Understanding the circle of care: Indigenous service providers’ perspectives on health and well-being

Abstract

There is a need for broadening understandings of health and well-being to fill the critical and persistent gap in culturally safe health and social service provision for Indigenous populations. While the importance of Indigenous cultural interventions in healthcare is increasingly recognized and the perspective of Indigenous patients increasingly sought, there has been little research on the views of Indigenous service providers themselves. Our study explores the views of Indigenous service providers and how they conceptualize and deliver health and social services, including how these services link to the principles of harm reduction. We conducted one-on-one semi-structured interviews and socio-demographic questionnaires with eight Indigenous emergency service providers from Thunder Bay, Ontario, in the Fall of 2021. The results reveal broad conceptions of health and well-being with a particular focus on harm reduction principles in delivering a wide range of services that address physical, mental, and spiritual health needs.

Introduction

Indigenous peoples have long faced barriers and systemic racism in accessing healthcare, leading to inequitable care. The impacts of settler colonialism and the ongoing marginalization of Indigenous peoples in the healthcare system are well documented (Allan & Smylie, 2015; Cooke & Shields, 2024; Eaker, 2021; Gone et al., 2019; Nelson & Wilson, 2018; Phillips-Beck et al., 2020). In response, healthcare systems are increasingly recognizing the importance of Indigenous leadership and ways of knowing within their systems, including the role that culturally safe care plays in addressing complex needs and improving health equity (Allen et al., 2020; Barnabe, 2021; Brooks-Cleator et al., 2018; Henderson et al., 2023). However, despite the need and moves towards culturally safe care, there remain critical differences in perspectives and knowledge on settler colonialism between Indigenous and non-Indigenous service providers, contributing to a persistent lack of culturally safe care and skewed views of the complexity of Indigenous people’s lived experiences (Browne & Fiske, 2001; Horrill et al., 2018; Nelson & Wilson, 2018; Roach et al., 2023; Sedgewick et al., 2021). Earlier work has studied non-Indigenous service providers’ perceptions of Indigenous clients and the extent to which dominant stereotypes and embedded settler-colonial racism inform their views and subsequent care practices, but there is a need for Indigenous perspectives in service provision (Browne, 2005; Browne & Fiske, 2001; Horrill et al., 2018; Nelson & Wilson, 2018; Sedgewick et al., 2021; Wylie & McConkey, 2019).

To address the broader gap in healthcare access and equity for Indigenous people, our research team partnered with the Ontario Aboriginal HIV/AIDS Strategy (OAHAS) and Elevate Northwestern Ontario (ENWO) to conceptualize the Circle of Care study, a multi-year project to increase accessibility and use of Indigenous health and well-being approaches through the establishment of an Indigenous Health Program with the local Indigenous community in Thunder Bay, Ontario. The focus on Thunder Bay stems from the need for culturally safe care while recognizing the extreme rates of anti-Indigenous racism in the community (Hay, 2019).

The Circle of Care study includes three objectives. First, strengthening the collaborative working relationship between Indigenous stakeholders involved in the health and well-being of Indigenous people and, second, developing a sustainable Indigenous Healing Program alongside community partners and service users in Thunder Bay. The third goal of the study is the focus of this particular article, where we are interested in identifying Indigenous health and well-being approaches desired and used by Indigenous women and delivered by Indigenous service providers and determining their understandings of health and well-being. As part of this broader objective, this article focuses more narrowly on the perspectives of Indigenous emergency service providers working in Indigenous and mainstream healthcare and social service organizations and how their conceptualizations of health and well-being inform how they prioritize emergency care in both clinical and social services. The results highlight linkages between mental, physical and spiritual health with a focus on well-being and suggest that service providers often conceive of and apply harm reduction principles to service beyond substance use and addiction.

