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A partnership for Indigenous knowledge translation : Implementation of a First Nations community COPD… Bendall, Cory Leanne; Wilson, Danielle Marie; Frison, Kelly Rose; Inskip, Jessica Ann; Camp, Patricia G. 2016

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RESEARCH ARTICLEA partnership for Indigenous knowledge translation:Implementation of a First Nations community COPDscreening dayCory Leanne Bendall BHSc (RT) MPH (HP)1,2, Danielle Marie Wilson MPH2, Kelly Rose Frison BHSc (RT)2,Jessica Ann Inskip PhD3,4, Pat G Camp BSc(PT) PhD3,4,5CL Bendall, DM Wilson, KR Frison, JA Inskip, PG Camp. A partnership for Indigenous knowledge translation: Implementation of a FirstNations community COPD screening day. Can J Respir Ther 2016;52(4):105–109ABSTRACTThis article suggests a method for integrating the principles of Aboriginal knowledge translation (KT) in the implementation of a pilot for chronic obstruc-tive pulmonary disease (COPD) screening to improve current practice and provide health programming that is culturally sensitive and relevant. The ele-ments of the Consolidated Framework for Implementation Research model guided a community informed design for the Lung Health Day that wasplanned with two communities of the Secwepemc Nation in British Columbia. By integrating the principles of Aboriginal KT, program implementationdesign can address the current disparities in respiratory care and management of COPD and improve the health status of First Nations patients.Key Words: Aboriginal health; First Nations; knowledge translation; knowledge exchange; implementation; chronic obstructive pulmonary diseaseTerms used to describe the Indigenous people of CanadaIn this research, the terms “Aboriginal” or “Indigenous” have beenused to refer inclusively to all three Indigenous populations inCanada: First Nations, Métis, and Inuit. The use of terminology isevolving. The term “Aboriginal” has less favor due to its historicalimposition by colonizing governments. To be consistent with cita-tions from previously published literature the term “Aboriginal”has been repeated only in the context that refers to the original refer-ence [1].INTRODUCTIONSmoking is the primary cause of chronic obstructive pulmonary disease(COPD) in Canada [2]. The prevalence of smoking in the Aboriginalpopulation is almost twice as high as the non-Aboriginal population(39% vs. 20.5%, respectively) [3]. As a result, Aboriginal Canadiansshoulder a large burden of health-related illness due to the effects ofsmoking [2, 4–6]. Ospina et al. [2] recently reported a higher incidenceof new cases of COPD among a First Nations cohort compared to anon-First Nations comparison group (incidence rate ratio of 2.1; 95%CI; 1.97, 2.27). Correspondingly, in their study the prevalence ofCOPD in the First Nations population was approximately 2.4 timeshigher than the non-First Nations cohort [2]. There is an increasedneed for COPD-related health services in First Nations communities;however, services are either not available or are not accessed by this pop-ulation [6]. Therefore, more effective programming is required to addressthe lung health needs of First Nations communities in Canada.Many Aboriginal people have experienced, and continue to experi-ence, cultural alienation and multi-generational trauma from residentialschool incarceration [7]. Economic and political marginalization and rac-ism also erode resiliency and the ability to maintain health and well-being[7]. Thus the residual aspects of colonization magnify the impact of keysocial determinants of health. Financial need, food insecurity, reducededucational opportunities, social isolation, and poor housing conditionspotentiate the COPD risk factors of tobacco use and childhood exposureto second-hand smoke in the Aboriginal population [2]. Research com-pleted by the Wellesley Institute [8] details systemic racism in the Cana-dian health system. This is supported by the findings of the Truth andReconciliation Commission where all levels of government are asked“… to acknowledge that the current state of Aboriginal health in Canadais a direct result of previous Canadian government policies including res-idential schools…” [9, p. 2]. The Indigenous population has current andhistorical health care experiences that mirror the previous trauma andneglect of institutional care (including residential schools and child wel-fare practices) [9]. These experiences reduce individual confidence in thecare they receive and may create reluctance to seek treatment [9].Aboriginal people in Canada may also experience inconsistent careand management once faced with a diagnosis of COPD when comparedwith non-Aboriginal patients with COPD [5, 6, 10]. Sin et al. [6] reporteda differential use of health care services for COPD between Aboriginal andnon-Aboriginal patients that was not explained by socioeconomic status