Content uploaded by Annette J Browne
Author content
All content in this area was uploaded by Annette J Browne on Jul 15, 2014
Content may be subject to copyright.
Report available
in alternate formats
British Columbia
Centre of Excellence
for Women’s Health
Vancouver, BC
CANADA
By Annette J. Browne
with Jo-Anne Fiske
and Geraldine Thomas
British Columbia
Centre of Excellence
for Women’s Health
First Nations Women’s
Encounters with
Mainstream Health
Care Services & Systems
By Annette J. Browne
with Jo-Anne Fiske
and Geraldine Thomas
British Columbia
Centre of Excellence
for Women’s Health
First Nations Women’s
Encounters with
Mainstream Health
Care Services & Systems
Women’s Health Reports
Copyright © 2000 by BC Centre
of Excellence for Women’s Health
All rights reserved. No part of this
report may be reproduced by any
means without the written permission
of of the publisher, except by a reviewer,
who may use brief excerpts in a review.
ISSN 1481-7268
ISBN 1-894356-09-8
Lorraine Greaves, Executive Editor
Celeste Wincapaw, Production Coordinator
Janet Money, Senior Editor
Robyn Fadden, Copy Editor
Michelle Sotto, Graphic Designer
Main Office
E311 - 4500 Oak Street
Vancouver, British Columbia
V6H 3N1 Canada
Tel 604.875.2633
Fax 604.875.3716
Email bccewh@bccewh.bc.ca
Web www.bccewh.bc.ca
British Columbia
Centre of Excellence
for Women’s Health
Centre d’excellence de la
Columbie-Britannique
pour la santé des femmes
Canadian Cataloguing
in Publication Data
Browne, Annette J.
First nations women’s encounters with
mainstream health care services and
systems
1. Indian women—Medical care—British
Columbia, Northern. I. Fiske, Jo-Anne,
1946- II. Thomas, Geraldine. III. BC Centre
of Excellence for Women’s Health. IV. Title.
RA450.B7B76 2000
362.1’089’9707118
C00-910346-5
Contents
.
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
I. Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
II. Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
III. Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
IV. Research Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
A. Design. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
B. Data Collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
C. Data Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
D. Theoretical Perspectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
E. Community Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
V. Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
A. Invalidating Encounters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
B. Affirming Encounters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
VI. Conclusion and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Appendices
Appendix 1: Health Care Systems and Services
Used by Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . .30
Appendix 2: Examples of Questions that Guided
Interviews with Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Appendix 3: Memorandum of Understanding Between
Research Team and First Nation Community . . . . . . . . . . . . . . . 32
Project Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
FIRST NATIONS WOMEN’S ENCOUNTERS WITH MAINSTREAM HEALTH CARE SERVICES & SYSTEMS
1
For further information about this study contact:
Geraldine Thomas or Annette J. Browne
c/o Northern Secretariat
British Columbia Centre of Excellence for Women’s Health
University of Northern British Columbia
3333 University Way
Prince George, British Columbia V2N 4Z9
Telephone: (250) 960-5602, or (250) 960-6509
Fax: (250) 960-5536
Email: browne@unbc.ca
BC CENTRE OF EXCELLENCE FOR WOMEN’S HEALTH2
Acknowledgments
Funding for this research was provided by the British Columbia
Centre of Excellence for Women’s Health. The research team
gratefully acknowledges the generosity of the women and elders
whom we interviewed. We also thank Maryka Senema for her
assistance at the outset of the project, and Kristiann Allen, for
her valuable contributions as this project was completed.
FIRST NATIONS WOMEN’S ENCOUNTERS WITH MAINSTREAM HEALTH CARE SERVICES & SYSTEMS
3
Executive Summary
This investigation of First Nations women’s encounters with main-
stream health care services was carried out in a small reserve
community in northern British Columbia. A qualitative research
design was used, comprising a series of two interviews each with
10 First Nation women.
Women described their encounters with health care services under
broad categories of invalidating or affirming. Although this report ex-
amines invalidating encounters in greater detail than affirming encoun-
ters, the discrepancy reflects the emphasis provided by the research
participants. Both types of encounters are described along with their
influences, and policy implications are raised and listed in the authors’
conclusions. The women’s stories may be read as illustrations of the
broader social, economic and political forces at work influencing the
lives of First Nations women in relation to the dominant social systems.
A second phase report on this research will examine in greater detail
recommendations for change and possible alternative strategies to
address the issues raised in this phase.
I
BC CENTRE OF EXCELLENCE FOR WOMEN’S HEALTH4
First Nations women’s encounters with mainstream health care practi-
tioners influence their access to and utilization of these services (Browne,
1995; Frideres, 1994; O’Neil, 1989; Sherley-Spiers, 1989; Waldram, 1994).
Although there have been numerous studies examining the nature of
women’s interactions with physicians in particular, few studies have
described the ways in which First Nations women experience their
encounters with providers and other aspects of the health care system.
The purpose of this study is to describe, in depth, Aboriginal women’s
encounters with mainstream health care services with a long-term view
to generating ideas for improving health care delivery and policy. Building
on previous work conducted by the project leader (Browne, 1993; 1995;
1997), attention was given to the issue of respect in the context of health
care interactions between First Nations women and mainstream health
care providers. This research adds to previous work undertaken by the
BC Association of First Nation Women (Todd-Denis, 1996) and the First
Nation Women’s Group of Prince Rupert (Angus, 1995), and is informed
by studies that have discussed or investigated the range of factors
influencing First Nations peoples’ encounters with the dominant health
care system (Culhane-Speck, 1987; Dion-Stout, 1996; Dion-Stout &
Kipling, 1998; Hooper & Hagey, 1994; O’Neil, 1989; Sherley-Spiers, 1989).
Background
II
FIRST NATIONS WOMEN’S ENCOUNTERS WITH MAINSTREAM HEALTH CARE SERVICES & SYSTEMS
5
The impetus for this study arose out of a series of community meetings
involving northern women held by the Northern Secretariat of the B.C.
Centre of Excellence for Women’s Health (BCCEWH) located at the
University of Northern British Columbia (UNBC). At these meetings we
learned that First Nations women’s encounters with mainstream health
care systems and services were of particular concern. Discussions
revealed that these encounters influenced not only the health and well-
being of First Nations women, but also the health of their families and
communities. In order to recommend changes to the health care system
at either the micro or macro levels, more needed to be learned about
the nature of women’s encounters and the ways in which these experi-
ences affected their health and well-being.
Two research questions guided our study:
• How do First Nation women describe their encounters with local,
mainstream health services?
• How do these encounters influence the health and well-being of First
Nation women?
Objectives
III
BC CENTRE OF EXCELLENCE FOR WOMEN’S HEALTH6
Research Methods
IV
A. Design
In developing our qualitative research design, we were concerned
with understanding women’s accounts of their health care experiences
from their own perspective. For this reason, we were influenced by
phenomenological strategies of inquiry (Van Manen, 1997) and women-
centred ethnographic research approaches. Understanding women’s
lived experiences, and accepting them as real and valid, for the pur-
poses of “disclos[ing] the social processes from within as it is lived,”
are among the major principles women-centred ethnography shares
with phenomenology (Smith, 1986, p. 12). Women-centred research
principles can be conceptualized as having three broad goals: (1) to
document the experiences and activities of women, (2) to understand
these experiences from their point of view, and (3) to discern women’s
behaviour as an expression of social contexts (Reinharz, 1992). An
egalitarian approach to the research process was a grounding principle
shaping this study, which provided the opportunity to understand partici-
pants’ narratives and their connections with social and political praxis
(Enslin, 1994).
B. Data Collection
This study was conducted in a Carrier First Nation reserve community
located in the northern interior region of B.C. This community was
selected in part because of the renowned leadership in health provided
by several community women, among whom are elders, health profes-
sionals and community leaders. The strength of female leadership
reflects the respect the Carrier, who are a matrilineal society, bestow
on women and the value placed on the authority held by female elders
within extended family units. Additionally, two members of the research
team have had a long-term working relationship in the community, which
facilitated initiation of this research endeavour. In turn, the community
believed that it would benefit from documentation of women’s encoun-
ters with the local health services systems as it developed short and
long-term goals for improving access to and utilization of health services
for community members.
