Enhancing health care equity with Indigenous populations: evidence-based strategies from an ethnographic study

Cultural safety was originally developed in New Zealand by Māori nurse leaders in consultation with Māori communities as a pragmatic tool for moving nursing and health care practices beyond the notion of cultural sensitivity to more actively address inequitable power relations, discrimination and racism, and the ongoing impacts of historical injustices on health and health care [84]. Cultural safety has the potential for shaping health care practices, organizations, and policies by identifying social justice goals as integral to health care, and by shifting attention away from cultural differences as the source of the ‘problem’ and onto the culture of health care as the site for transformation. Increasingly in Canada, the USA and Australia, cultural safety is featured as an essential element of health care involving Indigenous peoples [85‐87]. In New Zealand, cultural safety is legislated as a basic requirement of nursing and medical professional education [88].

The concept of trauma is used increasingly to inform care provided to people who are marginalized by social and structural inequities [57, 61, 62, 89, 90]. The term trauma can be problematic in part because it signifies both traumatic events (often presumed to have occurred only in the past) and the responses to such events (often presumed to be only psychological). Indigenous and non-Indigenous scholars [62] critique this ‘trauma trend’ because it both obscures the impact of ongoing structural violence and is often used to pathologize Indigenous peoples. We share these concerns and endorse the call for using a decolonizing lens when discussing trauma in relation to Indigenous peoples [62]. Integrating attention to violence when discussing trauma keeps the focus on violence (both historic and ongoing), and reduces the likelihood of locating the ‘problem’ only in relation to the psychological impacts for those who have experienced violence, rather than also on structural violence and the conditions that support it [62].

Our understanding of TVIC draws on previous work on trauma-informed care, but is founded on the assumption that people disadvantaged by systemic inequities experience varying forms of violence that have traumatic impacts on an ongoing basis. These impacts include a wide range of symptoms and health problems such as chronic pain, mental health issues and substance use. TVIC involves providing care that is respectful and affirming, and requires all staff within any given organization to (a) recognize the intersecting health effects of structural and individual violence, and other forms of inequity; (b) understand people’s health and social issues in context; and (c) work to reduce re-traumatization. Importantly, TVIC is not about eliciting trauma histories; rather, the goal is to create a safe environment for all based on an understanding of the traumatic effects of historical and ongoing violence and discrimination.

Expanding the concept of patient- and family-centred care, contextually tailored care includes services that are explicitly tailored to the local communities and populations served. This may include tailoring practices and/or organizational policies and clinical guidelines to address the needs of local population demographics, and social and community realities that often shift depending on local politics, epidemiological trends, and economic conditions. For example, depending on need, some populations might benefit from mental health support for families dealing with the intergenerational effects of residential schools, support for women raising young children, or home visits for isolated seniors. Individuals working in health care cannot enact these strategies without supportive organizational strategies and policies, or without an awareness of the multiple contexts that shape both Indigenous peoples’ health and the broader sociopolitical environment in which health care is provided. We emphasize the following four general approaches as a basis from which to enact strategies to operationalize the key dimensions of equity-oriented care for Indigenous populations.

Partnerships with Indigenous peoples and/or leaders, agencies, and communities are required to operationalize and tailor these key dimensions to local contexts. These partnerships can begin in small ways and develop over time [91, 92]. For example, in Canada, partnerships could be developed through consultations with local Elders, Friendship Centre⁶ staff, local First Nations, Metis and Inuit organizations, and/or by structuring Boards or other governance bodies to include Indigenous peoples or representatives.

The practices of individual health care providers are important, but insufficient to achieving health equity. Action is required (a) at the intrapersonal level among all levels of staff involved in health care organizations and systems, with an emphasis on people's values, beliefs and assumptions, and their capacity for reflexivity; (b) at the interpersonal level to optimize the interactions among providers and patients, among staff, and between different health and social service organizations; and (c) at the contextual level, including efforts by staff, managers, and leaders to affect change within health care organizations and the wider community.