orliving location. They reported that Aboriginal patients experienced gaps inCOPD care and treatment, and were 55% (95% CI; 52%–58%) less likelyto see a specialist and 66% (95% CI; 63%–70%) less likely to undergo spi-rometry than non-Aboriginals [6]. These results highlight the need for anassessment of how health care providers (HCPs) approach care, includinghow stereotyping and bias may unconsciously limit the care and treatmentoptions for Aboriginal respiratory patients [8].Gaps in care hinder respiratory health. There are numerous knowledgetranslation (KT) strategies that aim to increase uptake of research-basedclinical practice to ultimately improve the health outcomes for patients[10, 11]. However, to facilitate uptake into practice in a First Nations con-text, an optimal KT strategy should incorporate principles of Indigenousknowledge sharing, which includes a community-developed approach,experiential knowledge, and an emphasis on oral traditions [7, 11, 12].Strategies to improve respiratory care that integrate the principles of Indig-enous KT may have the greatest potential to address existing health status1Department of Physical Therapy, UBC, Vancouver, British Columbia, Canada; 2Centre for Heart Lung Innovation, Vancouver, British Columbia, Canada;3St. Paul’s Hospital Pulmonary Rehabilitation Clinic, Vancouver, British Columbia, Canada; 4Michael Smith Foundation for Health Research Scholar,Vancouver, British Columbia, CanadaCorrespondence: Pat G Camp, 1081 Burrard Street, Vancouver, B.C., V6Z 1Y6, e-mail Pat.Camp@hli.ubc.caThis open-access article is distributed under the terms of the Creative Commons Attribution Non-Commercial License (CC BY-NC) (http://creativecommons.org/licenses/by-nc/4.0/), which permits reuse, distribution and reproduction of the article, provided that the original work isproperly cited and the reuse is restricted to noncommercial purposes. For commercial reuse, contact editor@csrt.comCan J Respir Ther Vol 52 No 4 Fall 2016 105inequities and disparities in COPD treatment. This paper describes how aKT strategy that incorporated the principles of Indigenous KT was used toimplement a First Nations community-based screening day in partnershipwith the Adams Lake and Neskonlith First Nations of the SecwepemcNation in British Columbia, Canada.INTEGRATED KNOWLEDGE TRANSLATIONIt has been estimated that it takes an average of 17 years for 14% ofresearch findings to be adopted into clinical practice [13]. KT uses differ-ent strategies to encourage and support clinicians to embed evidence-based research into clinical best practice to improve patient outcomes.The Canadian Institutes of Health Research define western-medicinebased KT as an “...iterative process that includes synthesis, dissemination,exchange and ethically sound application of knowledge” [11]. However, awestern-based approach to KT may not be relevant in Indigenous healthcare. The scientific method for gathering and disseminating evidence islargely unidirectional from researcher to clinician to patient. In contrast,Aboriginal KT fosters an approach where the researcher, clinician, andthe community are seen as resources for each other [11, 14]. There is amutual sharing of knowledge that is inclusive of a variety of perspectives.Table 1 indicates the components of western-medicine based KT andapplies them in an Aboriginal context. Aboriginal knowledge structuresinclude community voices that illustrate “different ways of knowing”[11, 12, 14–16]. Dr. Jeanette Armstrong, an adjunct professor at the Uni-versity of British Columbia Okanagan and a member of the Syilx Nation,noted in a recent keynote presentation at the 2nd Okanagan CulturalSafety symposium that:Just as written grammar systems have rules that establish pre-ciseness of meaning, Indigenous languages develop precisenessfrom the understanding that has been established by the peo-ple... who have created information packages that are repre-sented by characters in nature (plants and animals) developedover 12 thousand years of oral tradition. [12]Thus, in a First Nations context, local understanding is often sharedthrough linguistic constructs such as story, song, or ceremony. This methodfor intergenerational knowledge sharing has supported the health andwellness of Aboriginal people for centuries [11]. While western-medicinebased KT gains academic rigor through iterative scientific method, levelsof evidence, and established research methodologies, Indigenous KTshares best societal practices and social instruction through a system oforal documentation practiced over thousands of years [11, 12].It is critical that health interventions integrate the principles ofAboriginal KT and align with the community’s geographical, social, cul-tural, and political history [11, 15, 16]. For example, often the four quad-rants of the medicine wheel (physical, emotional, mental, and spiritual)guide the content and context of health