FIRST NATIONS WOMEN’S ENCOUNTERS WITH MAINSTREAM HEALTH CARE SERVICES & SYSTEMS
7
The study was granted approval
by the UNBC Ethical Review
Committee before data collection
began. Additionally, the Royal
Commission on Aboriginal Peoples
Guidelines (1993) for research with
First Nations were followed. To this
end, a memorandum of understand-
ing was signed between members
of the research team and the First
Nation community outlining the
research process, ethical principles,
and ways of sharing control over
data collected (Appendix 3). Finally,
the women provided written consent
before participating, confirming their
understanding of the purpose of the
study and the ways in which the
results were to be used.
We conducted in-depth interviews
with 10 women. Community leaders,
elders and the investigator who
was based at the reserve selected
the participants using a purposive
sampling procedure. Although
general questions provided guide-
lines for discussions (see Appendix
2), participants were able to direct
the conversation according to their
preferences. As illustrated in the
type of general questions posed,
an effort was made to elicit partici-
pants’ descriptions of “model case”
encounters and “contrary case”
encounters as a way of gaining an
understanding of both positive and
negative interactions (Browne, 1995;
Kaufert, Koolage, Kaufert & O’Neil,
1984).
All interviews were taped and then
transcribed verbatim. Second inter-
views were held with all participants,
except one who became ill, to vali-
date and clarify information discussed
in previous interviews. To maintain
consistency in interviewing, all data
were collected by one researcher.
Field notes were recorded as soon
after the interviews as possible in
order to capture issues or insights
related to interview content or pro-
cess, to provide methodological
notes for the research team, and
to make theoretical connections
to other studies and literature.
C. Data Analysis
Data obtained from interviews
and field notes were treated as
text, or text analogues. The interpre-
tive thematic analysis was primarily
guided by principles and stages
identified by Van Manen (1997). First,
the narrative text was reviewed as
a whole by the research team for
an overall understanding of the text.
Second, the text was read repeat-
edly to identify patterns of regulari-
ties, and recurring ideas and experi-
ences that linked participants’ per-
spectives. Through this process we
drew categories and themes from the
data. Third, through critical question-
ing and by reflecting on the theoreti-
. . . an effort was
made to elicit
participants’
descriptions of
“model case”
encounters and
“contrary case”
encounters as a
way of gaining
an understanding
of both positive and
negative interactions . . .
BC CENTRE OF EXCELLENCE FOR WOMEN’S HEALTH
8
cal perspectives, we developed
further themes and linked these
with sections of the narrative text.
Fourth, as themes and categories
emerged from the data, we sought
critique and validation from commu-
nity participants. Finally, excerpts of
data and the themes and categories
they illustrated were discussed with
an outside qualitative research ex-
pert who assessed the degree
of reliability within the analysis.
Throughout the data analysis
process, the “decision trail” (Guba
& Lincoln, 1981) was spelled out so
that others could audit the process.
D. Theoretical Perspectives
Following analysis of the text, we
turned to issues of political economy
and the position of the First Nation
community relative to the decision-
making structures that constrain
health practice. How the women
perceive and respond to health
delivery services today reflects
the consequences of a century
of power politics in which decision
making and policy development
have remained in the hands of the
dominant society. Like many First
Nations in Canada, the people of this
First Nation, whether they reside on
or off the reserve, find themselves
at the margins of the local political
economy and virtually excluded
from the powers of the state,
whether these be the decision-
making bodies of federal, provincial
or municipal regimes, or the demo-
cratic institutions of non-government
organizations and social movements.
As Frideres (1991) has argued, the
linkages between government and
non-government institutions are a
dimension of the dominant health
system; the power relations embed-
ded in them, and the normality that
they come to represent, are taken
for granted by those who benefit from
them to the extent that anyone who
is excluded risks being seen as
deviant. Cast as outsiders by social
processes, First Nations are repre-
sented as the “other”, a representa-
tion that is perpetuated through the
colonial-like structures of mainstream
health institutions.
Building on the concepts of “struc-
tural communication” (Arno, 1985)
and “cultural safety” (Cooney, 1994;
Ramsden, 1992, 1993; Wood &
Schwass, 1993), we sought under-
standings of the structural barriers
the women encountered and of the
social and health implications of
these barriers. We were concerned
with the way structural communica-
tion reinforced inequality between
First Nation and non-First Nation
authorities, giving the state influence
over local ideas and actions that
affect women’s cultural safety.
Cultural safety moves beyond
notions of cultural sensitivity to
an analysis of power imbalances,
Like many First Nations
in Canada, the people
of this First Nation,
whether they reside
on or off the reserve,
find themselves
at the margins of
the local political
economy and virtually
excluded from the
powers of the state
FIRST NATIONS WOMEN’S ENCOUNTERS WITH MAINSTREAM HEALTH CARE SERVICES & SYSTEMS
9
institutional discrimination, and the
nature of relationships between
the colonized and colonizers as
they apply to health care interactions
at the macro and micro levels. The
principles of cultural safety can
be gained by understanding their
antithesis, culturally unsafe practices:
“Any actions that demean or
disempower the cultural identity
and well-being of an individual.
The crucial elements within the
cultural safety concept are that
unsafe practitioners diminish,
demean and/or disempower those
of other cultures, whilst safe practi-
tioners recognize, respect and
acknowledge the rights of others”
(Cooney, 1994, p. 6).
Ultimately, cultural safety is con-
cerned with changing attitudes
and with gaining an awareness
of the political and historical forces
shaping the dynamics of health care
interactions with Aboriginal people.
Repeatedly, participants who
worked in health care commented
on the limited impact of conventional
cross-cultural training programs on
providers’ attitudes and behaviours.
Recognizing this limitation, “cross-
cultural training” could be better
accomplished by deconstructing
clinical interactions and studying
them in the wider context of
political, economic, historical and
social determinants. The principles
of cultural safety provide a lens
through which “cross-cultural
training” could occur. An excellent
model for this type of instruction is
found in Kaufert, Koolage, Kaufert
and O’Neil (1984) where “trouble
cases” are used to examine the
influence of socio-cultural and
political factors on clinical com-
munication.
Conditions of cultural safety, how-
ever, cannot be achieved solely
through individual interactions.
Relations of structural communica-
tion must be radically altered to allow
for transfers of power to First Nations
governments. Cultural safety can be
achieved only through meaningful
participation in decision making,
that is, decision making that moves
beyond marginalization to enhance
rather than dismiss or violate cultural
values and social practices. These
premises, although expressed
somewhat differently, underlie the
“population health approach” advo-
cated by the Canadian state, which
calls for recognition “that a state of
best health is not merely a function of
physical capacity, but is also closely
related to a whole set of personal and
social resources” (Dion-Stout 1996,
citing Standing Committee on Health
1995). Whether we draw from pre-
cepts of cultural safety or from the
population health approach, we find
that a key expression of women’s
health lies in encounters and prac-
Cultural safety
can be achieved
only through
meaningful
participation
in decision making
BC CENTRE OF EXCELLENCE FOR WOMEN’S HEALTH
10
tices that uphold “the high esteem
that Aboriginal women bestow upon
human life and family,” and contribute
“to Aboriginal social stability and
social integration, thereby creating
a healthy living context for Aboriginal
women” (ibid.).
The concepts of cultural safety and
structured communication help us to
understand how political economic
structures constrain isolated efforts
to reform policy and practice. Hence,
we now turn to a description of the
historical and political context of the
First Nation.
E. Community Setting
The First Nation with which we
conducted our study has a popula-
tion of 600 members, the majority of
whom live on-reserve. Their commu-
nity is located in a rural area, 20
kilometres by country road from a
small rural non-Native municipality
(population 4,400). A highway
connects the First Nation com-
munity to a northern regional city
(population 80,000) 125 km away.
The largest southern urban city is
1,000 km to the south by road or
one hour by jet from the regional city.
An overview of the range of health
care services in each centre utilized
by women from the reserve is
provided in Appendix 1.
Relations between the First Nation
and the dominant community are
marked by a hierarchy of power sites
that disadvantage the members of
the First Nation and bind them in
relations of structural communication.
