When Future Directions are Rooted in Past Knowledge;

Ontario’s shift to including indigenous healers and culturally sensitive approaches for indigenous peoples in healthcare.

Introduction

In March 2022, the Ministry of Health announced new regulations, which involved a repeal of the Home Care and Community Services Act, 1994 in anticipation of Bill 175, Connecting People to Home and Community Care Act, 2020 and a number of changes were announced, including a statement that patients who identify as First Nations, Metis or Inuk would have the right to receive services in a culturally safe manner (Ontario Ministry of Health and Long-Term Care, 2022). In a memorandum from The Ministry of Health, Directed to Home and Community Care Support services (2022), Amy Olmstead, Executive lead, further explains that the ministry received feedback in consultation with First Nations, Inuit and Métis communities on the plan to add traditional healing and Indigenous cultural support services as new services available by Home and Community Care, and its Service Provider Organizations. Olmstead offers further direction for this service to be delivered by Indigenous persons or organizations. This came on the heels of the Truth and Reconciliation Report (2015) which included this call to action; “We call upon those who can effect change within the Canadian health-care system to recognize the value of Aboriginal healing practices and use them in the treatment of Aboriginal patients in collaboration with Aboriginal healers and Elders where requested by Aboriginal patients.” (Truth and Reconciliation Commission of Canada, 2015, p.3). There is evidence that this shift is not only a necessary effort to reconcile the actions against indigenous people, but it promotes equity for a vulnerable population, addresses cultural and social determinants of health, and it has the potential to influence health at multiple levels of the social ecological model of health.

Definition

First let’s define what is meant by Indigenous healing. The First Nations Health Authority (n.d.) defines it as;

“Traditional healing refers to the health practices, approaches, knowledge and beliefs that incorporate First Nations healing and wellness. These practices include using ceremonies, plant, animal or mineral-based medicines, energetic therapies and physical or hands-on techniques.” (n.d., p. 1). Literature on Indigenous Healing often references the medicine wheel, which is divided into 4 sections representing four seasons, four directions, four sacred animals, and four sacred plants and is thought to have been used by many generations of Indigenous people for health and healing (Canadian Breast Cancer Network, 2020). Traditional healing examples may include the use of herbs, healing circles, sweat lodges, and/or smudging as well as traditional diets (Canadian Breast Cancer Network, 2020).

Figure 1

Indigenous Medicine Wheel

Note; Joseph, B. (2020, May 24). What is an Indigenous Medicine Wheel? [Graphic] Indigenous Corporate Training Inc. Retrieved August 1, 2022, from https://www.ictinc.ca/blog/what-is-an-indigenous-medicine-wheel

The Social Determinants of Health

There are many societal factors that go beyond the individual that impact health, these are often referred to as the “social determinants of health”. Incorporating Indigenous healing practices into modern health care systems addresses several of the determinants of health and they help explain why certain vulnerable populations such as indigenous people experience higher rates of disease and worse health outcomes than other population groups (Webcamigad et al., 2020). These determinants of health include the following;

-Income and social status

-Employment and working conditions

-Education and literacy

-Childhood experiences

-Physical environments

-Social supports and coping skills

-Healthy behaviors

-Access to health services

-Biology and genetic endowment

-Gender

-Culture

-Race / Racism

-Health inequities (Public Health Agency of Canada, 2020).

Incorporating indigenous healing into modern health care systems may impact on several determinants of health. For example, if indigenous children have access to culturally appropriate healthcare, social supports and coping skills, this could impact childhood experiences. Another example would be an increased awareness and practice of indigenous healing practices could impact on culture and race/racism. Lastly, this inclusion may help address some of the health inequities facing Indigenous populations. One case study looking at unregistered births among indigenous people living in northern Ontario highlights the barriers and impact that environmental conditions have on an individual’s life and health that comes with inability to access essential services (Sanders &Burnett, 2019). The authors present the case of “Susan” and the many systematic challenges she faces in obtaining a birth certificate for her daughter which is essential for her to access services and attend school (Sanders &Burnett, 2019). By legislating Indigenous Healing practices in integrating them into our modern health care system, impacts can be seen in multiple determinants of health for this vulnerable population, which is a step towards health equity.

