Opioid use disorder treatment disruptions during the early COVID-19 pandemic and other emergent disasters: a scoping review addressing dual public health emergencies.

BACKGROUND: During public health emergencies, people with opioid use disorder (PWOUD) may be particularly impacted. Emergent disasters such as the COVID-19 pandemic disrupt already-strained harm reduction efforts and treatment availability. This study aims to answer three research questions. How do public health emergencies impact PWOUD? How can health systems respond to novel public health emergencies to serve PWOUD? How can the results of this scoping review be contextualized to the province of Alberta to inform local stakeholder responses to the pandemic? METHODS: We conducted a scoping review using the 6-stage Arksey and O'Malley framework to analyse early-pandemic and pre-pandemic disaster literature. The results of the scoping review were contextualized to the local pandemic response, through a Nominal Group Technique (NGT) process with frontline providers and stakeholders in Alberta, Canada. RESULTS: Sixty one scientific journal articles and 72 grey literature resources were included after full-text screening. Forty sources pertained to early COVID-19 responses, and 21 focused on OUD treatment during other disasters. PWOUD may be more impacted than the general population by common COVID-19 stressors including loss of income, isolation, lack of rewarding activities, housing instability, as well as fear and anxiety. They may also face unique challenges including threats to drug supplies, stigma, difficulty accessing clean substance use supplies, and closure of substance use treatment centres. All of these impacts put PWOUD at risk of negative outcomes including fatal overdose. Two NGT groups were held. One group (n = 7) represented voices from urban services, and the other (n = 4) Indigenous contexts. Stakeholders suggested that simultaneous attention to multiple crises, with adequate resources to allow attention to both social and health systems issues, can prepare a system to serve PWOUD during disasters. CONCLUSION: This scoping review and NGT study uncovers how disasters impact PWOUD and offers suggestions for better serving PWOUD.

"There are still a lot of things that I need": a qualitative study exploring opportunities to improve the health services of First Nations People with arthritis seen at an on-reserve outreach rheumatology clinic.

BACKGROUND: Arthritis is a highly prevalent disease and leading cause of disability in the Indigenous population. A novel model of care consisting of a rheumatology outreach clinic in an on-reserve primary healthcare center has provided service to an Indigenous community in Southern Alberta since 2010. Despite quality assessments suggesting this model of care improves accessibility and is effective in meeting treatment targets, substantial improvements in patient-reported outcomes have not been realized. Therefore, the objective of this study was to explore the experiences of Indigenous persons with arthritis and healthcare providers involved in this model of care to inform the development of health service improvements that enhance patient outcomes. METHODS: This was a narrative-based qualitative study involving a purposeful sample of 32 individuals involved in the Indigenous rheumatology model of care. In-depth interviews were conducted to elicit experiences with the existing model of care and to encourage reflections on opportunities to improve it. A two-stage analysis was conducted. The first stage aimed to produce a narrative synthesis of concepts through a dialogical method comparing people with arthritis and health providers' narratives. The second stage involved a collective effort to synthesize concepts and propose specific recommendations to improve the quality of the current model of care. Triangulation, through participant checking and discussion among researchers, was used to increase the validity of the final recommendations. RESULTS: Ten Indigenous people with arthritis lived experience, 14 health providers and 8 administrative staff were interviewed. One main overarching theme was identified, which reflected the need to provide services that improve people's physical and mental functioning. Further, the following specific recommendations were identified: 1) enhancing patient-provider communication, 2) improving the continuity of the healthcare service, 3) increasing community awareness about the presence and negative impact of arthritis, and 4) increasing peer connections and support among people living with arthritis. CONCLUSIONS: Improving the quality of the current Indigenous rheumatology model of care requires implementing strategies that improve functioning, patient-provider communication, continuity of care, community awareness and peer support. A community-based provider who supports people while navigating health services could facilitate the implementation of these strategies.

An implementation history of primary health care transformation: Alberta's primary care networks and the people, time and culture of change.

