Table 2.

The E4E Care Framework for engaging the social reality

KEY CONCEPTS OF ENGAGING THE SOCIAL REALITY	RECOMMENDATIONS
Social and economic resource disparities^* Socioeconomic disadvantages Socioeconomic disadvantage is a normalized state for many patients, limiting choices while increasing stress and diminishing capacity for self-care and healthy behaviour patterns	Considering Indigenous patients’ social and economic realities: Screen for and explore resource limitations that influence diabetes onset and management Acknowledge with the patient the effect of resource limitations on diabetes onset and management Support access to key proximal health determinants Assess diabetes knowledge and health literacy

Family and limited resources These are contexts in which self-care might occur. Food and financial sharing within large families results in diversion of resources, becoming another stressor

Knowledge barriers Health knowledge is affected through structural access barriers to learning, ongoing adverse life experiences, and discord within the health care relationship
Accumulation of adverse life experiences^† Family adversity and support Family and community are viewed as supportive but also potentially stressful in the context of pervasive social dysfunction arising from the outcomes of historical trauma, poverty, and underlying inequities from colonization	Considering patients’ adverse life experiences: Acknowledge with the patient the connections between adverse life experiences and capacity fordiabetes management Explore patients’ perspectives on personal adverseexperiences in the context of diabetes in order toaddress their priorities

Personal and collective loss The nature and extent of multiple forms of loss (eg, personal, cultural, historical) are key features of adversity affecting individuals, families, and communities

Effect of residential schools The residential school experience traumatized individuals, disrupted communities, and continues to adversely influence health and health behaviour
Culture frames knowledge^‡ Knowledge contextualization and exchange Knowledge contextualization and exchange rather than just information delivery was identified as an effective means to facilitate patient education	Helping build Indigenous patients’ knowledge about diabetes care: Build a shared understanding of diabetes that integrates and contextualizes biomedical, social, political, and cultural explanatory frameworks Use language appropriate for the patient’s educational and cultural background; consider metaphors within a narrative approach
Culture as therapeutic^§ Culture is protective Health is positively correlated with a sense of security in cultural identity and access to cultural knowledge and traditions	Recognizing culture as therapeutic: Strive for cultural congruency of management recommendations Explore patients’ preferences and support choices for accessing cultural resources Engage with the community to learn about local beliefs and practices, as well as healing resources

Traditional medicine and ceremony Traditional medicine and ceremony are desired modalities to access and reconnect with, in conjunction with Western medicine

E4E—Educating for Equity.
↵* Relationships between resource limitations, socioeconomic status, and the social environment directly affect health and diabetes through material deprivation, as well as indirectly through psychosocial pathways such as stress, depression, anxiety, and loss of control. The ongoing process of colonization is conceptualized to be the apparatus responsible for these barriers affecting Indigenous people’s health and their experiences with diabetes.
↵† Persistent and recurring throughout the life course of Indigenous individuals and communities, adverse experiences accumulate and pervasively influence wellness and health by undermining health behaviour patterns and diminishing resilience and capacity to cope with disease.
↵‡ Placing diabetes care knowledge within the cultural, social, and political landscape of Indigenous people can facilitate patient engagement and learning. In addition, culture is fundamental to effective communication for achieving knowledge exchange and patient education.
↵§ Recognizing culture as a protective factor in promoting health ensures that efforts toward improved diabetes care include using a cultural lens to view Indigenous peoples’ experiences of health and illness, as well as understanding patients’ own preferences and connections, and barriers to cultural resources.