International Journal of Circumpolar Health

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Acute health care among Indigenous patients in

Canada: a scoping review

Laura-Philippe Vigneault, Ella Diendere, Catherine Sohier-Poirier, Margo Abi

Hanna, Annie Poirier & Maude St-Onge

To cite this article: Laura-Philippe Vigneault, Ella Diendere, Catherine Sohier-Poirier, Margo Abi
Hanna, Annie Poirier & Maude St-Onge (2021) Acute health care among Indigenous patients
in Canada: a scoping review, International Journal of Circumpolar Health, 80:1, 1946324, DOI:
10.1080/22423982.2021.1946324

To link to this article: https://doi.org/10.1080/22423982.2021.1946324

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INTERNATIONAL JOURNAL OF CIRCUMPOLAR HEALTH
2021, VOL. 80, 1946324
https://doi.org/10.1080/22423982.2021.1946324

Acute health care among Indigenous patients in Canada: a scoping review

a
Laura-Philippe Vigneault , Ella Diendereb, Catherine Sohier-Poiriera, Margo Abi Hannac, Annie Poirierd
and Maude St-Onge d
a
Faculté de médecine, Université Laval, Quebec, Canada; bCentre de recherche sur les soins et les services de première ligne de l’Université
Laval (CERSSPL-UL), Quebec, Canada; cFaculty of Medicine and Health Sciences, McGill University, Montreal, Canada; dDépartement de
médecine familiale et de médecine d'urgence, Université Laval, Quebec, Canada

ABSTRACT ARTICLE HISTORY

A recent report by the Chief Public Health Officer of Canada demonstrates the inferior health Received 15 March 2021
status of Indigenous Peoples in Canada when compared to non-Indigenous populations. This Revised 14 June 2021
scoping review maps out the available literature concerning acute health care for Indigenous Accepted 17 June 2021
Peoples in Canada in order to better understand the health care issues they face. All existing KEYWORDS
articles concerning health care provided to Indigenous Peoples in Canada in acute settings were Indigenous health; acute
included in this review. The targeted studied outcomes were access to care, health care satisfac­ health care; Canadians’
tion, hospital visit rates, mortality, quality of care, length of stay and cost per hospitalisation. 114 health; emergency
articles were identified. The most studied outcomes were hospitalisation rates (58.8%), length of department; hospitalisation
stay (28.0%), mortality (25.4%) and quality of care (24.6%) Frequently studied topics included
pulmonary disease, injuries, cardiovascular disease and mental illness. Indigenous Peoples pre­
sented lower levels of satisfaction and access to care although they tend to be over-represented
in hospitalisation rates for acute care. Greater inclusion of Indigenous Peoples in the health care
system and in the training of health care providers is necessary to ensure a better quality of care
that is culturally safe for Indigenous Peoples.

Introduction policies of cultural assimilation are reflected in the cur­

rent relations between Indigenous Peoples and govern­
In 2016, 1 673,780 Indigenous people were identified in
ment institutions such as health care services.
Canada, representing 4.76% of the Canadian population
In Canada, the health care of Indigenous Peoples is
[1]. Indigenous Peoples include three major groups: First
mainly managed by the federal government since the
Nations (61%), Inuit (4%) and Métis (32%) Peoples [2]. It
adoption of the Indian Act in 1985. However, important
is important to recognise that within these three groups,
differences in health care management between
there are over fifty different Indigenous nations and over
Indigenous communities persist. Indigenous commu­
six hundred Indigenous communities, each of them with
nities in the province of Quebec have the authority to
their own traditions and experiences [3]. Although
manage their own health care services whereas others
Indigenous communities are distinct from one another,
communities depend on the federal government. The
they share certain common experiences. An example of
health care coverage and access also differ for
such experiences is the Residential School Program
Indigenous Peoples living on-reserve and off-reserve
imposed by the Government of Canada until 1996. This
and for those who identify as Métis [1]. These differ­
program aimed to assimilate Indigenous Peoples by for­
ences in health care management have a direct impact
cing Indigenous children to attend boarding schools
on the health care provided to Indigenous Peoples in
directed by religious authorities and the Canadian gov­
Canada.
ernment. This program led to significant intergenera­
A recent report by the Chief Public Health Officer of
tional trauma due to the tearing of Indigenous children
Canada establishes that Indigenous Peoples in Canada
from their culture and community in addition to the
have a shorter life expectancy at birth than non-
abuse inflicted upon them in these schools [4,5]. The
Indigenous populations. Indigenous Peoples are also
Residential School Program is only one example of
less likely to report a very good or excellent state of
many government policies and measures, which aimed
health [2]. Additionally, several studies demonstrate
to assimilate Indigenous Peoples in Canada. These
significant disparities between Indigenous and non-

CONTACT Laura-Philippe Vigneault [email protected] 5250, rue Molson, Montreal, H1Y 0C7, Quebec, Canada
© 2021 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (http://creativecommons.org/licenses/by-nc/4.0/), which
permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
2 L.-P. VIGNEAULT ET AL.

