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Indigenous Women’s Perspectives on Heart Health and Well-being: A Scoping Review

Open AccessPublished:October 21, 2022DOI:https://doi.org/10.1016/j.cjco.2022.10.007

      Abstract

      Indigenous women tend to have higher rates of cardiovascular disease and/or stroke and are less likely to report their health as good or excellent in comparison to Indigenous men. Cultural values and lived experiences of Indigenous women can inform the relationship between them and their healthcare provider and approaches to self-management of cardiovascular disease and stroke. Health research often neglects to consider the subjective and cultural nature of health and well-being. A scoping review was conducted to identify available literature regarding Indigenous women’s perspectives on heart health. The research question for this scoping review was: “How do Indigenous women who are at risk of and/or living with cardiovascular disease and stroke perceive their heart health and well-being?” Database searches generated 4757 results with an additional 37 articles identified from grey literature depositories. A total of 378 articles were assigned a full-text review of which 10 articles met the criteria for this analysis. The available literature provided evidence on how lifestyle, gender roles, relationships, mental and emotional health, health literature, culture, ceremony and healing, and experiences in the healthcare system impacts the perspective that Indigenous women have on heart health. Despite this population being at a high risk for heart-related illnesses, Indigenous women’s perspectives on cardiovascular health and well-being continue to be underrepresented in the existing literature, warranting the need for culturally appropriate health policies informed by their lived experiences.

      Keywords

      Abbreviations and Acronyms:

      AI (American Indians), NA- AN (Native American – Alaskan Native), CVD (Cardiovascular disease), CVD/s (Cardiovascular disease and/or stroke), HCPs (Healthcare provider(s)), MBH (Mending Broken Hearts project), RHD (Rheumatic heart disease), SDOH (Social determinants of health)

      Researcher Positionality Statements

      Dr. Bernice Downey is a Medical Anthropologist and a former Registered Nurse. She is of mixed Ojibwe-Saulteaux/Celtic ancestry with kinship ties to Lake St. Martin and Dauphin River First Nations in Manitoba. Dr. Downey’s mother, Evelyn Desjarlais, Downey McLaren is Saulteaux/Cree, was born in Lake St. Martin, and raised in Dauphin River First Nation situated in Treaty 2 in Manitoba. Due to Canadian Laws, Dr. Downey was not able to identify as an “Indian” under the Indian Act and can only list her status as being a “non-status Indian”. This is a term that is known to Indigenous people as being of Canadian “Indian” descent but without legal status as an “Indian”. While Dr. Downey is not able to legally recognize her Indigenous heritage and in spite of growing up in an urban environment, she maintains her Indigenous identity through her family and the larger Indigenous community. Dr. Downey is engaged in a life-long learning process towards experiencing and understanding her Saulteaux culture and language. Dr. Downey has invested most of her professional career working with Indigenous peoples toward informing and mobilizing self-determining approaches to health and research. She is the Associate Dean, Indigenous Health with the Faculty of Health Sciences at McMaster University in Hamilton, Ontario.
      Dana Hart is a Research Officer in the Faculty of Nursing at the University of Toronto, and an Anthropologist. Their background is Mi’Kmaq and settler with Newfoundlander roots.
      Zoya Gomes is a medical student enrolled at Dalhousie University, and is currently residing in Halifax, Nova Scotia in Mi’kma’ki, the ancestral and unceded territory of the Mi'kmaq People. Zoya identifies as a non-Indigenous, woman of colour with settler roots. Zoya acknowledges that she is in a lifelong process of learning about the complex history of Indigenous Peoples, and is dedicated to practicing community-based, culturally safe research in the field of Indigenous health and well-being. Zoya completed her MSc. Global Health at McMaster University under the supervision of Dr. Bernice Downey, and is assisting with the MBH project.
      The strategic priority of promoting and educating non-Indigenous healthcare providers regarding Indigenous cultural safety is responsive to the Truth and Reconciliation Commission of Canada’s Calls to Action in their 2015 Final Report. This is linked to one of the objectives of the Mending Broken Hearts project, which encompasses the training of HCPs to be more culturally responsive and safe when treating Indigenous women with heart illness.

      Introduction

      Traditionally, Indigenous women have been central to the health and well-being of their families and communities, taking on prominent roles as nurturers and leaders.
      • McBride K.F.
      • Rolleston A.
      • Grey C.
      • Howard N.J.
      • Paquet C.
      • Brown A.
      Māori, Pacific, Aboriginal and Torres Strait Islander Women’s Cardiovascular Health: Where Are the Opportunities to Make a Real Difference?.
      ,
      • Monchalin R.
      • Monchalin L.
      Closing the health service gap: Métis women and solutions for culturally-safe health services.
      Colonial legacies, however, have perpetuated structural inequities, land displacement, and the silencing of female narratives, leading to negative health outcomes and a lack of access to health services.
      • Monchalin R.
      • Monchalin L.
      Closing the health service gap: Métis women and solutions for culturally-safe health services.
      The effects of colonization have transcended into all aspects of Indigenous Peoples’ health and well-being on physical, mental, emotional, and spiritual levels.
      • Wilk P.
      • Maltby A.
      • Cooke M.
      Residential schools and the effects on Indigenous health and well-being in Canada—a scoping review.
      Inequities are most pronounced for Indigenous women, who tend to have higher rates of chronic disease and are less likely to report their health as excellent or good in comparison with Indigenous Men.

      Diffey, L., Fontaine L., Schultz, ASH. Understanding First Nations women’s heart health. Published online 2019:32.

      A similarly elevated burden of disease for cardiovascular disease and stroke (CVD/s) has been observed in Indigenous Populations across the globe, with Indigenous women in Australia being twice as likely as non-Indigenous women to die from CVD/s.

      Australian Institute of Health and Welfare. Cardiovascular disease in Australian women - a snapshot of national statistics. 2019. https://www.aihw.gov.au/

      The Heart and Stroke Foundation of Canada advises that there is a gap between men and women in terms of CVD/s diagnosis, treatment, health promotion, and research, combined with a lack of support and resources targeted to women’s heart health.

      Heart and Stroke Foundation of Canada. Women and heart disease. Accessed April 21, 2021. https://www.heartandstroke.ca/en/heart-disease/what-is-heart-disease/types-of-heart-disease/women-and-heart-disease/

      Further, the literature indicates Indigenous women experience heart-related illnesses more frequently and at a younger age than other non-Indigenous women.
      • McBride K.F.
      • Rolleston A.
      • Grey C.
      • Howard N.J.
      • Paquet C.
      • Brown A.
      Māori, Pacific, Aboriginal and Torres Strait Islander Women’s Cardiovascular Health: Where Are the Opportunities to Make a Real Difference?.
      McBride et al. emphasizes that factors contributing to these disparities in diagnosis, treatment, and prevention are complex and interconnected.
      • Monchalin R.
      • Monchalin L.
      Closing the health service gap: Métis women and solutions for culturally-safe health services.
      This is partly due to differences in exposure to protective and risk factors and structural inequities in the healthcare system including barriers to culturally responsive CVD/s as a result of existing colonial legacies.
      • McBride K.F.
      • Rolleston A.
      • Grey C.
      • Howard N.J.
      • Paquet C.
      • Brown A.
      Māori, Pacific, Aboriginal and Torres Strait Islander Women’s Cardiovascular Health: Where Are the Opportunities to Make a Real Difference?.
      This review is a preliminary component of the Understanding & Mending ‘Broken’ Hearts: Linking European Colonization, Indigenous women’s Heart Health, and resiliency-focused approaches to health literacy (MBH) led by Dr. Bernice Downey. MBH is in partnership with three community partners: De dwa da dehs neye>s Aboriginal Health Centre (urban community), The Mississaugas of the Credit First Nation (on-reserve community) and Lake St. Martin First Nation (on-reserve community). MBH seeks to understand Indigenous women’s and community perspectives on heart health and well-being. Participants in this project include Indigenous women, traditional practitioners, community members, and organizational representatives who work with Indigenous women living with CVD/s. While these participants were not directly included in this review process, the findings from this review will be shared and discussed within our Project Advisory Committee, and with our community partners. It is expected that what we learn will support Indigenous women’s ability to self-manage their CVD/s more effectively.
      The objective of this scoping review was to identify and summarize the existing body of literature on Indigenous women’s perspectives on heart health and well-being. An overarching goal of this project is to inform the future development of culturally safe prevention and management strategies for CVD/s.

