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Developing a culturally safe and appropriate mobile health program with and for Indigenous people living… Campbell, Amber R. 2020

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DEVELOPING A CULTURALLY SAFE AND APPROPRIATE MOBILE HEALTH PROGRAM WITH AND FOR INDIGENOUS PEOPLE LIVING WITH HIV: COMMUNITY COLLABORATION AND QUESTIONNAIRE VALIDATION  by  Amber R. Campbell  B.Sc., The University of British Columbia, 2017  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  MASTER OF SCIENCE in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (Experimental Medicine)  THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)   April 2020  © Amber R. Campbell, 2020 ii  The following individuals certify that they have read, and recommend to the Faculty of Graduate and Postdoctoral Studies for acceptance, a thesis/dissertation entitled:  Developing a culturally safe and appropriate mobile health program with and for Indigenous people living with HIV: community collaboration and questionnaire validation  submitted by Amber Campbell in partial fulfillment of the requirements for the degree of Master of Science in Experimental Medicine   Examining Committee: Dr. Melanie Murray, Department of Medicine, University of British Columbia Supervisor  Dr. Helene Cote, Dept. of Pathology and Laboratory Medicine, University of British Columbia Supervisory Committee Member  Dr. Patrick Hill, Psychology and Brain Sciences at Washington University Supervisory Committee Member Dr. Lyana Patrick, Faculty of Health Sciences, Simon Fraser University Additional Examiner   iii  Abstract Introduction: In Canada, HIV disproportionately affects Indigenous persons and culturally safe combined antiretroviral therapy (cART) adherence programs are needed. WelTel is a bidirectional text-messaging program that improves cART adherence in persons living with HIV (PLWH). However, WelTel benefits individuals able to engage with the program most, and no demographic factors predict whom. Health psychology literature suggests understanding personal dispositions to assess behaviours impacting health. Measuring disposition is simple/rapid, and could personalize adherence supports. There is minimal research on associations between disposition and health among Indigenous communities. Furthermore, Indigenous knowledge has not been intertwined in WelTel. We sought to receive input on WelTel from Indigenous PLWH, and determine whether dispositional variables are valid and hold similar associations with health and wellbeing among Indigenous and low socioeconomic status (SES) communities in Vancouver, British Columbia.  Methods: An integrated knowledge exchange process was employed. Indigenous Elders and community collaborated in every study facet to ensure cultural safety. Sharing Circles were held to gain feedback on WelTel program and questionnaire design from Indigenous PLWH (women’s circle, n=8; men’s circle, n=10). We recruited 300 participants (149 Indigenous, 151 non-Indigenous) from various clinics/centres to complete measures of purpose, the Big Five personalities, health, and wellbeing. Factor and reliability analyses determined validation of measures. Correlational analyses determined associations with health.  iv  Results:  Indigenous PLWH expressed value in WelTel, suggesting it is accessible, empowers autonomy in healthcare, improves adherence, and may assist in strengthening community. They made recommendations to improve cultural safety. The majority of questionnaire participants (mean age 49 y, 58% male) had an income ≤$15,000/y and educational attainment <high school. Measures of personal disposition were reliable in Indigenous and low SES groups. Correlations were similar between Indigenous and non-Indigenous groups. Purpose was positively associated with health and wellbeing (all p<0.01); of the Big Five, conscientiousness was positively and neuroticism was negatively significantly associated with most health factors.  Conclusion: Community collaboration provided cultural safety improvements for WelTel for Indigenous PLWH. Similar to other populations, disposition is worth considering when understanding the health and wellbeing of Indigenous and low SES communities, and could be used to personalize HIV adherence supports.  v  Lay Summary In Canada, Indigenous people are more likely to have HIV than the general population, and there is a need for culturally safe programs that support taking medications regularly. WelTel is a text-messaging program that achieves this, but it most benefits those who are able to engage with the program. It is not known who this may be. In a community collaboration approach, we asked the community what they thought about WelTel and if assessing personal disposition could be used to personalize the program. We then sought to validate measures of disposition and assess their associations with health in Indigenous and low socioeconomic communities. We found that Indigenous persons living with HIV support WelTel, and that dispositions (purpose and conscientiousness) are reliable and associated with health and wellbeing among Indigenous and low socioeconomic communities living in Vancouver, BC as seen in other groups. Our findings can be used to personalize healthcare.  vi  Preface This project was designed and conducted by myself with supervision from my Supervisor, Dr. Melanie Murray, committee members, Dr. Patrick Hill and Dr. Helene Cote, and Indigenous Elders, Valerie Nicholson and Sandy Lambert. The content of this thesis, including all writing, figures, and tables, are my own original work. A Canadian Institute of Health Research Bridge Grant (H12-153404) funded this research. Ethics approval was acquired from the Children’s and Women’s Research Ethics Board at the University of British Columbia (H17-01792). Elders and Peer Research Associates assisted with data collection and knowledge translation, and were remunerated for their time and knowledge. This project is currently being written into two manuscripts for publication, one with content from Chapter 2 and one from Chapter 3. vii  Table of Contents Abstract ......................................................................................................................................... iii	Lay Summary ................................................................................................................................ v	Preface ........................................................................................................................................... vi	Table of Contents ........................................................................................................................ vii	List of Tables ................................................................................................................................ xi	List of Figures ............................................................................................................................. xiv	List of Abbreviations .................................................................................................................. xv	Acknowledgements .................................................................................................................... xvi	Dedication ................................................................................................................................. xviii	Chapter 1: Introduction ............................................................................................................... 1	1.1	 Human Immunodeficiency Virus Globally and in Canada ................................................ 1	1.1.1	 Adherence to HIV Medications .................................................................................. 4	1.2	 The Social Determinants of Health as Barriers to Care ..................................................... 6	1.2.1	 The Social Determinants of Health in Relation to HIV .............................................. 7	1.2.2	 Addressing the Social Determinants of Health in Programs ...................................... 8	1.3	 Indigenous Persons Living with HIV in Canada ............................................................... 9	1.3.1	 The Impacts of Canada’s History of Colonization ..................................................... 9	1.3.2	 Disproportional Rate of HIV among Indigenous Communities ............................... 14	1.3.3	 Healing of Indigenous Communities ........................................................................ 16	1.4	 Mobile Health and Medication Adherence ...................................................................... 18	1.4.1	 HIV Medication Adherence with Mobile Health ...................................................... 19	1.5	 Personal Disposition in Relation to Health and Wellbeing ............................................. 22	viii  1.5.1	 Personal Disposition Defined ................................................................................... 22	1.5.2	 Conscientiousness and Health ................................................................................... 24	1.5.3	 Agreeableness and Health ......................................................................................... 25	1.5.4	 Extraversion, Neuroticism, Openness and Health .................................................... 26	1.5.5	 Sense of Purpose and Health ..................................................................................... 27	1.5.6	 Medication Adherence and Personal Disposition ..................................................... 27	1.5.7	 Personal Disposition and Health in Indigenous and Low SES Communities .......... 29	1.6	 Community Collaboration in Research ............................................................................ 30	1.6.1	 Collaboration with Indigenous Communities ........................................................... 31	1.7	 Rationale .......................................................................................................................... 33	1.7.1	 Objectives and Hypotheses ....................................................................................... 34	Chapter 2: Research in a Good Way: Community Collaboration ......................................... 36	2.1	 Elder Consultation ........................................................................................................... 36	2.2	 Collaboration with Indigenous Centers and HIV Service Organizations ........................ 36	2.3	 Following Community Research Guidelines ................................................................... 37	2.4	 Funding and Ethics .......................................................................................................... 37	2.5	 Sharing Circles ................................................................................................................. 37	2.5.1	 Sharing Circles Methods ........................................................................................... 38	2.5.2	 Sharing Circles Results ............................................................................................. 40	2.5.2.1	 Perspectives on the WelTel Program ................................................................. 44	2.5.2.2	 Perspectives on Questionnaires and Researching Personal Disposition ............ 50	2.5.2.3	 Suggestions to Improve Community Engagement and Capacity ...................... 51	2.6	 Discussion of Sharing Circle Results ............................................................................... 52	ix  2.7	 Peer Research Associate Engagement and Training ........................................................ 56	2.8	 Integrated Knowledge Translation and Exchange ........................................................... 58	Chapter 3: Questionnaire Validation & Health Outcomes ..................................................... 60	3.1	 Methods – Questionnaires ................................................................................................ 60	3.1.1	 Questionnaire Design ................................................................................................ 61	3.1.2	 Recruitment and Participation ................................................................................... 63	3.1.2.1	 Inclusion/Exclusion Criteria .............................................................................. 64	3.1.2.2	 Participant Demographics .................................................................................. 65	3.1.3	 Analytical Plan .......................................................................................................... 66	3.1.3.1	 Questionnaire Validation - Factor and Reliability Analyses ............................. 67	3.1.3.2	 Health and Wellbeing Associations Analysis .................................................... 68	3.1.3.3	 Spiritual Health Correlation Analysis ................................................................ 68	3.2	 Questionnaire Results ...................................................................................................... 69	3.2.1	 Questionnaire Validation Results ............................................................................. 69	3.2.1.1	 Factor Analysis Results ...................................................................................... 69	3.2.1.2	 Reliability Results .............................................................................................. 76	3.2.1.3	 Adjustment of Measures .................................................................................... 79	3.2.2	 Associations with Health and Wellbeing .................................................................. 79	3.2.2.1	 Regression Associations with Health and Wellbeing ........................................ 83	3.2.3	 Spiritual Health Results ............................................................................................ 90	3.2.3.1	 Description of Spiritual Health Responses ........................................................ 90	3.2.3.2	 Associations of Spiritual Health with Disposition and Health Measures .......... 93	3.3	 Discussion on Questionnaire Validation and Health Correlations .................................. 96	x  3.3.1	 Sense of Purpose Validation and Health Correlations .............................................. 96	3.3.2	 Personal Disposition Validity and Reliability ........................................................... 98	3.3.3	 Conscientiousness and Agreeableness with Health and Wellbeing ........................ 100	3.3.4	 Extraversion, Neuroticism, and Openness with Health and Wellbeing .................. 102	3.3.5	 Suggestions to Further Assess Personal Disposition with Health .......................... 103	3.3.6	 Spiritual Health Discussion ..................................................................................... 104	Chapter 4: Summary, Limitations, Implications, and Conclusion ...................................... 107	4.1	 Summary of Findings with Implications Regarding HIV and mHealth ........................ 107	4.1.1	 Recommendations for Future HIV mHealth Research Methods ............................ 112	4.2	 Strengths and Limitations .............................................................................................. 113	4.3	 Implications for Personalized Medicine ........................................................................ 115	4.4	 Potential to Reduce Healthcare Costs ............................................................................ 117	4.5	 Cultural Safety Recommendations for Working with Similar Communities ................ 118	4.6	 Conclusions .................................................................................................................... 119	References .................................................................................................................................. 120	Appendices ................................................................................................................................. 156	Appendix A – Consent Forms ................................................................................................. 156	A.1	 Consent Form for Sharing Circles ............................................................................ 156	A.2	 Letter of Consent for Questionnaires ........................................................................ 164	Appendix B – Questionnaires ................................................................................................. 166	B.1	 Questionnaire – Indigenous Participants ................................................................... 166	B.2	 Questionnaire – Non-Indigenous Participants ........................................................... 175	 xi  List of Tables Table 1. Sharing Circle participant demographics. ....................................................................... 41	Table 2. Participant demographics for questionnaires. ................................................................. 66	Table 3. Summary of factor analysis for single-factor solutions with each factor in Indigenous and Non-Indigenous participant groups. ....................................................................................... 70	Table 4. Summary of factor analysis for single-factor solutions with each factor in equal or below and above $15,000/y participant groups. ........................................................................... 71	Table 5. Sense of purpose single-factor loadings in each participant group. ............................... 72	Table 6. Conscientiousness 8-item single-factor loadings in each participant group. .................. 72	Table 7. Conscientiousness 4-item single-factor loadings in each participant group. .................. 72	Table 8. Agreeableness 4-item single-factor loadings for each participant group. ...................... 73	Table 9. Agreeableness 3-item single-factor loadings for each participant group. ...................... 73	Table 10. Emotional stability 4-item single factor loadings for each participant group. .............. 73	Table 11. Emotional Stability 3-item single factor loadings for each participant group. ............. 73	Table 12. Extraversion 4-item single factor loadings for each participant group. ........................ 74	Table 13. Openness 4-item single factor loadings for each participant group. ............................. 74	Table 14. Openness 3-item single factor loadings for each participant group. ............................. 74	Table 15. Health single factor loadings for each participant group. ............................................. 75	Table 16. Life satisfaction single factor loadings for each participant group. .............................. 75	Table 17. Positive affect single factor loadings for each participant group. ................................. 75	Table 18. Negative affect single factor loadings for each participant group. ............................... 76	Table 19. Reliability analysis results for each factor by Indigenous or Non-Indigenous. ............ 77	Table 20. Reliability analysis results for each factor by equal or below and above $15,000/y. ... 78	xii  Table 21. Comparison of means for factors between Indigenous and Non-Indigenous participant groups. ........................................................................................................................................... 81	Table 22. Comparison of means for factors between equal or below and above $15,000/y participant groups. ......................................................................................................................... 81	Table 23. Correlations of dispositional characteristics with measures of health and wellbeing among each participant group. ...................................................................................................... 82	Table 24. Linear regression models for purpose with each health factor, controlling for demographics in each participant group. ...................................................................................... 84	Table 25. Linear regressions for purpose with health factors, controlling for demographics, conscientiousness, and agreeableness in each participant group. ................................................. 85	Table 26. Linear regressions for conscientiousness with health factors, controlling for demographics in each participant group. ...................................................................................... 86	Table 27. Linear regressions for agreeableness with health factors, controlling for demographics in each participant group. .............................................................................................................. 87	Table 28. Linear regressions for emotional stability with health factors, controlling for demographics in each participant group. ...................................................................................... 88	Table 29. Linear regressions for extraversion with health factors, controlling for demographics in each participant group. .................................................................................................................. 89	Table 30. Linear regressions for openness with health factors, controlling for demographics in each participant group. .................................................................................................................. 90	Table 31. Comparison of means for factors for Indigenous participants by whether traditional spirituality plays a role in their life or not. .................................................................................... 94	xiii  Table 32. Difference of means for factors of disposition and health between Indigenous participants who stated whether they felt connected to traditional practices or not. .................... 94	Table 33. Comparison of factor means stratified by whether traditional spirituality plays a role in their healthcare. ............................................................................................................................. 95	Table 34. Comparison of factor stratified by whether participant receives teachings from Elders for mental health purposes. ........................................................................................................... 95	 xiv  List of Figures Figure 1. Infographic of women’s Sharing Circle. Art created by visual facilitator. ................... 42	Figure 2. Infographic of men’s Sharing Circle discussion. Art created by visual facilitator. ...... 43	Figure 3. Percent of Indigenous participants who had participated in drumming, singing, dancing, or other activities for physical health purposes. ............................................................................ 91	Figure 4. Percent of Indigenous participants who had participated in any of the listed traditions for spiritual health purposes. ......................................................................................................... 92	Figure 5. Percent of Indigenous participants who had accessed Elders, healing circles, traditional healers, or counseling for mental health purposes. ....................................................................... 92	Figure 6. Percent of Indigenous participants who had accessed certain traditional medicines and foods for wellness purposes. ......................................................................................................... 93	 xv  List of Abbreviations  AIDS – Acquired Immune Deficiency Virus cART – Combined Anti-Retroviral Therapy BC – British Columbia DTES – Downtown Eastside GIPA – Greater Involvement of Persons living with HIV/AIDS HCP – Health-Care Provider HIV – Human Immunodeficiency Virus mHealth – Mobile Health  MIWA – Meaningful Involvement of Women living with HIV/AIDS OCAP – Ownership, Capacity, Access, and Possession OTC – Oak Tree Clinic PIRA – Peer Indigenous Research Associate PLWH – Persons Living with HIV PRA – Peer Research Associate SES – Socioeconomic Status UNAIDS – Joint United Nations HIV/AIDS Program WHO – World Health Organization xvi  Acknowledgements I would first like to gratefully acknowledge that this work was completed on the traditional and unceded territories of the Coast Salish Peoples including the xʷməθkʷəy̓əm (Musqueam), sel̓íl̓witulh (Tsleil Waututh) and sḵwx̱wú7mesh (Squamish) Nations.  I would like to thank all of our participants and the clinics/centres that hosted us for Sharing Circles and questionnaires. I would also like to thank our Peer Research Associates for assisting with questionnaire conduction and engaging in this project. Next, I would like to sincerely highly thank Indigenous Elders, Valerie Nicholson and Sandy Lambert, for taking time to guide me in this project and to teach me their traditions and Indigenous ways of knowing. Your teachings have been incredibly powerful and meaningful, and I look forward to continuing to learn to work and live in a good way. It has been an absolute honour to work with each of you. To my supervisor, Dr. Melanie Murray, I cannot thank you enough for all of your guidance, support, and leadership. I am lucky to have had such a caring and intelligent person to guide me through my project. The work you do every day to improve the lives of persons living with HIV inspires me. To my committee members Dr. Patrick Hill and Dr. Helene Cote, thank you for all of your advice and support in my work. I have learned immensely from each of you and look up to you with all of your outstanding accomplishments in your respective fields.  To the Oak Tree Clinic research team, thank you for all of your support and mentorship over the years and for continuing to advance the research of women and families living with and affected by HIV. And to the Oak Tree Clinic clinical team, thank you for all of the amazing work xvii  that you do every day to create a safer space to provide the best care possible to families living with HIV. To my parents, siblings, grandparents, and friends, thank you for all of your support, understanding, and help throughout my education thus far. I could not have achieved this without you and I cannot thank you enough.  xviii  Dedication This work is dedicated to my family and friends, the amazing staff at Oak Tree Clinic, and Elders Valerie and Sandy. Thank you for all that you do for me and for all that you have taught me. I could not have completed this without each one of you.1  Chapter 1: Introduction 1.1 Human Immunodeficiency Virus Globally and in Canada Globally, close to 40 million people are living with Human Immunodeficiency Virus (HIV), and over 1.5 million new infections are diagnosed each year, with the epidemic varying for each region [1]. For instance, the World Health Organization (WHO) stated that in 2018, two-thirds of persons living with HIV (PLWH) were in Africa, with the HIV prevalence rate at 1 in 25 people (4%) in Africa, compared to 0.17% in Canada [1, 2]. Furthermore, in 2018 the WHO estimated that there were 770,000 HIV-related deaths worldwide [1]. However, the population of PLWH is stabilizing as fewer PLWH are dying of HIV-related causes and the number of new infections per year is decreasing [1]. HIV is a retrovirus that weakens the immune system by decreasing the number of CD4+ T lymphocytes (a type of white blood cell). As the virus replicates, the plasma viral load (pVL) increases and in turn the number of CD4+ cells decrease; immunosuppression occurs when CD4+ levels drop below 200 copies/mL of blood [3, 4]. If left untreated, an individual living with HIV will develop Acquired Immunodeficiency Syndrome (AIDS) in about 10 years [5, 6]. AIDS is defined when the immune system becomes compromised and the individual can easily contract opportunistic infections and malignancies that may result in death [7]. When the HIV epidemic began in the 1980s, there was no treatment available; when someone contracted HIV, they would develop AIDS. In the mid-1990s, combination antiretroviral therapy (cART) became available, which targets the HIV virus from multiple angles to restrict replication and, when adhered to, results in durable HIV pVL suppression [8]. Although pVL is reduced, latent but replication-component viral genome remains integrated in CD4+ cells [9, 10]. In this way, cART 2  restricts viral replication and reconstitutes immune functioning, but cannot eradicate HIV. Nonetheless, with the success of cART, the health and quality of life of PLWH has greatly improved and life expectancies now approach those of the general population in Canada [8, 11]. In addition, by reducing HIV pVL, cART also benefits public health by preventing new infections [12]. However, optimal adherence rates ≥ 95% are necessary to suppress pVL to achieve these benefits [13, 14]. If an individual stops taking cART or takes it intermittently, the latent viral reservoir can replicate and HIV reemerges in circulation to attack the immune system. With intermittent use of cART, mutations can develop that alter viral proteins in a way that reduces the susceptibility of viral replication to be inhibited by a specific cART, thus causing drug resistance [15]. Altogether, there is a great importance to maintain ongoing high adherence to cART. HIV is transmitted via sexual intercourse, needle sharing, blood transfusion, and from mother to child during childbirth or breastfeeding [1, 16]. The HIV virus is found in bodily fluids including sperm, blood, rectal fluid, vaginal fluid, and breast milk [1, 16]. When an individual is on cART and has reached viral suppression, their virus is undetectable (less than 40 copies/mL). When undetectable, HIV cannot be transmitted to sexual partners, as undetectable equals untransmittable (U=U) [17, 18]. This also means that, a pregnant woman living with HIV, taking cART during her pregnancy and achieving an undetectable pVL until delivery can safely deliver a baby that will not have HIV. In Canada, the rate of transmission during childbirth is extremely low due to successful engagement in care, pregnant women’s adherence to cART, and post-exposure prophylaxis given to all infants [19]. However, Canadian guidelines recommend that 3  mothers living with HIV do not breastfeed, as the viral levels in breast milk can be different than in the blood and more research is needed to understand the risk [19]. In Canada, the stabilization of the number of PLWH is partly due to cART being widely available, resulting in people being undetectable, living longer, and the occurrence of fewer transmissions [8, 11, 13]. However, in the Canadian context, certain population groups remain at increased risk of acquiring HIV due to various social determinants of health, including persons who use injection drugs, men who have sex with men, Indigenous persons, and new immigrants [2, 20-24]. This has led to an imbalance of HIV among the ethnic make-up of PLWH in Canada, as 30% identify as white, and disproportionately 20-30% as Indigenous and 20-30% as African/Caribbean/Black, when each make up less than 5% of the general population [2, 23, 24]. For Indigenous persons, this is due to the impacts of colonization and resulting intergenerational trauma, whereas for Black persons, it is due to new immigrants living with HIV coming from Africa where the epidemic is greatest [22-26]. These groups may also have more difficulty achieving optimal cART adherence levels, along with women living with HIV who have poorer outcomes than men, due to a variety of social determinants of health such as low income, housing and food insecurity, low educational attainment, and substance use, among others [21, 22, 25, 27-32]. With the success of cART, HIV is less often causing death in Canadian PLWH, and instead concern is shifting to optimizing adherence rates, and treatment and prevention of chronic comorbidities. As PLWH are living longer, they are at an increased risk of developing age-related comorbidities, which differ slightly than the general population in type, are more frequent, and develop at an earlier age compared to those not living with HIV [33-36]. 4  Comorbidities often associated with HIV include osteoporosis, diabetes, hyperlipidemia, hypertension, cardiovascular disease, depression, and cancer [33-35, 37-40]. 