While the approaches and strategies in this paper are intended to promote equity in PHC for Indigenous peoples, we are explicitly not advocating a pan-Indigenous understanding. That is, in full recognition of the diversity of Indigenous peoples, an understanding of local history is essential. Although Indigenous peoples may have some shared experiences of historical and ongoing colonization, these histories are diverse, as are the cultures, languages, and traditions of the people involved. Promoting health equity requires understanding the erosion of Indigenous peoples’ power and resources as purposeful in the service of historical and contemporary colonial conquest.

We emphasize caution to pre-empt potentially harmful uptake of the 10 strategies outlined below, given predominant assumptions, policies, and practices that currently drive health care systems. Hence, we identify how to avoid, for example, the potential for culturalism⁷ or essentialism to seep into the interpretation of these strategies. Describing what the strategy ‘is not’ is particularly important in today’s health care climate where decisions about efficiencies and performance management may have serious implications for deepening, rather than ameliorating, health inequities among Indigenous populations.

Operationalizing an organization’s or unit’s commitment to health equity begins with attention to values, and an intention to work toward shared values at the level of individual health care providers, and in relation to organizational structures, policies, and processes. As emphasized by this physician about the clinic in which he worked: “It’s a bigger place for values, shared values… We do try and understand, you know, the historical context. We try and understand where people are coming from… the things that are impacting their health”.

Throughout Canada, health care organizations serve diverse communities and populations. We have argued elsewhere that it is important for health care organizations to develop strategies for fostering health equity in ways that will result in overall improvements in care [6, 42, 44]. However, in Canada, because the most extreme health inequities persist in relation to Indigenous peoples, and because racism toward Indigenous peoples is so pervasive, it is morally imperative to articulate an explicit commitment to foster health equity in relation to Indigenous peoples in mission or vision statements and in documents outlining strategic directions or aims. As emphasized above, partnerships with Indigenous peoples are integral to this strategy, and as we discuss further, the strategies have the potential to positively influence health services more widely.

While setting the intention is a first step, supportive infrastructure is required. Individual health care providers, managers, and funders must be supportive of the structures, policies, and processes that will foster equity for Indigenous peoples through the 10 strategies. This means every staff member must examine their values, assumptions, and privileges. Structures, policies, and processes related to hiring, performance evaluation, recognition, rewards and compensation, continuing education, and staff meetings all must be viewed with respect to equity. For example, staff whose values align with the commitment to equity must be recruited, hired and retained. This means that organizations need to invest time to recruit both Indigenous and non-Indigenous staff members whose values and motivations for working with Indigenous populations align with the social justice orientation underlying the key dimensions of equity-oriented care and the 10 strategies. Given health human resource shortages, and the relatively few nurses and physicians who are of Indigenous descent in the Canadian workforce, it remains challenging to recruit staff members who identify as Indigenous. As one First Nations staff member in our study described, although the goal is to hire Indigenous staff, it is not always possible; however, it is critical that staff demonstrate a commitment to values that align with a social justice and health equity mandate:

It doesn’t always have to be Aboriginal people that run an Aboriginal agency. The values just have to be there entrenched in the policies, being able to look at service delivery, those kinds of things… it can be very difficult if somebody comes to work here who may not have the same values.

Further, staff whose commitments are not aligned cannot be retained. In both clinics, staff members were asked to leave, or decided to leave with the remaining staff expressing consensus that there was a mismatch between the values of the organization and the particular person. This can be challenging in both unionized and non-unionized environments for different reasons, including both legal reasons and community opinions. For example, employees at the clinics who were well-known in the wider community were asked to leave because of mismatches, but the reasons for dismissal could not be shared, causing tensions. In some cases  considerable human resource and legal work was required to affect dismissal.

Importantly, staff members whose values do align with those of the organization must be supported to work effectively in their roles. Organizational supports, including access to support for vicarious trauma, are needed for all staff working with patients who experience the effects of structural violence on a daily basis. It is particularly essential for organizations to implement strategies to support Indigenous health care providers and other staff who have also been subjected to structural or other forms of violence and trauma in their lives, and who are caring for patients exposed to such trauma. In this study, staff members at both clinics provided care to people experiencing extreme forms of structural violence, but without adequate support for dealing with vicarious trauma, as this program manager emphasized:

In the last fourteen years we’ve lost about twenty Aboriginal staff…. And, of course, we don’t have any type of psychology services or EAP [employee assistance program]. What we have are each other… we can’t just hire Aboriginal people and not realize how this workplace can re-trigger… and re-traumatize… I’m saying we need experienced people. We make it a policy to hire Aboriginal people however when we hire people, we can’t just hire on the basis of being Aboriginal. You can’t just throw a new grad in and say “go to work”. You can’t.

