Educating for Equity Care Framework

Colonization and diabetes.

Colonization is the predominant determinant of health for Indigenous people.^37,38 Both patients and physicians recognized colonization as a distal determinant that undermines individual resilience and leads to negative health outcomes through pervasive poverty, adverse life experiences, and ongoing racism.^18,19 These unfavourable conditions underlie and exacerbate Indigenous people’s experiences of diabetes, as the structural barriers and psychosocial effects of poverty have consequences for health.^39,40 Research participants emphasized that historical discrimination against Indigenous people persists, resulting in their relatively low social status. Additionally, participants attributed the disruption of social cohesion or the development of dysfunctional relationships to the insidious effects of colonization. Thus, diabetes can be contextualized as a manifestation of social suffering originating from colonization and enacted through structural violence and inequity.^41–43

It is therefore important for clinicians to recognize that, far from being a distant historical event, colonization is indeed a process that has enduring effects. Moreover, it is essential to situate health care within a legacy of colonization. Using a postcolonial theoretical lens⁴⁴ to examine the experiences of Indigenous people with type 2 diabetes, the E4E initiative identified a great need for understanding the relationship between Canada’s colonial history and how Indigenous people experience both diabetes and the health care system. Health care can contribute to ill health when it is culturally unsafe⁴⁵ or complicit in the processes of colonization. This tension plays out within spaces structured by the unresolved legacy of colonization, from health care policies that provide differential access to health benefits⁴⁶ to discriminatory emergency department triage practices.⁴⁷ Care is thereby shaped through systemic and individual levels of racism⁴⁸ that might stir physician biases, trigger patient resistance, and sustain systemic barriers.

Framing diabetes care for Indigenous patients.

The guiding principles of the E4E Care Framework orient the clinician toward social factors that affect Indigenous patients with type 2 diabetes (Figure 2). Motivated by patient stories of harmful care,¹⁹ as well as by patient and physician descriptions of positive health care relationships,⁹ these principles highlight the dynamic nature of cultural humility and culturally safe care.⁴⁹ A clinical approach attuned to the Indigenous patient’s social and cultural realities facilitates congruent management strategies. Clinicians are reminded that the cultural experiences of Indigenous people are diverse. Engagement that considers cultural diversity is not about treating all patients alike, but rather it is about supporting and leveraging the necessary tools for each patient to build capacity and resilience. Providing effective care for Indigenous patients necessitates health care equity, where resources are discrimination free, are developed for the specific needs of Indigenous patients, and fill existing gaps.

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Figure 2.

Principles of the E4E Care Framework

E4E—Educating for Equity.

In addressing social factors that adversely influence the health care outcomes of Indigenous patients with diabetes, physicians are called upon to comprehend complex social domains within an already-complex biomedical explanatory model. The notion of stress-induced disturbances of the hypothalamic-pituitary-adrenal axis as a mechanism for diabetes outcomes^50–52 provides a rationale for clinicians to explore patients’ stress. Population health studies that link inequity and chronic disease through material, psychosocial, and political pathways^53–55 lend a useful framework. Within the Indigenous context, the political pathway plays out as the ongoing influence of colonization, while material and psychosocial pathways represent complex social effects on health, such as poverty and multi-generational trauma.

Described here is a call for clinicians to identify and address the systemic causes of disease within the patient’s environment. Metzl and Hansen²⁴ describe this approach in terms of structural competency, where clinicians are encouraged to move beyond an “individual choice” paradigm toward recognizing how social and economic status shape health resource access, health behaviour, and ultimately health outcomes.

To facilitate practice implementation, the E4E team developed a framework (Figure 3) best understood in terms of the interplay of structural competency and cultural safety within a patient-centred care approach. At its core, the E4E Care Framework provides 2 directives for clinicians: re-centring the clinical relationship and engaging the social realities of Indigenous patients to find opportunities for change. Each directive is grounded in Indigenous cultural concepts for addressing critical social variables, arising from the legacy of colonization, that influence patient health and clinical interactions. While the directives act synergistically, the framework intentionally describes the relational directive first, as developing a relationship is fundamental to effective care.¹⁹ Respectful inquiry can also engender a therapeutic relationship. The following sections describe the interplay of social and cultural concepts related to each directive.