1.1.1 Adherence to HIV Medications Even in Canada where cART is available free of charge, adherence is the greatest barrier to PLWH achieving health benefits and improved quality of life [41-43]. In British Columbia (BC), adherence rates have greatly increased over the past few years to about 80% in 2018 [44]. However, certain groups still experience difficulties with adherence. Physician advice and patient knowledge alone have proven insufficient to achieve optimal cART adherence rates, and some individuals require additional supports. Lower pVL suppression rates have myriad causes, often correlated with social determinants of health such as income, education, age, gender, ethnicity, housing, food insecurity, trauma, and incarceration [14, 31, 41, 42, 45-47]. For example, housing and food insecurities can act as barriers to accessing and adhering to cART, as meeting these daily needs would be of higher priority than remembering to take cART. Indigenous PLWH also face the intersectionality of multiple factors relating to colonization and the residential school system that include, but are not limited to, racism, discrimination, stigma, and trauma [41, 48, 49]. All of these determinants intersect and can have a great impact on engagement in care and cART adherence, resulting in disengagement of PLWH along the cascade of care continuum [21, 26, 45, 49]. As PLWH have an increased number of comorbidities compared to the general population, they also need to take more medications, which may cause pill burden and fatigue 5  [33, 37-39]. As such, poorer adherence rates may occur. In addition, increased polypharmacy elevates the risk of drug-drug interactions with cART [37, 50, 51]. Thus, concomitant medications often limit the available cART an individual may take, which could result in taking a regimen that is not ideal, adding an additional impediment to adherence rates [37, 52]. Another potential barrier to adherence and care engagement is a lack of rapport and trust between patients and healthcare providers (HCPs) [20, 53-56]. Having a positive connection with an HCP encourages autonomy in an individual’s healthcare, as PLWH may feel more comfortable in seeking assistance from their HCP. For instance, a study with PLWH who use injection drugs showed that connection with an HCP predicted cART use [20]. As such, enhanced patient-provider relationships are associated with improved cART adherence, viral suppression, and overall health outcomes [53, 55, 57, 58]. Furthermore, a study among Indigenous patients showed that rapport/trust can be difficult to achieve for various reasons including cultural or ethnic factors, short appointment duration, and patients not feeling that their needs are being heard [59]. It is evident that health programs must consider supporting patient-provider relationships to encourage safety, engagement in care, patient-autonomy in care decisions, and adherence to cART. In BC, treatment guidelines now recommend that all PLWH initiate cART immediately upon diagnosis, and reach and maintain optimal adherence rates [60]. In 2014, HCPs and policy makers globally set the 90-90-90 target, which is a goal that 90% of PLWH are diagnosed, 90% diagnosed are receiving sustained cART, and 90% on cART have undetectable pVL [18, 60, 61]. This strategy would work to curb the spread of HIV, while decreasing morbidity and mortality among PLWH, and transmission to others [60]. Thus, it is vital that programs are in place to 6  support PLWH to obtain optimal adherence to reach this target and further improve the health of individuals and the overall population. 1.2 The Social Determinants of Health as Barriers to Care The social determinants of health are the conditions that individuals are born, grow, work, and live in, including factors such as age, ethnicity, trauma, educational attainment, employment, and income [1, 62]. The latter three are indicators that comprise socioeconomic status (SES), which is correlated with health and wellbeing. For instance, low SES is linked with exposure to poor work and living conditions, chronic stress, and engagement in risky health-related behaviours such as smoking, substance use, violence, and risky sexual behavior, which all lead to poorer health outcomes [63, 64]. In fact, there is a socioeconomic gradient in healthcare in that the lower the SES an individual has, the worse their health outcomes are likely to be, while those with higher SES have better health outcomes [64]. In addition, social determinants of health have a biological impact, as low SES is associated with increased cortisol levels and inflammation [63, 65], which can lead to a myriad of health issues such as hypertension, diabetes, anxiety, and depression, among others. Low SES may also lead to increased exposure to infectious diseases, such as HIV, due to increased likelihood of engagement in risky health behaviours. However, social determinants of health are not only associated with the acquisition of diseases, but also with the severity of these illnesses. Experiencing low SES may limit access to health care services due to inability to overcome cost, travel, and/or time barriers, and thus limit effective access to treatment to mitigate illnesses [66-68]. Therefore, low SES communities face greater restrictions to improving their health, and this 7  differential access works to maintain and even further increase the inequity between SES groups locally and globally [62, 69, 70].  1.2.1 The Social Determinants of Health in Relation to HIV In regards to HIV, social determinants of health are crucial factors in leading to HIV acquisition and determining the outcomes of the disease. PLWH are disproportionately marginalized and more likely to experience social determinants of health that lead to poor health outcomes [27, 62]. This marginalization includes stigma, discrimination, trauma, racism, oppression, and increased likelihood of engagement in high-risk health behaviours [31, 48, 66, 71, 72]. Engagement in these behaviours can lead to the acquisition of HIV, disengagement from care, and transmission of HIV to others. Thus, these factors may have led the individual acquire HIV, or perhaps were developed after the individual was diagnosed, due to the many barriers they face. For instance, a group that experiences disproportionate rates of HIV and poor social factors is injection drug users (IDU) [27, 73]. IDU living with HIV experience increased HIV-related morbidity and mortality due to various social and structural barriers such as social exclusion, stigma, unstable and unsafe housing environments, and institutional oppression [27, 31, 48, 73]. Thus, their ability to support their health and HIV-related care is limited, as they must address and cope with these socio-structural barriers. In fact, for IDU in Vancouver, BC, about 50% discontinue cART and about 60% of those who remain on cART do not have optimal adherence levels [74, 75]. As previously mentioned, the health of individuals living with HIV requires optimal cART adherence rates, and sub-optimal rates have various causes, often correlated with social 8  determinants of health such as income, education, gender, race, housing, lived trauma, and incarceration [31, 41, 42, 45-47, 72]. These factors influence individuals differentially, and affect their health and adherence support needs. For instance, substance use, depression, and social isolation may affect cART adherence for all, while women may be more likely to struggle with intimate partner violence, fear of stigma, and care provider roles for children/partners [30, 31, 48, 73, 76]. Altogether, HIV health and adherence programs need to properly address social determinants of health to increase participant engagement and improve participant’s health.  1.2.2 Addressing the Social Determinants of Health in Programs Improving equitable access to care works to improve social determinants of health and health outcomes [62, 69, 70]. If low SES groups are unable to access services to attain improved health and wellbeing, they are likely to have poorer health outcomes. This causes a cycle of inequity, as those with poorer health are less likely to be able to achieve higher income and educational attainment, which in turn further prevents them from accessing health care and programs, again leading to decreased wellness [77-79]. As such, population approaches to health programs can exacerbate inequities when only high SES groups are able to access them [78, 79]. For instance, if a program for HIV care is “universally accessible” but is only available during business hours and in a certain location, high SES individuals may be better able to take time off from work and have access to a vehicle to reach the service [67]. Thus, programs need to provide assistance to those who need it via proportionate universality [70]. Proportionate universality is when there is a universal program paired with additional support for low SES groups to ensure they can overcome barriers to access the services equitably [70]. This may require providing transport, food, childcare, remote services, and programs after work hours. Programs that utilize 9  a proportionate universality approach work to address social determinants of health to improve the health outcomes of all SES groups in an equitable way [70]. 1.3 Indigenous Persons Living with HIV in Canada 1.3.1 The Impacts of Canada’s History of Colonization The history of colonization in Canada has had an extremely negative and far-reaching impact on the health and wellbeing of Indigenous communities [80]. Acts of assimilation including the Indian Act, Residential School System, Indian Hospitals, land dispossession, the Sixties Scoop, the Child Welfare System, etc., sought to strip Indigenous people of their cultures and beliefs, physically and mentally abused people, destroyed communities, instilled racism and discrimination towards Indigenous communities, and resulted in intergenerational trauma [49, 71, 81]. Intergenerational trauma is caused by a lifetime of emotional and psychological harm, passed down among generations, and is an underlying cause of the high prevalence of mental health, substance use, low SES, and health issues among Indigenous populations in Canada [82-84]. In fact, Indigenous communities experience higher rates of a variety of chronic illnesses than the general population due to these lasting impacts of colonization [25, 85]. Intergenerational trauma is reinforced through colonial practices and structural violence that continue to oppress and discriminate Indigenous communities.  Before European contact, the land that is now Canada was home to hundreds of thousands of Indigenous communities that spoke over 50 languages, lived with the land in harmony, and had rich cultures and traditions [86]. As colonizers arrived in the late 15th century, they began to take over the land and call it as their own. Knowledge of the land was taken from Indigenous communities and utilized to help colonizers thrive and monopolize the Fur Trade in 10  the 16th century. Colonizers began to strip Indigenous communities of their cultures, peoples, languages, lands, and rights. They created treaties that were extremely limiting toward Indigenous persons. The Constitution Act in 1867 gave control over “Indians” to the Canadian government, and in 1876, previous legislation was consolidated in the Indian Act [87, 88]. This act controlled who was declared as “Indian”, and what Indigenous people could do. For instance, the Indian Act outlawed Potlach, an important Indigenous cultural practice, and it controlled where Indigenous persons could live, isolating them to reserves [88]. This restriction discouraged travel to hunt and gather, an important part of Indigenous community sustainability, and so they became more dependent on the government for support. The Indian Act also implemented Residential Schools, which had one of the greatest negative impacts on Indigenous communities, of which remain today [49, 89]. The Residential School System (RSS) stripped children from their families in an attempt to assimilate them into colonial culture and white communities, or rather to strip the “Indian” from the child [82, 89, 90]. In partnership with the Canadian government, the Catholic Church, and multiple Christian denominations: Methodists, Presbyterians, and Anglicans, operated the Residential Schools with priest and nuns running the schools [90, 91]. The children lived at the schools where they experienced poor living conditions, emotional, physical, and sexual abuse, isolation from their family and community, and loss of their Indigenous culture and spirituality [82, 90, 91]. The students were banned from speaking their traditional languages or practicing any cultural traditions, and were abused by staff and religious figures if they disobeyed these rules [85, 90, 91]. Potentially over 6000 students died in the over 130 residential schools that operated in Canada, with the last school closing only in 1996 [92, 93]. The exact number of 11  deaths is unknown, as proper records were not taken, and students who passed away were often placed in unmarked and mass graves, or died in their attempts to flee Residential Schools and return to home communities [92, 93]. As the RSS ended, the Child Welfare System (CWS) was set to better the lives of the children by putting them into foster care, but this was just another form of colonialism by taking Indigenous children from their families and putting them into white, colonial families [91, 94, 95]. The CWS began with what is known as “the Sixties Scoop” where Indigenous children were scooped from their families and put into the CWS in the 1960s [91, 95]. However, the scoop actually began in the 1950s and children continue to be taken from their families to today. Currently, Indigenous children represent 40-60% of children in the CWS, province dependent, which is extremely disproportionate as Indigenous children only represent about 7% of children in Canada [91, 96]. This reflects the discrimination and racism towards Indigenous families through colonial processes that remain today [71]. In exiting the RSS and CWS, children often could not/cannot trace back to their reserves and families, and if they could, they may have experienced/will experience trouble reconnecting due to cultural differences, trauma, etc. [82]. It is evident that these systems have greatly affected the structure of families, as they were left without children since parents were deemed unfit to take care of them [82, 97]. This is devastating for the mental health of parents, leaving them with depression, feelings of unworthiness, and loneliness, which often led to/lead to substance use issues [72, 81, 82]. Furthermore, the children in the Residential Schools did not have parental figures, and so when it came time to raise their own children, they often did not have the parenting skills needed [88, 98, 99]. As the RSS school leaders abused the students, the RSS survivors brought abuse back to their communities, as this is what they were taught in how to raise children [88, 98]. Instead of assisting parents in developing healthier parenting skills and fixing the damage they had created, 12  the government used the CWS to take the next generation of children, thus continuing the cycle of loss of culture and family ties, and thus the continued dismantling of Indigenous communities and ways of living [94]. Legislative reasoning for removing children and placing them in the CWS is that they were living in poverty, when realistically, it would be much better if governments actually addressed this poverty instead of disassembling families [93]. In fact, the government has a responsibility to do so, as poverty in Indigenous communities can be traced back to colonization and the oppressive laws enacted by the Canadian government that still traumatize families and limit communities from thriving [49, 71, 93]. As previously mentioned, intergenerational trauma is the lifetime experience of emotional and psychological harm that is passed down among generations, as a result of the many harmful aspects of colonization [49]. Elders refer to symptoms of intergenerational trauma as spiritual injuries or soul wounds that deeply affect the wellbeing of the individual [83, 100]. Similarly, post-traumatic stress response is common among Indigenous people of Canada due to impacts of colonization, loss of culture, and intergenerational trauma, and it greatly affects their health [101]. To cope with intergenerational trauma and mental health issues, many people turn to substance use [72, 81]. Thus, this trauma is an underlying cause of the high prevalence of mental health and substance use issues existing among Indigenous populations. In addition to causing mental health and substance use issues, intergenerational trauma also acts as a barrier to resolving these issues. If the underlying trauma is not resolved, then it is very difficult for an individual to address the health issues that stem from it. In addition to cultural and mental health impacts, colonization has also had a detrimental epidemiological effect on Indigenous communities in Canada. European contact brought new 13  pathogens, discouraged the use of traditional medicines, and denied Indigenous peoples proper medical care. When Europeans came to Canada and took monopoly over the Fur Trade around 1580, they also brought diseases (smallpox, tuberculosis, measles, syphilis, etc.) that Indigenous populations had not yet been exposed to [80, 88, 89]. These new diseases killed thousands and left some Indigenous communities with few remaining members; the number of persons who died is not known due to missing data [88]. In addition, European colonizers banned the use of traditional Indigenous medicines and practices, removing access to spiritual healing [89]. In the 1900s, colonial hospitals denied Indigenous persons proper medical care and institutionalized them into “Indian Hospitals”, which were segregated from colonial hospitals, filthy, and provided minimal medical care [102, 103]. These hospitals originated partly because Tuberculosis was rampant in Residential Schools and reserves, and was falsely called “Indian Tuberculosis”, as colonizers thought it was a different disease than they themselves had. Thus, colonizers did not want to share hospitals with Indigenous communities, and isolated Indigenous persons from urban hospitals to “Indian Hospitals”. These “Indian Hospitals” were often run by missionaries, which disciplined and abused patients, and attempted to assimilate them into their religions [103]. Furthermore, a number of unsafe experiments were conducted on patients without their consent; an example of which was trialing a new tuberculosis vaccine [103]. Overall, this increase in disease and neglect of proper care created various long-term effects on Indigenous public health in Canada. It also created poor relationships between Indigenous persons and medical institutions, creating a lack of trust and fear, which remains as a barrier today [25, 71]. In fact, colonial practices have led Indigenous communities to now experience higher rates of a variety of chronic illnesses such as HIV/AIDS, diabetes, certain cancers, depression, and obesity [85]. As such, health inequities between Indigenous and non-Indigenous 14  peoples as a result of colonialism and intergenerational trauma need to be addressed and educated in health care so that proper care can be provided [101]. Due to the cultural, physical, emotional, and mental health impacts that remain today, Indigenous communities do not have full autonomy of their care and have lost much of their traditional practices that they are currently working to regain [85]. Colonization impacts have led to Indigenous communities experiencing disproportionately lower SES than the general population, with lower education attainment, income, and employment rates. As these social determinants of health are crucial to the overall wellness of individuals, the health and healing of Indigenous peoples is impacted in many harmful and inequitable ways. 1.3.2 Disproportional Rate of HIV among Indigenous Communities In Canada, Indigenous communities are disproportionally represented in the population of PLWH; Indigenous people represent less than 5% of the Canadian population, yet Indigenous PLWH represented 15-20% of all HIV infections and 11.3% of new infections from data released 2016-2018 [2, 104, 105]. Compared to other ethnicities, Indigenous populations in Canada have an HIV incidence rate that is 2.7 times higher [62]. This increase in prevalence is related to the impacts of colonization, including Residential Schools, sexual abuse, and Indian Hospitals, among others mentioned previously [72]. The effects of these events instilled intergenerational trauma, racism, abuse, discrimination, depression, etc., which have led to an increase in HIV acquisition risk factors such as injection drug use, having numerous sexual partners, having unprotected sex, and living on the streets [72, 101, 106]. In fact, it is estimated that approximately 60% of new HIV infections were due to injection drug use among Indigenous PLWH, compared to 11% among all PLWH in Canada [2, 104]. Recently, many of these new 15  infectious are concentrated in the province of Saskatchewan, where there is an HIV epidemic [107, 108]. Here, injection drug use is the primary cause of infection, and about 80% of persons with new diagnoses identify as Indigenous, despite Indigenous persons making up less than 20% of Saskatchewan’s population [109]. This speaks to the detrimental effects of colonization on the health and wellbeing of Indigenous persons, which is associated with substance use as a coping method, and consequently leads to increased risk of transmission of HIV.  In Vancouver, BC, injection drug use is also one of the main modes of HIV transmission, especially among Indigenous persons [2, 28, 110-112]. In fact, of newly HIV diagnosed IDU, a disproportionately high number are Indigenous [111, 112]. In addition, another route of HIV acquisition among Indigenous women is heterosexual sex [113, 114]. Owing to intergenerational, sexual, physical, and emotional trauma, Indigenous women are more likely to engage in risky sexual behavior including survival sex work and having numerous partners, which can increase the risk of HIV acquisition [72, 113-117]. This route of transmission is often seen with women of Vancouver’s Downtown Eastside (DTES), one of Canada’s poorest neighborhoods [113, 117, 118].  Furthermore, due to intergenerational trauma, poorer mental health, substance use, and all of the other social determinants of health that act as barriers to accessing healthcare, Indigenous PLWH in Canada experience an accumulation of factors that lead to struggles with cART adherence [22, 25, 28]. Thus, culturally safe programs that reduce barriers are needed to improve the adherence rates of Indigenous PLWH to best support their overall wellbeing [26, 119]. 16  1.3.3 Healing of Indigenous Communities  Despite discrimination, racism, intergenerational trauma, and other continued impacts of colonization, Indigenous communities have shown immense resiliency [71, 120]. Resilience involves self-determination and the ability to overcome devastating and distressful events. Resiliency is important for health, autonomy, and wellbeing, and has greatly driven the healing journey of Indigenous communities [117, 121, 122]. Indigenous persons are reconnecting with their culture and land, and are regaining their cultural practices and traditions that were lost due to colonization. By creating connections with Elders, participating in land-based healing practices, building a sense of community, and learning the medicine wheel and traditional medicines, Indigenous families and communities are working towards healing [80, 84, 100]. In fact, Indigenous persons who are raised in their traditional territories and immersed in their community, culture, and language, may show higher scores of resiliency [117]. Thus, restoring traditional healing practices and knowledge leads to empowerment and improved wellness of Indigenous individuals and communities [117]. For healthcare systems to support improvement of the health and wellbeing of Indigenous persons, healthcare programs need to address intergenerational trauma and promote healing through supporting connections to culture and including Indigenous practices, knowledge and people in their design and conduction [26, 119]. This is in line with “Indigenous ways of knowing”, which include practices involving holistic health, interconnectedness, humility, collaboration, reciprocity, and spirituality [123]. Practicing in a holistic way addresses the emotional, physical, mental, and spiritual aspects of the individual, opposed to the Western medical emphasis on physical health [117, 124]. In fact, in involving Indigenous ways of 17  knowing and traditional medicines, the soul can be mended, leading to the ability to address mental health, substance use, and other health issues can be addressed and resolved [26, 119, 124]. For instance, supporting connection to culture in programs that support HIV and Hepatitis C prevention and smoking cessation have been beneficial [117, 125]. By building upon the existing strengths that Indigenous people identify in their own lives, programs can promote wellbeing in ways that are consistent with Indigenous views of wellness [120]. Common strengths include sense of community, identity (of self and as an Indigenous person), traditions, coming through hardship, and contributing to others [126]. As such, building connection and community is beneficial to the healing of Indigenous persons [126, 127]. Further supporting these strengths will empower the improvement of the overall wellness of Indigenous people in Canada. However, it is vital that the community is collaborated with before program development even begins. This early connection will allow for meaningful inclusion of Indigenous peoples and practices to better ensure the cultural safety of the program, and that ownership of the work remains with the community. In attempt to address the impacts of colonization, the Canadian government created the Truth and Reconciliation Commission in 2008, which declared calls to action and set guidelines to support and encourage reconciliation between Western and Indigenous communities [92]. This was an important step, however there has not been enough change since it was implemented, as most agencies and institutions do not follow this, or even truly understand the importance of it. Thus, research and healthcare programs need to take the time to ensure that reconciliation and Indigenous peoples and knowledge are an integral part of their methods, ideally before design. 18  Programs must to be creative and flexible in the way health services are provided, especially to Indigenous and low SES populations.  1.4 Mobile Health and Medication Adherence As mobile phones are increasingly utilized, mobile health (mHealth) has become a popular method to engage patients in health care programs and treatments [128]. mHealth technology is whereby a mobile phone is used to connect a patient with an HCP in a unidirectional or bidirectional fashion [129-131]. Most commonly, mobile health is achieved through a text-messaging program or via an application (app) that the participant downloads to their mobile phone [128, 132]. A unidirectional method allows HCPs to send out messages of support, learning materials, appointment reminders, etc., whereas a bidirectional method achieves this and also allows the client to contact the HCP in return [133-135]. Thus, a bidirectional program enables the patient to request information or assistance in a timely manner as needed, but also allows the HCP check in when required. In turn, mHealth allows for an improved connection between patients and HCPs through the use of digital technology [135, 136]. In addition, mHealth may also reduce the need for clinic visits, as issues can be solved remotely, which in turn reduces healthcare costs [128, 137]. This provides great benefit for clients who may have barriers in attending clinic visits for a variety of reasons such as lack of transit, non-flexible work hours, caregiver responsibilities, living far from clinic, and living in rural areas, etc. [67, 68, 137, 138]. Another group that benefits particularly well from mHealth is youth, who accept mHealth as a favourable way to connect with an HCP as they regularly use their mobile phones [139, 140]. Furthermore, mHealth supports providing individualized care, as the unique needs of each patient can be independently addressed [128]. All of these factors lead 19  to enhanced medication adherence, clinic attendance, autonomy, and better health outcomes of clients. In fact, studies utilizing mHealth have shown success at improving engagement in programs and health outcomes for smoking cessation, diabetes, cardiovascular health, eldercare, cancer treatment, HIV, etc. [141-148].  1.4.1 HIV Medication Adherence with Mobile Health As cART adherence is important for improving the health of PLWH, methods to improve adherence are desirable and mHealth provides great opportunity to do so. However, mHealth in the context of HIV is more complicated than for other chronic diseases due to HIV stigma and confidentiality issues, therefore extra safety precautions are necessary [48]. Patient-centered approaches engaging mHealth technology with PLWH have been shown to improve adherence to cART and promote the achievement of suppressed HIV pVL [129, 148, 149]. Communication through mHealth with PLWH was first shown to significantly improve adherence to cART and pVL suppression in a text-messaging intervention study conducted in Kenya, WelTelKenya1 [129]. The WelTel program is a text-messaging mHealth service that provides a connection between patients and HCPs in a bidirectional manner [129, 131, 135, 148]. A weekly text message stating, “How are you?” is sent from an anonymous automated platform that is checked regularly by an HCP who addresses any problem responses that may arise [129, 135, 148]. The number, by which the platform texts, is not traceable back to the clinic, and HIV-related information is not texted to participants unless specifically requested, thus improving the privacy and safety of the program. Following WelTel’s success in Kenya, this bidirectional outpatient management service was then tested for acceptability and feasibility in a prospective mixed methods pilot study, 20  WelTelBC1, at the Oak Tree Clinic, an HIV clinic in Vancouver, Canada [135, 136]. HCPs involved with the pilot study reported that, although workload increased initially, program benefits went beyond improving pVL and addressed the social determinants of health that act as barriers to engagement in care and to medication adherence [135, 136]. This pilot was followed by the study, WelTelOakTree, which examined the effectiveness of this weekly text-messaging intervention over one year [148]. Inclusion criteria required that participants were PLWH who had detectable pVL, difficulty with cART adherence, and at least one other factor that could act as a barrier to accessing and engaging in care [148]. Results of the WelTelOakTree study demonstrated an improvement in cART adherence and HIV pVL among PLWH who received the program for one year, so that 47.5% of participants achieved undetectable pVL by study end [148]. WelTel allowed participants to request and receive assistance from an HCP on a variety of issues as they arose, when participants were not physically present at clinic; the majority of issues were related to physical, emotional, and mental health, housing and food security, and medication use and refills [135, 148]. WelTel also enabled HCPs to connect with patients and monitor their wellness between clinic visits, and allowed trust to be built between participants and HCPs [135, 148]. WelTelOakTree provided phones and basic plans to participants without one, making the program accessible to most everyone regardless of SES. Overall, only a modest amount of HCP time and costing were required to run the program. In fact, less than 53 minutes/participant/year of HCP time were utilized to manage all problem responses, costing less than $50/person/year [150]. When all costs were considered, including the platform and cell phone plans, WelTel program costs were less than $400/person/year [150]. This small cost and time investment may significantly reduce health care costs over time, since mitigating problems 21  as they arise and improving cART adherence can prevent progression of illness and decrease morbidity, thus avoiding costly hospitalizations [150-153].  