Toward intersectional and culturally relevant sex and gender analysis in health research.

Current institutional frameworks in sex- and gender-based analysis (SGBA) are promising, but significant gaps remain in their relation to recent developments in research praxis. In this paper we draw from our own experiences with a national health research funding agency, the Canadian Institutes of Health Research (CIHR), to critically examine the uptake and implementation of its current frameworks and practices of sex and gender analysis in health research. We conducted semi-structured interviews with a cohort of 18 health researchers alongside an institutional policy analysis to show how sex and gender have been understood, integrated, and addressed within the agency and initiative. Our findings reveal that attention to date has focused on representation (human and data) while deeper justice issues that are attentive to intersectionality, positionality and reflexivity-remain ambiguous. Finally, we discuss possible strategies for institutions to improve the uptake of knowledge, training, and policy to better support intersectional and culturally-relevant frameworks across the diverse research community.

Public health moves to innocence and evasion? Graduate training programs' engagement in truth and reconciliation for Indigenous health.

OBJECTIVES: Indigenous peoples are the first peoples of what is now called Canada. Canadians have benefitted from their largesse and contributions in a myriad of ways that remain unacknowledged. Indeed, ongoing colonization and systemic anti-Indigenous racism in all quarters of our society have had heinous impacts on their health and well-being. Despite this reality and multiple calls for redress, Indigenous health is still missing from the Core Competencies for Public Health in Canada, having obvious implications for public health training programs and subsequent practice. Our objective in this paper is to critically explore the reasons behind institutional apathy for reconciliation in Indigenous health. METHODS: Interviews were conducted with 19 leaders in Canadian Graduate Public Health Programs (CGPHPs) at 15 universities to explore the extent to which CGPHPs engage with Canada's 2015 Truth and Reconciliation Commission's Calls to Action to address Indigenous health. We used thematic discourse analysis to illuminate the landscape and make recommendations. RESULTS: Participants agree that Indigenous health is important, but our data reveal an uneven landscape for addressing the Calls to Action. Curriculum was limited though we noted modest positive change. On the whole, the non-Indigenous (white) professoriate still needs to educate themselves while not all see the need to do so. Many deflected responsibility. Yet anecdotally, there is desire among CGPHP students who are already unsettling themselves to see such competency in their training. CONCLUSION: It is a settler evasion to claim lack of expertise, to express a desire to limit the burden on Indigenous academics, and to stand on the sidelines of institutional inertia. Our findings are a call to CGPHPs to do better.

RéSUMé: OBJECTIFS: Les peuples autochtones sont les premiers peuples de ce qu'on appelle maintenant le Canada. Les Canadiens ont profité de leurs largesses et de leurs contributions d'une multitude de façons qui restent méconnues. Cependant, la colonisation en cours et le racisme systémique anti-autochtone dans tous les quartiers de notre société ont eu des effets odieux sur leur santé et leur bien-être. Malgré cette réalité et les multiples demandes de réparation, la santé des Autochtones est toujours absente dans les Compétences essentielles en santé publique au Canada, ce qui a des implications évidentes pour la formation en santé publique et la pratique subséquente. Notre objectif dans cet article est d'explorer de manière critique les raisons pour l'apathie institutionnelle pour la réconciliation en santé autochtone. MéTHODES: Des entrevues ont été menées auprès de 19 dirigeants des Programmes de Santé Publique Tertiaire Canadiens (PSPTC) dans 15 universités afin d'explorer dans quelle mesure les PSPTC s'engagent dans les appels à l'action de la Commission de vérité et réconciliation du Canada de 2015 pour améliorer la santé des Autochtones. Nous avons utilisé l'analyse thématique du discours pour éclairer la situation actuelle et faire des recommendations. RéSULTATS: Les participant(e)s ont convenu que la santé des Autochtones est importante, mais nos données révèlent un terrain inégal pour répondre aux appels à l'action. Leur programme était limité mais nous constatons de modestes changements positifs. Globalement, les professeur(e)s non-autochtones (blanc(he)s) doivent encore s'éduquer, alors que tous n'en voient pas la nécessité. Beaucoup ont détourné leurs responsabilités. Des preuves anecdotiques indiquent un désir parmis les étudiant(e)s du PSPTC, qui sont déjà en train de se perturber de manière décoloniale, de voir telle compétence dans leur formation. CONCLUSION: C'est une évasion de responsabilité de la part des colons de revendiquer le manque d'expertise, d'exprimer le désir de limiter le fardeau des universitaires autochtones et de rester en marge de l'inertie institutionnelle. Nos résultats sont un appel aux PSPTC à faire mieux.