Underpinning all 10 strategies is a commitment to creating spaces and places where people feel welcome when they come for health care, as described by this patient:

You don’t have to sit in a room, like in a doctor’s office, and be real square, you know, be really uptight. Here, it's like you see people walking back and forth, conversations happening all the time. It's like you’re a piece of this place, you're not just a number. It’s like a home.

This is especially significant given the patterns of dismissal that many Indigenous peoples experience. As Wendt and Gone [93] and others [53, 94] have argued, when people experience dismissal, invisibility, or conversely, are hyper-visible, it is especially important to create settings in which people feel they are deserving, understood, recognized, and accepted. As found in Wendt and Gone's [93] study of urban-Indigenous therapeutic landscapes, patients at the clinics reiterated their view of these places as crucial urban spaces often identified as home:

Like at other places, you don’t have a personal relationship with the staff… Here, like, you chat with the staff and they offer support for other things in your life that you need. It's more personal here.

Re-visioning the use of time in providing care is an essential feature of equity-oriented care. Flexibility is required to foster trust with people who are often dismissed or mistreated within the health care system. For example, in this study, both clinics’ scheduling systems were continuously revised (balancing drop-in with scheduled visits) to be as responsive as possible to what patients perceived as their highest priorities, as this woman described:

If we’re in a bad situation, we can more likely just pop in to see [one of the staff]. You know, and get it out of your system. It’s good to know that there’re people here that will actually listen to you.

Developing and allocating time for follow-up actions for those who might otherwise ‘fall through the cracks’ is especially important for patients whose social support systems are limited. This conveys to patients that staff are concerned about their well-being beyond the boundaries of the clinic’s physical space. This woman, a patient at one of the clinics, described the significance of such follow-up:

They record if I don’t come to the doctor, so that makes me feel good because, uh [pause], because I know that if something should happen to me outside of the clinic, and if I don’t come here, they’re going to definitely acknowledge that. Because they know how important to me my health is… and so they would definitely try to track me down through my family and so on… So, that’s one main reason that I come here.

Fostering genuine partnerships with communities or community leaders, and seeking their input into programs or policies, also requires flexible use of time to ensure meaningful involvement of all stakeholders [95]. Performance indicators and quality assurance measures are typically not designed to account for these kinds of investments in time. At both clinics, administrators and staff were frequently required by the Health Authority and funders to justify their regular interdisciplinary team meetings, which were essential to engaging in team-based case management, developing consistent approaches to care, and forming community partnerships. This highlights the need for measures and indicators that can capture the value of these activities, so that these aspects of service delivery are legitimized and made visible as essential components of equity-oriented health care [96, 97].

Given the historical and ongoing abuses of power toward Indigenous peoples in Canadian society and in health care, underpinning all other strategies is the investment required at all levels of the organization to continuously attend to power differentials. Working to mitigate power differentials requires attention to language and discourses in health care that sustain  inequities. For example, given the pervasiveness of individualist ideology in health care, and how often individualism is used as a framework to blame Indigenous peoples for their circumstances, health care staff need to actively develop diverse strategies to mitigate the myriad ways that judgments about ‘personal responsibility’ are conveyed in verbal and non-verbal interactions with patients. For example, providers at both clinics described how they had learned to respond to people in their professional and social networks who expressed judgements about Indigenous peoples as being responsible for their own suffering or having some genetic predisposition to health or social problems (such as substance use). Similarly, egalitarian discourses that advocate ‘treating everyone the same’ de-historicize and de-politicize the complex factors that underpin social suffering, and divert attention away from the structural inequities that influence health and access to health care [52]. Attending to power differentials in the context of providing health care to Indigenous peoples requires recognizing that the dominant ideological doctrine of ‘treating everyone the same’ can actually reproduce inequities by blinding health care providers to their relative privilege and biases, to the unequal power relationships between patients and providers, and to the social inequities that differentially shape people’s health. As these staff members explained:

So, it’s almost like you’re counteracting that. Like, I’m counteracting those things as a professional. And to be able to be aware of the reality of somebody who lives in the core [inner city] area, who is poor… I want to make this person feel that even though I’m a [provider], I am at the same level as they are. I don’t place myself above them or anything like that. There is no status of power when I work with people. I try to keep that as minimal as possible.