      Methods

      Study Inclusion Criteria

      Population

      Articles were included for review if the study population identified as Indigenous women. Articles were not restricted by age group to be inclusive of the perspectives of both Indigenous women and girls. Articles that reported on both Indigenous Men and Women were included if they provided data specific to women’s experiences.

      Cardiovascular Disease (CVD/s) Outcomes

      For the purposes of this review, the term CVD/s encompasses but is not limited to coronary artery disease (angina, myocardial infarction [MI]), stroke, heart failure, rheumatic heart disease, ischemic heart disease, cardiometabolic disorders, hypertensive heart disease, and peripheral artery disease. CVD/s risk factors including hypertension, hypercholesterolemia, and dyslipidemia were also considered. Health behaviours including physical activity, diet, smoking, and alcohol consumption, and comorbidities such as obesity and diabetes mellitus were considered in relation to CVD/s.

      Study Design, Publication Status, and Language

      All study designs, including experimental (randomized controlled trials), observational (cross-sectional, case studies, prospective, retrospective), secondary analyses, and qualitative were considered eligible. Study protocols, conference abstracts, opinion pieces, and editorials were excluded. Systematic and scoping review articles were also excluded. We searched peer-reviewed and grey literature sources for relevant articles. As a part of this grey literature review, Indigenous-led health-related websites were reviewed. Only articles published in English were eligible for this review.

      Study Framework

      A scoping review of both peer-reviewed and grey literature was conducted. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses’ reporting guidelines for scoping reviews [PRISMA-ScR] and was informed by Arksey and O’Malley’s framework.
      • Arksey H.
      • O’Malley L.
      Scoping studies: towards a methodological framework.
      The methodology consisted of five stages: 1) identifying the research question; 2) identifying relevant studies; 3) selecting the studies; 4) charting the data; and 5) collating, summarizing, and reporting the results.

      Step 1: Identifying the Research Question

      The research question for this scoping review was as follows: “How do Indigenous Women who are at risk of and/or living with cardiovascular disease and stroke perceive their heart health and well-being?”

      Step 2: Identifying Relevant Studies

      The search strategy for this systematic review was created in consultation with a health sciences librarian and a sample can be found in Supplemental Table S1. After relevant search and index terms were identified and refined, searches were carried out on January 28, 2021 in the following scholarly databases: MEDLINE (Ovid; 1946-Present), Emcare (Ovid; 1995 to 2021), HealthStar (Ovid; 1996 to January 2021), Web of Science, Informit: Indigenous Collection, University of Saskatchewan: iPortal, AnthroSource, and Sociological Abstracts. No restrictions were placed on the publication date of articles. This step was designed to be inclusive of all pertinent literature and to demonstrate how the literature related to Indigenous women’s heart health has evolved over time. A scan of the grey literature included a search of the following sources: Dissertations and Theses Global (ProQuest, 1957-Present) on April 16, 2021, Canadian Public Documents Collection on April 22, 2021, and Google Scholar on January 12, 2021. An advanced Google search of Indigenous health-focused websites (most of which are Indigenous-led or informed resources) was conducted using the search strategy and websites outlined in Supplemental Table S2. Scoping and systematic review articles were not included in this review, however, backward snowballing of articles took place which entailed searching through the reference lists of relevant review articles that were identified during the search for any potential articles that met the research scope.
      • Greenhalgh T.
      • Peacock R.
      Effectiveness and efficiency of search methods in systematic reviews of complex evidence: audit of primary sources.
      Lastly, a standard Google Scholar search was conducted using key terms also found in Supplemental Table S2 where a single reviewer (Z.G.) inspected and screened the first 3 pages of results for relevant articles and screened the subsequent 3 pages when relevant results were found, until no more relevant results were in sight.

      Step 3: Selecting the Studies

      Results from the database searches with citations as outlined in Figure 1and 2 were imported into a reference manager (Zotero) and duplicates were manually deleted. Citations were then exported to a Microsoft Excel template developed for screening. One reviewer (Z.G.) independently screened the title and abstract of all articles to identify potentially relevant articles.
      Figure thumbnail gr1
      Figure 1Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.
      Figure thumbnail gr2
      Figure 2Visual depiction of the intersecting factors having an impact on Indigenous women’s perspectives on heart health and well-being.
      Full texts of all articles meeting the inclusion criteria were obtained and reviewed independently by two reviewers (Z.G. and D.H.) using the screening software Rayyan. Following the blind full-text review, the authors met to discuss and resolve any discrepancies and to finalize the number of included articles (n=10).

      Step 4: Charting the Data

      A standardized data extraction template was developed to evaluate each article and identify all relevant information. The following preliminary data was summarized and extracted from the included articles: author(s); year of publication; study country; study objectives; a summary of study methods; participants; cardiovascular outcome(s); conceptualization of gender and sample size. Upon in-depth review and cross-examination of the articles, emerging themes, arguments, and perspectives of the articles were recorded and categorized accordingly.

      Step 5: Collating, Summarizing, and Reporting the Results

      The data charted in Step 4 were summarized in tables prior to conducting a thematic analysis. The authors collectively reviewed the extracted data, organized the findings into relevant themes, and resolved any discrepancies through discussion.

      Results

      As reported in Figure 1, the database searches as described above generated 4757 results. An additional 37 results were identified in grey literature outlets. After removing duplicates, 3007 results proceeded to title and abstract screening, with the results then narrowed to 378. After full-text screening, 369 articles failed to meet eligibility due to the following reasons: not Indigenous focused (n=17); lacked perspectives of Indigenous Women (n= 270); ineligible study design such as an opinion piece, editorial, study protocol, review (n=81); and irretrievable (n=1). A total of 10 articles met the inclusion criteria and proceeded to data extraction to be included in this scoping review.

      Eligible Article Characteristics

      The 10 eligible articles were published between the years 2005 to 2021 and focused on Indigenous populations from Canada (n=6), the United States (n=2), and Australia (n=2). The populations within these articles identified as Aboriginal and/or Torres Strait Islander (n=2), American Indian (n=2), First Nations and/or Métis (n=4), and Indigenous (n=2). Included articles followed a qualitative (n=8) or mixed-methods (n=2) study design. A summary of study objectives, study methods, population characteristics, and sample size of included articles can be found in Supplemental Table S3.

      Findings from Thematic Analysis

      The data extracted from this search was organized by emerging themes, which included: lifestyle, gender roles, relationships, mental and emotional health, understanding of heart health and health literacy, culture, ceremony and healing, and experiences in the healthcare system.