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Figure 3.

Conceptual model of the E4E Care Framework

E4E—Educating for Equity.

Re-centring the relationship.

Implicit physician bias results in health care inequities directly through misinformed physician decision making and indirectly through destabilizing the clinical relationship.⁵⁶ Patients reported being routinely discriminated against, stereotyped, and marginalized. The damaging and uneven historical relationships between Indigenous people and non-Indigenous Canadians means that many Indigenous patients have apprehensions about the Western medical system,¹⁹ which for many remains a living symbol of continuing oppression, mistreatment, and neglect. As a result, patients remain highly vigilant for any threat of stereotype.⁵⁷ Resistance, hesitation, withdrawal, and acquiescence are all potential patient responses to approaches that establish physician authority and power imbalance.

Re-centring clinical relationships involves attending to colonization and inequity within health care (Table 1). The E4E Care Framework directs clinicians to address dynamics related to “unequal treatment” and imbalance of “power and authority.” Clinicians must become aware of their potential complicity in perpetuating these concepts. Critical self-reflection is the first step in identifying one’s stereotypes, assumptions, and biases. Using the notion of power distance,⁵⁸ an agreeable power balance is achieved by direct inquiry, refraining from language rooted in oppression and racism, and using nonverbal communication cues⁵⁹ that mirror the patient’s communication approach. The framework recommends that clinicians examine any remaining moments of discord for underlying historical tensions.

The E4E Care Framework suggests what the concepts of cultural competency and cultural safety⁹ might look like for Indigenous patients, and how they might foster patient-physician concordance for management plans. We advocate refocusing on relational aspects of care by using a cultural lens that is attuned to Indigenous perspectives on sharing, time, and connectedness¹⁹ (Figure 4). Strategies in this area involve critical self-reflection on one’s own concepts of health and diabetes care, as well as assumptions about Indigenous perspectives, including preferences around professional distance or objectivity. Tools include strengthening skills in intercultural communication,⁶⁰ such as using narrative and indirect approaches more common in Indigenous contexts.^61,62 It could also involve increased community engagement.

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Figure 4.

Conceptual model of re-centring the relationship

Geraldine’s social environment: Key to Geraldine’s social context is a history of trauma originating from her first husband, with whom she has adult children and who was physically abusive until she escaped by leaving her reserve community years ago. This trauma is compounded by the adversity of growing up in poverty and her residential school experiences. You notice that Geraldine’s summer visits to the reserve with her children appear to trigger annual retraumatization that correlates with worsening of her diabetes control. She also has an unstable current home environment, where her second husband is a heavy drinker and is emotionally abusive. Grown children and grandchildren also live in her home to help supplement the rent, as she has trouble making ends meet.

You notice that her diabetes seems to improve when she is able to work regularly as a house cleaner. However, over the years, she has shared with you that she drinks to cope with her stressors. During those times, she is often not eating well and cuts back on her medications. She also works less at these times, often overwhelmed with spousal conflict and caring for her grandchildren. It seems that stressors and chronic joint pain influence her ability to work. How do you start to support Geraldine in order to improve her diabetes outcomes?

Engaging the social reality.

Effective health care for Indigenous patients is shaped by a deep understanding of the causal relationships between social factors specific to Indigenous people and health. These social factors form constant stressors that accumulate and operate concurrently to maintain chaotic and overwhelming living conditions, which lead to diabetes while undermining an individual’s capacity to cope with it. For instance, family networks can be a source of support, but within contexts of socioeconomic disadvantage family members can diminish capacity for self-care by pressuring a patient to divert limited resources elsewhere. For clinicians, engaging with social contexts of diabetes in Indigenous settings involves recognizing distinct barriers that hinder patients in achieving improved outcomes, developing strategies for achieving management and therapeutic goals, and identifying tools for fostering self-efficacy and positive health behaviour among patients (Table 2).

