinent to my pregnancy. And so ! leave the office and did
not voice my concerns.

[27] (p. 5)

Finally, one study highlighted a fear that disclosing spiritual gifts to

non-Indigenous healthcare providers could bring about a mental health
misdiagnosis [25], suggesting that Indigenous patients may not feel safe
disclosing traditional cultural practices to healthcare providers.

3.2.2. Medication Issues

Some participants who had a history of substance use were denied

medications for telling the truth about their substance use [20,34,35].
Two studies which included people who used illicit drugs highlighted
that when they told the truth about their drug use, they were kicked out
of the doctor’s office or were told that they needed a clean urine test
before they could receive their medications [20,35]. A non-Indigenous
nurse acknowledged that “there is a systemwide belief that Indigenous
peoples misuse pain medications, and as a result, Indigenous peoples are
not provided adequate pain medication” [48] (p. 43).

One study participant stated that her doctor did not know that she
should go on medication for her condition, and she had to educate him
[33]. There was an example of fear towards being overprescribed
medications with one participant reporting that they were terrified of
medication due to seeing a family member being heavily medicated
because of mental health issues [25].

3.2.3. Dismissal or Discharge by Healthcare Staff

Indigenous people living in urban areas described being either verbally
or physically dismissed from healthcare facilities and how this affected
their ability to access healthcare including instances where they
avoided/delayed seeking healthcare until they were very sick. Examples
of dismissal include being threatened by hospital security or being
involuntarily discharged from the hospital [16,20]. One participant said
the following:

My pneumonia hadn't even [gone away] and it was during winter time. And

one of the nurses came in and said the doctor is discharging you. I said I’m
not even better yet and she said, well it’s timefor you to go ... don’t let me
call security. And sure enough she called security. Security literally came in,
grabbed me behind my arms, dragged me down the hallways and threw me
out the door, with pneumonia, in winter time.

[16] (p. 1112)

3.2.4, Wait Times

Studies highlighted that Indigenous people spend a lot of time waiting for
healthcare services. Participants in Barnabe and colleagues’ (2017) study
said that they had difficulty having the physician make a referral,
obtaining an appointment once referred and waiting too long to see the
referral physician as the referral appointments were often cancelled or
deferred. Other participants reported that there were long wait lists to
access healthcare in general, long waiting times once they were in the
doctor’s office or emergency room and long waits for test results
[19,27,33,34,42,49,53]. Another participant, highlighted how long
waiting times discouraged them from seeking timely assessment:

I notice every time I go see a doctor, I’m waiting for a long time. Like my
knee, I handled that for about a week and a half before I even decided to go
[for treatment] because I knew the waiting time was just going to be a long
time.

[42] (p. 705)

3.2.5. Mistrust and Avoidance of Healthcare

Studies highlighted the mistrust that urban Indigenous people felt

towards the health care system [53]. Previous experiences of accessing
health services contribute to Indigenous mistrust of healthcare providers
[19,34]. One Indigenous Elder from Schill and colleagues’ (2019) study
commented that

Sometimes we don’t trust the doctors ... because we don’t know what
they’re going to give us. And sometimes that can harm our body ... That’s
why when I was smoking and I was coughing for three days, I didn’t go to
the hospital because I’m scared of hospitals. Sometimes it’s trust.

[39] (p. 871)

3.2.6. Racial Discrimination

Studies identified racial discrimination as a barrier to accessing health

services [15,29,30,39,41,43,48]. One study interviewed health care
providers about Indigenous patients with one healthcare professional
stating that “there are times when Indigenous patients come in with
expectations of poor treatment, which sets the stage for a challenging
interaction” [49]. A doctor also said, “as a physician, sometimes I become
defensive when an interaction with an Indigenous patient is not going well”
[48] (p. 40). Health professionals acknowledged their lack of
understanding of Indigenous issues and culture, and that their views
about Indigenous people were informed by the media.
Participants highlighted that being Indigenous elicited anti-Indigenous
discrimination [20,37,41,52]. One participant noted that

The healthcare workers treated me like crap and I know it was because I
was Native ... When you need the medical care we put up with it. We
shouldn’t have to.

[20]

Studies highlighted the harms that discrimination can have on an

individual’s health-seeking behaviours [18,40]. The Our Health Counts
Toronto study found that 71% of Indigenous adults living in Toronto
reported experiencing racism from healthcare professionals which then
prevented, stopped or delayed them from returning to seek healthcare
[45].
3.2.7. Poverty and Transportation

Poverty was identified as a barrier even within Canada’s universal health

care system [16,19,20,37,43,49,52].