Unlike the neighbouring rural munici-
pality, the reserve community suffers
from intolerably high rates of unem-
ployment, underemployment, and
reliance on social transfer payments.
This leads to a social distance
between the “white” and First Nation
societies that has a marked impact
on social well-being. Only rarely are
members of the First Nation invited
to join decision-making bodies, and
on those occasions they are often
invited as a sole representative (for
example, on the Regional Health
Board), giving rise to feelings of token-
ism and frustration because of the
inability to bring about meaningful
changes to their circumstances.
Pushed outside the social network
that underlies the voluntary sector,
the reserve community does not
directly share in the socio-economic
benefits garnered by voluntary agen-
cies. This exclusion from essential
decision making and the continuance
of culturally alien educational and
health practices has led the govern-
ing council of the First Nation to build
its own health clinic and school.
In keeping with the federal govern-
ment’s constitutional duties to all
Aboriginal peoples it recognizes as
status Indians, members of the First
Nation community receive some
Unlike the neighbouring
rural municipality, the
reserve community
suffers from
intolerably high rates
of unemployment,
underemployment,
and reliance on social
transfer payments.
FIRST NATIONS WOMEN’S ENCOUNTERS WITH MAINSTREAM HEALTH CARE SERVICES & SYSTEMS
11
non-insured health benefits through
the federal government Medical
Services Branch. Although this
service is a federal obligation, it
has given rise to resentment from
members of the dominant society
respecting “free” health services
and is often seen as an extension
of welfare or charity. As we shall
see, members of the First Nation
are acutely aware of this resent-
ment and recognize that these
perceptions contribute to negative
stereotypes and the process of
“othering” that alienates them from
public services.
All medical doctors in the nearby
rural municipality work from a
common medical clinic located
near the municipal hospital. It is
easy to understand the alienation
felt by First Nation women who
rely on these services. There are
no First Nation employees. The
clinic’s routines are determined by
the needs and expectations of the
dominant community, both in relation
to the organization of work as dic-
tated by the medical fee system and
in its spatial and temporal organiza-
tion. The small reception area and
adjoining waiting room do not allow
any privacy, nor are disabled pa-
tients well served by the reception
desk which consists of a high
counter that blocks reasonable
communication between chair-
bound patients and staff.
Timely patient schedules are a
priority; the clinic charges a $20
fee for missed appointments. This
practice, as we shall see, discour-
ages the building of healthy patient/
doctor relations because it is per-
ceived as unnecessarily punitive by
women who are unable to organize
their lives by the dictates of the clock.
The 20-kilometre trip to the clinic is
not easy to arrange; a patient who
neither owns a car nor has regular
funds to reimburse others for travel
expenses may be unable to prear-
range a ride that will bring her to the
clinic at the appointed time. She may
be forced to hitch-hike, an unpredict-
able and risky way to travel. In many
cases she will not be able to avoid
the $20 penalty as she will not
have a phone to call and cancel
her appointment. In consequence,
a woman may choose to avoid the
clinic when she or her family mem-
bers become ill and turn to the emer-
gency services at the hospital, which
again blocks the establishment of
sound patient/doctor relations. These
avoidance strategies do not alleviate
the stress and humiliation felt by the
women, but only serve to postpone
an inevitable confrontation with clinic
personnel.
Contemporary power relations
are troubled by a cultural legacy of
mistreatment and abuses that arose
in past decades, in particular in
educational practices. From 1917-
The clinic’s routines
are determined by
the needs and
expectations of the
dominant community,
both in relation to the
organization of work
as dictated by the
medical fee system
and in its spatial and
temporal organization.
BC CENTRE OF EXCELLENCE FOR WOMEN’S HEALTH
12
1946, children of this First Nation
were compelled to attend residential
school in order to receive an educa-
tion. In 1946, a day school was
opened on the reserve; however,
many families continued to have
their children placed in the resi-
dential school, often during times
of stress and economic hardship.
As has been made evident from
recent disclosures of former stu-
dents, abuses were common in
the schools. Of all the privations
and sufferings none is seen as
more personally harmful than sex-
ual abuse, which creates a lifetime
of fear, humiliation and mistrust.
Individual sexual violence, how-
ever, is not the only harm that
carries through to today. The very
strict teachings of sexual modesty
and morality have also left their
scars, not the least of which can
be a sense of shame of one’s body
and therefore a fear of exposing it
to medical staff. This dilemma is
compounded by the lived extremes
between ideals of sexual morality
and lived experiences of abuses
and hurts. A further consequence
of residential school, which was
strongly emphasised during the
community review of our draft
report, arises from imposed ide-
ology of stoicism and suffering.
As young girls, former students
were taught to suffer pain in silence,
which today leads women to avoid
seeking health care until they ex-
perience extreme symptoms. In sum,
as we detail below, the combination
of these complex, strained social and
political relations affects the capacity
of women to be accepted as credible
medical subjects.
FIRST NATIONS WOMEN’S ENCOUNTERS WITH MAINSTREAM HEALTH CARE SERVICES & SYSTEMS
13
Findings
V
Two broad themes emerged from the analyses of participants’ discus-
sions of encounters with mainstream providers and services. These
were identified as invalidating encounters and affirming encounters.
Invalidating encounters occurred on a variety of levels that formed six
patterns of experience. Similarly, affirming encounters were manifested
in a variety of ways. For the purpose of this report, emphasis is placed
on invalidating experiences because these were given greater attention
by the participants, and because they point to possible policy reforms
that could counter such experiences.
A. Invalidating Encounters
1. Being dismissed
Participants described situations in which their health concerns or
subjective symptoms were not taken seriously, were trivialized, or were
dismissed by health care providers, predominantly doctors or nurses.
In many cases, participants felt that nurses and doctors assumed there
was nothing wrong before assessing the patient’s condition. The follow-
ing excerpt captures this sense of dismissal.
“But a lot of these nurses, when they see Native people coming, they
always tell them, ‘No this is no problem. You shouldn’t worry about it’
and send them on their way, then they get more sick. I don’t know. . . But
some of these nurses that work in the clinics, they’re really intimidating.
They assume that nothing’s wrong with you.”
In addition to feeling that their concerns were dismissed by providers,
participants expressed their sense of not being “listened to” by their
providers. One participant, who works in health care, offered an expla-
nation for providers’ failure to listen to women from her community in the
following way.
“Only problems I’ve had were with people who didn’t listen to you. They
think they’re the nurse or the doctor and they don’t really listen to what
you’re saying. That’s the only problem I’ve had with them. Maybe be-
BC CENTRE OF EXCELLENCE FOR WOMEN’S HEALTH
14
cause I’m Native. I don’t know. You’re
not supposed to know these things.
{laugh} That’s the feeling I got from
them, eh?”
This participant questions whether
her provider’s dismissal of her
concerns stemmed from his or
her views of her as a First Nation
woman. This was not an isolated
interpretation of the underlying
causes of dismissive attitudes by
providers; other participants ex-
pressed similar views, pointing to
the ways in which the process of
“othering” constructs Aboriginal
women as patients who are “not
supposed to know these things.”
The risk of being dismissed was
compounded by women’s reluc-
tance to admit to pain or outwardly
express suffering, which they
explain is what they had been
taught by their Catholic teachers
in residential school. Paradoxical
situations are then created whereby
a woman may wait until her condi-
tion is severe before seeking ser-
vices, yet past experiences cause
her to fear that she will be dismissed
by her provider.
Participants felt that dismissal of
their concerns was also related to
providers’ perceptions of First Nation
women as passive participants in
health care interactions. However,
participants described that what is
assumed to be passivity during a
clinical interaction is actually a
culturally specific way of conveying
respect to people who are consulted
for advice or assistance. Further-
more, participants described how
residential school staff reinforced
this culturally defined behaviour in
order to encourage conformity and
lack of assertiveness. The propen-
sity to be viewed as passive or
unassertive created anxiety as
participants worried about the
possible consequences.
“I think that the one that had the
biggest impact was someone that
my mother knew when she lived in
[the regional city]. She knew some-
one who went to the hospital and
was very sick and was turned
away because they thought maybe
she was drinking or something. And
I think that the woman went home
and died, and that was quite horrible
and that’s kind of always, kind of
haunted me. When I think of my
mother going to hospital, maybe
getting turned away because she’s
not aggressive. . . If they said they
didn’t want to see her, she would go
[leave the hospital] even if she was
really sick. You know, she’s older. . .