Bonding social capital and health within four First Nations communities in Canada: A cross-sectional study.

To date, research on social capital in Indigenous contexts has been scarce. In this quantitative study, our objectives were to (1): Describe bonding social capital within four distinct First Nations communities in Canada, and (2) Explore the associations between bonding social capital and self-rated health in these communities. With community permission, cross-sectional data were drawn from the Canadian Alliance for Healthy Hearts and Minds study. Four reserve-based First Nations communities were included in the analysis, totaling 591 participants. Descriptive statistics were computed to examine levels of social capital among communities and logistic regression analyses were performed to identify social capital predictors of good self-rated health. Age, sex, education level, and community were controlled for in all models. Across the four communities in this study, areas of common social capital included frequent socialization among friends and large and interconnected family networks. Positive self-rated health was associated with civic engagement at federal or provincial levels (OR=1.65, p<0.05) and organizational membership (OR=1.60, p<0.05), but overall, sociodemographic variables were more significantly associated with self-rated health than social capital variables. Significant differences in social capital were found across the four communities and community of residence was a significant health outcomes predictor in all logistic regression models. In conclusion, this study represents one of the first efforts to quantitatively study First Nations social capital with respect to health in Canada. The results reflect significant differences in the social capital landscape across different First Nations communities and suggest the need for social capital measurement tools that may be adapted to unique Indigenous contexts. Further, the impact of social capital on health may be better explored and interpreted with more community-specific instruments and with supplementary qualitative inquiry.

Implementing Indigenous Gender-Based Analysis in Research: Principles, Practices and Lessons Learned.

Numerous tools for addressing gender inequality in governmental policies, programs, and research have emerged across the globe. Unfortunately, such tools have largely failed to account for the impacts of colonialism on Indigenous Peoples' lives and lands. In Canada, Indigenous organizations have advanced gender-based analysis frameworks that are culturally-grounded and situate the understanding of gender identities, roles, and responsibilities within and across diverse Indigenous contexts. However, there is limited guidance on how to integrate Indigenous gender-based frameworks in the context of research. The authors of this paper are participants of a multi-site research program investigating intersectoral spaces of Indigenous-led renewable energy development within Canada. Through introspective methods, we reflected on the implementation of gender considerations into our research team's governance and research activities. We found three critical lessons: (1) embracing Two-Eyed Seeing or Etuaptmumk while making space for Indigenous leadership; (2) trusting the expertise that stems from the lived experiences and relationships of researchers and team members; and (3) shifting the emphasis from 'gender-based analysis' to 'gender-based relationality' in the implementation of gender-related research considerations. Our research findings provide a novel empirical example of the day-to-day principles and practices that may arise when implementing Indigenous gender-based analysis frameworks in the context of research.

If only they had accessed the data: Governmental failure to monitor pulp mill impacts on human health in Pictou Landing First Nation.