Methods

Community-based research

Underpinning this study is the core value of community-based research, which inherently values multiple ways of knowing, collaboration, and equitable involvement of all research team members (Collins et al., 2018). This study began as a community-partnered project, with two partner organizations having determined the purpose of the project and conceptualizing how to deliver a culturally centred circle of care for Indigenous women who use their services by obtaining feedback from Indigenous clients and local Indigenous service providers. The first partner organization, OAHAS, is a provincial Indigenous-led and Indigenous-governed harm reduction and HIV/AIDS service organization with programme sites across the province. They provide access to culture, care, and support through HIV and other sexually transmitted blood-borne infection prevention, education, testing, harm reduction outreach, and system navigation services (OAHAS, 2022). The second organization, ENWO (2023), located in Thunder Bay, is the leading source in Northwestern Ontario for confidential HIV/AIDS, hepatitis C and harm reduction information and supplies, prevention, community outreach, advocacy, and case management.

These partner organizations developed the goals of the project, conceptualized the broader Circle of Care study and implemented the Indigenous Health Program alongside our research team. This work reflects both organizations’ commitment to the Truth and Reconciliation Commission of Canada’s (TRC, 2015) calls to action. These calls to action were part of a 2015 report detailing the impacts of Canada’s residential school system and outlining specific calls to action to advance the process of reconciliation. Specifically, OAHAS and ENWO conceptualized the Circle of Care study and programme in response to call to action #22:

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. (TRC, 2015, p. 3)

Etuaptmumk: two-eyed seeing principle

We used the guiding principle Etuaptmumk (two-eyed seeing), introduced to academia by Mi’kmaq (First Nations people whose traditional and current territories are in Atlantic Canada and Québec, Canada) Elders Marshall and Bartlett (2018). Etuaptmumk refers to

learning to see from one eye with the strengths of (or best in) Indigenous knowledge and ways of knowing and learning to see from the other eye with the strengths (or best in) Western knowledge and ways of knowing . . . and, most importantly, using both of these eyes together for the benefit of all. (Marshall & Bartlett, 2018, p. 2)

Several values are embedded within Etuaptmumk, including the importance of co-learning, the use of diverse perspectives, self-determination, spirit as connected to Indigenous knowledge, and responsibility for the greater good and future generations (Roher et al., 2021). Co-learning involves the partnerships between ENWO, OAHAS, and the research team. Throughout the project, the research team centred relationships by engaging in knowledge sharing and developing collaborative practices during study design, data collection and analysis, and manuscript review. Furthermore, the research team comprised members with varying backgrounds, learnings, and experiences, including the project Elder, Indigenous health researchers, Indigenous and non-Indigenous research staff, local service providers, those living with HIV, and community members. Self-determination through Indigenous leadership was critical for the success of the Circle of Care study.

Recruitment and study participants

We recruited Indigenous emergency service providers via convenience sampling through flyers and word of mouth at ENWO, OAHAS, local harm reduction sites, and Indigenous service organizations from Thunder Bay, Ontario. Potential study participants completed screening questions through a telephone call or via Zoom. Eligible participants responded yes to identifying as one of three recognized Indigenous peoples in Canada: First Nations, Métis (a distinct Indigenous people with both First Nations and Euro-Settler ancestry, Canada) or Inuit (Indigenous people of the Arctic or subarctic Canada); providing services to Indigenous clients at least 50% of their time; delivering or assisting their clients to access Indigenous health or well-being approaches or have a desire to do so; and delivering emergency services, for example, food banks, clothes donations, outreach services, housing services or shelters, employment services, or crisis response services. The emergency service inclusion criterion stems from the desire to capture broad conceptions of health and well-being and to identify perspectives from those addressing the oft-complex needs of Indigenous service users in Thunder Bay which includes our community partners, OAHAS, and ENWO.

Data collection and analysis

Data collection took place in Fall 2021. Screening questions as outlined above and descriptive statistics were used to summarize participant characteristics. Following the screening questions, service providers completed a 30- to 50-min semi-structured interview covering the following questions while allowing service providers to lead the conversation and offer wide perspectives on what is or ought to be included in a patient or service user’s circle of care:

1. What does being healthy look like for your clients?

2. What have clients said about being physically, mentally, spiritually, or emotionally healthy?

3. What have you done or would like to do to help clients stay or get healthy (including from Indigenous cultures) and are there things that get in the way?