We try as much as possible, I believe, to be not as judgmental. The way people, the patients, have told us, how they feel when they go to emergency or the other government bodies is that they feel kind of judged and discriminated against. I think we are all here to try to be non-judgmental and to treat everybody with respect and, you know, I think that pays off.

People who experience inequities and marginalization often experience dismissal and/or stigma when accessing health care or community services. As research continues to show, such power inequities are frequently magnified for Indigenous peoples in Canada [6, 30, 44, 53, 98]. Experiences of discrimination and dismissal, and the consequent lack of trust in health care systems, underpin people’s efforts to avoid contact with the health care sector. Health care providers and organizations need to anticipate and expect that many people, based on their own and others’ histories, will feel mistrustful of the health system’s ability to offer help, with further isolating effects. As one of the patients said of herself and others attending the clinic: “They don’t trust, and to gain their trust is to… kind of listen to them [patients], and it will come back”.

The significance of earning patients’ trust in the face of long-standing experiences of mistrust was described by another woman, who discussed her process of working with staff as she tapered herself off what she perceived to be an unhealthy, long-term dependence on benzodiazepines:

I’ve encountered so many people here [at the clinic], and nobody lies to me… But you know what: if it wasn’t for this place, I wouldn’t have been who I am today. Seriously. That is not a lie… They helped me find myself… They helped me with the trust. And a lot of people can’t trust a clinic, you know.

Attending to power differentials requires all staff to realize that how one is perceived as a member of the health care system cannot be separated from one’s position in broader socio-historical relations. Even if a staff member does not intend to act in a ‘power over’ or discriminatory manner, his or her social location as a member of the health care system can be seen by patients to imply that power inequities will be maintained and shape their access to services [52].

Countering power differentials in organizations involves adapting clinic procedures in ways that convey respect and preserve people's dignity. For example, both clinics explicitly decided not to staff waiting rooms with security guards. Rather, patients' expressions of anger or frustration were met with respectful responses, especially by medical office assistants. Our field notes reflected the relatively rare occurrences of aggressive or violent behaviour in the clinics in comparison to our field work observations in Emergency Units, where security guards were present.

Experiences of colonization have important similarities for many Indigenous peoples, and these similarities are the basis for many of the proposed strategies; however, the diverse and particular histories, cultures, and knowledge systems of the people served must be used as the foundation for tailoring care. This requires all staff (and board members if applicable) to learn about the specific pre-colonial and colonial histories of local communities. This can be supported by managers and leaders through staff orientation and continuing education, and by integrating Indigenous knowledges, languages and concepts into care. These efforts can be promoted through partnerships with knowledge keepers, Elders, and other Indigenous leaders. This approach is in direct opposition to the more common efforts by health care organizations to address the needs of Indigenous peoples through ‘cultural sensitivity training’. Although attention to culture is important, this is often done in isolation from other fundamental concepts and frameworks, such as social determinants of health, advocacy, and social justice [99, 100]. Cultural sensitivity training can also reinforce potentially stigmatizing notions of Indigenous identity, inadvertently resulting in ‘othering’ practices [99, 100]. Health care providers and organizations working with Indigenous populations, therefore, need to guard against the culturalist tendencies pervasive in health care, which reinforce popularized, stereotyped notions of culture as the primary analytical lens for understanding people’s health issues. For example, both clinics have worked hard to integrate culture into their health services, and regularly integrate smudging⁸ and teachings by Elders, as described by this staff member:

We have Elders here… and we have the smudge ceremony during our meetings… At one point someone [would] come in twice a week to do smudges with the clients and they would do the drum and sit out there [in the waiting room] and… would talk to people… There was much more of a calmer atmosphere when he was here… It really changed the dynamics of the waiting room… It’s like an innovative idea but it’s actually quite, in some ways I guess, common sense, but you don’t often think of putting someone who’s going to bring some healing words and energy into the waiting room.

