A total of 19 participants were interviewed during this study (see Fig. 1). Participants’ perspectives on incorporating PCH into Canadian healthcare training programs were analyzed into three themes: (1) content related to PCH that should be taught; (2) how this content should be delivered, and; (3) why this content should be taught (see Fig. 2). Participants indicated how considerations regarding PCH content influence its delivery, which is depicted by the overlapping circles in Fig. 2. Below, we present these themes in detail.
What content related to postcolonialism and health should be taught in Canadian healthcare training programs?
Three distinct but complementary content areas emerged based on participants’ perspectives: the experiences of Aboriginal communities resulting from colonialism in Canada, how structures of power rooted in colonialism continue to create health inequities in Canada and how Canadian HCPs’ own experiences of privilege and oppression affect their practice.
What experiences have Aboriginal populations had resulting from colonialism in Canada?
Participants expressed the necessity of teaching about the history of the colonization of Aboriginal Peoples in Canada when discussing Aboriginal health. There was agreement that most students do not enter healthcare training programs with sufficient knowledge in this area, especially as it relates to health and healthcare delivery.
Participants emphasized the importance of understanding how historical events link with an individual’s and community’s present day health status and healthcare experience. Many participants cited the Canadian residential school system as a salient but poorly-understood example of an historical event with a “multigenerational impact” on health status. Residential schools were boarding schools created by the Canadian government in the late 1880s and administered by churches that forcibly separated Aboriginal children from their families, forbade Aboriginal children from acknowledging their culture or speaking their languages, and often involved experiences of abuse [44, 45]. Most residential schools in Canada closed by the 1980s; the last closed in 1996. Participants noted that the residential school experience has led some Aboriginal People to mistrust and fear government institutions, including the healthcare system. One participant explained:
Those who were left behind, and traumatized by the abduction of their children, turned to alcohol to try and dull the pain and the grieving. They were no longer able to understand and communicate with their own children…So as those children grew and started their own families, many of them had turned to alcohol as well because they were foreigners in their own families…So there began the cycle of the impact.
Additionally, the Indian Act (1876) and the “Sixties Scoop” were described by participants as important in the education of HCPs. The Indian Act gives the Canadian government authority to decide who qualifies as an “Indian” as well as what land is included in First Nation reserves [4, 7]. Some participants indicated that students should learn how the Indian Act continues to affect First Nations, Inuit and Métis communities in Canada by determining access to healthcare and funding for health-related issues. Similarly, the “Sixties Scoop” refers to a period in the 1960s that saw the removal of Aboriginal children from their families into child welfare systems, usually without the permission of their families or Bands [46]. Participants emphasized that such trauma continues to negatively influence the health status of people belonging to Aboriginal communities in Canada. However, participants also expressed the importance of acknowledging the strengths and resilience of Aboriginal communities in the face of these challenges, in order to counteract negative stereotypes.
How do structures of power rooted in colonialism continue to contribute to health inequities in Canada?
Participants believed students should recognize that colonialism is not over: “You need to understand it is present. It’s present and [Canadians] are totally embedded in it.” In particular, participants explained that understanding why individuals and communities experience health inequities is linked to understanding how systems rooted in colonial practice can influence an individual’s health status:
If you look at the people who are most marginalized, it’s not that they are naturally in this position, it’s because we live in a society that puts them in that position… [I]f we are trying to improve their health we need to understand the systems that are going to continue to undermine their health as soon as they walk out of our office.
Some participants also cited the use of population health statistics as a useful method to explicate health inequities.
Participants agreed that students can better understand the effects of colonial systems of power when using postcolonialism in combination with existing concepts like the social determinants of health:
When you begin to take a look at an infection from a postcolonial lens, they’re not only thinking about bodily health alone. They begin to see that those health outcomes are dependent on social circumstances…And they begin to make those linkages into the sociopolitical context in which healthcare exists, in which these health inequities exist.
Participants also discussed that students should learn how the concepts pertaining to health and medicine are rooted in colonialism and continue to disproportionately marginalize certain populations. Particularly, participants emphasized that HCPs’ views on health and medicine are dominated by a Eurocentric worldview which limits what is accepted as legitimate knowledge: “Not everyone sees the world the way that white, Western Europeans do…we need to realize that there are other ways of looking at health and they are just as valid.” They described how a Western worldview privileges the individualistic, biomedical perspective and consequently devalues other forms of knowledge, such as traditional Aboriginal knowledge. Further, HCPs can unknowingly perpetuate colonial practices by imposing dominant ideas related to health and medicine on the populations they treat. Some participants also emphasized that students should learn about the unique health needs of local populations and understand the diversity within Aboriginal communities in order to avoid generalizing and stereotyping.