Indigenous peoples were concerned with how healthcare providers

might be responding to them based on their appearance as people living
in poverty and poor neighbourhoods [16,52].

One participant noted that

... you have to expect living in this area you're not going to get the best
healthcare. It seems like they care less when you're in a poverty-stricken
area ... the doctor’s office is kind of ghetto looking ... It doesn’t feel
personable, it doesn’t feel welcoming, and it feels like you're in and out, and
they are not doing their job. They don’t ask you how you're doing, as they
would in a different nicer area.

[47]
Poverty also includes not being able to afford to take transportation to
medical appointments and was mentioned in four studies [19,27,46,52].
One study interviewed an Indigenous pregnant woman who noted that

“I was supposed to go for an ultrasound, but I couldn't go. It was cold that
day and I wasn’t gonna walk. I didn’t have a bus fare ... didn’t want to
freeze my ears, so I just stayed home’.

[27]

3.3. Facilitators of Accessing Health Services

The facilitators to accessing health care were access to culture,

traditional healing, Indigenous-led healthcare services and support
around their needs such as food and transportation (Table
2 and Supplementary Table $1).

3.3.1. Access to Culture

The opportunity to use and practice culture was highly valued by

Indigenous peoples living in urban areas [13,14,22,25,36]. One
participant reported that, “to have wellness, it means having access to your
culture and to resources and support’ [25] (p. 94). Community-designed
teachings, traditional healing services, services in different Indigenous
languages (e.g., Oji-Cree, Cree, Inuktitut, Ojibway), medicine walks,
dancing, drumming, traditional arts and crafts, sweat lodges and
ceremonies were available and highly valued as part of their healthcare
[13,14]. Access to and use of traditional languages was also identified in
several studies as a facilitator of healthcare access [13,14,22,44].

There was recognition of mainstream medicine and its benefits, but this
was commonly in a context in which participants identified that they had
access to both mainstream and traditional Indigenous health and
wellbeing practices (e.g., naturopaths, social workers) [36]. One
participant remarked that
“I do see a clinical counsellor every couple of weeks but I don’t see that as
being more helpful than going to the beading group, than going to Métis
Night at the Friendship Centre’:

[25] (p. 95)

3.3.2. Traditional Healing

Access to traditional healing was identified as highly important in

multiple studies. The personal connection with Traditional Healers was
cherished by Indigenous people in these studies [13,17,23,36]. One
Indigenous person noted that

Doctors today don’t know who we are, especially when we are using
walk-in clinics. Our traditional doctors knew us, they knew our family, and
they talked to our ancestors in ceremony. If we got sick, our parents knew
where to go, and not just to one person, there were different people in the
community.

[36] (p. e395)

3.3.3. Indigenous-Led and Run Health Services

Grey literature provided valuable information regarding Indigenous

community-led and -run health services. These services improved access
and connection to traditional healing alongside mainstream medical
services [14,24,43]. A report by the Health Council of Canada (2012)
described a range of projects designed and based in Indigenous
communities. One example was Clinique Minowe which began in 2011
and included a nurse and a social worker providing home visits. Within
the two years, the program significantly increased access of a broad
range of health, social services and programs. Staff built trust through a
visible and active presence in the community. Families who have an
established relationship with Clinique Minowe were more likely to
attend their western medical or social service appointments compared to
before the clinic was set up [24].

Studies described the higher quality of care at Indigenous-led and -run

health services [39,44,46,51]. One participant commented that

I went to another downtown clinic and the doctor that I had was giving me
constantly the same pills all the time when I was getting sick. I went over to
the Native Health and the doctor there, as soon as she saw me, said, ‘Get to
the hospital.’And now she is my doctor. She is somebody who cares and
takes the time to listen to me.

[51] (p. 826)

3.3.4. Access to Culturally Safe Care

Cultural safety was identified as a high priority that increased access,

including return visits to health services, especially in one study where a
participant said the following:

I think that I have to mention cultural safety. It’s so important. It’s

something that should be a way of being for everyone, so that we can
develop respectful relationships with no matter who it is. [...] If | know
where our people are, like the Ki-Low-Na Friendship Society, I’d rather go
there.