4. How do you understand health and well-being?

5. How do you know when something works for your clients?

6. Would you like to share any additional information?

The interviews were conducted by two research assistants, both of whom had previously worked in and had connections to the community of Thunder Bay. The interviews were audio-recorded and transcribed verbatim. Transcripts were made available to research assistants who applied Strauss and Glazer’s constant comparison and followed their three stages of analysis which include grouping data based on reoccurring terms or concepts, followed by contextualizing these groups and assigning subthemes, and finally bringing subgroups together through linked terms to create themes (Strauss & Corbin, 1998). Given the small sample size of eight, no qualitative software was used. Instead, research assistants reviewed transcripts, coded manually for reoccurring terms and concepts, examined emerging subthemes, and discussed connections between themes and participant viewpoints. Throughout this process, multiple research assistants and co-authors reviewed the analysis and coding results to ensure accuracy and consistency of interpretation and draft results were circulated to our research team of more than 10, including academics, community partners, and those who conducted the interviews.

Results

Study participant characteristics

Seven First Nations and one Métis service providers completed the screening questions and the interviews. Participants were aged between 29 and 58 years. They had been working as service providers and delivering a range of clinical and social services for between 6 months and 15 years with a median of 3.7 years. This includes three clinical providers—nurse, midwife, and social workers, five social service providers—community outreach worker, housing worker, case management staff, and one Elder. Participants had a mix of experience providing emergency services, such as food banks, clothing donations, resource centres, housing/shelters, harm reduction and other outreach services, crisis care for mental health, and emergency room services, among others. They also had experience in providing cultural care, such as facilitating meetings with Elders, ceremonies—full moon, berry, or naming, facilitating sharing or talking circles, and medicine teachings, walks, picking, or growing.

Qualitative analysis

While the questionnaire and interview asked respondents about health and well-being at a general level and the ways in which service providers offer emergency and cultural services to Indigenous service users, respondents frequently centred harm reduction or reducing harms in their answers and this narrative informed much of their responses. This is explored in the subsections below, with selected data showing how service providers discuss and conceptualize health and well-being, how they measure and identify patient health as part of the emergency and cultural services offered, and finally, how they make sense of their practices and interpret their own actions as reducing harm.

Conceptualizing health and social services for well-being

Service providers often referred to the social determinants of health throughout their interviews and the role this played in the context of health and well-being. Throughout, the language around social determinants of health was applied in ways that included tangible caregiving and, at times, moved beyond traditional determinants linked to social and economic factors (Public Health Agency of Canada, 2001; World Health Organization, 2008:):

I would say that we really focus on the basics, like the basic social determinants of health. Like we have to make sure that people have housing, some income, a place safe to be. But they have like income and more security in their lives. Like those all have to be in place before somebody can be healthy or healthier in their life. (P7, clinical service provider)

Beyond social determinants of health, respondents also highlighted the role of relationality in the delivery of health services. In particular, they highlighted the importance of building connections with clients and how critical this is for getting to the true nature of client needs and delivering healthcare:

It’s really trying to bridge that gap and find a connection so that we can have a wholesome conversation about what are the needs that they need to have met. So that I, as a service provider, can be more in tune with what their needs are versus what I think their needs might be. (P5, social and cultural service provider)

Assessing health and well-being

Beyond defining and considering what health and well-being mean, service providers also talked about how they assess this in patient care. When discussing what it means for clients to maintain physical, mental, spiritual, or emotional health, service providers often refer to daily life activities and skills needed to maintain independent living. For their clients to move beyond, the guidance and support of their service providers to manage daily activities suggests a movement towards independence and quite possibly self-determination. In addition, a state of well-being sees clients that are able to move beyond care-based relationships to build a social network.

What I would like to do and see would be I would like to have clients be taught life skills. Like how to do their own laundry, how to help with cooking, how to learn to, you know, cook healthy foods, you know, the hygiene stuff, or how to budget. And all the everyday things that we do on the outside, I would love to see them get that. And eventually, find their own . . . help them find their own place and move on rather than be stuck homeless. That’s what I’d like to see. (P8, social and cultural service provider).

Then they go back to being healthy, they’re like stabilized, they’re more functional, they’re more open to other people rather than close themselves off with some other people. (P7, social and cultural service provider)

Beyond providing care and seeing where patients’ needs are, service providers often discussed their role in meeting people where they are and understanding choices in the context of positionality with a focus on choice and patient decision-making. As demonstrated below, some interviewees noted that beyond achieving physical health, the role of choice and commitment to healthy choices plays a key role in health and well-being.