interventions considered bythe community when promoting wellness as part of their unique oral his-tory [12]. The final synthesis of the information takes into account thepriorities of the people involved and asks for their contribution to imple-mentation in order to sustain the knowledge and practices within thecommunity. The design and implementation of Indigenous health pro-grams that integrate the principles of Indigenous KT may be more rele-vant, have more emphasis on an equity-focused approach to healthcare, and ultimately may be more successful at improving Indigenoushealth outcomes.Although in general western-based approaches to KT may not be agood match with Indigenous health and learning values, there aresome existing KT strategies or frameworks with components that do alignwith Indigenous health and learning values. The Consolidated Frame-work for Implementation Research (CFIR) is a model that combines sev-eral implementation theories to create a standardized method forapplying knowledge across diverse contexts [17]. Developed in 2009 byDamschroder et al. [17], it outlines implementation strategies based onfive fundamental components: (i) individual characteristics, (ii) interven-tion characteristics, (iii) inner setting, (iv) outer setting, and (v) the pro-cess of implementation. One component of the CFIR model detailsfive implementation actions to guide KT planning [17] (Table 2). Twostrengths of this model are that it utilizes an approach that focuses onknowledge sharing among all participants and the model componentscan be tailored to the principles of Indigenous KT. The following sec-tions of this article describe how the CFIR was used as the theoreticalfoundation for the Secwepemc Lung Health Day held approximatelythree hours north of Kelowna B.C. in the Adams Lake and Neskonlithtraditional territory.ACTIONING INDIGENEOUS KNOWLEDGETRANSLATION—SECWEPEMC LUNG HEALTH DAYThe Secwepemc community hosted this opportunity for knowledge shar-ing and actively promoted attendance by all community members. Table3 describes the agenda for the event. The day began with an Elders teach-ing circle for the HCPs and included chronic disease learning sessions.The Chief and her council presented on the community traditions forpromoting wellness and preventative care such as the traditional dietthat is sourced from the land and how seasonal activities maintain theNation’s health through this connection with their land. Lunch was pro-vided by the Elders and all participants continued to share knowledgeand network during the meal. The afternoon contained COPD screen-ing and follow up of the results with the HCPs. The day finished witha participant evaluation and a small gift exchange between the Eldersand the HCPs.Intervention characteristics—inclusive of multiple perspectivesDamschroder et al. [17] described the first CFIR domain “Intervention”as the characteristics of the intervention being implemented in the orga-nization, and they stressed that it is necessary to adapt the intervention tomeet the needs of the organization, without losing the core componentsof the intervention that are necessary for its success. This approach iswell-matched with the Aboriginal health emphasis on “Being InclusiveTABLE 1The process of non-Indigenous and Indigenous knowledgetranslation of research resultsNon-Indigenous IndigenousIdentify the problem Establish community trust and partnership toidentify a problem of significance to the peopleAnalyze the context Recruit culturally competent field workers andcommunity members to inform context and guideall stages of researchSelect the knowledge Create ongoing opportunities for knowledgesharing to facilitate collaborative decision makingSelect the intervention Commit to return results to communities forverification and validation before widerdissemination, implement the intervention in themost appropriate mode of delivery for thecommunity contextSupport the use in practice Communicate results to inform policy andpracticeAdapted from Jardine and Furgal [16] and Hoens et al [19].TABLE 2Five implementation actions that support community-established meaningActionsIdentify stakeholders,prioritize content, and integrate methods for knowledgetranslationCreate a shared vision and recruit internal and external change agents thathave gained community respectRemain faithful to implementation plan created by consensusCreate a safe atmosphere for information sharing, debriefing, and furtheradaptationIdentify formative goals that are S.M.A.R.T. (specific, measurable, attainable,relevant, and timely) from the community’s perspectiveAdapted from Jardine and Furgal [16] and Damschroder [17].106 Can J Respir Ther Vol 52 No 4 Fall 2016Bendall et alof Multiple Perspectives.” In 2009, Estey et al. [11] emphasized that the“large gaps in our knowledge about all Aboriginal health” would onlybe addressed if health interventions incorporated a “multiplicity of per-spectives”. Interventions characteristics should be legitimate, valid, andadaptable [17]. Legitimacy and validity are related to the communityand the HCPs’ perception of who created the intervention and designfor implementation. For the Lung Health Day it was essential to havethe Secwepemc Elders, First Nation employed HCPs, health authorityHCPs, and the University of British Columbia Family Practice Residents’Supervisor form a planning team to ensure respectful representation ofall stakeholders and to reinforce the legitimacy and validity of the event[16]. Feedback from the community members highlighted the impor-tance of bringing new physicians out into the community to witness,experience, and learn about local First Nation culture and health prac-tices. Adaptability of program components was essential as the stake-holders planned to bring the model for the Lung Health Day to manyof the Secwepemc communities as well as other First Nations communi-ties that are part of the health authority. The Lung Health Day pilot wasevaluated by the participants and the HCPs to improve future events.Success of the event was determined by a participant survey which indi-cated that 100% of participants would recommend participation in arepeat of the community event to friends and family. Evaluations ofthe day were also shared with the planning stakeholders and Secwepemcleadership, who suggested further improvements to the implementationto support sustainability of the KT by creating an online learningmodule.Inner setting—different sources of knowledge and outersetting–intergenerational knowledge sharingThe second CFIR domain is “Inner Setting,” which relates to the within-organization “structural, political, and cultural contexts through whichthe implementation process will proceed” [17]. It acknowledges that tobe successful, the intervention must acknowledge and incorporate thetangible and intangible networks and lines of communication that existwithin an organization. The CFIR “Outer Setting” domain refers to“the economic, political and social context within which the organizationresides” [17]. In practice, there is overlap between inner and outer set-tings, and these domains closely aligned with the Aboriginal KT conceptof “Different Sources of Knowledge” and of “Intergenerational Knowl-edge Sharing” (8, 12).Different sources of knowledge can facilitate an optimal climate forimplementation by contributing to the social architecture, methods ofcommunication, and opportunity for cultural recognition [17]. The foun-dation of the Lung Health Day’s inner setting were the health authorityHCPs who were comfortable with their established divisions of labourand professional scope of practice, but who also looked for opportunitiesfor coalitions of service with this First Nations community [14]. Theinner setting for the Lung Health Day also relied on existing receptivityto health learning within the Adams Lake and Neskonlith First Nationstheir role in adjusting the day’s content to improve community engage-ment; and the link of the event with the community priorities for addic-tion awareness, prevention, and treatment.The planning team also felt that the lung health day could create a set-ting for intergenerational knowledge sharing and cultivate learning aboutsmoking and the risk of developing COPD. However, this componentwas difficult to implement. Although the health authority team partici-pated in a recent student health fair to promote lung heath with the com-munity youth, it became apparent that more emphasis on this youngerpopulation would be required to address the community priorities andreflect a service partnership that was truly patient and communitycentred [11]. As the Lung Health Day was targeted to coincide with theSecwepemc Addiction Awareness week and World COPD Day 2014,there was only a small window of time for relationship building relatedto lung health for the community’s youth [16], and would require addedresources to increase the scope of the lung health day to includeprevention.Individual characteristics—mutual sharing of knowledgeThe fourth domain of the CFIR framework is the “Individual”, whichrefers to the unique characteristics of the people involved in the imple-mentation. It recognizes that individuals make choices, experimentwith interventions, and influence others [17]. This domain aligns withthe Indigenous KT principle of “mutual sharing of knowledge”, whichalso emphasizes the importance of including the perspectives of the mul-tiple stakeholders of the event. To formalize the importance of the mutu-al sharing of knowledge, the Secwepemc Lung Health Day relied on theTABLE 3Event scheduleTime Component Description08:30–10:30 Community teach-back to HCPs Session opened by drum song and prayerElders held discussion circle for HCPs on respectful approach to care, healing traditions, building relationships,and end-of-life