      Lifestyle

      Diet, Exercise, and Smoking. 8 out of the 10 articles directly discussed the connection between lifestyle—including the impacts of diet, exercise, and smoking—on Indigenous Women’s cardiovascular health.
      • McBride K.F.
      • Franks C.
      • Wade V.
      • et al.
      Good Heart: Telling Stories of Cardiovascular Protective and Risk Factors for Aboriginal Women.
      ,
      • Fontaine L.S.
      • Wood S.
      • Forbes L.
      • Schultz A.S.H.
      Listening to First Nations women’ expressions of heart health: mite achimowin digital storytelling study.
      ,
      • Medved M.I.
      • Brockmeier J.
      • Morach J.
      • Chartier-Courchene L.
      Broken heart stories: understanding Aboriginal women’s cardiac problems.
      ,

      Conklin A, Lee R, Reading J, Humphries K. Promoting Indigenous women’s heart health: lessons from gatherings with Elders and Knowledge-Holders. Published online August 30, 2019. doi:10.14288/1.0380719

      ,
      • Jones E.J.
      • Appel S.J.
      • Eaves Y.D.
      • Moneyham L.
      • Oster R.A.
      • Ovalle F.
      Cardiometabolic risk, knowledge, risk perception, and self-efficacy among American Indian women with previous gestational diabetes.
      ,

      Jones EJ, Peercy M, Cedric Woods J, et al. Identifying postpartum intervention approaches to reduce cardiometabolic risk among American Indian women with prior gestational diabetes, Oklahoma, 2012-2013. Prev Chronic Dis. 2015;12(4):1-12. doi:10.5888/pcd12.140566

      ,
      • Ziabakhsh S.
      • Pederson A.
      • Prodan-Bhalla N.
      • Middagh D.
      • Jinkerson-Brass S.
      Women-centered and culturally responsive heart health promotion among Indigenous women in Canada.
      ,

      Sanguins J. Living well: Understanding the experience of diabetes and cardiovascular disease in First Nations peoples. Ph.D. University of Calgary (Canada); 2006. Accessed via Proquest.com. Alternative link: https://central.bac-lac.gc.ca/.item?id=NR19577&op=pdf &app=Library&is_thesis=1&oclc_number=2890582 89

      Lifestyle factors identified by women as influencing one’s health included healthy eating, drinking water, being physically active, managing weight, having hobbies, and good sleeping habits. In contrast, an “unhealthy life” was described in relation to the consumption of processed foods, being overweight, living a sedentary lifestyle, using drugs, and gambling.
      • McBride K.F.
      • Franks C.
      • Wade V.
      • et al.
      Good Heart: Telling Stories of Cardiovascular Protective and Risk Factors for Aboriginal Women.
      Although many Indigenous Women participants in these articles expressed the importance of consuming a diet high in whole grains, proteins, fresh fruit, and vegetables, they also identified that highly processed and sugary foods were the most affordable—and sometimes the only option.
      • McBride K.F.
      • Franks C.
      • Wade V.
      • et al.
      Good Heart: Telling Stories of Cardiovascular Protective and Risk Factors for Aboriginal Women.
      ,

      Jones EJ, Peercy M, Cedric Woods J, et al. Identifying postpartum intervention approaches to reduce cardiometabolic risk among American Indian women with prior gestational diabetes, Oklahoma, 2012-2013. Prev Chronic Dis. 2015;12(4):1-12. doi:10.5888/pcd12.140566

      With regards to healthy eating habits, researchers identified additional factors affecting lifestyle choices including: living alone, lacking motivation to cook for oneself, and social pressures from family and friends to participate in social gatherings involving unhealthy foods.
      • Jones E.J.
      • Appel S.J.
      • Eaves Y.D.
      • Moneyham L.
      • Oster R.A.
      • Ovalle F.
      Cardiometabolic risk, knowledge, risk perception, and self-efficacy among American Indian women with previous gestational diabetes.
      ,
      • Ziabakhsh S.
      • Pederson A.
      • Prodan-Bhalla N.
      • Middagh D.
      • Jinkerson-Brass S.
      Women-centered and culturally responsive heart health promotion among Indigenous women in Canada.
      ,
      • Sanguins J.
      • King K.M.
      Diabetes and cardiovascular disease in first nations women - the Opaskwayak Cree Nation experience.
      Several articles highlighted the impact of Indigenous culture on the women’s lifestyle behaviours, with food being at the centre of many social settings considered a barrier to controlling diet.
      • Jones E.J.
      • Appel S.J.
      • Eaves Y.D.
      • Moneyham L.
      • Oster R.A.
      • Ovalle F.
      Cardiometabolic risk, knowledge, risk perception, and self-efficacy among American Indian women with previous gestational diabetes.
      ,
      • Ziabakhsh S.
      • Pederson A.
      • Prodan-Bhalla N.
      • Middagh D.
      • Jinkerson-Brass S.
      Women-centered and culturally responsive heart health promotion among Indigenous women in Canada.
      ,

      Sanguins J. Living well: Understanding the experience of diabetes and cardiovascular disease in First Nations peoples. Ph.D. University of Calgary (Canada); 2006. Accessed via Proquest.com. Alternative link: https://central.bac-lac.gc.ca/.item?id=NR19577&op=pdf &app=Library&is_thesis=1&oclc_number=2890582 89

      Smoking was identified by the women as negatively impacting their heart health and increasing the risk of comorbidities. Many study participants expressed interest in quitting smoking, but reported that social environments encouraging smoking behaviour made it challenging.
      • Medved M.I.
      • Brockmeier J.
      • Morach J.
      • Chartier-Courchene L.
      Broken heart stories: understanding Aboriginal women’s cardiac problems.
      Additional barriers to smoking cessation were fears related to physical and psychological responses to quitting: stress, overeating, partners who smoke, and the cost of nicotine replacement therapy.
      • Ziabakhsh S.
      • Pederson A.
      • Prodan-Bhalla N.
      • Middagh D.
      • Jinkerson-Brass S.
      Women-centered and culturally responsive heart health promotion among Indigenous women in Canada.
      ,

      Sanguins J. Living well: Understanding the experience of diabetes and cardiovascular disease in First Nations peoples. Ph.D. University of Calgary (Canada); 2006. Accessed via Proquest.com. Alternative link: https://central.bac-lac.gc.ca/.item?id=NR19577&op=pdf &app=Library&is_thesis=1&oclc_number=2890582 89

      Impacts of Colonialism on Lifestyle Changes. Colonial interferences on lifestyle were identified by study participants as affecting their heart health, and that of Indigenous Peoples more broadly.
      • McBride K.F.
      • Franks C.
      • Wade V.
      • et al.
      Good Heart: Telling Stories of Cardiovascular Protective and Risk Factors for Aboriginal Women.
      ,
      • Fontaine L.S.
      • Wood S.
      • Forbes L.
      • Schultz A.S.H.
      Listening to First Nations women’ expressions of heart health: mite achimowin digital storytelling study.
      Indigenous Peoples’ ancestors were hunters, gatherers, and fishermen who lived off the land and followed traditional practices such as gathering food and water.
      • Fontaine L.S.
      • Wood S.
      • Forbes L.
      • Schultz A.S.H.
      Listening to First Nations women’ expressions of heart health: mite achimowin digital storytelling study.
      In a study by Conklin et al., participants mentioned that hunting moose and foraging berries were the traditional food practices of their ancestors who subsequently did not suffer from chronic diseases.

