Decolonizing health care: Indigenous digital storytelling as pedagogical tool for cultural safety in health care settings

Shelley Wiart

Indigenous women’s health stories are complex due to their intersecting identities of race and gender, their experiences of colonialism, and social determinants of health. All of these factors can make it challenging for them to access culturally appropriate health care.

Indigenous Peoples make up approximately fifty percent of the population of the Northwest Territories (Government of the Northwest Territories [GNWT], 2018). They experience a higher burden of some chronic illnesses and a wider gap in health disparities in comparison to other residents (GNWT, 2018). Health care providers often fail to create an environment of cultural safety, defined as an outcome where Indigenous Peoples feel respected and safe from racism and discrimination when they interact with the health care system (GNWT, 2018). Moreover, health care providers may not understand the holistic health needs necessary to support Indigenous Peoples, and the systemic racism within the health care system that continues to contribute to health inequity and reinforces disparities (GNWT, 2018). In order for health care providers to have respectful relationships with Indigenous Peoples, they must honour the diversity among cultural groups and have an appreciation of the depth of First Nations, Métis, and Inuit concepts of “good health.”

Historically, through colonial policies like the Indian Act and the imposition of patriarchy on matriarchal societies, Indigenous women have been, and continue to be, marginalized by mainstream society (Dodgson & Struthers, 2005). A consequence of this marginalization is health disparities between Indigenous and non-Indigenous women. Indigenous women experience higher rates of chronic illnesses such as diabetes and heart disease, and have lower life expectancy, elevated morbidity and suicide rates in comparison to non-Indigenous women (Bourassa et al., 2004). Indigenous women past the age of 55 are more likely to report fair or poor health compared to non-Indigenous women in the same age group (Bourassa et al., 2004). Furthermore, social determinants of health for Indigenous Peoples reflect major disparities in relation to non-Indigenous Canadians including “higher levels of substandard and crowded housing conditions, poverty, and unemployment, together with lower levels of education and access to quality health-care services” (Greenwood et al., 2018).

The premier of Legacy: Indigenous Women’s Health Stories took place on August 15, 2019 at the Northern United Place in Yellowknife, Northwest Territories.(Front row l to r): Maxine Desjarlais, Elder & co-emcee, Gail Cyr, Dorothy Weyallon, Sheryl Liske & Tanya Roach. (Back row l to r): Beatrice Harper & Shelley Wiart. Photo credit: James O’Connor Unlimited

 

In order to close the gaps in health outcomes between Indigenous and non-Indigenous communities in Canada, it is critical that Indigenous People’s voices are central to the process of reconciliation in health care1. Reconciliation in health care aims to close the gaps in health outcomes that exist between Indigenous and non-Indigenous communities, and support Indigenous Peoples as they heal from colonization, the legacy of residential schools, and the ongoing systemic racism embedded in our institutions. Indigenous women’s knowledge is integral to sustaining traditional knowledge systems and healing practices, and to decolonizing knowledge production (Kermoal & Altamirano-Jimenez, 2016).

Maxine Desjarlais, Beatrice Harper, Sheryl Liske, Dorothy Weyallon, and Tanya Roach at the Legacy event. Photo credit: James O’Connor Unlimited

 

In this paper I examine how the use of Indigenous digital storytelling within the framework of Indigenous research methodology allows Indigenous women to share their health stories in a safe and respectful context. This decolonizing methodology allows for self-representation that challenges stereotypes and allows Indigenous communities to prioritize their own social and community needs and to protect their identities and cultural values in the process (Iseke & Moore, 2011). Furthermore, it is essential to the decolonization process that “Indigenous people speak with our own voices about our histories, culture, and experiences as we continue to resist the onslaught of colonial structures, policies and practices” (Regan, 2010). The digital stories that I discuss below allow participants and audiences to reflect on Indigenous women’s health. These stories also advance an understanding of holistic health and promote Indigenous women’s views on reconciliation in health care.