Anyway she was turned away for
whatever reason and I think that if
someone the same age would go
there, who is not First Nations,
who’s white, they would have taken
her because that’s just the attitude.”
Participants felt that
dismissal of their
concerns was also
related to providers’
perceptions of First
Nation women as
passive participants in
health care interactions.
FIRST NATIONS WOMEN’S ENCOUNTERS WITH MAINSTREAM HEALTH CARE SERVICES & SYSTEMS
15
It is not difficult to see how this
combination of factors – dismissal
on the part of providers, getting
turned away, reluctance to admit
to symptoms until they are severe,
and providers’ views of women as
passive – creates the potential for
tense or difficult health care interac-
tions and potentially poor health
outcomes for women.
2. Transforming One’s Self
Participants described situations
that they believed could be improved
by transforming themselves in terms
of appearance and behaviour. These
acts of transformation were under-
stood as a means of obtaining
credibility and reliability as medical
subjects. One participant described
her experience in the following way.
“It seemed like any time I go to a
doctor I would have to be well
dressed. I have to be on my best
behaviour and talking and I have
to sound educated to get any kind
of respect. That’s what usually
happened. If I went in, if I was
sicker than a dog and if I didn’t
want to talk and I didn’t care how I
sounded or whatever, I’d get treated
as such, like lower than low. But if I
was dressed appropriately and
spoke really well like I usually do
then I’d get treated differently. . . Now
why should I have to act like . . . not
act, but why do I have to try harder
to get any kind of respect? You
know, why do I have to explain?”
The statement above about “having
to try harder” is significant. This
participant felt that if she dressed
well (according to a standard under-
stood to be appropriate for health
care encounters) and presented
herself as an educated person, she
would be less likely to be dismissed.
These stories help to illustrate the
double bind that participants face. To
accept responsibility for transforming
oneself is to affirm judgements of
incredibility or inadequacy in the
eyes of health professionals.
In other circumstances, the situation
was ironically reversed: participants
were recognized by providers
because of their leadership positions
in the local community and were
afforded what they understood to
be special treatment. Participants
described this special treatment
either as tokenism or as occurring
because of providers’ concerns
about a participant’s capacity to be
politically influential. Thus, partici-
pants were unable to take for granted
the attention bestowed upon them by
physicians in particular, and criticized
the doctors’ actions with skepticism.
3. Negative Stereotypes
about Aboriginal Women
Participants’ understanding of their
overall relationship to the dominant
health care system and health
This participant felt that
if she dressed well and
presented herself as
an educated person,
she would be less
likely to be dismissed.
BC CENTRE OF EXCELLENCE FOR WOMEN’S HEALTH
16
professionals cannot be interpreted
outside of the larger socio-political
context stemming from the colonial
legacy of paternalism in health care
to First Nations people. The prevail-
ing reality remains that “health care
institutions are powerful symbols
of a recent colonial past. In this
context, seemingly innocuous
behaviour is often considered by
patients as racist” (O’Neil, 1989, p.
341). Given this socio-political and
historical context, it was not surpris-
ing that encounters with discrimina-
tory attitudes and behaviours were
pervasive throughout participants’
stories.
In some cases, participants realized
that they were judged in stereotypi-
cal negative ways and treated
accordingly. In other situations,
participants described a pervasive
sense of everyday encounters
with racism and saw health care
interactions as just one example
of taken-for-granted experiences
of discrimination. Subtle, everyday
expressions of discrimination were
encountered, for example, when
participants showed their Depart-
ment of Indian Affairs status card
at dentists’ offices, at the pharma-
cies, or when making purchases
in the rural municipality. Two partici-
pants described their perspectives
of everyday experiences of discrimi-
nation:
“I think too there’s really a myth out
there in the general society that First
Nations people get everything. You
know it’s like they get their education
paid, their medical paid. Anytime they
want money they go to the govern-
ment and it’s handed to them and I
think that’s another misconception
that’s out there.”
“Oh, I don’t usually like to talk about
discrimination because, you know,
it seems like it’s an ongoing thing
and you have to be, it takes a lot of
energy to be dealing with it all the
time. And I think for myself I only
deal with it maybe not even 50 per
cent of the time. Like 30 to 40 per
cent of the time I confront it when it
happens. Sometimes instead of
making the decision, I will just let it
go or whatever. Because it’s just
energy draining. The negativity for
me is, it just takes a lot of energy.”
Perhaps the most troubling conse-
quences of the colonial legacy in
health and social service sectors
are the discriminatory judgements
levelled against Aboriginal women
as mothers. Repeatedly, stories
were shared that described how
participants were viewed as negative
stereotypes, an act that denies the
centrality of mothers within Carrier
communities. The most dramatic
example was described by one
participant as follows.
“I just had my first child. I was very
FIRST NATIONS WOMEN’S ENCOUNTERS WITH MAINSTREAM HEALTH CARE SERVICES & SYSTEMS
17
athletic. I played fast ball. I got hit in
the face with a ball and my forehead
was all swollen. I ended up having
a black eye. And just at that time I
saw Dr. K. He was my doctor and
my daughter had a really bad rash
on her bum and over the weeks he
was trying different creams and it
just got worse. It got really, really
bad. Nothing helped and she got a
fever one night and this is when I
had the black eye. I went into the
emergency. I had this black eye. I
had my daughter, screaming, fever.
Her bum was just really red and
raw and they took her away from
me. They apprehended her from
me right there. As far as they were
concerned because of the way I
looked, and because they didn’t
check on her previous history, they
apprehended her. And they didn’t tell
me right then and there. They told
me the next day when I went to try
to visit her because they kept her.
And they wouldn’t let me see her.
They tried to prevent me from
seeing her. . . And I just raised hell
and I got hold of my mom and my
family. . . Because I had a really
good record with my own personal
doctor. . . They didn’t even contact
him to ask what the history was and
he was outraged. So, a few days
after that, they contacted him and
he set them straight and I was still
upset. But they allowed me to visit,
to see my daughter again, but I was
still upset and I said I was going to
take legal action against that. And
they wrote me a letter of apology
and regretted the whole incident and
I couldn’t believe it, and it just shows
you, I said, just because I’m a Native
person that came in with a black eye,
that looked like I wasn’t, you know,
because my child had a really bad,
severe rash, they just assumed the
worse. And I said, ‘You didn’t even
know who I was.’ . . . It was just
because of how I looked, eh? . . .
So it just shows you what extremes
people go to in making assumptions
about another person based on race.
. . . I was so hurt. I’ve never trusted
doctors after that because I was
very reluctant to bring my daughter
in. Anytime she was sick or anything,
that incident always comes back to
me and I think, I don’t want to ever go
through that again. I don’t want to be
judged morally, that I’m a bad mom. I
don’t want to ever be judged like that
again.”
This apparent denigration of partici-
pants’ roles as mothers is particularly
troubling considering the leadership
roles that some participants hold in
the community, and their influence as
female leaders in both non-traditional
and traditional arenas (Fiske, 1992).
These stories of negative stereotyp-
ing also underscore the perceived
need for participants to transform
themselves into credible medical
subjects in order to be treated
appropriately.
BC CENTRE OF EXCELLENCE FOR WOMEN’S HEALTH
18
Participants who worked in health
care also described the discrimina-
tory attitudes displayed by providers
toward Aboriginal women with
substance abuse problems, and
homeless persons who received
services in emergency departments
or hospital wards. In some cases,
participants who worked in health
care described how services were
sometimes withheld from known
alcoholics or street people. A health
worker, for example, cited cases in
which physicians had refused to
treat certain individuals or had failed
to provide adequate care even when
a health worker had challenged the
physicians to do so. As one partici-
pant said, “I feel that they’re being
treated, well, just like a piece of dirt.
They talk to them like that . . . I had
to tell one of [the physicians], ‘It’s
still up to you, it’s still your responsi-
bility to make sure that he’s okay.’”
In other situations, participants
described their sense of bearing
the blame and burden for other
women’s substance use problems.