Indigenous populations in Canada regarding health Embase, Cochrane Library, Web of science and
status [6–9]. PsycInfo databases up until 1 February, 2021. These
The clear health disparities between Indigenous and databases were selected in collaboration with librarians
non-Indigenous populations in Canada raise questions to ensure a maximum number of studies were found.
regarding inequalities in access, use and quality of An example of the research strategy is presented
health care. The primary objective of this scoping below. In summary, the research strategy focused on
review is to map out the available literature on acute three main concepts: Indigenous Peoples, North
health care provided to Indigenous Peoples in Canada. America and acute health care. An example of the
In doing so, it aims to better understand the health care detailed research strategy is presented in Figure 1.
issues Indigenous Peoples face and identify areas that Articles which did not correspond to the objective of
have not been fully explored in the current literature. In the scoping review were excluded from the analysis.
this study, acute health care refers to emergency This process is described in the flow chart presented
department care, intensive unit care or hospitalisation below (Figure 2). Articles were excluded based on the
for acute health problems. fact they did not correspond to the studied population
or the type of health care. Articles discussing public
health, veterans’ health or paramedical health care
Methods were therefore excluded from this analysis. Articles
This scoping review aims to identify all available litera­ that were not in English or in French were also
ture regarding acute health care (emergency care, excluded. The selection of articles was assessed by
intensive care or hospitalisation for acute health pro­ two independent authors (L.P.V., A.P., E.D., C.S.P).
blems) provided to First Nation, Inuit and Métis Peoples Canadian and American articles were divided into sepa­
of North America in order to better understand the rate groups given the major differences between their
health care issues they face. The studied outcomes are health care systems.
patient satisfaction, access to care, hospitalisation rates Data from each article were collected by three inde­
and emergency department visit rates, mortality, qual­ pendent readers, every article being reviewed by two
ity of care, length of stay and cost. To determine these readers (L.P.V., E.D., C.S.P). The data was entered inde­
outcomes, a preliminary exploration of the available pendently in a data collection form and two readers
literature on health care provided to Indigenous then discussed the results to ensure an objective data
Peoples was conducted by two authors in order to extraction process. To assess the quality of the different
identify recurring themes. We searched Medline, articles retrieved, we used the STROBE Statement

Indigenous "Health Services, Indigenous" [Mesh] OR "United States Indian Health Service" [Mesh] OR
Peoples "Continental Population Groups" [Mesh:NoExp] OR "American Native Continental Ancestry
Group" [Mesh:NoExp] OR "Indians, North American" [Mesh] OR "Alaska Natives" [Mesh] OR
Indigenous[TIAB] OR American Indian*[TIAB] OR First Nation*[TIAB] OR Native American* [TIAB]
OR Aborigin*[TIAB] OR "Inuits" [Mesh] OR Inuit*[TIAB] OR Eskimo*[TIAB]
Geographical "Canada" [Mesh] OR Canada [TIAB] OR "United States" [Mesh] OR "United States" [TIAB] OR
location "Artic Regions" [Mesh] OR "North America" [Mesh:NoExp] OR "North America" [TIAB]
Health care "Mortality" [Subheading] OR "Outcome Assessment (Health Care)" [Mesh] OR "Outcome and
and Process Assessment (Health Care)" [Mesh] OR "Patient Reported Outcome Measures" [Mesh]
outcomes OR "Patient Outcome Assessment" [Mesh] OR "Quality-Adjusted Life Years" [Mesh] OR "Fatal
Outcome" [Mesh] OR "Hospital Mortality" [Mesh] OR "Death"[Mesh:NoExp] OR "Long Term
Adverse Effects" [Mesh] OR "Patient Satisfaction" [Mesh] OR "Health Services Accessibility"
[Mesh] OR "Culturally Competent Care" [Mesh] OR "Clinical Audit" [Mesh :NoExp] OR "Medical
Audit" [Mesh] OR "Quality Assurance, Health Care" [Mesh] OR "Health Care Quality, Access, and
Evaluation" [Mesh] OR "Quality of Health Care" [Mesh] OR "Health Care Costs" [Mesh] OR
"Health Expenditures" [Mesh] OR "Treatment Outcome" [Mesh] OR "Patient Acceptance of
Health Care" [Mesh] OR "Healthcare Disparities" [Mesh] OR "Health Services Needs and
Demand" [Mesh] OR Outcomes [TIAB] OR Intervention* [TIAB] OR "Critical Care Outcomes"
[Mesh] OR "Emergency Treatment"[Mesh] OR "Emergency Service, Hospital" [Mesh] OR
"Emergency Medical Services" [Mesh] OR "Ambulatory Care" [Mesh] OR "Critical Care" [Mesh]
OR "Episode of Care" [Mesh] OR "Hospitalization" [Mesh:NoExp] OR "Length of stay"[Mesh] OR
"Patient admission" [Mesh] OR Patient care [Mesh:NoExp] OR "Healthcare" [TIAB] OR "Primary
health care"[Mesh] OR Health [TIAB] OR "Delivery of Health Care, Integrated" [Mesh] OR
"Mortality" [Mesh:NoExp] OR "Mortality, Premature" [Mesh] OR "Morbidity" [Mesh] OR "Long-
Term Care" [Mesh] OR "Patient Satisfaction" [TIAB] OR "Program Evaluation" [Mesh]

