Medicine, Faculty of
Obstetrics and Gynaecology, Department of
DSpace
UBCV
Martin-Ferris, Samantha
Master of Science - MSc
University of British Columbia
This thesis investigates the experiences of Indigenous people in Canada accessing sexual and reproductive health (SRH) services. Indigenous peoples face significant barriers to good health stemming from historical colonization and systemic oppression, which can lead to reluctance in engaging with SRH services. This research was guided by two aims: 1) To examine the existing literature to identify challenges and barriers Indigenous people face when accessing SRH services, and 2) To contribute new quantitative research to the SRH field through the analysis of Indigenous youth health statistics. Chapter 2 of this thesis presents a systematic review of 54 academic and grey literature articles (1993â2023) concerning Indigenous SRH access. Findings reveal that Indigenous peoples experience feelings of shame, fear, and stigma when accessing SRH-related services. Physical barriers include geographic isolation, lack of transportation, and limited access to culturally safe care. The review also notes a recent positive increase in Indigenous community participation and authorship. Chapter 3 examines Indigenous youth reproductive wellness by addressing the question: 'What contributes to negative sexual health outcomes for Indigenous youth aged 12â19?' Using data analysis and logistic regressions from the BC Adolescent Health Survey (BC AHS), findings demonstrate that Adverse Childhood Experience (ACE) factors, such as sexual abuse (Adjusted Odds Ratio 2.93, P. < 0.01) and residential school exposure (AOR 1.77, P. <0.01), play a significant contributing role in negative STI and pregnancy outcomes. Further BC AHS analysis revealed that Indigenous youth constituted 20% of the sexually active cohort who reported an STI. Through weighting and scaling the BC AHS statistics, the estimated STI rate among all sexually active BC youth aged 12â19 was 772.08 per 100,000, which exceeds national reporting averages. Additionally, Queer and Two-Spirit youth represent a disproportionate 25% of all STI cases among this cohort, highlighting a critical need for targeted support (Note: there was a high SE rate). The results emphasize the urgent need for culturally safe SRH services and improved sexual education tailored for Indigenous youth. Two-Spirit and queer identities require increased access to targeted and relevant programming.
i INTERSECTIONAL BARRIERS TO INDIGENOUS YOUTHS' REPRODUCTIVE WELLNESS IN CANADA by Samantha Martin-Ferris B.A., The University of British Columbia (Vancouver Campus), 2019 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE in The Faculty of Graduate and Postdoctoral Studies (Women+ and Childrenâs Health Sciences) THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) October 2025 © Samantha Martin-Ferris, 2025 ii The following individuals certify that they have read, and recommend to the Faculty of Graduate and Postdoctoral Studies for acceptance, the graduate thesis entitled: Intersectional barriers to Indigenous youthsâ reproductive wellness in Canada submitted by Samantha Martin-Ferris in partial fulfilment of the requirements for the degree of Master of Science in Women+ and Childrenâs Health Sciences Examining Committee: Dr. Aline Talhouk, Assistant Professor, Obstetrics and Gynecology, UBC Supervisor Elizabeth Saewyc, Director, School of Nursing, UBC Co-supervisor Sarah Munro, Assistant Professor, Health Systems and Population Health, University of Washington Supervisory Committee Member Annie Smith, Affiliate Professor, School of Nursing, UBC, Director, The McCreary Centre Society Supervisory Committee Member Brittany Bingham, Assistant Professor, Division of Social Medicine, UBC Additional Examiner iii Abstract This thesis investigates the experiences of Indigenous people in Canada accessing sexual and reproductive health (SRH) services. Indigenous peoples face significant barriers to good health stemming from historical colonization and systemic oppression, which can lead to reluctance in engaging with SRH services. This research was guided by two aims: 1) To examine the existing literature to identify challenges and barriers Indigenous people face when accessing SRH services, and 2) To contribute new quantitative research to the SRH field through the analysis of Indigenous youth health statistics. Chapter 2 of this thesis presents a systematic review of 54 academic and grey literature articles (1993â2023) concerning Indigenous SRH access. Findings reveal that Indigenous peoples experience feelings of shame, fear, and stigma when accessing SRH-related services. Physical barriers include geographic isolation, lack of transportation, and limited access to culturally safe care. The review also notes a recent positive increase in Indigenous community participation and authorship. Chapter 3 examines Indigenous youth reproductive wellness by addressing the question: 'What contributes to negative sexual health outcomes for Indigenous youth aged 12â19?' Using data analysis and logistic regressions from the BC Adolescent Health Survey (BC AHS), findings demonstrate that Adverse Childhood Experience (ACE) factors, such as sexual abuse (Adjusted Odds Ratio 2.93, P. < 0.01) and residential school exposure (AOR 1.77, P. <0.01), play a significant contributing role in negative STI and pregnancy outcomes. Further BC AHS analysis revealed that Indigenous youth constituted 20% of the sexually active cohort who reported an STI. Through weighting and scaling the BC AHS statistics, the estimated STI rate among all sexually active BC youth aged 12â19 was 772.08 per 100,000, which exceeds national reporting averages. Additionally, Queer and Two-Spirit youth represent a disproportionate 25% of all STI cases among this cohort, highlighting a critical need for targeted support (Note: there was a high SE rate). The results emphasize the urgent need for culturally safe SRH services and improved sexual education tailored for Indigenous youth. Two-Spirit and queer identities require increased access to targeted and relevant programming. iv Lay Summary This thesis has two aims: 1) To examine the literature to identify the challenges and barriers that Indigenous people face when accessing SRH services. 2) To contribute new research to the SRH field through quantitative analysis of Indigenous youth health statistics on SRH topics. I found 54 articles dated from 1993 to 2023. Articles indicated feelings of shame, fear and stigma about accessing SRH-related services. Physical barriers to accessing SRH-related services included living remotely, lacking transportation and limited access to culturally safe services. Chapter 3 of my thesis explores the topic of Indigenous youth by addressing the question âWhat contributes to negative sexual health outcomes for Indigenous youth aged 12-19?â Findings show that exposures such as sexual abuse and residential schools have a contributing role. Indigenous youth made up 1/5th of reported STI cases in BC. The average number among all sexually active youth aged 12-19 in BC was 3550.81 per 100,000. This is over 100% of PHACâs 2022 national reporting average of 250.6 in BC among all youth and adults. Results from this thesis highlight the need for culturally safe SRH services including better sexual education for Indigenous youth. Two-Spirit and queer identities particularly need increased services due to a lack of targeted programming. v Preface Statement of Collaboration and Student Contribution Chapter 2: Systematic Review (Objective 1) The systematic review portion was completed under the supervision of Dr. Sarah Munro as part of UBCâs Story project, which explores the family planning health service access experiences of Indigenous peoples in Canada. This work was conducted as part of a multi-person team including Sarah Munro, Samantha Martin-Ferris, Victoria Paller, Brooke Mounsey, Zeba Khan, Prubjot Gill, and Danette Jubinville. I led data library management proceedings and article cataloging with the assistance of one research assistant (Victoria Paller). Chapter 3: Statistical Analysis (Objective 2) Data analysis for the second section was conducted independently as a part of a Mathematics of Information Technology and Complex Systems (MITACS) fellowship. This work was supervised by the Stigma and Resilience Among Vulnerable Youth Centre (SARAVYC) and The McCreary Centre Society, with support from Dr. Aline Talhouk8. Both assisted with data checks. Following the cleaning of the primary 2023 data, I assisted Dr. Colleen Poon in participant selection and variable recoding. I independently conducted weighted analysis, basic frequency analysis, logistic regression and statistical analyses. Publications Arising from this Thesis Results in progress of Chapter 2 were presented at a peer-reviewed scientific meeting, with the abstract published as follows: Munro, Sarah & Martin-Ferris, Samantha & Jubinville, Danette & Mounsey, Brooke & Paller, Victoria & Khan, Zeba. (2023). Experiences of access to contraception and abortion care among Indigenous clients: A systematic review. Journal of Obstetrics and Gynaecology Canada. 45. 362. 10.1016/j.jogc.2023.03.069. Three additional manuscripts are currently under development at the time of this thesis regarding the results of Chapter 3. Ethics Approval Approval for secondary data analysis of the 2023 BC Adolescent Health Survey (BC AHS) was obtained through SARAVYC (Behavioural Research Ethics Board Certificate# H22-03063). Generative AI was not used for any part of this thesis. vi Table of Contents Abstract ...................................................................................................................................................................... iii Lay Summary ..............................................................................................................................................................iv Preface .......................................................................................................................................................................... v List of Tables â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦. ........................... viii List of Figures .............................................................................................................................................................ix List of Abberviationsâ¦â¦â¦â¦â¦â¦â¦//.â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦.â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦...â¦â¦â¦â¦.x Glossaryâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦.â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦...xi Acknowledgements ................................................................................................................................................... xii Dedicationâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦.â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦...â¦â¦...â¦â¦xiii 1 Introductionâ¦.. ........................................................................................................................................................ 1 1.1 Thesis Aims ........................................................................................................................................................ 4 1.1.2 Supporting Indigenous Communities ...................................................................................................... 4 1.3 Structure of the thesis ....................................................................................................................................... 6 1.5 Theoretical and Methodological Frameworks ................................................................................................ 6 1.5.1 Positionality Statement ............................................................................................................................. 6 1.5.2 Ownership, Control, Access and Possession (OCAP) ............................................................................ 9 1.5.3 Community Involvement ........................................................................................................................ 10 1.5.4 Anti-racism and Decolonization ............................................................................................................. 11 1.6 Conclusion .............................................................................................................................................. â¦.....12 2. Experiences of access to contraception and abortion care among Indigenous clients ............................... 13 2.1 Introduction ..................................................................................................................................................... 14 2.2 Methods ........................................................................................................................................................... 15 2.2.1 Study Design ............................................................................................................................................ 15 2.2.2Critical Approach..................................................................................................................................... 16 2.2.3 Self-Location ............................................................................................................................................ 17 2.2.4 Community Involvement ........................................................................................................................ 18 2.2.5 Search strategy ........................................................................................................................................ 18 2.2.6 Inclusion Criteria .................................................................................................................................... 20 2.2.7 Study Selection ........................................................................................................................................ 20 2.2.8 Appraisal .................................................................................................................................................. 21 2.2.9 Data extraction ........................................................................................................................................ 22 2.2.10 Data synthesis and integration ............................................................................................................. 22 2.3 Results .............................................................................................................................................................. 23 2.3.1 Quality appraisal ..................................................................................................................................... 25 2.3.2 Characteristics of included studies ........................................................................................................ 26 2.4 Results of integrative synthesis ...................................................................................................................... 27 2.4.1 Reproductive resistance: The impact of colonization .................................................................................. 27 2.4.2. Alone together: Navigating geographic isolation and privacy in rural and remote communities ....... 31 vii 2.4.3 Promising practices: What can we do to improve patient care and celebrate Indigenous health?.......33 2.5 Discussion ........................................................................................................................................................ 36 3. Statistical Analysis on Indigenous Youths Reproductive Wellness in BC ........................................................ 38 3.1 Introduction ..................................................................................................................................................... 38 3.2 Objectives & Aims .......................................................................................................................................... 39 3.3 Methods ........................................................................................................................................................... 41 3.3.1 Data Sources ............................................................................................................................................ 41 3.3.2Consent Process ........................................................................................................................................ 41 3.3.3 Usable Surveys ......................................................................................................................................... 42 3.3.5 Ethical Consultation ................................................................................................................................ 43 3.4 Measures .......................................................................................................................................................... 44 3.4.1 Bivariate Analysis.................................................................................................................................... 44 3.4.2 Logistic Regression.................................................................................................................................. 47 3.4.3 Statistical Analyses .................................................................................................................................. 48 3.4.4 STI Outcomes Scaling ............................................................................................................................. 48 3.4.5 Indigenous Ways of Knowing ................................................................................................................. 49 3.5 Results .............................................................................................................................................................. 52 3.5.1 Participants .............................................................................................................................................. 52 3.5.2 Sexual Activity ......................................................................................................................................... 53 3.5.3 Illegal Age Pairings and Sexual Abuse .................................................................................................. 53 3.5.4 Sex Education Access and Satisfaction .................................................................................................. 55 3.5.5 Contraceptive Use ................................................................................................................................... 56 3.5.6 Condom Use Amongst ACEâs ................................................................................................................ 58 3.5.7 Substance Use and Sexual Health .......................................................................................................... 59 3.5.8 STI and Pregnancy Rates ....................................................................................................................... 59 3.5.9 STIâs and Pregnancy Rate Comparisons to National Levelsâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦.â¦â¦....60 3.5.10 BC AHS Data on STIs and pregnancy ........................................................................................... 61 3.6 Conclusion ....................................................................................................................................................... 63 3.7 Limitations ....................................................................................................................................................... 64 4. Discussion .......................................................................................................................................................... 65 4.1 Summary of Findings ..................................................................................................................................... 65 4.2 Best practices ................................................................................................................................................... 68 4.3 Strengths and Limitations .............................................................................................................................. 71 4.3.1 Systematic Review ................................................................................................................................... 71 4.3.2 BC AHS Data Review ............................................................................................................................. 72 4.4 Key Takeaways ............................................................................................................................................... 73 4.5 Implications ..................................................................................................................................................... 75 References .................................................................................................................................................................. 77 Appendices ................................................................................................................................................................. 85 viii List of Tables Table 2.1 ............................................................................................................................... 27 Table 3.1: Measures Used ..................................................................................................... 45 Table 3.2: Exposures Used ................................................................................................... 46 Table 3.3: Variables Used in Logistic Regression ................................................................ 47 Table 3.4: What is Considered an illegal Age Pairingâ¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦53 Table 3.5: Scaled BC_AHS Participant Numbers ............................................................ â¦54 Table 3.6. Sex Ed Satisfaction by Indigenous and Non-Indigenous Youthâ¦â¦â¦â¦..