title: Enhancing health care equity with Indigenous populations: evidence-based strategies from an ethnographic study.
abstract: Structural violence shapes the health of Indigenous peoples globally, and is deeply embedded in history, individual and institutional racism, and inequitable social policies and practices. Many Indigenous communities have flourished, however, the impact of colonialism continues to have profound health effects for Indigenous peoples in Canada and internationally. Despite increasing evidence of health status inequities affecting Indigenous populations, health services often fail to address health and social inequities as routine aspects of health care delivery. In this paper, we discuss an evidence-based framework and specific strategies for promoting health care equity for Indigenous populations.
  
  
  
  Using an ethnographic design and mixed methods, this study was conducted at two Urban Aboriginal Health Centres located in two inner cities in Canada, which serve a combined patient population of 5,500. Data collection included in-depth interviews with a total of 114 patients and staff (n = 73 patients; n = 41 staff), and over 900 h of participant observation focused on staff members' interactions and patterns of relating with patients.
  
  
  
  Four key dimensions of equity-oriented health services are foundational to supporting the health and well-being of Indigenous peoples: inequity-responsive care, culturally safe care, trauma- and violence-informed care, and contextually tailored care. Partnerships with Indigenous leaders, agencies, and communities are required to operationalize and tailor these key dimensions to local contexts. We discuss 10 strategies that intersect to optimize effectiveness of health care services for Indigenous peoples, and provide examples of how they can be implemented in a variety of health care settings.
  
  
  
  While the key dimensions of equity-oriented care and 10 strategies may be most optimally operationalized in the context of interdisciplinary teamwork, they also serve as health equity guidelines for organizations and providers working in various settings, including individual primary care practices. These strategies provide a basis for organizational-level interventions to promote the provision of more equitable, responsive, and respectful PHC services for Indigenous populations. Given the similarities in colonizing processes and Indigenous peoples' experiences of such processes in many countries, these strategies have international applicability.
authors.affiliation: School of Nursing, The University of British Columbia, T201 -- 2211 Wesbrook Mall, Vancouver, British Columbia, V6T 2B5, Canada. annette.browne@ubc.ca.
authors.forename: Annette J
authors.initials: AJ
authors.lastname: Browne
authors.affiliation: School of Nursing, The University of British Columbia, T201 -- 2211 Wesbrook Mall, Vancouver, British Columbia, V6T 2B5, Canada.
authors.forename: Colleen
authors.initials: C
authors.lastname: Varcoe
authors.affiliation: Manitoba First Nations Centre for Aboriginal Health Research, 715 John Buhler Research Centre, 727 McDermot Ave, Winnipeg, Manitoba, R3E 3P5, Canada.
authors.forename: Josée
authors.initials: J
authors.lastname: Lavoie
authors.affiliation: Faculty of Health Sciences, University of Ontario Institute of Technology, 2000 Simcoe Street North, Science building, Room 3000, Oshawa, Ontario, L1H 7 K4, Canada.
authors.forename: Victoria
authors.initials: V
authors.lastname: Smye
authors.affiliation: School of Nursing and the Centre for Health Services and Policy Research, The University of British Columbia, T201 -- 2211 Wesbrook Mall, Vancouver, British Columbia, V6T 2B5, Canada.
authors.forename: Sabrina T
authors.initials: ST
authors.lastname: Wong
authors.affiliation: Central Interior Native Health Society, 365 George Street, Prince George, British Columbia, V2L 1R4, Canada.
authors.forename: Murry
authors.initials: M
authors.lastname: Krause
authors.affiliation: Department of Family Practice, The University of British Columbia, 5950 University Boulevard, Vancouver, V6T 1Z3, British Columbia, Canada.
authors.forename: David
authors.initials: D
authors.lastname: Tu
authors.affiliation: Prince George Division of Family Practice, 1302 7 Ave, Prince George, British Columbia, V2L 3P1, Canada.
authors.forename: Olive
authors.initials: O
authors.lastname: Godwin
authors.affiliation: School of Nursing, The University of British Columbia, T201 -- 2211 Wesbrook Mall, Vancouver, British Columbia, V6T 2B5, Canada.
authors.forename: Koushambhi
authors.initials: K
authors.lastname: Khan
authors.affiliation: Indigenous Health Program, Provincial Health Services Authority of British Columbia, 201-601 West Broadway, Vancouver, British Columbia, V5Z 4C2, Canada.
authors.forename: Alycia
authors.initials: A
authors.lastname: Fridkin
mesh_terms: D000884:Anthropology, Cultural; D002170:Canada / Q000208:ethnology; D003469:Culture; D000069581:Exposure to Violence / Q000208:ethnology; D000069576:Health Equity / Q000592:standards*; D006303:Health Services, Indigenous / Q000592:standards*; D054625:Healthcare Disparities / Q000208:ethnology / Q000706:statistics & numerical data; D006801:Humans; D007198:Indians, North American / Q000208:ethnology*; D016134:Organizational Policy; D011320:Primary Health Care / Q000592:standards*; D011369:Professional-Patient Relations; D063505:Racism / Q000208:ethnology / Q000517:prevention & control / Q000706:statistics & numerical data; D035502:Trust; D014754:Violence / Q000517:prevention & control / Q000706:statistics & numerical data
keywords: Canada; Cultural safety; Discrimination; Health disparities; Health equity; Health services; Indigenous people; Racism; Structural violence; Trauma informed care; Trauma- and violence-informed care