      Conklin A, Lee R, Reading J, Humphries K. Promoting Indigenous women’s heart health: lessons from gatherings with Elders and Knowledge-Holders. Published online August 30, 2019. doi:10.14288/1.0380719

      These practices provided a healthy life in comparison to contemporary times where access to junk food is common and more affordable than healthier options and traditional foods.
      • Fontaine L.S.
      • Wood S.
      • Forbes L.
      • Schultz A.S.H.
      Listening to First Nations women’ expressions of heart health: mite achimowin digital storytelling study.
      Food was described by participants in several articles as having medicinal properties and was considered integral to healing. Additionally, a shift from traditional, active lifestyles to more sedentary ones resulted in negative impacts on heart health.
      • Fontaine L.S.
      • Wood S.
      • Forbes L.
      • Schultz A.S.H.
      Listening to First Nations women’ expressions of heart health: mite achimowin digital storytelling study.
      ,

      Conklin A, Lee R, Reading J, Humphries K. Promoting Indigenous women’s heart health: lessons from gatherings with Elders and Knowledge-Holders. Published online August 30, 2019. doi:10.14288/1.0380719

      ,

      Sanguins J. Living well: Understanding the experience of diabetes and cardiovascular disease in First Nations peoples. Ph.D. University of Calgary (Canada); 2006. Accessed via Proquest.com. Alternative link: https://central.bac-lac.gc.ca/.item?id=NR19577&op=pdf &app=Library&is_thesis=1&oclc_number=2890582 89

      For example, one participant described traditional living as quite physical, with living off the land, hunting and gathering, and travelling by canoe being traditional activities that kept both the body and mind active.
      • Fontaine L.S.
      • Wood S.
      • Forbes L.
      • Schultz A.S.H.
      Listening to First Nations women’ expressions of heart health: mite achimowin digital storytelling study.
      Articles in this review discuss the impacts of colonialism on the uptake of behavioural changes for managing heart health and well-being. Resistance to lifestyle changes were connected to residential school experiences, where Eurocentric lifestyle activities were forced upon many Indigenous Peoples as a tool of systematic manipulation and control.
      • Medved M.I.
      • Brockmeier J.
      • Morach J.
      • Chartier-Courchene L.
      Broken heart stories: understanding Aboriginal women’s cardiac problems.
      One participant attributed her resistance to lifestyle changes to her negative experiences in residential schools, where she experienced psychological manipulation to the point where she could not distinguish her own thoughts.
      • Medved M.I.
      • Brockmeier J.
      • Morach J.
      • Chartier-Courchene L.
      Broken heart stories: understanding Aboriginal women’s cardiac problems.
      Some of the women in the study identified that they resented people telling them what to do and found the introduction of heart healthy lifestyle activities to be intrusive.
      • Medved M.I.
      • Brockmeier J.
      • Morach J.
      • Chartier-Courchene L.
      Broken heart stories: understanding Aboriginal women’s cardiac problems.
      Women further expressed that these sentiments are rooted in colonialism, as generations of colonizers have attempted to dictate the lives of Indigenous Peoples.
      • Medved M.I.
      • Brockmeier J.
      • Morach J.
      • Chartier-Courchene L.
      Broken heart stories: understanding Aboriginal women’s cardiac problems.
      Harsh economic realities facing many Indigenous Women have created additional barriers to healthy lifestyle changes.
      • Medved M.I.
      • Brockmeier J.
      • Morach J.
      • Chartier-Courchene L.
      Broken heart stories: understanding Aboriginal women’s cardiac problems.
      Globally, Indigenous communities face disproportionately higher rates of unemployment, leading to increased difficulty with making the costly dietary lifestyle changes deemed necessary by healthcare providers (HCPs) to prevent and manage CVD/s.
      • Medved M.I.
      • Brockmeier J.
      • Morach J.
      • Chartier-Courchene L.
      Broken heart stories: understanding Aboriginal women’s cardiac problems.

      Gender Roles and Expectations

      Burden of Caregiving. Another common theme was the integral role of Indigenous Women to the family structure, and how roles and responsibilities can influence the way that CVD/s manifests. In five of the articles, researchers explicitly report on the caregiving roles that women often take on throughout their lives and the burdens it can impose through stress, time, energy availability, and self-care.
      • Fontaine L.S.
      • Wood S.
      • Forbes L.
      • Schultz A.S.H.
      Listening to First Nations women’ expressions of heart health: mite achimowin digital storytelling study.
      • Medved M.I.
      • Brockmeier J.
      • Morach J.
      • Chartier-Courchene L.
      Broken heart stories: understanding Aboriginal women’s cardiac problems.

      Conklin A, Lee R, Reading J, Humphries K. Promoting Indigenous women’s heart health: lessons from gatherings with Elders and Knowledge-Holders. Published online August 30, 2019. doi:10.14288/1.0380719

      ,
      • Ziabakhsh S.
      • Pederson A.
      • Prodan-Bhalla N.
      • Middagh D.
      • Jinkerson-Brass S.
      Women-centered and culturally responsive heart health promotion among Indigenous women in Canada.
      ,

      Sanguins J. Living well: Understanding the experience of diabetes and cardiovascular disease in First Nations peoples. Ph.D. University of Calgary (Canada); 2006. Accessed via Proquest.com. Alternative link: https://central.bac-lac.gc.ca/.item?id=NR19577&op=pdf &app=Library&is_thesis=1&oclc_number=2890582 89

      For example, Medved et al. found that many women experienced the stress and distress associated with responsibility for other people (caregiving) and noted a lack of adequate support and appreciation for this work.
      • Medved M.I.
      • Brockmeier J.
      • Morach J.
      • Chartier-Courchene L.
      Broken heart stories: understanding Aboriginal women’s cardiac problems.
      Family as a Protective Factor. In contrast, women also described those that depended on them, such as husbands, grandchildren, and friends, to be a protective factor against developing heart problems.
      • Medved M.I.
      • Brockmeier J.
      • Morach J.
      • Chartier-Courchene L.
      Broken heart stories: understanding Aboriginal women’s cardiac problems.
      Being nurturers in the family was important to Indigenous Women, and contributed to feelings of love, connectedness, belonging, and identity.
      • Medved M.I.
      • Brockmeier J.
      • Morach J.
      • Chartier-Courchene L.
      Broken heart stories: understanding Aboriginal women’s cardiac problems.
      Therefore, the responsibility of caring for family was identified as a key driver to look after their heart health in the long-term. Some women also identified that under periods of illness or duress, family members would assume responsibility for household duties either on an ongoing basis or, in the case of more acute events, until they were able to manage.

      Sanguins J. Living well: Understanding the experience of diabetes and cardiovascular disease in First Nations peoples. Ph.D. University of Calgary (Canada); 2006. Accessed via Proquest.com. Alternative link: https://central.bac-lac.gc.ca/.item?id=NR19577&op=pdf &app=Library&is_thesis=1&oclc_number=2890582 89

      Impacts of Colonialism on Gender Roles. In the context of the traumatizing impact of residential schools, some women described a fear of putting oneself first as a woman and of having one's children taken away by social workers if they were to put themselves first.

