The experiences of Indigenous people in health care encounters in Western settings and contexts: A systematic review of qualitative evidence

Review question/objective The objective of this review is to analyse and synthesise the best available evidence on the experiences of Indigenous people who engage in health care encounters in Western settings and contexts. The review question is: What are the experiences of Indigenous people engaged in health care encounters in Western settings and contexts? Background According to the United Nations, “Indigenous communities, peoples and nations are those which, having a historical continuity with pre-invasion and pre-colonial societies that developed on their territories, consider themselves distinct from other sectors of the societies now prevailing on those territories, or parts of them”.(1, p.2) Unfortunately, Indigenous populations around the world today experience grave health inequities. In Canada, for example, First Nations people experience the most socioeconomic disadvantage and hence the poorest health status in the country.2 They have higher rates of suicide, lower levels of income and employment, higher rates of school dropout, shorter life expectancy, and higher rates of infectious and non-infectious diseases.2 Likewise, Indigenous Australians experience three times the burden of disease than their non-Indigenous national counterparts.3 In the United States of America (USA), health disparities between Indigenous and non-Indigenous populations are significant and long standing.4 For example, USA national data reveals earlier first use of drugs and alcohol, greater frequency and intensity of use, and much higher drug and alcohol related mortalities among Indigenous populations than any other racial group.4 There is also disparity between Indigenous and non-Indigenous populations, in terms of how these health and socioeconomic problems are understood and addressed. In general, Indigenous beliefs about the causes of illness vary considerably from Western biomedical explanations.3 Western, as opposed to Eastern, health care services are the focus of this review because of the unique colonial and post-colonial tensions that exist between Western and Indigenous cultures. Unfortunately, Western approaches to health and health care often ignore and render invisible Indigenous health beliefs and practices.2 Reliance on Western concepts of health and illness, without incorporating Indigenous explanatory models of the same, results in largely ineffective care that alienates rather than supports Indigenous people.2,5 Researchers have recently revealed that Indigenous people rarely receive culturally safe and relevant health care that effectively addresses their unique needs.5 Culturally safe care goes beyond cultural awareness and sensitivity toward actively promoting self-empowerment of Indigenous people to influence their care and support positive health outcomes.6 The concept of cultural safety emerged in postcolonial New Zealand in the late 1980s in response to the needs of the Maori people.7 Like Indigenous populations in other parts of the world, it was observed that the Maori people often did not access health care services until advanced stages of disease, were “non-compliant”, and often prematurely dropped out of treatment programs.7 In response to these trends, cultural safety was developed as a lens from which to critique and better understand health care encounters between ethno-cultural minority groups, such as the Maori of New Zealand, and service providers working in Western health care systems and contexts. Western providers and health care systems guided by cultural safety pay special attention to power imbalances and seek to redress the same.7 This review is rooted in the concept of cultural safety. Our aim is to better understand issues and challenges experienced by Indigenous people in their health care encounters in Western settings and contexts. Health care encounters occurring in a wide variety of settings, such as acute, chronic, palliative, and perinatal care, can serve to either invalidate or affirm Indigenous peoples' health-related experiences. For example, qualitative researchers have found that Indigenous clients can feel invalidated during health care encounters when health care providers dismiss their concerns, apply negative stereotypes, make them feel marginalised and lessened as persons, and/or disregard their unique socioeconomic and personal circumstances.8,9 Conversely, these researchers have also revealed that Indigenous clients can feel affirmed during health care encounters when health care providers treat them as equals, encourage them to actively participate in decisions related to their care, convey a genuine caring attitude, affirm their unique personal circumstances and cultural identity, and develop long-term trusting relationships with them.8,9 Understanding Indigenous people's health care encounters in Western settings and context -both positive and negative-is a critical step toward addressing issues and ensuring more equitable, accessible, and culturally safe health care for Indigenous people globally. The results of this review can be used to support ongoing efforts on the part of countries around the world to address health disparities experienced by Indigenous populations through improved education of health care providers and enhanced collaboration and consultation with Indigenous communities in the organisation and operation of their health care services.6 Of course, addressing health inequities among Indigenous people requires multiple approaches.10 Such approaches must go beyond illness care and include the social determinants of health. The way health services are designed and delivered is a powerful determinant of health.11 Appropriately configured health services, including individual, family, and community health care encounters, can be a resource to improve people's lives, protect them from the vulnerability of disease, enhance their sense of security, and build a common purpose.11 However, poorly configured health services and health care encounters can do just the opposite—they can “actively perpetuate injustice and social stratification”.