Figure 1. Research strategy for medline.

 INTERNATIONAL JOURNAL OF CIRCUMPOLAR HEALTH 3

Figure 2. Flow diagram.

checklist for cohort studies, cross-sectionals studies and the distribution of articles according to the studied
case-control studies [10]. These checklists provide province although articles often collected data from
a score based off of a total of 22 items. We also used more than one province or territory. Acute care pro­
a STROBE checklist for abstracts [10] which provides vided to Indigenous Peoples has been most studied in
a score out of 11. The checklist to assess the quality of the provinces of Alberta, Manitoba and Ontario. As
qualitative studies [11] provides a score out of 32 and indicated in Figure 4, most studies were retrospective
the checklist for case reports provides a score out of 13 (n = 86) and 14 articles were prospective. The rest of
[12]. For each of these checklists, a criterion was con­ the articles were either case reports (n = 4), qualitative
sidered not fulfilled if one of its sub-items was missing. (n = 6), descriptive (n = 2), cross-sectional (n = 1) or
Two independent readers (L.P.V., C.S.P, E.D.) completed comparative studies (n = 1).
the quality analysis for each article. The general characteristics of the articles are pre­
sented in Table 1. Most articles studied hospitalisation
(73,7%) and the most frequently studied population
Results
were First Nations (47.3%). Figure 5 illustrates the dis­
114 articles studying the Indigenous Peoples in Canada tribution of articles by year of publication. The number
and acute health care were retrieved. Figure 3 presents of studies discussing acute health care for Indigenous
4 L.-P. VIGNEAULT ET AL.

Figure 3. Distribution of articles by province.

Peoples exponentially increased in the 2000’s as only 17

studies were published before 2000. Table 2 shows the
distribution of articles according to their studied out­
comes. The most frequently studied outcome was hos­
pitalisation rates (58,8%), followed by length of stay
(28.0%), mortality (25.4%) and quality of care (24.6%).
The most studied health conditions are pulmonary dis­
eases (n = 27), injuries and poisonings (n = 16), cardio­
vascular diseases (n = 9) and psychiatric illnesses (n = 8)
as presented in Table 3.
The complete tables for each of the 114 studies are
presented in Appendix 1. Studies are distributed
according to their health condition of interest.
Figure 4. Studies’ design.
 INTERNATIONAL JOURNAL OF CIRCUMPOLAR HEALTH 5