People are at different levels of health and wellness. But I think it’s being able to continue or like steady fast kind of their way through whatever it is that they’re working with and that they’re able to make reasonable choices and without a lot of barriers. The ability to think about those choices, to come to them, and then be able to follow through with them, that’s somebody that’s in a healthy state. (P6, social and cultural service provider)

Theme 3. Applying the principles of harm reduction to health and well-being

Beyond discussing general health and well-being, participants also highlighted the extent to which they consider the principles of harm reduction, frequently bringing this language into their answers without being asked about it directly. Participants also articulated how the language used in mainstream healthcare differed from that within Indigenous circles of care, frequently bringing harm reduction terminology into areas outside of substance use. For one provider, conceptualizing health includes applying the principles of harm reduction to overall health such that it includes proactively assisting people with day-to-day activities that stabilize one’s daily living situation and forestall undesirable or adverse events associated with substance use:

It’s a harm reduction strategy. Fill your cupboards with food. Let’s go pay your rent. Let’s go pay for your phone. Let’s get all of that done. You know, now you’re going to have a better month where you’re not going to have that stress or that worry. Because, it’s usually cocaine use and opiate use here, and when people are high, they want to stay high, and they go through a bit of withdrawal. And then bills don’t get paid, and then their health goes down, right? (P6, social and cultural service provider)

Another provider (P5, social and cultural service provider) makes the point that the Indigenous community already had a profound understanding of harm reduction and how to effectively do it; though this has been interrupted by the historical and ongoing effects of settler colonialism. In particular, the interviewee suggested that harm reduction principles, insofar as they translate to a nuanced approach to substance use with community support, as opposed to a black-and white-view of addiction, have always had a place in traditional Indigenous health approaches, as noted in the quote below.

I’d rather do, I guess, a harm reduction approach. And I would do it more so from an Indigenous perspective. And what I mean by that is that I think we’ve always known what harm reduction was in the Indigenous community before colonization. We’ve always had a good grasp of it. And then when colonization happened, when the Europeans arrived on our shores, a lot of those things got lost. Like a lot of those values were lost. And it [colonization] prevented us from being very supportive of community because suddenly it was a Black-and-White issue rather than people being all part of the circle. (P5, social and cultural service provider)

Both quotes speak to the idea that Indigenous conceptions of care, including as they related to traditional harm reduction, were well established and that settler-colonial approaches to health dismantled this view and the community support or circle of care that was previously established. These responses also highlight that when it comes to client-directed approaches, service providers held mainstream understandings of harm reduction and found that there could be tension between reintroducing harm reduction in some healthcare settings. The respondent noted that while Elders in her community are actively working with her clients, there are often obstacles. Some Elders believe that cultural activities should not be practised while using substances and that clients must be abstinent for a certain time period prior to participating in ceremony for example:

I’ve got two [Elders who I work with]. I’m slowly fishing them in here. . .But otherwise, it’s hard finding somebody who’s into harm reduction and who’s into not turning people away, like “you have to stay sober for four days or 12 days,” or anything like that. (P1, social and cultural service provider)

The transcripts and ensuing thematic analysis highlight the importance of perspectives from Indigenous service providers in caring for Indigenous patients and service users. In particular, the results shed light on the need for culturally safe care while demonstrating that providers consider a wide range of services and outcomes when providing for health and well-being.

Discussion

Consistent with Indigenous holistic worldviews, service providers within Indigenous organizations have described the importance of providing a wide array of services for addressing the complex needs arising from the health and social concerns of their Indigenous clients (Sookraj et al., 2012; Wekerle et al., 2022) including where the services respond to existing inequities Indigenous peoples face accessing services (Lavalley et al., 2020). In addition, Indigenous service providers are accountable to the local community, reflect community values and beliefs, and provide comprehensive programmes from treatment and management, prevention, and health promotion to addressing determinants of health (First Nations Health Authority, 2023; Kennedy et al., 2022).