      Conklin A, Lee R, Reading J, Humphries K. Promoting Indigenous women’s heart health: lessons from gatherings with Elders and Knowledge-Holders. Published online August 30, 2019. doi:10.14288/1.0380719

      This fear that Indigenous Women face was said to negatively impact their ability to care for their own well-being and fostered social isolation.
      • Medved M.I.
      • Brockmeier J.
      • Morach J.
      • Chartier-Courchene L.
      Broken heart stories: understanding Aboriginal women’s cardiac problems.
      ,

      Conklin A, Lee R, Reading J, Humphries K. Promoting Indigenous women’s heart health: lessons from gatherings with Elders and Knowledge-Holders. Published online August 30, 2019. doi:10.14288/1.0380719

      ,
      • Ziabakhsh S.
      • Pederson A.
      • Prodan-Bhalla N.
      • Middagh D.
      • Jinkerson-Brass S.
      Women-centered and culturally responsive heart health promotion among Indigenous women in Canada.
      Indigenous Women who survived the residential schooling system also attributed deteriorating heart health to the forced separation from their community, family, and the land, which caused considerable stress and grief.
      • Fontaine L.S.
      • Wood S.
      • Forbes L.
      • Schultz A.S.H.
      Listening to First Nations women’ expressions of heart health: mite achimowin digital storytelling study.

      Relationships

      The theme of relationships was prominent across five articles, encompassing connectedness with oneself, family, community, and nation. McBride et al. stated that a strong identification with culture, family, community, and the environment provided a sense of connectedness, belonging, and love for Indigenous Women.
      • McBride K.F.
      • Franks C.
      • Wade V.
      • et al.
      Good Heart: Telling Stories of Cardiovascular Protective and Risk Factors for Aboriginal Women.
      Staying connected to community and having a support system of friends and family were identified as important factors for Indigenous Women's heart health, and family was considered essential to self-care.

      Conklin A, Lee R, Reading J, Humphries K. Promoting Indigenous women’s heart health: lessons from gatherings with Elders and Knowledge-Holders. Published online August 30, 2019. doi:10.14288/1.0380719

      Women described that reconnecting or strengthening relationships with their children and grandchildren was a route to healing their heart.
      • Fontaine L.S.
      • Wood S.
      • Forbes L.
      • Schultz A.S.H.
      Listening to First Nations women’ expressions of heart health: mite achimowin digital storytelling study.
      Downey found that relationships within the community serve as supportive networks and sources of health information, a primary resource for Indigenous Peoples managing their heart health and well-being.
      • Medved M.I.
      • Brockmeier J.
      • Morach J.
      • Chartier-Courchene L.
      Broken heart stories: understanding Aboriginal women’s cardiac problems.
      Relationships with younger generations were also identified as a facilitator of engagement in physical activity as a heart healthy activity.
      • Fontaine L.S.
      • Wood S.
      • Forbes L.
      • Schultz A.S.H.
      Listening to First Nations women’ expressions of heart health: mite achimowin digital storytelling study.
      ,

      Conklin A, Lee R, Reading J, Humphries K. Promoting Indigenous women’s heart health: lessons from gatherings with Elders and Knowledge-Holders. Published online August 30, 2019. doi:10.14288/1.0380719

      Mental and Emotional Health

      Indigenous Women reported that mental and emotional health and well-being were related to CVD/s in five of the articles. For example, changes that affected their emotional health impacted their cardiovascular health as well.
      • McBride K.F.
      • Franks C.
      • Wade V.
      • et al.
      Good Heart: Telling Stories of Cardiovascular Protective and Risk Factors for Aboriginal Women.
      ,
      • Medved M.I.
      • Brockmeier J.
      • Morach J.
      • Chartier-Courchene L.
      Broken heart stories: understanding Aboriginal women’s cardiac problems.
      ,

      Jones EJ, Peercy M, Cedric Woods J, et al. Identifying postpartum intervention approaches to reduce cardiometabolic risk among American Indian women with prior gestational diabetes, Oklahoma, 2012-2013. Prev Chronic Dis. 2015;12(4):1-12. doi:10.5888/pcd12.140566

      • Ziabakhsh S.
      • Pederson A.
      • Prodan-Bhalla N.
      • Middagh D.
      • Jinkerson-Brass S.
      Women-centered and culturally responsive heart health promotion among Indigenous women in Canada.

      Sanguins J. Living well: Understanding the experience of diabetes and cardiovascular disease in First Nations peoples. Ph.D. University of Calgary (Canada); 2006. Accessed via Proquest.com. Alternative link: https://central.bac-lac.gc.ca/.item?id=NR19577&op=pdf &app=Library&is_thesis=1&oclc_number=2890582 89

      Mental illnesses, including anxiety and depression, were further associated with CVD/s. Medved et al. found that many of the heart health stories shared by Indigenous Women described anxiety as causing weak hearts, which then further perpetuated anxiety.
      • Medved M.I.
      • Brockmeier J.
      • Morach J.
      • Chartier-Courchene L.
      Broken heart stories: understanding Aboriginal women’s cardiac problems.
      Sources of stress identified by women ranged from multiple health issues, challenges with family and community, financial hardship, racism, and discrimination.
      • McBride K.F.
      • Franks C.
      • Wade V.
      • et al.
      Good Heart: Telling Stories of Cardiovascular Protective and Risk Factors for Aboriginal Women.

      Impacts of Colonialism on Mental and Emotional Health.

      Multiple articles emphasized stress, grief, and trauma as influential factors causing a spiritual and physical breakdown of the heart.
      • McBride K.F.
      • Franks C.
      • Wade V.
      • et al.
      Good Heart: Telling Stories of Cardiovascular Protective and Risk Factors for Aboriginal Women.
      ,
      • Medved M.I.
      • Brockmeier J.
      • Morach J.
      • Chartier-Courchene L.
      Broken heart stories: understanding Aboriginal women’s cardiac problems.
      ,

      Conklin A, Lee R, Reading J, Humphries K. Promoting Indigenous women’s heart health: lessons from gatherings with Elders and Knowledge-Holders. Published online August 30, 2019. doi:10.14288/1.0380719

      They discussed the impact of personal losses causing Indigenous Women to have 'heart sickness,' denoting that trauma manifests in disease because the heart is broken.
      • Medved M.I.
      • Brockmeier J.
      • Morach J.
      • Chartier-Courchene L.
      Broken heart stories: understanding Aboriginal women’s cardiac problems.
      ,

      Conklin A, Lee R, Reading J, Humphries K. Promoting Indigenous women’s heart health: lessons from gatherings with Elders and Knowledge-Holders. Published online August 30, 2019. doi:10.14288/1.0380719

      Trauma experienced by Indigenous Women included losing parents and grandparents at a young age due to residential school.

      Conklin A, Lee R, Reading J, Humphries K. Promoting Indigenous women’s heart health: lessons from gatherings with Elders and Knowledge-Holders. Published online August 30, 2019. doi:10.14288/1.0380719

      Further, that being forced to internalize emotions of anger, fear, and rage was another source of heart sickness, because residential school staff did not allow Indigenous Children to express emotion.
      • Medved M.I.
      • Brockmeier J.
      • Morach J.
      • Chartier-Courchene L.
      Broken heart stories: understanding Aboriginal women’s cardiac problems.