In regards to the demographics of the WelTelOakTree study, approximately 30% of participants were Indigenous [148]. This reflects the disproportionate rates of HIV and the higher vulnerability of this population in Canada, as WelTelOakTree included participants who were at high-risk for poor adherence to cART due to various social determinants of health. Thus, there is a need to improve the cultural safety of the WelTel program to enhance the appropriateness for Indigenous PLWH. Overall, WelTel, the bidirectional mHealth program, works to improve cART adherence, pVL, and connections with HCPs in high-risk/vulnerable PLWH in a Canadian setting at a relatively low cost [135, 148, 150]. However, participant response rates varied, and those who regularly utilized WelTel benefitted most. In fact, no one factor could predict who was more likely to engage with the program, including baseline phone ownership and demographics [148]. This must be clarified before the program can be implemented into healthcare programs, as even though providing the program is cost effective, limited resources may be lost on clients who do not regularly use the program. Thus, it is necessary to pursue measures that streamline the provision of WelTel for those most likely to benefit by involving a more personalized approach [154, 155]. 22  1.5 Personal Disposition in Relation to Health and Wellbeing  1.5.1 Personal Disposition Defined Personal disposition is the set of factors that define who a person is both uniquely and in commonality to others [156]. All of the factors that make up an individual’s personality lead to certain views and behaviours enacted in their daily lives. In fact, personal disposition can predict various outcomes across the lifespan, such as happiness, health, relationship status, community involvement, criminal activity, and occupational choice [157]. Personal disposition is widely defined using a five-factor model of personality traits, however this model does not account for other important aspects such as a sense of meaning in life [158-160]. The five-factor model of personality traits, called “the Big Five”, includes the following factors: conscientiousness, agreeableness, neuroticism, extraversion, and openness [158, 161]. Each factor is on a continuum, so an individual may score high or low on each of the five traits. Conscientiousness reflects the tendency to be more organized, industrious, self-controlled, and reliable, or on the reverse side, more careless, easy-going, and less driven. Agreeableness describes the sympathy, kindness, affection, trust, and cooperativeness vs. the disagreement and detachment of an individual. Neuroticism explains the tendency toward negative affectivity, sensitivity, self-consciousness, and nervousness, vs. the opposite, termed emotional stability, being secure and having tendency towards positive affect. Extraversion is the tendency to be gregarious, active, and outgoing, vs. being more reserved, shy, and antisocial. Finally, Openness explains how an individual is open to new experiences, imaginative, intellectual, and adventurous vs. being more consistent, cautious, and closed to new ideas. The Big Five personality traits have shown reliability and validity across various countries and cultures, 23  evidenced in several places globally, with useful taxonomy that reflect broad dispositional characteristics [162]. An individual’s scores of each factor can change across the lifetime, often associated with gaining more maturity from adolescence to adulthood [163, 164]. For example, this could include increases in conscientiousness, agreeableness, and emotional stability as an individual becomes more controlled and confident, and less defiant and alienated [163, 164]. Though the five-factor model is widely accepted, it does not account for other important aspects of personal disposition such as spirituality and sense of purpose in life [159, 160]. Purpose is a cognitive process woven into a person’s identity, which involves having goals and a sense of personal meaning in life [165]. A sense of purpose offers direction in an individual’s life, and if they pursue their goals, purpose provides a self-sustaining source of meaning [165]. Cultivating a sense of purpose in youth may contribute to a stable identity and improved hope, happiness, wellbeing, self-image, and responsible behaviour [160, 166]. Having a higher sense of purpose can also lead to an easier transition from adolescence to adulthood [160]. As such, purpose also has a large impact on the life-course of an individual, independent of the Big Five personality traits [167]. As with the Big Five, sense of purpose is not stable and can be fostered throughout the lifespan [168, 169]. For instance, parent-child conflict can predict the sense of purpose of an individual in adulthood [170]. This adaptability allows for opportunities to improve a sense of purpose through activities such as setting and adhering to goals, or improving how one may view their self-image [160, 165, 168, 169].  Research in health psychology suggests examining personal disposition in an effort to understand which individuals are prone to healthier lifestyles [167, 171-173]. To capture and compare with health, sense of purpose can be measured using the Oregon Brief Purpose tool 24  [160]; and the Big Five can be measured via the Mini International Personality Item Pool (Mini-IPIP) measure of Big 5 Personalities [174]. Determining these relationships can help to predict the health behaviours, morbidity, longevity, and mortality risk of an individual. In particular, conscientiousness and purpose are most often associated with the overall wellness of an individual, and neuroticism and agreeableness are sometimes associated, whereas extraversion and openness are not. The relationships of these dispositions with health and wellbeing are described below. 1.5.2 Conscientiousness and Health Of the Big Five personality traits, conscientiousness is the greatest predictor of health outcomes and longevity [175, 176]. As more conscientious individuals are more organized, reliable, thorough, and self-controlled, they are more likely to follow health recommendations to achieve improved health [158, 173, 177, 178]. Higher scores of conscientiousness have been consistently linked with better health outcomes, such as greater longevity and lower mortality risk [175, 177, 179]. In fact, lower risk of mortality was predicted by conscientiousness, even when controlling for sociodemographic and health predictors, such as education, gender, age, cognitive functioning, and reported health conditions [175]. Conscientiousness has also been correlated with better cognitive functioning, which may partially explain the relationship with longevity [175]. Furthermore, childhood conscientiousness scores predict health ratings in midlife, independent of sociodemographic factors and health-related behaviours [180]. Perceived social support is also positively correlated with conscientiousness, in that social support is linked with developing conscientiousness overtime [181]. 25  The improved health and longevity associated with conscientiousness can be explained by its positive correlation to preventative health behaviours and negative correlation to risky health behaviours [175, 178]. Preventative behaviours linked with conscientiousness-related attributes include activity/exercise and healthy eating, while risky health behaviours include excessive alcohol use, drug use, unhealthy eating, risky driving, risky sex, tobacco use, and violence [178, 182]. Thus, more conscientious individuals tend to experience fewer major health problems and report lower incidence rates of high blood pressure, stroke, diabetes, joint problems, and psychiatric conditions [183]. Furthermore, conscientiousness has been linked with inflammation in low SES groups, in that individuals with higher conscientiousness have lower markers of inflammation in circulation [184]. In addition, more conscientious individuals have higher self-reported adherence to medication regimes and other physician recommendations in chronic health conditions [185, 186]. In regards to HIV, conscientiousness has shown to be predictive of disease progression, with lower CD4 counts and a higher pVL in PLWH who have lower scores of conscientiousness [187]. 1.5.3 Agreeableness and Health Agreeableness describes the sympathy, kindness, affection, trust, and cooperativeness of an individual [158, 173, 177, 188]. Typically, agreeableness has little direct relation with health behaviours and outcomes; however, agreeable individuals may benefit from a positive relationship with an HCP [189, 190]. Thus, agreeable individuals may engage better with programs that promote the building of social ties with HCPs [189, 191]. In fact, if an individual is high in agreeableness, they may benefit more from social ties than those who are less agreeable, in that these improved connections may lead to less depression [191]. Therefore, 26  agreeableness may be an important aspect to patients’ engagement in care, especially of those with chronic health issues such as diabetes, hypertension, and HIV. If so, health programs should consider and accommodate for individuals who may be more or less agreeable, accordingly. In addition, agreeableness may influence an individual’s perception of whether they can manage a treatment program; in fact, one study found that women who scored lower in agreeableness had lower perceived confidence and ability to manage their asthma [192]. Furthermore, eating healthy foods has also been positively correlated with agreeableness, which would improve the health of an individual [182]. 1.5.4 Extraversion, Neuroticism, Openness and Health Of the remaining Big Five personality factors, neuroticism is often associated with health factors, whereas extraversion and openness are not as often associated with health and wellbeing [177, 193, 194]. Low neuroticism is often positively associated with health, in that emotional stability is generally beneficial to health outcomes [177]. Opposite to conscientiousness, research has shown that high neuroticism is associated with mental health disorders and inflammatory risk [183, 184]. Though extraversion and openness have less consistent associations with health outcomes, a 2011 study found that both were associated with longer lifespan [194]. This same study found mixed results for neuroticism in that some components of it are beneficial to and others may detract from health and longevity [194]. In addition, neuroticism has been consistently positively associated with negative affect, whereas extraversion has been positively associated with positive affect [193, 195]. Furthermore, neuroticism and openness have been associated with lifetime trauma, possibly due to the reactive element of these traits [196]. These two factors, along with conscientiousness and agreeableness, have been associated with eating 27  healthy foods [182]. Altogether, associations of neuroticism with health and wellbeing are more consistent than with extraversion and openness, though further research is needed to broaden understandings. 1.5.5 Sense of Purpose and Health As purpose offers meaning in life and supports goal-setting, having a sense of purpose can lead to engagement in healthy behaviours that allow the individual to reach those goals [167, 197]. As a result, individuals with a higher sense of purpose often have improved health and wellbeing [165-167, 198]. Research has found that purpose is positively associated with reports of improved sleep quality, flossing, healthy eating, and increased physical activity [167]. These healthier behaviours and outcomes have been linked with purpose, even after controlling for the Big Five personality traits and demographic factors [167]. Furthermore, research suggests that individuals with a greater sense of purpose experience less of an increase in negative affect and/or a lower physical stress response when exposed to daily stressors [199]. These healthy behaviours, reactions, and sense of meaning in life lead to an association with purpose and lower mortality risk [198], lower levels of functional disability in aging adults [200], higher positive affect [166, 199], greater life satisfaction [168], and increased longevity [167]. Thus, having a sense of purpose in life, allows for an overall improved health and wellbeing. 1.5.6 Medication Adherence and Personal Disposition Several studies have investigated the associations between medication adherence and personal disposition for the Big Five personality factors, but there is minimal research in this area regarding sense of purpose. Of the Big Five, conscientiousness has been most often associated with higher self-reported adherence to medication regimes and other physician 28  recommendations in chronic health conditions [177, 185, 186]. This has been seen in the context of diabetes, asthma, and chronic kidney disease settings [192, 201, 202]. Though neuroticism is sometimes associated with health, studies that look at adherence and the Big Five find that conscientiousness as more predictive than neuroticism [185, 202]. This could be because neuroticism captures emotional stability, whereas conscientiousness captures reliability and organization, and the latter likely has more of an influence on adherence to treatment programs. In fact, a 2014 asthma study found that conscientiousness was positively associated with adherence to treatment, whereas neuroticism and agreeableness were instead associated with perception of whether treatment would be manageable; women who scored high in neuroticism and low in agreeableness were less likely to perceive that they could manage their asthma treatment [192]. As previously mentioned, individuals who are more agreeable may also be more likely to adhere to treatment programs that promote rapport with their HCP [189, 190]. As extraversion and openness have less consistent associations with health outcomes, they are less likely to affect adherence. Even though there is limited research, one might expect purpose to play a role in medication adherence, as a higher sense of purpose in life may lead individuals to engage in activities that promote health and future success [167, 197]. In regards to personal disposition in the context of cART adherence among PLWH, there has been minimal research. However, a 2007 study did find that conscientiousness correlated with higher cART adherence, lower pVL, and active coping among PLWH [187]. This is promising in suggesting that conscientiousness may play a significant role in cART adherence. However, cART side effects and pill burden have improved greatly since 2007, which could change the reasons why individuals may struggle with adherence [187]. 29  1.5.7 Personal Disposition and Health in Indigenous and Low SES Communities Though correlations between personal disposition and health are evident in the literature, these factors and associations have been understudied among low SES and Indigenous communities. However, some research has suggested that personality characteristics may in fact be more predictive of health outcomes for individuals with lower SES than higher SES [184], and similarly for participants with lower rather than higher levels of education [203, 204]. Other research with a Hawaiian sample, a community with a significant contingent of Indigenous citizens, finds relatively similar associations between personality and dietary behaviours for those higher or lower on SES [182]. As such, there is a clear need to further investigate the role of disposition with health among lower SES communities to determine if in fact there is a stronger effect. This is particularly true for sense of purpose, for which limited work has focused on SES differences.  Although agreeableness typically has little direct relation with health, it may be relevant to health of Indigenous communities. Indigenous communities highly value a sense of community and connection, so a strong rapport with a care provider may be beneficial to their health [120, 126, 127]. Agreeable individuals may benefit from a positive relationship with an HCP and may engage better with programs that promote the building of social ties [189, 190]. Thus, agreeableness may be an important aspect to Indigenous persons’ engagement in care, especially for those with chronic health issues and barriers to care who need to be engaged for long periods of time. To better understand the health and wellbeing of Indigenous and low SES communities, it would be beneficial to determine if dispositional constructs are valid and reliable indicators of 30  health in these groups. Determining these associations could provide insight into potential programs or adjustments to care provision necessary to improve health and wellness in these communities that face many unique challenges. This is particularly important to members of these groups who may be living with HIV, as both groups are disproportionately represented in the population of PLWH in Canada and face many socio-structural barriers that affect cART adherence [2, 22, 28]. This would also allow for a more personalized and equitable approach to cART adherence and care programs that may benefit individuals when universal care programs are not sufficient [70, 154, 155]. 1.6 Community Collaboration in Research The key to successful and meaningful research is community collaboration. Studies that utilize a community based research approach create results that properly address the needs of the community [205-208]. In doing so, researchers collaborate with the community along every step of the research including: designing the research questions and protocol, conducting the study, interpreting results, and translating knowledge. It is vital to foster lasting and genuine connections between researchers and the community, to ask what the community needs and let this guide the research, and to come to a research question and study design together. This allows for a client-centered approach that can best improve care and access to health services [209]. In regards to HIV research, it is crucial that PLWH are included at each step of the research process. This includes following the principles: Greater Involvement of Persons Living with HIV/AIDS (GIPA) [210], and Meaningful Involvement of Women Living with HIV/AIDS (MIWA) [209]. Following GIPA and MIWA allows for the involvement of PLWH in the 31  research from study design through to knowledge translation. In turn, this inclusion creates more meaningful findings and works to empower the community of PLWH [205-208]. 1.6.1 Collaboration with Indigenous Communities As previously mentioned, the relationship between Indigenous persons and research has historically been negative [25, 103, 211]. Research experiments were often unethical and forced upon Indigenous peoples, especially in Residential Schools and Indian Hospitals [103]. Indigenous knowledge was and still is often taken from communities in studies without acknowledgement or results being returned to the corresponding community. Thus, it is extremely important that all research with Indigenous communities provides autonomy, respect, and includes not only Indigenous ways of knowing in research methods, but also Indigenous people in larger and leading roles [211]. Research must be conducted “in a good way”, which is a phrase used by many Indigenous communities to encompass when a practice includes Indigenous ways of knowing, persons, traditions, and spirit [123]. Research begins to be done in a good way when following the OCAP principles (Ownership, Control, Access, Possession) [211]. With OCAP, Indigenous communities have power and control over what research is completed and management of information storage and accessibility, thus creating autonomy over the research involving them [211]. These strategies provide Indigenous communities with the ability to design their own research and become more involved with the process. As such, it is vital to go beyond merely consulting Indigenous communities to including Indigenous persons in larger and leading roles in research. These roles can include being a principal- or co-investigator, peer research associate, advisory board member, consultant, or other leading roles. Importantly, these community leaders 32  need to be remunerated as an appreciation for their time and knowledge. Collaboration and consultation with Indigenous Elders is also a very important part of conducting research in a good way [123]. Elders are the knowledge keepers of their communities and have immense expertise on traditional medicines and methods of healing [100, 123, 212]. The healing and support that Elders can provide amends the spiritual, emotional, and mental wellbeing of an individual. Including community leaders will work to address the OCAP principles to provide ownership of the research to the community that is being studied and for the creation of more meaningful findings [211]. When incorporating Indigenous perspectives, it is important to have a “Two-Eyed Seeing” approach, which is the combination of holistic Indigenous knowledge and Western medicine in practices [83]. Supported in a culturally safe way, methods that include a Two-Eyed Seeing approach address the aspects of health that are necessary for holistic care [119, 213]. Part of utilizing a Two-Eyed Seeing approach involves educating non-Indigenous researchers and HCPs in cultural safety practices to create safer spaces accessed by Indigenous persons [213]. This includes applying an intergenerational trauma framework where Indigenous practices are included to support the healing of individuals [101, 214]. For incorporation of an intergenerational trauma framework, care providers need to first be educated and trained, as many misunderstandings likely exist [101]. Improving the understanding of historical trauma and how many Indigenous peoples lost their connection to culture, would allow researchers to better understand their collaborators and participants. For HCPs, this holistic approach would allow the provider to look beyond the disease to the social determinants of health that are impacting care. 33  Once an educated understanding is achieved, culturally appropriate practices can better be included in research and healthcare.  With the ability to have input on research, Indigenous communities can begin to build trust and safety with the researchers, working to heal a historically negative relationship [25, 103, 211]. Furthermore, including Indigenous peoples and knowledge in the research will build capacity and create more meaningful and impactful results as community knows what the community needs best [211]. 1.7 Rationale  Optimizing tools to improve cART adherence and engagement in care is valuable for both personal and population health, as lowering pVL improves the health of PLWH and lowers risk of HIV transmission. Measuring personal disposition is simple and rapid, and could be used to personalize adherence support in the WelTel program to improve pVL and the overall lives of PLWH. However, there is minimal research on personal disposition and health in low SES and Indigenous communities of Canada, so measures of disposition cannot yet be utilized in these communities. This is imperative, as both groups are disproportionately represented in the population of PLWH in Canada. Furthermore, input and involvement from the Indigenous community is required to ensure the cultural safety of the WelTel program. Thus, the purpose of this study was to seek Indigenous collaboration, cultural safety and appropriateness in the design of WelTel, to validate purpose and personality measures in Indigenous and low SES communities, and to determine if purpose and personality are associated with health and wellbeing in these communities in Vancouver, BC. 34  1.7.1 Objectives and Hypotheses Objective 1: To gain input from the Indigenous community of Vancouver, BC, in the design of a clinical trial examining the impact of personal disposition on the use of the WelTel program, and of the program on personal disposition.  Hypothesis 1: The Indigenous community of Vancouver, BC, will see value in the WelTel program and examining personal disposition with the program, and will provide suggestions for improvement of the WelTel service for this community. Objective 2: To validate the Oregon Brief Purpose measure and the Big 5 personality assessment tool for use in Indigenous and low socioeconomic communities of Vancouver, BC. Hypothesis 2: Tools used to assess personality traits (Big 5 Personality tool) and sense of purpose in life (Oregon Brief Purpose measure) can be validated for use with Indigenous and low socioeconomic communities of Vancouver, BC. Objective 3: To examine whether measures of personal disposition are associated with measures of health and wellbeing among Indigenous and low socioeconomic communities of Vancouver, BC. Hypothesis 3: Measures of personal disposition are associated with measures of health and wellbeing among Indigenous and low socioeconomic communities of Vancouver, BC. In particular, we hypothesized that purpose, conscientiousness, agreeableness, and neuroticism would be correlated with all measures of health and wellbeing, and the other dispositional factors (extraversion and openness) would not be. 35  Exploratory Objective: To examine whether Indigenous spiritual health is correlated with health wellbeing, and personal disposition. Exploratory Hypothesis: Indigenous spiritual health is positively correlated with health, wellbeing, and/or personal disposition.   36  Chapter 2: Research in a Good Way: Community Collaboration An integrated knowledge translation and exchange process was employed whereby Indigenous Elders and community members participated in every facet of the study to ensure that study design was culturally safe and appropriate, and that validation of measures of personal disposition among Indigenous peoples of Vancouver, BC was done in a good way. 2.1 Elder Consultation This study was designed in collaboration with two Indigenous Elders from Vancouver, BC, both living with HIV. The Elders ensured the cultural safety and appropriateness of study procedures by including Indigenous ways of knowing in each step. They kindly shared Indigenous teachings with the non-Indigenous researchers along the way. Together, we created the research questions and protocol, assessed and created questionnaires, conducted the study, interpreted results, and designed knowledge translation tools. Elders were remunerated for sharing of their time and knowledge.   2.2 Collaboration with Indigenous Centers and HIV Service Organizations We collaborated with an Indigenous health clinic, Vancouver Native Health Society, to seek input on the project from their research team, administration, physicians, and one of their Elders. This team provided suggestions and support for the study design and questionnaires, as well as a space to host the Sharing Circles. Once questionnaires were designed, we connected with various clinics, HIV/AIDS Service Organizations (ASOs), and Indigenous centers throughout the Vancouver area. We provided information on the project, and received support from the clinics/centers to utilize their 37  space for our team to conduct the questionnaires with participants. In addition, ASO teams notified their clients of when we would be visiting their centre, which facilitated the participant recruitment process. 2.3 Following Community Research Guidelines All study protocols followed GIPA, MIWA, and OCAP principles to meaningfully involve and receive input from PLWH, women living with HIV, and the Indigenous community in all study aspects, from design through to knowledge translation [209-211]. We also addressed the national guidelines of the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans (TCPS-2), including Chapter 9: Research Involving the First Nations, Inuit and Métis Peoples of Canada. 2.4 Funding and Ethics This research was funded by a Canadian Institute of Health Research (CIHR) Bridge grant (H12-153404). We acquired ethics approval from the Children’s and Women’s Research Ethics Board at the University of British Columbia (H17-01792). Initially, the Research Ethics Board denied gifting of tobacco at the Sharing Circles, however we disputed this and took the opportunity to teach the Research Ethics Board on the cultural importance of tobacco [80, 100]. We then received approval to gift tobacco ties at Sharing Circles. 2.5 Sharing Circles Sharing Circles consist of the gathering of people to share about their lived experiences in qualitative research, while utilizing an Indigenous research framework [100]. Similar to focus groups, Sharing Circles allow researchers to collect information through a guided discussion on certain topics; however, Sharing Circles also have a sacred meaning in many Indigenous 38  communities [100]. Sharing Circles use a healing and learning method in which participants share aspects of the heart, mind, body, and spirit [100, 215]. This creates energy in the circle from the spirit of the participants and of their ancestors and the Creator [215]. Furthermore, Sharing Circles are completed in such a way that everyone is viewed as an equal, including the facilitator/researchers, so that all voices are heard and valued [216, 217]. This helps to create respect between circle members in a nonjudgmental, open, and supportive space [100]. Sharing Circles have an Elder present for support, begin with a smudging ceremony, and may have medicines placed in the centre of the circle [100]. Elders are important as they provide support, guidance, and help to create a safer space in the circle. Smudging involves cleansing of negative energy from one’s mind, body, and spirit, as well as the physical space, so that all Sharing Circle participants can enter the group with a clear mind [80]. The medicines placed in the centre often include four traditional medicines: sage, sweet grass, tobacco, and cedar, with cloth and twine to create bundles of the medicines [80, 218]. 2.5.1 Sharing Circles Methods We hosted two Sharing Circles with Indigenous PLWH to gain community input on the WelTel program, questionnaire design, and how they, as representatives of community, would like to be meaningfully involved in this research. We hosted one Sharing Circle with Indigenous individuals who identified as women, and one with Indigenous individuals who identified as men. Additional eligibility criteria included being 19 years of age or older and being able to communicate in English and provide informed consent. Participants were recruited through posters and word of mouth, with the aim of 8-12 participants for each group. Sharing Circles 39  were 3 hours long and were hosted at Vancouver Native Health Society clinic in the Downtown Eastside of Vancouver, BC.  Each Sharing Circle was designed and guided by the Elders working on the study, with the male Elder and female Elder facilitating the male and female Sharing Circles, respectively. There was an additional Elder, not affiliated with the study, present to provide support to the participants throughout the discussion. The four traditional medicines of Indigenous communities in Canada (cedar, sweet grass, sage, and tobacco) were offered in the centre of the table for participants to access and create medicine ties at any time during the circle [80, 218]. The circles began in a culturally traditional way, with an opening from an Elder, a land and people acknowledgement, smudge, prayer, and meal. We then reviewed the consent form as a group (Appendix A.1), and participants were given time to decide if they would like to stay for the discussion or leave. If they chose to stay, they signed the consent form. The Elder then asked the participants if the researchers had permission to be in the room during the discussion.  Discussion of the WelTel Program included the Principal Investigator providing a description of how the program works, the results of the efficacy study at Oak Tree Clinic, and how to best move forward with the program, knowing that those who use it most receive the most benefit. We asked participants what they thought of the program and how it is used to improve medication adherence, along with the overall wellness of clients. We also asked participants what they would like to see added to the program to make it more culturally safe and appropriate. Within the circles, we reviewed the questionnaire that included the measures of personal disposition, health, and wellbeing that the study team sought to validate in the Indigenous 40  community for future use in WelTel research. Questionnaires included measures of demographics, the Oregon Brief Purpose scale [160]; Satisfaction with Life scale [219], the Mini-IPIP measure of Big 5 Personality Traits [174], Short Form-6 (SF-6) measure of general health [220], and spiritual health questions (created by Elders) (Appendix B). Methods, results, and implications of the conduction and analysis of the questionnaires are detailed in section 3. In seeking further community engagement, we then asked participants about how they themselves and their community should best be meaningfully involved in this project. This was in line with GIPA, MIWA and OCAP principles [209-211]. We also asked the participants about how we can share knowledge on the study findings with them, the questionnaire participants, communities involved, other researchers, and beyond. To conclude each Sharing Circle, the Elders gave a closing ceremony and each participant was gifted a tobacco tie and $20 as remuneration for their participation. Elders were given remuneration and a gift as a thank you for their time and knowledge. Sharing Circles were audio recorded, transcribed, and thematically coded. In addition, a visual facilitator drew the thoughts and ideas discussed by participants into infographics for knowledge translation/exchange use. Participants and Elders received a print out of the infographics. 