How do Canadian HCPs’ own experiences of privilege and oppression affect their practice?
Participants emphasized the importance of learning about one’s own social location, particularly positions of power and privilege, as this knowledge is essential to establishing optimal therapeutic relationships between HCPs and clients:
My goal is to try to help nurses enter into practice with an awareness of their own privileges and the ways in which they’re positioned and benefitting from ongoing colonial practices. To help them be critically aware of how judgments and stigma play out. Not just play out in the interpersonal realm, but maintain relations of inequity and how they, in fact, benefit from those.
Related to learning about one’s privilege, participants believed students should reflect on their own assumptions and biases.
Participants identified dealing with the reactions of students, including denial and anger, as a consistent challenge: “These are sensitive issues because you’re deconstructing what [students] have learned throughout their lives…And by unpacking it you’re dissembling their worldview.” Participants explained that it is important for instructors to understand that the experience of learning about one’s privilege is a potentially traumatic experience, one that requires debriefing. One participant explained teaching about PCH first from a structural perspective and then shifting the locus of analysis to an individual’s own privilege may be an effective way to mitigate these reactions. When commenting on the learning needs of HCPs, participants offered reflections that suggested that most (but not all) students in healthcare training programs belonged to socially privileged groups.
Participants also described the notion of becoming “culturally safe” as important for future HCPs. While the terms cultural safety and cultural competency were often used interchangeably or in combination, some participants distinctly preferred cultural safety. These participants argued that cultural safety incorporates aspects of postcolonial theory into education regarding culture and therefore may be useful to help students understand how postcolonialism applies to healthcare. One participant noted that this approach “speaks more to a form of negotiation that…kind of inverts power relations that we have with healthcare providers and their patients.” Another participant described how the idea of cultural competency is problematic:
Some people, non-Aboriginal People in particular, they’re not sure how to approach the issue of culture in their direct care…It doesn’t mean you learn everything about a single culture, because who can do that? And besides, even people of a particular culture, you learn culture your whole life. You’re born into it, you’re raised in it, you’re learning it probably until the day you die…this notion of competency in someone else’s culture is ridiculous.
How should content related to postcolonialism and health be taught in Canadian healthcare training programs?
Participants’ perspectives on how to teach PCH content were categorized into three themes: the teaching strategies that instructors should use, who should teach PCH content to HCPs and when this content should be taught.
What teaching strategies should instructors use?
Participants indicated that the delivery of PCH content requires a combination of various methods and depends on factors such as class size and students’ level of postsecondary education.
Participants agreed that this type of content usually works best when it is interactive, whether that involves case studies, small group work or class discussion. Particularly, some participants discussed the importance of evoking an emotional response from students:
I want you to remember the things that you remember because it’s like a train wreck; it’s burned into your memory because it touched you… If it didn’t get to you at that level, then you didn’t truly learn it.
Several participants raised the importance of including the lived experience of Aboriginal People, which may involve inviting guest speakers into the classroom, conducting sharing circles with Elders and using various media (e.g., film, literature, art).
Participants touted experiential learning as an important way to teach PCH content because it encourages students to better understand the individuals that they might work with and see “how differences in power might manifest.” This may include attending local Aboriginal events, participating in traditional cultural practices or ceremony (e.g., sweat lodges), clinical placements, site visits to Aboriginal cultural organizations and visiting Aboriginal communities. However, one participant emphasized that students need to experience the Aboriginal community in a way that is not invasive. Participants also highlighted the necessity for student preparation before engaging in experiential learning, such as learning about the community as well as considering their own social positions and goals for the experience.
Some participants identified resistance from students and faculty members as a potential barrier to delivering this content. Particularly, participants reported that students do not always understand how postcolonialiasm is applicable to their clinical practice and may prefer to spend time learning technical skills. One participant discussed how it is also difficult to convince faculty members about the relevance of this content:
I think where everybody is fighting and struggling for more time to teach students in a limited program, this sometimes is seen as a ‘nice to know’ not a ‘need to know’…sometimes it actually means convincing your colleagues as well that this is really valuable information.