[39] (p. e827)

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4, Discussion

This study highlights the main barriers to health services for Indigenous
people living in urban areas and identified facilitators that could improve
Indigenous people accessing health services. Although this study focused
on the perspectives and experiences of Indigenous peoples, there was
one study that included the perspectives of health professionals when
providing services to Indigenous peoples in urban areas.

Only one study focused on Métis peoples [25] and Inuit peoples [43],
respectively. Additional studies that included Métis and Inuit peoples
also included First Nations peoples. Just under half of the studies in our
analysis included First Nations peoples only. The three distinct
Indigenous groups seemed to face similar challenges of racial
discrimination and negative interactions with health professionals. This
highlights the need for increased education among health professionals
about the three distinct Indigenous groups in Canada.

Studies described tensions between Indigenous peoples and health

professionals. The organizational practices within institutions such as
hospitals and primary health services can impact health professionals’
behaviour towards Indigenous people. In recent years Indigenous
leaders and communities have advocated for health institutions to
implement cultural safety training with their staff. Cultural safety is a
concept developed by Maori nurse Irihapeti Ramsden in the 1990s in
response to the way Maori people were being treated by health
institutions [54,55]. Her work proposes three steps towards culturally
safe practices: firstly, cultural awareness or understanding of differences;
secondly, cultural sensitivity where people accept the legitimacy of
difference; and thirdly, reflecting on the impact of the service provider’s
life experience and positioning on others. In Canada, a team in Montreal
implemented cultural safety training with 45 nurses, social workers and
doctors. The program was successful at raising awareness of Indigenous
culture and challenges Indigenous peoples face when accessing health
services, the importance of including Elders in the design and delivery of
services and to decolonize health care systems [56]. Similar to New
Zealand and Canada, Indigenous leaders in Australia have advocated for
cultural safety training. A report by McDermott and colleagues highlights
why institutions should imbed cultural safety as an ongoing program for
all health care staff to reduce racism, raise awareness and increase access
to health services for Indigenous peoples [57]. A review in Australia
found that the large disparity in health outcomes between Indigenous
and non-Indigenous people could be attributed to institutional racism
and intergenerational trauma [58,59]. From an institutional perspective,
cultural safety training may provide a step forward to improving
Indigenous peoples experiences with health professionals.

In our review, the study by Wylie and colleagues (2019) suggests that
stereotypes within the health profession regarding Indigenous peoples
set the stage for challenging interactions. This aligns with literature that
highlights “cultural differences”; nurses ‘othering’ Indigenous peoples;
and assumptions about Indigenous peoples that influenced clinical
practice [60,61]. The cultural safety approach taken by Indigenous
leaders in Canada, Australia and New Zealand could provide some useful
ways health care institutions could reduce racism and increase access to
health services for racial minorities in these developed nations. In the
United Kingdom, the National Health Service is attempting to reduce
challenges black and Asian populations face when accessing the National
Health Service (the United kingdom’s universal health system). Using the
approaches Indigenous leaders have taken may provide a starting point
to developing similar cultural safety training to achieve these reductions
in discrimination and raise awareness [62].

Access to Indigenous-led and -run health services was highly valued by

Indigenous peoples. These community-based health services are
commonly rooted in Indigenous ways of knowing and doing; Indigenous
community, identity and inclusion; and Indigenous culture and cultural
protocols—all of which can contribute to cultural safety. Two studies
highlighted the importance of these more inclusive ways of approaching
health and wellbeing and linked implementation strategies including
equity-focused organizational structures, policies and processes;
contextually tailored care; and culturally safe spaces for Indigenous
patients [44,52].

Holistic healthcare that includes a person’s emotional, mental and

physical wellbeing was identified as important to Indigenous peoples
[13,14,43]. The concept of holistic healthcare and wellbeing has been
widely acknowledged as having benefits [58]. There is some evidence
supporting the benefits of holistic wellbeing programs, particularly for
Indigenous peoples who have spent time in prison and then re-enter the
community [63]. Continued efforts to look beyond the one health issue
for which an individual is attending a health service are needed. This
indirectly results in other health conditions being identified early even
though the patient may not have attended the health care service for that
health issue. Programs in Australia that provide financial incentives to
Indigenous health service providers upon completion of general
preventative “health checks” have shown good uptake [64]. These adult
health checks aim to advance the wellbeing of Indigenous peoples in
Australia by conducting a range of general health checks to identify any
health issue early and commence a plan to address it. This could be one
way to provide holistic healthcare in Canada.