BACKGROUND: Primary care, and its transformation into Primary Health Care (PHC), has become an area of intense policy interest around the world. As part of this trend Alberta, Canada, has implemented Primary Care Networks (PCNs). These are decentralized organizations, mandated with supporting the delivery of PHC, funded through capitation, and operating as partnerships between the province's healthcare administration system and family physicians. This paper provides an implementation history of the PCNs, giving a detailed account of how people, time, and culture have interacted to implement bottom up, incremental change in a predominantly Fee-For-Service (FFS) environment. METHODS: Our implementation history is built out of an analysis of policy documents and qualitative interviews. We conducted an interpretive analysis of relevant policy documents (n = 20) published since the first PCN was established. We then grounded 12 semi-structured interviews in that initial policy analysis. These interviews explored 11 key stakeholders' perceptions of PHC transformation in Alberta generally, and the formation and evolution of the PCNs specifically. The data from the policy review and the interviews were coded inductively, with participants checking our emerging analyses. RESULTS: Over time, the PCNs have shifted from an initial Frontier Era that emphasized local solutions to local problems and featured few rules, to a present Era of Accountability that features central demands for standardized measures, governance, and co-planning with other elements of the health system. Across both eras, the PCNs have been first and foremost instruments and supporters of family physician authority and autonomy. A core group of people emerged to create the PCNs and, over time, to develop a long-term Quality Improvement (QI) vision and governance plan for them as organizations. The continuing willingness of both these groups to work at understanding and aligning one another's cultures to achieve the transformation towards PHC has been central to the PCNs' survival and success. CONCLUSIONS: Generalizable lessons from the implementation history of this emerging policy experiment include: The need for flexibility within a broad commitment to improving quality. The importance of time for individuals and organizations to learn about: quality improvement; one another's cultures; and how best to support the transformation of a system while delivering care locally.

Formation and control of nitrogenous DBPs from Western Australian source waters: Investigating the impacts of high nitrogen and bromide concentrations.

We studied the formation of four nitrogenous DBPs (N-DBPs) classes (haloacetonitriles, halonitromethanes, haloacetamides, and N-nitrosamines), as well as trihalomethanes and total organic halogen (TOX), after chlorination or chloramination of source waters. We also evaluated the relative and additive toxicity of N-DBPs and water treatment options for minimisation of N-DBPs. The formation of halonitromethanes, haloacetamides, and N-nitrosamines was higher after chloramination and positively correlated with dissolved organic nitrogen or total nitrogen. N-DBPs were major contributors to the toxicity of both chlorinated and chloraminated waters. The strong correlation between bromide concentration and the overall calculated DBP additive toxicity for both chlorinated and chloraminated source waters demonstrated that formation of brominated haloacetonitriles was the main contributor to toxicity. Ozone-biological activated carbon treatment was not effective in removing N-DBP precursors. The occurrence and formation of N-DBPs should be investigated on a case-by-case basis, especially where advanced water treatment processes are being considered to minimise their formation in drinking waters, and where chloramination is used for final disinfection.

'WE CAN'T GET WORMS FROM COW DUNG': REPORTED KNOWLEDGE OF PARASITISM AMONG PASTORALIST YOUTH ATTENDING SECONDARY SCHOOL IN THE NGORONGORO CONSERVATION AREA, TANZANIA.

