Indigenous access barriers to health care services in London, Ontario The Engaging for Change Improving Health Services for Indigenous Peoples qualitative study

Introduction: Indigenous peoples in Canada suffer higher rates of health inequalities and encounter a number of health services access barriers when compared to their non-Indige-nous counterparts. Indigenous peoples experience social and economic challenges, cultural barriers, and discrimination when accessing mainstream health services. Methods: In London, Ontario, 21 interviews and 2 focus groups (n = 25) with service providers were completed, each session spanning approximately 1 to 1.5 hours. Interviews were voice recorded and transcribed verbatim. Themes were identified using NVIVO 10 software. Findings: Approximately 2 to 5% of clients are Indigenous in hospital-based services. There are a number of social factors that influence whether Indigenous peoples access health services. Indigenous peoples do not have access to adequate pain medications because physicians are reluctant to provide Indigenous patients with pain medications due to common perceptions of addiction. Indigenous peoples also have barriers accessing a family physician because physicians are reluctant to take on new patients with complex health needs. Conclusion: Systemic discrimination is still alive in the health care system; therefore, there is a need for cultural safety training among physicians to increase awareness of access barriers and challenges that many Indigenous patients face when seeking health care.

introduction Indigenous peoples (First Nations, Inuit and Métis) face higher rates of adverse health issues than non-Indigenous people in Canada. Despite the high prevalence of respiratory and circulatory diseases, infectious diseases, injuries, obesity, diabetes, and some cancers, 1 Indigenous peoples do not receive adequate health care and/or do not like to access conventional medical services because of common experiences of discrimination and racism, delivery of poor quality health care, and other access barriers. [2][3][4][5][6][7][8][9] Research has shown that Indigenous peoples do use traditional Indigenous approaches to medicine, however, most Indigenous peoples have to seek conventional medicine because that is all that they have access to due to issues of funding and availability of these types of services. 7,10 With the increase in urbanization among Canada's Indigenous population, these issues have been more rapidly affecting the urban Indigenous population. This is problematic because today more than half of Canada's Indigenous population live in urban settings. 11 A main explanation for the increase in urbanization among this population is the need to relocate in order to access a range of health and social services. 12 Those that do not relocate into the city often have to travel far distances to access health and social services in an urban area. 8,13 Unfortunately, there are a number of challenges that Indigenous peoples face as a result of accessing mainstream services. Some of these challenges include financial challenges, transportation barriers, housing, racism and cultural barriers. 13 The primary goal of this study was to identify the main health service inequalities that Indigenous peoples experience in an urban setting through exploring the attitudes, knowledge and skills of health care providers that work in hospital and/or community-based health centres.

methods
The Engaging for Change: Improving Health Services for Indigenous Peoples project received research ethics approval from both Western University and Lawson Health Research Ethics Boards. A literature review and discussions with local Indigenous health leaders were carried out to determine priority health research areas for the Indigenous population in London, Ontario prior to commencement of qualitative interviews with health care practitioners. From August 2015 to June 2016, 21 one-on-one interviews and 2 focus group interviews (2 participants per focus group) were completed, each interview session spanning approximately 1 to 1.5 hours. Interviewees included physicians, nurses, social workers, patient navigators, patient experience specialists and individuals in a leadership position (eg Department Director) working in a range of health care settings, such as hospitals, community health centres and specialized clinics. Inclusion criteria for participants were those working in a health care setting in one of the five priority services areas (emergency, mental health, maternity, diabetes and cancer) within the London and surrounding area.
Written consent was obtained prior to commencement of a structured interview or focus group. All participants were asked 20 in-depth questions regarding their experiences working with or providing health care to Indigenous peoples. Focus group participants would take turns responding to the interview questions. Questions touched on topics including access barriers, positive and negative experiences, policies and protocols surrounding Indigenous health, and communication, coordination and collaboration with other local community health and social services. A full-list of

Indigenous access barriers to health care services in London, Ontario
The Engaging for Change Improving Health Services for Indigenous Peoples qualitative study Stephanie McConkey Faculty Reviewer: Lloy Wylie, PhD, MA (Department of Psychiatry) original article interview questions can be found in Appendix A. Qualitative interviews were voice recorded and transcribed verbatim by qualified research assistants. Afterwards, coding was completed using NVI-VO 10 Software to identify the main emerging themes.

Patient Population
Themes of qualitative interviews identified that hospital based programs noted that only 2 to 5% of patients and clients were Indigenous peoples, however, respondents identified that the percentage of Indigenous patients was higher in diabetes-related programs. Additionally, physicians believe that Indigenous peoples do not properly articulate their health issues to physicians, which could play a role in the low percentage of Indigenous patients and clients within the system.