(11, p.32) Unfortunately, the latter is more often than not the experience of Indigenous peoples around the world. Too often health care providers who engage in health care encounters with Indigenous people fail to take into account Indigenous cultural values, life ways, and social determinants of health. Instead, generalised care plans are applied that do not facilitate individualised and culturally safe approaches.5 Individual patients' explanatory models of health and illness, as well as their social, political and economic location within the wider social context must be taken into account. Unfortunately, such an individually tailored yet broadminded approach to health care does not occur often enough. To achieve culturally safe and relevant care, it is imperative that we gain a consolidated qualitative understanding of how health care encounters in Western settings and context are experienced by Indigenous people worldwide. Doing so will illuminate the gaps in preparedness among health care providers and identify areas of needed change in policy and in Western health care delivery systems, in general. The Joanna Briggs Institute Library of Systematic Reviews, Medline, CINAHL, and ProQuest Nursing and Allied Health databases were searched and no systematic reviews of this topic were found. From this it was determined that a systematic review of the experiences of Indigenous people in health care encounters in Western settings and contexts is needed. Inclusion Criteria Types of Participants Studies including two groups of participants, regardless of age or gender, will be considered for this systematic review. The first group is persons of Indigenous descent from the following countries and continents appearing most frequently in the literature: North America, South America, New Zealand, Australia, and Scandinavian countries. These countries include peoples such as First Nations, Native Americans, Metis, Inuit, North American Indians, South American Indians, Inca, Maori, Aboriginal and Torres Strait Islander peoples of Australia, and Sápmi. This list is not exhaustive, and any Indigenous population identified in a study will be included. Indigenous populations who immigrate to new countries will be excluded, given that immigrant status can confound Indigenous status. The second group of participants to be considered for inclusion is health care providers who work in Western settings and context, including, but not limited to, nurses, physicians, nutritionists, midwives, social workers, physiotherapists, occupational therapists, speech and language therapists, and respirologists. Phenomena of Interest The phenomenon of interest is the experience of Indigenous people in health care encounters in Western health care settings and context. Health care encounters refer to any interactions between an Indigenous person and a health care provider within the scope of Western health care services. All reasons for health encounters will be considered. Context The context will be Indigenous persons seeking health care services in Western settings and context. These services may be located within urban, rural, or remote health care settings where Western health care services are delivered. Types of Studies Qualitative studies using an interpretive, qualitative descriptive or qualitative observational approach, phenomenology, ethnography, grounded theory, hermeneutics, participatory action research, or critical theory will be considered for inclusion. In the absence of research studies with qualitative methodologies, text and opinion papers and reports will be considered. Search Strategy The search will include qualitative articles/studies in all languages (where translations resources are available) from 1985 to 2012. The start date 1985 was selected given that this was deemed as the relevant time frame for the emergence of this topic in the literature. The search strategy aims to be comprehensive by locating both published and unpublished studies. A three-step strategy will be utilised in this review. An initial limited search of MEDLINE, CINAHL, Embase, and Sociological Abstracts will be undertaken followed by analysis of the text words contained in the title and abstract and the index terms used to describe the article. A second search using all identified keywords and index/thesaurus terms will then be undertaken across all included databases. Thirdly, the reference lists of identified reports and articles will be hand searched for additional studies. The databases to be searched include: Academic Search Premier BioMed Central Canadian Electronic Library Canadian Periodicals CINAHL Cochrane Library CultureVision Current Contents EbscoHost HealthSource: Nursing/Academic Edition eHRAF World Cultures Elsevier ScienceDirect Embase Health Source Health Source Plus Health Star International Index Medicus (WHO) ISI Web of Science MEDLINE via PubMed ProQuest Nursing and Allied Health Psychiatry Online Psychology and Behavioral Sciences Collection PsycINFO Research Library Scirus SCOPUS Social Services Abstracts SocIndex Sociological Abstracts TRIP WorldCat and other library catalogues (for books) Other regional databases The search for unpublished studies or grey literature will include: Aboriginal Nurses Association of Canada Agency of Healthcare Research and Quality Australian Indigenous Doctors' Association Australian Indigenous Health InfoNet British Columbia EOHRN Grey Literature Wiki/Healthcare Canadian Centre for Substance Abuse (CCSA) Canadian Institute of Health Research Centre for Traditional Medicine Conference proceedings DIVA [dissertations and other publications in full text from Nordic universities] Google Scholar Grey Literature Bulletin (North West Health Library and