Records at the Endulen Hospital in the Ngorongoro Conservation Area (NCA), Tanzania, reveal that soil-transmitted helminth infections and protozoa are consistently in the top ten diagnoses for Maasai pastoralists, indicating a significant public health concern. Nevertheless, Maasai pastoralist adaptations to life in close proximity to livestock and to unreliable access to water raise important questions about experiences of, and resiliency to, parasitic infections. Though these infections are particularly prevalent among youth in low- and middle-income countries (LMIC), a focus on resiliency highlights local capacity to recover from and prevent illness. For instance, how is human parasitism perceived and experienced among communities displaying behaviours that studies have associated with transmission of diarrhoeal diseases, such as open defecation? Among these communities, how is parasitism seen to impact the health and development of children? And, what resources are available to endure or mitigate this heavy disease burden among affected communities? This study draws on formative research carried out in May 2014 in anticipation of an innovative school-based and youth-driven water, sanitation and hygiene education intervention rolled out in two boarding schools in the NCA in subsequent months. The initiative is grounded in a One Health approach to health promotion, drawing on partnerships in medicine, public health and veterinary medicine to appreciate the unique interactions between humans, animals and the environment that shape well-being among pastoralist communities. Qualitative data generated through group discussions with secondary school youth (n=60), Maasai teachers (n=6) and a women's group (n=8) in the NCA convey existing knowledge of the prevalence, prevention and treatment of human parasitism. An underlying principle of the larger initiative is to engage youth as creative agents of change in developing and sustaining locally relevant health promotion strategies. Findings highlight practical knowledge around certain 'neglected tropical diseases', namely helminths, among pastoralist communities in the NCA, in turn feeding into the development of the science fair and related interventions.

Advancing health equity for Indigenous peoples in Canada: development of a patient complexity assessment framework.

BACKGROUND: Indigenous patients often present with complex health needs in clinical settings due to factors rooted in a legacy of colonization. Healthcare systems and providers are not equipped to identify the underlying causes nor enact solutions for this complexity. This study aimed to develop an Indigenous-centered patient complexity assessment framework for urban Indigenous patients in Canada. METHODS: A multi-phased approach was used which was initiated with a review of literature surrounding complexity, followed by interviews with Indigenous patients to embed their lived experiences of complexity, and concluded with a modified e-Delphi consensus building process with a panel of 14 healthcare experts within the field of Indigenous health to identify the domains and concepts contributing to health complexity for inclusion in an Indigenous-centered patient complexity assessment framework. This study details the final phase of the research. RESULTS: A total of 27 concepts spanning 9 domains, including those from biological, social, health literacy, psychological, functioning, healthcare access, adverse life experiences, resilience and culture, and healthcare violence domains were included in the final version of the Indigenous-centered patient complexity assessment framework. CONCLUSIONS: The proposed framework outlines critical components that indicate the presence of health complexity among Indigenous patients. The framework serves as a source of reference for healthcare providers to inform their delivery of care with Indigenous patients. This framework will advance scholarship in patient complexity assessment tools through the addition of domains not commonly seen, as well as extending the application of these tools to potentially mitigate racism experienced by underserved populations such as Indigenous peoples.

Critically examining health complexity experienced by urban Indigenous peoples in Canada by exploring the factors that allow health complexity to persist: a qualitative study of Indigenous patients in Calgary, Alberta.

OBJECTIVES: This study aims to identify and critically examine the components of health complexity, and explore the factors that allow it to exist, among urban Indigenous peoples in Canada. DESIGN: Qualitative exploration with relational conversations. SETTING: Calgary, Alberta, Canada. PARTICIPANTS: A total of nine urban Indigenous patients were recruited from a multidisciplinary primary healthcare clinic that serves First Nations, Métis and Inuit peoples. Recruitment and data collection took place between September and November 2021. RESULTS: Thematic analysis revealed three main themes, namely: sources of health complexity, psychological responses to adversity, and resilience, strengths, and protective factors. Key sources of health complexity arose from material resource disparities and adverse interpersonal interactions within the healthcare environment, which manifest into psychological distress while strengths and resilience emerged as protective factors. CONCLUSION: The healthcare system remains inapt to address complexity among urban Indigenous peoples in Canada. Healthcare violence experienced by Indigenous peoples only further perpetuates health complexity. Future clinical tools to collect information about health complexity among urban Indigenous patients should include questions about the factors defined in this study.

Novel Application of the World Health Organization Community-Based Rehabilitation Matrix to Understand Services' Contributions to Community Participation for Persons With Traumatic Spinal Cord Injury: A Mixed-Methods Study.