      Understanding of Heart Health & Health Literacy

      Across five of the articles, Indigenous Women identified a need to better understand their heart and how to take care of it.
      • McBride K.F.
      • Franks C.
      • Wade V.
      • et al.
      Good Heart: Telling Stories of Cardiovascular Protective and Risk Factors for Aboriginal Women.
      ,
      • Medved M.I.
      • Brockmeier J.
      • Morach J.
      • Chartier-Courchene L.
      Broken heart stories: understanding Aboriginal women’s cardiac problems.
      ,
      • Jones E.J.
      • Appel S.J.
      • Eaves Y.D.
      • Moneyham L.
      • Oster R.A.
      • Ovalle F.
      Cardiometabolic risk, knowledge, risk perception, and self-efficacy among American Indian women with previous gestational diabetes.
      ,

      Jones EJ, Peercy M, Cedric Woods J, et al. Identifying postpartum intervention approaches to reduce cardiometabolic risk among American Indian women with prior gestational diabetes, Oklahoma, 2012-2013. Prev Chronic Dis. 2015;12(4):1-12. doi:10.5888/pcd12.140566

      ,
      • Belton S.
      • Kruske S.
      • Jackson Pulver L.
      • et al.
      Rheumatic heart disease in pregnancy: How can health services adapt to the needs of Indigenous women? A qualitative study.
      As identified by Jones et al., women who shared their knowledge and understandings of health related to CVD/s were found to have opinions which were influenced and shaped by their interactions and experiences with others (often family members) who faced similar burdens of heart disease.

      Conklin A, Lee R, Reading J, Humphries K. Promoting Indigenous women’s heart health: lessons from gatherings with Elders and Knowledge-Holders. Published online August 30, 2019. doi:10.14288/1.0380719

      One woman from this study felt she had a greater chance of acquiring a heart illness because of her genetics, namely due to her father who had a premature heart attack and mother who had heart problems early on, whereas other women felt that they had a low risk of heart disease if no one in their family had any forms of CVD/s.
      • Jones E.J.
      • Appel S.J.
      • Eaves Y.D.
      • Moneyham L.
      • Oster R.A.
      • Ovalle F.
      Cardiometabolic risk, knowledge, risk perception, and self-efficacy among American Indian women with previous gestational diabetes.
      Familial history of sickness, including cancer, diabetes, heart disease and stroke, was commonly associated with a perception of increased risk for CVD/s.
      • McBride K.F.
      • Franks C.
      • Wade V.
      • et al.
      Good Heart: Telling Stories of Cardiovascular Protective and Risk Factors for Aboriginal Women.
      ,
      • Medved M.I.
      • Brockmeier J.
      • Morach J.
      • Chartier-Courchene L.
      Broken heart stories: understanding Aboriginal women’s cardiac problems.
      ,
      • Jones E.J.
      • Appel S.J.
      • Eaves Y.D.
      • Moneyham L.
      • Oster R.A.
      • Ovalle F.
      Cardiometabolic risk, knowledge, risk perception, and self-efficacy among American Indian women with previous gestational diabetes.
      ,

      Jones EJ, Peercy M, Cedric Woods J, et al. Identifying postpartum intervention approaches to reduce cardiometabolic risk among American Indian women with prior gestational diabetes, Oklahoma, 2012-2013. Prev Chronic Dis. 2015;12(4):1-12. doi:10.5888/pcd12.140566

      Indigenous Women’s self-identified knowledge of risk factors and symptoms of CVD/s varied across the articles. Some women had a good understanding of stroke symptoms but did not feel confident in identifying signs of a heart attack due to a lack of information on the warning signs.
      • McBride K.F.
      • Franks C.
      • Wade V.
      • et al.
      Good Heart: Telling Stories of Cardiovascular Protective and Risk Factors for Aboriginal Women.
      On the other hand, some women said that the first sign of heart disease for them was experiencing a heart attack.
      • Medved M.I.
      • Brockmeier J.
      • Morach J.
      • Chartier-Courchene L.
      Broken heart stories: understanding Aboriginal women’s cardiac problems.
      In Medved et al.’s work, women described living in a chronic state of fear, not sure whether symptoms like a racing heart were the result of anxiety, a heart attack, or both.
      • Medved M.I.
      • Brockmeier J.
      • Morach J.
      • Chartier-Courchene L.
      Broken heart stories: understanding Aboriginal women’s cardiac problems.
      Only one study reported that participants displayed a high degree of knowledge of CVD/s risk factors, including an awareness of the role that physical activity, diet, cholesterol, and family history plays in risk for CVD/s.
      • Jones E.J.
      • Appel S.J.
      • Eaves Y.D.
      • Moneyham L.
      • Oster R.A.
      • Ovalle F.
      Cardiometabolic risk, knowledge, risk perception, and self-efficacy among American Indian women with previous gestational diabetes.
      Others found that women did not feel confident in identifying signs of a heart attack due to a lack of information about the warning signs.
      • McBride K.F.
      • Franks C.
      • Wade V.
      • et al.
      Good Heart: Telling Stories of Cardiovascular Protective and Risk Factors for Aboriginal Women.
      ,
      • Medved M.I.
      • Brockmeier J.
      • Morach J.
      • Chartier-Courchene L.
      Broken heart stories: understanding Aboriginal women’s cardiac problems.
      Some women expressed uncertainty and a lack of knowledge about preventing heart illness in general.

      Jones EJ, Peercy M, Cedric Woods J, et al. Identifying postpartum intervention approaches to reduce cardiometabolic risk among American Indian women with prior gestational diabetes, Oklahoma, 2012-2013. Prev Chronic Dis. 2015;12(4):1-12. doi:10.5888/pcd12.140566

      Overall, researchers found that many women were surprised to learn that they had developed heart problems.
      • Medved M.I.
      • Brockmeier J.
      • Morach J.
      • Chartier-Courchene L.
      Broken heart stories: understanding Aboriginal women’s cardiac problems.
      ,
      • Jones E.J.
      • Appel S.J.
      • Eaves Y.D.
      • Moneyham L.
      • Oster R.A.
      • Ovalle F.
      Cardiometabolic risk, knowledge, risk perception, and self-efficacy among American Indian women with previous gestational diabetes.
      ,
      • Belton S.
      • Kruske S.
      • Jackson Pulver L.
      • et al.
      Rheumatic heart disease in pregnancy: How can health services adapt to the needs of Indigenous women? A qualitative study.
      Medved et al. found that participants did not mention whether symptoms were different for Aboriginal women compared to non-Aboriginal people.
      • Medved M.I.
      • Brockmeier J.
      • Morach J.
      • Chartier-Courchene L.
      Broken heart stories: understanding Aboriginal women’s cardiac problems.
      When women were asked about how they understood the discrepancy between the high rates of CVD/s in their family and community in contrast to the general public, many hesitated and had difficulty explaining this inconsistency. Rheumatic Heart Disease (RHD) has a high prevalence in Aboriginal women in Australia, yet it is not well understood by participants or their families despite most women receiving a diagnosis during childhood.
      • Belton S.
      • Kruske S.
      • Jackson Pulver L.
      • et al.
      Rheumatic heart disease in pregnancy: How can health services adapt to the needs of Indigenous women? A qualitative study.
      Belton et al. found that few participants knew that environmental factors had an influence on RHD, particularly poor housing conditions, and many were unsure if RHD was a serious illness.
      • Sanguins J.
      • King K.M.
      Diabetes and cardiovascular disease in first nations women - the Opaskwayak Cree Nation experience.
      Many Aboriginal women expressed the belief that RHD had unknown or supernatural causes and could be passed down to family members.
      • Belton S.
      • Kruske S.
      • Jackson Pulver L.
      • et al.
      Rheumatic heart disease in pregnancy: How can health services adapt to the needs of Indigenous women? A qualitative study.
      For example, one participant said that her aunt would repeatedly tell her that if she was sick or died, the sickness would also be passed down to the next generation in her family.
      • Belton S.
      • Kruske S.
      • Jackson Pulver L.
      • et al.
      Rheumatic heart disease in pregnancy: How can health services adapt to the needs of Indigenous women? A qualitative study.
      Some women also described smoking cessation, exercising more, and eating fewer fatty foods as ways to managing their RHD, confusing it with ischemic heart disease.
      • Belton S.
      • Kruske S.
      • Jackson Pulver L.
      • et al.
      Rheumatic heart disease in pregnancy: How can health services adapt to the needs of Indigenous women? A qualitative study.