Digital storytelling as an Indigenous women’s health advocacy tool: Empowering Indigenous women to frame their health stories
From May to June 2019 I co-created two digital health stories with Indigenous women from the Women Warriors2 programs in Lloydminster and Onion Lake Cree Nation (OLCN), on the border of Alberta and Saskatchewan. I relocated to Yellowknife for the months of July and August and co-created three digital stories with Indigenous women there. I conceived of this project as community-based, participatory action research carried out through the lens of Indigenous feminism, which centres the participant as the person most knowledgeable about their own experiences (Green, 2017). The objectives of these health stories were to allow Indigenous women to share, with a medical audience3, their traditional knowledge and Indigenous healing practices, and to help them conceptualize and communicate about their own health stories and service needs. It also served to educate non-Indigenous people about traditional healing practices for different Indigenous groups, bridging the gap between biomedical Western medicine and traditional healing.

The relationship-building process and trust between my digital storytelling participants and I were central to this project (Wilson, 2008; Iseke & Moore, 2011). I had previous relationships with the women in Lloydminster/OLCN because they had participated in Women Warriors. Due to the fact that we had a good level of rapport, they felt comfortable exploring the legacy of residential schools in their lives and how it affects their health. In Yellowknife I was fortunate to have a summer student who was a member of Yellowknives Dene First Nations and grew up in the community. She helped to recruit one of our participants and establish rapport. Our last participant was recommended by a connection I had through Women Warriors, and both my summer student and I approached her to participate.

Shelley Wiart (podium). Speakers panel (l to r): Maxine Desjarlais, Beatrice Harper, Sheryl Liske, Dorothy Weyallon and Tanya Roach. Photo credit: James O’Connor Unlimited

 

There are several ways that I created a safe environment for these women to share their health stories. First, I was clear they had total control over every aspect of their stories. They chose every detail of their digital story, including writing their first-person narration, and picking out the personal photos and music that accompanied them. My role was to hold space for their stories, which meant listening with non-judgment, and offering support however they asked for it. For example, one of my digital storytelling participants asked me to go with her to the site of the residential school that her mother attended. I felt it was a healing experience for her, and we had a spiritual experience during our visit that I am not going to discuss in detail. As an Indigenous researcher I understand that there are certain things, such as sacred dreams, that are not appropriate to include in my formal research findings. Also, I demonstrated that I valued these women’s time, knowledge, and emotional labour by paying living wages while we worked on their stories, which took approximately one week.

I incorporated an integrated knowledge translation plan that allowed the participants to share ideas and input about how to disseminate the research and their digital stories to the community. I also have a continual consent process with my participants, which means I keep them informed when I present their digital stories at academic conference or events. I will continue sharing with them how their stories are impacting audiences, even after my formal research is done. I take direction from the project participants when they suggest spaces to share their digital health stories. For example, one of the participants emailed me to suggest we approach APTN to share the digital stories. I contacted Yellowknife video journalist Charlotte Morritt-Jacobs to share the details of this research. She interviewed me and one of the co-creators, Tanya, for a story that was featured on the APTN National News on Monday, November 18, 20194. We are also considering creating an Indigenous knowledge translation workshop where we screen the digital stories with health care professionals, then host talking circles, and have a group discussion on reconciliation in health care. I am in the process of searching for academic or health care conferences that we can attend as presenters.

Two digital storytelling presentations
Two events help to illustrate the scope and impact of the Indigenous digital storytelling methodology. At the first event, called “Legacy: Indigenous Women’s Health Stories,” we premiered five digital health stories on Thursday, August 15, 2019 at 6 pm-8 pm at Northern United Place, Yellowknife, NT (Figure 1).