â¦â¦.56 Table 3.7 Contraceptive use by Health Authority â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦..57 Table 3.8 PHAC - Average rates of STIâs Amongst those in Canada (57) .......................... 60 Table 3.9 STI data (STI Reports Nationally) ....................................................................... 60 Table 3.10: BCCDC STI Data (STI reports in BC â 0-19) .................................................. 61 Table 3.11 BC AHS STI Data (Among youth in BC 12-19) (only grades 7-12) ................ 61 Table 3.12 Logistic Regression â Preventing STI and Pregnancy Outcomes ...................... 62 ix List of Figures Figure 2.1 PRISMA flowchart .............................................................................................. 24 x List of Abbreviations ACE â Adverse Childhood Experience BC AHS â BC Adolescent Health Survey. PHACâ Public Health Agency of Canada. SRH â Sexual and reproductive Health. xi Glossary Non-binary â An umbrella term for having a gender identity which identifies as being outside only male or female. Non-binary people may identify as having multiple genders, a separate third gender or may be gender-fluid and switch between which gender they feel identifies them best. Two-Spirit âan umbrella term which includes those who identify as having both male and female spirits inside of them or identify as LGBTQ+ from an Indigenous lens. Two-Spirit people had a rich history before colonization of being regarded as teachers, knowledge keepers, herbalists, child-minders, and spiritual leaders and were accepted and honoured in Indigenous communities. Post-colonization, the term Two-Spirit was later reclaimed in the 1990s to identify the unique experiences of Indigenous LGBTQ+ people that exist outside of post-colonial spaces. Good Health: The WHO defines the termâ good health,â as a holistic concept featuring both physical and mental health. By facilitating the concept of âgood healthâ as a broad concept existing outside of just physical health, the rights of 2SLGBTQ+ individuals can be better understood and help to fight against racism, homophobia and oppression1. Reproductive Health: The WHO description of reproductive health is: âa state of complete physical, mental, and social wellbeing and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes.2â Indigenous childbearing peoplesâ reproductive rights have been targeted as a means of control during the ongoing process of colonization. Gendered violence, residential schools and child welfare systems have deliberately impacted Indigenous women, gender diverse and Two-Spirit people in their wellbeing and relation to land. An intersectional approach focusing on social justice must be taken when conducting Indigenous research regarding childbearing people regarding their bodily autonomy and rights. Forced and Coerced Sterilization: forced and coerced sterilization to control Indigenous populations took place at the discretion of provinces up into the late 80s until the act was fully condemned by the Canadian courts in the â80s to mid-early 2000s3. Forced and coerced sterilization continues to this day as the 2022 Senate report, The Scars We Carry, describes. These procedures are often conducted with a lack of consent and under duress 4. 1 United Nations General Assembly. The Right to Health. 2008. Geneva, Switzerland. 3 United Nations General Assembly. The Right to Health. 2008. Geneva, Switzerland. 4 Report of the Standing Senate Committee on Human Rights. The Scars That We Carry: Forced and Coerced Sterilizations of Peoples in Canada. 2022. Ottawa, Canada. xii Acknowledgements I would like to acknowledge all the mentors, elders and matriarchs who have trained, believed, and supported me on my journey. Thank you for being patient, compassionate and making me feel worthy in my pursuit of knowledge. To my parents, thank you for putting up with all my science experiments in the kitchen as a child. Thank you for sending me to science summer camp and most of all thank you for making me excited to learn. Listed below alphabetically are the academics who made this research possible with their support: Dr. Annie Smith â Director of The McCreary Centre Society Dr. Aline Talhouk â Co-supervisor Dr. Colleen Poon âSenior Research Associate â The McCreary Centre Society Dr. Elizabeth Saewyc â Director of the Stigma and Resilience Among Vulnerable Youth Centre and co-supervisor Evan Saikley â BA Medical Engineering Dr. Mauricio Coronel Villalobos â SARAVYC Postdoctoral Fellow Dr. Monica Rana âManaging Director of SARAVYC Dr. Sarah Munro â Committee member (previously primary supervisor) xiii Dedication This thesis is dedicated to the Indigenous women, children, and youth of Canada. May our mothers, matriarchs and elders continue to guide us on our journey to holistic reproductive wellness in Canada. 1 1 Introduction Indigenous Peoples face a history of colonization in sexual and reproductive health services (SRH) from Residential Schools, Indian Hospitals and forced and coerced abortion and sterilization. In the wake of these events, Indigenous communities have continued to rebuild diverse pathways which support culturally safe SRH services. However, there is still undeniable damage which has been done in the form of severance of Indigenous knowledge and trust about Indigenous healthcare related to sexual and reproductive health (1,2,3). Furthermore, the perpetuation of harm toward Indigenous Peoples in the ongoing practice of forced and coerced sterilization was recently acknowledged by the Canadian Senate in the form of the report The Scars We Carry (2). The report and subsequent investigation acknowledged that Indigenous people are still being forcefully sterilised either permanently or temporarily through non-consenting practices by doctors and other medical staff in the present day. At present, there is a gap in data available detailing Indigenous Peoplesâ experiences with navigating sexual and reproductive health (SRH) services as well as contraceptive use rates. Among the limited descriptive data available, some alarming trends are evident. For instance, the BC Adolescent Health Survey identified a trend from the years 2008-2015 with youth, both Indigenous and non-Indigenous, only using withdrawal as a contraceptive method (3). In their 2019 study, Lys identified Indigenous youth living in the Northwest Territories to have risks of chlamydia and gonorrhea at eight times the national average (4). There is also limited documentation of positive and protective factors for Indigenous Peoples engaging in sexual and reproductive health practices. Previous health surveys on Indigenous reservations have identified 2 that spiritual-related beliefs and attitudes were found to serve as a protective factor in always using condoms when needed (5). Specific beliefs and attitudes may impact overall health outcomes related to sexual health. Furthermore, Indigenous Peoples continue to have limited access to SRH-related services. Indigenous women who lived in remote and rural communities prior to the availability of mifepristone in 2015 were 3 times as likely to have to travel over 100km to access an abortion (6). While Mifepristone remains a safe and accessible option for pregnant able-bodied bodies in Canada, there still exists a gap in prescription-based abortion (7). For example, in interviews, pharmacists described overly complex training to receive the right to prescribe (7). Additionally, physicians used to have to perform an ultrasound and observe patients take the medication to be able to dispense it, which created hesitancy amongst (8). Because of this, physicians in interviews said that others may still recommend physical abortions over prescription-based ones to women living in rural locations, as they believe the ultrasound and prescription will take multiple visits (8). Indigenous youth in Canada may face unique intersecting barriers compared to their adult counterparts when accessing sexual healthcare services, which can lead to unintended poorer health outcomes, including sexually transmitted infections (STIs) and unplanned pregnancies (4). There are very few quantitative articles on Indigenous youth that examine the âwhyâ of these health outcomes. My research seeks to fill these gaps as a means of improving youth access to SRH services. The WHO defines âgood healthâ as âThe right to the enjoyment of the highest 3 attainable standard of physical and mental healthâ (9). In the context of Indigenous health services, the importance of patient care should be highlighted as having a need not just to treat the symptoms of conditions, such as STIs and unplanned pregnancy, but to examine the overall holistic well-being of the patient in a culturally safe way (1,10) In this thesis, I aim to understand these barriers and identify strengths-based opportunities and best practices so that Indigenous youth may be better supported in their journey in sexual health. This mixed-methods thesis involves two interrelated studies. The first is a systematic review of the literature investigating Indigenous Peoples' experiences with accessing contraception and abortion services in Canada. The second is an analysis of data from the BC Adolescent Health Survey. Through community partnership to generate knowledge on improving access to culturally safe family planning care, I aim to reduce health disparities and support Indigenous Peoplesâ rights to good health. Through this research, I respond to the Truth and Reconciliation Commission's Call to Action #19, which calls upon the federal government, in consultation with Indigenous Peoples, to establish measurable goals to identify and close the gaps in health outcomes for Indigenous people (10,11). My thesis also responds to the report In Plain Sight, which recommends that Indigenous knowledge be incorporated into healthcare for Indigenous people in a meaningful way to address systemic racism and barriers to achieving the WHOâs definition of good health (10). 4 1.1 Thesis Aims In this thesis, my aims are: 1) To investigate attitudes and experiences of Indigenous People accessing sexual health-related services. I present results from a systematic review of the published and grey literature related to Indigenous People in Canada and their experiences with accessing contraception and abortion-related services. 2) To identify the contraceptive use rates of Indigenous youth in BC. I use BC Adolescent Health Survey data to identify contraceptive use rates and compare them to previous benchmarks of STI and pregnancy rates in BC. I measure exposure-based outcomes informed by previous BC AHS research to identify how the landscape of STI and pregnancy-based outcomes for Indigenous youth is shifting. 1.1.2 Supporting Indigenous Communities Through this research, I synthesize and interpret qualitative and quantitative knowledge to gain a deeper understanding of the landscape of Indigenous youth reproductive health in Canada. I establish baselines of contraceptive use for Indigenous youth (aged 12-19) in BC and identify key limiting factors which may prevent youth from accessing contraception and abortion services in Canada. Improving access to culturally safe family planning care through community partnership can reduce health disparities, support self-determination, operationalize calls to action for Indigenous 5 health, and improve well-being (12). I have established a partnership with the Gitxsan Nation for this project. Gitxsan Health and the Gitanmaax Band have provided approval of my research activities as described in this thesis proposal, as well as identified definitions of success in this research for the nation. The findings of my research will have a direct impact on health service planning and priorities for the Gitksan community and other BC nations by providing quantitative justification for grant funding for reproductive health services. More broadly, this research supports Indigenous communities in their self-determination of their own reproductive wellness by providing insight into a topic that has not received much coverage. My overarching goal is to understand the factors that both limit and support Indigenous youth in achieving their optimal health and reproductive wellness. I use that knowledge of barriers and successes in Indigenous youth sexual health services to identify best practices that address the unmet needs of youth. My quantitative research explores the experiences of Indigenous youth aged 12-19 using the BC AHS dataset, which currently represents approximately 98% of youth attending public school in BC (15), which enhances the potential impact of my research. This project took place in partnership with UBCâs Contraception and Abortion Research Team (CART) under the umbrella of the 4-year CIHR-funded Story Project (Improving Access to Family Planning for Indigenous People through Storytelling) which focuses on Indigenous community members and health care providersâ experiences with accessing and providing contraception and abortion (14). This supportive environment enhances my potential for knowledge mobilization. As an ongoing commitment to doing this thesis work, I will also work to lift Indigenous communities, including the Gitksan Nation, by providing relevant and usable 6 knowledge translation of results which can be used by the community either for information services or as justification for grant proposals. The end goal of this research is to optimize access to contraception and abortion services for Indigenous youth in Canada. 1.3 Structure of the thesis In Chapter 1, I introduce my thesis and describe the limited prior literature on the experiences of Indigenous youth accessing sexual and reproductive health services. In chapter 2, I present the results of my systematic review of the experiences of Indigenous people in Canada accessing contraception and abortion services (Objective 1). In chapter 3, I present the results of my analysis of Indigenous youth reproductive health data from the 2023 BC AHS in partnership with the McCreary Centre Society (Objective 2). In chapter 4, I critically reflect on the results of my primary research chapters and situate my results within both the existing peer-reviewed literature and Indigenous knowledges. 1.5 Theoretical and Methodological Frameworks 1.5.1 Positionality Statement I, Samantha Martin-Ferris am a Gitksan researcher and an advocate for culturally safe, accessible and appropriate sexual and reproductive healthcare for Indigenous youth. My adult Gitksan name is Siim Guu Galx which means âready and willingâ. My grandmother gave me this name when she heard I was attending my Masterâs program, so that when I introduced myself to others in Indigenous communities, they knew I was ready to do the work. As I write this positionality statement nearing the end of my project journey, I would like to reflect on how I am honoured to 7 get to receive and listen to the stories of Indigenous people and their journeys accessing contraception and abortion services. My research is grounded in my own experiences as a Cis-queer woman who has had their own experiences with accessing contraception and abortion services. I have been privileged enough to have been raised both as a full member of the Gitksan community and in the urban setting of Vancouver, British Columbia. Because of this, I have had the honour of holding my own cultures and traditions closely while still being able to access institutions and services which other Indigenous youth may not have had the ability to. I have an undergraduate degree in First Nations and Indigenous Studies (FNIS) from UBC. During this time of study, I received OCAP certification and gained experience in conducting research with Indigenous communities through my practicum with the Aboriginal Community Career Employment Services Society (ACCESS) in Vancouverâs Downtown East Side. This work gives me grounding in my practices and reminds me of the people whose lives I am working to improve. I have been involved in leading youth-based research projects with the McCreary Centre Society for 6 years. From 2018 to 2022, I researched, co-designed, and led Ravens V: A Focus on Indigenous Youth Health, a 63-page report on Indigenous youthâs health in BC. Through this reportâs findings, I began to create an early hypothesis for my thesis. 8 As an academic trainee, I have been privileged to witness negotiations of power and structure within academic and medical-based institutions and negotiate my own place within these spaces. In turn, I have been honoured to see my colleagues and community stand up and work to decolonize these institutions while lifting up Indigenous voices. This has occurred through relational practices and a strong conviction that we will not be bystanders to the histories of colonization we collectively hold as a society. As an Indigenous woman who has been invited into an academic space, I have been allowed to step into my own place of power, and I would like to reflect on this by saying that I will do my best to take my time and quietly listen to the communities I work with as it is my job to bring forward the truths that they speak. If I have one request for this thesis to whoever reads it, it is that you will listen quietly too, and you will honour the fact that, as academics, it is not our job to cast our judgments but to shine a light on truths while setting aside our harmful biases. I hope that this work can support academics, healthcare professionals and Indigenous communities in a way that is holistic and does not stigmatize Indigenous youth. For us to truly decolonize, we must provide communities with support that truly prioritizes their own well-being and meets them where they want to be met. 9 1.5.2 Ownership, Control, Access and Possession (OCAP) My thesis has followed OCAP methodologies which have focused on community-led, participatory approaches. OCAP is a methodology established by the First Nations Governance Centre, which stands for: Ownership, Control, Access and Possession (15). Through my research, I aim to share my findings not only with the Gitksan community but also with other Indigenous communities interested in access to and care for family planning and sexual health. This includes: - Giving the Gitksan community the right to use this data in ways that they see fit to justify grant funding for themselves in the future (ownership and control). - Giving them the ability to create this research in a way that the community defines as successful (control). - Allowing them to have oversight over what goes into the project (access). - The Gitksan community will be given at the end, completed knowledge translation products which they can collectively use as a community (possession). My research has followed a community-based participatory action research (C-PAR) model, which focuses on involving the Indigenous community at all stages of the research. C-PAR may be used as a methodology which focuses on gaining feedback on research at the ground level by involving the community at all stages of development (16). Indigenous storytelling can be used 10 as a methodology, as it plays an important role in preserving and gathering traditional knowledge. 1.5.3 Community Involvement This work has included oversight from Gitksan Health, McCrearyâs Indigenous advisory board, and the Story Project. Specifically, for the Story Project, in fall 2022, the outline of my thesis proposal was reviewed and supported by the Matriarchs and Knowledge Keepers (MACK) Advisory Circle convened by the Vancouver Coastal Health Indigenous Health. McCrearyâs young Indigenous Advisory Team (YIRT) has also been a part of its development and will assist in KT tools going forward after completing my thesis. The results from this research will be synthesized into a community report as a part of the McCreary Center Societies Ravens VI: A Portrait of Indigenous Youth Health community report. This thesis will guide further analysis which will be conducted on McCrearyâs Homeless Youth Survey (HYS) sexual health section as a part of my MITACS fellowship. I apply a holistic Indigenous-based approach to data analysis throughout the thesis. This means that I examine my results through a Two-Eyed Seeing perspective which is to examine data and thought structures through both Western and Indigenous lenses. Using this methodology, I examine the mental, emotional, spiritual, and physical aspects which contribute to Indigenous youth wellness in relation to accessing family planning and abortion services. Two-Eyed Seeing complements a C-PAR approach by exploring knowledge in different ways outside of a colonial context, honouring and incorporating Indigenous ideologies. I believe that this will be important for me both during my feedback sessions with the community, and also while I conduct my research. 11 1.5.4 Anti-racism and Decolonization This work follows a grounded approach that focuses on recognizing my experiences as an Indigenous woman and researcher. As Indigenous ideologies and viewpoints are often relational, community-based and rooted in tradition, I believe that it is important that I incorporate Indigenous knowledge in a way that that is helpful and gives back to Indigenous communities. During this project I have had to negotiate my own space on how we can work to reduce harm to Indigenous bodies working on these kinds of projects. Because of this, my team and I have made a conscious decision to celebrate and uplift Indigenous projects that demonstrate best practices and achieve clear, positive outcomes. We have also worked to reduce the implicit and harmful bias seen in older articles reviewed for the systematic review. It should be acknowledged that we all implicitly bring bias to the table when conducting research; however, we can choose to examine it and use it constructively. In this practice, adopting an anti-racist, decolonial approach meant incorporating literature and worldviews that fell outside the traditional academic scope. We did this by including grey literature such as community health reports, which are meant to serve communities in a clear and easy-to-understand way. This also meant having discussions on the academic literature we found problematic. This involved examining the potential implicit bias that healthcare professionals may bring to the table when authoring academic literature and working to objectively measure their research in a way that would not perpetuate harmful stereotypes. 