PURPOSE: The aim of the study is to use the World Health Organization community-based rehabilitation matrix for understanding services' contributions to foster community participation for people with traumatic spinal cord injury. METHODS: This study used a convergent mixed-methods design with a quantitative arm describing the frequency with which services contributed to 22 of the community-based rehabilitation-matrix elements and a qualitative arm involving document reviews and stakeholder interviews. Results were integrated following Onwuegbuzie and Teddlie's method (i.e., quan + QUAL). RESULTS: Twenty of the 22 (91%) of the World Health Organization community-based rehabilitation elements were addressed by traumatic spinal cord injury services. Five types of services were identified. Integrated results showed that the strengths of traumatic spinal cord injury services were as follows: (1) comprehensiveness; (2) essential medical services publicly funded; (3) numerous social protections available; and (4) highly active community-based organizations. Identified opportunities to improve these services were as follows: (1) increase specificity for traumatic spinal cord injury and (2) increase communication and integration among services. CONCLUSIONS: Services available for people with traumatic spinal cord injury in the province studied address most of the elements of the World Health Organization community-based rehabilitation matrix. However, lack of cohesion between services could create gaps that hinder community participation. Addressing these gaps could improve the quality of life and outcomes of people with traumatic spinal cord injury.

Access, relationships, quality and safety (ARQS): a qualitative study to develop an Indigenous-centred understanding of virtual care quality.

BACKGROUND: Among Indigenous peoples in Canada, access to high-quality healthcare remains an important determinant of health. The shift to virtual and remote-based approaches, expedited during the COVID-19 pandemic, influenced the ways in which individuals accessed care and the quality of care received. This study sought to determine which elements are required for effective and sustainable virtual care approaches for delivery of primary care to Indigenous patients and develop quality indicators grounded in Indigenous community and experience. We share a conceptual framework to understand how Indigenous patients access and define high-quality virtual care, grounded in Indigenous patient experiences and worldviews. METHODS: Using principles of patient-oriented research, we grounded this work in social justice and participatory action research. We sought to gain an in-depth understanding of the Indigenous experiences of virtual care and specifically of primary care. This was developed through semistructured interviews with Indigenous patients and Indigenous virtual primary care providers. RESULTS: Thirteen participants were interviewed between 5 August 2021 and 25 October 2021. Using Framework Analysis, we constructed four domains including access, relationships, quality and safety as being primary facets of defining high-quality Indigenous virtual primary care. DISCUSSION: The results presented here indicate that the shift to virtual care, largely seen in response to the COVID-19 pandemic, does not compromise quality of care, nor does it lead to negative patient experiences. Optimal care is possible in virtual settings for some care needs and types of appointments and has the potential to decrease barriers to access and improve patient experiences of safety and quality while facilitating patient/provider relationships. CONCLUSION: In summary, high-quality Indigenous virtual care benefits from attention to patients' experiences of access, relationships, safety and quality with their service providers and healthcare teams.

Propelled by the Pandemic: Responses and Shifts in Primary Healthcare Models for Indigenous Peoples.

The COVID-19 pandemic posed a significant risk to the health and well-being of First Nations and Métis communities in Alberta. Communities' self-determined and integrated responses with embedded cultural supports - in collaboration with governments, organizations and providers - were key to minimizing morbidity and mortality. Maintaining and building these relationships in the continued pandemic response, broadening approaches to healthcare delivery and continuing to include culture will support attainment of the Indigenous primary healthcare model while addressing logistical challenges in transforming and sustaining healthcare systems in the background of ongoing inequities in the social determinants of health.

An equity-oriented admissions model for Indigenous student recruitment in an undergraduate medical education program.