These cultural practices are integral to both clinics, but alone are insufficient for equitable care. Rather, tailoring requires meaningful partnerships, integration of understandings of local history, and integration of Indigenous knowledges, as discussed by this physician:

I like to think that I use some of the bigger principles as in… taking the narrative and the stories from people and listening… They’re principles that kind of help me in keeping a more open view of the situation so I don’t get stuck on a medical model… It’s beyond that. It's the spiritual aspect and the family aspect and that historical aspect, because I mean history is every day in the clinic. There’s history that’s hugely significant in the work I’m doing there.

Organizations that are planning to tailor programs to local Indigenous contexts need to be flexible in how funds are allocated [101]. Indigenous knowledge can be integrated in a variety of ways through partnerships in the local community, and the process can have powerful impacts within an organization. These approaches should be locally-determined given that Indigenous knowledge is grounded in local contexts, communities, histories and protocols [102, 103].

Given the high proportion of Indigenous peoples in Canada who experience racism and discrimination, counteracting people's experiences of discrimination at an individual level requires that health care providers convey an understanding of history and context. As this patient described, these dynamics routinely shape many Indigenous peoples’ health care experiences:

Toward Native people, you know, if you go to a different organization, you know, you get all the looks, and you know, like, “what are you doing here?”, that kind of service. Just to get some kind of service, you have to really act good.

Conveying knowledge, genuine interest, and willingness to listen to people in an unhurried manner can create space for people to feel more fully understood, as described by this patient:

Like when you go to a regular doctor, they don’t sit and ask you how you’ve been, you know what I mean? So, they know your whole situation. I go to [another doctor] and he’ll just feed me pills.

Repeatedly, staff and patients identified that the impact of such efforts was often powerful. This physician described how supported his patient reported feeling after inquiring about the impact that residential schooling had on the patient's health:

I had discussions about the residential school, and I didn’t remember even ever talking about [it] and hadn’t documented much in the chart. Yet he thought that, or he felt that he’d been incredibly supported in his experiences through residential school and the traumas that he had there. So somehow, whatever he’d brought up, and whatever I did, he felt like he was validated. But I didn’t even think it was significant. So he was getting benefit that I didn’t even acknowledge or realize.

Countering racism and discrimination, which is linked to addressing unequal power relations, demands that health care providers have an acute awareness of how racism intersects with gendered inequities, classism, and other forms of discrimination, as this staff member explained:

Listening to somebody talk about how they went somewhere [within the health care system] and how they waited and how the doctors treated them differently. And then, it could be as simple as saying, “well I’m sorry that happened to you,” being able to validate how they feel rather than saying, “oh well, that’s the system and you have to work through it.” And it’s just really small little things. And it is people coming back and saying, “well, that really helped me.” And you may not even remember saying that or you may not even remember doing those kinds of things.

Organizations that develop strategies to counter racism and discrimination need to push back against dominant, neoliberal discourses that reinforce misconceptions about people having  equal access to health care and resources [52, 53, 98, 104]. The significance of ensuring that people feel welcome in health care spaces cannot be overemphasized. Repeatedly, patients explained the significance:

You see the people that walk in here, I mean, they’re not always nice looking characters. But you’re always welcome. They always treat you like you’re just as good as the next person.

Actively counteracting discrimination in organizations requires that claims of discrimination be considered seriously, regardless of intention. Often patients who express concern about being disrespected are assumed to be overly sensitive, reactive, or attempting to gain unfair advantage by making such claims, and research shows that people who experience discrimination on a daily basis may not be able to distinguish intentional from unintentional unfairness [44, 45, 47]. At the organizational level, it is therefore imperative to provide mandatory, explicit, anti-racist training for staff at all levels, including administrators, managers, receptionists, and direct service providers. Recurring training is required to revisit strategies for countering the persistent potential for Indigenous peoples to be treated in inequitable ways within the health care sector.