2.5.2 Sharing Circles Results We recruited 8 Indigenous women living with HIV for the women’s Sharing Circle and 10 Indigenous men living with HIV for the men’s Sharing Circle. All participants provided informed consent and stayed for the entire discussion. Mean age (SD) was 55.6 (+/- 6.6) years for female participants, and 53.1 (+/- 4.9) years for male participants (Table 1). The majority of 41  participants had not completed high school graduation, including 63% (5/8) of female participants and 60% (6/10) of male participants. Table 1. Sharing Circle participant demographics. Characteristics	Women's	Sharing	Circle	(n=8)	Men's		Sharing	Circle	(n=10)	Mean	Age	±	SD	(y)	 	55.6	±	6.6	 53.1	±	4.9	Preferred	Term	of		 Indigenous	 1	(12.5)	 1	(10)	Indigenous	Identity	 First	Nations	 1	(12.5)	 3	(30)			n	(%)	 Aboriginal	 1	(12.5)	 -		 Two-Spirit	 -	 1	(10)		 Native	 4	(50)	 -		 Metis	 -	 3	(30)		 Other	 1	(12.5)	 2	(20)	Education	 <	High	School	 5	(63)	 6	(60)			n	(%)	 High	School	Grad	 2	(25)	 1	(10)			 College/Trade	 -	 2	(20)			 University	 -	 1	(10)		 n/a	 1	(13)	 -	 Sharing Circles led to three main actions: amendment of the planned WelTel program and questionnaires to ensure cultural safety, creation of visual knowledge translation pieces, and hiring of two Indigenous PLWH as Peer Research Assistants to facilitate conducting questionnaires. Figure 1 depicts the women’s Sharing Circle discussion, and Figure 2 depicts the men’s Sharing Circle discussion via a visual description of the ideas of participants.     42               Figure 1. Infographic of women’s Sharing Circle. Art created by visual facilitator.  43             Figure 2. Infographic of men’s Sharing Circle discussion. Art created by visual facilitator. 44  2.5.2.1 Perspectives on the WelTel Program Indigenous PLWH expressed value in the WelTel program, stating that it improves medication adherence, is accessible and personal, empowers autonomy in health care, and may assist in regaining and strengthening connections with care providers, family, and community. These themes are stated and supported by quotations below.  Medication adherence is important and can be achieved via the WelTel program: Participants understood that medication adherence is important, and two men’s Sharing Circle participants stated that “Anything that helps me take my meds is very good!” and another said, “Sometimes I’ll be at home for a week and my phone doesn’t even ring. Not even a text message or anything, and I do forget my pills. This could be good.” Similarly, another participant added, “Sometimes I miss [taking my meds] quite a bit. Anything to help is good.” Furthermore, another men’s Sharing Circle participant said that, “I’m undetectable right now, but I’m not sure how long it’s going to last. What if I miss my meds? For right now I’m not going to spread it, the disease right? And this is what we want so we don’t do that.” Another added that it is “very important to take your meds because whatever level you’re at, if you’re struggling or not, you should always have someone important to you to pop in to say hi how are you doing to check in and see how you’re doing. Sounds like a good way to make sure everyone takes your meds because it’s important to take your meds, so this sounds like a fantastic idea.” In addition, Women’s Sharing Circle participants acknowledged that research and medication adherence are important for Indigenous PLWH as a participant said, “Indigenous 45  people are the highest group with HIV.” And another added “And last to adhere to their medicines, Indigenous women last and then men. Also high death rate.”  WelTel is an accessible and personal approach to health care: Sharing Circle participants expressed interest in the program because it is accessible and can be used by anyone: “I think it’s a good fit for all of us, the cell phone thing. I would use it”. And another said that, “This could be really good for isolated communities that can’t be reached. It could also work for many age demographics.” In discussing how WelTel is a bidirectional method, participants thought that it was beneficial in that, “Keeping in touch, it leads back to taking our medications. Hear something friendly at the other end, someone that cares, and you know that they are accessible.” When asked how often the participants would like the receive texts, a men’s Sharing Circle participant said: “Oh at least once a week. Someone might be going through some issues and being in touch is a really good thing. A reminder to be in touch and involved with somebody is very good. Monday is a good idea.” And another added, “It’s up to each individual. Some people might be going through some issues, some people are just fine going along, and just being in touch is always a good thing. You know, everyone is going through different things, right? But a reminder you know to be in touch and be involved with somebody is very good.”  Furthermore, participants thought that the WelTel program was “Making [healthcare] more human” and that “having a human come in and check in on you to make sure you’re okay because you could be in danger or really sick” is important and provides a more personal 46  approach. Then the support Elder at the women’s Sharing Circle added that “Wouldn’t it be great to have someone, with an individual, as a support?” The program may work towards regaining and strengthening connection with not only HCPs, but also with peers, family, and community: Sharing Circle participants acknowledged that, “connection to community is important, [and it is] good to have someone to talk to.” In fact, women’s Sharing Circle participants felt that they were “…making a community with WelTel. Having a phone and being able to have their own community, so that they have the numbers of the others… a web.” Another participant added, “It’s nice to not just have a phone, but to have a connection because I’m an introvert. When I go home, I go home by myself. I like it and then sometimes I don’t like it because I get down. It’s very lonely sometimes.” The group unanimously agreed when the facilitating Elder recapped what was discussed: “So you want others that are in the same study, if with permission, you have those connections with them through that same phone? Is that what I’m hearing? So you’re not only getting that support from there, but you’re also getting the peer support. That’s what I’m hearing.”  Furthermore, a men’s Sharing Circle participant stated that “This is helping to break out of isolation to build communication and connection… it’s going back to who we really are. If this can do that, then this is really good, you know?” Similarly, a women’s Sharing Circle participant also said that the WelTel program is about “Breaking out of isolation. It’s going a lot farther than we think it can go.” Another participant highlighted the importance of connection 47  through the phones at certain times of the year, “Especially during holiday times. This texting and keeping in touch with people, this would be a time of year that it matters.” The program may empower participants to have autonomy in their health care: Participants understood the importance of taking care of their own health, and saw how this could be very empowering. In fact, a women’s Sharing Circle participant said that, “There are so many young [Indigenous] women out there who don’t even have [a sense of community], and it would be so nice to have [the WelTel program] to give them a little bit of empowerment.” Another participant added, “I’m so proud of all the ladies here that are fighting for their health and us still being there, that’s awesome. It’s powerful.” When discussing opportunity to become more involved in the WelTel research, women’s Sharing Circle participants said that “It’s empowerment and peace of mind”, and another added, “I’m happy to be a part of this and included. I’m really excited and seeing that not only us, but healthcare is moving forward and not staying stagnant.” In addition, another participant added that indeed the program is helping with “Moving forward for healing.” Similarly, at the end of the Sharing Circles, participants overall felt empowered and hopeful with a member stating, “I feel excited and hopeful, and this is like, oh wow!” with another participant adding that “Wouldn’t it be great to have that empowerment…The hope and the heart can be saved.” Participants requested the safety and privacy of the program:  Participants wanted to ensure the safety, privacy, and confidentiality of the program. For example, a participant asked, “So if you’re in a bad relationship, maybe, or where your partner’s 48  very aggressive or jealous, [then what happens]?” Someone added: “or controlling.” And then the study PI explained that: “What we did for privacy in the past was when each person was enrolled we asked them what they wanted that number that the messages are coming from put in the phone as. So that it was something safe for you. So some people say I want it “study”, some people say they wanted it as you know, “Gloria” or “Marge” or “Joe”, or some, some name that would be safe because we don’t want someone finding your phone and something happening to you because they’re “who’s this texting you” for instance.” Then the facilitating Elder asked, “What kind of text would you like to receive? And I think this is maybe getting into how to keep you safe. So, you’re getting this text at noon on Monday. What kind of text would you like, that is checking in on your health and wellbeing?” Suggestions included: “How are you doing today?”, “G’day mate!”, “Hi there!”, “Hi Bro”, “Hi Sister” and “How are you?”, which is what the program previously used. The facilitating Elder said, “so going back to hi brother or hi bro or hi sister might be good to help keep [someone in a controlling relationship] safe.” Participants said that changing up the weekly text message might make it friendlier and less obvious that it’s coming from a computer.  In wondering more about the privacy of the program, a men’s Sharing Circle participant asked, “What about if you’re going through border patrol and they look through your messages and ask what it is?” And the facilitator explained that the texting program would not include anything about HIV or their health information unless the participant had specifically asked for it, and that the number is not traceable back to the clinic. Participants acknowledged that this was good.  49  Recommendations to add to the WelTel program: The main suggestion from Sharing Circle participants was that there should be a peer support group added to the WelTel program. This was unanimous, as women’s Sharing Circle participants felt that “it would be nice to have a wellness check [from a peer] if you say you’re not okay, and then don’t answer”, because they “don’t always want 911 involved” and stated that “we just want one of us. So, we can just say hey, so and so, come and help me please?” The Indigenous Elder who was facilitating summarized it as “So you want sort of a closed group that you know you’re on this program together. That you have that connection of a group text”, and participants agreed. A member suggested, “In the beginning [of the WelTel program] we could ask if you want to have a person to check in with. Identify other people within the group that it would be okay to check in with, in a connections community, like a buddy system. And you can opt in and out of it.” Similarly, men’s Sharing Circle participants said that, “Peer engagement is needed. People are more likely to listen to one of their peers who they know is positive.”  Participants then discussed having peer workers with larger and paid roles, stating, “What about having someone who is paid peer support that works, so when the nurse calls she can call one of three or four people and say hey, can you please do this.” Another member agreed “Ya, peer support research. And have an advisory board like what we are today. Meet every month to see how the study is going.” Another added “And have some paid positions in there. It gives us empowerment.” The facilitating Elder summarized, “The WelTel study is supposed to be supporting you, but we’ve turned it around so that we in WelTel can support each other… These are some very powerful words.” 50  In addition, Sharing Circle participants recommended that a materials kit should come with the study phone with “a little drawstring thing that you tie to your belt loop or something or your purse, and you open it up and it’s got your earphones, it’s got your reading glasses, and it’s got that WelTel phone.”  To further include cultural safety, all Sharing Circle participants suggested that having “access to Elders” would be very beneficial to the program. Another added, “It’s empowerment, culturally, emotionally and spiritually, by using peers and having an Elder on board and having an advisory board.” Furthermore, Women’s Sharing Circle participants all agreed when a participant said “A lot of ladies ask me to come smudge them, so if there is a way we can include the medicines in this?” Sharing Circle participants overall recommended including Indigenous ways of knowing into the program wherever possible. 2.5.2.2 Perspectives on Questionnaires and Researching Personal Disposition The facilitating Indigenous Elder read each of the questions aloud from the questionnaire to the participants. All of the demographic questions were approved until the question: “In the household of your upbringing, were you considered very poor, poor, average, well off, or very well off?” A participant stated “that one would be a hard one to answer because I never grew up with my family.” Another Sharing Circle participant added, “I don’t like that”, and then another agreed, “Ya, like I grew up rich on the land, but poor money-wise. But very rich on the land.” With another adding, “Ya, it’s a very colonial question. It’s not any of their business how rich or poor I was… that was then, and this is now. How’s that going to help? Some people just don’t want to go back there.” The facilitating Elder concluded that “from this group, we’re saying scrap it... this was a big negative.” In regards to the measures of disposition, health, and 51  wellbeing, participants understood the questions and did not have any concerns in regards to them. In fact, some participants stated that they recognized the questions in the SF-6 measure of general health from previous studies in which they participated. When asked what participants thought about measuring personal disposition with the WelTel program to determine who uses and benefits, participants had no concerns and thought it was a good idea. Indeed, a men’s Sharing Circle Participant said: “I think it’s a good idea what you’re doing... To help different people, you see everyone is different right, so it’s kind of hard to figure out what they need without asking that.” 2.5.2.3 Suggestions to Improve Community Engagement and Capacity Participants suggested that copies of the visual infographics created during the Sharing Circles be given to each of them, and that these graphics should be used in our results as much as possible, because visuals are more in line with Indigenous ways of knowing. Participants also suggested that Indigenous persons living with HIV be added as Peer Research Associates to help with the study, and one member added “Wouldn’t it be great to have somebody in charge of something?” In addition, participants in both groups suggested having an end-of-study Sharing Circle because it is “Very important to have a follow-up” and “Follow-up, ya, that is key”. They also expressed a need for further research capacity building in their communities, as they are involved in a lot of research, but may not know exactly how the research process works or how they can become more involved. To this, a women’s Sharing Circle participant added “We’ve been [involved in research] for a couple years and we still aren’t to the point where we’re considered eligible to be peer workers. You know what I mean?” And another added that they need “training or education at community forums” to be involved in larger research roles. 52  2.6 Discussion of Sharing Circle Results Indigenous PLWH whom attended our Sharing Circles expressed value in the WelTel program, an mHealth medication adherence program that has previously shown to be successful at improving cART adherence and reducing HIV pVL in participants at an HIV clinic in Vancouver, BC [148]. Sharing Circle participants suggested that the program improves medication adherence, is accessible and personal, empowers autonomy in health care, and may assist in regaining and strengthening connections with care providers, family, and community. Participants recommended amendments to add a peer-support component that would work to build connection and community, and to further include Indigenous persons and ways of knowing in the program. In regards to the project on assessing measures of personal disposition with WelTel, participants supported the step to possibly creating more personalized care and wanted to become more involved in the research. As Sharing Circles participants acknowledged that cART adherence is essential to improved health, that a safe program to improve their cART adherence would be helpful, and that WelTel would help to create this, our findings provide strong support to develop the cultural safety of the WelTel program. This will help to enhance engagement of the program, which will in turn improve the cART adherence of Indigenous PLWH [26, 119]. In addition, participants thought that WelTel could simultaneously provide empowerment, as the ability to receive healthcare on demand would allow participants to have autonomy in their health [221, 222]. Furthermore, participants echoed the literature on mobile health by suggesting that it lowers barriers in accessing care, which may be particularly useful for persons who live in isolated, rural areas, or on reserves that are distant from HIV care providers, have care responsibilities, or 53  inflexible work hours [67, 68, 137, 138]. Though our participants were from an urban Indigenous community, their input on this is valuable and further research into using WelTel for Indigenous PLWH in harder to reach areas is warranted. This may be particularly useful for addressing and reducing the disproportionately high rates of HIV in Saskatchewan’s Indigenous population, as many of whom live on reserves [107, 108]. However, each community in Saskatchewan, or on other reserves/rural areas across Canada, would need to be consulted and collaborated with to ensure cultural safety and appropriateness before WelTel is implemented. Altogether, WelTel could work towards improving equitable access to care, which could in turn improve the social determinants of health and overall health outcomes for Indigenous PLWH across Canada [69, 70, 72, 106]. Thus, there is great value in improving the cultural safety and applicability of the WelTel program to ensure that it is more suitable to Indigenous PLWH in various settings. An opportunity to improve Indigenous ways of knowing in the WelTel program that participants unanimously recommended is to build upon the sense of community that it can create. Sharing Circle participants were amiable with the idea of how WelTel may work to foster connections with HCPs, and suggested adding a peer support component and access to Elders to further build community. A peer-support component could include having a group of peers, whom are also participating in the study, that participants could text with to check in whenever they’d like to, but also when the HCP is unable to contact the participant and requires a trusted peer’s assistance. This could also include having a peer physically check in on a participant, if the participant had previously consented, which could avoid the need for emergency services. Adding such a peer-support component to WelTel may enrich the program by improving the sense of community and contribution to others that Indigenous communities value, as 54  participants would be able to check in on one another when needed [126]. In fact, HIV peer support has previously shown to improve cART adherence in a variety of contexts [223-225]. One study with women living with HIV who are IDU and live in Vancouver’s DTES, found that peer support worked to improve medication adherence [223]. Therefore, it would be beneficial for future research to investigate the role of peer support in mHealth for cART adherence. Additionally, including the ability to access Elders to increase support would allow for improved trust and engagement in the program, as well as support and healing at a spiritual level. This would work to enable WelTel to address intergenerational trauma alongside cART adherence [123, 226]. Overall, fostering community through the program may empower and strengthen the resiliency of Indigenous participants [120, 126, 127].  To further support cultural safety, Sharing Circle participants suggested including traditional medicines and Indigenous persons in leading roles throughout the program and entire research process. In embracing a Two-Eyed Seeing approach, the WelTel program can intertwine these Indigenous ways of knowing and Western medicine in a holistic way [83, 212]. This would help to address the impacts of colonization to allow intergenerational trauma to be mended, so that beyond medication adherence, the mental health and substance use issues of participants can begin to be healed [26, 72]. However, to fully address the cultural safety recommendations from Sharing Circle participants, WelTel HCPs and researchers need to be educated and trained to understand the harmful and lasting impacts of colonization and intergenerational trauma [83, 101, 119, 213]. This includes recognizing the need to be continuously open to listening and learning from Indigenous clients, as each has unique cultures, wisdoms, and experiences. Developing these cultural safety practices may work to further develop the relationship and trust 55  between HCP and participant, which may promote further engagement and cART adherence of participants [53, 55, 57, 58, 227]. For researchers, this may work to mend the historically negative relationship between researchers and Indigenous communities in a collaborative way [25, 103, 211]. Altogether, further supporting the cultural safety of the WelTel program could work to support reconciliation, connection to culture, and improve health outcomes of Indigenous PLWH [26, 119]. As mHealth has proven successful to enhance treatment adherence in many chronic illness contexts, our findings may be applicable to improve the cultural safety of such programs, or ideally, to create new programs that include Indigenous persons and practices from the beginning. Effective mHealth programs have shown improved health outcomes for smoking cessation, diabetes, cardiovascular health, eldercare, cancer treatment, etc. [141-148]. Cultural safety improvement of such programs would be particularly beneficial for chronic illnesses that disproportionately affect Indigenous communities, such as diabetes and depression, and for comorbidities often associated with HIV, including as diabetes, cardiovascular diseases, depression, and cancer [33-35, 37-40]. Improving the cultural safety of these programs would help to improve the efficacy and engagement for Indigenous persons who have these morbidities, whether living with HIV or not. However, to optimize cultural safety, the creation of new mHealth programs that collaborate with Indigenous persons and include Indigenous ways of knowing before innovation and then throughout program operation would support these chronic morbidities idyllically. Alternatively, WelTel could be amended to support various chronic illnesses experienced by Indigenous persons in a culturally safe way. In fact, WelTel is currently being studied for use with individuals living with asthma and tuberculosis in Vancouver, BC, as 56  well as with HIV in IDU across BC [26, 228-231]. Though effectiveness results are not yet determined for these studies, the bidirectional aspects of WelTel add the benefit of real-time advice from HCPs that could help to improve self-management of these illnesses and others [148]. Although WelTel was created in Kenya, and not with Indigenous persons in Canada, including cultural safety measures and Indigenous persons in design going forward will be essential. Altogether, the recommendations for improved cultural safety could work to improve not only cART adherence, but also treatment engagement for other chronic illnesses for Indigenous persons in Canada.  2.7 Peer Research Associate Engagement and Training  As Sharing Circle participants suggested hiring Peer Research Associates (PRAs) to support cultural safety, we created and hosted five workshops that provided PRA, or instead termed by our Elders, “Peer Indigenous Research Associate” (PIRA) training to two women’s Sharing Circle participants and one men’s Sharing Circle participant who showed great interest in becoming further involved in the project and in research in general. Instead of simply hiring PIRAs, we realized that to properly build capacity in research, PIRA training and teaching of resume/curriculum vitae (CV) related skills were needed to support the journey from participant to researcher [206, 208, 232]. Workshops were built upon Indigenous ways of knowing and included training on truth and reconciliation, research methods, ethics, knowledge translation, working as a PIRA, resume/CV writing, and how to navigate online research resources. Each workshop began in the traditional Indigenous way with a smudge, acknowledgement of the land and people, and a meal. These workshops were co-led by two Indigenous Elders (Elders Valerie and Sandy) and non-57  Indigenous researchers (myself and Dr. Murray) in a “kitchen table” style so that everyone was equal and together as one with no hierarchy. Elders and PIRAs received remuneration to honour and value their time and knowledge ($25/h for PIRAs and a larger sum for Elders). Upon completion of the workshops, we hosted a graduation celebration picnic and presented each new PIRA with a certificate and a gift. Elders Valerie and Sandy blanketed each PIRA and non-Indigenous researcher for embracing new knowledge and seeking to do things in a good way. Similar to previous research, PIRAs said that the opportunity to attain research skills and knowledge has been very empowering and motivating, and they look forward to utilizing these assets to make a positive difference in their community [206]. This process highlighted the importance of having non-Indigenous allies to exchange Indigenous ways of knowing with. As teachers we became learners, and as learners we became teachers. Ongoing exchange of knowledge between Indigenous and non-Indigenous researchers is vital to creating meaningful relationships and impactful research. PIRAs felt valued, empowered, and had a newfound confidence to become more involved in research. They are excited for their next steps and continuing to develop the connections and support created. Two of the PIRAs assisted with questionnaire conduction, all three assisted with end-of-study Sharing Circles for healthcare providers, and will participate in the planning and facilitation of a Sharing Circle to share what we have learned with the community in the near future. In addition, two of the PIRAs presented on the workshops and their journey in research at the Canadian Aboriginal HIV/AIDS Network Annual General Meeting in Fall 2019. We hope to utilize the framework of these workshops to train other Indigenous community members who are interested in becoming more involved in research. This will work to further ensure meaningful inclusion and 58  collaboration of Indigenous persons living with HIV to create more impactful research [208-211]. 2.8 Integrated Knowledge Translation and Exchange In continuing an integrated knowledge translation and exchange process, information gained from the Sharing Circles and questionnaires (Chapter 3) was shared via an end-of-study Sharing Circle with HCPs at the Urban Indigenous Health and Healing Co-operative (Kilala Lelem), and will be shared in a broader Sharing Circle with Indigenous community of Vancouver’s DTES. For the HCP gathering, attendees included physicians, social workers, outreach workers, and nurses. Elder Sandy opened and closed the gathering and assisted with facilitation, along with the PIRAs who presented on their experience with this project. We are currently in the planning stage for the broader Sharing Circle and plan to invite all participants from the first Sharing Circles, and participating questionnaire sites will advertise to their clients. Indigenous Elders and Peer Research Associates will also assist with the planning and facilitation of this gathering, and will be remunerated for their time and knowledge. Food will be provided for all attendees. To ensure the communities have control over the accessibility of the data and how it is shared, we will ask for feedback on the project, how we can best disseminate results with the broader community, and how we should move forward with our research. Furthermore, original Sharing Circle participants have received copies of the Sharing Circle infographics (Figures 1 and 2), which have been and will be handed out at all knowledge translation/exchange events, along with a description of the study findings for anyone interested. Moreover, as a team, we have presented results thus far at the 28th Annual Canadian Conference on HIV/AIDS Research (CAHR 2019), the American Psychosomatic Conference (APS 2019), 59  the Canadian Aboriginal HIV/AIDS Network Annual General Meeting of Fall 2019, as well as other local research symposiums. Our knowledge translation/exchange efforts are vital to providing other researchers with an example of community collaboration and doing work in a good way. Sharing our methods and findings will ideally assist with improving cultural safety in other research and healthcare programs. 60  Chapter 3: Questionnaire Validation & Health Outcomes Due to Canada’s history of colonization, it is crucial that research with Indigenous communities is culturally safe and appropriate by including Indigenous practices, knowledge, and people. Utilizing a Two-Eyed Seeing approach, by equally incorporating both Indigenous ways of knowing and Western medicine, allows for reconciliation by supporting ownership and capacity among communities, and creates more meaningful findings [26, 83]. In a culturally safe way, we sought to determine: (1) whether measures to assess purpose and the Big Five personality traits show single-factor structures and sufficient reliability in low SES and Indigenous communities living in Vancouver, BC; (2) whether these personal dispositions correlate with health and wellbeing, even when controlling for known socio-demographic predictors of health (i.e. income, sex, etc.), in these communities; and (3) whether spiritual health is correlated with measures of personal disposition, health, and wellbeing in the Indigenous community of Vancouver. We hypothesized that measures used to assess personal dispositions are (1) valid, reliable, and (2) correlated with measures of health and wellbeing beyond demographic predictors in Indigenous and low SES communities; and that (3) spiritual health is correlated with measures of health and wellbeing in this Indigenous community in Vancouver, Canada.  