BACKGROUND: With the 2015 publication of the Truth and Reconciliation Commission of Canada's calls to action, health professional schools are left grappling with how to increase the recruitment and success of Indigenous learners. Efforts to diversify trainee pools have long looked to quota-based approaches to recruit students from underserved communities, though such approaches pose dilemmas around meaningfully dismantling structural barriers to health professional education. Lessons shared here from developing one multi-layered admissions strategy highlight the importance of equity-rather than equality-in any recruitment for learners from medically underserved communities. SUMMARY: The promotion of fairness in the recruitment of future practitioners is not just a question of equalizing access to, in this case, medical school; it involves recognizing the wider social and structural mechanisms that enable privileged access to the medical profession by members of dominant society. This recognition compels a shift in focus beyond merely giving the disadvantaged increased access to an unfair system, towards building tools to address deeper questions about what is meant by the kind of excellence expected of applicants, how it is to be measured, and to what extent these recruits may contribute to improved care for the communities from which they come. CONCLUSION: Equity-based approaches to student recruitment move health professional schools beyond the dilemma of recruiting students from marginalized backgrounds who happen to be most similar to the dominant student population. Achieving this requires a complex view of the target population, recognizing that disadvantage is experienced in many diverse ways, that barriers are encountered along a spectrum of access, and that equity may only emerge when a critically, socially conscious approach is embedded throughout institutional practices.

BACKGROUND: Depuis la publication en 2015 d'un appel à l'action de la Commission de vérité et réconciliation du Canada, les établissements de formation en sciences de la santé sont à la recherche de moyens d'accroître le recrutement et la réussite des apprenants autochtones. Les efforts visant à diversifier le bassin d'apprenant ont longtemps été axés sur la mise en place de quotas pour les étudiants issus de communautés mal desservies, mais de telles approches entraînent des choix difficiles quant au démantèlement approprié des obstacles structurels à la formation professionnelle dans le domaine de la santé. Les leçons tirées de l'élaboration d'une stratégie d'admission à plusieurs niveaux montrent l'importance de l'équité ­ plutôt que de l'égalité ­ dans tout recrutement d'apprenants issus de communautés défavorisées. CORPS DU TEXTE: : La promotion de l'équité dans le recrutement des futurs praticiens va bien au-delà de la garantie d'un accès égal, dans ce cas, à l'école de médecine; elle passe par la reconnaissance des mécanismes sociaux et structurels plus larges qui donnent aux membres des couches dominantes de la société un accès privilégié à la profession médicale. Cette reconnaissance exige de ne plus se contenter de donner aux personnes défavorisées un meilleur accès à un système injuste, mais à mettre en place des outils permettant de s'attaquer aux problématiques sous-jacentes liées au type d'excellence attendu des candidats, à la manière dont elle doit être mesurée et à la contribution que ces recrues peuvent apporter à l'amélioration des soins pour les communautés dont elles sont issues. CONCLUSION: Les approches fondées sur l'équité permettent aux écoles professionnelles de santé de dépasser le dilemme du recrutement d'étudiants issus de milieux marginalisés qui se trouvent être les plus semblables à la population étudiante dominante. Pour y parvenir, il faut adopter une vision complexe de la population cible et reconnaître que les désavantages sont vécus de nombreuses manières différentes, qu'il y a tout un éventail d'obstacles à l'accès, et, enfin, que l'équité ne sera pas établie tant qu'on n'aura pas intégré une approche critique et socialement consciente à l'ensemble des pratiques institutionnelles.

The Indigenous primary health care and policy research network: Guiding innovation within primary health care with Indigenous peoples in Alberta.

In 2015, the Truth and Reconciliation Commission of Canada released its Final Report with 94 Calls to Action, several of which called upon the health care sector to reform based on the principles of reconciliation. In the province of Alberta, Canada, numerous initiatives have arisen to address the health legacy Calls to Action, yet there is no formal mechanism to connect them all. As such, these initiatives have resulted in limited improvements overall. Recognizing the need for clear leadership, responsibility, and dedicated funding, stakeholders from across Alberta were convened in the Spring of 2019 for two full-day roundtable meetings to provide direction for a proposed Canadian Institutes of Health Research Network Environment for Indigenous Health Research that focused on primary health care and policy research. The findings from these roundtable meetings were synthesized and integrated into the foundational principles of the Indigenous Primary Health Care and Policy Research (IPHCPR) Network. The IPHCPR Network has envisioned a renewed and transformed primary health care system to achieve Indigenous health equity, aligned with principles and health legacy Calls to Action advocated by the Truth and Reconciliation Commission of Canada.