Social Ecological Model of Health

Several models and frameworks have been developed that are aimed to influence the determinants of health and can be used to improve health outcomes. One such model is the Social- ecological model of health, a definition of which comes from the online textbook "Health Behavior and Health Education" (2008) which suggests that Ecological models of health have multiple levels of influences, including intrapersonal (biological, psychological), interpersonal (social, cultural), organizational, community, physical environmental, and policy.

There are several areas in this model that are impacted by the incorporation of Indigenous Healing into modern settings. As this requirement is now legislated in Bill 175, this would influence the largest circle, the level of policy. This change would also influence the level of community, in that an indigenous healer and elder are required to be a member of the indigenous community, and may also include community healing circles. The level of interpersonal impact would also be influenced as culture is incorporated in the treatment or intervention. Lastly, there would also be an impact on the individual or intrapersonal level as there would be a level of knowledge of traditional healing practices as well as respect for an individual that has been shown to lead to greater outcomes and self-efficacy, as highlighted by Auger, Howell and Gomes (2016), who found that a traditional based approach towards healthcare delivery for Indigenous people results in increased self-determination.

Figure 2

Social Ecological Model

Note; University of Washington. (2017, August 12). Social Ecological Model | [Graphic] Ecology of Health and Medicine. Retrieved August 1, 2022, from https://blogs.uw.edu/somehm/2017/08/12/social-ecological-model/

Evidence to support this future direction

There will of course be challenges to this adoption in an already stretched healthcare system. Funders and stakeholders might have concerns about the added cost of this shift, and whether it will have an impact on the health of indigenous people. So far there are several examples from the literature that suggest that this future direction to include indigenous Healing in modern health systems produces outcomes that are quite favorable, and further, have the potential to influence not just an individual, but families and communities. In an Ontario study using volunteers from First Nation Communities (George et al, 2018), the researchers found that while only a small minority (15%) used traditional healing practices, the majority of band members who did not use them responded that they would like to use them (51%). Common barriers included a lack of knowledge about their use, and a lack of access. Participants who used traditional healing practices were found to display stronger cultural identity, and improved spiritual health. One recent pilot project at a hospital in Sarnia, Ontario ran a program involving an indigenous healer paired with an elder, who offered care to 35 indigenous patients in the hospital. The pair provide traditional Indigenous approaches centered around providing culturally respectful and inclusive care. Feedback has been cited as being positive so far and the goal is to permanently integrate Indigenous Healing into the hospital (Kula, 2022). Another example of how care that is provided that is both culturally appropriate and non-judgmental can improve outcomes for Indigenous populations comes from a Winnipeg based community health center called "Manito Ikwe Kagiikwe", which means "the mothering project" (Centre for Excellent for woman health & CanFASD, 2017). The program was launched in 2014 with a focus on providing culturally appropriate support and resources to pregnant woman involved with substances. The uniqueness of the program is that it places particular emphasis on risk reduction, advocacy and support (as opposed to judgement, stigma and punishment) and so far the outcomes are promising, with early outcomes suggesting less substance use, improved access to housing and social supports, and over 50% of woman entering the program being able to take their babies home from the hospital (compared to 94% of mothers who had children in care prior to the program). Looking broader, a scoping review published in the BMJ open (Corso et al, 2022) highlighted negative outcomes on the health and wellness of indigenous people accessing modern healthcare, citing current issues of stereotyping, racism and discrimination. The authors issued a call to action for Indigenous healing practices to be integrated within the delivery of care. The review identified strategies used to integrate Indigenous healing practices within current health care models and concluded that successful strategies for integration were Indigenous-led, included community engagement, elder support and indigenous traditions (Corse et al, 2022). These are all great examples that show how the impact of providing health care within a framework of being culturally grounded, trauma informed and non-judgmental can have greater outcomes than modern approaches when implemented for particularly vulnerable populations.

Conclusion

Implementing culturally appropriate, indigenous-led, traditional healing practices into modern healthcare systems in Ontario is not only one step towards reconciliation, it also impacts several determinants of health, it is culturally sensitive, targets a vulnerable population and it influences health at the cultural and policy level which has been shown to lead to improved health outcomes. Though the roots of indigenous healing are of course not at all new or futuristic, incorporating indigenous healing into modern healthcare systems will set the foundation for frameworks that have the potential to lead to improved health outcomes for one of our most vulnerable populations.