3.1 Methods – Questionnaires As described in Chapter 2, we collaborated with Indigenous Elders, healthcare providers, and community members to incorporate Indigenous ways of knowing, cultural safety and appropriateness in each aspect of the study, and to build ownership and capacity in the research. We followed the Canadian guidelines on working with Indigenous persons (TCPS-2, Chapter 9, 61  Research Involving the First Nations, Inuit and Métis Peoples of Canada), and the OCAP principles) in study design through to knowledge translation. Elders and healthcare providers assessed questionnaires and provided appropriate amendments. Our Elders reviewed the survey measures and suggested the following to be amended/added: All Indigenous participants were asked how they self-identify, i.e. as Indigenous, Metis, First Nations, Inuit, Aboriginal, or any other term that describes a person whose ancestors were among the First Peoples of Canada, and participants can choose as many as they identify with. Elders also suggested we change the questionnaire such that the “I” sits at the beginning of every sentence rather than the top only, making it clearer. In addition, Elders created spiritual health questions to include the Medicine Wheel teachings and Indigenous ways of knowing in the questionnaire for Indigenous participants. Finally, Elders suggested that remuneration for survey participation should be $20. Community involved in the Sharing Circles gave input on study design and wanted to be more involved, so we hired two participants as PIRAs to assist with questionnaire conduction and knowledge translation. Questionnaires were amended based on Sharing Circle discussion to remove a question on childhood household income, as it was considered to be triggering of trauma from colonization impacts and not necessary for research findings. 3.1.1 Questionnaire Design The questionnaire included measures of demographics, sense of purpose, Big Five personality traits, health, life satisfaction, positive affect, and negative affect, as well as spiritual health questions for the Indigenous group only (Appendix B). The tools used to measure each are as follows.  62  Demographics: We collected age at study visit, gender, sex, ethnicity, first language, education (< high school, high school graduate, college/trade school, or university), and income (>$15,000 or ≤ $15,000 per year). Sense of Purpose: Purpose was assessed using the Oregon Brief Purpose Measure, a 4-item measure on a 5-point Likert scale from 1 (“strongly disagree”) to 5 (“strongly agree”) [160]. This scale has previously been associated with measures of health in various samples in the United States [167, 170]. An additional 3 items were added in case any of the first 4 were not valid in any group, to help to ensure that a reliable 4-item measure could be created. Big 5 Personality Traits: Utilized the Mini-IPIP measure of the Big Five personality traits to assess aspects of conscientiousness, agreeableness, extraversion, neuroticism, and openness on a 5-point Likert scale from 1 (“strongly agree”) to 5 (“strongly disagree”) [174]. Each factor had 4 items, but conscientiousness was enriched to have 8 items in the measure, as it is most commonly associated with health. The IPIP is a widely used and effective measure of the Big Five [233] and the mini-IPIP offers a shorter, reliable version that has been validated and measured with health and wellbeing across various samples [174, 234-236]. Health: The 6-item Short-Form (SF-6) measure of general health was used to assess the general health of participants with 6 items on a 5-point Likert scale [220]. The SF-6 measure of general health is widely used and has shown to be valid and reliable in various socioeconomic, ethnic, and disease contexts, including low SES and ethnic minority groups [237-240]. Wellbeing: To measure the wellbeing of participants, life satisfaction, positive affect, and negative affect were included. Life Satisfaction was assessed using 5 items on a 5-point Likert 63  scale from 1 (“strongly disagree”) to 7 (“strongly agree”) [219]. Positive and Negative Affect were assessed by participants indicating how frequently they experience various emotions on a 5-point Likert scale from 1 (“very slightly or not at all”) to 5 (“extremely”) with 10 items for each, for a total of 20 items [241]. Indigenous Spiritual Health: Additional questions created by our Indigenous Elders asked about engagement in Indigenous cultures and employed the Medicine Wheel teachings, which includes spiritual, mental, emotional, and physical health, and how these four components are inter-connected to create the overall, holistic health and wellness of an individual. Questions asked whether participants thought that their traditional spirituality plays a role in their life and in their healthcare, whether they felt connected to their culture, and whether they used traditional practices, as well as which practices they used, for each of the four Medicine Wheel components. 3.1.2 Recruitment and Participation We sought to recruit 150 Indigenous and 150 non-Indigenous participants to complete the questionnaires from various clinics/centres in Vancouver’s Downtown Eastside. Though there are many factors that contribute to low SES, income is consistently associated as a marker of SES. Thus, low SES participants were considered to be anyone with income ≤ $15,000 per year, as per previous HIV studies in Vancouver [32, 33]. Recruitment posters were displayed at the Vancouver Native Health Society, Oak Tree Clinic, and various other clinic/centres in Vancouver’s DTES. Participants reviewed a letter of introduction/consent (Appendix A.2) and provided verbal consent to participation. Questionnaires were completed in person with a researcher (myself or one of the PIRAs) guiding the participant, and took approximately 15-30 minutes to complete. Remuneration was $20 for 64  participating. To identify duplicates, birth month/year and initials were requested from participants. These identifiers were deleted after we assessed for duplicate questionnaires. 3.1.2.1 Inclusion/Exclusion Criteria Inclusion Criteria – Indigenous Participants:  1. Self-identifies as Indigenous (Aboriginal, Metis, Inuit, First Nations, or other term that describes a person whose ancestors were among the First Peoples of Canada).  2. Age 19 and above. 3. Able to understand and communicate in English. Inclusion Criteria – Non-Indigenous Participants:  1. Self-identifies as non-Indigenous (not Aboriginal, Metis, Inuit, First Nations, or other term that describes a person whose ancestors were among the First Peoples of Canada).  2. Age 19 and above. 3. Able to understand and communicate in English. Exclusion Criteria – All Participants: 1. Under 19 years of age. 2. Unable to understand and communicate in English.   65  3.1.2.2 Participant Demographics We recruited 153 Indigenous participants and 151 non-Indigenous participants. A total of 4 duplicate participants in the Indigenous group were identified based off of identical birth month/year and initials, and their second attempt was removed, giving a total of 149 Indigenous participants (N=300). We compared age, gender, sex, ethnicity, educational attainment, and income of Indigenous and Non-Indigenous groups, and again for lower income and higher income participants. A t-test was used to assess the difference in age between groups. For categorical variables (ethnicity, sex, education, and income), we ran a Chi-Square test to compare distributions between groups. Of 300 participants, one Indigenous participant self-identified as non-binary gender, so sex was used to stratify groups instead of gender. Age (p=0.52) and sex (p=0.09) were similar between Indigenous and non-Indigenous groups (Table 1). In both groups, a majority of participants reported having low income and educational attainment, with 68.9% (191/277) having an annual income ≤ $15,000 and 37% (111/300) completing less than high school, speaking to the low SES of this community (Table 1). There were significantly more Indigenous participants with lower income (p=0.01) and educational attainment (p=0.01) than non-Indigenous participants (Table 1).         66  Table 2. Participant demographics for questionnaires.  Characteristics	 Indigenous	(n=149)	Non-Indigenous	(n=151)	p-value	Ethnicity,	n	(%)	 Indigenous	 149	(100)	 0	 		 White	 0	 117	(77.5)	 		 Black	 0	 12	(7.9)	 		 Asian	 0	 11	(7.3)	 		 Other	 0	 11	(7.3)	 			Mean	Age	±	SD	(years)	 48.0	±	11.0	 48.8	±	11.5	 0.52			Sex					 			Male	 77	 96	 0.10		 			Female	 71	 55	 	Education,	n	(%)	 <	High	School	 72	(48.3)	 39	(25.8)	 0.01		 High	School	Grad	 31	(20.8)	 41	(27.2)	 		 College/Trade	 32	(21.5)	 37	(24.5)	 		 University	 14	(9.4)	 34	(22.5)	 	Income/year,					n	(%)	 ≤	$15,000	 113	(81.9)	 78	(56.2)	 0.01		 >	$15,000	 25	(18.1)	 61	(43.8)	 	  3.1.3 Analytical Plan For the comparison of the higher and lower income groups, participants were grouped as individuals with a household income of ≤ $15,000 per year or > $15,000 per year. For each measure, participants missing more than one item were removed from analyses involving that measure. Negatively coded items were reverse scored for each measure. Thus, items measuring neuroticism vs. emotional stability, coded for emotional stability. An alpha-level of .05 was utilized for designating significant findings, which were bolded throughout the tables. 67  3.1.3.1 Questionnaire Validation - Factor and Reliability Analyses Factor analyses and reliability analyses were conducted to understand the factor structure and validity of the scales of interest: Oregon Brief Purpose Measure and the Big 5 Personality scale (Mini-IPIP) in each participant group. This analysis determined if these previously validated measures showed single-factor structures and reliability in Indigenous and low SES communities in Vancouver, BC, and to create a set of items that can be used in future research with these groups. Measures of health, life satisfaction, positive affect, and negative affect were also assessed for validity and reliability to determine consistency with other study samples.  For the factor analyses, items were determined to load well onto one single-factor if they had scores > 0.5, but were sufficient if > 0.4. If scored lower than 0.4, that item was removed and the factor analysis was repeated without it. Eigenvalues and percent explained variances were determined to support factor-loading scores to determine a single-factor solution. For the reliability analyses, inter-item correlations, kurtosis, skewness, and Cronbach’s alpha scores were determined. Inter-item correlations provided insight into which items were more or less associated with the others, with a correlation alpha > 0.3 showing satisfactory association. Kurtosis determines if a distribution is too peaked, and skewness determines if too skewed or symmetrical; when a distribution is normal, kurtosis and skewness are 0, but if the values are above +1 or below -1, the data is more peaked (kurtotic) or skewed (positively and negatively) [242]. Measures with Cronbach’s alpha reliability coefficients of 0.6 or higher were considered reliable with internal consistency among the items, however scores 0.5 or higher were acceptable. Measures were adjusted to remove items according to validation and reliability 68  results to create scales that are effective in all participant groups; adjusted measures were included in the health association analysis described below. 3.1.3.2 Health and Wellbeing Associations Analysis Responses were averaged across items to create participants’ composite scores for each factor. Mean composite scores for each factor were compared using an independent samples t-test between Indigenous and non-Indigenous groups, and again between low- and high-income groups to determine equality of means. Pearson correlation analyses were conducted to determine associations of purpose and personal dispositions with measures of health and wellbeing for each group via correlation coefficients (r). Multiple linear regression analyses were conducted to assess whether these associations between personal disposition and health measures held while controlling for demographic factors including sex, age, income, ethnicity, and educational attainment (income only with regressions for Indigenous vs non-Indigenous groups, and ethnicity only with regressions for the income groups). Beta (𝛽) refers to the standardized correlation coefficient in the regression model, whereas B refers to the unstandardized correlation coefficient. The t-statistic is the coefficient divided by the standard error, with the larger the value meaning the greater the effect. Regression analyses determined if correlations with health and wellbeing are similar in our study groups as with previously studied populations. 3.1.3.3 Spiritual Health Correlation Analysis We sought to describe how Indigenous participants felt their spirituality impacts their health, the type of traditional health practices they use, and whether any practices were associated with measures of personal disposition, health, and wellbeing using a comparison of means. 69  3.2 Questionnaire Results 3.2.1 Questionnaire Validation Results  Measures of each factor were found to be (or were adjusted to be) reliable and valid for each participant group in the factor and reliability analyses as described below.  3.2.1.1 Factor Analysis Results Across all groups, items loaded well onto one factor for measures of purpose, extraversion, health, life satisfaction, positive affect, and negative affect, with all factor loadings > 0.5, except for scores of 0.4 for one item for health in the non-Indigenous and the above $15,000/y group, and one item for extraversion in the Non-Indigenous group (Tables 3-5, 12, & 15-18). Factor loadings were inconsistent with a single-factor solution across items and adjustment of the items included was required for conscientiousness (Tables 6 & 7), agreeableness (Tables 8 & 9), emotional stability (Tables 10 & 11), and openness (Tables 12 & 13). After adjustment, factor loadings reached 0.5 for all items in conscientiousness, agreeableness, and emotional stability (opposite neuroticism), however loadings were 0.4 in both of the income groups (Tables 3 & 4).            70  Table 3. Summary of factor analysis for single-factor solutions with each factor in Indigenous and Non-Indigenous participant groups. Participant	Group	Factor	Loading	Range	Eigenvalue	Percent	Explained	Variance	(%)	Indigenous	 		 		 					Sense	of	Purpose	 0.78	-	0.88	 2.86	 71.40				Conscientiousness	 0.08	-	0.68	 2.01	 25.11				Conscientiousness	Adjusted	 0.50	-	0.77	 1.71	 42.76				Agreeableness	 0.53	-	0.76	 1.70	 42.36				Agreeableness	Adjusted	 0.47	-	0.87	 1.58	 52.60				Emotional	Stability	 -0.04	-	0.83	 1.53	 38.28				Emotional	Stability	Adjusted	 0.62	-	0.83	 1.57	 52.42				Extraversion	 0.57	-	0.70	 1.78	 44.60				Openness	 -0.11	-	0.82	 1.29	 32.18				Openness	Adjusted	 0.53	-	0.81	 1.28	 42.70				Life	Satisfaction	 0.53	-	0.91	 3.02	 60.42				Health	 0.51	-	0.78	 2.63	 43.76				Positive	Affect	 0.54	-	0.80	 5.10	 51.10				Negative	Affect	 0.57	-	0.79	 4.70	 47.02	Non-Indigenous	 		 		 					Sense	of	Purpose	 0.87	-	0.91	 3.22	 80.43				Conscientiousness	 0.40	-	0.76	 2.40	 30.01				Conscientiousness	Adjusted	 0.49	-	0.79	 1.87	 46.77				Agreeableness	 0.47	-	0.79	 1.73	 43.36				Agreeableness	Adjusted	 0.65	-	0.81	 1.62	 54.00				Emotional	Stability	 0.57	-	0.70	 1.64	 40.93				Emotional	Stability	Adjusted	 0.65	-	0.76	 1.50	 49.90				Extraversion	 0.43	-	0.76	 1.63	 40.75				Openness	 0.46	-	0.76	 1.50	 37.60				Openness	Adjusted	 0.52	-	0.79	 1.49	 49.57				Life	Satisfaction	 0.74	-	0.83	 3.16	 63.26				Health	 0.41	-	0.85	 2.68	 44.71				Positive	Affect	 0.62	-	0.78	 4.90	 48.60				Negative	Affect	 0.55	-	0.78	 4.80	 48.43	Note:	emotional	stability	is	the	opposite	of	neuroticism.       71  Table 4. Summary of factor analysis for single-factor solutions with each factor in equal or below and above $15,000/y participant groups. Participant	Group	Factor	Loading	Range	Eigenvalue	 Percent	Explained	Variance	(%)	≤	$15,000/y	 		 		 					Sense	of	Purpose	 0.83	-	0.89	 2.98	 74.50				Conscientiousness	 0.08	-	0.64	 2.06	 25.79				Conscientiousness	Adjusted	 0.48	-	0.72	 1.68	 41.92				Agreeableness	 0.50	-	0.77	 1.70	 42.61				Agreeableness	Adjusted	 0.59	-	0.84	 1.54	 51.38				Emotional	Stability	 0.30	-	0.73	 1.47	 36.80				Emotional	Stability	Adjusted	 0.66	-	0.75	 1.47	 49.11				Extraversion	 0.52	-	0.68	 1.58	 39.40				Openness	 0.39	-	0.66	 1.28	 31.94				Openness	Adjusted	 0.54	-	0.79	 1.28	 42.80				Life	Satisfaction	 0.61	-	0.86	 2.97	 59.35				Health	 0.51	-	0.77	 2.56	 42.74				Positive	Affect	 0.55	-	0.80	 4.80	 48.30				Negative	Affect	 0.59	-	0.77	 4.60	 45.90	>	$15,000/y	 		 		 					Sense	of	Purpose	 0.84	-	0.94	 3.33	 66.61				Conscientiousness	 0.13	-	0.85	 2.47	 30.82				Conscientiousness	Adjusted	 0.45	-	0.90	 2.13	 53.31				Agreeableness	 0.28	-	0.82	 1.77	 44.31				Agreeableness	Adjusted	 0.57	-	0.85	 1.74	 57.89				Emotional	Stability	 0.42	-	0.73	 1.68	 41.94				Emotional	Stability	Adjusted	 0.55	-	0.82	 1.64	 54.80				Extraversion	 0.57	-	0.82	 1.98	 49.39				Openness	 -0.16	-	0.84	 1.55	 38.73				Openness	Adjusted	 0.42	-	0.83	 1.54	 51.34				Life	Satisfaction	 0.75	-	0.88	 3.23	 80.65				Health	 0.35	-	0.89	 2.76	 45.94				Positive	Affect	 0.66	-	0.84	 5.40	 53.60				Negative	Affect	 0.48	-	0.84	 5.20	 51.90	Note:	emotional	stability	is	the	opposite	of	neuroticism.       72  Table 5. Sense of purpose single-factor loadings in each participant group. Sense	of	Purpose	 Indigenous	 Non-Indigenous	 ≤	$15,000/y	 <	$15,000/y	There	is	a	direction	in	my	life	 0.78	 0.87	 0.83	 0.84	My	plans	for	the	future	match	with	my	true	interests	and	values	 0.85	 0.89	 0.85	 0.91	I	know	which	direction	I	am	going	to	follow	in	my	life	 0.87	 0.92	 0.88	 0.94	My	life	is	guided	by	a	set	of	clear	commitments	 0.88	 0.91	 0.89	 0.90	  Table 6. Conscientiousness 8-item single-factor loadings in each participant group. Conscientiousness	 Indigenous	 Non-Indigenous	 ≤	$15,000/y	 >	$15,000/y	I	get	chores	done	right	away	(rev)	 0.49	 0.40	 0.47	 0.31	I	work	hard	(rev)	 0.53	 0.70	 0.55	 0.80	I	like	order	(rev)	 0.56	 0.57	 0.62	 0.46	I	set	high	standards	for	myself	and	others	(rev)	 0.57	 0.76	 0.56	 0.85	I	make	a	mess	of	things	 0.68	 0.51	 0.64	 0.62	I	often	forget	to	put	things	back	in	their	proper	place	 0.38	 0.46	 0.50	 0.13	I	do	just	enough	work	to	get	by	 0.08	 0.42	 0.08	 0.38	I	am	not	highly	motivated	to	succeed	 0.50	 0.45	 0.42	 0.50	Note:	rev	=	item	was	reverse	scored.	  Table 7. Conscientiousness 4-item single-factor loadings in each participant group. Conscientiousness	(4-item)	 Indigenous	 Non-Indigenous	 ≤	$15,000/y	 >	$15,000/y	I	work	hard	(rev)	 0.74	 0.76	 0.70	 0.85	I	like	order	(rev)	 0.56	 0.66	 0.67	 0.45	I	set	high	standards	for	myself	and	others	(rev)	 0.77	 0.79	 0.72	 0.90	I	make	a	mess	of	things	 0.50	 0.49	 0.48	 0.64	Note:	rev	=	item	was	reverse	scored.	      73  Table 8. Agreeableness 4-item single-factor loadings for each participant group. Agreeableness	 Indigenous	 Non-Indigenous	 ≤	$15,000/y	 >	$15,000/y	I	sympathize	with	other's	feelings	(rev)	 0.72	 0.66	 0.72	 0.59	I	feel	others'	emotions	(rev)	 0.58	 0.47	 0.59	 0.28	I	am	not	really	interested	in	others	 0.76	 0.79	 0.77	 0.82	I	am	not	interested	in	other	people's	problems	 0.53	 0.68	 0.50	 0.82	Note:	rev	=	item	was	reverse	scored.	  Table 9. Agreeableness 3-item single-factor loadings for each participant group. Agreeableness	(3-item)	 Indigenous	 Non-Indigenous	 ≤	$15,000/y	 >	$15,000/y	I	sympathize	with	other's	feelings	(rev)	 0.47	 0.65	 0.59	 0.57	I	am	not	really	interested	in	others	 0.87	 0.81	 0.84	 0.85	I	am	not	interested	in	other	people's	problems	 0.78	 0.74	 0.70	 0.84	Note:	rev	=	item	was	reverse	scored.	  Table 10. Emotional stability 4-item single factor loadings for each participant group. Emotional	Stability	 Indigenous	 Non-Indigenous	 ≤	$15,000/y	 >	$15,000/y	I	am	relaxed	most	of	the	time	(rev)	 0.59	 0.64	 0.66	 0.64	I	seldom	feel	blue	(rev)	 -0.04	 0.57	 0.30	 0.42	I	have	frequent	mood	swings	 0.70	 0.70	 0.65	 0.74	I	get	upset	easily	 0.83	 0.65	 0.73	 0.73	Note:	rev	=	item	was	reverse	scored.	Emotional	stability	is	the	opposite	of	neuroticism.	  Table 11. Emotional Stability 3-item single factor loadings for each participant group. Emotional	Stability	(3-item)	 Indigenous	 Non-Indigenous	 ≤	$15,000/y	 >	$15,000/y	I	am	relaxed	most	of	the	time	(rev)	 0.62	 0.65	 0.66	 0.55	I	have	frequent	mood	swings	 0.71	 0.76	 0.69	 0.82	I	get	upset	easily	 0.83	 0.71	 0.75	 0.82	Note:	rev	=	item	was	reverse	scored.	Emotional	stability	is	the	opposite	of	neuroticism.	     74  Table 12. Extraversion 4-item single factor loadings for each participant group. Extraversion	 Indigenous	 Non-Indigenous	 ≤	$15,000/y	 >	$15,000/y	I	am	the	life	of	the	party	(rev)	 0.57	 0.59	 0.52	 0.63	I	talk	to	a	lot	of	different	people	at	parties	(rev)	 0.70	 0.43	 0.62	 0.57	I	don't	talk	a	lot	 0.70	 0.72	 0.68	 0.82	I	keep	in	the	background	 0.69	 0.76	 0.68	 0.77	Note:	rev	=	item	was	reverse	scored.	  Table 13. Openness 4-item single factor loadings for each participant group. Openness		 Indigenous	 Non-Indigenous	 ≤	$15,000/y	 >	$15,000/y	I	have	a	vivid	imagination	(rev)	 -0.11	 0.46	 0.39	 -0.16	I	am	not	interested	in	abstract	ideas	 0.62	 0.76	 0.56	 0.82	I	have	difficulty	understanding	abstract	ideas	 0.82	 0.64	 0.66	 0.84	I	do	not	have	a	good	imagination	 0.47	 0.55	 0.61	 0.40	Note: rev = item was reverse scored.   Table 14. Openness 3-item single factor loadings for each participant group. Openness	(3-item)	 Indigenous	 Non-Indigenous	 ≤	$15,000/y	 >	$15,000/y	I	am	not	interested	in	abstract	ideas	 0.59	 0.77	 0.62	 0.82	I	have	difficulty	understanding	abstract	ideas	 0.81	 0.79	 0.79	 0.83	I	do	not	have	a	good	imagination	 0.53	 0.52	 0.54	 0.42	           75  Table 15. Health single factor loadings for each participant group. Health	 Indigenous	 Non-Indigenous	 ≤	$15,000/y	 >	$15,000/y	In	general,	would	you	say	your	health	is	excellent,	very	good,	good,	fair,	or	poor?	 0.77	 0.78	 0.76	 0.78	Compared	to	one	year	ago,	how	would	you	rate	your	health	in	general	now?	 0.67	 0.41	 0.61	 0.35	I	seem	to	get	sick	a	litter	easier	than	other	people	 0.51	 0.52	 0.51	 0.57	I	expect	my	health	to	get	worse	 0.52	 0.62	 0.61	 0.49	I	am	as	healthy	as	anybody	I	know	 0.67	 0.74	 0.63	 0.82	My	health	is	excellent	 0.78	 0.85	 0.77	 0.89	  Table 16. Life satisfaction single factor loadings for each participant group. Life	Satisfaction	 Indigenous	 Non-Indigenous	 ≤	$15,000/y	 >	$15,000/y	In	most	ways	my	life	is	close	to	my	ideal	 0.82	 0.74	 0.78	 0.78	The	conditions	of	my	life	are	excellent	 0.80	 0.82	 0.79	 0.85	I	am	satisfied	with	my	life	 0.91	 0.83	 0.86	 0.88	So	far	I	have	gotten	the	important	things	I	want	in	life	 0.79	 0.83	 0.79	 0.82	If	I	could	live	my	life	over	I	would	change	almost	nothing	 0.53	 0.76	 0.61	 0.75	  Table 17. Positive affect single factor loadings for each participant group. Positive	Affect	 Indigenous	 Non-Indigenous	 ≤	$15,000/y	 >	$15,000/y	Interested	 0.71	 0.74	 0.70	 0.77	Excited	 0.71	 0.58	 0.64	 0.66	Strong	 0.75	 0.68	 0.71	 0.76	Enthusiastic	 0.80	 0.70	 0.75	 0.76	Attentive	 0.66	 0.62	 0.64	 0.66	Active	 0.62	 0.72	 0.66	 0.67	Proud	 0.54	 0.65	 0.55	 0.71	Alert	 0.74	 0.67	 0.70	 0.71	Inspired	 0.78	 0.79	 0.76	 0.84	Determined	 0.80	 0.78	 0.80	 0.77	    76  Table 18. Negative affect single factor loadings for each participant group. Negative	Affect	 Indigenous	 Non-Indigenous	 ≤	$15,000/y	 >	$15,000/y	Scared	 0.57	 0.72	 0.62	 0.69	Irritable	 0.57	 0.57	 0.59	 0.48	Ashamed	 0.77	 0.75	 0.75	 0.80	Nervous	 0.74	 0.78	 0.74	 0.78	Distressed	 0.75	 0.77	 0.74	 0.83	Upset	 0.79	 0.76	 0.77	 0.84	Guilty	 0.68	 0.70	 0.63	 0.80	Hostile	 0.68	 0.55	 0.64	 0.57	Jittery	 0.60	 0.60	 0.60	 0.62	Afraid	 0.68	 0.73	 0.68	 0.71	  3.2.1.2 Reliability Results Reliability results were strong for measures of purpose, health, life satisfaction, positive affect, and negative affect, all with alpha reliabilities > 0.7 and inter-item correlations > 0.3 in each participant group (Tables 19 & 20). Extraversion was also strong, with alpha reliabilities    ≥ 0.5 in all participant groups. Alpha reliabilities and inter-item correlations were not strong with original measures, but were improved and satisfactory with the adjusted measures of conscientiousness, agreeableness, and emotional stability (opposite of neuroticism), with reliability scores ≥ 0.5 and inter-item correlations approximately 0.3 (Tables 19 & 20). Openness did not have strong reliability in its original form or when adjusted, with adjusted alpha scores of 0.31, 0.48, 0.32, and 0.49, and inter-item correlation means of 0.13, 0.24, 0.14, and 0.25 for Indigenous, non-Indigenous, ≤ $15,000/y and > $15,000/y groups respectively (Tables 19 & 20).        77  Table 19. Reliability analysis results for each factor by Indigenous or Non-Indigenous.  	Group	 Composite	Mean	±	SD	 Skewness	 Kurtosis	Alpha	Reliability	Inter-Item	Correlate	Mean	Indigenous	 		 		 		 		 					Sense	of	Purpose	 3.74	±	1.02	 -0.60	 -0.42	 0.87	 0.62				Conscientiousness	 3.48	±	0.64	 -0.15	 -0.12	 0.53	 0.13				Conscientiousness	Adjusted	 3.72	±	0.83	 -0.43	 -0.17	 0.53	 0.23				Agreeableness	 3.63	±	0.85	 -0.05	 -0.72	 0.53	 0.22				Agreeableness	Adjusted	 3.60	±	0.95	 -0.21	 -0.82	 0.52	 0.27				Emotional	Stability	 3.08	±	0.79	 -0.11	 0.05	 0.37	 0.13				Emotional	Stability	Adjusted	 3.15	±	0.95	 -0.10	 -0.41	 0.54	 0.28				Extraversion	 3.13	±	0.92	 -0.09	 -0.21	 0.58	 0.26				Openness	 3.42	±	0.72	 0.34	 -0.33	 0.22	 0.07				Openness	Adjusted		 3.36	±	0.84	 -0.02	 -0.13	 0.31	 0.13				Life	Satisfaction	 4.34	±	1.49	 -0.29	 -0.69	 0.82	 0.49				Health	 3.28	±	0.83	 -0.26	 -0.53	 0.73	 0.32				Positive	Affect	 3.55	±	0.81	 -0.17	 -0.47	 0.89	 0.45				Negative	Affect	 2.14	±	0.80	 0.95	 0.79	 0.87	 0.41	Non-Indigenous	 		 		 		 		 					Sense	of	Purpose	 3.53	±	1.13	 -0.46	 -0.66	 0.92	 0.74				Conscientiousness	 3.54	±	0.69	 -0.16	 -0.36	 0.65	 0.19				Conscientiousness	Adjusted	 3.69	±	0.85	 -0.52	 0.10	 0.61	 0.28				Agreeableness	 3.74	±	0.78	 -0.26	 -0.15	 0.55	 0.24				Agreeableness	Adjusted	 3.78	±	0.87	 -0.35	 -0.24	 0.57	 0.31				Emotional	Stability	 3.18	±	0.79	 0.17	 -0.43	 0.52	 0.21				Emotional	Stability	Adjusted	 3.23	±	0.87	 0.08	 -0.43	 0.50	 0.25				Extraversion	 3.04	±	0.77	 -0.13	 -0.04	 0.50	 0.20				Openness	 3.57	±	0.73	 -0.24	 0.42	 0.43	 0.16				Openness	Adjusted		 3.54	±	0.82	 -0.21	 0.00	 0.48	 0.24				Life	Satisfaction	 4.03	±	1.49	 -0.04	 -0.94	 0.85	 0.54				Health	 3.31	±	0.78	 -0.36	 -0.01	 0.74	 0.32				Positive	Affect	 3.39	±	0.76	 -0.09	 -0.43	 0.88	 0.43				Negative	Affect	 1.99	±	0.74	 0.85	 0.35	 0.88	 0.42	Note:	Inter-Item	Correlate	Mean	is	the	mean	score	of	the	correlations	for	all	of	the	items	within	each	factor.	Emotional	stability	is	the	opposite	of	neuroticism.	    78  Table 20. Reliability analysis results for each factor by equal or below and above $15,000/y.  Group	 Composite	Mean	±	SD	 Skewness	 Kurtosis	Alpha	Reliability	Inter-Item	Correlate	Mean	≤	$15,000/y	 		 		 		 		 					Sense	of	Purpose	 3.54	±	1.12	 -0.40	 -0.77	 0.89	 0.66				Conscientiousness	 3.41	±	0.67	 -0.04	 -0.22	 0.55	 0.14				Conscientiousness	Adjusted	 3.61	±	0.85	 -0.37	 -0.11	 0.53	 0.22				Agreeableness	 3.59	±	0.84	 -0.13	 -0.45	 0.53	 0.23				Agreeableness	Adjusted	 3.56	±	0.84	 -0.27	 -0.53	 0.51	 0.26				Emotional	Stability	 3.11	±	0.80	 0.03	 -0.03	 0.40	 0.14				Emotional	Stability	Adjusted	 3.14	±	0.92	 -0.03	 -0.24	 0.48	 0.24				Extraversion	 3.02	±	0.84	 0.12	 0.25	 0.48	 0.19				Openness	 3.42	±	0.74	 0.16	 0.11	 0.28	 0.09				Openness	Adjusted		 3.36	±	0.82	 0.02	 0.01	 0.32	 0.14				Life	Satisfaction	 3.99	±	1.51	 -0.01	 -0.85	 0.82	 0.49				Health	 3.19	±	0.80	 -0.30	 -0.31	 0.72	 0.31				Positive	Affect	 3.44	±	0.81	 0.03	 -0.55	 0.88	 0.42				Negative	Affect	 2.11	±	0.78	 0.77	 0.39	 0.87	 0.40	<	$15,000/y	 		 		 		 		 					Sense	of	Purpose	 3.86	±	1.04	 -1.04	 0.60	 0.92	 0.74				Conscientiousness	 3.72	±	0.64	 -0.28	 0.01	 0.62	 0.17				Conscientiousness	Adjusted	 3.90	±	0.84	 -0.73	 0.29	 0.68	 0.35				Agreeableness	 3.84	±	0.75	 0.02	 -0.93	 0.54	 0.23				Agreeableness	Adjusted	 3.88	±	0.87	 -0.18	 -1.09	 0.62	 0.36				Emotional	Stability	 3.17	±	0.80	 -0.07	 -0.51	 0.53	 0.22				Emotional	Stability	Adjusted	 3.29	±	0.91	 -0.05	 -0.70	 0.58	 0.31				Extraversion	 3.14	±	0.90	 -0.40	 -0.50	 0.65	 0.32				Openness	 3.67	±	0.67	 0.05	 -0.86	 0.34	 0.11				Openness	Adjusted		 3.63	±	0.83	 -0.37	 -0.16	 0.49	 0.25				Life	Satisfaction	 4.62	±	1.44	 -0.45	 -0.77	 0.87	 0.58				Health	 3.54	±	0.76	 -0.25	 -0.68	 0.74	 0.32				Positive	Affect	 3.53	±	0.81	 -0.44	 -0.27	 0.90	 0.48				Negative	Affect	 1.95	±	0.76	 1.28	 1.81	 0.89	 0.45	Note:	Inter-Item	Correlate	Mean	is	the	mean	score	of	the	correlations	for	all	of	the	items	within	each	factor.	Emotional	stability	is	the	opposite	of	neuroticism.	    79  3.2.1.3 Adjustment of Measures  According to the factor and reliability analyses, adjusted measures of conscientiousness, agreeableness, emotional stability (opposite of neuroticism), and openness were created. For adjusted measures of conscientiousness (Table 7), agreeableness (Table 9), and emotional stability (Table 11), items loaded well onto a single factor (loadings >0.5), and both percent explained variance and reliability results improved to satisfactory levels (Tables 3, 4, 19 & 20). For openness, the item “I have a vivid imagination” had a factor loading score <0.5 for all groups, with a negative score for the Indigenous and lower income groups. Removal of this item allowed for a single-factor solution with loadings >0.5, except for with “I do not have a good imagination” in the higher income group (Table 14); however, reliability analysis results showed that the openness measure is not reliable in these groups (Tables 19 & 20). Altogether, adjusted scales for conscientiousness, agreeableness, emotional stability, and openness without the outlier items as described above were used in all further analyses. The original measure for purpose was satisfactory in factor and reliability analyses, and the additional 4-items were not required. In addition, extraversion, health, and wellbeing were also satisfactory in factor and reliability analyses. 3.2.2 Associations with Health and Wellbeing There were no significant differences in mean scores across all factors between Indigenous and non-Indigenous participants (Table 21), whereas participants in the above $15,000/y group had a significantly higher mean for purpose, life satisfaction, health, conscientiousness, agreeableness, and openness than the ≤ $15,000/y group (Table 22).  80  Sense of purpose was significantly associated with all health and wellbeing factors in all participant groups (Table 23). Correlations with health were similar between Indigenous and non-Indigenous groups: health was significantly correlated with purpose (0.28 and 0.34, p<0.001), conscientiousness (0.19, p=0.02, and 0.18, p=0.03), emotional stability (0.39, p<0.001, and 0.33, p<0.001), but not with agreeableness in the Indigenous group (-0.08, p=0.35, and 0.17, p=0.04) nor with extraversion in the non-Indigenous group (0.24, p=0.003, and 0.13, p=0.13) (Table 23). Life satisfaction was significantly positively correlated with purpose (0.55 and 0.58, p<0.001) and emotional stability (0.31, p<0.001, and 0.29, p<0.001) in both groups, with conscientiousness only in the non-Indigenous group (0.13, p=0.12, and 0.18, p<0.001), and with agreeableness in neither group (-0.04, p=0.60 and 0.09, p=0.28). Positive affect was significantly positively correlated with purpose, emotional stability, and extraversion in all groups, and with conscientiousness in all groups except for the above $15,000/y group (Table 23). Negative affect was significantly negatively correlated with purpose and emotional stability in all groups, but only with conscientiousness in the Indigenous and ≤ $15,000/y groups (Table 23).  As can be seen in Table 23, the magnitudes of the associations were markedly similar for all group comparisons by Indigenous status or by income level. The only instances in which the magnitudes even differed by as much as 0.2 were with respect to agreeableness when associated with self-rated health for both Indigenous status and income level, and with openness when associated with negative affect for income level.       81    Table 21. Comparison of means for factors between Indigenous and Non-Indigenous participant groups.    Indigenous	(n=149)	Non-Indigenous	(n=151)	 	  Mean	±	SD	 Mean	±	SD		 p-value		Sense	of	Purpose	 3.74 ±	1.02	 3.53	±	1.13	 0.09	Life	Satisfaction	 4.34	±	1.49	 4.03	±	1.49	 0.07	Health	 3.28	±	0.83	 3.31	±	0.78	 0.76	Positive	Affect	 3.55	±	0.81	 3.39	±	0.76	 0.09	Negative	Affect	 2.13	±	0.80	 1.99	±	0.74	 0.11	Conscientiousness	 3.72	±	0.83	 3.69	±	0.85	 0.74	Agreeableness	 3.63	±	0.85	 3.82	±	0.79	 0.60	Extraversion	 3.13	±	0.92	 3.04	±	0.77	 0.37	Emotional	Stability	 3.15	±	0.95	 3.23	±	0.87	 0.43	Openness	 3.36	±	0.84	 3.54	±	0.82	 0.07	Note:	emotional	stability	is	the	opposite	of	neuroticism.   Table 22. Comparison of means for factors between equal or below and above $15,000/y participant groups.   ≤	$15,000/y	(n=191)	<	$15,000/y	(n=86)	 	  Mean	±	SD	 Mean	±	SD		 p-value		Sense	of	Purpose	 3.54	±	1.12	 3.86	±	1.04	 0.02	Life	Satisfaction	 3.99	±	1.51	 4.62	±	1.44	 0.001	Health	 3.19	±	0.80	 3.54	±	0.76	 0.001	Positive	Affect	 3.44	±	0.81	 3.53	±	0.81	 0.46	Negative	Affect	 2.11	±	0.78	 1.95	±	0.76	 0.11	Conscientiousness	 3.61	±	0.85	 3.90	±	0.84	 0.01	Agreeableness	 3.67	±	0.93	 3.97	±	0.71	 0.01	Extraversion	 3.02	±	0.84	 3.14	±	0.90	 0.28	Emotional	Stability	 3.14	±	0.92	 3.29	±	0.91	 0.22	Openness	 3.36	±	0.82	 3.63	±	0.83	 0.01	Note:	emotional	stability	is	the	opposite	of	neuroticism.      