As discussed in the first strategy, addressing the root causes of health, social, and health care inequities requires partnerships with Indigenous peoples and community members. Engagement can take many forms, depending on organizational context, governance structures, and patient populations. Patients involved in this study, for example, reiterated the significance of being asked for input or volunteering their time to assist with seemingly mundane tasks related to upkeep of the clinic’s premises. As this patient explained:

When I sit out here [in the clinic’s waiting room], I see different skills of people… So I’m thinking, when I go back to my reserve, I want to give back. Everybody has that. I want to give back. Look at how much I’ve taken from my family. Everyone down here has that feeling. Even when they have nothing they want to give back.

In some settings, the formation of a Community Advisory Committee or an Elders Committee may be instrumental in ensuring that integration of Indigenous knowledge aligns with culturally safe intentions, and to avoid the appropriation of knowledge. In other settings, opportunities for employing patients as peer support workers or volunteers may be feasible, and can have significant impacts on the quality of life for those involved, as this patient described:

I want to help people, I want to do stuff in this world for people and this is one of… why I’m doing this [as a] positive prevention peer support worker.

Finding opportunities for community members to be meaningfully involved in some aspect of the clinic or programming also provides a means for acknowledging and drawing on the strengths, capacity, and agency of community partners.

Health care providers need to recognize that some Indigenous people may be survivors of multiple forms of violence with traumatic effects, while still experiencing current and ongoing interpersonal violence (including racial violence and intimate partner violence), and ongoing structural violence (such as systemic and organizational racism, absolute poverty, etc.) [11, 105‐107]. Tailoring care, therefore, means offering comprehensive care that simultaneously addresses the multiple consequences of interrelated forms of violence.

TVIC is one way of respectfully tailoring care to the impact of history, specifically histories of violence, on people’s lives. At the individual level, this includes acknowledging the impact of social injustices and structural violence on people's sense of agency, that is, the constraints and possibilities for health and well-being in any individual's life. Thus, the strategy of re-visioning time intersects with this strategy in that the ‘pace’ of healing will be influenced by each individual’s history. At the organizational and provider levels, tailoring to address interrelated forms of violence involves developing strategies to acknowledge that dispossession from Indigenous lands, territories, cultures and languages is a fundamental determinant of health and form of structural violence that is often at the root of people's mental health and substance use issues [21, 108].

Research shows that organizations informed by understandings of TVIC recognize that issues of substance use, chronic pain, and histories of trauma are integrally interconnected for people experiencing structural violence [11, 25, 37, 58, 89, 105, 109‐111]. Such organizations also recognize that people who present with these intertwining issues frequently mistrust health care services. Therefore, for example, services must simultaneously address substance use, and the health consequences of violence and trauma, including post-traumatic stress disorder, chronic pain, and sleep problems according to the patients' priorities. As in most PHC settings, pain was one of the most common presenting concerns among patients in this study, as this provider explained:

Managing pain in this environment is exceedingly challenging because people do have emotional pain and they do have physical pain and there is a gray area and they overlap.

Addressing the consequences of interrelated forms of violence includes being responsive to the multi-faceted nature of pain, and developing strategies for addressing pain from a trauma- and violence-informed perspective. Similarly, substance use issues must be addressed by taking chronic pain and trauma histories into account. This requires adapting conventional guidelines for treating chronic pain, mental health issuses, and substance use in ways that recognize the effects of trauma and violence on health, and that extend beyond the often tense negotiations for prescription drugs.

Elsewhere we have described the experiences of Indigenous peoples who express concerns about being viewed as ‘drug seeking’ when they were seeking help for what they perceived to be legitimate pain issues [44, 53, 112]. Similarly, in this study patients argued for:

… a lot more doctors with compassion for Aboriginal people, instead of just looking at them like they’re drug addicts or alcoholics, and not helping with the real pain, which all of us do have real pain.

Without a broader understanding of the intertwining nature of trauma, pain, and substance use, negative judgments conveyed to patients, particularly those who experience problematic substance use, can have harmful consequences, as this patient described:

The whole thing of addiction is having people listen, and not judging. And most doctors I know, except for the select few that are here, they are all judging, very judgmental of addicts [sic]. Especially at the hospital. I would rather go through severe pain than go to the hospital.