For over fifty years, Pictou Landing First Nation (PLFN), a small Mi'kmaw community on the northern shore of mainland Nova Scotia, Canada, has been told by a Joint Environmental Health Monitoring Committee (JEHMC) mandated to oversee the health of the community that their health has not been impacted by exposure to 85 million litres of pulp mill effluent dumped every day into what was once a culturally significant body of water bordering their community. Yet, based on lived experience, the community knows otherwise, and despite countless dollars spent on government and industry-sponsored research, their concerns have not gone away. Using biopolitical theory, we explore why JEHMC never fully implemented its mandate. We will use a Mi'kmaw environmental 'theoretical' framework to demonstrate that indicators of a relational epistemology and ontology that have been consistently and persistently overlooked in Indigenous environmental health research demands that Indigenous connections to the air, land and water must be taken into consideration to get a full understanding of environmental health impacts. Guided by the principle of Etuaptmumk (Two-Eyed Seeing), which brings together the strengths of both western and Indigenous knowledge, and employing a community-based participatory research approach, we use data that could have been accessed by the JEHMC that might have signaled that human health studies were warranted. Further, we developed an environmental health survey that more appropriately assesses the impacts on the community. Finally, we will discuss how an Indigenous-developed framework can adequately assess the impacts of land displacement and environmental dispossession on the health of Indigenous communities and illustrate how our framework can serve as a guide to others when exploring Indigenous environmental health more broadly.

Are the natural sciences ready for truth, healing, and reconciliation with Indigenous peoples in Canada? Exploring 'settler readiness' at a world-class freshwater research station.

The Experimental Lakes Area in Northwestern Ontario, Canada, is a globally prominent freshwater research facility, conducting impactful whole-of-lake experiments on so-called 'pristine' lakes and watersheds. These lakes are located in traditional Anishinaabe (Indigenous) territory and the home of 28 Treaty #3 Nations, something rarely acknowledged until now. Indeed, Indigenous peoples in the area have historically been excluded from the research facility's governance and research. Shortly after it changed hands in 2014-from the federal government to the not-for-profit International Institute of Sustainable Development (IISD)-the Truth and Reconciliation Commission (TRC) of Canada released its Calls to Action to all Canadians. The newly named International Institute of Sustainable Development-Experimental Lakes Area (IISD-ELA) began to respond with a number of initiatives aimed to develop relationships with local Indigenous peoples and communities. In this paper, from the perspectives of IISD-ELA staff members, we share findings from an exploratory study into the relationships beginning to develop between IISD-ELA and Treaty #3 Nations. We used semi-structured interviews (n = 10) to identify how staff perceived their initial efforts and contextualize those with the current literature on meaningfully engagement in reconciliation. Our analysis highlights perceived barriers, including time, resources, and funding constraints, as well as an acknowledged lack of cultural awareness and sensitivity training. Participants also recognized the need to engage Indigenous knowledge holders and embrace their ways of knowing at the research station. While the study is small in scale, as an international leader in freshwater science, transparency in the IISD-ELA's journey in reconciliation has the potential to inform, influence, and 'unsettle' settler-colonial scientists, field stations, and institutions across the country and beyond.

The public health emergency of climate change: how/are Canadian post-secondary public health sciences programs responding?

OBJECTIVE: The Intergovernmental Panel on Climate Change recently issued a statement that the fate of human society and human health is at serious risk of catastrophic impacts unless we take bold action to keep global warming under 1.5 °C. In 2015, the Canadian Public Health Association noted emerging efforts to embrace intersectoral approaches to global change in public health research and practice. In this study, we question the extent to which Canadian Graduate Public Health Sciences Programs have kept pace with these efforts to see climate change surface as a new frontier for training the next generation of researchers and practitioners. METHODS: Semi-structured interviews (19) were conducted with Department Heads (or equivalents) of graduate-level Public Health Sciences Programs at 15 Canadian universities concerning the place of climate change in their respective curricula. Interviews were designed to elicit participants' institutional perspectives on the importance of climate change in the Public Health Sciences and identify perceived challenges and opportunities. RESULTS: Despite wide recognition among participants that climate change is a public health "crisis", very few reported having substantive curricular engagement on the topic. Key challenges identified were lack of resources, organizational issues, and political barriers. Key opportunities to adapt curricula to address this new frontier in Public Health were faculty interest and expertise, cross-disciplinary collaboration, and pressure from the institution. CONCLUSION: Our findings provide evidence for post-secondary Public Health Sciences Programs to understand the need to address their own sluggishness when what is needed are bold, even radical, shifts to existing curricula.