82   Table 23. Correlations of dispositional characteristics with measures of health and wellbeing among each participant group. Factors					Indigenous	 						Non-Indigenous	 			≤	$15,000/y	 	<	$15,000/y					(n=149)	 								(n=151)	 					(n=191)	 				(n=86)			 		r	 p-value	 						r	 p-value	 				r	 p-value	 					r	 p-value	Correlation	with	health	 		 		 		 		 		 		 						Sense	of	purpose	 0.28	 <	0.001	 0.34	 <	0.001	 0.29	 <	0.001	 0.33	 0.002					Conscientiousness	 0.19	 0.02	 0.18	 0.03	 0.17	 0.02	 0.20	 0.07					Agreeableness	 -0.08	 0.35	 0.17	 0.04	 -0.04	 0.59	 0.18	 0.11					Extraversion	 0.24	 0.003	 0.13	 0.13	 0.22	 0.002	 0.08	 0.45					Emotional	Stability	 0.39	 <	0.001	 0.33	 <	0.001	 0.36	 <	0.001	 0.41	 <	0.001					Openness	 -0.03	 0.72	 0.06	 0.49	 -0.10	 0.17	 0.08	 0.46	Correlation	with	life	satisfaction	 		 		 		 		 		 						Sense	of	purpose	 0.55	 <	0.001	 0.58	 <	0.001	 0.53	 <	0.001	 0.67	 <	0.001					Conscientiousness	 0.13	 0.12	 0.18	 0.03	 0.11	 0.13	 0.22	 0.04					Agreeableness	 -0.04	 0.60	 0.09	 0.28	 -0.07	 0.31	 0.12	 0.26					Extraversion	 0.24	 0.003	 0.14	 0.09	 0.20	 0.01	 0.17	 0.11					Emotional	Stability	 0.31	 <	0.001	 0.29	 <	0.001	 0.32	 <	0.001	 0.20	 0.07					Openness	 -0.01	 0.94	 0.15	 0.07	 -0.03	 0.67	 0.15	 0.16	Correlation	with	positive	affect	 		 		 		 		 		 						Sense	of	purpose	 0.48	 <	0.001	 0.56	 <	0.001	 0.50	 <	0.001	 0.60	 <	0.001					Conscientiousness	 0.28	 <	0.001	 0.27	 0.001	 0.31	 <	0.001	 0.15	 0.17					Agreeableness	 0.10	 0.25	 0.20	 0.02	 0.12	 0.09	 0.18	 0.10					Extraversion	 0.38	 <	0.001	 0.28	 0.001	 0.35	 <	0.001	 0.33	 0.002					Emotional	Stability	 0.25	 0.003	 0.33	 <	0.001	 0.31	 <	0.001	 0.23	 0.03					Openness	 0.12	 0.14	 0.21	 0.01	 0.11	 0.12	 0.15	 0.19	Correlation	with	negative	affect	 		 		 		 		 		 						Sense	of	purpose	 -0.21	 0.01	 -0.28	 0.001	 -0.23	 0.002	 -0.22	 0.05					Conscientiousness	 -0.23	 0.01	 -0.15	 0.06	 -0.20	 0.01	 -0.16	 0.16					Agreeableness	 0.04	 0.60	 -0.07	 0.40	 0.06	 0.44	 -0.11	 0.31					Extraversion	 -0.15	 0.08	 -0.14	 0.08	 -0.17	 0.02	 -0.02	 0.83					Emotional	Stability	 -0.42	 <	0.001	 -0.49	 <	0.001	 -0.38	 <	0.001	 -0.59	 <	0.001					Openness	 0.001	 0.99	 -0.18	 0.03	 0.05	 0.50	 -0.31	 0.004	Note:	emotional	stability	is	the	opposite	of	neuroticism.     83  3.2.2.1 Regression Associations with Health and Wellbeing After controlling for demographic factors (age, income, sex, education attainment), sense of purpose remained significantly independently associated with health, life satisfaction, positive affect, and negative affect (all p<0.01) in regression models for all participant groups (Table 24). When also controlling for conscientiousness and agreeableness, sense of purpose remains significantly associated with the health factors for all groups (Table 25). With respect to conscientiousness, though some predictors were significant in one group but not the other, the magnitudes of the effect sizes again were similar between Indigenous vs. non-Indigenous groups and ≤ $15,000/y vs. > $15,000/y groups (Table 26). Agreeableness remained positively associated to positive affect in the non-Indigenous group (Table 27). Emotional stability remained positively associated to positive affect, life satisfaction, and health, and negatively associated with negative affect when controlling for demographic factors for all groups, except with life satisfaction in the > $15,000/y group (Table 28). Thus, in reverse, neuroticism is negatively associated with positive affect, life satisfaction, and health, and positively associated with negative affect. Extraversion remained associated to positive affect in all groups and health and life satisfaction in the Indigenous and ≤ $15,000/y groups when controlling for demographic factors (Table 29). Openness remained associated with negative affect in the > $15,000/y group (Table 30)         84    Table 24. Linear regression models for purpose with each health factor, controlling for demographics in each participant group. Purpose	Unstandardized	Coefficients	Standardized	Coefficients	 			 B	 SE	 β	 t	 p-value	Indigenous	(n=149)	 	 	 	 	 	Life	Satisfaction	 0.77	 0.11	 0.53	 7.33	 <	0.001	Health	 0.22	 0.07	 0.27	 3.27	 0.001	Positive	Affect	 0.38	 0.06	 0.47	 6.23	 <	0.001	Negative	Affect	 -0.14	 0.07	 -0.18	 -2.09	 0.04	Non-Indigenous	(n=151)		Life	Satisfaction	 0.73	 0.09	 0.55	 8.10	 <	0.001	Health	 0.23	 0.05	 0.34	 4.18	 <	0.001	Positive	Affect	 0.38	 0.05	 0.57	 7.92	 <	0.001	Negative	Affect	 -0.20	 0.05	 -0.32	 -3.77	 <	0.001	>	$15,000/y	(n=86)		 	 	 	 	Life	Satisfaction	 0.93	 0.11	 0.67	 8.19	 <	0.001	Health	 0.22	 0.08	 0.31	 2.95	 0.004	Positive	Affect	 0.47	 0.07	 0.60	 6.66	 <	0.001	Negative	Affect	 -0.17	 0.08	 -0.23	 -2.07	 0.04	≤	$15,000/y	(n=191)	 		 		 		 			Life	Satisfaction	 0.70	 0.08	 0.52	 8.34	 <	0.001	Health	 0.21	 0.05	 0.29	 4.08	 <	0.001	Positive	Affect	 0.35	 0.05	 0.48	 7.74	 <	0.001	Negative	Affect	 -0.15	 0.05	 -0.22	 -3.06	 0.003	        85   Table 25. Linear regressions for purpose with health factors, controlling for demographics, conscientiousness, and agreeableness in each participant group. 	Purpose	 Unstandardized	Coefficients		Standardized	Coefficients	 		 				 B	 SE	 β	 t	 p-value	Indigenous	(n=149)		 	 	 	 	Life	Satisfaction	 0.75	 0.11	 0.51	 7.06	 <	0.001Health	 0.19	 0.07	 0.23	 2.82	 0.01	Positive	Affect	 0.35	 0.06	 0.44	 5.93	 <	0.001	Negative	Affect	 -0.11	 0.07	 -0.14	 -1.63	 0.11	Non-Indigenous	(n=151)	 		 		 	 	 	Life	Satisfaction	 0.79	 0.09	 0.60	 8.39	 <	0.001	Health	 0.22	 0.06	 0.33	 3.81	 <	0.001	Positive	Affect	 0.35	 0.05	 0.52	 6.92	 <	0.001	Negative	Affect	 -0.19	 0.06	 -0.31	 -3.41	 0.001	>	$15,000/y	(n=86)		 		 	 	Life	Satisfaction	 0.97	 0.13	 0.70	 7.62	 <	0.001	Health	 0.18	 0.09	 0.25	 2.13	 0.04	Positive	Affect	 0.50	 0.08	 0.63	 6.22	 <	0.001	Negative	Affect	 -0.15	 0.09	 -0.20	 -1.61	 0.11	≤	$15,000/y	(n=191)	 		 		 	 	 	Life	Satisfaction	 0.68	 0.09	 0.51	 8.01	 <	0.001	Health	 0.19	 0.05	 0.26	 3.59	 <	0.001	Positive	Affect	 0.33	 0.04	 0.46	 7.58	 <	0.001	Negative	Affect	 -0.13	 0.05	 -0.18	 -2.54	 0.01	        86   Table 26. Linear regressions for conscientiousness with health factors, controlling for demographics in each participant group. Conscientiousness	Unstandardized	Coefficients		Standardized	Coefficients	 		 				 B	 SE	 β	 t	 p-value	Indigenous	(n=149)		 	 	 	 	Life	Satisfaction	 0.20	 0.15	 0.11	 1.30	 0.20	Health	 0.21	 0.09	 0.21	 2.48	 0.01	Positive	Affect	 -0.20	 0.08	 -0.21	 -2.47	 0.02	Negative	Affect	 -0.20	 0.08	 -0.21	 -2.47	 0.02	Non-Indigenous	(n=151)	 		 		 		 		 		Life	Satisfaction	 0.27	 0.15	 0.15	 1.86	 0.07	Health	 0.14	 0.08	 0.16	 1.82	 0.07	Positive	Affect	 0.22	 0.08	 0.25	 2.92	 0.004	Negative	Affect	 -0.16	 0.07	 -0.18	 -2.09	 0.04	>	$15,000/y	(n=86)		 	 	 	 	Life	Satisfaction	 0.42	 0.19	 0.25	 2.28	 0.03	Health	 0.20	 0.10	 0.22	 2.01	 0.05	Positive	Affect	 0.17	 0.11	 0.17	 1.55	 0.13	Negative	Affect	 -0.15	 0.10	 -0.16	 -1.45	 0.15	≤	$15,000/y	(n=191)	 		 		 		 		 		Life	Satisfaction	 0.17	 0.13	 0.10	 1.33	 0.19	Health	 0.16	 0.07	 0.17	 2.33	 0.02	Positive	Affect	 0.28	 0.07	 0.29	 4.33	 <0.001	Negative	Affect	 -0.19	 0.07	 -0.20	 -2.82	 0.01	              87    Table 27. Linear regressions for agreeableness with health factors, controlling for demographics in each participant group. Agreeableness	 Unstandardized	Coefficients		Standardized	Coefficients	 		 				 B	 SE	 β	 t	 p-value	Indigenous	(n=149)	 		 		 		 		 		Life	Satisfaction	 -0.16	 0.14	 -0.10	 -1.16	 0.25	Health	 -0.10	 0.08	 -0.11	 -1.26	 0.21	Positive	Affect	 0.06	 0.08	 0.07	 0.73	 0.47	Negative	Affect	 0.08	 0.07	 0.10	 1.11	 0.27	Non-Indigenous	(n=151)	 		 		 		 		Life	Satisfaction	 0.08	 0.14	 0.05	 0.57	 0.57	Health	 0.14	 0.08	 0.16	 1.86	 0.07	Positive	Affect	 0.17	 0.08	 0.19	 2.20	 0.03	Negative	Affect	 -0.06	 0.07	 -0.07	 -0.78	 0.44	>	$15,000/y	(n=86)	 		 		 		 		 		Life	Satisfaction	 0.23	 0.19	 0.14	 1.21	 0.23	Health	 0.19	 0.10	 0.22	 2.00	 0.05	Positive	Affect	 0.18	 0.11	 0.19	 1.71	 0.09	Negative	Affect	 -0.08	 0.10	 -0.09	 -0.80	 0.43	≤	$15,000/y	(n=191)	 		 		 		 		Life	Satisfaction	 -0.09	 0.14	 -0.05	 -0.65	 0.52	Health	 -0.11	 0.08	 -0.11	 -1.50	 0.14	Positive	Affect	 0.10	 0.07	 0.10	 1.41	 0.16	Negative	Affect	 0.07	 0.07	 0.07	 0.92	 0.36	             88    Table 28. Linear regressions for emotional stability with health factors, controlling for demographics in each participant group. Emotional	Stability	 Unstandardized	Coefficients		Standardized	Coefficients	 				 B	 SE	 β	 t	 p-value	Indigenous	(n=149)		 	 	 			Life	Satisfaction	 0.42	 0.13	 0.26	 3.17	 0.002			Health	 0.34	 0.07	 0.39	 4.82	 <0.001			Positive	Affect	 0.19	 0.07	 0.22	 2.60	 0.01			Negative	Affect	 -0.35	 0.07	 -0.41	 -5.24	 <0.001	Non-Indigenous	(n=151)				Life	Satisfaction	 0.47	 0.14	 0.27	 3.36	 0.001			Health	 0.35	 0.07	 0.39	 4.93	 <0.001			Positive	Affect	 0.30	 0.07	 0.34	 4.05	 <0.001			Negative	Affect	 -0.42	 0.07	 -0.50	 -6.37	 <0.001	>	$15,000/y	(n=86)		 	 	 			Life	Satisfaction	 0.33	 0.18	 0.20	 1.85	 0.07			Health	 0.40	 0.08	 0.47	 4.83	 <0.001			Positive	Affect	 0.21	 0.10	 0.24	 2.11	 0.04			Negative	Affect	 -0.50	 0.08	 -0.60	 -6.54	 <0.001	≤	$15,000/y	(n=191)	 		 		 		 				Life	Satisfaction	 0.50	 0.12	 0.30	 4.27	 <0.001			Health	 0.33	 0.06	 0.37	 5.27	 <0.001			Positive	Affect	 0.25	 0.06	 0.29	 4.08	 <0.001			Negative	Affect	 -0.32	 0.06	 -0.38	 -5.39	 <0.001	Note:	emotional	stability	is	the	opposite	of	neuroticism.            89   Table 29. Linear regressions for extraversion with health factors, controlling for demographics in each participant group. Extraversion	 Unstandardized	Coefficients	Standardized	Coefficients	 	 				 B	 SE	 β	 t	 p-value	Indigenous	(n=149)		 	 	 			Life	Satisfaction	 0.35	 0.14	 0.21	 2.48	 0.01			Health	 0.20	 0.08	 0.22	 2.56	 0.01			Positive	Affect	 0.34	 0.07	 0.38	 4.76	 <0.001			Negative	Affect	 -0.15	 0.07	 -0.17	 -1.94	 0.05	Non-Indigenous	(n=151)	 		 		 		 				Life	Satisfaction	 0.25	 0.16	 0.13	 1.57	 0.12			Health	 0.12	 0.08	 0.12	 1.39	 0.17			Positive	Affect	 0.26	 0.08	 0.27	 3.17	 0.002			Negative	Affect	 -0.09	 0.08	 -0.10	 -1.14	 0.26	>	$15,000/y	(n=86)		 	 	 			Life	Satisfaction	 0.33	 0.13	 0.18	 2.53	 0.01			Health	 0.20	 0.07	 0.21	 2.91	 0.004			Positive	Affect	 0.31	 0.07	 0.32	 4.72	 <0.001			Negative	Affect	 -0.16	 0.07	 -0.17	 -2.36	 0.02	≤	$15,000/y	(n=191)	 		 		 		 				Life	Satisfaction	 0.32	 0.18	 0.20	 1.79	 0.08			Health	 0.09	 0.10	 0.10	 0.90	 0.37			Positive	Affect	 0.32	 0.10	 0.35	 3.21	 0.002			Negative	Affect	 -0.01	 0.10	 -0.01	 -0.10	 0.92	              90  Table 30. Linear regressions for openness with health factors, controlling for demographics in each participant group. Openness	 Unstandardized	Coefficients		Standardized	Coefficients	 		 				 B	 SE	 β	 t	 p-value	Indigenous	(n=149)	 		 		 		 		 		Life	Satisfaction	 -0.02	 0.16	 -0.01	 -0.15	 0.88	Health	 -0.05	 0.09	 -0.05	 -0.60	 0.55	Positive	Affect	 0.14	 0.09	 0.14	 1.63	 0.11	Negative	Affect	 0.07	 0.08	 0.07	 0.80	 0.43	Non-Indigenous	(n=151)	 		 		 		 		Life	Satisfaction	 0.11	 0.16	 0.06	 0.67	 0.51	Health	 -0.01	 0.09	 -0.01	 -0.11	 0.92	Positive	Affect	 0.13	 0.09	 0.13	 1.45	 0.15	Negative	Affect	 -0.18	 0.08	 -0.20	 -2.15	 0.03	>	$15,000/y	(n=86)	 		 		 		 		 		Life	Satisfaction	 0.36	 0.20	 0.21	 1.78	 0.08	Health	 0.15	 0.11	 0.17	 1.46	 0.15	Positive	Affect	 0.18	 0.12	 0.18	 1.52	 0.13	Negative	Affect	 -0.29	 0.10	 -0.32	 -2.78	 0.01	≤	$15,000/y	(n=191)	 		 		 		 		 		Life	Satisfaction	 -0.09	 0.14	 -0.05	 -0.65	 0.52	Health	 -0.11	 0.08	 -0.11	 -1.50	 0.14	Positive	Affect	 0.10	 0.07	 0.10	 1.41	 0.16	Negative	Affect	 0.07	 0.07	 0.07	 0.92	 0.36	  3.2.3 Spiritual Health Results  3.2.3.1 Description of Spiritual Health Responses Of Indigenous participants, 70% said that traditional spirituality plays a role in their life and 46% said that traditional spirituality influences their healthcare. In regards to whether traditional practices have always been in their life, 38% said yes, that they have always been in their life, 18% said no, but they have reconnected, 35% said no but they are reconnecting, and 9% said no and they have not reconnected. Of Indigenous participants, approximately, 50-60% 91  partook in drumming, singing or dancing for physical health purposes (Figure 3); 50-60% accessed each of the listed services for mental health purposes (Figure 5); and 60-70% used the 4 traditional medicines (sage, sweet grass, cedar, and tobacco), salmon, berries, and bannock (Figure 6). The most common spiritual health tradition practiced was smudging (Figure 4).   Figure 3. Percent of Indigenous participants who had participated in drumming, singing, dancing, or other activities for physical health purposes.  0	20	40	60	80	100	Drumming	 Singing	 Dancing	 Other	 None	Percent	of	Pargcipants	(%)	92   Figure 4. Percent of Indigenous participants who had participated in any of the listed traditions for spiritual health purposes.    Figure 5. Percent of Indigenous participants who had accessed Elders, healing circles, traditional healers, or counseling for mental health purposes. 0	20	40	60	80	100	Percent	of	Pargcipants	(%)	0	10	20	30	40	50	60	70	80	90	100	Elders	 Healing	Circles	Tradi`onal	Healers	Counselling	 Other	 None	Percent	of	Pargcipants	(%)	93    Figure 6. Percent of Indigenous participants who had accessed certain traditional medicines and foods for wellness purposes.    3.2.3.2 Associations of Spiritual Health with Disposition and Health Measures We assessed whether spiritual health was associated with measures of personal disposition, health, and wellbeing, and found several correlations. Sense of purpose was significantly higher for participants who said that their spirituality plays a role in their life, compared to those who did not (p=0.03) (Table 31), and again with participants who said that they felt connected to their culture, compared to those who did not (p=0.01) (Table 32), but there was no significant difference in mean scores of purpose between participants who said they thought their spirituality played a role in their health or not (p=0.39) (Tables 33). In addition to purpose, participants who reported connection to culture also scored significantly higher with life satisfaction (p=0.01) and positive affect (p<0.001) than those who were not connected to their 0	20	40	60	80	100	Percent	of	Pargcipants	(%)	94  culture (Table 32). Participants who reported accessing teachings from Elders had significantly higher positive affect (p=0.04) (Table 34). Conscientiousness, agreeableness, emotional stability (opposite of neuroticism), extraversion, health, and negative affect were not associated with spiritual health responses. Table 31. Comparison of means for factors for Indigenous participants by whether traditional spirituality plays a role in their life or not. 	 Plays	role	in	life	Does	not	play	role	in	life		 		 (n=103)	 (n=45)	 			 Mean	±	SD	 Mean	±	SD	 p-value	Purpose	 3.85	±	1.05	 3.47	±	0.92	 0.03	Life	Satisfaction	 4.35	±	1.52	 4.32	±	1.44	 0.91	Health	 3.25	±	0.83	 3.37	±	0.83	 0.43	Positive	Affect	 3.63	±	0.76	 3.37	±	0.90	 0.08	Negative	Affect	 2.11	±	0.83	 2.18	±	0.75	 0.64	Conscientiousness	 3.49	±	0.61	 3.46	±	0.71	 0.78	Agreeableness		 3.71	±	0.95	 3.36	±	0.93	 0.04	Emotional	Stability	 3.12	±	0.95	 3.21	±	0.97	 0.63	Extraversion	 3.14	±	0.96	 3.11	±	0.86	 0.86	Openness	 3.42	±	0.84	 3.25	±	0.84	 0.27	Note:	emotional	stability	is	the	opposite	of	neuroticism. Table 32. Difference of means for factors of disposition and health between Indigenous participants who stated whether they felt connected to traditional practices or not. 	 Connected	 Not	connected	 		 (n=134)	 (n=13)	 			 Mean	±	SD	 Mean	±	SD	 p-value	Purpose	 3.82	±	1.00	 3.04	±	0.71	 0.01	Life	Satisfaction	 4.46	±	1.47	 3.37	±	1.07	 0.01	Health	 3.31	±	0.82	 2.96	±	0.88	 0.15	Positive	Affect	 3.63	±	0.80	 2.79	±	0.48	 <0.001	Negative	Affect	 2.13	±	0.82	 2.18	±	0.62	 0.82	Conscientiousness	 3.74	±	0.84	 3.57	±	0.74	 0.49	Agreeableness		 3.62	±	0.95	 3.54	±	1.02	 0.80	Emotional	Stability	 3.15	±	0.96	 3.14	±	0.96	 0.98	Extraversion	 3.16	±	0.94	 2.83	±	0.84	 0.22	Openness	 3.38	±	0.86	 3.17	±	0.69	 0.39	Note:	emotional	stability	is	the	opposite	of	neuroticism. 95    Table 33. Comparison of factor means stratified by whether traditional spirituality plays a role in their healthcare. 	 Does	influence	healthcare	Does	not	influence	healthcare	 		 (n=68)	 (n=80)	 			 Mean	±	SD	 Mean	±	SD	 p-value	Purpose	 3.82	±	1.11	 3.67	±	0.94	 0.39	Life	Satisfaction	 4.19	±	1.63	 4.47	±	1.36	 0.26	Health	 3.23	±	0.91	 3.33	±	0.75	 0.44	Positive	Affect	 3.70	±	0.84	 3.42	±	0.77	 0.04	Negative	Affect	 2.14	±	0.82	 2.13	±	0.79	 0.90	Conscientiousness	 3.53	±	0.64	 3.45	±	0.65	 0.43	Agreeableness		 3.68	±	0.98	 3.54	±	0.93	 0.37	Emotional	Stability	 3.02	±	0.97	 3.26	±	0.93	 0.13	Extraversion	 3.19	±	0.92	 3.08	±	0.94	 0.45	Openness	 3.36	±	0.94	 3.37	±	0.75	 0.93	Note:	emotional	stability	is	the	opposite	of	neuroticism.   Table 34. Comparison of factor stratified by whether participant receives teachings from Elders for mental health purposes. 	 Teachings	from	Elders	No	Teachings	from	Elders	 		 (n=94)	 (n=54)	 			 Mean	±	SD	 Mean	±	SD	 p-value	Purpose	 3.85	±	1.00	 3.54	±	1.03	 0.07	Life	Satisfaction	 4.36	±	1.55	 4.30	±	1.41	 0.82	Health	 3.24	±	0.87	 3.35	±	0.76	 0.42	Positive	Affect	 3.66	±	0.85	 3.35	±	0.72	 0.03	Negative	Affect	 2.16	±	0.83	 2.10	±	0.75	 0.66	Conscientiousness	 3.78	±	0.83	 3.63	±	0.83	 0.27	Agreeableness		 3.65	±	1.00	 3.53	±	0.87	 0.46	Emotional	Stability	 3.04	±	0.93	 3.34	±	0.98	 0.08	Extraversion	 3.21	±	0.93	 3.00	±	0.92	 0.20	Openness	 3.44	±	0.90	 3.24	±	0.71	 0.17	Note:	emotional	stability	is	the	opposite	of	neuroticism.  96  3.3 Discussion on Questionnaire Validation and Health Correlations Indigenous and low SES communities experience disproportionately worse health outcomes than the general population in Canada [25, 64, 106], however little is known about the relationship between personal disposition and health and wellbeing in these groups [184]. This study was one of the first to examine the reliability and validity of measures of personal disposition, health, and wellbeing, as well as the associations between these measures, among and compared between Indigenous and low SES communities in Vancouver, Canada. We found that measures of health, wellbeing, purpose, conscientiousness, agreeableness, neuroticism, and extraversion are reliable and valid in our groups, however adjustment to the measures of conscientiousness, agreeableness and neuroticism were required; openness reliability could not be improved. Similar to other populations [166, 167, 179, 193, 198], purpose, conscientiousness and neuroticism were correlated with health and wellbeing across all groups, whereas correlations with the remaining Big Five personal dispositions varied. Finally, purpose, life satisfaction, and positive affect were significantly higher with certain aspects of spiritual health in Indigenous participants. The implications of these findings are discussed below. 3.3.1 Sense of Purpose Validation and Health Correlations As found in previous populations [166, 167, 198], individuals in our study groups who had a greater sense of purpose were more likely to have improved health and wellbeing, even when controlling for sociodemographic factors. Furthermore, correlations with health and wellbeing were similar in magnitude among our groups and to previous research [167, 168, 199]. In fact, our results suggest strong reliability, validity, and correlation with health and wellbeing for sense of purpose in all of our groups. Therefore, an individual’s sense of purpose is likely to 97  be a strong predictor of health and wellbeing for members of our communities, including Indigenous and low SES populations.  Accordingly, opportunities to improve the sense of purpose of individuals may lead to healthier outcomes in our groups, which is particularly important for Indigenous and low SES communities who face disproportionately worse health than the general community [25, 64, 106]. As previous research shows that sense of purpose includes having goals for one’s self [160, 165, 168, 169], programs to encourage goal setting may work to empower individuals to have autonomy in their healthcare. For low SES participants, it is possible that goal setting and improved sense of purpose could work to improve social determinants such as employment, income, and quality of life, thus potentially functioning to reduce inequity between SES groups. In addition, indirect associations have been found between having a natural mentor, purpose, and coping strategies [243]. As such, programs that support mentorship may benefit an individual’s sense of purpose. In Indigenous communities, Elders are natural mentors who are the knowledge keepers of the community and create immense support for their mentees [80, 84, 100, 123]. Thus, improving connections with Elders may be a way to strengthen sense of purpose among Indigenous persons. Furthermore, improving purpose among Indigenous communities may go beyond health enhancements to addressing healing from intergenerational trauma. Though purpose is focused on goal setting and having a sense of meaning in life, the self-determination and empowering aspects might be similar to that of resiliency; furthermore, resiliency is also important for health, autonomy, and wellbeing [244-248]. Indigenous communities embody and strengthen resilience as they heal from intergenerational trauma and regain their culture and traditions, which works to improve their overall wellness, and thus 98  reduce the inequity of disease rates compared to the general population [71, 85, 117, 120, 247]. However, individuals are at different stages of healing, and opportunity to support resilience and healing of communities would be beneficial. If purpose does act similarly to resilience, improving sense of purpose may work to enhance the healing and overall wellness of Indigenous communities. Thus, future research is needed to determine similarities between purpose and resilience, and whether improving purpose can support healing of Indigenous communities. 3.3.2 Personal Disposition Validity and Reliability  Factor and reliability analyses for extraversion were satisfactory across all groups; in contrast, adjustment of the measures of conscientiousness, agreeableness, neuroticism, and openness were required to improve factor loading scores, alpha reliabilities, and inter-item correlations to satisfactory levels. However, openness did not improve in reliability when adjusted. The lower reliabilities of the original measures are likely due to our small sample size, rather than the measures having different meanings in our groups compared to previous studies. This is suggested, as (1) low reliabilities were similar and consistent across all of our groups; (2) Indigenous and non-Indigenous groups did not significantly differ in composite scores for all of the factors, and the magnitudes of the correlations were similar between these groups; and (3) despite there being a low cut off for income, there was still a significant difference in all factors between our >$15,000 and ≤ $15,000 per year groups; which was expected, as income has previously been positively associated with conscientiousness, purpose, and the overall health and wellbeing of an individual, likely due to the ability to access more services, healthier food, etc. [64, 184]. 99  Our findings with openness are not surprising, as of the Big Five personality traits, openness is often the most difficult to capture, as it describes a broad range of components: being open to new experiences, curiosity, favoring aesthetics and novelty, and adopting more liberal values [162, 249]. In fact, research has found that the vivid imagination and fantasy components of openness were positively associated with low agreeableness, impulsivity, and being anti-social, whereas the components involving being more liberal and open to new ideas were positively linked with being more agreeable and calm [249]. Thus, facets of openness could operate in opposite ways, which could explain why openness had the lowest reliability in our groups. As previously mentioned, we worked with the community to ensure that the items were appropriate, and participants were allowed to ask for clarification on any questions that were not clear. Very few individuals utilized this resource, suggesting that they understood what the items were concerning. However, one of the items that participants sometimes asked clarification for was “I have a vivid imagination” in the openness scale, as the word vivid was unclear. This item had the weakest factor loading score across all groups and was removed from the scale. Participants may have difficulty with words they haven’t heard before or those that are atypical. This again reflects the difficulty to capture openness, as it includes unfamiliar wording in an attempt to assess the aesthetic, imaginative, and liberal components. As such, education level and word familiarity need to be considered to avoid words like “vivid” that may not be commonly used. Altogether, our findings suggest that our groups are similar, and that sample size may be the reason for the weak reliabilities on the original measures in addition to the difficulty of measuring openness. Furthermore, short scales often do not provide strong reliabilities, but our 100  intent was to deliver short, useable measures for researchers and care providers. Thus, it would be important to study larger sample sizes, ensure that the language of the measures is familiar to the study group, and include longer measures with more items, such as the full IPIP, in order to better assess the reliability of measures of the Big Five personal dispositions in these groups [233]. This would allow for further clarification of whether measures of the Big Five should be adjusted for Indigenous and lower income groups as we have found in our sample.  3.3.3 Conscientiousness and Agreeableness with Health and Wellbeing As in previous research [175, 177, 179, 183, 193] conscientiousness was positively correlated with measures of health and wellbeing in all groups, whereas agreeableness was only positively correlated with health and positive affect in the non-Indigenous group. In addition, correlations of conscientiousness and agreeableness with health and wellbeing were similar in magnitude between Indigenous and non-Indigenous groups, and to the literature that has previously studied these factors with health and wellbeing [175, 177, 183, 193]. Though the correlations for conscientiousness with life satisfaction varied across groups, life satisfaction is seldom strongly correlated with conscientiousness or agreeableness [193, 250]. Furthermore, because agreeableness has been positively linked with a strong relationship between patients and healthcare providers, we had speculated that agreeableness might have been relevant to health in Indigenous participants, as sense of community and social ties are highly valued among Indigenous communities [120, 126, 127, 189, 190]. Though we did not see these outcomes, our findings are in par with the literature, as agreeableness is more likely to be not correlated at all, or indirectly correlated to health outcomes [173, 177, 193]. Overall, we see no difference in the mean factor scores or correlations with health and wellbeing between Indigenous and non-101  Indigenous groups, and conscientiousness may be a factor worth considering when understanding and improving the health of our communities. In regards to our analysis of the participants split by income, there were more significant correlations with health in the ≤ than the > $15,000/y group (15/24 vs. 9/24 respectively). In fact, previous research has suggested that personality characteristics may be more predictive of health outcomes for individuals lower on SES relative to higher SES participants [184], and similarly for participants with lower rather than higher levels of education [203, 204]. Indeed, we found that conscientiousness was positively associated with health and positive affect, and negatively associated with negative affect in the lower income group, but not in the higher income group. However, correlations were similar in magnitude between groups, so further research is needed to better assess these relationships stratified by SES. Nonetheless, these associations suggest opportunity to enhance the health and wellbeing of low SES groups by improving their levels of conscientiousness. This would then work to reduce the inequity between low and high SES groups, as improving the health of an individual will enhance other aspects of their life such as employment, education, income, and quality of life [63, 64]. As individuals can change in their levels of personal dispositions over time, there is opportunity to make changes that will in turn positively influence their health [163, 164, 251, 252]. For instance, research suggests that individuals may change dispositional traits in response to contexts that compel them to new behavioural tendencies [251]. Personality traits can change sustainably over periods of a year with targeted programs such as cognitive behaviour therapy, even when those programs are actually focused on other outcomes such as health and mental wellbeing [173]. For instance, being part of a regular intervention protocol may encourage one to 102  become more organized and reliable, thus promoting conscientiousness [173, 253]. Such programs to improve conscientiousness involve the participant learning how their behaviours and actions are linked with outcomes, and then creating goals to provide motives to change conscientiousness states and influential moderators [251]. These changes would lead to more desirable behaviours that would foster higher levels of conscientiousness and thus could work to promote health and wellbeing in our communities [252, 254]. 3.3.4 Extraversion, Neuroticism, and Openness with Health and Wellbeing As expected from previous research [184, 193-195, 255], openness was not associated with measures of health and wellbeing, however extraversion and neuroticism were associated with some measures in each group. Extraversion was associated with positive affect in all groups, but only with health and life satisfaction in the Indigenous and lower income groups; this parallels the literature, as extraversion is inconsistently linked with health measures [194, 195, 255, 256]. These associations in the Indigenous group could be due to Indigenous communities valuing reciprocity and social-connectedness in supporting wellbeing, which could be related to extraversion [123, 126]. Conversely, neuroticism was consistently negatively associated with health and wellbeing measures in all groups, except with life satisfaction in the higher income group. Neuroticism is often negatively linked with health and wellbeing, including markers of inflammation, mental health issues, and longevity [172, 184, 194]. Interestingly, one study found that those high in neuroticism had more inflammation if they had low SES than if they had high SES [184]. Our overall sample had relatively low SES, which could explain why we saw neuroticism correlated with health and wellbeing to a similar extent across groups. However, further research is needed with a broader range of SES groups and with various health measures 103  to better assess the impact of SES on the relationship between neuroticism and health. Nonetheless, it is possible that neuroticism is higher with lower than higher SES, as low SES individuals face more stigma and discrimination that lead to vulnerability, low self-esteem, and self-consciousness, all components of neuroticism. This may result in poor coping strategies, anxiety, depression, and hostility, thus leading to a greater effect on health [257, 258]. Altogether, our findings suggest that extraversion and neuroticism are factors worth considering when studying the health and wellbeing of our study groups. This may result in poor coping strategies, anxiety, depression, and hostility, thus leading to a greater effect on health [257, 258]. Altogether, our findings suggest that extraversion and neuroticism are factors worth considering when studying the health and wellbeing of our study groups. 