traditionsPermission was received to record the session to create online cultural safety resource10:30–11:00 Break Reflect on what was sharedIntroduce HCPs to community members who were now arriving11:00–12:00 Chronic disease learning sessions(15 minute presentations)Traditional tobacco use and the importance of community in health—IH Aboriginal Tobacco CoordinatorCOPD management, physiology overview, signs, symptoms, and breathing techniques—IH KnowledgeCoordinatorChronic co-morbid disease associated with COPD—Family Practice ResidentAnxiety and depression and community contacts—IH Mental Health Services12:00–1:00 Chief and Council presentationand lunchCommunity traditions of preventative care and seeking information to support wellnessPrayer of thanksLunch of traditional food prepared by the EldersSharing food as part of knowledge transfer1:00–3:00 COPD screening COPD-6 device used to screen all participantsAbnormal screening results follow-up with screening Spirometry stations with Family Practice resident andRRT consultationsResources set up for smoking cessation and COPD management including mental health and substance useissues3:00–4:00 Wrap-up and gifts Band RN spoke with all participants and reviewed recommendations and plan for follow upIH Aboriginal Practice lead initiated short evaluation of the day with participants before they leftFood to take home offered to allSmall gifts exchanged between Elders and HCPsNote: HCP, health care provider; IH, interior health; COPD, chronic obstructive pulmonary disease; RRT, Registered Respiratory Therapist; RN, Registered Nurse.Can J Respir Ther Vol 52 No 4 Fall 2016 107A partnership for Indigenous knowledge translationrelationship that had been established between the Adams Lake and Nes-konlith First Nations and the Government of British Columbia’s InteriorHealth (IH) Authority via a letter of understanding. This letter describedthe collaborative relationship between the First Nation and the IHemployees to inform the components of the day and clearly describedhow the mutual sharing of knowledge would be facilitated. One key fea-ture of the sharing of knowledge was the use of a talking circle with thecommunity Elders. The talking circle gave the HCPs time with the Elderswho shared their knowledge of culturally appropriate approaches tobuilding care relationships such as mutual sharing of family history.This approach strengthened the credibility of the day as the Neskonlithchief and council members presented on the importance of preven-tion and appropriate care in sustaining the health of the people,and how seeking and sharing knowledge has ensured the well-beingof the community [12].Process of implementation—community established meaningThe final domain of the CFIR focuses on the “Process of Implementa-tion” [17]. Process is recognized as having many components whichmay be happening simultaneously or in a non-linear fashion. This domainis reflected in the Indigenous KT concept of “community-establishedmeaning,” which emphasized that the creation of the lung health daywas transparent and included multiple stakeholders from the healthauthority, the community health workers, and the Elders. There was alsoan emphasis on discussing the event, revisiting the main objectives of theday, and revising as new suggestions arose.Evaluation and knowledge disseminationEvaluation of the day was completed using participant and provider sur-veys that were collaboratively developed by the community-based plan-ning team. Fifty-five of 800 First Nation community members came tothe event (7%). Forty-four individuals were screened for COPD usingthe COPD-6™ (Vitalograph, Hamburg, Germany) device which mea-sures forced expiratory volume in one second (FEV1), forced expiratoryvolume in 6 seconds (FEV6), the FEV1/FEV6 ratio, and the percent ofpredicted values, as well as a calculated obstructive index or lung age.Twenty-six participants completed an evaluation at the end of the day.As well, an online HCP survey completed one week after the eventallowed the event organizers to gain insight as to how the program designcould be improved and possibly adapted for other chronic diseases. Asummary of the survey results was presented to the Secwepemc NationLeadership Council in January of 2015, and the HCP surveys wereshared with the Neskonlith and Adams Lake First Nation health direc-tors for future use.The screening day identified 10 individuals who required spirometrytesting and follow-up with their family physicians. All the testing resultswere submitted for IH respirologist interpretation, and the results andinterpretations were sent to patients’ family physician or communitynurse practitioner. The screening day exposure has helped increaseawareness of chronic lung disease in the community and the HCPshave been asked to repeat the screening day with different communitieswithin the Secwepemc Nation.DISCUSSIONIndigenous health care