RéSUMé: OBJECTIF: Le groupe d'experts intergouvernemental sur l'évolution du climat a récemment publié une déclaration que le destin de la société humaine et de sa santé font face à de graves risques des conséquences catastrophiques, à moins que nous ne prenions des mesures audacieuses pour maintenir le réchauffement planétaire à moins de 1,5°C. En 2015, l'Association canadienne de santé publique a pris note des efforts en cours pour adopter des approches intersectorielles du changement planétaire dans la recherche et la pratique en santé publique. Dans cette étude, nous nous demandons dans quelle mesure les programmes d'études supérieures des programmes de sciences de la santé publique canadiens ont suivi le rythme de ces efforts pour faire en sorte que les changements climatiques deviennent une nouvelle frontière pour la formation de la prochaine génération de chercheurs (euses) et de praticiens (ciennes). MéTHODE: Des entretiens semi-structurés (19) ont été menés avec les chefs de département (ou équivalents) des programmes d'études supérieures de sciences de la santé de 15 universités canadiennes sur la place du changement climatique dans leurs programmes respectifs. Les entretiens ont été conçus de manière à obtenir les perspectives institutionnelles des participants sur l'importance du changement climatique dans les sciences de la santé publique et à identifier ce qu'ils voient comme défis, obstacles et voies de changement. RéSULTATS: Bien que les participants aient largement reconnu que le changement climatique était une « crise ¼ de santé publique, très peu de participants ont signalé un engagement substantiel avec le sujet dans leurs programmes. Les principaux problèmes identifiés étaient le manque de ressources, les problèmes d'organisation et les obstacles politiques. Les principales opportunités pour adapter les programmes d'études à cette nouvelle frontière de la santé publique sont l'intérêt et l'expertise des professeurs (es), la collaboration interdisciplinaire et les pressions exercées par l'institution. CONCLUSION: Nos résultats démontrent que les programmes d'études supérieures de sciences de la santé doivent comprendre la nécessité de traiter à leur propre lenteur, alors que nous avons besoin d'un changement audacieux, même radical, vers les programmes existants.

Explaining the variability in cardiovascular risk factors among First Nations communities in Canada: a population-based study.

BACKGROUND: Historical, colonial, and racist policies continue to influence the health of Indigenous people, and they continue to have higher rates of chronic diseases and reduced life expectancy compared with non-Indigenous people. We determined factors accounting for variations in cardiovascular risk factors among First Nations communities in Canada. METHODS: Men and women (n=1302) aged 18 years or older from eight First Nations communities participated in a population-based study. Questionnaires, physical measures, blood samples, MRI of preclinical vascular disease, and community audits were collected. In this cross-sectional analysis, the main outcome was the INTERHEART risk score, a measure of cardiovascular risk factor burden. A multivariable model was developed to explain the variations in INTERHEART risk score among communities. The secondary outcome was MRI-detected carotid wall volume, a measure of subclinical atherosclerosis. FINDINGS: The mean INTERHEART risk score of all communities was 17·2 (SE 0·2), and more than 85% of individuals had a risk score in the moderate to high risk range. Subclinical atherosclerosis increased significantly across risk score categories (p<0·0001). Socioeconomic advantage (-1·4 score, 95% CI -2·5 to -0·3; p=0·01), trust between neighbours (-0·7, -1·2 to -0·3; p=0·003), higher education level (-1·9, -2·9 to -0·8, p<0·001), and higher social support (-1·1, -2·0 to -0·2; p=0·02) were independently associated with a lower INTERHEART risk score; difficulty accessing routine health care (2·2, 0·3 to 4·1, p=0·02), taking prescription medication (3·5, 2·8 to 4·3; p<0·001), and inability to afford prescription medications (1·5, 0·5 to 2·6; p=0·003) were associated with a higher INTERHEART risk score. Collectively, these factors explained 28% variation in the cardiac risk score among communities. Communities with higher socioeconomic advantage and greater trust, and individuals with higher education and social support, had a lower INTERHEART risk score. Communities with difficulty accessing health care, and individuals taking or unable to afford prescription medications, had a higher INTERHEART risk score. INTERPRETATION: Cardiac risk factors are lower in communities with high socioeconomic advantage, greater trust, social support and educational opportunities, and higher where it is difficult to access health care or afford prescription medications. Strategies to optimise the protective factors and reduce barriers to health care in First Nations communities might contribute to improved health and wellbeing. FUNDING: Heart and Stroke Foundation of Canada, Canadian Partnership Against Cancer, Canadian Institutes for Health Research.

