Providing culturally safe care to Indigenous people living with diabetes: Identifying barriers and enablers from different perspectives

Abstract In recent years, cultural safety has been proposed as a transformative approach to health care allowing improved consideration of Indigenous patient needs, expectations, rights and identities. This community‐based participatory study aimed to identify potential barriers and enablers to cultural safety in health care provided to Atikamekw living with diabetes in Québec, Canada. Based on a qualitative descriptive design, the study uses talking circles as a data collection strategy. Three talking circles were conducted with Atikamekw living with diabetes and caregivers, as well as with health professionals of the family medicine teaching clinic providing services to the community. Two team members performed deductive thematic analysis based on key dimensions of cultural safety. Results highlight four categories of barriers and enablers to cultural safety for Atikamekw living with diabetes, related to social determinants of health (including colonialism), health services organization, language and communication, as well as Atikamekw traditional practices and cultural perspectives of health. This study is one of the few that provides concrete suggestions to address key aspects of diabetes care in a culturally respectful way. Our findings indicate that potential enablers of cultural safety reside at different (from individual to structural) levels of change. Solutions in this matter will require strong political will and policy support to ensure intervention sustainability. Patient or public contribution Partners and patients have been involved in identifying the need for this study, framing the research question, developing the data collection tools, recruiting participants and interpreting results.


| INTRODUC TI ON
In Canada, the prevalence of diabetes is four times higher for Indigenous adults living on reserve in comparison with the general population. 1 The onset of this disease is rooted in historical context of colonial policies and harmful experience in residential schools, including metabolic long-term effects of starvation and stress, 2,3 experiences of food restrictions that may promote subsequent inadequate nutrition behaviours, 2,3 food insecurity in remote regions where some Indigenous communities are located 4 and environmental degradation of traditional food sources such as fish and maritime products. 5 In recent years, cultural safety has been proposed as a transformative approach to health care allowing improved consideration of Indigenous patient needs, expectations, rights and identities. [6][7][8][9] Cultural safety aims to support Indigenous patients by dismantling colonialism currently embedded in the healthcare system. While literature on this topic is still scarce, culturally safe clinical practices are associated with higher levels of satisfaction and improved clinical outcomes for patients living with diabetes. 10 Ensuring a culturally safe approach to diabetes care is especially important since this condition involves coordinated care and frequent encounters with the healthcare system and health professionals, who play an important role in good diabetes management. Some authors have proposed framework and principles for cultural safety in primary care, 11 but the application of these principles in diabetes care stays complex and not wholly understood. [12][13][14] As a previous step of this project, our team conducted a rapid review of the scientific literature to identify interventions that improve cultural safety for Indigenous people living with diabetes in the healthcare setting. 10 Our review only found seven studies (including two from Canada) that highlighted cultural education, modified environment of care and integration of the Indigenous workforce as relevant strategies to improve cultural safety in diabetes care. While these results provide a good starting point, they consist in scattered strategies implemented in various settings, which are sometime far different from those in Canada. The current stage of knowledge on cultural safety in diabetes care does not allow to develop a local understanding of this issue nor to support an informed clinical practice. There is a need to identify current obstacles to cultural safety in health care for patients living with diabetes as well as relevant strategies to implement this concept in partnership with Indigenous peoples in Canada. This community-based participatory study aimed to identify potential barriers and enablers to cultural safety in health care provided to Atikamekw living with diabetes in Québec (Canada).

| Context of the project
Manawan is one of the three Atikamekw communities (First nation of the Anishinaabe cultural group) located in Lanaudière (Québec, Canada), about 189 km from Joliette, a city with more complete and specialized health services available. Atikamekw communities are bonded by shared cultural values, which include caring for extended family and community, respect for elders, equality between men and women, as well as a relationship of interdependence with the territory. 15 Thanks to the continuing oral transmission from one generation to the other, 95% of Atikamekw people still speak the Atikamekw language. 15 Although many Atikamekws are bilingual in that they also speak French (the official language of the province of Quebec), some elders and young children are unilingual, speaking Atikamekw but not French.
Like many Indigenous communities in Québec, Manawan experiences a high prevalence of chronic diseases and related complications. The prevalence of diabetes is estimated at 25.6% of Manawan adults. 16 In cooperation with Health Canada, Manawan manages a local community health centre (Centre Masko-Siwin), a nursing station which offers some primary care services. Other specific arrangements are in place, such as a transportation service that runs 5 days a week to transfer Manawan patients needing care to Saint-Charles-Borromée's hospital, Joliette. The Manawan local health centre is supported by the nearest family medicine teaching clinic,