4. Marginalization from
the Mainstream
Participants also described their
experience of discrimination in terms
of marginalization from mainstream
health services. They expressed
their sense of being on the “outside”,
as “intruding” on the system and as
lacking connection to the social
processes inherent in mainstream
health systems. One participant
described her impression as an
“outsider” during visits to the medical
clinic in the nearby rural municipality.
She contrasts her experience with
observations of non-Native women’s
propensity to navigate health care
situations.
“I think with white women, they’re
more vocal, their families know one
another. I go into the clinic and I see
white people talking to each other,
asking about sons, people that are
common to each of them. You go,
you have a Native person come in,
you don’t hear that exchange and
conversation between Natives and
whites saying, ‘Oh, how’s your
family?’ That really doesn’t happen.
So there’s that. The social factor. We
don’t socialize together. So it’s us and
them. And we feel like we’re using,
we’re intruders on their system. A lot
of times, I feel that way. And probably
a lot of Native people would feel the
same, I think. That we’re intruding, it’s
their service.”
Paradoxical situations are created
whereby the taken-for-granted
dominant styles of social discourse
do not necessarily include the style
of social discourse with which
participants are comfortable. The
lack of participation in the “small talk”
that occurs at the clinic carries the
potential to further reinforce the
FIRST NATIONS WOMEN’S ENCOUNTERS WITH MAINSTREAM HEALTH CARE SERVICES & SYSTEMS
19
perception of Aboriginal women
as others, as outsiders or as intrud-
ers on the system. The sense of
marginalization continues to occur
despite the fact that the reserve
community and rural municipality
are separated by only 20 kilometres
of farmland and there is an ongoing
flow of business from the reserve
to the municipality.
5. Situations of Vulnerability
Participants described a common
consequence of attending residential
schools: an extreme sense of vul-
nerability when having to expose
their bodies for physical examina-
tions. One woman described her
own experience at having to un-
dergo a full physical exam for the
first time as a young woman.
“I don’t know why, I didn’t want
anybody to look at my body. Be-
cause we were told not to show
our bodies. Maybe it has to do with
our upbringing and by the way we
were taken out of our homes and
told to be ashamed of our bodies.
Like in [residential school] they
used to tell us we’re just Indians,
they call us worse names but I
don’t want to repeat what they call
us. That we’re forbidden to look at
anybody, even the opposite sex, so
you had a dislike for your body and
your person, as a Native person.
And I was scared. I was embar-
rassed. The doctor, I guess some-
how I went through that and I really
didn’t like it. Every time I saw the
doctor after that I was, didn’t want
to look at him. But now I’m a mature
woman I look at it differently because
I work in the nursing field too. . . It’s
just like a routine thing so now I
understand. But when I was young . . .”
In the context of the recent disclo-
sures of abuses endured at resi-
dential schools, it is understandable
that some Aboriginal women would
be reluctant to seek out health care
encounters involving bodily exposure
in order to avoid feeling invalidated
or shamed. A younger participant
described a similar sense of vulner-
ability experienced by Aboriginal
women who may not have attended
residential schools, but who had
been physically or sexually abused
in other situations.
“There’s lots of sexual abuse too that
happened, probably still happens in
the community, and younger women,
they hide their bodies. They don’t
want to draw any attention to them-
selves or to their physical ailments or
whatever or because they’re afraid to
let anybody touch them because of
the sexual abuse that’s happening.
Myself, I was sexually abused so I
sort of know the feeling of being
examined the first time by a doctor, I
was ashamed. So you have to deal
with that. And the doctors are not
BC CENTRE OF EXCELLENCE FOR WOMEN’S HEALTH
20
sensitive to this. You know, they
don’t know the full picture of what
goes on behind closed doors,
what happens in this community. . .
And the same thing with physical
abuse, . . . again, that’s where you
find really shy women. Especially
when you have a male doctor
talking like an authority to you or
feeling that you’re being talked
down to. If you’re the woman that
was constantly being beaten,
you’re going to clam right up,
you’re going to be quiet, you’re
going to be submissive. You know,
that’s just an indicator of an abuse
situation. You have these misinter-
pretations. ‘Is this part of their
culture?’ ‘Is this why they’re so
submissive?’”
One can sense the concern
expressed by this participant that
providers might miss the underly-
ing social factors contributing to
women’s apparent passivity,
reticence or shyness.
6. Disregard for Personal
Circumstances
For participants, lack of consider-
ation for their personal circum-
stances contributed to their
experience of invalidation during
health care encounters. Lack of
regard for socio-economic pres-
sures was one way that partici-
pants felt their personal circum-
stances were not considered.
The $20 fine levied against patients
who miss appointments at medical
clinics in the rural municipality and
the regional city indicates a lack
of regard for the difficulties many
women face. Although the cancella-
tion fee may be necessary to the
economic viability of the clinics, it
creates a double-bind for women
from the reserve who cannot afford
home phones and who do not have
access to a phone, or who may not
be able to secure transportation into
town to attend their appointments or
afford a taxi. The impoverished
conditions in which many reserve
women live preclude them from
having the structures and conve-
niences in place that would allow
them to arrive for appointments on
time or to phone ahead and cancel.
In other situations, participants
described how they were made
to wait for excessively long times
because they were a few minutes
late for their appointment, represent-
ing, to them, a form of penalization.
The embarrassment associated with
being late, or being asked to pay the
cancellation fine when they lacked
the money, illustrate the ways in
which clinic policies framed partici-
pants’ experiences by blaming indi-
viduals for circumstances beyond
their control.
B. Affirming Encounters
Although the authors and participants
The $20 fine levied
against patients who
miss appointments
at medical clinics in
the rural municipality
and the regional city
indicates a lack
of regard for the
difficulties many
women face.
FIRST NATIONS WOMEN’S ENCOUNTERS WITH MAINSTREAM HEALTH CARE SERVICES & SYSTEMS
21
in this report have stressed invali-
dating encounters as a means to
understanding what requires change
in health care, we also gave serious
consideration to affirming experi-
ences. From the view of policy
makers, these experiences are
significant. They direct attention to
what works best, for whom, and
in what circumstances. They are
useful in the quest for understanding
what processes and practitioner/
patient relations have best served
First Nation women and have
enabled some to move beyond
disempowering experiences.
Given the context of the recent
colonial nature of health services,
and the difficulties that characterized
participants’ encounters with current
mainstream services, it became
apparent that descriptions of positive
health care encounters were sym-
bolic of what mattered most: sharing
knowledge and power with partici-
pants over health care decisions,
conveying respect for the partici-
pants as women with unique cultural
heritages, and forming effective
interpersonal relationships in ways
that reduced the distance between
participants and others in relation to
the health system.
1. Actively Participating
in Health Care Decisions
Being able to speak openly and to
participate in health care decisions
was extremely important for partici-
pants. One participant stressed the
need for “a good talking relationship”
that allows for an exchange of know-
ledge and contributes to personal
empowerment. For one woman, this
sharing included receiving a pharma-
ceutical book from her physician in
recognition of her interest in medici-
nal properties. Another participant
praised a physician who encour-
aged her to ask questions and who
seemed more concerned about her
patient’s concerns than establishing
time constraint.
“I had a doctor here and you know
she was really good and I don’t know
if it has to do with being female, but
she was really good. . . When I first
went there, we talked, but every time
I had to go, if there was some proce-
dure or something happening, I could
ask questions. There was no time
limit and she helped me to become
more in control of my own health,
which was the big thing. So I didn’t
feel uncomfortable asking questions
or [saying] ‘Okay, well no I don’t want
to do that, can you try something
different?’ That’s what I’ve noticed.
That’s why she was a good doctor. I
wasn’t just a piece of meat {laughter}.”
The ability to exercise self-determi-
nation is seen by this patient to
transform not only her immediate
relationship with her physician but
also to validate her as a respected
One participant
stressed the need
for “a good talking
relationship” that
allows for an
exchange of knowledge
and contributes to
personal empowerment.
BC CENTRE OF EXCELLENCE FOR WOMEN’S HEALTH
22
patient, who was acknowledged to
be more than “just a piece of meat.”