The tools at their fingertips: How settler colonial geographies shape medical educators' strategies for grappling with Anti-Indigenous racism.

Settler colonialism implicates settler and Indigenous populations differently within ongoing projects of settlement and nation building. The uneven distribution of benefits and harms is a primary consequence of settler colonialism. Indeed, it is a central organizing feature of the settler state's governance of Indigenous societies and is animated, in part, through pervasive settler ignorance and anti-Indigenous racism, which has manifested in persistent health disparities amongst Indigenous peoples. This broader socio-political context surrounding medical schools, which are seeking to develop teaching and learning about Indigenous health presents a significant challenge. Understanding the cognitive and affective tools that settler educators use when grappling with questions of race, racialization, and Indigenous difference is an important step in addressing anti-Indigenous racism in health care provision. This paper reports on findings from in-depth semi-structured interviews with educators at one Canadian medical school. Our intent was to elicit respondents' understandings, experiences, and attitudes regarding Indigenous-settler relations, Indigenous health and healthcare, and the inclusion of Indigenous health in the curriculum as a means of identifying facilitators and barriers to improving Indigenous health and health care experiences. Respondents were generally sympathetic and evinced an earnest desire to include more Indigenous-related content in the curriculum. What became clear over the course of the data collection and analysis, however, was that most respondents lacked the tools to engage critically with questions of race and racialization and how these are manifested in the context of asymmetrical settler colonial power. We argue that this inability, at best, limits the effectiveness of much needed efforts to incorporate more content relating to Indigenous health, but worse yet, risks re-entrenching anti-Indigenous racism and settler dominance.

Awareness as a dimension of health care access: exploring the case of rural palliative care provision in Canada.

OBJECTIVES: In Canada, the rural elderly population is increasing in size, as is their need for palliative care services in these settings. This analysis aims to identify awareness-associated barriers to delivering rural palliative care services, along with suggestions for improving service delivery from the perspective of local health care providers. METHODS: A total of 40 semi-structured interviews with various formal and informal health care providers were conducted in four rural and/or remote Canadian communities with limited palliative care resources. Interview data were thematically coded using Penchansky and Thomas' five dimensions of access (i.e. availability, (geographic) accessibility, accommodation, acceptability and affordability). Saurman's recently added sixth dimension of access - awareness - was also identified while coding and subsequently became the primary focus of this analysis. RESULTS: Identified barriers to palliative care awareness and suggestions on how to enhance this awareness, and ultimately palliative care delivery, corresponded with three key themes arising from the data: limited palliative care knowledge/education, communication and coordination. Participants recognized the need for more palliative care education, open lines of communication and better coordination of palliative care initiatives and local resources in their communities. CONCLUSIONS: These findings suggest that identifying the barriers to palliative care awareness in rural communities may be foundational to addressing barriers to the other five dimensions of access. A thorough understanding of these three areas of awareness knowledge, communication and coordination, as well as the connections between them, may help enhance how rural palliative care is delivered in the future.

