Supporting Medication Appropriateness Among Indigenous Peoples in Canada: Reflections on the Development and Implementation of a Network Action Plan

Indigenous Peoples in Canada continue to experience significant inequities in social determinants of health and health outcomes due to colonial practices. Although they are the youngest population in Canada, Indigenous Peoples have a higher prevalence of many chronic conditions and are more likely to experience polypharmacy. Data from the Canadian Institutes of Health Research (2016) show that 82.2% of older adults who made prescription drug claims to the First Nations and Inuit Health Branch were taking five or more medications, compared to 65.7% across all Canadian jurisdictions [1, 2]. In Canada, Indigenous Peoples include First Nations, Métis and Inuit (FNMI), each group comprising many distinct Nations and communities with unique identities, cultures and experiences. Canada's colonial history—including the atrocities of forced assimilation and cultural genocide—has had a profound impact on FNMI [3]. Both internationally and nationally, with the United Nations Declaration on the Rights of Indigenous Peoples [4] and the Truth and Reconciliation Commission of Canada's Calls to Action [5], there have been calls for acknowledgement of the ongoing harms of this colonial history and for action to protect Indigenous rights, decrease inequities and improve health. There has been limited research on the health of Indigenous Peoples as it relates to safe and appropriate medication use. For example, no Canadian studies have investigated polypharmacy and deprescribing from Indigenous perspectives. A single study, Coyote's Food Medicines, using community-based participatory research and the Indigenous method of storytelling, was designed to initiate discussions about polypharmacy and encourage Indigenous patients to discuss their medications with healthcare professionals [6]. The Canadian Medication Appropriateness and Deprescribing Network (CADeN) is a national organization composed of people with lived experience, community organization leaders, clinicians, educators, policymakers and researchers. The network promotes the safe and appropriate use of medications for all people in Canada through research, knowledge mobilization and community engagement. Recognizing the importance of addressing health inequities observed in Indigenous communities and acknowledging our shortcomings in Indigenous partnerships, in 2023, CADeN committed to strengthening relationships with Indigenous Peoples and supporting Indigenous-led solutions that respond to community priorities concerning medication appropriateness. Herein, we reflect on key insights and learnings from the early and foundational steps taken by our national health research network to work with Indigenous Peoples in a meaningful way. CADeN aspired to engage with Indigenous Peoples across Canada from its inception; however, it identified a lack of funding and established connections with Indigenous communities as primary barriers. At the onset of stable, multi-year funding, we set a goal to adapt our public medication safety toolkit—comprising plain language resources on medication safety topics—to better meet the needs of Indigenous Peoples. Seeking guidance from clinicians and academics within the Indigenous health field, the network recognized that creating safe and relevant tools for Indigenous Peoples in Canada involves much more than simply translating research, tools and education already developed for Western audiences and presenting them to Indigenous communities for review, comment and approval. It is harmful to apply a Western approach to research that excludes Indigenous Peoples from deciding what is studied and how it is studied. Indigenous Peoples are rightfully wary of participating due to decades of unethical, extractive research that has caused harm and dismissed the validity of Indigenous knowledge systems and ways of knowing [7, 8]. In Canada, engagement with Indigenous Peoples differs from other multicultural approaches in several key ways: it requires truth-telling and reconciliation to address colonial and racist harms, respect for sovereignty and self-determination, account for the profound differences between Indigenous and Western worldviews and recognition of the diversity among Indigenous cultures. Principles from community-engaged and cross-cultural health research offer some guidance in this area [9]. Our work was also guided by examples from both international and Canadian contexts, which uphold foundational principles of engaging in research with Indigenous Peoples, including relationality, reciprocity, respect and prioritization of Indigenous research methodologies [10, 11]. To achieve the network's goal of creating medication resources appropriate for Indigenous Peoples, we recognized that building relationships with Indigenous communities needed to come first. We initiated this process by asking current network members about their experiences engaging in Indigenous advocacy and community-engaged research. Because trust takes time to develop, partnering with those who already had established connections provided an important introduction and a baseline of trust. These relationships opened the door to our first meetings, where we began building trust in CADeN through consistent actions and commitments. Working with Indigenous individuals and communities cannot be rushed or transactional, and requires humility in understanding that entrenched Western, academic ideas of relationships, research and time frames do not fit within Indigenous worldviews. Additionally, relationality, or understanding the connection between all things (e.g., land, nature, animals, the spiritual), is