Table 1. Main features of articles. 40

Indigenous Peoples by group: 54
First Nations 14 35
Métis 21

Number of articles
Inuit 45 30
Non specified Indigenous peoples
Age of population cohorts All ages: 57 25
Paediatric*: 29
Adults*: 28 20
Type of acute health care 84
Hospitalisation 29 15
Emergency department visits 8
Intensive care unit admissions 6
Surgical intervention 5
10
Other/Non defined
Journals which published >1 Am J Public Health: 4 5
retrieved articles Am J Resp Crit Care: 2
BMC Public Health: 2 0
C J Public Health: 4
Can J of Cardiol: 3
Can J of Psychiat: 2
Chest: 2
CJEM: 3
CMAJ: 6
CMAJ Open: 2 Year of publication
Chron Dis Inj Can: 2
Ethnic Health: 2 Figure 5. Distribution of articles by year of publication.
Health Rep: 4
Int J Infect Dis: 2
Int J Circumpol Heal: 7
J Pediatr: 2
J Rheumatol: 2 Health care satisfaction
Pediatr Infect Dis J: 3
Pediatr Pulm: 2
PLoS One: 3 Nine articles collected information concerning
* Given that the age of majority differs between provinces, the distinction Indigenous Peoples’ health care satisfaction. One article
between paediatric and adult patients was adjusted according to the reported great satisfaction of Indigenous Peoples while
province of origin of the studies. The age of majority is 18 years old in
Alberta, Prince-Edward-Island, Manitoba, Ontario, Quebec and
consulting through telemedicine [13]. Another article
Saskatchewan and is 19 years old in British Columbia, New-Brunswick, concluded that the health care satisfaction is inferior
Nova-Scotia, Nunavut, Newfoundland and Labrador, Northwest territory for Indigenous patients suffering from mental illness
and Yukon.
when compared to non-Indigenous patients [14]. The
other seven studies reported several cases of stigmati­
Table 2. Distribution of articles by studied outcomes. sation and racism in the health care system. Study
Outcomes Number of articles (%)
participants evoked certain barriers in their access to
Health care satisfaction 9 (7.9%)
Access to care 14 (12.3%) health care such as long wait times, trouble commu­
Hospitalisation rate 67 (58.8%) nicating and difficult interactions with health care pro­
Emergency department visit rate 26 (22.8%)
Mortality 29 (25.4%)
fessionals. Most of these issues were attributed to
Quality of care 28 (24.6%) cultural differences and misinterpretations, often exa­
Length of stay 32 (28.0%) cerbated in a bustling hospital setting [15,16]. Another
Cost 7 (6.1%)
important problem reported was the misperception by
many health care professionals that Indigenous patients
Table 3. Studied health conditions. are seeking health care in order to receive drugs [17,18].
Illness Number of articles Others mentioned that health care providers tend to
Pulmonary diseases 27 attribute illnesses to alcohol or drug consumption with­
Injuries and poisonings 16 out completing a thorough history with the patient
Cardiovascular diseases 9
Psychiatric diseases 8 [17]. An Indigenous patient also stated not always
Rheumatologic diseases 5 inquiring about illness or treatment options due to
Neurological diseases 5
Endocrine-related conditions 5 communication barriers and subsequent difficulties
Paediatric-related diseases 5 understanding the information provided [15]. It has
Gastrointestinal diseases 4
Infectiology-related diseases 4 also been mentioned that some Indigenous patients
Obstetrical and gynaecological conditions 4 are afraid of visiting hospitals and will avoid them by
Nephrological-related conditions 1
all means [17,19]. Many Indigenous patients felt they
6 L.-P. VIGNEAULT ET AL.

were treated differently and appreciated when health [30]. Firestone reported that 60% of questioned
care professionals treated them as they would any Indigenous patients consider their access to care to be
other patient while also recognising and respecting excellent or good whereas 11% of them consider it to
their Indigenous identity [15,18]. be poor [31]. A study reported that Indigenous patients
Tang published two articles in which he interviewed mainly use the emergency department to access health
health care professionals working in an urban emer­ care [19]. Another study reported that, for psychiatric
gency department in Canada as well as Indigenous patients, hospitalisation rates are higher if the primary
patients. In his study published in 2008, Indigenous source of health care is an hospital rather than
patients expressed often experiencing discrimination a nursing centre [32]. Finally, one study was a case
in the emergency department setting. Four health report and no conclusions can therefore be drawn [33].
care providers were questioned on this subject and
presented similar answers. They maintained that they
Hospitalisation rates
provide the same quality of care to all patients includ­
ing Indigenous patients, however, certain contradic­ 67 articles studied hospitalisation rates. 48 studies
tions were raised in the testimonies of different health found higher hospitalisation rates for Indigenous
professionals. A health care provider said: “As an ED patients. 16 studies mentioned no difference whereas
staff person, you tend to have a vision of every 3 articles mentioned reduced hospitalisation rates for
Aboriginal person having a drug and alcohol issue Indigenous patients. 6 articles did not provide any
[. . .]” [20]. This same provider later admitted to being comparison between hospitalisation rates for
more guarded when meeting an Indigenous patient. In Indigenous and non-Indigenous patients [34–39]. For
Tang’s study published in 2015, health care providers articles concerning multiple health issues, 10 articles
were asked to describe their perception of Indigenous concluded to higher hospitalisation rates for
patients. A few health care providers provided similar Indigenous patients [31,40–48]. With regards to pul­
answers which can be summarised by the following monary diseases, seven articles concerning pneumonia
statement by health care provider 11: “A lot of them [22,49,50], LRTI (lower respiratory tract infection) [51],
are on welfare or drug pushers [. . .]. They don’t seem to bronchiolitis [52] or H1N1 Influenza A [23,53] showed
have jobs, not well dressed, dirty, unkempt, using increased hospitalisation rates. 4 articles showed no
drugs, not taking care of themselves”. [21] Another difference in hospitalisation rates for asthma and
health care provider explained why, in his opinion, COPD (chronic obstructive pulmonary disease) [40],
Indigenous patients are dissatisfied with the health LRTI [54,55] and aspiration pneumonia [22].
care they receive: “We’ll meet all of their needs, and Senthilselvan’s study on asthma presented increased
when that doesn’t happen, there is a great deal of hospitalisation rates for age groups ranging from 0–4
frustration of their part which makes it almost confron­ and 35–64 years old. Meanwhile the group aged from
tational at times, it can be incredibly challenging to 15 to 34 years old showed no difference in hospitalisa­
remain compassionate and non-judgemental about tion rates and the group aged from 5 to 14 years old
patients we see, when that kind of situation arises”. [21] had decreased hospitalisation rates [56]. As for uninten­
tional injuries, 8 articles presented higher hospitalisa­
tion rates [57–64] whereas two articles mentioned no
Access to health care
difference [65,66]. Three articles studied intentional
Articles discussing access to care presented data that injuries, two of which showed an increased hospitalisa­
for the most part cannot be grouped given the great tion rate for Indigenous patients [64, 67] while the other
diversity of studied outcomes. Four articles reported an showed no difference [60]. With regards to poisonings,
inferior access to care when compared to non- two articles published in 2007 by Myers mentioned
Indigenous Canadians. This decreased access is charac­ a risk ratio for hospitalisation for acetaminophen over­
terised by a longer time between onset of symptoms dose of approximately 4 [68,69]. For cardiovascular dis­
and hospital presentation [22,23], a lower proportion of eases, three articles provided results of increased
patients with access to prenatal care [24] and a lower hospitalisation rates [70–72] and one article mentioned
satisfaction towards health care in general [16]. Five decreased hospitalisation rates [73]. Atzema reported
articles reported no difference in access to care for increased hospitalisation rates related to hypertension
Indigenous Peoples when compared to other and congestive heart failure and found no difference for
Canadians [25–29]. One study reported that specialist acute coronary syndromes, strokes and atrial fibrillation
follow-up visits after an episode of arrhythmia occurs [74]. Kapral also found no difference in hospitalisation
approximately 80 days earlier for Indigenous patients rates for strokes [75]. Increased hospitalisation rates
 INTERNATIONAL JOURNAL OF CIRCUMPOLAR HEALTH 7