There were approximately fifty-five community members in attendance for the free community meal of bannock and chili, followed by welcoming remarks by Dr. Irlbacher-Fox, Scientific Director of Hotıì ts’eeda, and Lesa Semmler, the Inuvialuit Regional Corporation representative of the Hotıì ts’eeda Governing Council. Gail Cyr, the co-emcee of the event and community Elder, shared meaningful insights about Indigenous women’s health. I provided context for the screening of the stories by sharing the importance of storytelling and listening in Indigenous culture. It was my intention to create a decolonized space by asking those in attendance – both Indigenous and non-Indigenous people – to be responsible, reflexive listeners.5

This community event featured a speaker’s panel with all five digital storytelling participants. The panel discussed three questions: What was the impact of residential school on your physical, spiritual, mental, and emotional well-being? How did the process of digital storytelling affect you? What does good health mean to you from your own perspective? (Métis, Cree, Dene, Tłı̨chǫ and Inuit)?

Prior to the event we collectively discussed what type of questions the panel felt comfortable answering and decided not to open the floor for questions and answers. I explained to the audience that it was my responsibility as the lead Principal Investigator of this research to keep my participants safe from colonial violence during their time with me. I explained that a seemingly innocent question might be perceived as impolite, cruel or violent. As well, there are very few spaces for Indigenous women-only voices and decolonizing this space means Indigenous women’s voices take precedence over everyone else’s voices. This community event was about creating a space where Indigenous women felt empowered to advocate for themselves, and safe enough to be vulnerable as they shared their health stories.

Digital health stories have the potential to initiate community dialogue about issues that are concerning to the participants and the audience (Rieger et al. 2018). These digital health stories also served to open space for conversations about reconciliation in health care. Audience members at the Legacy event, which consisted of health care professionals, academics, post secondary students, government employees, non-profit executive directors, City of Yellowknife employees and Indigenous artists, healers, and Elders were asked to fill out a leaf for the “I Wish” Tree. They completed the sentence, “I wish health care providers would…” and hung their leaves on an ornamental tree. This tree was representative of community connection and “growing” our ideas together to close the gaps in health disparities between Indigenous and non-Indigenous Peoples. Furthermore, it is my intention to share the themes of the I Wish Tree with health care professionals when I screen the stories at various events (Figure 2). Sharing this community feedback may significantly decrease the time between knowledge generation and knowledge implementation by directly sharing grassroots ideas with health care professionals (Rieger et al., 2018).

At the second event I hosted a screening at the Stanton Territorial Hospital on August 8th and 9th, 2019. There are several uses for digital storytelling in health care settings, including educating health care professionals, and engaging them in critical reflection of their practice (Rieger et al., 2018). An important part of my research methodology is capturing the medical community’s awareness of their own perceptions of Indigenous People’s health, and reflecting on how they can incorporate information from the digital stories into their practice.

At the Stanton event there were 15 employees from a variety of backgrounds including administration, registered nurses, respiratory therapists, medical interpreters, and members of the Aboriginal Wellness program. After watching the stories, they were asked to provide feedback on a quality improvement evaluation that I provided. Their responses demonstrated that the digital stories served as a pedagogical tool for understanding the legacy of residential schools and increasing their cultural safety skills. The goal of cultural safety is for all people to feel respected and safe when they interact with the health care system (GNWT, 2018). Culturally safe health care services are free of racism and discrimination, and people are supported to draw strengths from their identity, culture and community (GNWT, 2018). A culturally competent and safe health care system can help improve health outcomes and quality of care, and can contribute to the elimination of racial and ethnic health disparities (Figure 3).

The Stanton Territorial Hospital and the Legacy events allowed Indigenous women to showcase their resilience and strength while shifting mainstream stereotypes and deficit-based stories towards asset-based stories about their health, communities, and culture. These events encouraged health care professionals to better understand Indigenous women’s unique lived experiences and elicit cultural perspectives with respect to health issues, diagnosis, and treatments. A community member from the Legacy event stated that she would be better able to respond to her Indigenous clients needs in “ways that are more meaningful and truly supportive.” Furthermore, it directed me to further focus my presentations to health care professionals, attending to deep listening (to their patients), promoting cultural competency and cultural safety training as part of their formal education, and sharing the values that patients most want from their providers (patience, humility, respect, reciprocity, and relationships).