foundational in Indigenous ways of knowing [12]. Relationships are not formed with a single meeting, but through ongoing interactions, discussions and sharing of meals, during which time is taken to learn about what is vital from Indigenous perspectives. Relationships need to be created with equity in mind, recognizing that a Western model of hierarchy between academic researchers and Indigenous researchers or collaborators does not lead to trust. These relationships require ongoing nourishment. Through this process, CADeN reflected on the requirements for Indigenous relationship building, including the necessary time and resource commitments, and revised our initial goals. Rather than modifying an existing toolkit, we formed an Indigenization Working Group (IWG). We began by inviting two CADeN members with established connections to FNMI communities and asked them to recommend additional members. The IWG includes Indigenous and non-Indigenous researchers, clinicians, educators, advocates and community leaders. To ensure Indigenous leadership, the chair role is reserved for an Indigenous person, and as the group grows, we are committed to having 75% Indigenous membership that reflects the diverse cultures, identities and experiences of Indigenous Peoples across Canada. The committee's initial mandate was to create and then help effectuate a five-year action plan outlining a series of recommendations to decolonize and indigenize the network's activities. Recognizing the need to acknowledge and reciprocate members' time and contributions, we secured funding to provide IWG members with an honorarium. While sustaining the committee requires ongoing resources, it has fostered meaningful learning and the beginnings of trusting relationships and collaborative projects with Indigenous Peoples that extend beyond our initial goals. We learned that humility and flexibility are essential to align activities with Indigenous community priorities and expectations. Reflecting on the beginning of this work, it was not easy to know where or how to begin. However, it was critical to our organization to start the work using humility to acknowledge our organization's stage in the learning journey. Through this process, we used reflection with humility and a willingness to learn. Working with Indigenous communities and organizations must include the intent to undertake initiatives that benefit the community. To ensure these underlying principles are incorporated into our work, the four Rs of respect, relevance, reciprocity and responsibility [13] were built into the action plan. Our action plan defines what each of those principles means to our network and how we can achieve them. We keep these underlying principles central to ground us in our intention of conducting this meaningful work. Regarding relevance (one of the four ‘Rs’), we have been intentional about discussing whether our focus is Nation-specific, community-specific or ‘pan-Indigenous’ (meaning a result or decision that applies to all Indigenous communities). This is important as oftentimes a pan-Indigenous approach is taken following broad consultation. However, needs and priorities vary greatly between and within FNMI. Asking a community to engage and share their knowledge requires careful, preliminary and intentional consideration of the four ‘Rs’, leading to reflection on how we may best support the needs and achieve community goals. Historically, CADeN has considered community and patient members as equal partners, contributing valued perspectives to the network's research and knowledge mobilization. In engaging with Indigenous communities, we have reflected on the great care required to approach these groups not as data sources but as co-creators, and on the importance of data sovereignty from Indigenous perspectives. Data sovereignty protects Indigenous communities and knowledges from extractive research practices. FNMI have established protocols to safeguard their knowledge and data. Our work to date has primarily involved First Nations, so we have followed the principles of Ownership, Control, Access and Possession (OCAP) [14]. As we build relationships with Inuit and Métis communities, we are committed to implementing each group's specific data sovereignty protocols. Upholding data sovereignty requires attention early in the relationship, particularly when applying for grants or funding, underscoring the importance of Indigenous-led research and the involvement of communities from the outset. Tensions can arise between OCAP principles and Western research expectations, which often rely on strict timelines and academic deliverables. For example, findings cannot be disseminated without community approval, as some knowledge is not to be shared. CADeN has navigated these tensions by seeking participant input and approval for reports developed on key themes from network-led sharing circles, ensuring no data is shared without consent and providing participants with copies of the data for use in their work and communities. We also recognize challenges posed by research, government and funding timelines and deliverable expectations, and recognize the change that must occur for better alignment with Indigenous ways of knowing, and to allow for thoughtful local interpretation and dissemination through community sharing of the findings. For decades, research with Indigenous Peoples has been deficit-focused, emphasizing weaknesses and perpetuating myths of inadequacy. In contrast, strengths-based research builds on what works and what is positive within a community [15]. Integrating Indigenous strengths and ways of knowing, being and doing is central to our network's research and activities. Forming the IWG to guide our work to address potentially inappropriate