were reported for pyelonephritis [76], acute complica­ and for psychiatric illnesses [107] when compared to
tions of dialysis [77], epilepsy [78] and traumatic brain non-Indigenous patients.
injury [79] and for all types of arthritis except ankylos­
ing spondylitis [80]. One article found no difference in
Mortality
hospitalisation rates for cancer-related complications
[81]. For mental health issues, five articles presented Mortality was studied as an outcome in 29 studies. 8
increased hospitalisation rates [32,82–85]. Carrière’s arti­ articles reported an increased mortality, 10 articles
cle showed increased hospitalisation rates for all mental found no difference in mortality rates and 5 articles
illnesses except for personality disorders [82] and reported a decreased mortality for Indigenous patients.
Soleimani’s article mentioned increased hospitalisation 7 articles provided mortality data without providing
rates for women but decreased rates for men [85]. comparison to non-Indigenous patients and therefore
Articles about paediatric-related illnesses concluded to no conclusion can be drawn for these results [105,108–
increased hospitalisation rates for acute otitis media 113]. With regards to pulmonary diseases, two articles
[86], as well as for infections, congenital anomalies, mentioned increased mortality for Indigenous patients
respiratory, cutaneous, neurological and endocrine dis­ hospitalised for pneumonia [114] and COPD [40], two
eases and found no difference in hospitalisation rates studies revealed no difference in mortality for H1N1
for other health problems [87]. Finally, three articles Influenza A and asthma [40,115] and three studies
showed higher hospitalisation rates for diabetes- showed decreased mortality for Indigenous patients
related complications [88–90] and one article showed hospitalised for pneumonia [22,49,50]. For injuries and
no difference between Indigenous and non-Indigenous poisonings, two studies reported a higher mortality rate
patients [91]. for Indigenous patients [57,60] and one study found no
significant difference [116]. Studies reported no differ­
ence in mortality rates caused by strokes [75] or obste­
trical diseases [24]. As for cardiovascular diseases, most
Emergency department visit rates
articles reported an increased mortality rate for
26 articles presented results regarding emergency Indigenous patients [70,71,73,117] although some arti­
department visit rates. 17 studies found higher emer­ cles did not report any difference in mortality rates
gency department visit rates for Indigenous patients. 6 [74,118]. For articles discussing multiple health pro­
articles showed increased emergency visit rates for blems, three studies reported increased mortality for
Indigenous patients with asthma or COPD [92–97] Indigenous patients [46,47,119] and one article
while one article reported no difference [40]. Two arti­ reported no change in mortality [45]. Finally,
cles reported higher visit rates for LRTI [98,99]. Ospina’s Oppenheimer’s study in 2007 found an increased mor­
article showed increased visit rates for all Indigenous tality rate for Indigenous patients hospitalised for blas­
communities except for Métis people for whom no tomycosis of joints and bones [28].
difference was reported [92]. In articles discussing mul­
tiple acute health conditions, 2 articles found higher
Quality of care
visit rates [31,40] while 4 articles reported no difference
[26,27,43,100]. Most articles found higher emergency A total of 28 studies discussed the quality of care in
department visit rates for cardiovascular problems their results. Quality of care was often studied for car­
[30,70,74] with the exception of Atzema’s study which diovascular diseases. Atzema found no difference
reported higher visit rates for all illnesses except for between Indigenous and non-Indigenous patients
hypertension [74]. One article found higher visit rates regarding the use of beta-blockers after an acute cor­
for epilepsy [78]. For diabetes-related complications, onary syndrome or echocardiography in follow-up of
one study found higher emergency department visit atrial fibrillation [74]. Three studies found no difference
rates for all Indigenous patients [88] whereas another in the use or percutaneous coronary intervention (PCI)
study found that only First Nation patients living off- and coronary artery bypass grafting (CABG) [25,71,117]
reserve had higher visit rates [101]. Only one study whereas one study found no difference for CABG but
found lower emergency department rates for a decreased rate of Indigenous patients receiving PCI
Indigenous patients [94]. Four studies did not present [72]. Two studies found Indigenous patients less likely
a comparison with non-Indigenous patients and con­ to undergo a coronary angiogram [72,117] and one
clusions could therefore not be drawn [102–105]. study mentioned that Indigenous patients tend to
Finally, Newton found that Indigenous patients had wait longer before their coronary angiogram [25]. For
double the rate of emergency visits for self-harm [106] pulmonary diseases, two studies found no difference in
8 L.-P. VIGNEAULT ET AL.