Predictors of medical student interest in Indigenous health learning and clinical practice: a Canadian case study.

BACKGROUND: Including content on Indigenous health in medical school curricula has become a widely-acknowledged prerequisite to reducing the health disparities experienced by Indigenous peoples in Canada. However, little is known about what levels of awareness and interest medical students have about Indigenous peoples when they enter medical school. Additionally, it is unclear whether current Indigenous health curricula ultimately improve students' beliefs and behaviours. METHODS: A total of 129 students completed a 43-item questionnaire that was sent to three cohorts of first-year medical students (in 2013, 2014, 2015) at one undergraduate medical school in Canada. This survey included items to evaluate students' sociopolitical attitudes towards Indigenous people, knowledge of colonization and its links to Indigenous health inequities, knowledge of Indigenous health inequities, and self-rated educational preparedness to work with Indigenous patients. The survey also assessed students' perceived importance of learning about Indigenous peoples in medical school, and their interest in working in an Indigenous community, which were examined as outcomes. Using principal component analysis, survey items were grouped into five independent factors and outcomes were modelled using staged multivariate regression analyses. RESULTS: Generally, students reported strong interest in Indigenous health but did not believe themselves adequately educated or prepared to work in an Indigenous community. When controlling for age and gender, the strongest predictors of perceived importance of learning about Indigenous health were positive sociopolitical attitudes about Indigenous peoples and knowledge about colonization and its links to Indigenous health inequities. Significant predictors for interest in working in an Indigenous community were positive sociopolitical attitudes about Indigenous peoples. Knowledge about Indigenous health inequities was negatively associated with interest in working in an Indigenous community. CONCLUSIONS: Students' positive sociopolitical attitudes about Indigenous peoples is the strongest predictor of both perceived importance of learning about Indigenous health and interest in working in Indigenous communities. In addition to teaching students about the links between colonization, health inequities and other knowledge-based concepts, medical educators must consider the importance of attitude change in designing Indigenous health curricula and include opportunities for experiential learning to shape students' future behaviours and ultimately improve physician relationships with Indigenous patients.

Canadian Alliance for Healthy Hearts and Minds: First Nations Cohort Study Rationale and Design.

BACKGROUND: This is the first national indigenous cohort study in which a common, in-depth protocol with a common set of objectives has been adopted by several indigenous communities across Canada. OBJECTIVES: The overarching objective of the Canadian Alliance for Healthy Hearts and Minds (CAHHM) cohort is to investigate how the community-level environment is associated with individual health behaviors and the presence and progression of chronic disease risk factors and chronic diseases such as cardiovascular disease (CVD) and cancer. METHODS: CAHHM aims to recruit approximately 2,000 First Nations indigenous individuals from up to nine communities across Canada and have participants complete questionnaires, blood collection, physical measurements, cognitive assessments, and magnetic resonance imaging (MRI). RESULTS: Through individual- and community-level data collection, we will develop an understanding of the specific role of the socioenvironmental, biological, and contextual factors have on the development of chronic disease risk factors and chronic diseases. CONCLUSIONS: Information collected in the indigenous cohort will be used to assist communities to develop local management strategies for chronic disease, and can be used collectively to understand the contextual, environmental, socioeconomic, and biological determinants of differences in health status in harmony with First Nations beliefs and reality.

Chemical and microbial characteristics of municipal drinking water supply systems in the Canadian Arctic.