use of medicines—rather than adapting existing tools and presenting them to Indigenous Peoples—was a first step in adopting a strengths-based approach. This method recognizes Indigenous Peoples as experts in their own health, best placed to design interventions that tackle community-defined priorities while building on existing strengths, knowledge, experiences and infrastructure. Indigenous Peoples are often portrayed in terms of deficits, creating a narrative of those who must be ‘saved’. Yet Indigenous Peoples have a wealth of knowledges and are integral in developing solutions—especially within their communities. When Western organizations want to weave Indigenous worldviews into research, tools and education, Indigenous perspectives—from both internal and external members—must be integrated. CADeN applies a strengths-based approach to create a voice for Indigenous Peoples by fostering an environment focused on community-led priorities, allowing members to voice their own needs and identify solutions. While CADeN previously applied this approach with older adults, it now guides all discussions and activities related to Indigenous communities, countering the historical deficit narrative. Throughout the creation and initial work of the CADeN IWG, there have been multiple opportunities to reflect upon the process of challenging and disrupting a solely Western research perspective and of integrating Indigenous ways of knowing, being, doing and relating across our network's approach to polypharmacy and deprescribing research. In this piece, we have attempted to share what we have learned about carrying out meaningful work in this area through describing our approach, grounded in humility, intentionality and strengths-based research. Although this is a Canadian perspective, integrating the 4Rs is relevant globally, with local consideration and adaptation. Reflection and reflexivity are ongoing iterative processes that non-Indigenous and Indigenous researchers alike must attempt to engage in throughout their work alongside FNMI communities to build strength-based solutions for improving medication safety, health and wellness. Indeed, our work focuses explicitly on deprescribing and medication appropriateness; however, the ideas we have presented can be implemented in numerous facets of research with Indigenous Peoples. Members of the Canadian Medication Appropriateness and Deprescribing Network's Indigenization Working Group, with a special thank you to Verna Arcand and Robin Guyer. Amber Ruben has received research support from the Canadian Medication Appropriateness and Deprescribing Network, a health research and knowledge mobilization organization that receives funding from Canada's Drug Agency, Accelerating Clinical Trials Canada and the Canadian Institutes of Health Research. Ms. Ruben is chair of the Network's Indigenization Working Group. She has received funding for research with a First Nation from the Social Sciences and Humanities Research Council in Canada. She is on the Board of Directors for the Indigenous Pharmacy Professionals of Canada. Jennie Herbin is the lead for patient and community engagement with the Canadian Medication Appropriateness and Deprescribing Network, a health research and knowledge mobilization organization that receives funding from Canada's Drug Agency, Accelerating Clinical Trials Canada and the Canadian Institutes of Health Research. Amy Lamb is a member of the Canadian Medication Appropriateness and Deprescribing Network's Indigenization Working Group. She is the Executive Director of the Indigenous Pharmacy Professionals of Canada. She owns a share in Heritage Health Group Inc., which operates pharmacies in Saskatchewan. Dr. Larry Leung is a member of the Canadian Medication Appropriateness and Deprescribing Network's Indigenization Working Group and sits as a volunteer member of the Board of Directors for Indigicare Medicines Ltd. He currently holds grant funding from Vancouver Foundation, McKesson Foundation and the Canadian Foundation for Pharmacy. Dr. Jason Min currently holds grant funding from the Vancouver Foundation and McKesson Foundation, related to supporting Indigenous-led community pharmacy models and supporting Indigenous pharmacy students, respectively. He is a member of the Canadian Medication Appropriateness and Deprescribing Network's Indigenization Working Group and is on the Board of Directors for Indigicare Medicines, an Indigenous-owned community pharmacy. Inès Paschos is the coordinator for public engagement and health promotion with the Canadian Medication Appropriateness and Deprescribing Network, a health research and knowledge mobilization organization that receives funding from Canada's Drug Agency, Accelerating Clinical Trials Canada and the Canadian Institutes of Health Research. Dr. Wade Thompson receives grant funding from Health Canada and NIH, and is supported by a salary award from Michael Smith Health Research BC. Dr. Emily McDonald is the director of the Canadian Medication Appropriateness and Deprescribing Network, a health organization that receives funding from Canada's Drug Agency, the Canadian Institutes of Health Research and Accelerating Clinical Trials Canada. Dr. Emily McDonald has received funding from CIHR and the Centre for Aging and Brain Health Innovation for her ongoing research evaluating the impact of MedSafer on prescribing practices. Dr. Cheryl Sadowski is a member of the Indigenization Working Group, Research Committee and Health Care Provider Committee with the Canadian Medication Appropriateness and Deprescribing Network. She holds funding for research with a First Nation from the Social Sciences and Humanities Research Council in Canada.

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