Introduction

The Indigenous peoples of Canada - including the First Nations, Inuit and Metis - are the original inhabitants of their traditional lands long before the arrival of European settlers.1 In the previous 150 years or so, Indigenous peoples have experienced colonization, forced assimilation, cultural oppression and various forms of violence.2 These experiences have been consistently associated with high rates of social distress and health disparities in many Indigenous communities.3,4 Despite these challenges, many Indigenous peoples have managed to attain a high level of health and wellness, while continuing to pass on their cultural heritage to future generations.5 This should be acknowledged as salient evidence of courage, motivation, resilience and resourcefulness of Indigenous peoples, in spite of the challenging environment (e.g. remote and rural areas) in which they often live.6

In recent years, the concept of "historical trauma" is used as an explanatory framework to locate the origins of postcolonial suffering among Indigenous peoples.7 The term has been defined as "[horizontal ellipsis]the legacy of numerous traumatic events a community experiences over generations and encompasses the psychological and social responses to such events".8^(p.320) For Indigenous peoples in Canada, a significant amount of historical trauma comes from the residential school system, which involved removing Indigenous children from their families and communities with the explicit intention of eradicating Indigenous cultures and languages.2 The harm done was considerable, as many were left with a confused cultural identity that is compounded with shame, self-hatred and powerlessness.9,10 Under chronic exposure to this unresolved trauma, many Indigenous peoples turned to alcohol, drugs, violence and other high-risk behaviors as coping mechanisms.9,11 Further, the colonial injuries endured by residential school survivors were often transmitted to the next generation through varied mechanisms (e.g. impaired parenting or distressing narratives), resulting in future trauma for their descendants.12,13 Within this context, the continuing inequities in Indigenous health and well-being are entrenched in the historical, social and political processes of colonization.

In contemporary times, legacies of colonization continue to marginalize Indigenous peoples, creating healthcare institutions devoid of Indigenous worldviews.14 For example, "health" for many Indigenous peoples is a holistic concept, with its physical, emotional, mental and spiritual dimensions being interconnected.15 Health also extends beyond the individual level and requires harmonious relationships with family, community, nature and the spiritual world.15,16 However, mainstream health services are mostly structured under the Western biomedical paradigm, which views the human body as a sum of segregated compartments.17 In addition, most healthcare institutions do not have a consistent plan to inform practitioners about historical trauma and its impact on Indigenous well-being.18,19 As a result, many practitioners continue to focus on individual pathologies instead of the wider historical context behind ill health.20 In such circumstances, Indigenous peoples are often labeled as a "problematic" group with poor lifestyles, high-risk behaviors, and low adherence to treatment plans.21,22 These racial stigmas further traumatize Indigenous peoples and constitute a structural barrier to equitable care.23,24

In the past, Indigenous healing primarily involved the use of traditional herbal medicines and other remedies to treat physical ailments.14 As Indigenous peoples strive to recover from colonization, the term "healing" has been given additional layers of meaning that accentuate psychosocial and spiritual well-being.25 In its broadest sense, healing can be viewed as "the transition that restores the person, community, and nation to wholeness, connectedness, and balance".26^(p.32) This definition resonates with the interconnectedness of Indigenous health, promoting a return to meaningful relations that were once disrupted by colonization. In order for healing to occur, Indigenous peoples need to be involved in retelling the colonial history and acknowledging the impact of historical trauma.27 There also needs to be an increased validation of Indigenous cultural activities characterized by an ongoing connection to the past, based on specific beliefs, values and practices that go back to the time prior to European contact.25 Since each Indigenous group, or each individual within a community, has unique historical experiences of colonization, the pathway to healing is inherently variable and highly relevant to personal agency and individual readiness.28

Recognizing the history of colonization has influenced the collective identity of Indigenous peoples, as well as their vision for health and wellness. Phrases such as "culture is treatment"26 and "cultural wounds demand cultural medicines"29 have shifted Indigenous health research in significant ways, leading to the pervasive discourse that culture is therapeutic in its own right.7 Culture within this context can be described as "[horizontal ellipsis] a dynamic and adaptive system of meaning that is learned, shared and transmitted from one generation to the next".30^(p.1) Specifically, culture refers to the distinct beliefs, values and worldviews reflective of historical and contemporary Indigenous traditions. These shared perspectives are found to be a significant source of Indigenous resilience, generating a strong sense of self and belonging that is fundamental to both individual and collective well-being.31