Groupe de Médecine de famille universitaire de Saint-Charles-Borromée
(GMF-U SCB), located in Joliette. In 2017, doctors from the GMF-U SCB did three-day rotations twice a month at the local centre in Manawan and provided on-call support service 24/7. To improve effectiveness in answering the needs of their patients, the GMF-U SCB implemented a patient group management system, which involves assigning patients (i.e. patients from Manawan) to a group of doctors, rather than to a specific doctor (group-practice model).
In 2017, the GMF-U SCB recognized challenges in following up on and meeting the needs of Indigenous patients living with diabetes. Clinicians from the GMF-U SCB contacted the principal investigator (MCT) at Université Laval (Québec, Canada) to help improve their services and better meet their patients' needs. They were concerned about patients' lack of adherence to care and the difficulty to conduct follow-ups. They suggested that these issues may be linked to cultural aspects of care for Indigenous patients.

| Design and approach
This study builds on a participatory approach involving a partnership between a research team, the community of Manawan, the Native friendship centre of Lanaudière and the GMF-U SCB. Organizational and community partners have been involved in identifying the need for this study, framing the research question, developing the data collection tools, recruiting participants, and interpreting results.
Based on a qualitative descriptive design, the study uses talking circles as a data collection strategy. Talking circles are frequently used to collect data in many Indigenous contexts, offering a means to collect data that encourages story-telling and collective listening. 17 Following this method, participants sit in a circle and are invited to speak in turn about a specific issue in a respectful and safe manner. This study is approved by the Research Ethics Board of both Université Laval (no. 2017-205) and the CISSS de Lanaudière (no. 318-03-N-14).

| Conceptual framework
This study is rooted in the concept of cultural safety. Cultural safety involves an equitable partnership between patients and health professionals that enables parties to recognize, respect and nurture the unique cultural identities of Indigenous populations. [6][7][8][9] There is a lot of variability in the way cultural safety is conceived and applied. 12,18 Although interpretations of this concept differ, 12 they usually share similar features. In this project, we used a definition of cultural safety that emphasizes concrete principles and different levels of application of this concept, as conceived by Smye and colleagues. 8 According to Smye et al, 8 cultural safety requires four key principles ( Figure 1). The first principle involves health professionals understanding the general context in which Indigenous people's health is rooted. This includes considering both the influence of historical, social and economic determinants affecting health of Indigenous populations, and the devastating impact of colonialism and intergenerational trauma on the health of Indigenous peoples. 8,12,19 The second principle focuses on building equitable partnerships with Indigenous communities and promoting support structures inclusive of Indigenous communities, including elders, families and healthcare professionals. 8 The third principle requires 'safe communication', which involves not only promoting the patient's language as much as possible, but also using accessible language to communicate with the patient, free of technical or medical jargon. 8 The fourth principle of cultural safety is based on the recognition of Indigenous health practices as legitimate options for intervention, and respect for Indigenous traditional knowledge. 8,19

| Data collection
We conducted three talking circles with three different groups of participants (total of 30 participants). The groups of participants (Table 1)  circles started with a land acknowledgement by the researchers, followed by a brief introduction of each person, including the researchers. The principal investigator and a member of the research team moderated the discussions. A first subject of discussion was introduced to the circles by the researchers, and the participants were invited to speak in turn while holding a talking stick that had been provided by the Native Friendship Center. Participants were invited to listen respectfully in a non-judgemental way, and everyone was allowed to remain silent if they preferred. Talking circles ranged from 1 hour (with health professionals) to 2 hours (with Atikamekw patients and caregivers) in length. Discussions were led in French and were audio-recorded. All participants provided written consent and received a financial compensation.

| Data analysis
Interviews were professionally transcribed verbatim, and transcripts were verified by a research team member (MBL) for accuracy. All transcripts and project documents were analysed using NVivo 12.
Two team members (MCT and MBL) performed deductive thematic analysis 20 based on the four principles of cultural safety as initial themes. While mainly deductive, the coding process remained flexible enough to allow for current themes to be redefined or potential new themes to emerge. The two analysts (MBL and MCT) generated the initial codes and then associated codes to themes relevant to barriers and enablers of cultural safety in care. Coding differences were resolved by consensus. Partners and some project participants Participants generally agreed with the interpretation proposed, but suggested some modifications in wording, such as using 'family' and 'extended family' instead of 'informal caregiver' (as initially proposed).

| RE SULTS
Results highlight four categories of barriers and enablers to cultural safety for Atikamekw living with diabetes ( Table 2). These four categories generally mirror the four principles of cultural safety previously described. The second principle (i.e. relationship and support structures) has been reframed as structures of health service organizations, which emerged from the data as a more relevant theme.

| Enablers
Corresponding levers for action associated with colonialism and social determinants of health were also identified. According to participants, one enabler of cultural safety associated with this category is providing education that sensitize health professionals to discrimination and racism, and foster attitudes of openness and respect. For Another potential solution brought by participants is to develop and implement a mechanism to systematically handle complaints regarding racism and discrimination in health organizations. As suggested by a patient: When I go to a ward for treatment, the hospital is not necessarily aware of what is going on downstairs.
Someone would have to meet with a manager in the hospital, so that they know what they are doing there.
(…) Maybe put a service as patient protector, something like that. As an ombudsman but in the hospital for healthcare and social services.
Participants emphasized solutions to colonialism that went from providing education to professionals at an individual level, to changing support structures for patients in organizations. Another barrier reported by the participants was the group-practice model being put in place by the GMF-U SCB.

| Health services organization
Health professionals mentioned that some patients found it hard to be followed by several doctors instead of having the opportunity to develop a trusting relationship with one. One of the health professionals reported: Often they want to see the doctor again, then it is certainly our system that makes sure they do not necessarily see us again, and then the connection is more difficult. (…) sometimes there are some who are less comfortable with that. They prefer to see the same person again, in 3 months.