2. Feeling Genuinely Cared For
In some cases, participants shared
stories of health providers who de-
monstrated an outstanding ability
to convey a caring attitude. This
was reflected in the interpersonal
strengths of the practitioners, which
highlight the importance of style and
manner in interacting with patients.
Trust was created when participants
felt the practitioners truly cared
about them and their families and
when the women sensed that they
were being treated like a “regular
person” rather than being dismissed
through negative stereotyping.
“I really felt by that doctor that he
looked at my health and gave me
the best care that he could, that was
me and my family. And I always felt
that about him and felt safe under his
care. . . He always treated me like I
was, I always felt that he talked to
me and explained everything very
clearly and he was very courteous
to me and treated me like, you know,
just like a regular person. You know
what I mean? He was very, his man-
ner was very warm and courteous
and you knew that he cared for you.”
The participants also expressed
gratitude for moments when practi-
tioners went the “extra mile” to offer
emotional support at times of great
stress, as happened at the death of
one woman’s husband.
“Well, the best treatment I ever had
was when my husband died, my
doctor came, phoned me to tell me
to come in to talk with him and see if
I was okay and things that happened
and nobody had control over any-
thing. . . And he explained it to me
really softly, things like this happen.
He was such a good doctor. He was
really caring. And that was the best
thing that ever happened to me was
him phoning me on his own to tell me
that. . . My own family doctor. He’s
passed away now. We can’t find one
better than him now. You know, to
treat a patient. He knew everything
about me, that doctor, and I trusted
him with my life. {laugh} And he took
really good care of me. I often re-
member him for doing that. I said if all
the doctors were like him, it’d be nice.
They listen to you and they care for
you even though it’s going that extra
mile for you.”
In some cases, outstanding care
was described as unanticipated
acts of kindness, and was highly
valued by participants. Participants
described their impressions of
gestures and actions from health
providers that were understood to
be beyond the call of duty and un-
expected. Examples ranged from the
decision of a hospital nurse to remain
with a participant during a premature
Trust was created
when participants
felt the practitioners
truly cared about them
and their families . . .
FIRST NATIONS WOMEN’S ENCOUNTERS WITH MAINSTREAM HEALTH CARE SERVICES & SYSTEMS
23
delivery rather than leaving at the
end of her shift, to respect shown
by hospital staff toward culturally
specific ways of attending to a
dying relative. One participant
spoke appreciatively of a gynae-
cologist who comforted her after
a miscarriage; his soothing voice
calmed her as he sought to reas-
sure her.
“He said, ‘Well, look you can try
to have another baby.’ But I’ll never
forget him. . . it must have been his
voice that was so, so soothing.”
The attending nurse was also seen
as being very kind.
“I remember her, she was, I don’t
know who she was, but she stood
with me. She stood there for a long
time. She was holding my hand, eh?”
It was at these moments, when
practitioners responded to the
holistic needs of their patients by
striving to offer emotional as well
as medical support, that the partici-
pants felt both comforted and
listened to.
Another participant described the
kindness extended to family mem-
bers who were attending to a dying
relative in the local hospital.
“You know, they never once said,
‘We want you guys to leave. It’s after
hours.’ Or anytime we asked for
anything they were helpful. . . When
she turned for the worse, they told
us . . . you can call your family and
they can come, stay and you can
go have coffee upstairs and stuff
like that. And they didn’t mind us
being there. . . and at one point, there
was probably about twenty of us.
But we were probably, after I thought
about it a couple of years later, people
have work to do in there and stuff.
They never once got mad about it or
I don’t remember them getting mad.”
As the participant described above,
visitors expected that their presence
would annoy staff, they would be
asked to leave, or they would have
to defend their reasons for wanting
to remain at the bedside. Rather, the
participant described the comfort
taken from the unanticipated support
and care provided by staff.
3. Affirmation of Personal
and Cultural Identity
Affirmation of participants’ identity
arose from conditions of cultural
safety. Fundamental to the validation
of many First Nation women is
recognition of traditional knowledge
and the expertise founded on that
knowledge, such as the expertise
held by local herbal specialists. A
significant shift in relations with the
local municipal and regional hospi-
tals, for example, has occurred with
the hospitals’ acceptance of patients’
use of traditional medicines. Accep-
tance of this knowledge as a legiti-
A significant shift in
relations with the local
municipal and regional
hospitals, for example,
has occurred with the
hospitals’ acceptance
of patients’ use of
traditional medicines.
BC CENTRE OF EXCELLENCE FOR WOMEN’S HEALTH
24
mate medical practice reflects the
esteem that First Nation women
place upon both traditional and
western epistemologies and helps
to foster First Nation values. Affirma-
tion of the value of traditional medi-
cines by the mainstream health
system therefore represents an
important way of validating the
caring practices of First Nation
women.
Some participants reported being
affirmed as Aboriginal women by
practitioners who either validated
their pride in their culture and history
or affirmed culturally defined body
images. Validation of self-identity
and cultural pride signalled a willing-
ness to listen to the patient and to
understand her health within the
social and cultural dimensions
that she defined as most important
to her. This stood out in sharp
contrast to experiences that left
the patient sensing she had not
been respected. One participant
described how impressed she was
when her family physician recog-
nized her pride in her cultural heri-
tage, and the influence that it had on
her self-esteem.
“He recognized that I was proud of
my culture. He talked about my
culture and the positives about the
Aboriginal people, the land. He
recognized that we were here first
and he respected us for that. He
talked about how he owes a lot to
my race for them being here and
those kinds of things. He was proud
that, he was happy, I was going to
school, I was doing well. I talked
about my goals and things like this
to him and he, he encouraged me.
He encouraged me and he said that
there’s nothing holding me back and
I can be better than he is. And that’s
what I liked, eh? He didn’t set himself
on a pedestal because he was a
doctor. . . So that’s why I say, I have
a really good perspective on crappy
doctors and really good doctors.”
The participant also describes how
the distance that characteristically
exists between health professionals
and patients was kept to a minimum,
because the doctor did not put him-
self “on a pedestal” in relation to her.
For participants, an exceedingly
important way of affirming cultural
identity was providers’ capacity to
support and convey respect for
families as they cared for dying
relatives in home or hospital. Partici-
pants described how health providers
demonstrated respect for women’s
roles as caregivers by extending
themselves as supporters in appro-
priate ways. Participants also placed
a high value on home visits by health
care providers, particularly for elderly
people or terminally ill people. This
was not simply described as a per-
sonal preference; visiting someone in
Participants also
placed a high value
on home visits by
health care providers,
particularly for elderly
people or terminally
ill people.
FIRST NATIONS WOMEN’S ENCOUNTERS WITH MAINSTREAM HEALTH CARE SERVICES & SYSTEMS
25
her own home is an important,
culturally based way of conveying
respect to the patient and her family.
For example, one participant de-
scribed how significant it was that
a doctor made a home visit on the
reserve to her dying daughter
several years ago.
“. . . the doctor was good to us, like
when my oldest daughter was very
sick with cancer, the doctor even
went to her house to visit with her.
That was really, I thought really it
was a very good doctor. Just out
of his way, he had to check on her
in her house, you know. Not very
many do that nowadays.”
Others described how appreciative
they were of hospital staff who
accommodated culturally specific
ways of caring for dying patients.
Home visits and support for grieving
family members represent ostensi-
bly simple, but powerful, ways of
acknowledging participants’ cultural
identity, roles and practices. These
gestures supported women’s caring
practices “which is in our culture, we
feel for one another, and we can’t let
go of that.”
4. Development of a Positive,
Long-Term Relationship
with a Health Care Provider
Affirming encounters frequently
arose out of long-term, positive
relationships with family doctors or
community health nurses. Unfortu-
nately, these types of relationships
were difficult to develop and maintain.
Lack of choice among small num-
bers of providers in the local area,
high turnover rates among health
professionals in northern and rural
regions, the social distance and
sense of other that typically existed
in relation to health professionals,
and the frequency of invalidating
experiences all contributed to difficul-
ties in forming long-term relationships
with providers. Despite the barriers
to forming satisfying alliances with
health professionals, participants
recognized the value of having a
stable provider whom they trusted,
and sought out relationships with
family physicians in particular. This
process was described by one
participant in the following way.