12 1.6 Conclusion The goal of this thesis is to investigate the reproductive health barriers and best practices for Indigenous peoples in Canada. From this, it is my hope that we can begin to start planning for the future of reproductive health for Indigenous people in Canada. I do this by reviewing the limited literature available on Indigenous peoplesâ experiences with accessing sexual healthcare services in Canada as part of a systematic review. I have also conducted my own original research on the background of the sexual health of Indigenous youth in BC aged 12-19 through the 2023 BC AHS survey. Alongside this, I have examined what factors may contribute to negative sexual health outcomes such as STIs and unplanned pregnancy. 13 2. Experiences of access to contraception and abortion care among Indigenous clients; A systematic review and integrative synthesis of qualitative and quantitative studies âSome nurses and doctors returned. I could hear them talking. My partner, who was sitting on my left side by my head, told me that the delivery team were huddled at my feet. A nurse then approached me on my right-hand side and said really loud that I couldnât hold another baby, and it was best that they tie my tubes. I was confused and I looked towards my partner. The nurse then turned to my partner, and she said, âShe canât hold another child. Itâs in her best interest to have this procedure done.â My partner reiterated what the nurse had said, so I asked if it was reversible. She said yes. I had no time to think, and I couldnât think clearly. The nurse informed me that I needed to decide. I was coerced into deciding, still being fully exposed, my abdomen still open from the C-section, my arms still tied down and numb. I felt pressured to say yes. Moments later I could smell something burning and thought, âDid they just burn my tubes?â Then the doctor proceeded to close me up. I trusted the medical team but knew something wasnât right when I smelt the burning flesh. These were strangers who I had no previous encounters with who insisted I tie my tubes. The medical team took advantage of me in a vulnerable state.â â Nicole Rabbit, The Scars We Carry, p. 14 (2). 14 2.1 Introduction Indigenous people face a history of colonization in sexual and reproductive health services from residential schools, Indian Hospitals, and ongoing forced and coerced abortion and sterilization. In the wake of these events, Indigenous communities have continued to rebuild diverse pathways which support culturally safe sexual and reproductive health services. However, there is still undeniable damage which has been done in the form of severance of Indigenous knowledge and trust in relation to Indigenous healthcare related to sexual and reproductive health (17). In recent years, Indigenous peoples have been cited as one of Canadaâs fastest-growing populations yet remain disproportionately represented in sexual health-related statistics (18). For example, Indigenous peoples make up 6% of the population, yet they were reported to make up 10% of all HIV cases in Canada in 2016 (19). The ongoing harm towards Indigenous peoples in the form of forced and coerced sterilization was recently acknowledged by the Canadian Senate in the report The Scars We Carry (2). The report and subsequent investigation identified that Indigenous peoples continue to be forcefully sterilized through non-consenting practices by healthcare professionals in the present day. The report included evidence that these ongoing harmful practices lead to fear and reluctance among Indigenous peoples seeking to access sexual and reproductive health services in Canada. Historically, Indigenous communities have identified and implemented wise practices in sexual and reproductive health, simultaneously empowering community members while mitigating exposure to anti-Indigenous racism in the healthcare system. Culturally safe programs respond to 15 the needs of patients and attend to the diversity of Indigenous health practices. For example, the Native Youth Sexual Health Networkâs âSexy Health Carnivalâ seeks to destigmatize sexual health education for youth by delivering it through carnival games that celebrate the culture and language of local Indigenous communities (20) . To scale up such wise and promising practices, it is critical to understand the past and present experiences of Indigenous peoplesâ access to contraception and abortion care in Canada, identify harmful practices, and highlight opportunities for strengths-based, safe care. Ultimately, naming these truths is a first step in reducing disparities in access and outcomes. We sought to conduct a systematic review to identify, appraise, and synthesize the literature on Indigenous clientsâ experiences of access to contraception and abortion services in Canada. The evidence generated by systematic reviews often forms the building blocks for policies, practices, and implementation. Thus, our secondary aim was to identify specific wise practices in culturally safe contraception and abortion care that could be adapted or scaled up to improve health services. 2.2 Methods 2.2.1 Study Design We used a convergent integrated synthesis approach, which is ideal for synthesizing diverse quantitative and qualitative knowledge to corroborate results across study designs and provide greater analytical depth and breadth of the evidence (21). We analyzed and reported results from quantitative and qualitative evidence together and integrate our interpretation in the Discussion (21). 16 We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 statement to guide the process and reporting for our literature review (22). Following best practices for systematic reviews, our team also included an informational specialist who co-constructed and conducted the database searches (PJ). This review was registered on PROSPERO (CRD42022382157). 2.2.2Critical Approach Traditional research practices have historically ignored the health knowledge and practices of Indigenous peoples. Decolonizing research aims to counter this suppression by relinquishing control of the research process and respectfully engaging with Indigenous peoples and knowledge to ensure community benefits (23â25). Anti-racist research practices work to erase discrimination while celebrating wise practices from racialized academics and communities. Indigenous community-based research is one such anti-racist practice that seeks to create grassroots-led knowledge and solutions, which in turn work to decolonize harmful spaces. In our systematic review, our critical, anti-racist approach prioritized the epistemic assumptions and knowledge systems of Indigenous peoples in Canada (26). For instance, through inclusion of grey literature, we sought to center culturally relevant and specific knowledge, practices, and protocols for abortion and contraception care. We also used trauma-informed practices when working with the review data to promote safety, empowerment, and respect for the co-authors. This included regular check-ins with team members who were at risk of experiencing second-hand or vicarious trauma in reviewing data on gender-based violence and reproductive coercion. 17 In our synthesis and interpretation, our trauma-informed, anti-racist approach focused on respecting culture as medicine, as well as framing the results to reduce the implicit bias displayed in some of the papers. We sought to name and reframe stereotypes and use strengths-based language. For example, some papers included substance use as an indicator for at-risk sexual and reproductive health outcomes rather than as an exposure, that is, a byproduct of colonization. By reframing these implicit biases, we sought to acknowledge that the social determinants of good health identified in the articles we identified were directly and indirectly impacted by colonization (27). 2.2.3 Self-Location I am an Indigenous graduate student of the Gitksan First Nation and a non-Indigenous cis-gender female. My supervisor is of English and Scottish ancestry and conducts research on equitable access to family planning care (SM). The search strategy, screening, and extraction were guided by the lead authors and completed by an Indigenous medical student and member of the Simpcw First Nation (BM), two non-Indigenous graduate students (VP, ZK), and a non-Indigenous information specialist who supported the co-design of the search strategy (PG). The last author is an Indigenous scholar and birthworker of Cree, Saulteaux, Jewish, and mixed-European ancestry who belongs to the Cyr family from the Pasqua First Nation (DJ). Together we iteratively reviewed, reanalyzed, and reframed the results of this review to remove Euro-western and racist constructs, particularly when synthesizing results of studies prepared by non-Indigenous researchers. 18 2.2.4 Community Involvement In addition to the co-author team above, our review was informed by an advisory circle of Indigenous health scholars, matriarchs, and knowledge keepers. The circle members advised our team through bi-annual discussions and provided guidance on the design and interpretation of this review and reviewed all materials prior to publication. 2.2.5 Search strategy The search strategy development consisted of iterative steps to ensure rigour and comprehensiveness. First, four team members (ZK, PJ, DJ, SM) created a search strategy of keywords and tested it in Medline. We began with search terms related to family planning and reproduction, including abortion, induced; contraception; sterilization; reproduction; pregnancy. Next, to ensure that the search terms accurately reflected Indigenous community names and concepts of Indigenous health and wellbeing, we shared the initial search strategy and Medline results with Indigenous and librarians at the Ì±Xwi7xÌ±wa Library (University of British Columbia), the University of Alberta, and Simon Fraser University. We cross-referenced search terms against the First Nations Métis and Inuit Indigenous Ontology list developed by the Canadian Federation of Library Associations â Indigenous Matters Committees. Finally, we adapted the search strategy to both indexed and grey literature databases. Our search strategies used a comprehensive combination of medical subject headings (MeSH) and keywords for the concepts of Indigenous peoples and family planning. We searched the indexed and grey literature for English language records from January 1, 1998 until November 15, 2023. 19 Our indexed literature search was conducted in three phases: 1) electronic database searching, 2) hand-searching of key journals and foundational studies, and 3) checking the reference lists and citations of studies that met our inclusion criteria (21). For Phase 1, we searched the following 6 indexed databases: CINAHL, Pubmed, Medline (Ovid), Psycinfo, EBSCO, and the Native Health Database. Our search of the grey literature was completed by two team members (BM, DJ) and likewise involved three phases: 1) electronic database searching, 2) hand-searching of key websites, and 3) consulting subject experts and relevant authorities. For Phase 1, we searched the following 8 databases recommended by the information specialist on our team (PG): UBC Theses and Dissertations, ProQuest Theses and Dissertations Global, Web of Science Core collections, CADTH, TRIP, CIHI, desLibris, and Native Health Database. For Phase 2 of the grey literature search, we used Advanced Google search to identify relevant documents on relevant authoritiesâ website domains using our grey literature search terms (see Supplementary File 1). We then further narrowed results for specificity using âfilename: pdfâ to identify documents. For authorities without an Indigenous-specific focus, family planning search terms were used in conjunction with Indigenous populations identifier search terms to achieve greater specificity. For each search, the date and total number of results were recorded in a spreadsheet and the number of documents saved for further review. The first 100 results of each search were reviewed for consistency. For the detailed search strategies see Supplementary File 1. 20 2.2.6 Inclusion Criteria To be included in the systematic review, all studies had to be: 1) conducted in Canada, and 2) include Indigenous peoples' experiences with accessing sexual and reproductive health services for contraception and/or abortion. We did not restrict based on sex or gender and included studies involving Indigenous women, men, youth, Two-Spirit, trans, and queer Indigenous people. We included Indigenous peoples in Canada, which includes First Nations and Métis peoples, and Inuit. For the search of indexed literature, we included any kind of studies that included primary research whether they be quantitative, qualitative, or mixed methods. We also included studies involving health policy analysis. We excluded literature reviews. For the grey literature search we included theses, dissertations, reports, conference proceedings, working papers, government documents, program evaluations, and unpublished research and data. 2.2.7 Study Selection To facilitate the study selection process, all search results were uploaded to Covidence software and automatically screened to exclude duplicates. Two team members (SMF, VK) independently screened titles and abstracts and then read potentially relevant studies in full text. At both stages of screening, we documented reasons for exclusion and any discrepancies in interpretation were discussed with the co-first author (SM) or the research manager for the Story Project. Search 21 results are presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram (Figure 1). 2.2.8 Appraisal Two reviewers (SMF, VP) conducted all quality assessments in duplicate. All indexed studies that met the inclusion criteria after full-text screening were then appraised using the Well Living House quality appraisal tool [12]. Each document was scored in 3 categories: 1) local Indigenous community relevance of method and measures, 2) rigour and internal validity of the evaluation method, and 3) strength of the evidence. The first category is scored out of eight, and the following two categories are each scored out of four for a total score of twelve. Sources that scored less than 6 were excluded from the study. One reviewer (BM) assessed the grey literature using the AACODS checklist (Authority, Accuracy, Coverage, Objectivity, Date, Significance), which evaluates the quality of sources based on six yes or no questions: 1) Authority: who is responsible for the content? 2) Accuracy: is the content clear and consistent? 3) Coverage: what is the scope? 4) Objectivity: what are the underlying biases (stated or unstated)? 5) Date: how current is the content? 6) Significance: is the resource meaningful, representative, or impactful? If a study scored less than 3, it was removed from the study. 22 2.2.9 Data extraction Two reviewers extracted key data (design, study period, study aim, study location, sample size and characteristics, results, abortion studied, contraception studied) using a form adapted from previous mixed methods reviews of contraception and abortion research.[14] We resolved discrepancies through discussion with the co-lead author (SM). 2.2.10 Data synthesis and integration We summarized the quantitative data descriptively and used Sandelowskiâs method of âqualitizing dataâ to extract findings and rewrite each into a portable declarative statement, while preserving the context of their production (28). Together we (SM, SMF, VP) drafted the declarative statements, and discussed with the Story team where necessary to achieve interpretive consensus. We then analysed these statements using a comparative coding strategy derived from thematic synthesis (29). Thematic synthesis, one of the Cochrane Collaborationâs recommended methods of qualitative evidence synthesis, builds on established techniques from thematic analysis to go beyond the content of individual studies to identify patterns and produce a summary of the current state of knowledge in relation to our review question. I (SMF) iteratively synthesized the characteristics of the studies drawing from the declarative statements. I met regularly with my supervisor (SM) and shared results in progress with members of the Story Project team to refine and extend my analysis. 23 Throughout, we took a relational, decolonizing approach that began with âseeing beyond âthe gapââ to see silences in the literature as learning opportunities (24). We considered the inclusion (or lack thereof) of Indigenous team members in the studies and explored texts outside of the indexed academic literature. By self-locating our identities and motivations to conduct this review, we further aim to reflect on power dynamics, intentions, and collective experiences in research with and for Indigenous communities. 2.3 Results The electronic search yielded 4766 unique citations after removal of duplicates, from which 4660 were removed after title/abstract screening. A total of 101 studies were selected for full text review, from which 47 were excluded, most based on the primary exclusion criteria (they did not capture abortion and/or contraception experiences, n=22). We thus were left with 54 unique citations that involved Indigenous clientsâ experiences accessing contraception and abortion services in Canada and were eligible for full inclusion in our synthesis. (See Figure 1, PRISMA flow chart) 24 Figure 1.1 PRISMA flowchart 25 2.3.1 Quality appraisal Academic articles were assessed using the Well-Living House Quality Appraisal Tool (WLHQAT) based on the following criteria: 1) community relevance, 2) rigour and internal validation of the evaluation methodology 3) the strength of the evidence provided (30) (See Appendix). Among the 101 articles assessed for eligibility, 8 scored less than 7 WLHQAT. These studies were excluded from the synthesis. The average WLHQAT score for a peer-reviewed, indexed article included in the systematic review was 10.7 out of 12 (rounding up to the nearest decimal). Low scoring was more frequent among quantitative than qualitative studies and primarily due to a lack of Indigenous community involvement or lack of Indigenous definitions of success. Grey literature was assessed by evaluating the authority, accuracy, coverage, objectivity, date of publication and significance (ACCODS) of the article (31). The average ACCODS score for a grey literature article was 5.9 out of 6. Among the 40 quantitative articles, all grey literature assessed had Indigenous community involvement in some way. Because of this, they more frequently also included Indigenous community definitions of success in their work. In contrast, for the 14 quantitative peer-reviewed studies, the full-text review process often identified that there was little consultation of Indigenous communities in the research. Because of this, grey literature may pose a better 26 understanding of Indigenous and sexual-related health materials in the quantitative sample as they were developed in partnership with Indigenous communities. 2.3.2 Characteristics of included studies Table 1 (see Appendix) presents the main characteristics of the 54 included studies. Registered databases that yielded results included Pubmed, CINHAL, and PSYCHINFO. Search results from EBSCO and the Native Health Database did not retrieve new articles. In total 4766 of the 5838 articles met title criteria for screening. Among these 101 were eligible for assessment after abstract review. 47 articles were screened out leaving 54 articles for full-text review. Common reasons for being screened out included covering reproductive health topics but not covering contraception or abortion, not including Indigenous peoples in Canada, as well as not meeting minimal scoring criteria. 27 2.4 Results of integrative synthesis Our analysis and synthesis resulted in development of a framework depicting Indigenous clientsâ experiences accessing contraception and abortion services in Canada, and opportunities for health service improvement: 1. Reproductive resistance: The impact of colonization on contraception and abortion experiences of Indigenous peoples 1. 2. Alone together: Navigating geographic isolation and privacy in rural and remote communities â¢ 3. Promising practices: What can we do to improve patient care and celebrate Indigenous health? Table 2.1 2.4.1 Reproductive resistance: The impact of colonization on contraception and abortion experiences of Indigenous peoples Our analysis identified a pattern across the included literature, highlighting the system-level barriers that impede Indigenous peoples from attaining sexual health and well-being. These system-level barriers are due to the ongoing direct and indirect impacts of colonization on Indigenous health. Colonization has severely disrupted Indigenous peoples' ability to make autonomous decisions regarding their reproductive health and futures. The included literature specifically points to an erosion of traditional knowledge systems around sexual education and reproductive practices, stripping communities of generational wisdom, and colonial policies that violated Indigenous bodily integrity through coerced and forced sterilization. This oppression of 28 Indigenous reproductive knowledge and rights has been a deliberate tool of colonial control (32,33). As Stote notes in her book, An Act of Genocide, forced and coerced sterilization to control Indigenous populations took place at the discretion of provinces up into the late 80âs until the act was fully condemned by the Canadian courts in the â80s to mid-early 2000s (1) Forced and coerced sterilization continues to this day as the 2022 Senate report, The Scars We Carry, describes. These procedures are often conducted with a lack of consent and under duress (2). System-level impacts of colonization also include increased health risks. For example, the breakdown of cultural values and knowledge transmission has created health disparities for Indigenous communities, such as higher rates of STIs and early pregnancy among Indigenous youth (34). Multiple articles referenced the need to return to the use of traditional practices, including medicines, ceremonies and birthing practices, to regain this self-determination (32). The impact of system-level access barriers can be seen in the results of population-level surveys, which have identified decreases in contraception utilization among some Indigenous youth over time. The McCreary Centre Society published the report Ravenâs Children V: A profile of First Nations, Métis, and Inuit youth health in BC (2022) (3) . The study was based on the 2018 BC AHS and included 3,800 Indigenous youth, which represented 10% of the total 12-19 youth population in the province of BC. Among all Indigenous youth in BC, 29% had ever had intercourse. Among those that had ever had sex, 21% of youth who ever had oral sex used 29 protection the last time they did so, while there was a decrease in the percentage of those who used condoms the last time they had intercourse (57% vs. 68% in 2013). Since 2013 there was also an increase among Indigenous youth using withdrawal as their only contraception method (11% vs. 6% in 2013. There was also an increase in those who reported using an IUD (4% vs. 1% in 2008). We also identified that several studies took a deficit-based approach to investigating contraception and abortion experiences of Indigenous peoples. This included focusing on âat riskâ populations and risky health behaviours (e.g. drug and substance use). In this context, we define âat-riskâ as populations that have other health risks, such as those who may be using substances other than alcohol or marijuana, those who may be homeless or facing homelessness or those who may have a sexually transmitted disease such as HIV or AIDS. Dunn et al.