Today, Indigenous peoples in Canada are actively engaged in reclaiming their cultures and knowledge to create a decolonized context, while advancing the holistic well-being of their peoples. Their collective endeavors have contributed to a growing number of Indigenous healing strategies in Canada. For example, the Aboriginal Healing Foundation has funded a wide range of community-based initiatives since its establishment in 1998, the majority of which make innovative use of traditional healing practices.32 Many Indigenous organizations have put forward strategic plans, guidelines and protocols with careful consideration of Indigenous values and taboos.33-35 Meanwhile, Indigenous leaders, scholars and community members are actively asserting themselves through speeches, writings and artistic pursuits that create transformative change.16 Despite many differences, First Nations, Inuit and Metis face the common predicament of cultural oppression and the resultant loss and trauma. In the light of this, the urgency to promote overall healing is a shared challenge and opportunity for all.

There is a growing number of Indigenous healing strategies, yet literature describing these strategies has not been systematically scoped. To address this gap, this scoping review will identify characteristics of Indigenous healing strategies in Canada, such as guiding principles, main components and human resources in the literature. We also aim to explore the culturally relevant approaches used in research process, specifically how Indigenous ways of knowing were respected and followed. Although cultural differences exist among Indigenous groups, the findings of this review will potentially inform healthcare providers, researchers and policy makers to effectively integrate Indigenous cultures with novel healing strategies targeted at specific populations.

A preliminary search was conducted in JBI Database of Systematic Reviews and Implementation Reports, Cochrane Library, PROSPERO, CINAHL and MEDLINE on September 30, 2018. No systematic reviews (completed or underway) were identified on this topic.

Review questions

i. What are the characteristics (e.g. guiding principles, main components and human resources) of Indigenous healing strategies in Canada?

ii. What approaches have been used in research process to improve the cultural relevance to local Indigenous contexts?

Inclusion criteria

Participants

This review will consider literature that includes First Nations, Inuit and Metis in Canada as the population of interest. Although these three groups are formally recognized by the Canadian Constitution,1 Indigenous peoples may prefer to self-identify by other terms derived from their nations (e.g. Anishinabek, Cree), traditional lands (e.g. Inuvialuit), or languages (e.g. Chipewyan, Dene).36,37 In such cases, the preferred names of Indigenous peoples will be included as search terms in this review. There will be no exclusion criteria based on age, sex or health conditions of participants.

Concept

Literature will be included if it describes an Indigenous healing strategy in Canada. While there is no internationally agreed definition of strategy, for the purpose of this review, it pertains to any attempt to promote health and healing for Indigenous peoples of Canada, for example: i) health services and programs; ii) policies and guidelines; iii) models and frameworks; and iv) Indigenous narratives and expert opinions. Characteristics of a healing strategy will include, but not be limited to, guiding principles, main components and human resources. Existing literature that provides narrative text on any of these characteristics, either in part or as a whole, will be considered for inclusion.

Context

This review will focus on healing strategies based in Canada. According to the 2016 Census, Indigenous peoples live in all administrative jurisdictions of Canada, including 10 provinces and three territories.38 Statistics show that the First Nations population was concentrated in Ontario and western provinces, namely, British Columbia, Alberta, Manitoba and Saskatchewan.38 More than three-quarters of Inuit live in their traditional territories across the Canadian Arctic in four regions, collectively known as Inuit Nunangat.38 These regions are: Inuvialuit (Northwestern Territories), Nunavut, Nunavik (northern Quebec) and Nunatsiavut (Labrador).39 In comparison, the Metis population is mostly likely to live in urban centers.38

Healing strategies delivered in all service settings, including health, justice, child welfare, reconciliation and education, are eligible for inclusion.

Types of sources

Eligible sources of evidence in existing literature will include: primary research of all study designs, reviews and meta-analyses, text and opinion papers, conference proceedings, newsletters, and publications by Canadian government/Indigenous organizations. Theses and dissertations will be excluded due to a limited time frame of this review.