'Communities are attempting to tackle the crisis': a scoping review on community plans to prevent and reduce opioid-related harms.

OBJECTIVES: We sought to understand the implementation of multifaceted community plans to address opioid-related harms. DESIGN: Our scoping review examined the extent of the literature on community plans to prevent and reduce opioid-related harms, characterise the key components, and identify gaps. DATA SOURCES: We searched MEDLINE, Embase, PsycINFO, CINHAL, SocINDEX and Academic Search Primer, and three search engines for English language peer-reviewed and grey literature from the past 10 years. ELIGIBILITY CRITERIA: Eligible records addressed opioid-related harms or overdose, used two or more intervention approaches (eg, prevention, treatment, harm reduction, enforcement and justice), involved two or more partners and occurred in an Organisation for Economic Co-operation and Development country. DATA EXTRACTION AND SYNTHESIS: Qualitative thematic and quantitative analysis was conducted on the charted data. Stakeholders were engaged through fourteen interviews, three focus groups and one workshop. RESULTS: We identified 108 records that described 100 community plans in Canada and the USA; four had been evaluated. Most plans were provincially or state funded, led by public health and involved an average of seven partners. Commonly, plans used individual training to implement interventions. Actions focused on treatment and harm reduction, largely to increase access to addiction services and naloxone. Among specific groups, people in conflict with the law were addressed most frequently. Community plans typically engaged the public through in-person forums. Stakeholders identified three key implications to our findings: addressing equity and stigma-related barriers towards people with lived experience of substance use; improving data collection to facilitate evaluation; and enhancing community partnerships by involving people with lived experience of substance use. CONCLUSION: Current understanding of the implementation and context of community opioid-related plans demonstrates a need for evaluation to advance the evidence base. Partnership with people who have lived experience of substance use is underdeveloped and may strengthen responsive public health decision making.

Advancing Indigenous primary health care policy in Alberta, Canada.

For Indigenous people worldwide, accessing Primary Health Care (PHC) services responsive to socio-cultural realities is challenging, with institutional inequities in healthcare and jurisdictional barriers encumbering patients, providers, and decision-makers. In the Canadian province of Alberta, appropriate Indigenous health promotion, disease prevention, and primary care health services are needed, though policy reform is hindered by complex networks and competing interests between: federal/provincial funders; reserve/urban contexts; medical/allied health professional priorities; and three Treaty territories each structuring fiduciary responsibilities of the Canadian government. In 2015, the Truth and Reconciliation Commission (TRC) of Canada released a final report from over six years spent considering impacts of the country's history of Indian residential schools, which for more than a century forcibly removed thousands of children from their families and communities. The TRC directed 94 calls to action to all levels of society, including health systems, to address an historical legacy of cultural assimilationism against Indigenous peoples. To address TRC calls that Indigenous health disparities be recognized as resulting from previous government policies, and to integrate Indigenous leadership and perspectives into health systems, PHC decision-makers, practitioners, and scholars in the province of Alberta brought together stakeholders from across Canada. The gathering detailed here explored Indigenous PHC models from other Canadian provinces to collaboratively build relationships for policy reform and identify opportunities for PHC innovations within Alberta.