principles use a community-focused approach toensure that care is based on building relationships and fostering trustwithin the health system as well as addressing the reasons behind a reluc-tance to seek care [8, 18]. This social approach to care may not be wellsuited to western-based KT strategies that tend to target a specific medicalaudience without necessarily understanding of the context within whichhealth care takes place. The integration of the principles of IndigenousKT with those of western-medicine based KT creates an opportunity tocontextualize health care and, in so doing, may address racial inequalitiesas they relate to COPD management [18].The high prevalence of Indigenous tobacco use often results in anincreased need for healthcare services over time. This burden may be fur-ther amplified in the Indigenous populations if there is a lack of diagnos-tic services or reluctance to seek care because of structural racism in thehealth system. To combat this, a COPD screening day that was developedfor and by First Nation peoples relied on approaching the community asequals and used a knowledge translation framework that incorporatedIndigenous KT principles. This model for implementation created pro-cesses that were adaptable and balanced standardized evidence-basedcare with community informed priorities for health.Specifically, the community members were acknowledged as expertsin their knowledge of the people, culture, wellness, and health traditions;instead of a unidirectional approach, there were opportunities to developa day that was based on the knowledge held by all the stakeholders.LIMITATIONSThis paper describes the pilot COPD screening day held in one FirstNations community in British Columbia. In general, Aboriginal knowl-edge is developed by the community over time. This increases communityengagement and uptake into practice. Different First Nations may havedifferent approaches to learning, collaboration and health care so theapproach we used may not be transferable to other communities [14].Sustainability relies on maintaining collaborative relationships where allstakeholders can inform further health initiatives based on evolving com-munity priorities. However, health system pressures challenge sustainabil-ity. As local health authorities are funded based on changing systempriorities, it is not clear if future screening days will be funded, and com-munity partners may see this as a lack of commitment to advance Aborig-inal health, reduce treatment disparities, and apply Indigenous KT.CONCLUSIONQuantifying the current respiratory health status of Canada’s Indigenouspopulation is limited due to sparse data compared to the Non-Indigenouspopulation. Further research is required to address community identifiedbarriers to effective, appropriate, accepted, accessible services that pro-mote improved culturally safe, health outcomes for Indigenous people.Integrating Indigenous KT into program implementation is one way toeffect change in the health system, and amend the approach to care forIndigenous patients. Our experience suggests that by integrating the prin-ciples of Indigenous KT, program implementation can begin to addressracial and ethnic disparities in current respiratory care and managementof COPD. Ultimately, we believe that incorporating the principles ofIndigenous KT as part of health programming design and implementa-tion will improve evidence informed practice for Indigenous patientswith chronic respiratory illness.ACKNOWLEDGEMENTS: The authors would like to thank the peopleof the Secwepemc Nation who participated in this event and the key indi-viduals who felt strongly about promoting lung health within the com-munity including the health director for the Neskonlith First Nation,Ms. Jody Leon, and the health director for the Adams Lake First Nation,Ms. Shirley Anderson.REFERENCES1. National Collaborative Centre for Aboriginal Health. Landscapes forFirst Nations, Inuit, and Metis Health: An Environmental Scan of Orga-nizations, Literature and Research. Prince George, BC: National Collab-orating Centre for Aboriginal Health; 2014, pp. 6–19.2. Ospina MB, Voaklander D, Senthilselvan A, et al. 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Fostering implementation of health services research findings intopractice: A consolidated framework for advancing implementation sci-ence. Implement Sci 2009;4:50. doi: 10.1186/1748-5908-4-50.18. Ball J. Cultural Safety in Practice with Children, Families and Communi-ties. Victoria, BC; 2014.<http://www.ecdip.org/culturalsafety/> (AccessedFebruary 28, 2016).19. Hoens AM, Reid WD, Camp PG. Knowledge brokering:an innovativemodel for supporting evidence-informed practice in respiratory care.Can Resp J 2013;20(4):271–4. doi: 10.1155/2013/121654.Can J Respir Ther Vol 52 No 4 Fall 2016 109A partnership for Indigenous knowledge translation


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