      Culture, Ceremony & Healing

      The sharing of traditional knowledge about healthy living and ceremony were described as integral factors for preserving the health of Indigenous Women and their communities.

      Conklin A, Lee R, Reading J, Humphries K. Promoting Indigenous women’s heart health: lessons from gatherings with Elders and Knowledge-Holders. Published online August 30, 2019. doi:10.14288/1.0380719

      ,
      • Ziabakhsh S.
      • Pederson A.
      • Prodan-Bhalla N.
      • Middagh D.
      • Jinkerson-Brass S.
      Women-centered and culturally responsive heart health promotion among Indigenous women in Canada.
      ,
      • Downey B.
      Diaspora health literacy: Reclaiming and restoring nibwaakaawin (wisdom) and mending broken hearts.
      Downey found that women reported an interest in learning more about their Indigenous heritage or utilizing Indigenous knowledge and healing approaches to address health issues.
      • Belton S.
      • Kruske S.
      • Jackson Pulver L.
      • et al.
      Rheumatic heart disease in pregnancy: How can health services adapt to the needs of Indigenous women? A qualitative study.
      Ziabakhsh et al. found that women identified culture as key for health promotion and acknowledged a cultural void in their own lives and communities.
      • Ziabakhsh S.
      • Pederson A.
      • Prodan-Bhalla N.
      • Middagh D.
      • Jinkerson-Brass S.
      Women-centered and culturally responsive heart health promotion among Indigenous women in Canada.
      Further, women referred to “culture as prevention” stating that it is important to make the connection between where women come from and their health to get through tough times.
      • Ziabakhsh S.
      • Pederson A.
      • Prodan-Bhalla N.
      • Middagh D.
      • Jinkerson-Brass S.
      Women-centered and culturally responsive heart health promotion among Indigenous women in Canada.
      However, this cultural connection is not always accessible for Indigenous populations living off-reserve, since many of them have lost access to their culture through colonial teachings.
      • Ziabakhsh S.
      • Pederson A.
      • Prodan-Bhalla N.
      • Middagh D.
      • Jinkerson-Brass S.
      Women-centered and culturally responsive heart health promotion among Indigenous women in Canada.
      With regards to traditional healing, some women reported that they turned to traditional teachings and practices to understand and cope with their heart problems.
      • Medved M.I.
      • Brockmeier J.
      • Morach J.
      • Chartier-Courchene L.
      Broken heart stories: understanding Aboriginal women’s cardiac problems.
      An important component of healing that was identified was incorporating traditional practices such as harvesting traditional medicines, performing spiritual ceremonies, and talking to spirits and ancestors.
      • Medved M.I.
      • Brockmeier J.
      • Morach J.
      • Chartier-Courchene L.
      Broken heart stories: understanding Aboriginal women’s cardiac problems.
      ,
      • Downey B.
      Diaspora health literacy: Reclaiming and restoring nibwaakaawin (wisdom) and mending broken hearts.

      Experiences in the Healthcare System

      A lack of culturally safe care was repeatedly mentioned in Indigenous Women’s experiences of mainstream healthcare in four of the included articles.
      • Fontaine L.S.
      • Wood S.
      • Forbes L.
      • Schultz A.S.H.
      Listening to First Nations women’ expressions of heart health: mite achimowin digital storytelling study.
      ,

      Conklin A, Lee R, Reading J, Humphries K. Promoting Indigenous women’s heart health: lessons from gatherings with Elders and Knowledge-Holders. Published online August 30, 2019. doi:10.14288/1.0380719

      ,

      Jones EJ, Peercy M, Cedric Woods J, et al. Identifying postpartum intervention approaches to reduce cardiometabolic risk among American Indian women with prior gestational diabetes, Oklahoma, 2012-2013. Prev Chronic Dis. 2015;12(4):1-12. doi:10.5888/pcd12.140566

      ,
      • Belton S.
      • Kruske S.
      • Jackson Pulver L.
      • et al.
      Rheumatic heart disease in pregnancy: How can health services adapt to the needs of Indigenous women? A qualitative study.
      Indigenous Women frequently described mistreatment and racism experienced as a result of healthcare providers (HCPs) making assumptions about drug and alcohol use as the cause of illness in the absence of an accurate medical assessment.

      Conklin A, Lee R, Reading J, Humphries K. Promoting Indigenous women’s heart health: lessons from gatherings with Elders and Knowledge-Holders. Published online August 30, 2019. doi:10.14288/1.0380719

      In one instance, Fontaine et al. interviewed a participant who said a relative was turned away from accessing healthcare due to the HCP’s belief that nothing was wrong other than alcohol abuse.
      • Fontaine L.S.
      • Wood S.
      • Forbes L.
      • Schultz A.S.H.
      Listening to First Nations women’ expressions of heart health: mite achimowin digital storytelling study.
      Many of the women interviewed by Fontaine et al. also shared that they felt their medicines, ways of knowing, and worldviews were invalidated by HCPs and the healthcare system.
      • Fontaine L.S.
      • Wood S.
      • Forbes L.
      • Schultz A.S.H.
      Listening to First Nations women’ expressions of heart health: mite achimowin digital storytelling study.
      Women found that their primary care centres were not accommodating to the specific needs of Indigenous Women, and in some cases, did not permit patients to bring in traditional foods or perform traditional healing practices.

      Conklin A, Lee R, Reading J, Humphries K. Promoting Indigenous women’s heart health: lessons from gatherings with Elders and Knowledge-Holders. Published online August 30, 2019. doi:10.14288/1.0380719

      ,
      • Belton S.
      • Kruske S.
      • Jackson Pulver L.
      • et al.
      Rheumatic heart disease in pregnancy: How can health services adapt to the needs of Indigenous women? A qualitative study.
      Sanguins noted that, typically, HCPs approach Indigenous Peoples living with CVD/s as needing clinical and behavioural interventions but fail to consider the value and trust they may have in traditional healing practices.

      Sanguins J. Living well: Understanding the experience of diabetes and cardiovascular disease in First Nations peoples. Ph.D. University of Calgary (Canada); 2006. Accessed via Proquest.com. Alternative link: https://central.bac-lac.gc.ca/.item?id=NR19577&op=pdf &app=Library&is_thesis=1&oclc_number=2890582 89

      Transportation to and from healthcare centres also posed challenges to Indigenous Women receiving adequate cardiac care. Travelling long distances between primary health centres and regional hospitals resulted in long periods of time away from home.
      • Jones E.J.
      • Appel S.J.
      • Eaves Y.D.
      • Moneyham L.
      • Oster R.A.
      • Ovalle F.
      Cardiometabolic risk, knowledge, risk perception, and self-efficacy among American Indian women with previous gestational diabetes.
      Women also described the potential for seeking care far from home to be unsafe, especially if they were discharged during the night.
      • Jones E.J.
      • Appel S.J.
      • Eaves Y.D.
      • Moneyham L.
      • Oster R.A.
      • Ovalle F.
      Cardiometabolic risk, knowledge, risk perception, and self-efficacy among American Indian women with previous gestational diabetes.
      ,
      • Downey B.
      Diaspora health literacy: Reclaiming and restoring nibwaakaawin (wisdom) and mending broken hearts.
      Sanguins found that participant’s willingness to access westernized healthcare services was influenced by previous experiences within the system.