3.3.5 Suggestions to Further Assess Personal Disposition with Health To broaden our understanding of the correlations between personal disposition and health in Indigenous and low SES communities, it would be beneficial to utilize different measures of health and wellbeing. For instance, including health reports from friends and family would help to avoid self-report biases [259, 260]. Furthermore, it would be useful to assess the relationships between personality and health behaviours, the frequency and type of health diagnoses, medication adherence, longevity, and relation to stress and inflammation in our groups. This would be particularly beneficial with purpose and conscientiousness, due to their associations with these health behaviours and outcomes in previous studies [167, 175, 182-184, 186, 192, 198-200, 261]. If purpose and conscientiousness are linked to these various health outcomes among our communities, it provides opportunity to create programs that benefit high or low purposeful or conscientious individuals accordingly. 104  3.3.6 Spiritual Health Discussion Our exploratory analysis involving Indigenous spiritual health questions showed spiritual health linked with purpose, life satisfaction, and positive affect. Sense of purpose was significantly higher for participants who said that their spirituality plays a role in their life, and again for those who said that they felt connected to their culture. This could be due to the empowerment associated with connection to culture/spirituality, and thus the improved sense of purpose of an individual [26, 119, 124]. As such, this suggests that opportunities to improve engagement in traditional practices and cultures could lead to improvement of sense of purpose, which in turn would enhance the overall health and wellbeing of individuals [181]. In addition to purpose, participants who reported connection to culture also had significantly higher life satisfaction and positive affect, which are both aspects of wellbeing. Importantly, participants who reported that they accessed teachings from Elders had significantly higher scores of positive affect. These findings are consistent with the literature in suggesting that connection to Indigenous culture and spirituality is important for wellbeing [26, 119, 121, 124]. This also implies that health research should include connection to culture/spirituality in assessments, and health programs should support these connections to thus support overall wellbeing. A majority of Indigenous participants stated that they accessed traditional activities/services for their mental (mind), physical (body), spiritual (spirit), and emotional (heart) health. In particular, accessing Elders, smudging, and using four traditional medicines (sage, sweet grass, tobacco, and cedar) were very common. Thus, programs that utilize these Indigenous ways of knowing and practices may improve participant engagement and cultural safety, as well as the sense of purpose and wellbeing of clients. Indeed, by encouraging 105  Indigenous ways of knowing, such as creating connections with Elders, participating in land-based healing, building a sense of community, and learning the medicine wheel and traditional medicines, programs may be able to help communities in healing [80, 84, 100, 123, 212]. Thus, restoring traditional healing practices and knowledge will lead to the improved wellness of Indigenous individuals and communities [117]. Interestingly, we did not see aspects of spiritual health associated with self-reported health, which was expected, as research suggests that engagement in culture has positive health outcomes for Indigenous persons [100, 117]. However, this could be because our spiritual health questions asked, “do you use” or “have you ever”, but did not include length or frequency of cultural involvement and access of services. In fact, those who engage more frequently in their traditional culture and speak their traditional language at home may have higher scores of resilience and health [117]. Thus, including this information in future studies would provide a better evaluation of spiritual health and its importance to the individual. In addition, it could also allow for a factor analysis to create a measure that contributes to a single-factor solution of spiritual health. This would help for validation purposes and assessment of correlations with health and wellbeing in our sample and in others. However, spiritual health and connection to culture have different meanings depending on the individual or community, so spirituality could be difficult to capture in a single factor. For instance, the Medicine Wheel teachings are not universal to all Indigenous communities, and could explain why we did not find associations with health. Thus, when assessing spiritual health, it is essential that questions are relevant to each individual. Therefore, creating a validated measure could be problematic, and would require flexibility in the questions. For example, the measure could include general validated questions, 106  however it would also require specific cultural questions for each individual/community accordingly to optimally assess spiritual health. Altogether, future research is needed to determine how to best measure spiritual health, as it is evidently an important aspect of Indigenous health and wellbeing and should be included in health research, programs, and systems [26, 119, 121, 124]. 107  Chapter 4: Summary, Limitations, Implications, and Conclusion 4.1 Summary of Findings with Implications Regarding HIV and mHealth Though the mHealth program, WelTel, has proven to be successful at improving adherence to cART and pVL in PLWH, there is a need to develop its cultural safety for Indigenous PLWH and its personalization to best benefit users [148]. As research suggests that understanding personal disposition may help to identify who may be more likely to engage in healthier lifestyles, personal disposition could potentially be used to make the WelTel program more personalized by determining whom it benefits most. However, personal disposition had not been validated in Indigenous and low SES communities in Vancouver, BC, of which individuals make up majority of WelTel participants. Thus, the overall purpose of this project was to collaborate with the Indigenous community of Vancouver to 1) receive input in the design of an mHealth program that improves medication adherence of PLWH, and of examining the impact of personality and purpose on the use of this program; to 2) validate measures of personal disposition and 3) determine correlations of these measures with health and wellbeing in Indigenous and low SES communities of Vancouver, BC. The exploratory objective was to 4) determine if Indigenous spiritual health was associated with measures of personal disposition and health. To address objective 1, we collaborated with Indigenous community members and hosted Sharing Circles to receive input and advice from Indigenous PLWH on the WelTel program and studying personal disposition. As hypothesized, Indigenous PLWH expressed interest and value in an mHealth cART adherence program, as it may be empowering and help to build sense of community, and made recommendations for improvement and increased cultural safety. Sharing 108  Circle participants suggested the importance of social support and saw that the program could provide this through including peers and Elders. In fact, the WelTel program is built on social support, by providing a bidirectional connection between a healthcare provider and participant [148]. Interestingly, social support is not only important for engagement in HIV care, but is advantageous to improving conscientiousness and sense of purpose [181, 243]. Thus, an mHealth program that supports connection to others may benefit cART adherence rates and could work to improve the purpose and conscientiousness of individuals through providing social support, which would further improve health and wellbeing in a cyclic manner. Importantly, Indigenous PLWH supported the studying of personal disposition with WelTel program use to better personalize adherence supports. To address objectives 2-4, the second portion of the project involved conducting questionnaires with 149 Indigenous and 151 non-Indigenous persons, of whom 69% had income ≤ $15,000/y (low SES group), and 31% had income > $15,000/y (high SES group) for our low SES vs. high SES analysis. Our hypothesis for objective 2, that tools used to assess sense of purpose (Oregon Brief Purpose measure) and personality traits (Big 5 Personality Mini-IPIP measure) are valid for use with this community, was supported for purpose, conscientiousness, agreeableness, neuroticism, and extraversion, although adjustment of conscientiousness, agreeableness and neuroticism were required; whereas, openness did not show strong reliability. Our hypothesis for objective 2, that purpose, conscientiousness, neuroticism, and agreeableness would be correlated with health and wellbeing, and openness and extraversion would not be, was supported for purpose, conscientiousness, neuroticism, and openness, but not for agreeableness 109  and extraversion. Correlation findings for each factor and their implications with WelTel are described next.  As in previous studies, the sense of purpose measure was reliable and associated with health and wellbeing across our study groups, including Indigenous and low SES groups [167, 197, 198]. Thus, purpose is a factor that can be measured with WelTel participation to attempt to determine who uses and benefits from the program. Though purpose has not been studied with medication adherence previously, purpose does have a strong association with health and wellbeing, and adherence is likely an important part of maintaining health to reach one’s goals. In addition, it may suggest that improving sense of purpose could benefit HIV medication adherence, thus improving the health of PLWH. Of the Big Five, conscientiousness is most consistently associated with health outcomes and greater longevity due to conscientious individuals being more likely to adhere to treatment programs, physician recommendations, and healthy behaviours [175, 177, 179, 185, 186]. As hypothesized, we also found that conscientiousness is associated with health measures in our groups, thus, it is plausible that conscientiousness may be positively associated with WelTel program use. In fact, conscientiousness has been previously linked with higher CD4 counts and a lower pVL in PLWH with higher conscientiousness [187]. Thus, conscientiousness may be a predictive factor in HIV disease progression, and gaining an understanding of its role in the WelTel program may benefit PLWH. This includes determining whether conscientiousness predicts who is most likely to use the program and if program use improves conscientiousness. If conscientiousness were linked with program use, perhaps opportunities to improve an 110  individual’s conscientiousness would benefit the adherence to cART and thus the overall health of PLWH. Although agreeableness typically has little direct relation with health behaviours and outcomes, agreeable individuals may benefit from a positive relationship with a healthcare provider and may engage better with programs that promote the building of social ties [189, 191]. Though we did not see correlations with agreeableness and health, agreeableness may still be a valuable factor to understand when investigating the likelihood that an individual will use the WelTel program. As WelTel is a bidirectional program, it supports the development of a relationship with a healthcare provider, which more agreeable individuals may benefit from.  Our research with the Big Five was attentive to conscientiousness and agreeableness, as we suspect they may be more involved in treatment adherence and patient engagement, yet neuroticism and extraversion were associated with health factors in our groups. As hypothesized, neuroticism was negatively associated with all health factors, except for life satisfaction in the higher income group. In contrast, we hypothesized that extraversion would not be associated with measure of health and wellbeing, yet it was positively associated with positive affect in all groups, and health and life satisfaction in the Indigenous and lower income groups. However, extraversion is often associated with positive affect in the literature [193, 195]. Indeed, neuroticism has been more often associated with health than extraversion in the literature [171, 184, 262]. Furthermore, the remaining Big Five personality factor, openness, was not associated with health and wellbeing. As such, neuroticism and extraversion are factors worth considering when studying the health and wellbeing of our groups and may be useful in understanding WelTel program use. Our findings could suggest that lower neuroticism and higher extraversion 111  may be related with increased program use, however there is minimal research on these factors with medication adherence, so future research is necessary. The hypothesis for the exploratory objective (4), that Indigenous spiritual health would be positively correlated with measures of health, wellbeing, purpose, and/or other personal dispositions, was partially supported. Results showed that 1) measures of spiritual health, including connection to culture and whether spiritual health plays a role in an individual’s life, were positively associated with sense of purpose, life satisfaction, and positive affect, and 2) participants who reported that they accessed teachings from Elders had significantly higher scores of positive affect; both of which align with previous research and cultural safety suggestions from Sharing Circle participants [120, 123, 126, 127]. However, measures of spiritual health were not associated with self-reported health, which we had not hypothesized, and thus future research is needed to better assess spiritual health and it’s relation to various health outcomes; this would be important for future use in WelTel. Nonetheless, the associations of spiritual health with purpose, life satisfaction, and positive affect suggest that spirituality and engagement in culture are important for overall wellness of our Indigenous participants, and that it should be considered in the WelTel program. This will be particularly important to measure when cultural safety recommendations from Sharing Circle participants are included, as individuals who value spirituality and connection to culture could potentially see more benefit than those who do not. Altogether, measures of personal disposition can be used in a clinical trial to assess who uses and benefits most from the WelTel program, as these tools are now inclusive of and applicable to Indigenous and low SES communities who may be involved in this work. If 112  personal disposition is in fact associated with program use, findings will allow for the program to be made more personal and effective by utilizing the measures of disposition to screen for who may benefit from the program and who may be better suited with a different cART adherence program. Overall, this will provide insight into how to improve the program to enhance the cART adherence of PLWH in a personalized approach. 4.1.1 Recommendations for Future HIV mHealth Research Methods Our findings have important recommendations for what should be included in a future clinical trial to improve cultural safety and assess whether personal disposition is associated with WelTel program use and cART adherence. First, Sharing Circle participants gave suggestions to improve the social support of the program, including having access to Elders and a peer support component, which would also work to improve cultural safety [123]. Methods to further improve Indigenous ways of knowing in the program include hiring PRAs, consulting the community along each step, and following OCAP principles so that ownership of the research is with the community. This would also work to build research capacity and empowerment among the communities involved in the research. In addition, it would be crucial to have an end-of-study Sharing Circle to receive feedback on the program from those who participated and to determine how it can be further improved. Furthermore, all program staff should be trained in cultural safety and have experience working and collaborating with Indigenous communities. This would improve the understanding of intergenerational trauma, which would allow providers to better understand their clients to offer improved medication adherence support. In addition, Sharing Circle participants asked about the privacy related to HIV in the WelTel program, emphasizing the role that HIV stigma has in their 113  lives [48]. Thus, privacy and confidentiality should be kept at high priority and the details of the design of the platform should be clearly explained to participants. Ensuring this safety will allow WelTel to break through the HIV stigma that may otherwise limit PLWH from accessing healthcare services [48]. In regards to the questionnaires, measures of purpose, conscientiousness, agreeableness, neuroticism and spiritual health should be included in assessing the WelTel program, in addition to the measures of health and wellbeing. For the Big Five personality factors, adjusted measures need to be included for conscientiousness, agreeableness, neuroticism, and openness if used; however, extraversion does not appear to need adjustment. Furthermore, spiritual health questions need to ask about the frequency and value of each practice to be able to better assess spiritual health associations. In addition, it would be beneficial to measure personal dispositions before, during, and after program use. This would allow for investigation of whether certain levels of each factor indicate program usage, as well as whether levels of the factors change over time with program use, thus determining if the program has an influence on dispositional factors. 4.2 Strengths and Limitations Strengths of our project include foremost that this work was completed in collaboration with the Indigenous community and persons living with HIV in Vancouver, BC throughout the entire research process. Following OCAP, GIPA, and MIWA principles in an integrated knowledge translation and exchange process, we worked to ensure the cultural safety and appropriateness of the project [209-211]. Indigenous collaborators provided guidance, support, knowledge, and assistance while taking on leading roles. In addition, this was one of the first studies to attempt to validate measures of personal disposition with respect to the health and 114  wellbeing among Indigenous and low SES communities. Though the measures were not created in these communities, using previously validated measures allows for connection to the extant literature and thus has cost saving benefits. Furthermore, we included additional items for purpose and conscientiousness, the measures that are most often associated with health and wellbeing, to allow for creation of reliable 4-item measures that are tailored to our communities. Nonetheless, our findings are not without their limitations that should direct future work. Our sample provides limited generalizability, as participants were recruited only in the Vancouver area, and thus may not be applicable to other cities or countries. Our Indigenous participant group was made up of an urban Indigenous community, which is a mix of diverse Indigenous backgrounds and cultures, and thus findings may not be generalizable to Indigenous communities on reserves or in rural areas. For our Sharing Circles, we only had 18 participants in total, so it would be beneficial for future research to include more voices to recommend amendments for HIV mHealth programs. In addition, it was not a requirement to have previously used the WelTel program, and thus Sharing Circle findings were based off of participants’ thoughts on the program design rather than direct experience using the program. In regards to the questionnaire, it would be beneficial for future studies to utilize different health and wellbeing measures to further assess associations with disposition in this population, such as assessing health behaviours, objective health measures, and utilizing reports from friends and family to avoid self-report biases [259, 260]. However, the latter is also fraught with biases and should be used to supplement the self-report and objective data. In addition, though we did consult with the community and allow participants to ask for clarification, survey questions could be interpreted in different ways than the intended meaning, potentially leading to 115  differences in answers for individuals. Furthermore, Indigenous cultural questions did not detail quantity or frequency. Querying how often certain cultural traditions are practiced may provide a deeper understanding of an individual’s cultural involvement, thus allowing for better assessment of spiritual health with measures of personal disposition, health, and wellbeing. Moreover, based off of previous research, our cut-off for the lower income group was ≤ $15,000/y, which was quite low, and thus several, if not most individuals in the > $15,000/y group received a very low income for a Canadian setting [32, 33]. As the openness scale was not very reliable, and conscientiousness, agreeableness, and neuroticism required adjustment to improve reliability, future research would benefit from having a larger sample size (300-1000 in each group) to further assess the reliabilities of the Big Five measures and their associations with health, as this would improve the power and reliability of findings [263]. 4.3 Implications for Personalized Medicine Beyond opportunity for personalization of the WelTel program, the reliability of measures of personal disposition and their correlations with health and wellbeing suggest possibility to utilize a personalized medicine approach to healthcare in Indigenous and low SES communities. Personalized medicine often includes genomic testing of an individual to find a medication that is best fit for their biological make-up; however, personalized medicine also commonly includes personal disposition, which works to address the social and environmental aspects of an individual [264, 265]. Including disposition is vital, as it is evident that the health of an individual goes beyond their biology to their behaviour and environment. As such, though genomic testing may improve drug efficacy, including personal disposition can assist with determining how to best support a client in a more holistic approach [264]. For instance, 116  individuals with low conscientiousness who are more likely to have poor medication adherence could be identified and provided with additional adherence supports [265]. This more holistic way of health would be particularly beneficial for Indigenous clients, as addressing mental, emotional, and spiritual health, in addition to physical aspects, better incorporates Indigenous ways of knowing [117, 123, 124]. Furthermore, personal disposition has been found to not only influence health behaviours, but also the genetic expression in an individual [256, 266, 267]. For instance, higher levels of conscientiousness have been correlated with reduced expression of pro-inflammatory genes, implying that these individuals have less inflammation and improved health [256, 267]. Thus, simply capturing genetic information is not sufficient, and measuring personal disposition is crucial to understanding the overall health of an individual to better personalize medicine. In addition, the biology of an individual does not always explain or predict health outcomes and longevity, and personal disposition can assist to fill that gap. Measuring the psychosocial aspects of an individual may allow for forecasting of their future health outcomes, disease onset, wellbeing, and longevity [194, 255, 268-270]. This could inform opportunity to personalize health supports accordingly, as well as determine potential to intervene and improve levels of personal disposition, such as purpose and conscientiousness [252, 265]. For instance, learning strategies like self-control and goal setting may be useful in supporting long-term health benefits [251, 265]. Altogether, personalized medicine could be particularly useful for populations whom experience higher rates of chronic illness, such as PLWH, low SES, and Indigenous communities, through supporting their medical treatment or working to prevent the illness in the first place.  117  4.4 Potential to Reduce Healthcare Costs Whether improving cART adherence for PLWH or treatment engagement for other chronic illnesses, mHealth and personalized medicine can assist with reducing healthcare costs. Indeed, it is known that PLWH with sustained viral suppression have considerably lower non-cART direct medical costs [153]. As complications involving medication tolerance and adherence are solved, adherent individuals become healthier over time [8], requiring less frequent medical appointments and fewer hospitalizations [153, 271]. In fact, the WelTelOakTree study required modest time and costs, with less than 53 minutes/participant/year of HCP time to manage all problem responses from participants, costing less than $50/person/year for PLWH with detectable pVL and experiencing social determinants of health as barriers to adherence [150]. Furthermore, stable, virally suppressed individuals could use the WelTel program for follow-up to allow less frequent in clinic visits [272]. In addition, through improved cART adherence and HIV viral suppression, the WelTel mHealth program could also lower risk of HIV transmission from participants to others, an important public health consideration [153, 273-275]. Consequently, fewer HIV transmissions and therefore fewer new cases of HIV per year would result in a lower cost of HIV care [276]. Finally, improving the personalization and effectiveness of WelTel would likely further improve benefits, which in turn would further reduce costs. This would also create opportunity to implement the program into healthcare systems where funding is limited and allocated to effective platforms. Beyond WelTel and PLWH, personalizing healthcare in general will allow cost effectiveness by finding treatments and programs that would work best for an individual. 118  4.5 Cultural Safety Recommendations for Working with Similar Communities As our findings may inform programs to address or utilize measures of personal disposition among Indigenous communities, we strongly recommend that Indigenous persons and ways of knowing be incorporated in each step of the process. This is evident in the literature and was reiterated in our Sharing Circles. In a Two-Eyed Seeing approach, programs could address purpose, conscientiousness, and other dispositions with health and wellbeing while also working to recognize intergenerational trauma and improve the meaning and accessibility for Indigenous persons [83, 119]. In fact, measuring disposition with health may be in line with Indigenous ways of knowing, as it goes beyond the physical aspects of Western medicine to a more holistic approach [123, 124]. Applying the cultural safety recommendations from Sharing Circle participants will support building upon the existing common strengths that Indigenous people identify, which can promote wellbeing in ways that are consistent with Indigenous views of wellness [120, 124]. Furthermore, part of enacting this Two-Eyed Seeing approach involves educating non-Indigenous researchers and care providers in cultural safety practices to create a safer space for Indigenous participants [213]. In addition, including Indigenous persons in larger and leading roles in any of these potential programs is vital to building capacity and providing ownership to the community [25, 103, 208, 211]. If such programs practice cultural safety and appropriateness, it may improve participant engagement and provide opportunity to work towards healing [80, 117]. This holistic approach while utilizing dispositional tools may empower the improvement of the overall wellbeing of Indigenous persons in Canada.  119  4.6 Conclusions  Indigenous PLWH expressed interest and value in the mHealth medication adherence program, WelTel, and made recommendations for improvements, including increased cultural safety. Indigenous community involvement builds capacity by empowering ownership and accessibility of the research and findings, and should be included in future research. Among low SES and Indigenous communities, measures of purpose and the Big Five personal dispositions may be reliable and valid; however, of the Big Five, measures of conscientiousness, agreeableness, and neuroticism require adjustment to improve reliability, and openness may not be reliable even after adjustment. Similar to other populations, personality and purpose are associated with health and wellbeing, and are factors worth considering when understanding the wellness of low SES and Indigenous communities in Vancouver, BC. In addition, aspects if Indigenous spiritual health may be associated with purpose, life satisfaction, and positive affect. Findings can be used to further develop the WelTel program and assess relationships between personal dispositions and program use. This will work to develop a culturally safe, appropriate, equitable, and personalized medication adherence program to support the health and wellbeing of PLWH. 120  References  1. WHO. Summary of the global HIV epidemic (2018): World Health Organization (WHO); 2018 [Available from: https://www.who.int/gho/hiv/en/]. 2. Bourgeois A-C, Edmunds M, Awan A, Jonah L, Varsaneux O, Siu W. Can we eliminate HIV?: HIV in Canada—surveillance report, 2016. Canada Communicable Disease Report. 2017;43(12):248. 3. 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Psychoneuroendocrinology. 2014;50:181-93. 153  268. Israel S, Moffitt TE, Belsky DW, Hancox RJ, Poulton R, Roberts B, et al. Translating personality psychology to help personalize preventive medicine for young adult patients. Journal of personality and social psychology. 2014;106(3):484. 269. Anglim J, Horwood S, Smillie LD, Marrero RJ, Wood JK. Predicting psychological and subjective well-being from personality: A meta-analysis. Psychological Bulletin. 2020;146(4):279. 270. Weston SJ, Hill PL, Jackson JJ. Personality traits predict the onset of disease. Social Psychological and Personality Science. 2015;6(3):309-17. 271. Sutton SS, Hardin JW, Bramley TJ, D'Souza AO, Bennett CL. Single-versus multiple-tablet HIV regimens: adherence and hospitalization risks. The American journal of managed care. 2016;22(4):242-8. 272. Phillips A, Shroufi A, Vojnov L, Cohn J, Roberts T, Ellman T, et al. Sustainable HIV treatment in Africa through viral-load-informed differentiated care. 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Aids. 2010;24(12):1929-35. 155  156  Appendices Appendix A  – Consent Forms A.1 Consent Form for Sharing Circles                     157  Participant Information and Consent Form WelTelWORKS  Individual Disposition and mHealth: Personalized Care to Improve Outcomes Addressing the Bridging Grant Questions: Sharing Circles  Site Principal Investigator:  Dr. Melanie Murray, MD, PhD, FRCPC   UBC Department of Medicine BC Women’s Hospital, Oak Tree Clinic   604-875-2212  Local Co-investigators:  Dr. Helene Cote, PhD UBC Dept. Pathology and Laboratory Medicine  University of British Columbia, UBC Hospital   604-822-9777   Dr. Christy Sutherland, MD  UBC Department of Family Medicine  Portland Health Society Clinic  604-683-0073 ext. 363   Dr. David Tu, MD  UBC Department of Family Medicine  Vancouver Native Health Society  604-254-9949    Dr. Neora Pick, MD  UBC Department of Medicine BC Women’s Hospital, Oak Tree Clinic   604-875-2212   Dr. Ariane Alimenti, MD  UBC Department of Medicine BC Women’s Hospital, Oak Tree Clinic   604-875-2212   Ms. Sarah Chown   YouthCo HIV and Hep C Society  604-688-1441                                                       Funding:   This study is being funded by the Canadian Institutes of Health Research (CIHR).   Study Contact - Amber Campbell 604-875-2000, ext 6706   158   1. Invitation We are conducting a research study to see if questionnaires that study personality traits and sense of purpose in life can be used in the same way among Indigenous peoples in Canada as they are in other populations. You are being invited to take part in this research study as an Indigenous person.  Before deciding to participate, you should understand the information in this consent form, the risks and benefits to make an informed decision, and ask questions if there is anything you do not understand. Please read this entire consent form that contains a full explanation of the study and take your time to make a decision. If you decide to participate in this study you will be asked to sign and date this form, and a copy will be given to you.    2. Your participation is voluntary Your participation is voluntary. You have the right to refuse to participate in this study. If you decide to participate, you may still choose to withdraw from the study at any time without any negative consequences to the medical care, education, or other services to which you are entitled or are presently receiving.  