Drinking water in the vast Arctic Canadian territory of Nunavut is sourced from surface water lakes or rivers and transferred to man-made or natural reservoirs. The raw water is at a minimum treated by chlorination and distributed to customers either by trucks delivering to a water storage tank inside buildings or through a piped distribution system. The objective of this study was to characterize the chemical and microbial drinking water quality from source to tap in three hamlets (Coral Harbour, Pond Inlet and Pangnirtung-each has a population of <2000) on trucked service, and in Iqaluit (population ~6700), which uses a combination of trucked and piped water conveyance. Generally, the source and drinking water was of satisfactory microbial quality, containing Escherichia coli levels of <1 MPN/100 mL with a few exceptions, and selected pathogenic bacteria and parasites were below detection limits using quantitative polymerase chain reaction (qPCR) methods. Tap water in households receiving trucked water contained less than the recommended 0.2 mg/L of free chlorine, while piped drinking water in Iqaluit complied with Health Canada guidelines for residual chlorine (i.e. >0.2 mg/L free chlorine). Some buildings in the four communities contained manganese (Mn), copper (Cu), iron (Fe) and/or lead (Pb) concentrations above Health Canada guideline values for the aesthetic (Mn, Cu and Fe) and health (Pb) objectives. Corrosion of components of the drinking water distribution system (household storage tanks, premise plumbing) could be contributing to Pb, Cu and Fe levels, as the source water in three of the four communities had low alkalinity. The results point to the need for robust disinfection, which may include secondary disinfection or point-of-use disinfection, to prevent microbial risks in drinking water tanks in buildings and ultimately at the tap.

"Put It Near the Indians": Indigenous Perspectives on Pulp Mill Contaminants in Their Traditional Territories (Pictou Landing First Nation, Canada).

BACKGROUND: Pictou Landing First Nation (PLFN), a small Mi'kmaw community on the Canadian east coast, has had a relationship with a tidal estuary known as A'se'k for millennia. In the 1960s, it became the site of effluent disposal from a nearby pulp mill. Almost immediately, health concerns regularly and consistently reverberated throughout the community. OBJECTIVES: The Pictou Landing Native Women's Group (PLNWG) formed a community-based participatory research (CBPR) partnership with an academic team to conceptualize community well-being in the context of environment and human health connections. This paper documents Mi'kmaw Elders' stories of A'se'k before it became contaminated. METHODS: Using narrative inquiry vis-à-vis oral histories, we carried out conversational interviews with 10 Elders from PLFN. These interviews were thematically analyzed and 're-storied' through a process of (w)holistic content analysis. RESULTS: Our findings present four broad story layers, recounting the themes that emerged through analysis and presenting a broad Mi'kmaw narrative of A'se'k. These story layers share: what A'se'k originally provided, the historical/cultural context of PLFN, changes to land and health after the mill was put in, and reflections on the past and future of A'se'k. CONCLUSIONS: Our research offers a novel contribution to the literature by showing how Mi'kmaw perspectives on the pollution at A'se'k reveal the close connection between Mi'kmaw livelihood, local ecologies, and health and well-being. Our research also provides insights into the way the research relationship developed between the PLNWG and the academic team, providing a pathway for others seeking to decolonize the research landscape.

Revisiting the use of 'place' as an analytic tool for elucidating geographic issues central to Canadian rural palliative care.

In 2010, Castleden and colleagues published a paper in this journal using the concept of 'place' as an analytic tool to understand the nature of palliative care provision in a rural region in British Columbia, Canada. This publication was based upon pilot data collected for a larger research project that has since been completed. With the addition of 40 semi-structured interviews with users and providers of palliative care in four other rural communities located across Canada, we revisit Castleden and colleagues' (2010) original framework. Applying the concept of place to the full dataset confirmed the previously published findings, but also revealed two new place-based dimensions related to experiences of rural palliative care in Canada: (1) borders and boundaries; and (2) 'making' place for palliative care progress. These new findings offer a refined understanding of the complex interconnections between various dimensions of place and palliative care in rural Canada.

Increasing Response Rates on Face-to-Face Surveys with Indigenous Communities in Canada: Lessons from Pictou Landing.