Some participants indicated that students might take content related to PCH more seriously if it were explicitly included in course objectives and tested.
Who should teach the content?
Participants’ remarks regarding who should be involved in teaching depended on the specific content being taught, an interdependency that is illustrated in Fig. 2. For example, participants were not prescriptive about who should teach about privilege and power, or “whiteness.” Participants also emphasized that educators should be cautious of teaching lived experiences if they are “outside of that experience.” To that end, participants indicated that Aboriginal educators should be directly involved in the design, review and teaching of curriculum related to Aboriginal history, tradition and present-day issues. They discussed this as an important consideration for building capacity within Aboriginal communities, while also bringing unique expertise into clinical training programs. Participants acknowledged the limited number of individuals from Aboriginal communities who may be available to teach this content (given their other competing demands in addressing Aboriginal inequities), but emphasized that every effort to identify and build relationships with these instructors should be taken.
In particular, there was recurring discussion of forming partnerships with Elders, which refers to people who are recognized within Aboriginal communities as possessing special knowledge of history, culture and traditions.
Regardless of the content, most participants agreed that inclusion of instructors who have relevant personal experience is essential but might not be sufficient:
It’s not what experiences you have. It’s how critical you are of them and how much analysis you’ve done of them. So, the experience doesn’t guarantee that you can analyze it.
There was disagreement among participants regarding the academic qualifications that instructors need to teach this content. While most participants felt that higher education and status as a lecturer at a post-secondary institution should not be a requirement, others felt it may be important depending on the nature of the content. Finally, participants believed that in addition to having insight into issues related to PCH, instructors who teach this content should be aware of the importance of creating a safe space for educators and learners.
When should this content be taught?
There was consensus that content related to PCH should be introduced early in curricula and integrated throughout in a longitudinal approach. Concepts that students can more readily grasp, such as cultural safety and social determinants of health, should be introduced earlier in the curriculum. These ideas prime students for more complex topics such as the root causes of health disparities, including the colonial processes that continue to disadvantage some and privilege others in Canada.
Participants cautioned against teaching PCH content as a single class or course. Rather, instructors should strive to include concepts relating to PCH into various parts of curricula and revisit critical concepts regularly to emphasize their importance and scaffold learning.
Participants also noted that students should demonstrate their understanding of this material prior to interacting with patients, especially those who are adversely affected by colonization, including Aboriginal and immigrant populations. Many participants also noted that knowledge of this material would facilitate and enhance interactions with all patients, regardless of their background because of the insights students gain about othering.
Why should this content be taught?
Ultimately, participants agreed that it is essential to include content related to PCH in healthcare training programs in order to increase health equity. Some participants also emphasized the moral and ethical responsibility HCPs have to work toward this goal. Participants discussed several ways in which including this content may help to achieve this goal, as discussed below.
Participants emphasized that learning content related to PCH would improve the quality of care delivered by HCPs to populations negatively impacted by colonialism. HCPs would be more aware of the intricate power relations between themselves and clients and prepared to address this power differential without harming clients. Specifically, in a clinical context, participants highlighted that HCPs would be able to determine the root cause of a client’s health issues, and therefore, deliver more effective and holistic interventions.
In addition, participants discussed how improved quality of care increases access to healthcare services. Participants describe that some individuals, particularly from Aboriginal populations in Canada, do not access health services due to previous negative experiences and mistrust of the healthcare system. One participant explained:
If you experience a health practitioner who seems to understand you, you’re more likely to go see that health practitioner, right? It comes down to the way health practitioners will treat their Aboriginal clients or patients.
Additionally, some participants argued that learning about PCH would equip HCPs with the tools required to become better advocates for their clients both within the healthcare system and society at large. Participants agreed that improved quality of care, access and advocacy are stepping stones to increasing health equity:
[Learning about content related to PCH] would hopefully encourage more Aboriginal People to engage in care because the environment is seen as safe …They become a better provider of care…of course people’s health is going to benefit because they’re accessing care more often…If you’re an advocate for your client, then you’re going to help them to navigate other systems that might not be as culturally safe for them. So I think it has a huge ripple effect.
In summary, participants believed that including PCH content should include a foundational history of colonialism in Canada and how power structures in society operate to create different lived experiences and health inequities. Participants also suggested PCH content should be integrated longitudinally though a variety of interactive teaching strategies and developed in collaboration with local communities in order to increase health equity.