Please review the consent document carefully when deciding whether or not you wish to be part of the research and sign this consent only if you accept being a research participant.   If you wish to participate in this study, you will be asked to sign this form.  Please take time to read the following information carefully and to discuss it with your family, friends, and doctor before you decide.  3. Who is conducting this study? The study is being conducted by Dr. Melanie Murray, an Oak Tree Clinic doctor. She is planning to conduct a study to find out who benefits most from a weekly text message check-in from their health care provider. One of the things she needs to do before she can do the text-messaging study, is to receive input from Indigenous members of the Community in regards to the priorities that Indigenous persons have regarding such a program, so that the voices of Indigenous persons may be heard and their priorities addressed in the formulation and management of the study. The study is being funded by the Canadian Institutes of Health Research.  The study will be inviting participants from the Portland Hotel Society, and Vancouver Native Health Society in Vancouver, BC and will be held at the Vancouver Native Health Society.  4. Background  In Canada, there are over 70,000 people living with HIV. HIV medication has greatly improved the health and survival for many of these people. Furthermore, the HIV medication controls and decreases the viral load (amount of virus in the body) which helps prevent the virus from being spread. Although there are HIV medications available that work well to control the virus, their benefit is only realized if people take their medications with a high degree of adherence. This means that they are taking their medications regularly and are able to supress (reduce) the viral load. Physicians’ advice and patient knowledge alone are not enough to help everyone take their medications every day, as a large number of persons living with HIV still do not have 159  control of their HIV virus. More needs to be done both with respect to developing interventions to promote adherence, and to tailor HIV care to each individual’s situation. Mobile health (mHealth), the use of a mobile phone to deliver health care, is becoming more popular and has been shown to help patients with their medication adherence. In a study where patients received a weekly text message from their care providers, this resulted in better control of the HIV virus especially for those who responded to these text messages. It was hard to figure out, however, why some people used the text messaging program, and others did not.  Research has also shown value in looking at people’s personality. There are five main personality traits: 1) Conscientiousness, or being careful about doing what you are supposed to do correctly 2) Agreeableness, or how willing you are to accept and agree 3) Extraversion, how much you enjoy interacting with other people 4) Openness to experience, or how willing you are to consider new ideas and opportunities 5) Emotional stability, or how prone you are to negative emotions and anxiety  Studies have found that people who are conscientious are less likely to have major health issues and have been linked to general adherence to doctor’s orders as well as medication adherence to diseases that require similar management as HIV.   When people feel a sense of purpose in life or a commitment to long-term goals, their actions and ability to connect with people in order to reach the goal is affected. Studies have shown that having a higher sense of purpose is linked to better health including a lower chance of dying. People with a purpose believe they are in greater control of their health. We are hoping to figure out if certain personality traits, or sense of purpose make text messaging a better fit for some people in helping them to take their HIV medications.   5. What is the purpose of the study? The purpose of the study is to receive input from Indigenous members of the Community in regards to the priorities that Indigenous persons have regarding such a program, so that the voices of Indigenous persons may be heard and their priorities addressed in the formulation and management of the study. The study investigators have met with Elders in order to have community engagement and support to ensure that the study is run properly and is relevant to the community so that it can be impactful.	Elders have had input in developing protocol, consents and questionnaires, and have been reimbursed with study funds for their time.     6. Who can participate in the study and who should not participate in this study? You may be able to participate in this study if you are: - a person who identifies themselves as Indigenous, Aboriginal, First Nations, Inuit, Métis or other term that describes a person whose ancestors were among the First Peoples of Canada. - Living with HIV - 19 years old or older - able to converse in English to the extent required in order to provide written informed consent and participate in a Sharing Circle that is in English.  7. What does the study involve? This study will involve us collecting your initials, age, ethnicity and education to identify you. We will then ask you to participate in a Sharing Circle led by Elder, Mr. Sandy Lambert (for Indigenous persons who identify as male); or a Sharing Circle led by Elder, Ms. Valerie 160  Nicholson (for those persons identifying as female).	Each Sharing Circle will consist of a maximum of 12-15 participants and will begin in the traditional way, involving an acknowledgment of the territories and of those in the room, as well as smudge. An Elder (in addition to the Sharing Circle leaders) will be available to you for the duration of the group. The Elders will be reimbursed with study funds for their time during the Sharing Circle. A short presentation detailing the proposed text messaging study will be presented by Dr. Murray, followed by introduction from the Elders (Lambert, Nicholson) of 5-6 questions for group discussion. Sharing Circles will be voice recorded for later transcription and any identifiers (such as your name) will be removed in transcription. In addition, Ms. Corrina Keeling will be present at the Sharing Circles to visualize the thoughts and ideas that arise by drawing them out. Drawings will not include identifiers or photos of you. Please see Ms. Keeling’s website for a better understanding of the visual communication work: http://www.lovelettersforeverybody.ca/. We expect that the Sharing Circle will take between 1 and 2 hours of your time. There will be food provided before or after the sharing circle.  8. What are the possible harms and discomforts? There are few risks that can result from being in this study. We will make every effort to protect your privacy and confidentiality during the study, and will remind all participants that things said in the Circle should remain confidential outside of the room. However, as the Sharing Circles will have other participants who will also be in the room, and we cannot guarantee that things that you might say could be shared by others outside of the Circle. We will collect your initials (or an alternate name that you wish to be identified by), and age for the study. Names and identifiers will be transcribed in such a way that participant identifiers are changed when recordings are transcribed. It is possible that some of the questions will make you feel uncomfortable or upset during the Sharing Circle. If this is the case, there will be an Elder present at the Sharing Circle to meet with as needed and you can page Dr. Melanie Murray at 604-682-2344, call the Crisis Intervention & Suicide Prevention Centre of BC at 604-872-3311 or call HealthLink BC at 8-1-1. You do not have to answer any questions that you do not feel comfortable in answering.  What are the potential benefits of participating?  You may benefit from sharing your ideas and beliefs in the Sharing Circle, and in having your voice heard in regards to your needs in such a study. You may, however, not benefit from participating in this study. However, results from this study may help us to ensure that the planned text messaging study is appropriate and applicable to Indigenous persons.    9. What happens if I decide to withdraw my consent to participate? Your participation is entirely voluntary. You may withdraw from this study at any time without giving reasons. If you choose to enter the study and then decide to withdraw at a later time, you have the right to request the withdrawal of your information [and/or samples] collected during the study. This request will be respected to the extent possible. Please note however that there may be exceptions where the data will not be able to be withdrawn for example where the data is no longer identifiable (meaning it cannot be linked in any way back to your identity) or where the data has been merged with other data. If you would like to request the withdrawal of your data, please let your study doctor know.      161  10. Can I be asked to leave the study? If during the Sharing Circle your presence/actions/words were to be felt to be threatening to another in the room, then you may be asked to leave the study. This would only occur after every attempt could be made to improve the situation.   11. How will my taking part in this study be kept confidential? Your confidentiality will be respected. However, research records and health or other source records identifying you may be inspected in the presence of the Investigator or his or her designate by representatives of the University of British Columbia Research Ethics Board for the purpose of monitoring the research. No information or records that disclose your identity will be published without your consent, nor will any information or records that disclose your identity be removed or released without your consent unless required by law.  You will be assigned a unique study number as a participant in this study. This number will not include any personal information that could identify you (e.g., it will not include your Personal Health Number, SIN, or your initials, etc.). Only this number will be used on any research-related information collected about you during the course of this study, so that your identity will be kept confidential. Information that contains your identity will remain only with the Principal Investigator and/or designate. The list that matches your name to the unique study number that is used on your research-related information will not be removed or released without your consent unless required by law  We will only record your initials, gender, ethnicity, age and education level for the purposes of this study. Names spoken in any recordings will be changed when the transcription takes place, and recordings will be deleted once transcriptions are made. While the transcription is being done the information containing your personal information will remain only with the Principal Investigator and/or designate, and will not be removed or released without your consent unless required by law.  Your rights to privacy are legally protected by federal and provincial laws that require safeguards to ensure that your privacy is respected. You also have the legal right of access to the information about you that has been provided to the sponsor and, if need be, an opportunity to correct any errors in this information. Further details about these laws are available on request to your study doctor.  Disclosure of Race/Ethnicity Studies involving humans now routinely collect information on race and ethnic origin as well as other characteristics of individuals because these characteristics may influence how people respond to different adherence strategies. Providing information on your race or ethnic origin is voluntary.  12. What happens if something goes wrong? By signing this form, you do not give up any of your legal rights and you do not release the study doctor, participating institutions, or anyone else from their legal and professional duties. If you become ill or physically injured as a result of participation in this study, medical treatment will be provided at no additional cost to you. The costs of your medical treatment will be paid by your provincial medical plan.   162  For emergencies you can page Dr. Melanie Murray at 604-682-2344, or call the Crisis Intervention & Suicide Prevention Centre of BC at 604-872-3311.  13. Are there any costs or reimbursements with this study? There will be no direct costs to you for study-related visits. After you enroll in the study, you will be asked to participate in a Sharing Circle that will take from 1 to 2 hours of your time. Remuneration will be $20 for participating.   14. Who do I contact if I have questions about the study during my participation? If you have any questions or desire further information about this study before or during participation, you can contact Dr. Murray at the Oak Tree Clinic (604-875-2212) or Evelyn Maan, the Research Program Manager (604-767-5044).   15. Who do I contact if I have any questions or concerns about my rights as a participant? If you have any concerns or complaints about your rights as a research participant and/or your experiences while participating in this study, contact the Research Participant Complaint Line in the University of British Columbia Office of Research Ethics by e-mail at RSIL@ors.ubc.ca or by phone at 604-822-8598 (Toll Free: 1-877-822-8598).  16. After the study is finished At the end of the study, information gained from the surveys will be shared via a Sharing Circle at Vancouver Native Health Society and at the Portland Health Society which you would be welcome to attend. Information on these Sharing Circles will be posted at each of these locations notifying you when they are happening. In addition, study results and drawings from Sharing Circle will be available as handouts at all of our clinic sites.                           163  Individual Disposition and mHealth: Personalized Care to Improve Outcomes WelTelWORKS Addressing the Bridging Grant Questions   Participant Consent  My signature on this consent form means: • I have read and understood the information in this consent form. • I have had enough time to think about the information provided. • I have been able to ask for advice if needed. • I have been able to ask questions and have had satisfactory responses to my questions. • I understand that all of the information collected will kept confidential and that the results will only be used for scientific purposes. • I understand that my participation in this study is voluntary. • I understand I am completely free at any time to refuse to participate or to withdraw from this study at any time, and that this will not change the quality of care that I receive. • I understand that I am not waiving any of my legal rights as a result of signing this consent form. • I understand that there is no guarantee that this study will provide any benefits to me.   I will receive a signed copy of this consent form for my own records.  I consent to participate in this study.           Name of Participant Signature of Participant   Date    Name of Person obtaining  consent Signature of Person obtaining  consent and Study role Date       164  A.2 Letter of Consent for Questionnaires LETTER OF INTRODUCTION/CONSENT  February 2, 2018  Hello,   Text messaging helps some people take their medicines regularly, so we are testing out a questionnaire to help figure out what makes text messaging a better fit for some people. To do this, we first need to find out if the questionnaires that measure personality traits and sense of purpose in life can be used in the same way among Indigenous peoples in Canada as they are in other populations. You are being invited to participate in this survey to help us determine this. The study is being conducted under the direction of Dr. Melanie Murray (a doctor working at the Oak Tree Clinic).    Who Can Participate In The Study? Participation in this survey is open to anyone who can communicate in English. You must be 19 years of age or older to participate. We will be completing 300 surveys; 150 surveys with people who identify as Indigenous, and 150 surveys with people who identify as non-Indigenous.  Voluntary Participation Your participation in this survey is entirely voluntary.  It is up to you to decide whether or not to take part in it.  This information sheet/consent form will tell you about this portion of the study, why it is being done, and the possible benefits, risks and discomforts.   By completing the survey, you are providing consent to be included in the study. You do not need to sign this form and you are encouraged to keep a copy of this consent for your records.  If you decide not to participate you will not lose the benefit of any medical care to which you are entitled or are receiving at this point.    What Does The Study Involve?  If you are interested in participating in the study, you will be asked to fill out a questionnaire that will ask you questions assessing the characteristics of your personality and sense of purpose in life. This study will involve us collecting your initials, gender/sex, ethnicity, education and month and year of birth to identify you. If you identify as an Indigenous person, the survey will also be asking for basic information about yourself and your connection with traditional Indigenous practices. It will take approximately 20 minutes to complete the questionnaire. Please do NOT sign or put your name on the questionnaire.  Please note that this research study is anonymous and confidential.  165   Who is Conducting this Study? The study is being conducted by Dr. Melanie Murray, an Oak Tree Clinic doctor. She is planning to conduct a study to find out who benefits most from a weekly text message check-in from their health care provider. One of the things she needs to do before she can do the text-messaging study, is to test the questionnaires for that study and make sure that they tell us the same things for Indigenous peoples as they do for other peoples who have done these questionnaires before. The study is being funded by the Canadian Institutes of Health Research.  What Are The Benefits Of Participating In This Study?  You may not personally benefit from participation in this survey.  You may contribute new information that may benefit people in the future.  You will receive $20 to thank you for your time participating in the survey.    What Will The Study Cost Me?  Participation in the study will not cost you anything.      What are the Possible Harms and Discomforts? There are few risks that can result from being in this study. It is possible that some of the questions will make you feel uncomfortable or upset during the survey. You do not have to answer any questions that you do not feel comfortable in answering. For crises you can page Dr. Melanie Murray at 604-682-2344, call the Crisis Intervention & Suicide Prevention Centre of BC at 604-872-3311 or call HealthLink BC at 8-1-1.  If you have any questions or desire further information about this study, you can contact Amber Campbell at 604-875-2000 ext. 6706 or amber.campbell@cw.bc.ca. If you have any concerns about your experience or rights as a research participant, please contact the Research Participant Complaint Line in the University of British Columbia Office of Research Ethics by e-mail at RSIL@ors.ubc.ca or by phone at 604-822-8598 (Toll Free: 1-877-822-8598).  Thank you for your help.   Sincerely,     Dr. Melanie Murray MD, PhD, FRCPC Infectious Disease Physician, Oak Tree Clinic Assistant Professor, UBC       166  Appendix B  – Questionnaires B.1 Questionnaire – Indigenous Participants                 167  WelTelWORKS Questionnaire - Indigenous Participants  ID: _______________ Date: __________________  1. What gender do you live day to day as? m Male m Female m Write In ____________________  2. What is your biological sex? Were you born male, female or other? m Male m Female m Other _________  3. What is your age? ____________________________  4. What is your first language? (if English, skip #5) ____________________________  5. Understanding that many of us have lost our languages, we are asking how long have you spoken English? ____________________________  6. Education à highest level completed m Elementary / Grade school m Some High School / Secondary m High School Graduate (or GED, General Education Diploma) m Trade or Technical Training m College / CEGEP m Any University m Other ______________________  7. How do you define your Ethnicity? (check all that apply) m Aboriginal m Indigenous m Metis m Inuit m First Nations m Other ______________________    168   8. Does your traditional spirituality play a role in your life? m Yes -How so? ______________________________ m No   9. Does it influence your healthcare? m Yes -How so? ______________________________ m No   10. Have traditional practices always been in your life?  m Yes, traditional practices have always been a part of my life. m No, I have reconnected to my people’s traditional practices. m No, but I am finding out more about my traditional practices. m No, I have not yet learned about my people’s traditions.   Physical Health: 11. Have you ever participated in…? m Drumming m Singing m Dancing m Other ________________________   Spiritual Health:  12. Have you ever participated in…? m Sweat lodges m Long house m Ceremony m Pow Wow m Sun dance m Smudge m Teachings from Elders m Other _________________________       169  Wellness: 13. What traditional medicines and foods do you use?  m Juniper m Sweet grass m Cedar m Sage m Tobacco m Salmon m Ooligan m Berries m Bannock m Other __________________   Mental Health: 14. Do you seek out or use…? m Elders m Healing circles m Traditional healers m Counseling m Other __________________   15. Household Income (from all household sources): m Less than $15 000 m More than $15 000  170  16. This scale consists of a number of words that describe different feelings and emotions. Read each item and then mark the appropriate answer in the space next to that word. Indicate to what extent you generally feel this way, that is, how you feel on the average. Use the following scale to record your answers.  Very Slightly or Not At All A Little Moderately Quite A Bit Extremely Interested m  m  m  m  m  Excited m  m  m  m  m  Strong m  m  m  m  m  Scared m  m  m  m  m  Enthusiastic m  m  m  m  m  Irritable m  m  m  m  m  Ashamed m  m  m  m  m  Nervous m  m  m  m  m  Attentive m  m  m  m  m  Active m  m  m  m  m  Distressed m  m  m  m  m  Upset m  m  m  m  m  Guilty m  m  m  m  m  Hostile m  m  m  m  m  Proud m  m  m  m  m  Alert m  m  m  m  m  Inspired m  m  m  m  m  Determined m  m  m  m  m  Jittery m  m  m  m  m  Afraid m  m  m  m  m    171  17. On a 5-point Likert-scale, ranging from 1 (Strongly Disagree) to 5 (Strongly Agree), please indicate how characteristic each item is of yourself.  Strongly Disagree Moderately Disagree More or Less Moderately Agree Strongly Agree There is a direction in my life. m  m  m  m  m  My plans for the future match with my true interests and values. m  m  m  m  m  I know which direction I am going to follow in my life. m  m  m  m  m  My life is guided by a set of clear commitments. m  m  m  m  m   18. Please indicate how much you agree or disagree with each of the following statements:  Strongly Disagree Moderately Disagree More or Less Moderately Agree Strongly Agree I live life one day at a time and don’t really think about the future. m  m  m  m  m  I sometimes feel as if I have done all there is to do in life. m  m  m  m  m  Some people wander aimlessly through life but I am not one of them. m  m  m  m  m     172    19. Below are five statements with which you may agree or disagree. Using the 1-7 scale below, indicate your agreement with each item by placing the appropriate number on the line preceding that item. Please be open and honest in your responding. The 7-point scale is: 1 =strongly disagree, 2 = disagree, 3 = slightly disagree, 4 = neither agree nor disagree, 5 =slightly agree, 6 =agree, 7 =strongly agree.   Strongly Disagree Disagree Slightly Disagree Neither Agree nor Disagree Slightly Agree Agree Strongly Agree In most ways my life is close to my ideal. m  m  m  m  m  m  m  The conditions of my life are excellent. m  m  m  m  m  m  m  I am satisfied with my life. m  m  m  m  m  m  m  So far I have gotten the important things I want in life. m  m  m  m  m  m  m  If I could live my life over, I would change almost nothing. m  m  m  m  m  m  m   173  20. In general, would you say your health is: m Excellent m Very Good m Good  m Fair m Poor  21. Compared to one year ago, how would you rate your health in general now? m Much better than one year ago m Somewhat better now than one year ago m About the same m Somewhat worse now than one year ago m Much worse now than one year ago  22. How true or false is each of the following statements for you?  Definitely True Mostly True Don't Know Mostly False Definitely False I seem to get sick a little easier than other people. m  m  m  m  m  I am as healthy as anybody i know. m  m  m  m  m  I expect my health to get worse. m  m  m  m  m  My health is excellent m  m  m  m  m    23. Please rate your agreement to each of these items on a scale from: 1 (Strongly Agree) to 5 (Strongly Disagree).                                                                        Strongly Agree                                              Strongly Disagree I am the life of the party       1 2 3 4 5 I sympathize with others’ feelings 1 2 3 4 5 I get chores done right away          1 2 3 4 5 I have frequent mood swings 1 2 3 4 5 I have a vivid imagination 1 2 3 4 5 174                                                                         Strongly Agree                                              Strongly Disagree I don’t talk a lot 1 2 3 4 5 I am not interested in other people’s problems 1 2 3 4 5 I often forget to put things back in their proper place 1 2 3 4 5 I am relaxed most of the time 1 2 3 4 5 I am not interested in abstract ideas 1 2 3 4 5 I talk to a lot of different people at parties 1 2 3 4 5 I feel others’ emotions 1 2 3 4 5 I like order 1 2 3 4 5 I get upset easily 1 2 3 4 5 I have difficulty understanding abstract ideas 1 2 3 4 5 I keep in the background 1 2 3 4 5 I am not really interested in others 1 2 3 4 5 I make a mess of things 1 2 3 4 5 I seldom feel blue 1 2 3 4 5 I do not have a good imagination 1 2 3 4 5 I work hard 1 2 3 4 5 I set high standards for myself and others 1 2 3 4 5 I do just enough work to get by 1 2 3 4 5 I am not highly motivated to succeed 1 2 3 4 5        175  B.2 Questionnaire – Non-Indigenous Participants WelTelWORKS Questionnaire - NON-Indigenous Participants  ID: _______________ Date: __________________  1. What gender do you live day to day as? m Male m Female m Write In ____________________  2. What is your biological sex? Were you born male, female or other? m Male m Female m Other _________  3. What is your age? ____________________________  4. What is your first language? (if English, skip #5) ____________________________  5. How long have you spoken English? ____________________________  6. Education à highest level completed m Elementary / Grade school m Some High School / Secondary m High School Graduate (or GED, General Education Diploma) m Trade or Technical Training m College / CEGEP m Any University m Other ______________________  7. How do you define your Ethnicity? (check all that apply) m Caucasian/White m African/African-American/African-Canadian m Hispanic/Latin American m Middle Eastern m Asian/Asian-American/Asian-Canadian m Other    176  8. Household Income (from all household sources): m Less than $15 000 m More than $15 000   9. This scale consists of a number of words that describe different feelings and emotions. Read each item and then mark the appropriate answer in the space next to that word. Indicate to what extent you generally feel this way, that is, how you feel on the average. Use the following scale to record your answers.  Very Slightly or Not At All A Little Moderately Quite A Bit Extremely Interested m  m  m  m  m  Excited m  m  m  m  m  Strong m  m  m  m  m  Scared m  m  m  m  m  Enthusiastic m  m  m  m  m  Irritable m  m  m  m  m  Ashamed m  m  m  m  m  Nervous m  m  m  m  m  Attentive m  m  m  m  m  Active m  m  m  m  m  Distressed m  m  m  m  m  Upset m  m  m  m  m  Guilty m  m  m  m  m  Hostile m  m  m  m  m  Proud m  m  m  m  m  Alert m  m  m  m  m  Inspired m  m  m  m  m  Determined m  m  m  m  m  Jittery m  m  m  m  m  Afraid m  m  m  m  m    177  10. On a 5-point Likert-scale, ranging from 1 (Strongly Disagree) to 5 (Strongly Agree), please indicate how characteristic each item is of yourself.  Strongly Disagree Moderately Disagree More or Less Moderately Agree Strongly Agree There is a direction in my life. m  m  m  m  m  My plans for the future match with my true interests and values. m  m  m  m  m  I know which direction I am going to follow in my life. m  m  m  m  m  My life is guided by a set of clear commitments. m  m  m  m  m    11. Please indicate how much you agree or disagree with each of the following statements:  Strongly Disagree Moderately Disagree More or Less Moderately Agree Strongly Agree I live life one day at a time and don’t really think about the future. m  m  m  m  m  I sometimes feel as if I have done all there is to do in life. m  m  m  m  m  Some people wander aimlessly through life but I am not one of them. m  m  m  m  m    178  12. Below are five statements with which you may agree or disagree. Using the 1-7 scale below, indicate your agreement with each item by placing the appropriate number on the line preceding that item. Please be open and honest in your responding. The 7-point scale is: 1 =strongly disagree, 2 = disagree, 3 = slightly disagree, 4 = neither agree nor disagree, 5 =slightly agree, 6 =agree, 7 =strongly agree.   Strongly Disagree Disagree Slightly Disagree Neither Agree nor Disagree Slightly Agree Agree Strongly Agree In most ways my life is close to my ideal. m  m  m  m  m  m  m  The conditions of my life are excellent. m  m  m  m  m  m  m  I am satisfied with my life. m  m  m  m  m  m  m  So far I have gotten the important things I want in life. m  m  m  m  m  m  m  If I could live my life over, I would change almost nothing. m  m  m  m  m  m  m   179  13. In general, would you say your health is: m Excellent m Very Good m Good  m Fair m Poor  14. Compared to one year ago, how would you rate your health in general now? m Much better than one year ago m Somewhat better now than one year ago m About the same m Somewhat worse now than one year ago m Much worse now than one year ago  15. How true or false is each of the following statements for you?  Definitely True Mostly True Don't Know Mostly False Definitely False I seem to get sick a little easier than other people. m  m  m  m  m  I am as healthy as anybody i know. m  m  m  m  m  I expect my health to get worse. m  m  m  m  m  My health is excellent m  m  m  m  m   16. Please rate your agreement to each of these items on a scale from: 1 (Strongly Agree) to 5 (Strongly Disagree).                                                                        Strongly Agree                                              Strongly Disagree I am the life of the party       1 2 3 4 5 I sympathize with others’ feelings 1 2 3 4 5 I get chores done right away          1 2 3 4 5 I have frequent mood swings 1 2 3 4 5 I have a vivid imagination 1 2 3 4 5                                                                        Strongly Agree                                              Strongly Disagree 180  I don’t talk a lot 1 2 3 4 5 I am not interested in other people’s problems 1 2 3 4 5 I often forget to put things back in their proper place 1 2 3 4 5 I am relaxed most of the time 1 2 3 4 5 I am not interested in abstract ideas 1 2 3 4 5 I talk to a lot of different people at parties 1 2 3 4 5 I feel others’ emotions 1 2 3 4 5 I like order 1 2 3 4 5 I get upset easily 1 2 3 4 5 I have difficulty understanding abstract ideas 1 2 3 4 5 I keep in the background 1 2 3 4 5 I am not really interested in others 1 2 3 4 5 I make a mess of things 1 2 3 4 5 I seldom feel blue 1 2 3 4 5 I do not have a good imagination 1 2 3 4 5 I work hard 1 2 3 4 5 I set high standards for myself and others 1 2 3 4 5 I do just enough work to get by 1 2 3 4 5 I am not highly motivated to succeed 1 2 3 4 5     

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