Access to traditional healing was also of high importance among

Indigenous participants [13,14,32,37,43]. A study by Hossain et al.
(2020) found that having a strong connection to your Indigenous culture
seemed to have health benefits. A review by Asamoah and colleagues
highlighted that in Canada, Australia and New Zealand, traditional
healing was used in three ways: firstly, as the main choice of treatment;
secondly, as an add-on option to western medical treatment; and thirdly,
through adopting traditional knowledge within mainstream health care
institutions [65]. This suggests that Indigenous people who move to
urban areas for a range of reasons might benefit from connecting to
Indigenous culture and with other Indigenous people living in urban
areas.

4.1. Limitations
Limitations include quantitative studies that, while providing useful
information, were not constructed to provide in-depth information
regarding barriers and facilitators [19,29,30,46,49,52].

4.2. Future Research

There is a need for longer-term funding of Indigenous-led healthcare

services and Indigenous child and youth services [41,45]. Funding is
needed both for healthcare institutions to collaborate with Indigenous
organizations and peoples to design and implement cultural training and
for Indigenous organizations and peoples to evaluate these cultural
safety programs. It is also important to provide continuing cultural
awareness and education opportunities for non-Indigenous healthcare
workers [29].

Future research needs to also advance Indigenous-led health information

infrastructure for Indigenous peoples living in urban areas. For example,
the various Our Health Counts studies have demonstrated limitations in
estimating the true number of Indigenous peoples living in urban areas
[66]. One component of this work includes linking cohorts of Indigenous
peoples living in urban areas to provincial healthcare utilization datasets
to address gaps in population-based information regarding healthcare
usage. Regular reporting of primary and tertiary healthcare use for
Indigenous peoples is essential to identify service gaps and to identify
ways to reduce emergency room visits and hospitalizations. This work
should be Indigenous-led and focus on the research questions that the
community wants answered. Smylie and colleagues (2011) noted that
“self-determination is fundamental and thus [Indigenous] peoples must
have full involvement and choice in all aspects of health care delivery,
including governance, research, planning and development,
implementation and evaluation” [4.1] (p. 82).

Future research that examines the barriers Two-Spirit peoples face when
accessing healthcare and the barriers and facilitators to healthcare for
Indigenous Elders living in urban areas is also needed [22].
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5. Conclusions

Indigenous people living in urban areas are experiencing barriers in

healthcare access. A history of discrimination is negatively influencing
interactions between non-Indigenous health professionals and
Indigenous peoples. Practical ways to implement the facilitators is a way
forward to increasing access. Indigenous-led research that meets
community needs should be encouraged. Additionally, providing and
evaluating cultural safety and awareness training to non-Indigenous
healthcare providers is needed.

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Acknowledgments

All authors are Indigenous peoples and would like to acknowledge the
important role Indigenous people have in leading, designing and
implementing health services for and with Indigenous communities.

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Supplementary Materials

The following supporting information can be downloaded

at: https://www.mdpi.com /article/10.3390/ijerph20115956/s1, Table
S1: Barriers and facilitators of accessing health care among First Nation,
Métis and Inuit peoples in urban areas of Canada.

Click here for additional data file.2™

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Funding Statement

The first author was able to travel to Toronto to collaborate with the
other authors through a University of Melbourne Dyason fellowship
(number: 604426). The first author’s salary is supported by an
Australian National Health & Medical Research Council Investigator
Grant (number: 2009727). The last author is supported by a Tier 1
Canada Research Chair in Advancing Generative Health Services for
Indigenous Populations in Canada (number: 950232638).

Author Contributions

Conceptualization, S.G. and N.M.M.; methodology, S.G. and N.M.M.;

validation, S.G. and N.M.M.; formal analysis, S.G. and N.M.M.;
investigation, S.G. and N.M.M.; data curation, S.G. and N.M.M.;
writing—original draft preparation, S.G., N.M.M. and J.S.; writing—review
and editing, S.G., N.M.M., J.S. and J.W.F; funding acquisition, S.G. and J.S.
All authors have read and agreed to the published version of the
manuscript.

Institutional Review Board Statement

This study did not receive ethical approval as itis a systematic review of
published studies.
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Informed Consent Statement

Informed consent was not obtained because this is a systematic review of

published studies.

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Data Availability Statement

No new data were created or analyzed in this study. Data sharing is not
applicable to this article.

Conflicts of Interest

The authors declare no conflict of interest.

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Footnotes

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