“When I moved to [the rural munici-
pality] and started to go to the clinic,
you just get whoever, so I was
getting bumped around and seeing
whatever doctor was available at the
clinic. I don’t know how come they do
it differently up there, but they do.
Until I finally got hold of a doctor that
I thought we could work something
out with, and I asked him to be my
doctor and that’s who I just see now
all of the time. But since talking to
him, I’ve noticed a big difference in
how I’m treated. . . I told him I’m tired
of being bumped around all over and
would you be my doctor {laughter}.
BC CENTRE OF EXCELLENCE FOR WOMEN’S HEALTH
26
What does he think? And he was
kinda shocked that anybody would
ask. I guess they just have to take
whoever they’re given. But I wanted
a better relationship so I didn’t feel
like a cow going through the clinic.”
Thus, seeking out long-term family
physicians helped participants to
cope with the lack of continuity of
care encountered otherwise. This
strategy marks women’s commit-
ment to their well-being and the
significance of provider/patient
relationships grounded in mutual
respect and dignity.
FIRST NATIONS WOMEN’S ENCOUNTERS WITH MAINSTREAM HEALTH CARE SERVICES & SYSTEMS
27
Conclusion and Recommendations
In sum, findings from this study provided detailed insights into the nature
of health care encounters from the perspective of First Nation women
residing in a northern reserve community. The women’s stories highlight
the importance of viewing their perspectives in terms of the larger
social, economic and political forces influencing Aboriginal women’s
lives and encounters with the dominant health care system.
From a political standpoint, the goals of research must move beyond
simply exploring and documenting phenomena of concern to women.
Research must also be critical, action-oriented, and contribute to the
development of strategies for addressing women’s oppression (Ander-
son, 1991; Enslin, 1993). The development and exchange of knowledge
is a political process. To facilitate this process we address initial ideas
for change with full awareness of the limitations of these suggestions
in the context of structural and political forces driving health care.
The text arising from our research also helps to identify and clarify
issues pertinent to policy analysis and development. However, when
we view the tensions between the First Nation and the dominant sites
of power as structural communication, it is evident that the power im-
balances that give rise to the women’s concerns regarding their health
care cannot be redressed without radical changes in the political rela-
tions. Thus, when we considered implications for policy arising from our
study, we recognized that incremental policy reform will only ameliorate
aspects of service delivery that shape First Nations women’s experi-
ences and cannot, on its own, rectify the causes of their oppression.
Nevertheless, the policy implications we identify here are grounded in
our findings and reflect the ways in which health service delivery can
be improved for First Nation women of this community.
Recommendations
Cultural Safety
Further exploration is needed to develop ways of integrating the concept
of cultural safety into policies guiding health services to Aboriginal patients.
VI
BC CENTRE OF EXCELLENCE FOR WOMEN’S HEALTH
28
For these reasons, policies that
adopt principles of cultural safety
may be one way of encouraging
health care agencies to look beyond
descriptions of cultural differences
in order to gain a deeper under-
standing of factors influencing
health care for Aboriginal women,
their families and communities. Just
as anti-racist policies brought issues
of discrimination and racism to the
forefront, policies addressing cultural
safety can provide a mechanism for
linking macro-level issues to micro-
level interactions in a health care
context.
Limits of Cross-
Cultural Training
Health care agencies should recog-
nize the limits of cross-cultural
training programs in relation to the
insights of cultural safety. In areas
where there are high proportions of
Aboriginal people, continuing educa-
tion policies should recommend
learning strategies for health provid-
ers, staff and administrators that
move well beyond descriptions of
cultural differences and etiquette to
an analysis of the socio-political and
historical factors influencing health
care encounters.
The Role of
Aboriginal Women
Health service delivery to Aboriginal
women should be guided by policies
that recognize the central caregiving
role held by many Aboriginal women.
These policies should safeguard
against false accusations and
negative stereotypes of Aboriginal
women as unfit mothers. As gate-
keepers to health care for family
members, Aboriginal women must
feel comfortable and have trust in
the services received. Until policies
are developed that protect Aboriginal
women from institutional discrimina-
tion in mainstream post-colonial
health care systems (Frideres,
1991), it will be difficult for Aboriginal
women to fully trust these services.
Punitive Policies
Cancellation policies that impose
financial penalties for circumstances
beyond women’s control should be
reeval-uated. Blanket penalties
applied to all, regardless of circum-
stance, obscure the social and
economic context of health care
interactions. These policies level
undue blame on individual women
for social problems such as poverty,
unemployment and lack of opportunity.
Home Visits
Development of policies that would
allow nurses, physicians and other
professionals to run clinics or make
home visits on reserve should be
considered. Although home visits
may not be seen as an efficient way
of delivering services, they could
help to foster connections between
the reserve and sectors of the local
FIRST NATIONS WOMEN’S ENCOUNTERS WITH MAINSTREAM HEALTH CARE SERVICES & SYSTEMS
29
health system. Clearly, this would
require revisions/exceptions to
jurisdictional issues that currently
impede implementation of alternate
approaches to on-reserve health
care delivery.
Input into Health Policy
Regional health boards and service
agencies need to develop mecha-
nisms and structures (and con-
comitant funds) that would ensure
meaningful input by First Nation
women into local health policies.
For example, one area of service
delivery policy that participants
identified as immediately important
was for Aboriginal liaison or support
workers (and ultimately for Aborigi-
nal health care providers) in health
agencies. Participants highlighted
the value of the Aboriginal liaison
worker currently employed in the
regional city hospital and recom-
mended that this role be extended
to other health agencies to alleviate
women’s sense as outsiders or
intruders on the system.
Social Focus
With the focus of health care reform
primarily on the financing and struc-
turing of health care systems, atten-
tion has been diverted from the socio-
political context of health service
delivery. Health reform must also
focus on policies that address those
critical determinants of health,
including:
the absence of discrimination, social
justice to prevent systemic discrimi-
nation and health inequalities, and
social relationships that respect
diversity (cf. Canadian Public Health
Association, 1996). Examining the
ways in which these determinants
can be addressed through policy
will require meaningful involvement
of Aboriginal women who are af-
fected by such policies. (See also
Lefebvre, 1996).
BC CENTRE OF EXCELLENCE FOR WOMEN’S HEALTH30
Appendix 1
Health Care Systems and Services Used by Participants
Residents from the First Nation community receive the majority of their
primary medical care, community health nursing, and dental services
from the nearby rural municipality. The medical clinic in the nearby
community houses seven doctors and staff. Alternatively, residents
who are unable to access a physician or who wish to use the services
of other providers travel to the regional city. In both the rural municipality
and the regional city, it is exceedingly difficult to find a family physician
who can accept new individuals and families into their already over-
burdened practices. Many women from the reserve therefore cope for
years without a steady family physician.
Uncomplicated in-patient care is provided at a small rural hospital
located in the rural municipality. If more extensive acute care is required,
patients are transported to the larger regional hospital located in the
regional city. Patients must also travel to the regional city for most dia-
gnostic and specialist services. If community members require more
intensive or specialized acute care and diagnostic services, they travel
to the hospital in the southern urban centre 1000 km away.
Community health nursing services (for example, home visits to new
mothers and infants, and childhood immunizations) are provided on
reserve a few days per month. The community health nurses are based
at a branch of the provincial public health unit located in the nearby rural
municipality. At the time of data collection, a locally controlled health
centre was being constructed on the reserve. When completed, this
health centre will be responsible for providing community health nursing
and various social services to reserve residents. No primary care
medical services will be provided at the new health centre unless, in
the future, a physician runs a clinic on an interim basis or a nurse works
in an expanded scope of practice (for example, if a nurse practitioner is
employed).
FIRST NATIONS WOMEN’S ENCOUNTERS WITH MAINSTREAM HEALTH CARE SERVICES & SYSTEMS
31
Appendix 2
Examples of Questions that Guided Interviews with Participants
• Tell us how health care providers behave toward you and your family.
• Tell us about a time when the health care you received had a big effect
on you or your family.
• Tell us about a particularly good experience you or your family had with
health care.
• Tell us about a particularly negative experience that you or your family
had with health care.
• From your experience, what part of the health system really works for
you and your family? What part does not?
