Kloshe Tillicum (good relations) move at the speed of trust

Why is it important for public health and health care providers to build trust with Indigenous patients and communities? This question came to the forefront due to the health impacts, stress, and inequality exacerbated by the COVID-19 pandemic. Importantly, the uptake of COVID-related public health measures required trust in both public health guidance and health care providers. However, in April 2020, a provincial survey of over 3000 participants assessing COVID misinformation in BC found that only 31% of Indigenous respondents trusted pandemic guidance from public health leaders, compared with 66% of white respondents. Further, Indigenous respondents were nearly twice as likely to report misinformation on treatments for COVID compared with white respondents (59% vs 37%). Ongoing legacies of colonization and the Indian Act, anti-Indigenous racism in the health care system,[1] and the shameful history of Indian hospitals[2] serve as fundamental sources of mistrust for Indigenous people in Canada today.

To get to the heart of this question, we launched Kloshe Tillicum (“good relations” in Chinook jargon): creating trustworthy and culturally meaningful public health guidance to address COVID-19, a Canadian Institutes of Health Research–funded collaboration between Indigenous and settler researchers from Chee Mamuk, an Indigenous-led health program within the BCCDC, and Simon Fraser University’s Faculty of Health Science. Between 2020 and 2022 we conducted nine focus groups with 53 Indigenous individuals in urban and rural locations across BC to hear about their experiences during the COVID pandemic.

Trust emerged as a key theme. Overall mistrust toward the health care system was a common refrain shared by Indigenous participants. Approaches that emphasized building relationships, listening, and collaboration were preferred:

“I feel like I’ve seen some really forceful approaches and people being quite aggressive about it, making these kinds of things mandatory, and I’ve been with other health care professionals who were actually quite compassionate and understanding and had a very gentle approach that felt safe for me. So I think it’s like—when I think of trusting something, it’s like how safe do I feel with this person or with this information? That really makes a huge difference for me.”

Participants shared that community leaders stepped up during the pandemic as a trusted source of information amid rapidly evolving public health guidance and rampant misinformation spread by social media platforms like Facebook. Remote communities reported having limited access to doctors and health resources, making their trusted point person critical. Serving in this role was a double-edged sword: the community trusted their guidance and adopted their recommendations, yet that person faced extreme levels of pressure daily to get the guidance right for their Elders, children, and neighbors.

Kloshe Tillicum begin by recognizing why building trust is essential in health. Collectively we have a poor track record in Canada when it comes to Indigenous people, and as health care providers, we have a history of past and current harm to surmount. However, we have an opportunity ahead of us to build trust through new ways of working together. A recent meta-analysis observed that trust toward health care providers has a direct correlation with health outcomes.[3] Trust is built by taking time to build relationships, understand fear and concerns, and acknowledge the social realities that may influence adherence to public health guidelines and treatment recommendations (for example, affordability of medication, transportation to appointments, and access to life necessities like food and housing).[4] We can better support the critical role of trusted leaders in Indigenous communities by providing accessible and culturally relevant information to share among their networks. Lastly, we can all commit to walking our own journeys of reconciliation, as modeled through the anti-Indigenous racism work and the dismantling of white supremacy being led within the Office of the Provincial Health Officer.[5]
—Kloshe Tillicum Research Team: Chee Mamuk BCCDC, Simon Fraser University

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This article is the opinion of the BC Centre for Disease Control and has not been peer reviewed by the BCMJ Editorial Board.

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

References

1.    Turpel-Lafond ME. In plain sight: Addressing Indigenous-specific racism and discrimination in BC health care. Summary report. November 2020. https://engage.gov.bc.ca/app/uploads/sites/613/2020/11/In-Plain-Sight-Summary-Report.pdf.

2.    Indian Residential School History and Dialogue Centre. Indian hospitals in Canada. University of British Columbia. Accessed 6 September 2023. https://irshdc.ubc.ca/learn/indian-hospitals-in-canada.

3.    Birkhäuer J, Gaab J, Kossowsky J, et al. Trust in the health care professional and health outcome: A meta-analysis. PLoS One 2017;12:e0170988.

4.    Wadhawan V. From “doctor’s orders” to trusted guidance: The importance of building trust in healthcare. Environics Research. Accessed 6 September 2023. https://environics.ca/article/from-doctors-orders-to-trusted-guidance-the-importance-of-building-trust-in-healthcare.

5.    Canadian Medical Association. Challenging anti-Indigenous racism in health care. 14 August 2023. Accessed 6 September 2023. www.cma.ca/news/challenging-anti-indigenous-racism-health-care.