âs analysis of non-use of contraception by Canadian youth aged 15 to 24 identified risky behaviours associated with non-contraceptive use among 300,000 youth who answered the 2009-2010 Community Health Survey administered by Statistics Canada (35). Among Indigenous youth, 25% were found to have an AoR of 1.67 (1.18â2.37) for contraceptive use, with 25% being identified as contraceptive non-users. Risk factors among all youth for non-contraceptive use included belonging to lower income sociodemographic backgrounds (Adjust AOR 0.90, 0.83â0.97 P. Value 0.0077) and smoking 1.55 (1.24â1.92). Alcohol use was not considered a factor. 30 The Cedar Project was a prospective cohort study that aimed to understand the HIV and Hepatitis C related vulnerabilities of young Indigenous people who use drugs in Prince George and Vancouver's Downtown Eastside (DTES)(36). Chavoshi et al (2013) enrolled 605 participants aged between 14 and 30 who had smoked or injected drugs in the past month. Women who did not use condoms consistently were also more likely to have reported being in a relationship (Unadjusted GEE 3.01;95% CI 2.30,3.94 P. Value <.001) and having had an STI in the past 6 months (Unadjusted GEE 1.75, 95% CI 1.12,2.19 P. Value .01)(36). For men, the factors associated with inconsistent condom use included smoking crack cocaine daily (Unadjusted GEE 1.67 95% CI, 1.11, 2.53 P Value .01) as well as being in a relationship (Unadjusted GEE 5.30 95% CI, 3.83,7.32 P. Value <.001). Daily heroin smoking was also marginally associated with inconsistent condom use amongst both groups (Unadjusted GEE, 1.72 95% CI 0.99, 3.02 P Value .06). Age was not found as a covariate factor among any groups. Saewyc et al. (2008) explored the experiences and social determinants of health of marginalised and street-involved youth in BC, using data from McCreary Centre Societyâs 2006 Youth Homeless Survey (37) . Among the 763 youth surveyed; 410 youth identified as Indigenous (54%). Youth surveyed were between the ages of 12-18 in BC. Among all youth surveyed, 69% had had oral sex and 79% had had sexual intercourse and the majority of the youth surveyed (73%) reported using some form of contraceptive the last time they had sex. Among all youth, 30% of males and 23% of females reported that they had been sexually exploited. 31 One quantitative article highlighted the impact of the COVID-19 pandemic on access to contraception. Baaske et al. (2022) examined the impact of the COVID-19 pandemic on 3691 women aged 25-69 in BC, exploring access to birth control and emergency contraception, as well as attendance at cervical and breast cancer screening in BC (38). While the study cites Indigenous women facing higher barriers to accessing contraceptives it does not list their sample size. The study cites Indigenous women had an AOR of 5.56 times that of non-Indigenous women in accessing contraceptives (95%CI2.44e12.50; P<0.001). 2.4.2. Alone together: Navigating geographic isolation and privacy in rural and remote communities Geographic access to care was highlighted as a critical challenge in remote northern areas, where there are fewer healthcare providers and options for sexual health services, which in turn creates logistical and confidentiality barriers unique to contraception and abortion care. Confidentiality concerns were noted as a specific barrier in smaller tight-knit communities as there may be a lack of anonymity in accessing services that clients wish to keep private (39). Qualitative study participants received inconsistent information when contacting abortion service providers and travelled significant distances to access abortion. âI called and I made the appointment, and it was a couple weeks later â¦ I didnât have a car, so I didnât know how I was getting there. I didnât have money to get there. Itâs about a seven- or eight-hour drive from where I was living, and thatâs the only place that anyone in Newfoundland can go.â - Interview #6 (1). 32 Leason et al. highlight this intersection between confidentiality and rural location in their analysis of maternal experiences in the Okanagan valley. They juxtaposed quantitative data from Indigenous women's responses from the Canadian Maternity Experience Survey with interviews they conducted on maternity experiences. In the context of abortion and contraception, Leason found that 21% of First Nations women and 16% of Inuit and Metis reporting ever having an abortion, versus 12% of non-Indigenous women (2017). In their interviews they found a fear of confidentiality as the main concern when accessing abortion services on reserve. Sethna and Doull's GIS study (2013) highlighted the importance of providing accessible abortion services for those that may have to travel outside of their communities either because they do not have access to services there or for fear of lack of confidentiality (6). Among 17 of the 26 freestanding abortion sites that were in Canada during the study period, 1186 women participated who were between the ages of 12 and 48. Although only 7.4% of respondents were Indigenous, they were 3 times more likely than other groups to report that they needed to travel over 100 km to access an abortion (OR=0.67 [95%CI:0.48,0.93]). They cited a need for readily accessible abortion providers as hospitals may have lengthy wait-times, may have biased staff or may lack confidentiality. This study was completed prior to the introduction of mifepristone medication abortion to Canada in 2017, which shifted the provision of abortion from purpose-specific abortion clinics to primary care settings. Beyond geographic accessibility, we identified that reproductive health policies and narrow provider scope of practice limits abortion access. Participants noted that some doctors refused to 33 provide a referral for contraception or abortion care due to personal beliefs. This disproportionately impacted and created delays for rural clients (40). Additionally queer Indigenous people identified that on top of having difficulty accessing SRH services due to location that they also feared for a lack of privacy when accessing sexual health testing services (41). 2.4.3 Promising practices: What can we do to improve patient care and celebrate Indigenous health? Quantitative results suggested that abortion and contraceptive access varied by Indigenous populations and setting, highlighting opportunities to build on promising trends. For instance, in the Ta Saantii Deu/Neso report involving data from 410 Métis youth aged 12-19 in BC who participated in the 2018 BC Adolescent Health Survey, Poon et al. (2019) identified that Métis youth were more likely than non-Métis youth to have ever had oral sex (34% vs. 21%) or intercourse (33% vs. 19%), but were just as likely to have used protection the last time they were sexually active (42) . The methods Métis youth used to prevent pregnancy the last time they had intercourse (among those who ever had intercourse) were, in order of frequency: condoms (55%); birth control pills, birth control patch, Nuva Ring, or other method prescribed by doctor or nurse (50%); withdrawal (46%), emergency contraception (6%), and IUD (5%). The 2002/3 First Nations Regional Health Survey conducted by the First Nations Governance Centre involving 22,602 survey respondents (10,962 adults, 4,983 youth and 6,657 children) found that among female Indigenous respondents in British Columbia, 62% of adults and 23% of 34 youth reported using some form of contraception (43) , with higher uptake in urban areas compared to rural areas. In addition to identifying gaps in care, our analysis suggests that implementation of Indigenous-led solutions can increase Indigenous reproductive autonomy and access to culturally safe reproductive health services (33). Burchell et al (1997) observed a positive association between traditional knowledge and proactive condom use (5). The authors interpreted that this behaviour may be associated with higher rates of self-esteem and better health knowledge. Shercliffe et al (2017) identified a negative correlation between the age of first sexual encounter and condom use, which suggests interventions that prevent sexual abuse also support improving the trends seen in low contraceptive use(44). In our sample, Indigenous-led solutions were generated typically through participatory research approaches that engaged Indigenous clients as equal partners to inform program development and policy concerning Indigenous reproductive health. The results of participatory research involving Indigenous-led contraception and abortion services included low-barrier clinical services via drop-ins, extended hours, and open-door access, which increased the availability of reproductive healthcare. Offering housing help, mental healthcare, and legal aid alongside reproductive services for Indigenous women addressed the structural barriers they faced (45). Culturally safe education was a means of building trust, promoting confidentiality, and reducing stigma around contraception and abortion in Indigenous communities (46). Confidential systems for referrals and telehealth options may assist in protecting privacy around Indigenous 35 reproductive healthcare choices, especially in small, close-knit communities where there may be a lack of anonymity (39). The Sexy Health Carnival developed by the Native Youth Sexual Health Network (NYSHN) uses games and posters to get Indigenous youth under 30 excited by sexual health. Evaluation of the program successfully indicated that key ingredients for success included integrating cultural elements, local languages, medicines, and animals to create relevant conversations for youth (20). Position papers included in this review, which cite primary knowledge from Indigenous knowledge holders and experts, call for concrete actions to mitigate past violations of Indigenous reproductive autonomy. They affirm patient rights, condemn ongoing paternalism, and advocate for self-determined, culturally safe sexual and reproductive health services. Their calls to action provide guidance to policy makers and healthcare providers. For instance, the National Council of Indigenous Midwives' statement on forced and coerced sterilization demands an immediate end to involuntary procedures. It urges healthcare practitioners to ensure informed choice when providing sexual and reproductive health services. The First Nations Health Authority's Sacred and Strong report calls for maternal health practices to be rooted in ceremony in relation to community connection and land. Their section on Sexual Well-Being and Reproductive Justice calls for Indigenous women's rights to choose their own sexual health journeys and that contraceptives empower a woman's right to choose (12). Similarly, Pauktuutit's Access, Respect, Consent report on Inuit women's healthcare highlights the need for culturally safe services and a full range of contraceptive options. It notes that 36 attitudes of healthcare providers and community members can pose barriers alongside systemic issues like staffing shortages in the North (47). 2.5 Discussion Our systematic review highlights the complex connections between colonial legacies and contemporary barriers to SRH access among Indigenous peoples. Three key themes emerged from our analysis: the lasting impacts of colonial reproductive oppression; geographic and privacy challenges unique to rural and remote communities; and promising practices for Indigenous-led healthcare solutions. The historical context of forced sterilization and the erosion of traditional knowledge systems continues to shape present-day reproductive healthcare experiences for Indigenous pregnant-abled bodies (20). As documented in recent Senate reports these violations persist into the present, highlighting the urgent need for systemic change (4). Population-level surveys indicate that contraception utilization among Indigenous youth, suggesting that these systemic barriers are affecting health outcomes (5,38,43). However, our analysis also reveals promising paths forward through Indigenous-led solutions and culturally safe approaches to care (23,33). Successful interventions typically feature participatory research approaches, low-barrier clinical services, and comprehensive support that addresses structural barriers alongside healthcare needs. 37 Moving forward, healthcare systems must prioritize Indigenous reproductive autonomy and self-determination (33). This includes supporting Indigenous-led healthcare initiatives, ensuring informed choice in reproductive care, and implementing culturally safe practices that honour traditional knowledge and ceremonial approaches to health. Future research should continue to centre Indigenous voices and experiences while working to address the systemic barriers identified in this review. 38 3. Statistical Analysis on Indigenous Youths Reproductive Wellness in BC In this chapter, I conducted a comprehensive analysis of reproductive health statistics pertaining to Indigenous youth. This includes the examination of sexually transmitted infections (STIs), as well as pregnancy. Chapter 2 of my thesis delineated the predominant attitudes that Indigenous populations may exhibit towards engaging in sexual and reproductive health (SRH) services. Due to historical experiences of forced and forced sterilization, colonization, and religious medical practices, Indigenous communities understandably exhibit a lack of willingness to utilize medical services (1). From the findings of the systematic literature review, we identified a current gap in the literature on barriers to good sexual and reproductive health (SRH) experiences of Indigenous youth. Of the 54 articles reviewed, only 12 provided a quantitative analysis. These articles mainly focused on contraceptive use, income levels, and substance use; however, few considered contributing factors, such as exposure to adverse childhood experiences (ACE). Potential ACEs include events that can cause significant stress in childhood development, such as a divorce, incarceration of a parent, or physical or sexual abuse. In their research, Wood et al. (2022) found a positive correlation between a high number of ACE exposures and risky sexual behaviour (48). Similarly, Devries et al. (2009) found a correlation between Indigenous youth in BC who had experienced sexual abuse and also experienced risky sexual behaviour (49). 3.1 Introduction 39 Currently, there are no national estimates available for STI rates among Indigenous people in Canada, as cases are recorded solely by sex at birth and age. Ethnic identity is currently not recorded as an identifier. HIV/AIDS contraction rates, however, are reported on a roughly 5-year basis at a national level for Indigenous people (50). In 2020, the Community AIDS Treatment Information Exchange (CATIE) estimated that 6,472 Indigenous people lived with HIV in Canada, accounting for 10% of all HIV cases in the country. It was noted that where there are 4 HIV infections per 100,000 in non-Indigenous groups, there are 15.2 per Indigenous persons, more than three times higher (51) Geographic location can exacerbate Indigenous people attempting to access medical care (6,39). Given their geographic location, Indigenous populations may encounter additional barriers to accessing sexual and reproductive health (SRH) services, with some youth reporting the need to travel as far as Edmonton for care in the Arctic (39). Public Health Canada (PHAC) monitors STI data through the Canadian Notifiable Diseases Surveillance System (CNDSS) (52). A significant gap identified was the absence of national estimates for Indigenous people living with HIV or STI in Canada, suggesting potential underrepresentation and hindering the targeting of reduction goals (52). The most recent report on sexually transmissible diseases estimated an average of 3,876.8 cases per 100,000 in Nunavut, compared to a national average of 370.8 in Canada, which is 10 times the national average (52). 3.2 Objectives & Aims 40 In this chapter, I aim to replicate and update the findings of the study titled 'Factors Associated with Pregnancy and STI among Aboriginal students in British Columbia' by Devries et al. (2009), conducted initially 22 years ago, utilizing data from the 2003 BC Adolescent Health Survey (49). In their investigation, Devries et al. reported that 11% of Indigenous youth in British Columbia who participated in the survey experienced or caused a pregnancy, with the likelihood being equally distributed between genders. Through logistic regression analysis, Devries et al. identified that lifetime substance use and a history of sexual abuse were the principal exposures that contributed to an increased risk of encountering an STI or pregnancy. In comparison, the incidence for non-Indigenous youth was 8%. In this chapter, I seek to address the following research questions: â¢ What are the current rates of STIs and pregnancy among young people in British Columbia in 2023? â¢ What distinguishing factors are evident in the sexual health profiles of Indigenous versus non-Indigenous youth? â¢ How do various demographic groups differ in their experiences of sexual interactions? â¢ What are the critical differences concerning how Indigenous youth, differentiated by gender and sexual orientation, experience sex education? â¢ Do geographical locations affect contraceptive utilization rates? My research updates the results outlined in Devrie's earlier work and also seeks to focus on the sexual health of Two-Spirit youth and the impact of residential school exposures, using newly 41 available questions within the BC AHS. These measures can help assess the intergenerational trauma resulting from residential schools as an adverse childhood experience (ACE) affecting negative sexual health outcomes. 3.3 Methods 3.3.1 Data Sources I use data collected from Indigenous youth enrolled in public schools through the 2023 BC Adolescent Health Survey (BC AHS). Every five years, the McCreary Center Society administers the BC AHS throughout British Columbia. The BC AHS encompasses a comprehensive range of questions related to determinants of good health among young people aged 12-19 years. These areas include, but are not limited to, nutrition, sleep, physical and mental well-being, school and home environments, and sexual health (53) In 2023, BC AHS was conducted in 59 out of the 60 school districts (BREB certificate #H22-03063). Schools were given the option to participate using a paper survey or an online format. 69% of school districts chose the online format, while 29% elected the paper version. Additionally, one school district requested a mixed survey format, using both online and paper methods (54). To be included in the BC AHS, youth had to be in Grades 7 to 12, live in British Columbia, and be attending public school. 3.3.2Consent Process 42 School districts could choose between parental notification and signed parental consent for their studentsâ participation. School districts could opt for participation by requiring parent-signed permission slips, student consent, or parent notification with the option to withdraw. Student consent was required for all surveys. Parental notification yielded the highest participation rate, with 77% of youth participating when the school sent home a notification, compared to 53% for those requiring permission (54). 3.3.3 Usable Surveys Among those eligible to participate, 29% did not complete the survey. The most common reasons were absence from school (16%), followed by nonreturn of the parental consent form (8%). The rejection rate was 2% among parents and students. The non-useable survey rates amounted to 1% (54). 3.3.4 Sampling McCreary conducted an a priori power calculation to determine the required sample sizes, which were allocated proportionately to the school districts in each HSDA. The larger regions were calculated to have a standard deviation of 3%, while the smaller regions had a standard deviation of 4%. BC AHS data were weighted based on probability of selection, nonresponse adjustment, and population readjustments. An estimated 28,400 participants were needed to obtain accurate measurements for 2023 (54). The total number of samples for BC AHS represented 20% of the total population of young people aged 12-19 in grades 7-12 attending BC public schools (total N = 272,865). In total, 43 54,156 of the 272,865 enrolled youth aged 12-19 were selected for participation, representing 20% of the total school population in BC. The sampling was conducted by surveying every third classroom in the school. To participate, the classrooms had to have a minimum of 10 students. Once the survey was completed, independent random samples were selected from classrooms in each region by grade for complete randomization (53). Before administration, the survey underwent a pilot phase in the province that involved a random selection of 600 youth to evaluate the comprehensibility of the questions in various formats. The final sample size for the BC AHS was 38,488 (54). 