Despite being oft-neglected, the perspectives of Indigenous service providers echo much of this recent literature calling for culturally safe care. In particular, the results reaffirm the strength of local Indigenous providers in recognizing the complex needs of those in their care and advocating for a circle of care built on relationality and trust. This mirrors earlier literature highlighting the importance of relationality and the challenges of upholding culturally safe care given the power dynamics inherent in the patient–provider relationship (Curtis et al., 2019; O’Brien et al., 2017). Recall that cultural safety focuses on the “experience of the recipient of care” and calls for the integration of Indigenous culture into caregiving (Nguyen, 2008, p. 991). Respondents spoke to this directly, suggesting that for clients to be able to benefit from health and well-being services, their choices had to be recognized, and only through authentic relationship building could the providers truly understand client needs and meet their clients where they were (Frankeberger et al., 2023).

Beyond conceptualizing health in terms of relations and understanding the need for wide-ranging services built on trust, the results also speak to the distinct ways in which study participants measure and assess health. While understandings of health and well-being are broad, context-dependent, and vary among healthcare systems and even providers, study participants bring an added layer into consideration: relations outside the care network and daily living activities. These considerations are particularly important to those with complex needs and more so for those receiving emergency services. Providers spoke to the importance of maintaining independent living and building life skills, considerations critical to health but oft-complex for Indigenous peoples (Nelson & Wilson, 2018; OAHAS, n.d.; Webkamigad et al., 2020).

While the interview questions focused largely on general health and well-being, the results point to a somewhat surprising result. Several participants frequently brought harm reduction terminology and discussions into the conversation. This may have resulted because Indigenous harm reduction also involves a focus on undoing the harms of colonialism by addressing the underlying causes of substance use. This echoes the work undertaken by Black and Latinx harm reduction programme directors who see that harm reduction requires “a community-based movement that addresses root causes of overdose by fostering inclusion, cultivating social networks of support, meeting basic needs beyond drug use, and organizing politically for health justice” (Hughes et al., 2022, p. 136). In particular, this can mean focusing on the importance of connection and relationship building with the community, including with people who use substances, something which service providers highlighted through the interviews (Levine et al., 2021).

These findings mirror earlier studies by showing that the language and applications of harm reduction approaches are both context-dependent and understood uniquely by both service providers and service users (Denis-Lalonde et al., 2019; Gallagher et al., 2021; Thomas, 2005). Respondents detailed harm reduction as including services like food banks, clothing donations, helplines, and employment services. They noted that even in roles typically thought to be outside of the harm reduction space, for example, midwifery, service provision still includes harm reduction services and adopting the harm reduction approach of meeting people where they are.

This is noteworthy given recent studies that have found narrower adoption of harm reduction policies at the provincial level with few provinces rarely naming specific harm reduction interventions and instead using the term without clear application (Hughes et al., 2022; Hyshka et al., 2017). The variation in the way service providers use language has important implications for policy implementation and measurement, especially where Indigenous ways of knowing may see a broader definition of terms and applicability in the approach (Cooper et al., 2019).

Limitations

While rooted in community-based research and subject to review and contributions from a diverse research team, this study is not without its limits. Primarily, the small sample size of only eight and the place-based context in Thunder Bay, Ontario limit the generalizability of the findings. Furthermore, recruitment was based on convenience and snowball sampling, so respondents may not be representative of broader Indigenous service provider views in the community. However, given the need for Indigenous service providers’ perspectives in the literature and within healthcare policy more broadly, the data provide a nuanced perspective in a critical and underserved area of health delivery.

Conclusion

Indigenous ways of knowing and Indigenous ways of healing, including cultural teachings, cultural interventions, attending ceremony, and integrating traditional medicines into care, improve health access and outcomes for Indigenous peoples (Hewson & Rowold, 2012; Jiwa et al., 2008; Menzies, 2008; Rowan et al., 2015). For those providing care to Indigenous people, understanding and providing this full circle of care is critical, as is ensuring their perspectives are sought. These findings may help service organizations and policymakers in understanding the baseline conceptualization of health and well-being in caring for Indigenous peoples. More importantly, perhaps though, the results broaden perspectives on well-being in support of improved service provision for Indigenous peoples and centre Indigenous voices in broader conversations about health and well-being for and by Indigenous peoples.