Information Services UK) Health Canada Index to Theses Indian and Northern Affairs Canada Indigenous Health Research Development Program Indigenous Physicians Association of Canada Institute for Health and Social Care Research (IHSCR) Institute of Aboriginal Peoples' Health National Library of Medicine Networked Digital Library of Theses and Dissertations (NDLT) New York Academy of Medicine's Grey Literature Report NLM Gateway Ontario Public Health Libraries Association (OPHLA) ProQuest Dissertations and Theses PsycExtra Public Health Agency of Canada Science.gov Stats Can System for Information on Grey Literature in Europe (SIGLE) Theses Canada Portal Trove Virginia Henderson International Nursing Library Initial keywords to be used will include, but not be limited to: Terms relating to Indigenous populations from North America, South America, New Zealand, Australia, and Scandinavian countries, such as First Nations, Native Americans, Aboriginal and Torres Strait Islander peoples of Australia, Metis, Inuit, Sápmi, North American Indians, South American Indians, Inca, and Maori.In the database PubMed, some of these population groups are represented by Medical Subject Heading (MeSH) terms such as “Oceanic Ancestry Group,” “American Native Continental Ancestry Group,” and others. The controlled vocabulary terms and any other synonyms for persons of Indigenous descent will be used in the searches. Terms related to health care setting, such as Indigenous health, health services, health care services, mental health, primary health care, primary care, emergency treatment, emergency medical services, emergency medicine, emergency department, emergency room, urgent care center/centre, rehabilitation, public health, community health, mobile outreach, resident care, long term care, nursing home, home care, home nursing, extramural, community health centre, homeless nursing, street nursing, clinic, surgery, and school nursing. Terms related to the health care encounter, such as clinical encounter, client encounter, patient encounter(s), therapeutic interaction, therapeutic relationship, therapeutic partnership, non-therapeutic interaction, client meeting, family meeting, non-judgemental (and non-judgmental) care, clinical relationship, clinical care, clinical relationship, professional-patient relationships, patient engagement, client engagement, nurse-client communication, nurse-patient communication, doctor-client communication, doctor-patient communication, physician-patient communication, physician-client communication, nurse-client relationship, helping relationships, caring relationships, relational practice, critical caring approach, welcomeness, unwelcomeness, conversation, attitude of health personnel, respect, trust, cultural competency, cultural safety, health care disparity, inequality, inequity, marginalize (and marginalise), intersectionality, multiple jeopardy, seeking care, seeking help, access to healthcare. Terms related to health care providers, such as health care professional, health care provider, health care personnel, Western health care providers, non-Indigenous health care providers, non-Aboriginal health care providers, nurses, physicians, nutritionists, midwives, and social workers. Terms related to qualitative research, such as qualitative design, ethnography, auto-ethnography, phenomenology, hermeneutics, interpretive phenomenology, descriptive phenomenology, grounded theory, lived experience, narrative inquiry, participatory research, action research, participatory action research, interpretive description, case study, field study, focus group, interview, observation, photovoice, document analysis, narrative analysis, and thematic analysis. The search strategy will be adapted to the features and vocabulary of each database searched. Assessment of Methodological Quality Qualitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using a standardised critical appraisal instrument from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. In the absence of research studies, textual papers selected for retrieval will be assessed by two independent reviewers for authenticity prior to inclusion in the review using a standardised critical appraisal instrument from the Joanna Briggs Institute Narrative, Opinion and Text Assessment and Review Instrument (JBI-NOTARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Data Collection Qualitative data will be extracted from papers included in the review using the standardised data extraction tool from JBI-QARI (Appendix II). In the absence of research studies, textual data will be extracted from papers included in the review using the standardised data extraction tool from JBI-NOTARI (Appendix II). Data Synthesis Qualitative research findings will, where possible, be pooled using JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings rated according to their quality and categorising these findings on the basis of similarity in meaning. These categories will then be subjected to a meta-synthesis in order to produce a single comprehensive set of synthesised findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the findings will be presented in narrative form. In the absence of research studies, textual papers will, where possible, be pooled using JBI-NOTARI. This will involve the aggregation or synthesis of conclusions to generate a set of statements that represent that aggregation, through assembling and categorising these conclusions on the basis of similarity in meaning. These categories will then be subjected to a meta-synthesis in order to produce a single comprehensive set of synthesised findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the conclusions will be presented in narrative form. Conflicts of Interest No conflict of interest. Acknowledgements We wish to gratefully acknowledge the Queens Joanna Briggs Collaboration for Patient Safety for their ongoing support and feedback.

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