Methods

The proposed review will follow the JBI scoping review methodology.40

Search strategy

A three-step search strategy will be conducted through consultation with an experienced JBI systemic review library scientist. The initial search will be undertaken in CINAHL and Sociological Abstracts, followed by an analysis of text words contained in the title and abstract along with index terms used to describe the article. A second search will then be conducted using all identified keywords and search terms across all included databases. Thirdly, the reference lists of all identified articles will be searched for additional record. Key journals related to Indigenous health will be hand searched for eligible studies. Studies that were published from 2008 onward will be included. This decision is based on the establishment of the Truth and Reconciliation Commission of Canada in 2008, which gave rise to a new wave in Indigenous healing. Since English is the only common language that the reviewers speak, studies will be excluded if they are not available in English. The search strategy for Sociological Abstracts is presented in Appendix I.

Information sources

The databases to be searched will include: CINAHL, Sociological Abstracts, PsycINFO, MEDLINE and Academic Search Premier. Searches for gray literature will be conducted in iPortal of the University of Saskatchewan, Canadian Electronic Library, and Canadian government and Indigenous organization websites. These websites will include, but are not limited to: Health Canada, Public Health Agency of Canada, Indigenous and Northern Affairs Canada, National Collaborating Centre for Aboriginal Health, Aboriginal Healing Foundation, Native Women's Association of Canada, Quebec Native Women, Canadian Aboriginal AIDS Network, Pauktuutit Inuit Women of Canada and Inuit Tapiriit Kanatami. In addition, the following journals will be handsearched for eligible studies: International Journal of Indigenous Health (formerly known as the Journal of Aboriginal Health) and International Journal of Circumpolar Health.

Study selection

All identified citations will be entered into an online systematic review platform, Covidence (Covidence, Melbourne, Australia), and duplicates across databases will be removed automatically. Two reviewers will complete title and abstract screening independently, selecting studies against the pre-defined inclusion criteria. Following this step, the full text of eligible literature will be retrieved and uploaded into Covidence. Two reviewers will independently assess the eligibility of full-text articles and provide a rationale for exclusion, which will be listed in an appendix in the final review report. Throughout the study selection phase, discrepancies between two reviewers will be settled through discussion or possibly a third reviewer, if required. In the final review, the study selection process will be summarized in a PRISMA flowchart,41 using the output function of Covidence.

Data extraction

The following details will be extracted from included literature: author(s), year of publication, type of literature, aim/purpose, Indigenous population, contexts (geographical location and service setting), type of strategy, characteristics of strategy, main findings/author's conclusion and culturally relevant approach(es). Among these, culturally relevant approaches will be extracted only from primary research studies included in this review, because other types of literature do not technically include a research process with Indigenous participants. Initially, two reviewers will trial the charting table on three articles and compare results. The remaining data extraction will be completed independently by two reviewers, and discrepancies will be resolved through discussion or a third reviewer, if required. When two or more articles are included in this review which describe the same strategy, data will be extracted simultaneously as one. If key data are unclear in the full-text article, the corresponding author will be contacted for further information. As data extraction continues, the charting table will likely be updated, and the final version will be presented in the report as an appendix. A sample charting table is presented in Appendix II.

Data presentation

Characteristics of healing strategies - including guiding principles, main components, and human resources - will be summarized in tabular forms accompanied by narrative text. As the review progresses, other characteristics will likely emerge from the literature and be presented in the final report. Culturally relevant approaches will be summarized thematically; for each category, a narrative explanation will be provided with exemplar illustrations extracted from studies. The geographical locations of healing strategies will be denoted on a map of Canada, highlighting the distribution of resources across the country.

Funding

This review is supported by a Dalhousie University Graduate Entrance Scholarship (ZY), Dalhousie University International Differential Scholarship (ZY), Mitacs Globalink Graduate Fellowship (ZY), and a Canadian Institutes of Health Research Catalyst Grant (RN319808 - 384071, received by AS and partially provided to ZY as a graduate student stipend.

Acknowledgments

This review will contribute toward a Master of Science in Nursing degree from Dalhousie University, Canada for ZY.

Appendix I: Search strategy for Sociological Abstracts

Searched on Oct 22, 2018; filter: studies published in English

Appendix II: Charting table

References