Social Determinants of Health
Health care professionals understood that there are a number of reasons why Indigenous peoples may be reluctant to access health care services. While some physicians did express the need for patients to take individual responsibility, the majority of respondents acknowledged the social determinants of health that may hinder access to health care. Social determinants of health that were discussed in the interviews included high levels of poverty and unemployment, low education levels, and other social issues that may influence an individual's health and wellbeing. Transportation to health facilities was believed to be the main access barrier among Indigenous peoples living in rural and/or remote communities, such as reserves. For example, one physician responded, "I would say that people living in the community that don't have the resources or the support to come to London. I think they definitely struggle more with accessing services" (AB10P).
Another commonly emerging theme was that physicians believed that Indigenous peoples suffer from more co-morbidities than their non-Indigenous counterparts and admitted that there may be an issue with physicians being reluctant to take on patients with complex health care needs. A physician noted, "so there is a new doc who you know, is setting up a shingle in town and a new office and they interview patients and they go 'wow, you are pretty complicated I don't really want to get involved with you' and so that exacerbates the whole doctor shortage" (H23P).
This finding demonstrates the shortage of family doctors, but highlights the particular challenges for people with complex health needs, which is more common among Indigenous peoples. [14][15][16] Racism and Discrimination A number of participants shared that they were unaware of traditional Indigenous practices and perspectives of health and wellbeing, however they acknowledged that these practices differed from conventional approaches to medicine. It was also identified that Indigenous practices and perspectives of health and wellbeing were not valued in the health care system. Findings also suggest that physicians are reluctant to prescribe pain medications to Indigenous peoples because of common perceptions of addictions and drug abuse. For example, one physician shared his beliefs about systematic discrimination within the health care system as, "I would think that there are, that on our side there are some frequency of notions that they are all drug seekers. Which clearly isn't true, but I think that if you lined up 10 patients with the same condition and how much pain meds would you give this person if they were Aboriginal, I would bet less, because the fear would be that they are there looking for pain meds to abuse or sell, so I think that as a group they are linked" (A04P).
This response signifies that physicians are aware that there are still discriminatory behaviours among physicians that may affect how an Indigenous patient is cared for.
Physicians also raised the issue that many of their Indigenous clients discontinue services. Physicians believe that this theme may be correlated to poor follow-up and/or lack of appropriate referrals, however, research has shown that it could be strongly related to the experiences of discrimination and racism that Indigenous peoples face within the system. 3,7 Another explanation for lack of follow-up could be jurisdictional challenges. For example, "I had several unfortunate patient situations when I worked in the emergency department specific to Aboriginal patients and that was around getting appropriate follow-up care and access to follow-up care because there were difficulties in having community care access get onto the reserve to provide care there. There were some barriers around that" (A03L).
This response provides evidence that there are jurisdictional issues that Indigenous peoples living on-reserve face which negatively influences the types of follow-up care they have access to.

discussion
The findings from this research show that there is a high need for mandatory Indigenous cultural competency and safety training among all providers working in the health care system so that they will be able to provide more culturally relevant and safe care. Research has shown that there is a lack of culturally appropriate health services, 4,17-18 and our findings align with research that suggests that Indigenous peoples are still facing systemic discrimination when accessing mainstream health care services and programs. 3 Racial misconceptions can strongly influence an individual's health and wellbeing, and make them reluctant to access health care as a result. [3][4][5][6][7] Therefore, health provider training should take on the biases and stereotypes that lead to the provision of poor standards of care for Indigenous patients. Participation in cultural safety training would be a means of reducing racist and discriminatory perceptions original article about Indigenous peoples that are widespread within the health care system. Additionally, cultural awareness will be beneficial for care providers to support their understanding of the different perspectives of health and wellbeing among Indigenous peoples. Such knowledge would facilitate improved patient support and better communication and coordination with community-based services.
Supports need to be put in place to facilitate access to health care services. It is clear that transportation is definitely a barrier to those who do not reside in the city, because reserves do not have the same structural support that any given city would in regards to health care. Therefore, individuals need to travel to the city to get adequate access to health care. 8,13 Funding for transportation for those living in rural settings would provide Indigenous patients and families the ability to access health services within and out of their community.
More awareness and communication between hospital programs and community supports (ie. Southwestern Ontario Aboriginal Health Access Centre, N'Amerind Friendship Centre, etc.) are needed to ensure patients needs are being met and proper referrals are being completed. Additionally, further research on continuity of care needs to be done to understand why it is lacking among the Indigenous population in London, Ontario.
Limitations of this study is that there was a small sample size (n = 25) and only health care provider perspectives were included in the research at this time. Additionally, ethnicity data is not collected in hospital-based services, therefore the number of Indigenous patients was an estimation based on the respondents' recollection.
conclusion In order to improve health access for Indigenous peoples, health care providers need to be aware of the issues and challenges that many Indigenous peoples have surrounding primary health care, most importantly the social determinants of health. Physicians working in diabetes-related services should be aware of the higher percentage of Indigenous peoples in these services, and proper training should take place to ensure cultural needs are being met. It is evident that racism and discrimination are still alive in the health care system and it has strong influences on the health and wellbeing of Indigenous peoples. The next steps for this research is to understand the impact of cultural safety training on health care workers and to determine what other institutional supports are needed to transform practice and patient experiences. In addition, the project aims to understand patient perspectives and needs to identify how to ensure appropriate care is provided when they access hospital and community-based programs in London, Ontario.
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