3.3.5 Ethical Consultation Consultation procedures were carried out, including all school districts participating in the BC AHS. Educators and healthcare professionals from both postsecondary, secondary and elementary institutions participated in consultations on the survey questions (54) Engagement with Indigenous communities was facilitated through collaboration with McCreary's Indigenous advisory group, which comprises Indigenous professionals and academics, with whom I worked closely. Additionally, I assisted in delivering feedback from McCreary's Young Indigenous Research Team (YIRT), which consists of youth with lived experiences in government care, and SARAVYCâs Two-Spirit advisory committee, comprising Two-Spirit educators and healthcare professionals. 44 Additionally, for my research design and feedback, I consulted with Gitksan Health and elders in my community on the development of research questions. As Two Spirit research is still an emerging topic, I consulted with the Two Spirit Advisory of the Stigma and Resilience Among Vulnerable Youth Center (SARAVYC) regarding gender-based analysis, including research involving Two Spirit youth. The research was conducted under SARAVYCâs data ethics approval certificate (BREB Certificate: H22-03063). 3.4 Measures 3.4.1 Bivariate Analysis In total, 2 outcome measures (Table 1) and 15 exposure measures (Table 2) were examined. Sexual behaviour outcomes were measured using binary variables indicating whether youth had been diagnosed with an STI by a doctor or nurse, or whether they ever experienced or caused a pregnancy. Similarly to Devriesâ work, I hypothesized that ACE factors continue to contribute to STI rates and teen pregnancy. Rates of contraception use and related exposures for Indigenous youth aged 12-19 were examined using summary statistics. Cross-tabulations and bivariate analyses were used to compare the rates of sexual activity and the rates of sexual and reproductive health outcomes. Indigenous youth's sexual health was compared to non-Indigenous youth. Exposures were specifically focused on STI and pregnancy rates of Indigenous youth to see how they were impacted by the measures. 45 The measures consisted of a mix of forced-choice and multiple-response questions. For example, when youth were asked about their satisfaction with the sex-ed, they responded both whether they had received sex-ed, and whether they had found it helpful. Youths' substance use was classified in multiple ways with the goal of removing stigma. The Canadian Centre for Substance Use (CCDUS) defines binge drinking as consuming 5 drinks within a single setting for men and 4 for women within a few hours. It also defines moderate weekly alcohol consumption as 3 or more drinks in a week, with 7+ being considered heavy consumption (12). Instead of looking at whether youth had ever tried alcohol or had been drinking recently, rates of youth stating that they had problematic substance consumption were used. A patient intervention/exposure comparison outcome (PICO) framework approach was adopted to prioritize the outcomes of the exposures that Indigenous youth faced in their lives that impacted their reproductive health outcomes. In this case, outcomes included positive findings of either pregnancy or STIs. It should be noted that in this case, pregnancy is considered a neutral outcome, and STIs are considered a negative finding. Table 3.1: Measures Used Measures Value label Sexual Health outcome Q126: Have you ever been pregnant or have you had someone pregnant? 1=Yes 0=No Sexual Health Outcome Q127: Have you ever been told by a doctor that you have an STI/STD such as HPV, chlamydia, etc.? 1=Yes 0=No 46 Table 3.2: Exposures Used Exposures Written label Value label Racial background Q 2: Do you identify as having an Indigenous background? 1=Y 0=N Racial background Q3 What is your Indigenous background? First Nations Metis Inuit Other (written in) 1=First Nations 2=Metis 3=Inuit 4. Other 1. Age Q1: What is your age? 12 or younger, 12-19 19 or older Sexual Activity Q119: Have you ever had sex (other than oral or masturbation)? Yes No 1=Y 0=N Sexual activity Q120: How old were you when you first had sex? 12 or under 13-14 15-16- 17 or older. 1= 12 or younger 2= 13-14 3= 15-16 4 = 17 or older Gender Identity Q14: What gender do you identify as? Male Female Non-binary 1 = female 2 = female 3 = Nonbinary 4=something else (fill in the box) Gender Identity and Orientation Q6: Do you identify as Two-Spirit? Yes, No, I donât know what Two-Spirit means. 1=Y 0=N 2=I donât know Educational influence Q116: Have you ever received sex education at school? Yes, and it was helpful. Yes, but it was not helpful No [also recoded as yes, no] 0 = No 1 = Yes, and it was helpful 2 = Yes, but it was not helpful (recoded later to binary) Educational Influence Q166: The sex education I received... -Was respectful of my culture/religion. -Started at the right age -Was relevant to my gender identity?? -Was relevant to my sexual orientation Yes No Not applicable... 1=Y 0=N 2=N/A Location Health Authority Northern Interior Vancouver Island Vancouver Coastal Fraser 1 2 3 4 5 47 3.4.2 Logistic Regression Individual variables were tested using logistic regression to determine whether they significantly impacted STI and pregnancy outcomes. Variables were selected based on bivariate analysis findings. It should be noted that pregnancy and STI cases were sorted together to allow for low pregnancy N rates. Analysis was conducted later, separating the two variables, and results were similar for both groups. Including whether youth received any sex education was to test whether it was a protective factor, which it was. Condom use was also tested to better understand if, as an exposure, non-condom use was a related variable (which it was). Similarly to bivariate analysis, sexual abuse and residential school exposure were also found to be factors. Table 3.3: Variables Used in Logistic Regression Measures Value Label Sex ed any Y/N Did not use condoms Y/N Faced any kind of sexual abuse Y/N Had a family member attend residential school Y/N 48 3.4.3 Statistical Analyses Statistical analysis was conducted using SPSS Version 29.0.2.0 (IBM Corp., Armonk, NY, USA). All responses were weighted by McCreary to ensure proportionate representation, and the SPSS Complex Samples module was used to account for the complex sample design. Bivariate Associations were evaluated using cross-tabulation, and Chi-square tests were used to assess statistical differences. Two logistic regression models were used to determine which exposures influenced the STI and pregnancy outcomes amongst Indigenous youth. The variables to include in the model were chosen based on the modelling from Devriesâs original paper; we also augmented the model by adding variables identified as significant from the bivariate analysis. All results were reported with a 95% CI interval. In addition, âAgeâ was added as a predictor of STI and pregnancy outcomes. To determine the final model, we used a stepwise variable selection whereby variables were entered and removed from the model if their p-value was lower than 0.05. The final model was evaluated, including the final set of significant variables. 3.4.4 STI Outcomes Scaling Additionally, in logistic regressions and bivariate analysis, I conducted inferential statistics using epidemiological weighting and scaling methods to compare STI statistics between BC AHS results and PHAC surveillance data up to its most recent reporting period (2022). I first weighted and scaled BC AHS based on estimates and then calculated the rate of decay of PHAC results to find the average yearly rate of STIs among all youth in BC between 2019 and 2023. 49 Considering only data from Indigenous youth, I compared results based on gender identities, as well as Health Authorities (HA), to determine differences in regional contraception use. Contraceptive use rates were deliberately not reported on to avoid creating comparisons between the two populations. Instead, pregnancy and STI outcomes based on negative exposures were measured to determine the impact on health outcomes. Additionally, I compared STI statistics between BC AHS results and PHAC surveillance data up to its most recent reporting period (2022). 3.4.5 Indigenous Ways of Knowing As with other components of this thesis, I used Indigenous methods to examine health and wellness data from a new lens. In this context, collaborative knowledge-weaving sessions were held amongst Indigenous working group members and members of the Young Indigenous Research Team to highlight important information. Two-Eyed Seeing was used as a framework to examine harmful narratives in data that emerge from implicit bias. In this context, I focused on reframing the narrative to emphasize the sexual health outcomes associated with Adverse Childhood Experiences (ACEs), rather than solely concentrating on the exposures that contribute to those outcomes. For example, in the literature I reviewed, alcohol use was identified as a contributing factor in STI and pregnancy outcomes (55). However, in my own research using bivariate analysis, I found that substance use itself was not inherently problematic. Rather, individuals who reported that they had substance use 50 problems with either drugs or alcohol were more likely to report not using a condom during their last sexual encounter (26). By exploring substance use behaviours more deeply, I uncovered evidence of a broader, more holistic issue associated with intergenerational trauma (55)(26). 3.4.6 Evaluation of significance In conjunction with a PICO framework, I employed Abelson's criteria of magnitude, articulation, generality, interestingness, and credibility (MAGIC) to substantiate the significance of my research Abelson states that significant p-values suggest to readers that the results of an experiment hold statistical significance; however, they do not demonstrate the magnitude or relevance of the finding (56). In his book "Statistics as Principled Argument," Abelson asserts that the significance of a p. value is insufficient to establish a causal link to the hypothesis. Consequently, it is necessary to engage in a deductive analysis through statistical methodologies (56). 3.4.7 Magnitude I transformed the odds ratios into effect sizes to illustrate the extent to which patient groups were impacted (11). The rationale for using both odds ratios and effect sizes was to facilitate the reproducibility of this study by researchers conducting a meta-analysis (9). Moreover, I have adjusted the population rates of STI reporting numbers among Indigenous and non-Indigenous youth to align them with PHAC cases per 100,000. 51 3.4.8 7 Articulation In my work, I detail variables and question methods for clarity in conclusions. A challenge with BC AHS data is that questions did not separate frequency from exposure; for example, youth were asked only about their last contraceptive use, not its frequency. This aims to prevent survey fatigue, but it complicates the linking of variables to outcomes. My goal was to clearly present my calculations for the reader's understanding. My logistic regression includes variable analysis based on Devries' findings and ACE exposures, using significant data from prior analysis. 3.4.9 Generality Abelson finds the hypothesis applicable due to the wide-ranging conclusions (10), favouring a Bayesian approach to identify significant factors. Using Bayesian statistics in my logistic regression supports my initial findings with stronger data. Comparing BC AHS STI rates to those of CNDSS aims to provide a broader perspective on the topic. 3.5.10 Interestingness This data takes a new approach since STI and pregnancy-related outcomes among Indigenous youth in Canada have not been studied quantitatively in over 10 years. I hope this helps policymakers, clinicians, and Indigenous communities support youth with better sexual health resources. I use Statistics Canada's most recent public health report on STI rates (52), converting STI population rates per 100,000 to emphasize the importance of studying youth STI rates. 52 3.4.11 Credibility By using all of the above methods, I hope that I can provide a credible picture of STI and pregnancy outcomes for Indigenous youth in BC. 3.4.12 Missing Data Youth had a choice in whether they chose to participate in all questions in the BC AHS. Because of this there may be missing data in the form of non-responses. Non-responses may come from either survey fatigue or due to not being comfortable with the content of the question. 3.5 Results 3.5.1 Participants Analysis was conducted among all 12- to 19-year-old youth who participated in the British Columbia Adolescent Health Survey (BC AHS) 2023 across British Columbia in 2023, specifically focusing on those who were sexually active (total N of all participants = 38,488). Among the respondents, 4,552 (11.8%) were Indigenous. Of these Indigenous respondents, more than half (61%) identified as First Nations, while the rest identified as Métis (37%) or Inuit (2%). The youth had the option to select multiple Indigenous identities on the survey. The Northern and Interior regions of BC were the most densely populated regions for indigenous youth. 11% of indigenous youth had lived in a reserve in the past. Two-Spirit youth were the most likely to say that they currently lived in a reserve (18%). 53 Analysis focusing on topics related to sex was conducted among all participants. Further analysis of sexual health required participants to have had an experience with penetrative sexual intercourse. 3.5.2 Sexual Activity Overall, 20% of youth in BC reported being sexually active, with Indigenous youth comprising 14% of these cases. Within their own group, 20% of Indigenous youth were sexually active, compared to 18% of non-Indigenous youth. Non-binary and Two-Spirit Indigenous youth reported higher rates of sexual activity (30%). The most common age for first sexual activity among Indigenous youth was 15, mirroring their non-Indigenous peers. Non-binary youth were more likely to report first sexual activity under the age of 12 (28%). 3.5.3 Illegal Age Pairings and Sexual Abuse In Canada, illegal age pairings are defined as sexual pairings where the difference in age between all participants falls outside of the legally acceptable range for the youngest participant. These limits are meant to counteract power imbalances in relationships due to age. Table 3.4: What is Considered an illegal Age Pairing 12-13 > 2 years 14-15 > 5 years Sixteen percent of youth identified as having sex under the age of 12. Non-binary youth were found to be more likely, with 28% reporting this. Similarly, non-binary and Two-Spirit youth 54 were more likely to report ever being sexually abused. Rates of sexual abuse and illegal age pairings were lower than Devriesâ report; however, rates were close to double that of non-Indigenous youth (22% vs. 12%). Sexual abuse rates remained similar across all regions, except Vancouver Coastal, where it was slightly lower. Table 3.5: Scaled BC_AHS Participant Numbers Total BC Census Indigenous Census Non-Indigenous Census BC AHS total BC AHS Indigenous 283,968 35,052 248916 38,488 4,552 To assess the accuracy of scaling, the total number of Indigenous youths in the BC Adolescent Health Survey (BC AHS) was compared to active enrollment figures from Statistics Canada (2023). In the 2022â2023 school year, 283,968 youth were enrolled in grades 7â12 in British Columbia. Of these, 35,052 (14%) identified as Indigenous (13). When scaled, the BC AHS data estimated 33,585 Indigenous youth, representing 11% of the population, which was a 3% discrepancy. This difference may be due to student absences on the survey day or the exclusion of one school district that did not participate in the BC AHS. Going forward, all numbers have been weighted and scaled to represent the total population of youth aged 12-19 attending public secondary schools in BC. All numbers are rounded to the nearest second decimal. 55 3.5.4 Sex Education Access and Satisfaction Youth could check off multiple boxes to indicate where they got their sex-ed information from. Indigenous youth were more likely to have received sex education compared to non-Indigenous youth (80% vs. 77%), though both groups had similar dissatisfaction with their education. Indigenous boys were least likely to seek sex-ed information. An inverse relationship can be observed with how different genders accessed sex-ed information. For example, both Two-Spirit and non-binary youths were found to be much less likely that those that identified as male or female to be talking to friends and family members about sex-ed topics . In turn, they were found to be more likely to be accessing less popular forms of sex-ed information such as print resources. Both Indigenous and non-Indigenous youths expressed similarly low satisfaction ratings with receiving sex education (sex-ed); however, Indigenous youths were more likely to say that they had ever received any sex-ed (80% vs. 77%). In this case, sex-ed did not prove to increase rates of condom use or lower the rates of youth using withdrawal as their only method for preventing pregnancy the last time that they had sex. Indigenous Non-binary youth were the least likely to report being satisfied with the sex-ed they received with only 43% saying they found the material relevant. 56 Table 3.6. Sex Ed Satisfaction by Indigenous and Non-Indigenous Youth Exposure Variable Indigenous Non-Indigenous Received sex ed 29,304. (80%) 422,801.61 (77%) Received sex ed and found it helpful 17,948.70 (49%) 279,037.43 51% Sex ed-Started at the right age 26,739.90 (73%) 18760 (77%) Sex-ed was respectful of culture 19,047.60 (52%) 422,799.61 54% Sex ed was relevant to gender identity 26,007.30 (71%) 411,819.75 (75%) Sex ed was relevant to sexual minority â Among sexual minorities 19,780.20 (54%) 296,510.22 (54%) 3.5.5 Contraceptive Use Condom use varied by region and identity. About half of heterosexual pairings used condoms during their last sexual encounter, while only a quarter of same-sex couples did. Indigenous youth in the Fraser and Northern regions reported lower condom use. A history of sexual abuse was linked to reduced condom use, corroborating Devries' logistic regression findings. Additionally, youth with family members who attended residential schools were less likely to use condoms. 57 Table 3.7 Contraceptive use by Health Authority (among those that ever-had intercourse Northern Interior Vancouver Island Vancouver Coastal Fraser Condom 45% (2,012.13) 53% (2,953.58) 53% (1,550.63) 66% (719.94) 44% (812.23) Did not try to prevent pregnancy 12% (4,365.29) 5% (2,319.06) 7% (1,364.15) NR NR Withdrawal only 20% (3,459.45) 14% (2,965.24) 13% (1,623.82) NR 19% (22) Birth control pill, patch or NuvaRing 30% 1,977.32) 34% (3,063.45) 38% (1,587.42) 23% (389.89) 34% (1,030.43) About half of all heterosexual pairings used condoms the last time they had sex, while only a little over a quarter of same-sex couples used a condom. This might indicate opportunities for better sexual education on the use of condoms among queer youth. 16% of heterosexual youth indicated that they used withdrawal as their only method when having sex. There was a difference though in Indigenous sexual minorities satisfaction with their sex-ed with Indigenous youth who identified as a sexual minority less likely to find their sex ed relevant to their orientation. 58 Condom use was found to be reduced among those that had a history of sexual abuse. This supports Devries' original logistic regression which shows that sexual abuse was a major factor in pregnancy and STI cases. There were some regional differences in contraceptive use. For example, condom use rates were found to be lower for Indigenous youth in both the Fraser and Northern regions. This might be explained by higher rates of contraceptive use which can be seen in the table above. Vancouver Coastal saw the lowest rates for any kind of contraceptive use outside of condoms. The Northern region also had higher rates of youth stating the last time they had sex they did not try to prevent pregnancy and saying that the only contraceptive method they used the last time they had sex was withdrawal. There were no regional differences in sexual education rates or how helpful youth found sex-ed. 3.5.6 Condom Use Amongst ACEâs In the context of this research, ACEâs are exposures that a youth may face in their lifetime which may contribute to risky sexually behavior outcomes. Condom use was found to be reduced among those that had a history of sexual abuse. This supports Devries' original logistic regression which shows that sexual abuse was a major factor in pregnancy and STI cases. 59 Additional bivariate analysis was done to see if negative exposures played a role in contraceptive use. For example, with residential school exposure, there wasnât any observed difference in same-sex pairings however, heterosexual pairings who also said they had a family member (parent, grandparent or relative) attend residential school were less likely to say that they used a condom the last time they had sex (47% Vs. 56%). The same was also observed among Indigenous youth who had ever been sexually abused (43% Vs. 58%). Non-Indigenous same-sex pairings were also found to similar contraceptive use rates. For example, rates for using withdrawal only or trying to prevent a pregnancy were found to be non-significant. Age was not found to be associated with negative sexual health outcomes. 3.5.7 Substance Use and Sexual Health Substance use was correlated with lower contraceptive use among those that said that they had a problem with their use. Among sexually active Indigenous youth, 26% reported substance use addiction, compared to 16% of non-Indigenous youth. A quarter of sexually active youth reported substance use during their last sexual encounter, with non-binary youth being the least likely to do so (3%). Youth with substance use issues were less likely to use condoms (39% vs. 51%). 3.5.8 STI and Pregnancy Rates The STI rate among BC youth aged 12-19 was 781.31 per 100,000. Indigenous youth accounted 60 for 85.83 per 100,000 of all cases but had a higher rate within their cohort (646.71 per 100,000). Pregnancy rates were similar, with Indigenous youth representing 23% of cases. The pregnancy rate among Indigenous youth was estimated at 1,371.1 per 100,000. 