the quality of care for people with lower respiratory any comparison with non-Indigenous patients
tract infections [55,115] and one study concluded that [33,36,37,52,108,112]. There was no difference in length
Indigenous patients with asthma or COPD were 55% of stay for Indigenous patients with traumatic brain
less likely to see a specialist and 66% less likely to have injury [122], blastomycosis of bones [28] or appendicitis
a spirometry [96]. For injuries, one study found that [123]. Finally, Indigenous neonates stayed longer in the
Indigenous patients wait longer for their follow-up intensive care unit when hospitalised [24].
[106], are less likely to opt for palliative health care
and undergo more surgeries [116]. Two studies showed
Cost
a decreased chance for Indigenous patients to consult
a specialist for their health problem [48,120]. For neu­ Seven studies discussed cost of health care for
rological illnesses, Indigenous patients tend to have Indigenous patients. Five articles concluded to
fewer surgeries for spinal cord trauma [121] and longer increased health care cost for Indigenous patients living
wait times before follow-up after a traumatic brain in remote areas [36,51] as well as for Indigenous
injury [122]. As for strokes, the only difference found patients in general [22,91,125]. One study showed no
was that Indigenous patients were less likely to receive statistically significant difference in health care cost
thrombolysis [75]. No difference in health care quality [126] and one article provided no comparison with non-
was noted for rheumatological diseases [28] or in neo­ Indigenous patients [37].
natal intensive care [24]. Two studies by Newton
demonstrated that Indigenous patients receive less fol­
Discussion
low-up after a visit to the emergency department for
mental illness [103,107]. A study found that Indigenous In this study, we found 114 articles that studied acute
patients presenting with appendicitis underwent more health care provided to Indigenous patients. Most stu­
open surgeries and waited longer between their time of dies presented results for Indigenous patients of all
presentation at hospital and the beginning of their ages, focused on hospitalisation rates and were mainly
surgery [123]. Rose’s study found that Indigenous retrospective. Only six articles out of 114 were qualita­
patients underwent more forefoot and below the knee tive, which is surprising considering the importance of
amputations and fewer toe or above the knee amputa­ qualitative studies in understanding the perception of
tions for diabetes-related complications [90]. Finally, health care of Indigenous patients. All provinces and
seven articles did not provide any comparison with territories of Canada were represented in the retrieved
non-Indigenous patients [33,109–112,124]. articles. Hospitalisation rates was the most studied out­
come as it was analysed in more than half of all articles.
48 articles out of 67 reported higher hospitalisation
Length of stay
rates for Indigenous patients when compared to non-
For Indigenous patients with pneumonia or COPD, three Indigenous patients and 17 articles out of 26 found
studies revealed an increased length of hospital stay higher emergency department visit rates. Access to
[55,56,114], two studies found no difference [54,115] care was studied in 14 articles from which four articles
and five studies showed decreased length of stay when noted a decreased access to care, five reported no
compared to non-Indigenous patients [22,49,50,92,93]. difference and one reported a better access for
Two articles mentioned longer hospitalisations for burn Indigenous patients. For mortality, it is difficult to
injuries [58,116]. For articles discussing multiple acute draw conclusions as eight articles reported an increased
health problems, two studies showed a longer length mortality, 10 articles reported no difference and five
of stay for Indigenous patients [42,46], one study articles reported a decreased mortality for Indigenous
reported a shorter length of stay [119] and four studies patients. As for quality of care, care for cardiovascular
showed no difference [26,27,45,104]. Although no statis­ diseases was similar for major interventions. The main
tically significant difference was noted, Laupland found difference in access to care was that Indigenous
that over 17% of Indigenous patients were delayed in patients had less follow-up with specialists or longer
their discharge because of transportation issues or lack wait times than non-Indigenous patients
of resources in their community [45]. For psychiatric [48,96,103,107,120,122]. Studies discussing length of
diseases, length of stay was found to be longer in one stay provided diverging results and no clear conclusion
study [14] and shorter in two other studies [32,84]. One can be drawn seeing as nine studies showed increased
article found no difference between the length of stay in length of stay, nine showed no difference and eight
the emergency department for Indigenous and non- showed a decreased length of stay. Cost for health
Indigenous patients [103]. Six studies did not provide care seems to be higher for Indigenous patients since
 INTERNATIONAL JOURNAL OF CIRCUMPOLAR HEALTH 9