Audience at the Legacy event. Photo credit: James O’Connor Unlimited

 

Conclusion
Indigenous women’s health stories can serve as a pedagogical tool to teach cultural safety in health care settings. Indigenous digital health stories inform solutions that are community-driven, culturally relevant to Indigenous Peoples and based specifically in local knowledge. Indigenous women’s digital health stories fill a gap in research on how health care providers can incorporate Indigenous knowledge and healing practices into patient care plans so that Indigenous women feel respected and can build safe health care relationships. Moreover, sharing Indigenous women’s stories opens space for reconciliation in health care conversations, supporting collaboration to transform health care systems, policies, and practices to improve Indigenous women’s health outcomes. These stories are an innovative way to decolonize health care, build relationships and trust with health care providers, and seek collaborative solutions to reconciliation in health care.

This research suggests that the methodology of digital storytelling is adaptable in the following ways: It can facilitate a deeper level of self-expression for the participants, and empower them by sharing their health stories and advocating for their own service needs. Screening the digital stories with health care professionals can engage them to reflect on their own clinical practices, thereby increasing cultural safety in health care settings. In community settings, screening the digital health stories can open space for dialogue about reconciliation in health care and allow for community-driven solutions that have the potential to be heard by those in decision-making roles. Furthermore, digital storytelling facilitators can be trained in Indigenous communities to create their own digital storytelling projects, thereby increasing community capacity and decolonization of health care. These stories can feature region-specific healing practices and can locate the barriers to quality care in each region.

Digital storytelling allows Indigenous women to share how colonization and the loss of cultural identity have negatively affected their health. At the same time, it highlights how Indigenous women have managed to maintain their holistic health practices and what that means for the health of their families and communities. The health care providers’ feedback from the screenings suggests that they want more opportunities to connect with communities to better understand Indigenous worldviews and healing practices.

The most important aspect of this research has been the formation of empathetic connections between health care providers and Indigenous women’s stories of cultural genocide such as the forced removal of Indigenous children to residential schools, and how it manifested in Indigenous Peoples’ physical, spiritual, mental and emotional health. Indigenous women’s health stories are a form of reconciliation in health care because they assist medical professionals in understanding their own positionality and reflect on the ways they may disrupt the systemic racism embedded in our institutions. ◉

Shelley Wiart is Métis and a member of the North Slave Métis Alliance, Yellowknife, Northwest Territories. She is currently enrolled full-time at Athabasca University in her fourth year of a four-year B.A. degree with a concentration in sociology. She is the co-founder of an Indigenous-focused holistic health program, Women Warriors, which is aimed at improving Indigenous women’s health outcomes. These digital health stories can be viewed at www.womenwarriors.club

Notes
1. Reconciliation in health is recognized in two documents that serve as a framework for reconciliation across Canada and internationally: The United Nations Declaration on the Rights of Indigenous Peoples (UNDRIP), Article 24, and The Truth and Reconciliation Commission of Canada’s Calls to Action (2015), #’s 18-24.

2. Women Warriors is an Indigenous-focused holistic health program aimed at improving Indigenous women’s health outcomes. Shelley co-founded the program in 2015 in Lloydminster and it expanded to Onion Lake Cree Nation, on the border of Alberta and Saskatchewan, and to the City of Calgary in 2018-2019.

3. The Alberta Indigenous Mentorship in Health Innovation (AIM-HI) network sponsored the Alberta portion of this research. This network is associated with the University of Calgary’s Cumming School of Medicine and as part of Shelley’s research dissemination she will present these stories to medical residents.

4. The APTN National News Story can be viewed at: HTTPs://www.youtube.com/watch?v=MlPoOzcdzjs&feature=youtu.be

5. Regan (2010) states that a responsible listener poses questions about the content of the information being presented, in addition to posing questions about our own questions. This type of self-reflexivity is essential to the reconciliation process as colonial-settlers examine their roles and responsibility in the process of colonization. Cultural sensitivity training often places Indigenous Peoples as the focus of the training, when instead it should teach settlers to reflect on their own history, cultural practices, worldviews and values.

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