3.5.9 STIâs and Pregnancy Rate Comparisons to National Levels Diseases Canada notifiable disease database reports a rate of 1% rate of any kind of STI amongst the general population of youth aged 15-19 in Canada per 100,000 (N Cases= 1,080) in the year of 2022-23. Chlamydia made up the bulk of the cases with gonorrhea being the second most common (see chart below) It should be noted that cases werenât able to be separated by province (57). The average rate of national cases of youth under 19 was 3,892.6. Table 3.8 PHAC - Average rates of STIâs Amongst those in Canada (57) Table 3.9 STI data (STI Reports Nationally) Condition 2019 2020 2021 2022 2023 Gonorrhea 3217 4040 2459 2351 - 61 Syphilis 433 478 623 700 - 28211 20658 18330 19113 - Table 3.10: BCCDC STI Data (STI reports in BC â 0-19) (including post-secondary youth) Condition 2019 2020 2021 2022 2023 Gonorrhea 159 182 127 145 88 Syphilis 14 14 36 30 30 Chlamydia 2439 1998 1798 1851 1702 Table 3.11 BC AHS STI Data (Among youth in BC 12-19) (only grades 7-12) Category Rate Per 100K PHAC National Average (2019-22) 3892.6 Per 100K BC (2019-2023) 903.3 Per 100K BC AHS -All (if youth had ever been diagnosed with an STI)(among all youth) 485.73 Per 100K BC AHS Indigenous b(among all Indigenous Youth) 646.71 3.5.10 BC AHS Data on STIs and pregnancy From AHS results the total calculated rate of a youth in BC in grades 7-12 ever having an STI was 485.73 per 100,000. This was a 53% decrease from BCCDC data which can be explained as it did not include 18â19-year-olds not attending a secondary 62 school. Indigenous cases represented 95.3 per 100,00 of all cases. Indigenous youth showed an increased risk of contracting STIâs amongst their own cohort of sexually active Indigenous youth. Based off weighted and scaled data STI rates for BC for youth aged 12-19 having an STI is 772.08 cases per 100,000. Amongst the total sexually active cohort both 3% of all indigenous youth and non-Indigenous youth were found to ever have had an STI. Indigenous youth were found to be at a greater risk for STIâs amongst their own cohort with 11% of sexually Indigenous youth had ever experienced an STI versus 4% of non- Indigenous youth. Pregnancy Similar to STI rates, pregnancy rates were found to be 897.7 per 100,000. Indigenous youth were found to represent 23% of the cohort (209.05 per 100K). Amongst themselves 7% of sexually active Indigenous youth had ever had a pregnancy versus 4% amongst sexually active non-Indigenous youth. Amongst 100,000 Indigenous youth the rate of pregnancy was estimated to be 1371.1. Table 3.12 Logistic Regression â Preventing STI and Pregnancy Outcomes (separate variable analysis) Odds Ratio P. Value Lower Upper Sex ed any .50 <0.01 0.84 .153 Did not use condoms to prevent pregnancy 2.58 <0.01 1.55 4.29 Faced any kind of sexual abuse 2.93 <0.01 1.67 5.14 63 Had a family member attend residential school 1.77 <0.01 .929 3.38 *Age was not found to be a covariate factor Logistic regression analysis found that exposures to ACEâs impacted STI and pregnancy outcomes. Sex ed lowered rates of both STIâs and pregnancy while not using condoms raised the risk. Indigenous Youth who experienced sexual abuse were close to 3 times as likely than youth who did not to either have a pregnancy or an STI which supports Devries findings. All variables tested with a P value of <0.01. 3.6 Conclusion This thesis offers new insight into STI cases in Canada by showing that ACEâs play a role in STI and pregnancy outcomes. This work supports Devriesâ results from 15 years prior from the BC AHS by showing Indigenous youth as being at an increased risk for sexual abuse. It also updates their findings by showing how intergenerational trauma impacts STI and pregnancy outcomes. This was done through examining the relationship through logistic regression analysis among youth 12-19 with family members who attended residential school (parents, aunties, uncles and grandparents). Results show that AHS STI results are in line with BCCDC reporting results, however there may be gaps in reporting at a national level as PHAC reporting shows lower rates per 100,000 for the whole country. This puts British Columbia in the unique position of being able to 64 showcase best practices in STI reporting in partnership with the BCCDC. Additionally, it proves that youth are likely to answer honestly their experiences with sexual health diagnosis. 3.7 Limitations BC AHS data is self-reported, so health outcomes are not recorded by medical professionals. Additionally, this survey does not represent Indigenous youth who are not attending public school or who are not in school. Comparisons between active enrolment numbers and BC AHS answered surveys show a 30% discrepancy which indicates that the most at-risk groups in this survey are most likely missing. 65 4. Discussion 4.1 Summary of Findings Through my thesis I seek to uphold Canadaâs calls to action to support Indigenous people in their rights to good health by exploring barriers, strengths-based opportunities, and best practices in sexual health so that Indigenous youth may be better supported in their health and wellbeing journeys. In my final chapter, I present the key findings from Chapter 1, Chapter 2 and Chapter 3, compare my findings with other literature, discuss the importance of my results as well as knowledge gaps, and provide direction for future research. My thesis research began with a systematic review and integrative synthesis of qualitative and quantitative studies investigating experiences of access to contraception and abortion care among Indigenous clients (Chapter 2). Analysis identified that Indigenous people still face barriers to reproductive wellness because of colonization and that at present there are limited examples in academic literature on what is being done to solve this problem. Key themes encountered in literature included: shame and fear of stigma accessing contraception and abortion resources, fears of anonymity from medical professionals and local community members as well as accessibility issues in Northern communities. Queer and Two-Spirit Indigenous people continue to be marginalized in their communities when it comes to reproductive health access(39). Queer Indigenous youth were more likely to be at 66 risk for housing issues due to their orientation and because of this sit at a crossroad of intersectional issues regarding healthcare (37). Articles cited a lack of options to choose from regarding healthcare options as well as having to travel long distances to receive gender-affirming medical care(58). A positive change which was noticed was that later published articles were more likely to include Indigenous communities in consultation with development of the research as well as to focus on Indigenous views on sexual and reproductive health. It should be noted that many of the authors of these articles were also members of these communities which indicates an influx of Indigenous authors in the SRH field. Our findings echoed scoping reviews that had covered similar topics. Bacciaglia et al.'s scoping review on Indigenous maternal health in Canada found many of the same themes, including accessibility barriers for Indigenous women, poorer outcomes in rural areas, and the need for culturally sensitive care (59). Their review of 89 articles found most studies on service provision report Indigenous women feel uncomfortable with current maternal healthcare, facing shame, stigma and blame. Geography compounds issues, with distances and transportation difficulties, especially for those with diabetes needing frequent care. Similarly, Community-based participatory research was recommended to Indigenize health promotion (59). Mikhail, Kelly and Davison found similar results regarding sexual and reproductive health for Inuit youth in the North. In their scoping review of 11 articles, 3 found remote travel to be an issue (46). Close to half of included studies referenced a need for 67 community-based participatory action research to improve SRH related health services in the Nunavut region. Qualitative articles in our systematic review featured robust scores, with the average score being 10.86 out of 12 versus a score of 12 for quantitative articles. Highly scoring articles not only provided concrete evidence of the experiences of Indigenous people accessing contraception and abortion-based services but also worked with communities to identify best-practices and community-measured definitions of success. The authors of this paper theorise that this may be due to a process of community consent being involved for interviews versus indirect collection methods for quantitative-based data. For example, 11 of the 29 qualitative articles occurred in the Nunavut region. All research done in this region must be met by the approval of the Nunavut Research Institute (NRI); all NRI applications must not only meet REB requirements but must also explain in their applications how they plan to involve the Nunavut community in the development of their research and how they plan to share back the knowledge gathered (46). Quantitative analysis found similar barriers to Indigenous youthsâ reproductive wellness. This looked like low satisfaction rates among all youth in regard to the sex-ed they had received as well as low satisfaction amongst gender diverse Indigenous youth in programming relating to their gender identity. Similarly, Indigenous youth had low engagement rates with accessing sex-ed information. Analysis points towards risky behaviour and ACE factors playing a role in STI and pregnancy-based outcomes. In the context of this research this looked like the lasting effects of having family members attend Residential Schools as well as those who had faced sexual abuse. 68 4.2 Best practices Community reports stressed the importance of holistic, culturally grounded understandings of wellness. They call for Indigenous-led solutions that respect women's choices, ceremonies, and relationships to land. These community perspectives add nuance to the meaning of reproductive justice and strategies to serve Indigenous women better. Overall, findings point to a need for anti-colonial efforts to deconstruct systemic barriers at policy, institutional, and interpersonal levels. Promoting reproductive justice will require enhancing accessibility, health literacy, patient-centred care, provider diversity, policy reform, community-based research, and culturally grounded education. Best practices that we saw included diverse methods which centred around community-based approaches (58,60) Articles which included Indigenous involvement at all levels featured robust scores which reflected community definitions of success. Solutions to these problems ranged from âSexy Health Carnivalsâ in Indigenous languages (23), body mapping which located colonial histories (41), and community assessment models for HIV built in consultation with community (60). Only 12 of the 54 included articles were quantitative. This suggests that over the past 30 years very little has been done to monitor Indigenous SRH needs. Similarly, queer, non-binary, and Two-Spirit people were underrepresented with only four articles involving gender-diverse populations. Only two articles specifically were focused on addressing queer Indigenous SRH 69 health (39,38,49,41). In their report on the 2006 Marginalized and Street-Involved Youth Survey, Saewyc et al. identified that marginalized Indigenous youth were less likely to identify as straight versus their non-Indigenous counterparts in the BC Adolescent Heath Survey. Only 44% of Indigenous females identified as heterosexual at the time of the Marginalized and Street-Involved Youth survey versus 76% of Indigenous AHS survey participants (77% vs. 85% for males) (37). In addition, Saewyc et al. reported participants specifically noted a lack of access to specialized services, such as services for queer Indigenous youth. A theme that was commonly addressed in queer focused qualitative articles was the need for cultural-based services (37). There currently exists a lack of support for queer, lesbian, gay and Two-Spirit rights to reproductive health services (61). In their findings, Brotman et al. state that queer Indigenous health can be better supported by facilitating queer rights to good health as a holistic wellness concept that recognizes the spiritual and emotional needs of patients being treated (61). Through increased Indigenous authorship in queer and Two-Spirit academic literature, we can be better understanding what good health looks like to the queer community and help to fight against racism, homophobia, and oppression. Quantitative analysis illustrated the importance of removing bias from quantitative research. In my thesis this meant recontextualizing stereotypes such as all substance use leading to STIâs and instead recategorizing it to examine what kind of substance use might lead to risky behaviour such as non-condom use. Additionally, this thesis proves that increased levels of trust need to be put into youths self-reported responses for medical diagnosis. 70 This thesis proposes that more needs to be done to explore why there are reporting discrepancies between BC and the national reporting average for BC. At present STI reporting methods in Canada arenât standardized and itâs up to the province to decide how to best conduct them (62) BC AHS and CDDC results seem to be in line with each other for youth 12-19 which suggests that there are best practices to be studied for STI surveillance protocols in BC. Additionally, analysis from the weighting and scaling of BC AHS data shows that more needs to be done to address gender identity gaps in STI reporting metrics among all youth as they currently remain underreported due to low N counts. Two-spirit and those with identities that fall outside of the norm are often excluded in quantitative reporting statistics due to fears of anonymity however more needs to be done to navigate lifting up their lived experiences. Similarly, more needs to be done to identify gaps in sex-ed programming for queer and Two-Spirit Indigenous youth. While satisfaction rates were found to be low of sex-ed regarding gender and orientation amongst non-binary and Two-Spirit youth it was also found that they were more likely to have higher engagement rates with social media and print based materials to get sex-ed information. Literature also called for diverse digital options for supporting Two-Spirit reproductive wellness. This looked like extended telehealth services, and improved sex-ed information on social media sites such as Tumblr and Instagram (39). 71 4.3 Strengths and Limitations 4.3.1 Systematic Review Our systematic review included 54 articles looking at the experiences of Indigenous people in Canada accessing SRH based services. We achieved this in a multidisciplinary team including myself, my supervisor, and an Indigenous scholar in medical school residency, with the help of a medical librarian who helped us identify best practices for data library search strategies. Databases included: CINAHL, Pubmed, Medline (Ovid), PsycINFO, EBSCO, and the Native Health Database. Similarly to our high scoring articles, we involved Indigenous scholarship at all stages of development so that feedback could be maintained on important factors. This included how we went about our search strategy, who we quality appraised articles as well as how we maintained cultural safety methods for future Indigenous researchers reading our work. One limitation of the systematic review is the low quality of the earlier published literature, which included covert and overt racism as well as lack of community participation. The Well Living House quality appraisal tool helped me identify high quality studies that involved Indigenous communities, authors, and methodologies. However, I found that one limitation of the tool was the inability to deduct points for harmful ideologies. For example, multiple articles assumed that Indigenous people's poor health outcomes were associated with substance use or sexual activity. While our team took steps specifically to remove low quality studies from analysis, more could be done. To reduce fatigue for Indigenous authors, the tool could include a notation (trigger warning) or option to deduct points. As an Indigenous researcher I would have found this less harmful to my own mental health in the research process. 72 4.3.2 BC AHS Data Review As a methodology I chose to use an exposure versus outcome framework as methodology for my data analysis. I originally intended to utilize a PICO patient framework as this would have allowed me to continue the patient-oriented focus that I had previously used in Chapter 2. The challenges in this however was that the non-specific questions of the BC AHS made it difficult to answer intervention/exposure-based questions. For example, when youth were asked what contraceptive use methods they used, they were only asked for what method they used to prevent pregnancy the last time they had sex. Because of this I chose to modify the PICO framework to focus on an exposure versus outcomes-based design. I also chose to implement Dr. Abelson âs magnitude, articulation, generality, interestingness, credibility (MAGIC) criteria to prove the significance of my research. I did this by specifically working on the articulation of research by demonstrating the magnitude of effect the exposures had on STI and pregnancy-based outcomes. I also worked to scale BC AHS results for STI outcomes. A strength of my quantitative analysis (Chapter 3) is the survey data source. McCrearyâs survey has some of the only data available with a large enough sample size to run logistic regressions with accurate p values on STI and pregnancy outcomes of youth in the country. One limitation of the data from BC AHS results is they are self-reported. The survey may include non-answers, potential falsification of answers, and youth misunderstanding questions. Because of this, work 73 that I have done to model STI data suggests that more needs to be done to investigate national STI rates among youth in Canada. Furthermore, SRH related questions on the BC AHS account for only one small part of the survey. As the author of this thesis, I often found myself wishing for more accurate descriptions of how youth used contraceptives. For example, youth only listed what kind of contraception they used the last time they had sex, not what their regular contraceptive habits looked like. I believe that the sexual health section could be expanded on to reflect better contraceptive use habits as well as better express how different genders and sexual orientations use contraceptives. 4.4 Key Takeaways This thesis showcases the need for the greater improvement of quantity and quality of articles researching STI and pregnancy outcomes for Indigenous youth in Canada. At present there is a widening gap between Indigenous and non-Indigenous youth experiencing STIâs and pregnancy with no clear SRH guidance being provided. Indigenous people remain overrepresented in STI statistics with the Arctic regions being particularly at-risk. (41) There is currently no tracking STI rates at a national level that separates by ethnicity. Because of this we will not know explicitly at a national level how these rates are changing. Until a change is implemented, I suspect that this gap will continue to widen. Key takeaways from Chapters 2 and 3 find that we need to reframe negative sexual health outcomes away from processes of implicit bias. Instead, we need to consider STIs as the 74 outcome of exposures to ACEâs which lead to risky behaviors which have poor outcomes. To support Indigenous rights to good health, sound quantitative evidence needs to be presented which understands the root causes of poor sexual health outcomes. At present literature from quantitative articles may be missing the mark by misattributing exposures. Regarding the high estimated numbers of STIâs among all youth aged 12-19 I would like to recommend that more work needs to be done to investigate this potential issue. This could be done in the form of a follow-up exploring STI surveillance policy along with qualitative interviews with healthcare providers on the process of STI reporting in Canada. Another recommendation is that more research needs to be conducted among all youth on how sexual education can be improved. With this work an intersectional approach needs to be taken so that we can better identify how race, gender identity, sexual orientation and spirituality plays a role in satisfaction of sex-ed curriculum. In the form of program building there is much need for the development of relevant sex-ed materials for Indigenous youth in Canada. For example, only 54% of queer Indigenous youth said in the 2023 BC AHS that they found the sex-ed they received was relevant to their sexual orientation. Results from my research found that non-binary and Two-Spirit youth were less likely to seek out sex-ed information in person but more likely to look for resources either in print format or online. 75 4.5 Implications At present, there has still been no formal apology for the continued forced and coerced sterilization of Indigenous women in Canada. As of July 2022, the Canadian Senate Committee calls for both an apology as well as for a formal investigation process to be made for reproductive rights of Indigenous women being threatened (4). Additionally, more needs to be done to advocate for the range of Indigenous womenâs abortion options, as currently the focus is on forced sterilization (tubal litigation) (33). The field of Indigenous SRH health is still young and Indigenous authors and community partnerships are emerging. When the research involves Indigenous leadership and participation, we see creative solutions like âSexy Health Carnivalsâ in Indigenous languages (23), body mapping which locates colonial histories (41) and community assessment models for HIV which seek to meet the needs to the community (60). Healthcare professionals require comprehensive training in providing patient-centred, culturally safe reproductive care to Indigenous women as a means of honouring their rights as life givers in their communities. Other recommendations for healthcare professionals include: allowing for longer times for appointments to build trust, moving away from fee-for service models as well as hiring more Indigenous staff to provide culturally relevant care (54). One solution is to move away from fee-for-service models so that care providers could provide more time with their patients. This also looked like increasing the authority of non-doctor related 76 healthcare practitioners, such as nurses, so they could provide prescriptions for contraceptives and abortion care such as mifepristone (54). As the author of this thesis, itâs my own suggestion that more needs to be done to conduct real-time reporting of STI reporting so that we can avoid outbreaks of treatable diseases. Overall, the field of reproductive wellness for Indigenous people in Canada remains a largely untouched space which needs to be deeper delved into. In the context of this space, this means taking a strengths-based community approach to creating research which reflects the diverse backgrounds of Indigenous people in Canada. This looks like involving Indigenous communities in the development of programs and tools which supports their rights to good health in a sustainable, equitable way. 