out of 6 studies, 5 articles reported higher costs. Finally, and these differences must be recognised in order to
nine articles discussed satisfaction with health care. provide culturally safe care [132].
Most of them reported cases of miscommunication The use of health services by Indigenous Peoples has
and misinterpretation between Indigenous patients been studied for various health conditions in Australia
and health care professionals that had an impact on over the past years. A review published in 2016 dis­
satisfaction with care [15,16]. Throughout these studies, cussed the use of the emergency room by Indigenous
Indigenous patients often mentioned not being satis­ Peoples living on Torres Island. Indigenous patients
fied with their access to health care and encountering consulted at the emergency department more often
multiple barriers in the health care system. These bar­ than other Australians [133]. An article studying visits
riers include long wait times [15,16],, difficulty commu­ to the emergency department by Indigenous patients
nicating [15] as well as prejudices and discrimination in 2004–2005 arrived to the same conclusion but also
[17,19–21]. Indigenous patients mentioned simply found that Indigenous patients were more likely to
wanting to be treated like any other patient by practi­ leave the emergency department before being seen
tioners who respect their Indigenous identity [15,18]. by a health care practitioner [134]. A study with the
According to our research, no previous review has same aim has recently been published in Canada and
gathered all articles dealing with disparities in health the results are very similar to those found in Australia
care between Indigenous and non-Indigenous patients [135]. Another study published in Australia about inten­
all illnesses combined. Our scoping review highlights sive care unit admissions also obtained similar results.
important disparities between Indigenous and non- Indigenous patients were over-represented in the ICU
Indigenous patients in Canada, especially with regards and more frequently required emergency admissions
to access to care, satisfaction with health care and although no difference was found in mortality [136].
hospitalisation or emergency department visit rates. Some authors have suggested solutions to improve
A systematic review on the experiences of the quality of health services provided to Indigenous
Indigenous patients during hospitalisation for acute patients. A study in Australia suggested that health care
care was published in 2017 [127]. This review found services managed by Indigenous patients are the best
21 qualitative articles which provided three themes way to maximise their access to care [137]. A scoping
characterising the experience of Indigenous patients. review published in 2009 grouped articles regarding
Firstly, Indigenous patients reported feeling like they Indigenous patients’ experience within emergency
were going into a foreign land when they were hospi­ departments in Canada [138]. The author’s concluded
talised as health care practitioners are not always accus­ that developing cultural competency is essential in
tomed to their culture and traditions [128,129]. order to upgrade the quality of health care. In order
Furthermore, communication difficulties were frequent to achieve this, it is necessary to have a shared under­
because of language barriers and/or cultural differences standing of Indigenous communities and to collaborate
[130–132]. Finally, relationships with practitioners were with them. It is also essential to prevent discrimination
sometimes difficult because of diverging views of by providing appropriate training to professionals and
health care and prejudices they may have had. This by promoting access to health care services [138].
review is consistent with our findings which tend to A systematic review published in 2015 obtained the
confirm that many Indigenous patients have experi­ same conclusions. It identified training health care
enced negative encounters with health care profes­ workers and recruiting Indigenous workers as the
sionals. As for access to care, our study did not most effective interventions to improve cultural com­
provide any clear conclusions but some important ele­ petency. These interventions improve patient’s satisfac­
ments have nonetheless emerged. A study published in tion of care [139]. Another strategy for improving
2018 aimed to identify barriers to health care access quality of care is integrated care [140]. Health care
and presents similar results as our review. In this study, provided in a multidisciplinary approach, which encom­
the most important barriers for Indigenous patients passes all aspects of health can reduce disparities in
were long wait times, substandard quality of care and health care and help communities achieve a better
discrimination. This article provides an interesting per­ state of health. This approach involves the patient as
spective, especially regarding long wait times. Indeed, an active partner in his health care and aims to include
long wait times are experienced by all patients seeking psychological and spiritual aspects of health care [140].
health care in Canada. However, this article underlines Changes in the health care system must be made to
the way in which different cultures and past experi­ improve the quality of health care provided to
ences lead to different interpretations of certain events Indigenous Peoples in Canada. Solutions to reconcile
10 L.-P. VIGNEAULT ET AL.