• What do you think women from this community need most from the
health care system?
BC CENTRE OF EXCELLENCE FOR WOMEN’S HEALTH32
Appendix 3
Memorandum of Understanding Between Research Team
and First Nation Community
I. Purpose of the Agreement
This letter of agreement between the Project Team and the First Nation
is being undertaken for the purpose of engaging in research that exam-
ines First Nation women’s encounters with the health care system. This
study is funded by the BC Centre of Excellence for Women’s Health.
II. Obligations of the Project Team
The Project Team and the First Nation wish to confirm by this Letter of
Agreement that the Project Team will carry out their work according to
the following terms.
A. The Project Team will be responsible for conducting the research
according to the methods outlined.
B. All costs incurred as a result of the research will be covered by
funding provided the BC Centre of Excellence for Women’s Health.
Full accounting of expenditures will be maintained by the Project Leader.
C. The Project Team agrees to comply with the guidelines set forth in
the Royal Commission on Aboriginal Peoples Ethical Guide lines for
Research (1993).
D. The Project Team agrees to keep the First Nation informed of the
progress of the research.
E. The Project Team pledges to maintain the confidentiality of all persons
involved in the study. The research methods have been designed to
ensure that the identity of any persons will not be disclosed.
FIRST NATIONS WOMEN’S ENCOUNTERS WITH MAINSTREAM HEALTH CARE SERVICES & SYSTEMS
33
III. General Provisions
A. Conducting the Project
1. The First Nation reserves the
right to provide advice or direction
to the Project Team at anytime.
B. Utilization of Research Findings
1. The Project Team agrees to
consult and collaborate with the
First Nation prior to publishing
findings or results of the research.
2. No findings shall be published
without the consent of persons
participating in the project.
3. Unless otherwise negotiated,
the Project Team as listed above
will hold first, second and third
authorship on publishedmaterials.
C. Time Frame for the Agreement
1. The agreement will commence
on September 30, 1997 and expire
18 months later unless otherwise
negotiated.
2. This agreement may be amended
by mutual consent of the parties
concerned.
BC CENTRE OF EXCELLENCE FOR WOMEN’S HEALTH34
Project Team
Annette J. Browne, RN, MSN
Project Leader
Assistant Professor
Nursing Program
University of Northern British Columbia
Jo-Anne Fiske, PhD
Associate Professor
Anthropology and Women’s Studies Programs
University of Northern British Columbia
Geraldine Thomas
Band Councillor and Treaty Manager
FIRST NATIONS WOMEN’S ENCOUNTERS WITH MAINSTREAM HEALTH CARE SERVICES & SYSTEMS
35
References
Anderson, J. M. (1991). Current directions in nursing research: Toward a
poststructuralist and feminist epistemology. Canadian Journal of Nursing
Research, 23(3), 1-3.
Angus, J. (1995). Women’s health conference and health workshops
report and health survey. Prince Rupert: First Nations Women’s Group.
Arno, A. (1985). Structural communication and control communication:
An interactionist perspective on legal and customary procedures for
conflict management. American Anthropologist 87, 40-55.
Browne, A. (1993). A conceptual clarification of respect. Journal of
Advanced Nursing, 18, 211- 217.
Browne, A. J. (1995). The meaning of respect: A First Nations perspec-
tive. Canadian Journal of Nursing Research, 27(4), 95-109.
Browne, A. J. (1997). A concept analysis of respect; Applying the hybrid
model in cross-cultural settings. Western Journal of Nursing Research,
19(6), 762-780.
Canadian Public Health Association. (1996). Action statement for health
promotion in Canada. Ottawa: Canadian Public Health Association.
Cooney, C. (1994). A comparative analysis of transcultural nursing and
cultural safety. Nursing Praxis in New Zealand, 9(1), 6-12.
Culhane-Speck, D. (1987). An error in judgement: The politics of medical
care in an Indian/White community. Vancouver: Talon Books.
Dion-Stout, M. (1996). Aboriginal Canada: Women and health. Canada-
U.S.A. Women’s Health Forum Commissioned Papers [On-line]. Available:
http://www.hc-sc.gc.ca/canusa/papers/canada/english/indigen.htm
Dion-Stout, M., & Kipling, G.D. (1998). Aboriginal women in Canada:
Strategic Research Directions for Policy Development. (No. SW21-20/
1998). Ottawa: Status of Women Canada.
BC CENTRE OF EXCELLENCE FOR WOMEN’S HEALTH
36
Enslin, E. (1994). Beyond writing:
Feminist practice and the limitations
of ethnography. Cultural Anthropol-
ogy, 9(4), 537-568.
Fiske, J. (1992). Carrier women and
the politics of mothers. In G. Creese
& V. Strong-Boag (Eds.), British
Columbia Reconsidered: Essays
on women, pp. 198-216. Vancouver:
Press Gang Publishers.
Frideres, J. (1991). From the bottom
up: Institutional structures and the
Indian people. In B.S. Bolaria, Social
issues and contradictions in Cana-
dian society, pp. 108-132. Toronto:
Harcourt Brace Jovanovich.
Frideres, J. (1994). Health Promotion
and Indian communities: Social
support of social disorganization. In
S. Bolaria, & R. Bolaria, Racial
minorities, medicine and health.
Halifax: Fernwood.
Guba, E. G., & Lincoln, Y.S. (1981).
Effective evaluation: Improving the
usefulness of evaluation results
through responsive and naturalistic
approaches. San Francisco:
Jossey-Bass Publishers.
Hooper, B.J.K., & Hagey, R. (1994).
Control issues in native health care:
Perspectives of an urban community
health centre. In B.S. Bolaria & H.D.
Dickinson (Eds.), Health, illness,
and health care in Canada (2nd ed.),
pp. 221-244. Toronto: Harcourt Brace
& Company.
Kaufert, J. M., Koolage, W. W.,
Kaufert, P. L., and O’Neil, J. D. (1984).
The use of “trouble case” examples
in teaching the impact of sociocul-
tural and political factors in clinical
communication. Medical Anthropol-
ogy, 8(1), 36-45.
Lefebvre, Y. (1996). Women’s health
research in Canada: A Canadian
perspective. Canada-U.S.A.
Women’s Health Forum Commis-
sioned Papers [On-line]. Available:
http://www.hc-sc.gc.ca/canusa/
papers/canada/english/researab.htm.
O’Neil, J. D. (1989). The cultural and
political context of patient dissatisfac-
tion in cross-cultural clinical encoun-
ters: A Canadian Inuit study. Medical
Anthropology Quarterly, 3(4), 325-344.
Ramsden, I. (1992). Teaching cultural
safety. New Zealand Nursing Jour-
nal, 21-23.
Ramsden, I. (1993). Cultural safety
in nursing education in Aotearoa
(New Zealand). Nursing Praxis in
New Zealand, 8(3), 4-10.
Reinharz, S. (1992). Feminist meth-
ods in social research. New York:
Oxford University Press.
Royal Commission on Aboriginal
Peoples (1993). Ethical guidelines
for research. Ottawa: Royal Commis-
sion on Aboriginal Peoples.
Sherley-Spiers, S. K. (1989). Dakota
perceptions of clinical encounters
FIRST NATIONS WOMEN’S ENCOUNTERS WITH MAINSTREAM HEALTH CARE SERVICES & SYSTEMS
37
with western health-care providers.
Native Studies Review, 5(1), 41-51.
Smith, D. (1986). Institutional eth-
nography: A feminist method.
Resources for Feminist Research,
15(1), 6-13.
Todd-Denis, A. R. (1996). Qwum
Qwum Sleni: A report on aboriginal
women’s health issues in the lower
mainland. Vancouver: B.C. Women’s
Hospital and Health Centre.
Van Manen, M. (1997). Researching
lived experience. London, ON:
Althouse Press.
Waldram, J.B. (1994). Cultural and
socio-economic factors in the
delivery of health care services
to aboriginal peoples. In Bolaria
B.S. & Bolaria, R. (Eds.), Racial
minorities, medicine and health.
Halifax: Fernwood Publishing.
Wood, P., & Schwass, M. (1993).
Cultural safety: A framework for
changing attitudes. Nursing Praxis
in New Zealand, 8(1), 4-15.