Obesity in adults: a clinical practice guideline

Obesity is a complex chronic disease in which abnormal or excess body fat (adiposity) impairs health, increases the risk of long-term medical complications and reduces lifespan.1 Epidemiologic studies define obesity using the body mass index (BMI; weight/height2), which can stratify obesity-related health risks at the population level. Obesity is operationally defined as a BMI exceeding 30 kg/m2 and is subclassified into class 1 (30­34.9), class 2 (35­39.9) and class 3 (≥ 40). At the population level, health complications from excess body fat increase as BMI increases.2 At the individual level, complications occur because of excess adiposity, location and distribution of adiposity and many other factors, including environmental, genetic, biologic and socioeconomic factors.

Obesity management and indigenous peoples

Exploring obesity within the context of multiple co-occurring health, socioeconomic, environmental and cultural factors, and situating these within policy/jurisdictional structures specific to Indigenous populations (e.g., federal versus provincial health funding), can facilitate emerging opportunities for obesity management. These contexts highlight a tension that providers must navigate, between drivers of obesity embedded in social- and system-level inequities and protective factors that promote healing through relationships and culturally contextualized approaches to care. Healthcare professionals should consider the following contextual factors when providing obesity care for Indigenous peoples: Structural inequities (i.e., social and systemic in origin) are embedded in health, education, social services and other systems, and they maintain social disadvantage for a large segment of the Indigenous population. These inequities influence food security, for example, through lower wages perpetuated by inaccessible education and high food costs in urban and remote areas, or through limited access to activity-based resources at individual and community levels. Indigenous people have experienced systemic disadvantage throughout their lifespan and those of their family members, producing a cumulative effect on obesity. In Indigenous contexts, obesity is therefore deeply affected by responses to pervasive stressors, as individuals navigate social and systemic barriers to meeting their goals. Overwhelming stress from social (e.g., discrimination) and systemic exclusion (e.g., poor or absent primary healthcare) can disempower Indigenous people in maintaining healthy behaviours. Patients may appear to be resistant to healthcare recommendations, where together with healthcare providers they may come to feel fatalistic toward their capacity to address obesity. Healthcare professionals often interpret such patient incongruity with recommendations in a deficit lens, labeling it as patient non-compliance or non-adherence. This non-concordance, or seeming apathy, may actually be a sense of paralysis in the face of overwhelming stress. Exploration of the patient's social reality can open opportunities for contextualized approaches to obesity management. Reflection on assumptions about seeming apathy may contextualize patient motivations, where deep exploration of one's own perceptions, attitudes and behaviours toward Indigenous patients may uncover anti-Indigenous sentiment implicit in healthcare practices or systems. Validation of a patient's experiences of inequity can empower both patients and providers to identify steps to address social factors that influence health behaviours. Culture and relationships facilitate learning of complex knowledge. The interaction of obesity with co-occurring structural factors represents complex knowledge that is critical for patients to gain deep understanding of their health. Non-Indigenous healthcare providers may have ways of knowing and doing that are inconsistent with Indigenous patient perspectives on health knowledge and how it should be exchanged. Obesity management in this context requires a longitudinal, relationship-centred approach that engages and explores interactions with co-existing factors to build both knowledge and trust, in a manner aligned with Indigenous principles for communication. Connection: When patients connect with healthcare providers around their co-occurring health needs, there are complex linkages between wider structures and their health. The therapeutic relationship may be critically supportive when knowledge is delivered in a relevant way and makes sense to the patient. Trust-building: Healing of the therapeutic relationship is itself fundamental to engaging and supporting patients within contexts of multi-generational trauma to explore complex intersections in relation to health and health behaviour change. Differing worldviews: Western concepts of healthy behaviours related to obesity management, including preferences for body size, activity and food, may be dis­cordant with Indigenous perspectives. Patients may not identify with provider perspectives, and providers must not assume that patients share provider worldviews or principles around how to communicate health knowl­edge. Discordant perspectives may involve a distinct sense of locus of control, self-efficacy and modes for speaking about the pathways into and out of obesity. An Indigenous approach to knowledge exchange in­cludes contextualizing knowledge within the world of the patient and employing a narrative-based and indi­rect approach to sharing knowledge.