At an organizational level, training about providing care for patients who have experienced violence, and the intersecting health and social impacts, has been shown to increase clinicians’ confidence, knowledge, and efficacy [113‐115]. Such training is essential to integrate understandings of the long-term impact of trauma into practices and policies, and to avoid inadvertently creating an invalidating environment [61, 90, 116]. This provider explained the growing integration of TVIC at their PHC clinic:

… critically thinking how we provide care and always going back to those core things of where that person has come from. So now when we talk [at staff meetings], we don’t just talk about [patients] needing this or that, we go to a much deeper level. It’s very interesting to see the switch that’s happened with staff because they’re now talking about, you know, that’s really re-traumatizing or do you realize the level of trauma this person comes from? Or do you realize how difficult it is for that person to walk through that door? Or do you realize how difficult it was for that person to actually bring up their concern to you?… And so we, we now are getting into conversations around our table about power imbalances and about how our interactions can really affect this. So I’ve seen our place come from being just a place of, you know, a safe place to come to, but it’s now come to a place where I can see staff grasping these ideas and talking to each other.

Given the high rates of state apprehensions of Indigenous children [10] and growing evidence of the benefits of supporting women to care for their own children [117, 118], it is critical for PHC organizations and individual providers to develop strategies for building trusting relationships with women and families. Strategies include working with social workers and other team members to support parents’ access to visitations with children removed from their care. At an organizational level, these kinds of efforts could be framed as part of a larger strategy to support both men and women. PHC providers can contribute to interrupting the intergenerational effects of residential school by recognizing the continuities between residential school and contemporary child protection practices, and supporting Indigenous peoples to parent their own children. For example, in one of the clinics, support for pregnant and post-partum women who were under surveillance by state authorities involved working in partnership with child protection workers, social workers, and other social services staff to develop shared-case management plans.

Increasing access to the social determinants of health is important for all people who experience health inequities. Due to welfare state colonialism, economic constraints on reserves, and discriminatory policies, this strategy requires intensive effort in relation to Indigenous peoples.

At a provider level, health issues must be continually understood and addressed within the context of the social determinants and how they are specifically constrained by myriad colonial policies for Indigenous peoples. For example, access to stable housing is constrained by the consequences of the reserve system in Canada, by shifting policies that determine who has ‘status’ and by discrimination in housing, employment, and education. As this physician explained, the social determinants of inequities for Indigenous peoples must continuously inform clinical care:

It does shape diagnostic and therapeutic decisions… If their housing is unstable… those kinds of things are all very pertinent to making therapeutic plans that are going to be more likely to succeed… I’m genuinely interested in who they [patients] are as individuals. I think that can be only expressed by having those types of conversations and asking the follow up questions: “so did you get in touch with your daughter, how’d that work out? How’s the housing situation coming along, any luck, any leads?"

At a minimum, people’s social circumstances and the restrictions that these circumstances place on health must be understood and acknowledged. Further, practical steps can be taken, as this provider explained:

… there’s a water cooler [in the waiting room] and sometimes there’s leftover food… and we’ve had toothbrushes and toothpaste, and samples of stuff because we recognize… Well, nobody has even two dollars to buy that stuff… And so I think there’s that level of recognition of the degree of need, and the poverty that [some are] living in. And it’s understood and not judged.

At an organizational level, structures and time allocation must support providers to address people’s socio-economic needs, either through partnership arrangements with other agencies or by creating a network of multi-disciplinary team members to whom patients can be referred. This requires reconsidering priorities given the local organizational context, as this administrator explained:

Well when you sit back and think about it, there’s a need for so many things that are non-medical that ultimately come to bear upon people’s medical conditions. Like housing, and like even education… and those kinds of things. And you know, we’re not able to pay enough attention to those particular areas.

While PHC organizations can acknowledge people’s circumstances, create networks, and facilitate access to the social determinants of health, ultimately broader social change is required to achieve health equity. Health care providers and health care organizations must participate in broader democratic processes and social advocacy, bringing their unique vantage points to bear on public decision-making.