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Available from: https://doi.org/10.14745/ccdr.v45i23a03 63. World Health Organization. Constitution of the World Health Organization. 1948. 85 Appendices Included Articles ID Academic or Grey Literature Study Type Study Aim Participant Characteristics Study Design Study Location Sample Size Study Procedures Abortion Studied? Contraception Studied? 5877 Akbari (2021) Grey Article To describe the effects of Canadaâs history and ongoing practice of forced sterilization and eugenics on Indigenous women. Indigenous women Policy analysis Toronto Ontario NA Exploratory literature review about Canadaâs history of settler practices, genocide, and the changing perception of Indigenous women, history of eugenics and forced sterilization towards Indigenous populations followed by two case examples of Indigenous women who have recently experienced forced N Y 86 sterilization in Saskatchewan. 1768 Archibald (2004) Grey Report To explore the many complex issues surrounding teenage pregnancy in Inuit communities. Inuit women and youth, Elders, and professionals from healthcare, social services, education, and Inuit organizations. Qualitative community health study Ottawa, Ontario n=53 Twenty structured interviews were conducted with Inuit women. The views of Inuit youth were included through three focus groups held in Ottawa. Interview responses were recorded by hand and transcribed. Inuktitut interviews were translated at the time of the interview and written out in English. Focus group notes were recorded on flip charts and later transcribed. Transcribed responses were then reviewed to identify key themes, Y y 87 commonalities, and differences. 1780 Assembly of First Nations (2007) Grey Report The First Nations RHS is a longitudinal study run by first nations communities with the goal of measuring health outcomes for Canadian Indigenous people in Canada Participants represent 22,602 surveys in 238 communities from 2002 to 2003. This represented approx. 5.9% of Indigenous people across Canada in 2002-2003. Participants had to self-identify as belonging to an Indigenous Canadian group. longitudinal study Canada 22602 A customized Computer Assisted Personal Interviewing (CAPI) package was developed for laptop computers and fieldworkers were hired by each region to administer the surveys. The adults were interviewed directly. First Nations children were surveyed by proxy, with a person who knew them well, most often the mother or occasionally the father. First Nations youth normally completed the RHS themselves. n y 88 5 Baaske (2022) Academic Article To examine how access to contraception and cervical and breast cancer screening in British Columbia, Canada, has been affected by the COVID-19 pandemic. Residents of BC aged 25 to 69 Self-administered survey BC N=3691 (n = 2542 for contraception outcomes) Survey that included 4 contraception outcome measures: (1) regularly accessed birth control methods (e.g., birth control pill), (2) accessed emergency contraception (e.g., Plan B), (3) had difficulty accessing birth control methods, and (4) had difficulty accessing emergency contraception. Those who indicated that they had difficulty accessing contraception were asked âWhat made accessing birth control or emergency contraceptives difficult during COVID-19?â y 89 569 Benoit (2003) Academic Article To examine the effectiveness of Urban Aboriginal Health Centers in meeting the specific health needs of Indigenous women. Aboriginal women, organization staff, health professionals, and community health workers with expertise in Aboriginal issues in the Downtown East side of Vancouver. Qualitative community health study Vancouver, BC N=61 Participant observation, 25 semi-structured interviews and 3 focus groups were the primary methods of determining Aboriginal womenâs perceptions of health care services at VNHS. Thematic analysis was chosen as the most appropriate method for analyzing the data n y 5884 Boyer (2017) Grey Report The purpose of this report was to measure the impact of tubal litigation amongst Indigenous women in Saskatchewan. Data collection included interviews with 7 Indigenous women who had negative experiences with tubal litigation after birth and 9 SRH service providers. Qualitative interview study A c-par methodology was used to develop guidelines for data collection and interview topics. Interviews ranged 1-2 hours and were conducted by an Indigenous interviewer who was fluent in Cree and an Active member y 90 of the local first nations community. 1777 First Nations Information Governance Committee (2005) Grey Report The purpose of this report was to share the results of the 2002/3 BC RHS results. 712 adults, 566 youth and 666 children. Community health report BC N=1994 First Nations people in B.C. completed the BC First Nations Regional Health survey. The First Nations Chiefsâ Health Committee, under the direction of the BC First Nations Health Research Committee, carried out analysis of the data. All results have been statistically weighted to represent the First Nations population distribution. y 1774 Burchell (1997) Grey Thesis To describe patterns of condom-use among First Nations people living Individuals who had sexual intercourse in the last twelve months Cross-sectional survey and interviews Ontario N=400 Face-to face interviews were held with members from each of the 11 First Nations communities. y 91 on-reserve in Ontario. were included, living in one of 11 reserve communities. For sensitive questions surrounding sexual history and attitudes, participants self-completed answer booklets. Statistical analysis was used to analyze the data 1595 Chavoshi (2013) Academic Article To compare sexual vulnerability as measured by predictors of inconsistent condom use over time among the 605 indigenous young men and women who are participating in the Cedar Project. Indigenous youth between the ages of 14-30 who had smoked or injected drugs in the past month prior to the study. TBD cohort mixed methods? Prince George and Vancouver B.C. N=456 At enrollment, participants completed an interviewer-administered questionnaire to elicit sociodemographic data, data on non-injection and injection drug use, sexual behaviors, and utilization of health services as well as provided venous blood samples to test for HIV and HCV antibodies. The data sample included responses from all Cedar y 92 Project participants who returned for at least one follow-up interview between October 2004 and May 2005. Continuous variables were elicited in reference to the 6 months prior to the interview. 5871 Clarke (2021) Academic Article This academic article is a commentary on the topic of the history of forced and coerced sterilization of Indigenous people in Canada. Canada N/A This commentary looks at the eugenics policies that shaped the history of forced and coerced sterilization in Canada. It covers political protests and outcomes up to the time of publication (2021) on the ongoing fight against forced and coerced sterilization against Indigenous women. n 93 533 Cole (2004) Academic Article To address the need for culturally specific data on beliefs and behaviours in order to design and implement appropriate public health interventions. School-aged children from 3 schools on Baffin Island Cross-sectional study Baffin Island, Nunavut N = 71 Iqaluit high school students form 3 schools on Baffin Island Teachers administered the Nunavut Youth Sexual Health Survey to their students. Part one of the survey had 36 statements pertaining to sexual health and respondents were asked to circle "True", "False" or "Donât Know" for each statement. Part two had questions about sexual health behaviours and about sex education. To analyze the data, statistical analysis was performed. y 215 Corosky (2016) Academic Article To generate youth-focused evidence on experiences of sexual and reproductive health and rights (SRHR) relating to access to care 9 male youth between 17 and 22 years, 10 female youth between 16 and 22 years, and 6 Phenomenological qualitative study Arviat, Nunavut n = 25 In-depth interviews were conducted with youth and community leaders. Snowball sampling was used to engage y 94 in Arviat to better inform locally authored interventions geared towards improving youth SRHR community leaders informants, and data analysis followed an approach similar to conventional content analysis, where emphasis was placed on ââimmersion and crystallizationââ of data, corresponding to the Inuit concept of Iqqaumaqatigiinniq in the PRM. Findings were continuously checked with community members in Arviat during the analysis phase, and their feedback was incorporated into the report. 5863 Devries (2009) Academic Article This study seeks to examine the outcomes of Indigenous youth SRH health outcomes 2476 Indigenous youth (8% of total) who self-identified as Indigenous who were Secondary analysis of health survey data BC N=2476 This survey covers secondary analysis of BC AHS data. Random sampling was conducted y 95 based on 2003 AHS data. between the ages of 12-19 across 40,070 classrooms. Descriptive statistics and linear regression was used to calculate odds ratios of STI and pregnancy outcomes. 1406 Devries (2010) Academic Article To describe sexual relationship and condom use patterns among Canadian Aboriginal young people, and how these patterns relate to the socio-structural context as experienced by young people. To describe sexual relationship and condom use patterns among Canadian Aboriginal young people, and how these patterns relate to the socio-Self-identified Indigenous young people between the ages of 15-19. Ethnographic study? GT? B.C., Canada N=22 Interviews were held between interviewers and youth to discuss for the purpose of seeking young peoplesâ views on sexual health and condom use to make better sex education programsâ. Interviews were tape-recorded and transcribed. The data was analysed drawing on techniques from Grounded Theory. Transcripts of the interviews were coded initially using y 96 structural context as experienced by young people. âin vivo codesâ, reflecting the language of the participants. After coding the first seven interviews, a coding framework was developed 1411 Devries (2011) Academic Article To explore how Aboriginal young men and women operate within, and challenge, gendered social norms in their sexual relationships Fifteen male and fifteen female young people aged 15-19 who self-identified as Aboriginal were recruited. Ethnographic study? GT? B.C., Canada n = 30 (Compare with above) Lightly structured in-depth interviews occurred between youth and a study member. Interviews were tape-recorded and transcribed. N6 software (QSR International 2006) was used to organise the data and facilitate analysis. Transcripts were read and re-read, and initially coded thematically by both authors using a coding framework developed based on the y 97 first seven interviews. Various qualitative techniques, including constant comparison and searching for deviant cases were used to develop and refine themes. 393 Duff (2011) Academic Article To describe levels of pregnancy and contraceptive usage among a cohort of street-based female sex workers (FSWs) in Vancouver. 211 women who engaged in sex work and reported using drugs aged 18-49, 47% were Indigenous, 176 of all women had experienced a pregnancy Cohort study Vancouver, BC n=211 Participants completed a baseline and 6-monthly follow-up interview-administered questionnaires by trained peer researchers. Questionnaire covered demographics, health service use, working conditions, violence, sexual and drug risk practices. Statistical analysis was conducted among sex workers who had ever y 98 reported being pregnant (211 of the 252 in the cohort). Contraceptive types and uses were studied along with pregnancy outcomes. 153 Dunn (2019) Academic Article To determine non-contraceptive use factors among youth aged 15-24. Individuals aged 15 to 24 who were defined as âat riskâ for unintended pregnancy meaning if they indicated that they had been sexually active in the past 12 months, were heterosexual (only reported for those aged 18 and above), were not currently pregnant or sterilized, and agreed or strongly Cross-sectional survey Canada Unidentified number of respondents, but the survey had a 72% response rate. The Canadian Community Health Survey targets individuals â¥12 years of age living in private dwellings and spans the 10 provinces and three territories. It uses a multistage, cross-sectional design allocating proportion- ally to populations within each health region. The survey excludes individuals living on First Nations reserves and some very y 99 agreed that it was important for them or their partner to avoid getting pregnant right now. remote communities, institutionalized individuals, and full- time members of the armed services. The 2009â2010 CCHS data were collected from January 2009 through December 2010, with a 72% response rate. 1776 First Nations Health Authority (2021) Grey Report This report, Sacred and Strong, aims to focus on First Nations women and girls living in B.C. and share their experiences of wellness, how they stay well, and their hopes for the future. This report focuses on First Nations women and girls and features their voices. It shares their experiences of wellness, how they stay well, and their hopes for the future. An effort has been made to include voices from a diversity Community health report BC To gather data from and about First Nations women and girls, data was collected directly from individuals, a variety of secondary sources, such as published articles, books, interviews, and videos. The report also contains quantitative data from a variety of sources on many aspects that contribute y 100 of First Nations, language groups, gender and sexual identities, ages, and perspectives. to a womanâs health and wellness at different phases of her/their life, from before birth, to childhood, youth, adulthood, and old age. 1775 Healey (2015) Grey Thesis The goal of this thesis was to explore the attitudes of Inuit parents and children on sexual health and relationship topics in the Arctic Youth interviewed were between the ages of 16-19, parents interviewed had a child between the ages of 13-19. Qualitative participatory research Nunavut N=37 17 Inuit youth, 20 Inuit parents Parents and youth were conducted using Unikkaaqatigiinniq (storytelling) based methodologies with the goal of finding Iqqaumaqatigiinniq (meaning and understanding) on the interviewed topic. Consensus from stories was reached that the goal of sex and relationships was to be Pittiarniq (good) to each other and s y 101 Inuuqatigiittiarniq (respectful) 267 Hulme (2022) Academic Article This study aimed to identify gaps and opportunities for equitable access to knowledge, services and methods of family planning in Canada. Participants were key stakeholders from government agencies, professional organizations (medicine, nursing and pharmacy), advocacy and not-for-profit groups organizations who spoke English or French. Semi-structured interviews Canada n=72 The team recruited key stakeholders from government agencies, professional organizations (medicine, nursing and pharmacy), advocacy and not-for-profit groups for in-person interviews. The research team then conducted semi-structured interviews either by phone or in person. u 1769 Kinnon (2020) Grey Report This document, Access, Respect, Consent, aims to summarize results from an environmental scan and community visits on Inuit womenâs key contacts in sexual and reproductive health services in the four Inuit regions and southern referral centres Community health report (qualitative) Rankin Inlet, Arviat, Kuujjuaq, Inuvik, Iqaluit, and Nain. n = 22 Telephone or in person interviews were conducted with key contacts in sexual and reproductive health services in the four Inuit regions and southern referral centres. 102 reproductive health, in particular free, prior and informed consent to reproductive health procedures. The interviews focussed on Inuit womenâs access to reproductive healthcare, from sexual and reproductive health education and information, temporary and permanent contraception, pregnancy options, pre- and post-natal care, and birthing. The analysis identified key factors that contribute to Inuit womenâs reproductive health rights. 5872 Lamberti (2022) Grey Thesis To investigate the use of birth control in Canada, focusing on racialized and Indigenous women. Are racialized and Indigenous women less likely to use effective Racialized, Indigenous and White women who responded to the 2020 Canada Community Health Survey. Quantitative Analysis Canada N=3064 Data looked at the results of the 2020 Canada Community Health Survey. Exploratory data analysis used statistical distributions of predictor and outcome variables in y 103 contraception, and is this mainly because of financial barriers? both univariate and bivariate contexts. Bivariate associations were evaluated using Chi-square tests to determine statistical significance with a significance threshold set at p > 0.05. The study utilized three sets of multi-variable binary logistic regression models to investigate relationships between the outcome variable and predictor variables. The first set of models focused on the binary outcome of contraception use versus non-use. The second set looked at usage of long-acting reversible contraception 104 among women who reported using birth control. Lastly, the third set of models explored the usage of contraceptives versus non-usage, specifically within distinct racial categories. 4314 Larcombe (2019) Academic Article To (1) pilot the process for understanding the level of community readiness around HIV issues and preparedness in a northern Manitoba First Nation community; (2) involve partnership building in the context of CRA through the training and assessment processes and develop an action plan to A First Nation and non-First Nation research team trained to administer the CRA tool at (Northlands Denesuline First Nation) NDFN in Manitoba. Five informants were interviewed using the CRA tool. Cross-sectional design with qualitative interviews Northern Manitoba, Canada N=5 The Community Readiness Act (CRA) is a method to train and engage community members to reflect on a particular issue through a process of asking key informants (4â6 people) 22 questions, summarising and evaluating the results and then developing an action plan to create change. The interview questions cover y 105 move forward to support risk reduction for HIV in a way that is appropriate for their community; and (3) provide evidence as to whether or not the CRA tool is best practice as a first step for identifying and planning culturally appropriate programmes and interventions. six themes that assess the respondentâs knowledge about HIV and the resources, programmes, and community- based initiatives. Interview responses are scored using a Likert-type scale from 1 to 10 where â1â is no knowledge or awareness of the issue through to a â10â where the respondent can identify a high level of community ownership and action regarding the issue. 1788 Leason (2017) Grey Thesis To explore Indigenous womenâs maternity experiences and how Indigenous womenâs social determinants 410 of the 6,412 women who responded to the MES survey which identified as Indigenous. Review of secondary survey data and qualitative interviews National for MES results, Okanagan BC for qualitative interviews N= 410 Aboriginal respondents N= 10 qualitative interviews Responses from those that answered the Canadian Maternity Experiences Survey were looked at including health y 106 relate to their experiences with pregnancy. indicators and risks for infant mortality miscarriage and abortion. 1806 Lesperance (2022) Academic Article In this paper, Sexy Health Carnival facilitators make the case for the importance of bringing health promotion messaging to cultural spaces in the country now known as Canada, and detail some of the tensions that arose when they tried to implement their vision. Participants were carnival leaders who came from a diversity of Indigenous cultures, including Cree, Haudenosaunee, Anishinaabe, and Métis, Interview-based study 6 First Nations, 3 Métis, and 2 Inuit cultural gatherings in Canada (Winnipeg, Saskatoon, Ottawa, Victoria, Nunavut, Cochrane, Dauphin, Driftpile First Nation, Beaver Lake First Nation, Port Alberni, and Puvirnituq) N =10 In this study, ten peer facilitators, from a diversity of Indigenous cultures, including Cree, Haudenosaunee, Anishinaabe, and Métis, participated in semi-structured interviews by telephone to share their experiences of the Carnival. Facilitators were asked to reflect on their favourite aspects of the carnival, challenging experiences, community reception, and their advice for others. Interviews were transcribed verbatim, and transcripts y 107 were uploaded to NVivo for inductive thematic coding and analysis. Summaries of the themes were compiled and shared with the peer leaders. 