BACKGROUND: Designing an effective survey for gathering primary health data using a community-based participatory research (CBPR) approach in Indigenous communities in Canada has its challenges. Yet, the Pictou Landing First Nation (PFLN) Native Women's Group (NWG) and academic research partners achieved a 59% response rate. OBJECTIVES: To share lessons learned with both campus and community-based research teams engaged in CBPR involving Indigenous communities on the process of team development, and particularly survey development and execution, as well as the factors that led to a reliable and valid household level environmental health survey that achieved a 59% response rate. METHODS: Multiple debriefings conducted over the course of the 12-month data collection period allowed us to modify our protocol to fit with community oscillations. RESULTS/LESSONS LEARNED: Unique aspects of CBPR allowed for the development of a culturally appropriate survey protocol and culturally relevant variables that reflected the concerns of the NWG, and presenting preliminary data to the community also encouraged community buy-in to participate. CONCLUSIONS: Sharing lessons learned in this project are intended to have positive implications for future CBPR projects wanting to collect primary health survey data involving Indigenous communities.

Palliating inside the lines: The effects of borders and boundaries on palliative care in rural Canada.

We draw lines to divide our world into specific places, territories, and categories. Although borders and boundaries are dynamic and socially constructed, their existence creates many broad impacts on our lives by geographically distinguishing between groups (e.g., us/them; here/there; inside/outside) at various scales from the national down to the personal spaces of the individual. Particularly, borders and boundaries can be used to define a variety of differing spaces such as the familial, social, economic, political, as well as issues of access - including access to health services. Despite the implicit connection between borders, boundaries, and health, little research has investigated this connection from a health geography perspective. As such, this secondary thematic analysis contributes to addressing this notable gap by examining how borders and boundaries are experienced and perceived to impact access to palliative care in rural Canada from the perspectives of the formal and informal providers of such care. Drawing upon data from qualitative interviews (n = 40) with formal and informal palliative caregivers residing in four different rural Canadian communities, five forms of borders and boundaries were found to directly impact care delivery/receipt: political; jurisdictional; geographical; professional; and cultural. Implicitly and explicitly, participants discussed these borders and boundaries while sharing their experiences of providing palliative care in rural Canada. We conclude by discussing the implications of our findings for palliative care in rural Canada, while also emphasizing the need for more health geography, and related social science, researchers to recognize the significance of borders and boundaries in relation to health and healthcare delivery. Lastly, we emphasize the transferability of these findings to other health sectors, geographical settings, and disciplines.

Asthma Prevention and Management for Aboriginal People: Lessons From Mi'kmaq Communities, Unama'ki, Canada, 2012.

BACKGROUND: Asthma affects at least 10% of Aboriginal children (aged 11 or younger) in Canada, making it the second most common chronic disease suffered by this demographic group; yet asthma support strategies specific to Aboriginal peoples have only begun to be identified. COMMUNITY CONTEXT: This research builds on earlier phases of a recent study focused on identifying the support needs and intervention preferences of Aboriginal children with asthma and their parents or caregivers. Here, we seek to identify the implications of our initial findings for asthma programs, policies, and practices in an Aboriginal context and to determine strategies for implementing prevention programs in Aboriginal communities. METHODS: Five focus groups were conducted with 22 recruited community health care professionals and school personnel in 5 Mi'kmaq communities in Unama'ki (Cape Breton), Nova Scotia, Canada, through a community-based participatory research design. Each focus group was first introduced to findings from a local "social support for asthma" intervention, and then the groups explored issues associated with implementing social support from their respective professional positions. OUTCOME: Thematic analysis revealed 3 key areas of opportunity and challenges for implementing asthma prevention and management initiatives in Mi'kmaq communities in terms of 1) professional awareness, 2) local school issues, and 3) community health centers. INTERPRETATION: Culturally relevant support initiatives are feasible and effective community-driven ways of improving asthma support in Mi'kmaq communities; however, ongoing assistance from the local leadership (ie, chief and council), community health directors, and school administrators, in addition to partnerships with respiratory health service organizations, is needed.