Member Spotlight: Working with Indigenous Populations
July 7, 2016
Leanne Loranger, PT, Practice Advisor
Imagine you work in a community where access to clean drinking water and sanitation is limited, where reliable transportation is not a given, and where 12 or more family members share one small home. Imagine working in a community where a significant portion of the adults and role models have developmental challenges. Imagine how these conditions might affect your work as a physiotherapist.
You may think that I’m describing a far-away developing nation. I’m actually describing the work of Physiotherapy Alberta member Donna LaRocque-Hennig. Donna is a long time member of Physiotherapy Alberta, with years of experience in private practice. About four years ago, after selling her clinic and moving out of province for a brief period, the opportunity presented itself for Donna to work in the unique and challenging practice area of Indigenous health. She began work for the Yellowhead Tribal Council, comprised of five First Nations including the Alexander, Alexis, Enoch, O’Chiese and Sunchild bands.
How global health relates to Indigenous health
“The conditions seen on many reservations are similar to conditions seen in developing countries,” says Donna. “There are significant issues with housing, sanitation and transportation. Issues that aren’t typical in the western environment.”
Because of this reality, the needs of Indigenous peoples align more closely with the needs seen in the developing world, as do the programs required to serve these communities.
There’s no doubt that there are many challenges faced by Indigenous peoples, ranging from basic infrastructure issues like housing, transportation, sanitation and communication to social issues of addiction, violence, and suicide along with significant bureaucracy and barriers to accessing services. Donna explains that the living conditions on reserves are radically different from what many of us are accustomed to, and are far from ideal. For those who are not familiar with or previously exposed to this practice setting, it can be a significant adjustment.
Health-care workers are also often challenged by the fact that they can be seen as “outsiders” by the community they serve. According to Donna, even health-care workers who are Indigenous can face unique pressures and challenges, including pressure to fix every problem or be constantly available and the challenge of being from a different band.
All of these challenges impact the patient’s ability to access services, their ability to attend treatment and follow-through with their physiotherapist’s recommendations and the ability to develop an effective patient-provider relationship.
Developing cultural awareness
“I’ve been really lucky to work [at Yellowhead Tribal Council] with colleagues who have huge insight into the [band] politics and culture and how it’s best to approach things or what’s best to leave alone,” says Donna. “We also have staff meetings about every six weeks where we can get together and learn from each other.”
Donna has gained valuable insight from working with an occupational therapist of Indigenous descent and gaining her colleague’s perspective on how to approach challenging situations.
Donna works for several bands and despite the fact that each is distinct, there are many similarities in how best to approach her patients. Some basic tips that she has learned from presentations she has attended, her own experiences and from colleagues include:
- Don’t make direct eye contact, this is considered rude unless you know the other person very well.
- Provide lots of time for your patient to respond to your questions, realizing that the patient may be considering how much to trust you and what to divulge. Also realize that a direct approach to treatment discussions often won’t work with this population.
“Physiotherapists are often pretty honest and tell their patients ‘you need to do this, this and this or the surgeon won’t operate,’ but that approach doesn’t work with this population. They just shut down. You can’t push,” says Donna.
- Realize that you are not viewed as a safe person. The fact that you are in health care doesn’t change the fact that you are an outsider. You need to be in the community for a long time and develop relationships before you will be viewed as safe.
- Pay attention to non-verbal cues.
“[My patients] typically don’t directly say ‘no’. You have to learn the signs of the unspoken ‘no,’” explains Donna.
Donna also highlights that the cultural beliefs that she encounters when working with Indigenous peoples also impact her daily work as a physiotherapist.
“Their cultural background is acceptance of the things that have happened to you and not feeling particularly in control of it,” says Donna.
Though she is quick to point out that this attitude is not consistent with all bands, it can be a challenge to work within that belief system and to let go of a lot of the expectations that you would have if working with other patient populations. This may include our expectations of patients attending appointments on time or the level of awareness and knowledge the patient presents with.
Donna also discovered that many of her patients aren’t very comfortable with hands-on treatment.
“They prefer modalities and think it will do more good. Many aren’t comfortable with close contact,” she says.
Donna has learned to provide the treatment that the patient believes in and is comfortable with, in order to develop a rapport and have the patient trust you and allow you to provide other treatments that you may have greater confidence in. This, combined with a good measure of cultural humility, is the core of patient-centered care.
The future of Indigenous health
Donna highlights that there are many reasons to hope for the future. One trend she noted was the move within some bands to focus on their traditional culture as a way to strengthen the community and address the prevalent social issues which have a major impact on health.
Donna tells a story of when she was at Canadian Physiotherapy Association (CPA) Congress 2016 she heard a presentation about how one First Nation in British Columbia is working with a dietitian to re-establish traditional foods and ceremonies as a way to strengthen the community while simultaneously addressing some of the health concerns that band is facing. Because of this, she is starting to think of ways to approach broader health concerns within her patient population that will integrate physiotherapy principles and traditional cultural practices.
Donna also notes the many young people who leave their communities to advance their education return with the aim of improving things for their community. Many people who continue to advocate for improved services for Indigenous communities are further signs of hope for the future.
What every physiotherapist should know about this practice area
“First off, we need to recognize that there is a problem in Canada and take responsibility without imposing our way of dealing with things on another culture,” says Donna. “We need to have a dialogue with each band asking ‘What is it that you need here to make your life better? How do you see us helping you?’”
Donna has patients who attempted to access the health-care system with significant illness or injury and were met with significant bias and assumptions about why the person was seeking care. She points to several cases where such assumptions led to serious, life-long consequences for the patient, as the bias caused the health-care provider to miss significant health problems that they would have likely caught in another patient. Donna has witnessed the ongoing racism and discrimination Indigenous people face when accessing “off-reserve” health-care services.
“It’s easy to understand their frustration with our health-care system and with outsiders because we don’t listen and take them seriously.” Donna challenges everyone to reflect on and reconsider the biases we carry when working with Indigenous peoples.
The rewards of working in this practice area
Despite all the challenges and negative perceptions that she encounters in her work, Donna feels strongly that there is reason for hope.
“There are communities that are really trying to change things and improve things, there are health-care workers who are working really hard to be what the people need and to improve things,” she says.
Donna and her colleagues work in this area of practice in the hope of helping to bring about important changes to support the health of Indigenous peoples.
Donna graduated in 1979 from the University of Alberta with a Bachelor of Science Degree in Physical Therapy. This was only the beginning of her lifelong love affair with physiotherapy and learning. She has been privileged to work with and treat many people over the years that have challenged her and caused her to grow in ways she would never have dreamed of 35 years ago. Donna has developed an interest in the complexities of treating chronic pain, children, women’s health issues and animal rehab. These areas of interest have led her to take many additional areas of training such as acupuncture, chronic pain and pelvic pain courses, body awareness courses, and to become certified in animal rehab among many other courses. Donna teaches Canine and Equine Rehabilitation. She loves being a physiotherapist and working with people and animals to help them meet their goals.