The E4E Care Framework recommends that clinicians consider the broader environment through screening for resource limitations and adverse life experiences, and then acknowledging these as playing a role in diabetes onset and management. This approach is concordant with traditional Indigenous perspectives of relational, indirect, and nonconfrontational approaches.⁶¹ The screening question, “Do you ever have difficulty making ends meet at the end of the month?,” is aligned with recommended Indigenous approaches.⁶³ Screening is best framed by asking about “hardship” beyond poverty that is related to discord within the family, community, and broader society. At this point, clinicians could indicate that they have some understanding of the outcomes of colonization on health and then explore those experiences.

A strategy for incorporating social factors within care is to speak with patients about population health evidence that demonstrates material and psychosocial pathways to chronic disease. For example, the concept of effort-reward imbalance⁶⁴ on health outcomes was a strong theme within our research. Additional key themes arising from the legacy of colonization include lateral violence,⁶⁵ intergenerational trauma, attachment,⁶⁶ and the need for social support.^67–69 Clinicians are advised to be aware of the principles of trauma-informed care when exploring adverse life experiences.³⁶ Even though behaviour change remains important in the path to wellness, this contextual approach is intended to facilitate patient empowerment in addressing social factors that operate as barriers to health. In concordance with the concept of structural competency, the framework invites clinicians to engage as advocates at the system level in order to sustain individual patient change.

Helping Geraldine cope with adverse social contexts: One element of the E4E Care Framework encourages you to help patients cope with social barriers to well-being by acknowledging connections between adverse life experiences and patients’ capacity to manage diabetes. In Geraldine’s case, this includes helping her to address family stressors and to maintain employment in order to avoid poverty. Heavy drinking appears to be a marker of not coping well with her retraumatization and ongoing adversities, while it undermines her diabetes management through inconsistent eating and reduced medications. Given that Geraldine’s heavy drinking is episodic and driven by the same social stressors as her diabetes, you use her alcohol consumption patterns to gauge where she is at in terms of being overwhelmed. Alcohol is therefore a point of entry into addressing the social contexts influencing her diabetes, helping you to reinforce the interconnection of social stressors with her health outcomes.

While the E4E Care Framework speaks to how a context of acculturation worsens diabetes outcomes and how accessing cultural resources might be a means for improving health outcomes through traditional knowledge and social support networks, Geraldine’s past traumas make her hesitant to reconnect with Indigenous cultural practices. In this case, as in all, care follows the patient’s priorities and contexts.

Culture as therapeutic: Culture is a key facilitator for approaching diabetes management, and we must understand that cultural beliefs, values, and practices might play a role for patients in acquiring health knowledge and resilience (Table 2). Culture was viewed as a protective factor and a facilitator for improving health and managing diabetes. Resilience through reaffirming cultural identity and continuity is nurtured by accessing cultural knowledge and cultural supports, which can be accomplished by engaging in ceremonies and having relationships with community knowledge keepers, for example.^70–72 This should not imply that all patients are equally connected to traditional Indigenous practices, but that culture serves a role in positioning a person within wider networks of community and support. Of note, patients often perceived the same social barriers to health as influencing their health literacy and access to cultural resources. Clinicians are advised to nonjudgmentally ascertain patient knowledge and access to resources of both biomedical and Indigenous contexts (Figure 5). By exploring patients’ cultural perspectives and preferences for health, while sharing biomedical perspectives, clinicians and patients might build a shared understanding. In this way, clinicians can attain congruency of diabetes management with the social and cultural reality of the patient. The intent of the framework’s knowledge contextualization and exchange recommendation is to build patient capacity through health literacy using an acceptable rapport-building strategy. Notably, culture influences health literacy in important ways, in turn shaping capacity for chronic disease management.^73,74 Physicians are encouraged to engage with their local traditional community to learn more about cultural healing practices and resources.

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Figure 5.

Conceptual model of engaging the social reality