918 Logie (2019) Academic Article To fill knowledge gaps regarding the sexual healthcare experiences and recommendations of LGBTQ+ persons in the NWT Participant characteristics included members from the LGBTQ+ community (youth aged 15-24 and adults 25 and over) and key people who work with this community. They were also categorized based on sexual identity, gender identity, and race/ethnicity In-depth interviews NWT, Canada n = 46 The research team conducted semi-structured interviews from May 2015 to October 2015 with LGBTQ+ persons in the Northwest Territories. All interviews were digitally recorded and transcribed by Peer research assistants. Once transcripts were checked for accuracy, they were uploaded to the qualitative data analysis software, NVivo 11. n 108 They used a thematic analysis approach to discern and classify emerging patterns within interview data that made use of both inductive and deductive analytic strategies 5861 Lys (2019) Academic Article The goal of this study was to explore Indigenous youthsâ relationship with contraception use and access examining their relationships with colonization through the process of body mapping. Indigenous participants between the ages of 13-17. Body mapping with semi-structured interviews Northwest Territories. N= 41 An arts-based intervention was taken through using the FOXY method to body map youths experiences while conducting semi-structured interviews. Through this youth mapped their experiences with accessing contraception and SRH related services. y 109 5876.0 Martin-Ferris (2022) Grey Report To investigate social determinants of Indigenous youth health within the BC 2018 Adolescent Health Survey. Youth in grades 7-12 (aged 12-19) attending public Elementary and High Schools in BC, Canada. This report focuses on responses from Indigenous youth who self-identified as Indigenous and completed the survey. Quantitative Analysis BC N=38,000 The report was created using data from the BC Adolescent Health Survey (BC AHS); a voluntary and anonymous pencil and paper survey administered to students in Grades 7 to 12 in mainstream public schools across the province. The data plan was developed with community partnership. y 1787 McKenzie (2020) Grey Thesis To understand the social determinants of substance-use during pregnancy from the perspective of young Aboriginal women themselves, a convergent mixed methods research project was conducted Eligibility criteria for qualitative portion included being an Aboriginal woman that was a current participant of the Cedar Project, who has had experiences with pregnancy between the Literature review and participatory research study Vancouver, Prince George and the Interior region of British Columbia, Canada n = 23 qualitative participants Ethnographic open-ended, in-depth interviews were used to elicit womenâs life histories (Part A) and supplemented by the use of a participant-generated mapping activity (Part B) that was used as an interview probe. y 110 ages of 14-30 years old. 40 McKenzie (2022) Academic Article The goal of this study was to examine the experiences of Indigenous women who had experiences with forced and coerced sterilization in Saskatchewan, Saskatoon, Winnipeg and Manitoba. Participants were Indigenous women and Two-Spirit people who identified as having experiences with forced and coerced sterilization in Hospitals. Semi-structured interviews with environmental scan Saskatchewan, Winnipeg, Saskatoon, Manitoba N=20 32 collaborators came together, 29 of which identified as Cree to design the study. Collaborators were women and two-spirit people. 20 went on to be interviewed with their experiences of forced and coerced sterilization. In phase 2 of the study an environmental scan was conducted to create policy suggestions from interviews. y 1798 Miller (2023) Grey Thesis Canadian Policies on reproductive health were reviewed to look at how they impacted Indigenous Policy analysis Canada N/A Inductive analysis was conducted to examine SRH frameworks that impacted Indigenous women n 111 women in Canada. reproductive rights. Policy review started with the 1876 Indian Act to present day. 54.0 Moisan (2022) Academic Article To improve our understanding of adolescent pregnancy among Inuit women in Nunavik by (1) assessing the distribution of attitudes toward pregnancy; (2) determining the sociodemographic, psychosocial, sociocultural, and behavioural factors that are associated with those linked with high pregnancy likelihood attitudes (HPLA; indifferent, favourable, and Inuit women aged 16 to 20 years. Cross-sectional survey Nunavik n=159 Data for the current study were drawn from the Nunavik Inuit Health Survey Qanuilirpitaa 2017. Conducted in the 14 communities of Nunavik. Out of 1,326 Nunavimmiut who participated in the survey, 172 women aged 16 to 20 years were recruited, and 159 of them answered two questions on attitudes toward pregnancy. Statistically analysis of the data of these 159 survey respondents to assess the distribution of different y 112 ambivalent); and (3) if perceived bene- fits of childbearing is significantly associated to HPLA, determining which have a unique contribution. attitudes toward pregnancy and the factors associated with high pregnancy likelihood attitudes (HPLA; favorable, indifferent, and ambivalent), focusing on the perceived benefits of childbearing (BOC). 1797 Monchalin (2023a) Academic Article To advance knowledge around access to and experiences with abortion services among Indigenous Peoples in Canada. Participants identified with Métis, Cree, Dene, Inuit, Haudenosaunee, Anishinaabe, and Mi'kmaq nations, across nine provinces and territories. Exploratory qualitative study Canada n=15 Conversational interview method to collect data which were analyzed using Flicker and Nixonâs six-stage DEPICT model and review by an Indigenous Advisory Committee. y 5883 Monchalin 2023b 113 1794.0 National Collaborating Centre for Indigenous Health (2021) Grey Report This report summarizes the results from an NCCIH forum on forced and coerced sterilization. N/A Summary Report Ottawa, Ontario N/A This forum was convened after the 2015 reports of two Indigenous women in Canada being forcefully sterilized. Indigenous women and healthcare professionals gathered to discuss the importance of informed consent in medical practices and provide cultural safety guidance. n 1770 National Council of Indigenous Midwives (2019) Grey Position Statement To provide an overview of the position of the National Aboriginal Council of Midwives regarding forced and coerced sterilization of Indigenous Peoples. The National Aboriginal Council of Midwives (NACM) Canada NACM states their views on forced, coerced, and involuntary sterilization of Indigenous Peoples. The NACM also shares recommendations for healthcare providers to follow to provide culturally safe n 114 care to Indigenous People. They also list calls-to-action for policy makers at all levels of government and stakeholders involved in medical education and delivery to uptake immediately to improve the health and well-being of Indigenous People in Canada. 1779 National Inquiry into Missing and Murdered Indigenous Women and Girls (2019) Grey Report Reclaiming Power and Place: The Final Report of the National Inquiry into Missing and Murdered Indigenous Women and Girls. The two-volume report calls for transformative legal and social changes Family members, survivors of violence, experts and Knowledge Keepers Public hearings and evidence gathering Canada N= more than 2,380 truths presented Truths were shared over two years of cross-country public hearings and evidence gathering. The synthesis delivers 231 individual Calls for Justice directed at governments, institutions, social service providers, n 115 to resolve the crisis that has devastated Indigenous communities across the country. industries, and all Canadians. 5879 Native Womenâs Association of Canada (2020) Grey Report To highlight structural factors rooted in colonialism that contribute to sexual and reproductive health and social challenges for Indigenous women, girls and gender diverse people and actively interfere with the provision of adequate, quality, sexual and reproductive outcomes, and healthcare. Prepared for the UN call for submissions for their report "Womenâs and girlsâ sexual and reproductive Indigenous women Policy analysis Canada Report focuses on access to culturally safe, sexual and reproductive healthcare for Indigenous women and girls. Authors hold the stance thatit is imperative that appropriate steps, that are underscored by principles of cultural safety and trauma-informed care, are taken to address the consequences of ongoing injustices caused by Canadaâs colonial history. y 116 health and rights in situations of crisis" 1773 Reeves (2008) Grey Thesis To expand available research concerning the sexuality and sexual health of young adult First Nation women in Atlantic Canada to look at how do social determinants of health create feedback loops into sexual health experiences and how outcomes can be changed. sexually active, English speaking, First Nation women, between the ages of 18 and 30. literature review & qualitative research Atlantic Canada N=11 For the qualitative study component of this thesis, participants were recruited in 2 provinces within Atlantic Canada. Participants who were eligible voluntarily agreed to take part in a semi-structured interview with the researcher. Data management was assisted by the use of the ATLAS-ti computer software program. The data was analyzed using qualitative techniques including grounded theory y 117 1786 Saewyc (2008) Grey Report This report takes a closer look at a health survey of marginalized and street-involved youth in six communities across British Columbia. This report focuses on the experiences of those Aboriginal youth who completed the survey and also discusses the response to these findings of community stakeholders in the nine communities that participated. Young people involved in a street lifestyle, including those who were homeless, panhandling, involved in the sex trade, selling or using drugs, engaging in criminal activities, or who had recently left these situations. Cross-sectional study results and discussion with community stakeholders BC Canada N=410 Survey of marginalized and street- involved youth in nine communities across the province, plus additional discussions with stakeholders in the nine participating communities, as well as the work of a team of Aboriginal researchers and project advisors. Community discussion forums were held in each of the nine communities that participated in the 2006 survey. y 1583 Sethna (2013) Academic Article This study aimed to systematically track, map, and analyze the travel women undertake to access Women who received abortions from 17 freestanding abortion clinics Cross-sectional survey Canada n = 17 abortion clinics n = 1186 women A self-administered written questionnaire to track, map, and analyze women's journeys to clinic abortion y 118 abortion services at freestanding clinics throughout Canada. services was distributed for one month at each participating clinic. Results of statistical analysis provide a graphic illustration of spatial disparities in abortion access in Canada. 1278 Shercliffe (2007) Academic Article To determine efficacy of condom, use amongst vulnerable Indigenous youth using a self-administered survey. Aboriginal youth aged 11-20, who are incarcerated, work as sex trade workers, use needle exchange programs, are homeless, or attend alternative school programs. Community Health Survey Regina, SK N=240 Initial sample N= 133 final sample = number of youths who indicated at least one lifetime experience of sexual intercourse Surveys were conducted through 12 agencies in Regina which serve vulnerable populations. Two aboriginal research assistants-built relationships with the agencies and recruited aboriginal youth to participate. They shared the survey with a group of youth at a time to facilitate completion. The survey had y 119 2 parts. The first part focussed on demographic questions, whereas the second part explored sexual health practices and behaviours. The survey questions were culturally adapted and made easily understandable for youth. Statistical analysis was used to analyze the results. 1156 Shoveller (2007) Academic Article Content to be added. Missing content for this table. Women aged 15-29 who had accessed emergency contraceptive services. Structured interviews BC N=57, 52 women and 5 healthcare professionals Women were recruited across 32 sites to have phone interviews conducted for pre-screening. 90-min interviews were conducted in person with a research assistant and Nvivo was used to code results. Themes focused around y 120 knowledge and use of emergency contraception. 1793 Shwartz (2015) Grey Report To provide advice and recommendations to the BC Tripartite First Nations and Aboriginal Maternal and Child Health Strategy Table (Strategy Table) on the key elements of a promising practice in maternal and child health (MCH)âwhat works, what does not work and what we need to do to improve and accelerate positive changes Health directors and maternal child health program coordinators from First Nations communities, as well as health authority and government staff responsible for implementing maternal and child health and early child development programs in BC. Qualitative interviews BC, Canada n=47 Interviews were analyzed and presented for discussion and validation to two working groups and a coordinators' meeting. Report drafts were discussed at working group meetings and distributed to the Strategy Table and the Provincial Advisory Committee for the BC Healthy Connections Project for their feedback. y 729 Sillett (1998) Grey Position Statement This is a position statement from Pauktuutit (the national organization which N/A Commentary Canadian Arctic N/A In this article, the president of Pauktuutit states the concerns that Inuit people face, especially women and y 121 represents Inuit women from across Canada) concerning Inuit peopleâs, specifically Inuit womens health. those living in rural and remote communities. The 8 chosen concerns were discussed and agreed upon at the annual general meeting which Pauktuutit held in Spence Bay N.W.T. prior to being presented in this article. 670 Stern (1995) Grey (unindexed academic paper) Article To identify the practices of sexual health and wellness in the Inuinnait and Kitlinermiut Inuit communities in the Arctic. Cohort involved Elders (women in their 50âs to 60âs and 70âs), middle aged women (30âs and 40âs) and young women (under 30). Cohort study - qualitative? Victoria Island, Arctic N=400 Interviews with Inuit women in both English and Inuinnaqtun on the topic of reproductive and sexual health as well as overall attitudes on topics such as childbearing, contraception and menstruation. Thematic analysis occurred to share stories and themes from the data. y 122 1804 Stote (2012) Academic Article To understand how the practices of coercive sterilization were carried out on Aboriginal women despite coercive sterilization policies been recognized as racist, sexist, and imperialist. Critical historical and policy analysis Canada A review of existing literature focussed on tracing the rise of sexual sterilization as a cost-effective public health measure and show how presenting eugenic ideology as fact served to obfuscate the problems arising from industrial capitalist relations in the early twentieth century, followed by an overview of some of what is known about the sterilization of Aboriginal women in Canada, and finally placing this practice within the larger context of Indian n 123 policy in Canada 1799 Stote (2022) Academic Article To shed light on the persisting issue of coerced sterilization in Canada but has affected over 100 Indigenous women, including cases as recent as December 2018. Relevant literature including debates, legislation, and other relevant literature to support their argument that indigenous women still face coerced sterilization in Canada. Critical historical and policy analysis Canada Analysis of debates surrounding the decriminalization of birth control in 1969 and the subsequent federal family planning program in 1970 n 1784 Tourand (2016) Grey Report To showcase the successes and challenges that Métis youth ages 12â19 face in BC, through analysis of data from the BC Adolescent Health Survey (BC AHS). Youth in grades 7-12 (aged 12-19) attending public Elementary and High Schools in BC, Canada- this report focuses on responses from Métis youth who self-identified as Métis and Quantitative Analysis BC N = 7% of 30,000. A voluntary and anonymous pencil and paper survey was administered to students in Grades 7 y 124 completed the survey. 5866 Villebrun (2022) Grey Thesis To investigate what it means among Indigenous women without children to live well. Indigenous knowledge keepers and elders, and five Indigenous women who did not have children. Qualitative interviews Alberta N = 7 Interviews were conducted on Zoom after going through cultural protocols. One on one interviews were conducted along with circled interviews. Data analysis followed an Indigenous approach where data is viewed as a whole and their relationships. y 245 Wilson (2016) Academic Article To examine associations of being of Aboriginal ethnicity with sexual risk behaviours and related health services use among young adults through secondary Sexually active female university students under age 30 years from eight post-secondary institutions in the Maritime Survey Maritime Provinces n=5010 In the online survey, students were asked about their ethnic backgrounds, health services use and sexual health behaviours. In this sub-analysis, logistic y 125 analysis of survey data gathered from sexually active female students attending universities. Provinces of Canada regressions were used to compare Aboriginal students to Caucasian students regarding their sexual health behaviours and services use 23 Winquist et al. (2016) Academic Article To assess differences in utilization of maternal serum screening (MSS) and prenatal diagnostic testing between population subgroups and to determine the impact on chromosomal anomaly birth rates. Female residents from Saskatchewan, eligible for provincial health benefits coverage and who either delivered a baby (live or stillborn), experienced a fetal loss (spontaneous abortion), or had a pregnancy termination between 1 January 2000 and 31 December 2005. Population based cohort study Saskatchewan n = 35527 Women with a documented pregnancy were grouped as either exposed (i.e. those who underwent maternal serum screening (MSS)) or unexposed (i.e. those who did not have MSS) and followed for one year to determine the incidence of prenatal diagnostic testing, termination of pregnancy for fetal anomaly (TOPFA), and live born infants with congenital anomalies n 126 (CA). Factors contributing to both MSS and prenatal diagnostic testing utilization were evaluated using statistical analysis 1129 Worthington et al. (2009) Academic Article To describe health risks, outcomes and health services use of Calgary street-involved youth and investigate differences in these by their level of street involvement in order to inform health and street services delivery Street-involved youth who were required to be English speaking, and not under the influence of drugs or alcohol at the time of participation and be within the ages of 24 or younger. Cross-sectional survey Calgary, Alberta n=355 Study participants completed a self-administered survey. Community members (including 3 street-involved youth and representatives of 14 agencies) acted as research team members and contributed to the development of study questions and survey and interview instruments, survey collection, and data interpretation. Various methods of statistical y 127 analysis were used to analyze the data collected from the survey. 633 Young (1998) Academic Article To investigate the association between sexual abuse and a variety of clinical, lifestyle and reproductive factors and to obtain some indication of the differences between the lives of women who have been sexually abused and those who have not. Women attending a community health centre in a predominantly low-income inner-city area of Winnipeg Cross-sectional survey Winnipeg, Manitoba n=843, of which Indigenous participants were n=368 Procedures included a clinical examination, laboratory tests and an interviewer-administered questionnaire. Separate analyses were performed for aboriginal and non-aboriginal women. y 128 Covid Ence # Author (Date) Academic or Grey Literature Quality Appraisal Tool Used Score 5877 Akbari (2021) Grey ACCODS 6 1768 Archibald (2004) Grey ACCODS 6 1780 Assembly of First Nations (2007) Grey ACCODS 6 5 Baaske (2022) Academic WLH 10 569 Benoit (2003) Academic WLH 12 5884 Boyer (2017) Academic N/A N/A 1777 First Nations Information Governance Committee (2005) Grey ACCODS 6 1774 Burchell (1997) Grey ACCODS 6 1595 Chavoshi (2013) Academic WLH 12 5871 Clarke (2021) Academic N/A N/A 533 Cole (2004) Academic WLH 11 215 Corosky (2016) Academic WLH 12 5863 Devries (2009) Academic WLH 10 1406 Devries (2010) Academic WLH 12 1411 Devries (2011) Academic WLH 12 393 Duff (2011) Academic WLH 8 153 Dunn (2019) Academic WLH 6 1776 First Nations Health Authority (2021) Grey ACCODS 6 1775 Healey (2015) Academic WLH 12 267 Hulme (2022) Academic WLH 9 1769 Kinnon (2020) Grey N/A N/A 5872 Lamberti (2022) Grey N/A N/A 4314 Larcombe (2019) Academic WLH 12 1788 Leason (2017) Grey ACCODS 6 1806 Lesperance (2022) Academic WLH 12 918 Logie (2019) Academic WLH 12 5861 Lys (2019) Academic WLH 12 5876 Martin-Ferris (2022) Grey ACCODS 12 1787 McKenzie (2020) Grey ACCODS 6 40 McKenzie (2022) Academic WLH 12 1798 Miller (2023) Grey N/A N/A 54 Moisan (2022) Academic WLH 12 1797 Monchalin (2023a) Academic WLH 12 5883 Monchalin (2023b) Academic WLH 12 129 Covid Ence # Author (Date) Academic or Grey Literature Quality Appraisal Tool Used Score 1794 National Collaborating Centre for Indigenous Health (2021) Grey N/A N/A 1770 National Council of Indigenous Midwives (2019) Grey N/A N/A 1779 National Inquiry into Missing and Murdered Indigenous Women and Girls (2019) Grey N/A N/A 5879 Native Womenâs Association of Canada (2020) Grey N/A N/A 1773 Reeves (2008) Grey ACCODS 6 1786 Saewyc (2008) Grey ACCODS 6 1583 Sethna (2013) Academic WLH 8 1278 Shercliffe (2007) Academic WLH 12 1156 Shoveller (2007) Academic WLH 12 1793 Shwartz (2015) Grey ACCODS 6 729 Sillett (1998) Grey N/A N/A 670 Stern (1995) Grey (unindexed academic paper) N/A N/A 1804 Stote (2012) Academic WLH 11 1799 Stote (2022) Academic WLH 12 1784 Tourand (2016) Grey ACCODS 6 5866 Villebrun (2022) Grey ACCODS 6 245 Wilson (2016) Academic WLH 6 232 Winquist et al. (2016) Academic WLH 8 1129 Worthington et al. (2009) Academic WLH 10 633 Young (1998) Academic WLH 8
Thesis/Dissertation
eng
Women+ and Childrenâs Health Sciences
Vancouver : University of British Columbia Library
Attribution-NonCommercial-ShareAlike 4.0 International
Graduate
Talhouk, Aline
Saewyc, Elizabeth Marie
Intersectional barriers to Indigenous youths' reproductive wellness in Canada
Text