References

Auger, M., Howell, T., & Gomes, T. (2016). Moving toward holistic wellness, empowerment and self-determination for Indigenous peoples in Canada: Can traditional Indigenous health care practices increase ownership over health and health care decisions? Canadian journal of public health = Revue canadienne de sante publique, 107(4-5), e393–e398. https://doi.org/10.17269/cjph.107.5366

Canadian Breast Cancer Network. (2020, June 22). Indigenous Traditional Healing. Retrieved August 1, 2022, from https://cbcn.ca/en/blog/our-stories/Indigenous-Traditional-Healing

Centre for excellence for woman’s health & CanFASD. (2017, June 26). The Mothering Project. Girls, Women, Alcohol, and Pregnancy. Retrieved July 18, 2022, from https://fasdprevention.wordpress.com/tag/the-mothering-project/

Corso, M., DeSouza, A., Brunton, G., Yu, H., Cancelliere, C., Mior, S., Taylor-Vaisey, A., MacLeod-Beaver, K., & Côté, P. (2022). Integrating Indigenous healing practices within collaborative care models in primary healthcare in Canada: a rapid scoping review. BMJ open, 12(6), e059323. https://doi.org/10.1136/bmjopen-2021-059323

First Nations Health Authority. (n.d.). Traditional Wellness and Healing. Retrieved July 24, 2022, from https://www.fnha.ca/what-we-do/health-system/traditional-wellness-and-healing

George, J., MacLeod, M., Graham, K., Plain, S., Bernards, S., & Wells, S. (2018). Use of Traditional Healing Practices in Two Ontario First Nations. Journal of community health, 43(2), 227–237. https://doi.org/10.1007/s10900-017-0409-5

Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). (2008). Health Behaviour and Health Education (4th ed.). Jossey-Bass. accessed June 17, 2022 from https://www.med.upenn.edu/hbhe4/part5-ch20.shtml#:~:text=The%20core%20concept%20of%20an,%2C%20physical%20environmental%2C%20and%20policy

Kula, T. (2022, July 7). Traditional-healing pilot launched at Bluewater Health for Indigenous patients. The Sarnia Observer. Retrieved July 24, 2022, from https://www.theobserver.ca/news/local-news/traditional-healing-pilot-launched-at-bluewater-health-for-indigenous-patients

Olmstead, A. (2022, March 11). New Framework for Home and Community Care Services in Ontario [Memorandum]. Ministry of Health Ontario Health Teams Division. Retrieved August 1, 2022, from https://www.mcmasterforum.org/docs/default-source/rise-docs/partner-resources/moh-memo---new-hcc-regulations-(2022–03-11)v8.2signed_en.pdf?sfvrsn=31c60deb_11

Ontario Ministry of Health and Long-Term Care. (2022, March 22). Health System Integration Update: Filing of Regulations for Improved Home and Community Care Framework while Continuing to Maintain Stability of Services. Retrieved August 1, 2022, from https://www.health.gov.on.ca/en/news/connectedcare/2022/CC_20220322.aspx

Public Health Agency of Canada. (October 7, 2020). Social determinants of health and health inequalities. Government of Canada. Retrieved June 11, 2022, from https://www.canada.ca/en/public-health/services/health-promotion/population-health/what-determines-health.html

Sanders, C., & Burnett, K. (2019). A Case Study in Personal Identification and Social Determinants of Health: Unregistered Births among Indigenous People in Northern Ontario. International journal of environmental research and public health, 16(4), 567. https://doi.org/10.3390/ijerph16040567

Truth and Reconciliation Commission of Canada. (2015). Truth and reconciliation commission of Canada: Calls to action. Truth and Reconciliation Commission of Canada.

Webkamigad, S., Rowe, R., Peltier, S., Froehlich Chow, A., McGilton, K. S., & Walker, J. D. (2020). Identifying and understanding the health and social care needs of Indigenous older adults with multiple chronic conditions and their caregivers: a scoping review. BMC geriatrics, 20(1), 145. https://doi.org/10.1186/s12877-020-01552-5