Barriers like racism, distrust may be main cause of health-care disparities for Indigenous women, study says
National study quantifying health-care inequities is 1st of its kind, lead author says
Just before Tina Campbell had a minor medical procedure recently, she remembered the discrimination she says she felt while trying to access health care nearly two decades ago.
"When I was getting ready, I was thinking I've got to look nice, be presentable, because I don't want to be treated differently," Campbell said.
"That's something that I had shared with my non-Indigenous friends, and they were kind of like, 'Wow, I never even thought about that.'"
Campbell, who is from the Mosakahiken Cree Nation in northern Manitoba, is a registered nurse with the Northern Inter-Tribal Health Authority in Prince Albert, Sask. and is working to provide culturally safe care for Indigenous people in the region.
Her role addresses a health-care inequity problem that researchers and Indigenous people say persists across Canada and was quantified in a study published Monday in the Canadian Medical Association Journal.
Researchers at the Public Health Agency of Canada set out to measure the differences in health-care access for Indigenous women, not including First Nation women living on-reserve, compared with non-Indigenous women across Canada. They found evidence of a number of systemic barriers, particularly during pregnancy.
Using data from the Canadian Community Health Survey — an annual countrywide survey created by Statistics Canada — from 2015 to 2020, the new study found 18.6 per cent more non-Indigenous women who were recently or currently pregnant had a regular health-care provider, compared to Indigenous women.
Compared with non-Indigenous women, 14.2 per cent fewer Indigenous women said they had a place to go for immediate, non-urgent care in urban and rural areas.
"After sociodemographic adjustment, health-care disparities persisted, suggesting that systemic barriers, such as racism leading to distrust of health-care systems, may be chiefly responsible," the study says. "These findings did not surprise our Indigenous advisers."
It's the first study of its kind to quantify these inequities on a national scale, according to lead author Sebastian Srugo, and fills a gap in data about First Nation, Métis, and Inuit women's health-care access.
"What we found is that these gaps still existed throughout the country, whether it was in a remote location or an urban location," said Srugo.
"Indigenous women used hospital services more for non-emergencies. They had less access to specialized care, they were less likely to have a consultation with an eye professional or a dentist, and they also less often received the care that they needed, especially for mental health."
These now-quantified gaps might have been larger if the study included women living on reserve — people living in First Nations are excluded from the national health survey — and if the comparison was made more specifically with white women, according to Srugo.
"Twenty-nine per cent of the reference group was part of racialized communities within Canada," Srugo said. "It's very possible that these gaps are actually larger if we were to compare to white people only. There's data to show that other racialized communities also have problems accessing care."
Indigenous women have been speaking out for years about systemic racism in health-care settings, with birth alerts and forced sterilizations still an ongoing reality in parts of the country.
As a result, a number of Indigenous care providers and communities have taken matters into their own hands, finding ways to lessen the gaps even as a growing doctor shortage leaves more and more people without health care.
Finding care in Indigenous-led spaces
Rural, remote, Indigenous communities are some of the hardest-hit by staff shortages in health care, forcing many to seek care in urban clinics, according to Campbell.
"It's really difficult when communities don't have assigned medical transportation," she said. "Again, you need human resources for that to operate effectively."
Once Indigenous women reach an urban hospital or clinic, Campbell said, some face the added barrier of not speaking English as their first language. A lack of Indigenous staff who speak languages like Cree or Dene sometimes means patients do not know exactly what they have agreed to, she said.
On top of that, Campbell said, Indigenous patients regularly face discrimination in these spaces, making them hesitant to seek care. Campbell remembers her own experiences from nearly two decades ago.
"When I was a young university student … in Saskatoon, I unfortunately had a couple [of] experiences [where] I faced discrimination when I went to access health care," Campbell said. "To feel that when you access care makes you hesitant to want to access it more in the future. That feeling has stuck with me."
One of her goals as a nurse in the public health sector is to form a bridge between Indigenous peoples and the health-care system "to show them that there are people that are caring, compassionate and understanding of the history," she said.
A separate study published in the Canadian Medical Association Journal in May 2023 found that culturally safe care is found in Indigenous-led spaces that provide holistic, wraparound services. That paper was based on responses from Vancouver residents in sharing circles led by Indigenous elders.
After citing reports of racism and their ensuing mistrust in health care, the 26 participants (most of whom were women) shared positive experiences at an urban Indigenous-led clinic in Vancouver.
"This clinic provided supports and services not typically available within other clinics. For example, a participant experiencing homelessness described how the staff not only worked to address their health concerns, but also assisted them with securing housing," the report said.
"In another example, a participant discussed their appreciation for how a health-care provider intervened on their behalf following a negative experience with a specialist physician they had been referred to, which made them feel safer when accessing care and confident that their health concerns would be addressed in a meaningful way."
Srugo said access to culturally safe health care is particularly important during pregnancy and was one of the reasons why his team sought to quantify the barriers that exist for Indigenous women.
"We were thinking — and there's a lot of research about this — [about] how equitable health care at that life stage is really important, because it might be able to interrupt intergenerational cycles of disease and also narrow gaps in health outcomes that we see in Canada," he said.
'There is often judgment'
A shortage of health care in Canada in 2023 is not limited to Indigenous peoples, said Cheryl Whiskeyjack, executive director of the Bent Arrow Traditional Healing Society in Edmonton — but the level of discrimination is, which leads to inconsistent care.
"What we hear from our women is that they will often hop from medicentre [clinic] to medicentre … because there is often judgment," said Whiskeyjack. "They'll see this medicentre [doctor] and will feel some stigma attached to whatever issue it is that they're bringing to that [doctor]. They don't want to face that, so the next time they need a doctor, they'll go to a different medicentre."
As a result of not having a regular doctor, Indigenous women's health issues get overlooked. Referrals for a mammogram or specialist consultations, for example, are missed, according to Whiskeyjack.
She recalled a story of pain medications being withheld after surgery because the doctor assumed the Indigenous patient was an addict, and another of a doctor asking a married woman if she knew who the father of her baby was, leaving her feeling reprimanded on what was otherwise a happy occasion.
The best way to improve things, Whiskeyjack said, is for practitioners to learn more about Indigenous communities and their history.
"The ability to connect those dots really helps," Whiskeyjack said. "I think if we start talking to people in medical school, in nursing school, if we start having those kinds of opportunities to educate, then the picture looks different when you see the whole picture instead of just this person sitting in front of you that day."
Now that their paper has been published, Srugo said the next step is to write up a plain-language version of the text to make it accessible to more people. After that comes more research.
"We've already created this relationship with these Indigenous women's organizations and two-spirit people's organizations, so we are definitely looking into other questions that the community might need answers to," Srugo said.
This research, he said, is a step toward answering one of the calls to action from the Truth and Reconciliation Commission of Canada: to identify, monitor and address health-care inequities impacting Indigenous peoples.
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With files from Paige Parsons