(Group 3)
Finally, congestion in the health-care system itself was mentioned as an important barrier related to health service organizations. This kind of obstacle was mostly identified by participating health professionals. Congestion was considered as inhibiting the implementation of a patient-centred approach, which would allow to better consider the cultural diversity of the clientele.
Then we're on the go, we're on the go, we prescribe, we do our best, but if we had more availability we might have more time to have more in-depth discussions, and not just do physicals. (…) Yes, we try to take the time, but when we have twenty patients and we are two hours late, we have less time to look for these barriers.

(Group 3)
Establishing a culturally safe therapeutic relationship requires time to share and bonds with patients, which appears unrealistic to health professionals in the current system due to their heavy patient load.

| Enablers
Some enablers of culturally safe diabetes care identified by participants are located at the level of health services organization.

| Barriers
Language and communication were consensually identified as prominent barriers to culturally safe care by all groups of participants.
These barriers relate to the fact that many Atikamekw are unable to obtain services in their mother tongue (i.e. Atikamekw) while consulting outside of their community. Given the fact that many In short, language and communication barriers were perceived as hindering mutual understanding and trust, which is fundamental to the development of a safe therapeutic relationship.

| Enablers
Enablers to culturally safe communication in health care were also identified by participants. Providing interpreter service was mentioned by a majority of participants. Another potential solution identified by many was in health professionals learning basic terms of the Atikamekw language. A professional related that she has started to use some words of Atikamekw during consultations as a way to comfort her patients: I started to do it lately, it's really practical: it's just that I learned two words, hello and then goodbye in Atikamekw. That makes it a little touch, then I ask 'OK can you explain me how to say goodbye?' It's really a small start, but I say to myself over time, I will never be bilingual, but I will learn maybe some casual words like that. I say to myself that at the base it is just respectful of the other.

(Group 3)
A final suggested strategy to enable cultural safety in communication is to promote the utilization of simple language in health-care encounters. According to a patient, this involves 'taking the time to explain well, to use terms that we can better understand'. (Group 2).

| Barriers
A last category of barriers to culturally safe care is related to the difficulty to take into account Atikamekw traditional health practices, and cultural perspectives of well-being. One specific obstacle is that health education material disseminated to Atikamekw living with diabetes is not relevant to Atikamekw food and lifestyle. For instance, an informal caregiver reported: You have a panoply of medications to take, then what you are often given for your diet are pamphlets that already prepared, which are not pamphlets adapted for example to what Atikamekw eat and cook.
(Group 2) On this matter, a health professional also acknowledged: It must also be said that our cardio-metabolic course is not really adapted to this clientele. This is a question we asked ourselves if there was something specific to adapt to their culture.

(Group 3)
A patient that had previously worked as a nurse in the community remarked that adapted material already exists, but was not really used: We made an Atikamekw food guide, then we never They expressed their desire to know more but were unsure about where to start and how to apply this knowledge in practice.

| Enablers
Potential levers for action associated with traditional practices and cultural perspectives were suggested by participants. A first solution identified was in providing culturally appropriate health education material for Atikamekw living with diabetes (e.g. an adapted nutrition guide). Patients and health professionals were aware that some resources specific to Atikamekw culture already existed and they emphasized the importance of using them.
Another important strategy identified by participants was to provide education for health professionals regarding Atikamekw Maybe we could do some kind of initial contract, which would make it possible to explore that more at the beginning before entering the medical records.

(Group 3)
In sum, participants emphasized the importance of being, not only more sensitive to, but also more knowledgeable of culture, values and perspectives in order to ensure diabetes care that respects Atikamekw's needs and practices.

| Validity and limitations
Results of this study must be interpreted in their context. Reliability and quality of the results were strengthened through the use of a database, a rigorous protocol and through a structured thematic analysis strategy involving two analysts. Interpretation of the results was validated by participants and stakeholders of the project through a deliberative workshop where results were presented and discussed.
However, results are based on a limited number of views that are specific to the Atikamekw community and generalization to other contexts should be done with caution. Furthermore, participants may not be representative of all Atikamekws, since they were most likely to speak and understand French.

| CON CLUS ION
This study aimed to identify potential barriers and enablers to cul-