Indigenous cultures with hospital practices to provide presents the same risk since the authors are non-
health care in a culturally safe organisation should be Indigenous. To diminish the importance of this bias,
explored. Future health care workers must be taught articles were included with objective inclusion criteria
about the cultures and traditions of Indigenous Peoples and studied outcomes were clearly defined. Also, sub­
in regard to health care. To increase cultural compe­ jective data was drawn directly from published data
tency and prevent racism, future health care providers and does not reflect personal opinions. To prevent
must recognise and understand cultural differences, in subjectivity in data interpretation, at least two different
order to adapt their practice to each patient. authors were involved in the reading of articles and
Furthermore, no studies have focused on understand­ extraction of data. Another limit of this article is the
ing the fundamental causes behind the differences in small number of articles that exist relative to certain
the prevalence of health problems disproportionately specific topics such as health care costs making it
affecting Indigenous Peoples. Interventions to reduce impossible to draw conclusions about their impact on
the disproportionately high prevalence of certain dis­ Indigenous Peoples. Finally, the small number of exist­
eases affecting Indigenous Peoples need to be ing qualitative studies may affect the generalisability of
explored. Finally, very few qualitative studies were per­ conclusions about satisfaction with health care since
formed with Indigenous Peoples in Canada. Studies only a small proportion of Indigenous patients and
examining ways in which health care could be communities were questioned on this particular topic.
improved with Indigenous communities would be
important. Indeed, it is essential to include Indigenous
communities in the discussions about health care to
Conclusion
ensure their perspectives and traditions are respected. Indigenous Peoples in Canada still face significant inequal­
Given that our study is a literature review, its quality ities in their access to health care when compared to non-
depends of the quality of the articles included. The Indigenous Canadians. They also carry a greater burden of
articles retrieved are mostly retrospective or prospec­ health problems requiring acute health care, particularly
tive cohort studies (median STROBE score = 15/22). The in regards to pulmonary, cardiovascular, traumatic and
quality scores differ for qualitative studies (median = 21/ psychiatric illnesses. Furthermore, their satisfaction with
32), case reports (Median = 7/13) and abstracts (med­ health care is lower than that of other Canadians which in
ian = 7/11). No randomised control trials have been turn limits their use of health care services. Given the
published about health care issues of Indigenous historical context of colonialism in Canada and the persis­
Peoples in Canada in an acute care setting. 18 articles tence of significant disparities between Indigenous and
were published before 2000 and the quality of their non-Indigenous populations, it is essential to include
evidence may therefore differ from current standards. Indigenous communities in the organisation of health
It is important to mention that although all included care. Indigenous Peoples are most well informed of their
Indigenous Peoples live in Canada, important differ­ reality and are best suited to identify their needs. It is
ences exist between each community. Indeed, access essential to ensure that Indigenous Peoples in Canada
to care may vary depending on the location of the have access to culturally safe health care, which embraces
community. Furthermore, every community has their unique perspective on health.
a unique history and traditions as well as a unique
perspective on health care. The health care system in
Canada also varies depending on the territory and Disclosure statement
nation of Indigenous Peoples. This thus limits the gen­ No potential conflict of interest was reported by the author(s).
eralisation of our results as data retrieved from
a specific community may not apply to others. Our
ORCID
study is at risk of a publication bias since articles with
positive results are more likely to be published than Laura-Philippe Vigneault http://orcid.org/0000-0001-6540-
0003
negative studies. To minimise this bias, incomplete arti­
Maude St-Onge http://orcid.org/0000-0001-5157-1442
cles were included in the analysis and available data
was used. A publication bias would increase the pro­
portion of articles showing disparities between health References
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