      Sanguins J. Living well: Understanding the experience of diabetes and cardiovascular disease in First Nations peoples. Ph.D. University of Calgary (Canada); 2006. Accessed via Proquest.com. Alternative link: https://central.bac-lac.gc.ca/.item?id=NR19577&op=pdf &app=Library&is_thesis=1&oclc_number=2890582 89

      Those who had poor experiences in walk-in clinics or in an emergency department found that it resulted in delayed diagnosis or care, making them reluctant to seek out services again.

      Sanguins J. Living well: Understanding the experience of diabetes and cardiovascular disease in First Nations peoples. Ph.D. University of Calgary (Canada); 2006. Accessed via Proquest.com. Alternative link: https://central.bac-lac.gc.ca/.item?id=NR19577&op=pdf &app=Library&is_thesis=1&oclc_number=2890582 89

      Having discriminatory experiences with HCPs also increased participants' reluctance to access services therefore, further delaying CVD/s treatment.

      Sanguins J. Living well: Understanding the experience of diabetes and cardiovascular disease in First Nations peoples. Ph.D. University of Calgary (Canada); 2006. Accessed via Proquest.com. Alternative link: https://central.bac-lac.gc.ca/.item?id=NR19577&op=pdf &app=Library&is_thesis=1&oclc_number=2890582 89

      Sanguins found that mistrust in the healthcare system also stemmed from legends that the Opaskwayak Cree Nation People were experimented on as a product of colonization.

      Sanguins J. Living well: Understanding the experience of diabetes and cardiovascular disease in First Nations peoples. Ph.D. University of Calgary (Canada); 2006. Accessed via Proquest.com. Alternative link: https://central.bac-lac.gc.ca/.item?id=NR19577&op=pdf &app=Library&is_thesis=1&oclc_number=2890582 89

      For example, stories of the organs of Indigenous Peoples being taken and used for another person were shared within the community and contributed to an increased reluctance to access health services.

      Sanguins J. Living well: Understanding the experience of diabetes and cardiovascular disease in First Nations peoples. Ph.D. University of Calgary (Canada); 2006. Accessed via Proquest.com. Alternative link: https://central.bac-lac.gc.ca/.item?id=NR19577&op=pdf &app=Library&is_thesis=1&oclc_number=2890582 89

      Relationship with Healthcare Providers

      A recurring theme in four articles was the relationship between Indigenous Women and their HCP, and its effect on caring for their heart health

      Conklin A, Lee R, Reading J, Humphries K. Promoting Indigenous women’s heart health: lessons from gatherings with Elders and Knowledge-Holders. Published online August 30, 2019. doi:10.14288/1.0380719

      ,

      Sanguins J. Living well: Understanding the experience of diabetes and cardiovascular disease in First Nations peoples. Ph.D. University of Calgary (Canada); 2006. Accessed via Proquest.com. Alternative link: https://central.bac-lac.gc.ca/.item?id=NR19577&op=pdf &app=Library&is_thesis=1&oclc_number=2890582 89

      ,
      • Belton S.
      • Kruske S.
      • Jackson Pulver L.
      • et al.
      Rheumatic heart disease in pregnancy: How can health services adapt to the needs of Indigenous women? A qualitative study.
      ,
      • Downey B.
      Diaspora health literacy: Reclaiming and restoring nibwaakaawin (wisdom) and mending broken hearts.
      Belton et al. found that language barriers were an issue in communication between Australian Aboriginal women and their HCPs, as the HCPs spoke formal English laced with medical jargon, and the women spoke Aboriginal English, recognized as linguistically different.
      • Belton S.
      • Kruske S.
      • Jackson Pulver L.
      • et al.
      Rheumatic heart disease in pregnancy: How can health services adapt to the needs of Indigenous women? A qualitative study.
      None of the women who experienced language barriers in the study were offered interpreters during their clinical encounters, meaning that the health services provided were unsafe and lacking informed consent.
      • Belton S.
      • Kruske S.
      • Jackson Pulver L.
      • et al.
      Rheumatic heart disease in pregnancy: How can health services adapt to the needs of Indigenous women? A qualitative study.
      This degree of sub-optimal communication resulted in many Aboriginal women feeling disengaged from their healthcare.
      • Belton S.
      • Kruske S.
      • Jackson Pulver L.
      • et al.
      Rheumatic heart disease in pregnancy: How can health services adapt to the needs of Indigenous women? A qualitative study.
      Additionally, Conklin et al. found some women who had a heart attack or were diagnosed with heart problems expressed that their doctors did not effectively communicate strategies on how to live with and manage the disease, and that this lack of knowledge contributed to the women’s fear about their health status.

      Conklin A, Lee R, Reading J, Humphries K. Promoting Indigenous women’s heart health: lessons from gatherings with Elders and Knowledge-Holders. Published online August 30, 2019. doi:10.14288/1.0380719

      In some cases, women identified that caring and respectful relationships with their healthcare providers enabled them to ‘live well’ with heart illness.

      Sanguins J. Living well: Understanding the experience of diabetes and cardiovascular disease in First Nations peoples. Ph.D. University of Calgary (Canada); 2006. Accessed via Proquest.com. Alternative link: https://central.bac-lac.gc.ca/.item?id=NR19577&op=pdf &app=Library&is_thesis=1&oclc_number=2890582 89

      ,
      • Downey B.
      Diaspora health literacy: Reclaiming and restoring nibwaakaawin (wisdom) and mending broken hearts.
      The degree of trust Indigenous Women had in their relationship with their HCP was strongly influenced, both positively and negatively, by previous experiences.

      Conklin A, Lee R, Reading J, Humphries K. Promoting Indigenous women’s heart health: lessons from gatherings with Elders and Knowledge-Holders. Published online August 30, 2019. doi:10.14288/1.0380719

      ,

      Sanguins J. Living well: Understanding the experience of diabetes and cardiovascular disease in First Nations peoples. Ph.D. University of Calgary (Canada); 2006. Accessed via Proquest.com. Alternative link: https://central.bac-lac.gc.ca/.item?id=NR19577&op=pdf &app=Library&is_thesis=1&oclc_number=2890582 89

      ,
      • Belton S.
      • Kruske S.
      • Jackson Pulver L.
      • et al.
      Rheumatic heart disease in pregnancy: How can health services adapt to the needs of Indigenous women? A qualitative study.

      Facilitators to Cardiac Care for Indigenous Women

      In three of the articles, women identified potential facilitators to care that they would like to see incorporated into successful heart health promotion programs.

      Jones EJ, Peercy M, Cedric Woods J, et al. Identifying postpartum intervention approaches to reduce cardiometabolic risk among American Indian women with prior gestational diabetes, Oklahoma, 2012-2013. Prev Chronic Dis. 2015;12(4):1-12. doi:10.5888/pcd12.140566

      • Ziabakhsh S.
      • Pederson A.
      • Prodan-Bhalla N.
      • Middagh D.
      • Jinkerson-Brass S.
      Women-centered and culturally responsive heart health promotion among Indigenous women in Canada.

      Sanguins J. Living well: Understanding the experience of diabetes and cardiovascular disease in First Nations peoples. Ph.D. University of Calgary (Canada); 2006. Accessed via Proquest.com. Alternative link: https://central.bac-lac.gc.ca/.item?id=NR19577&op=pdf &app=Library&is_thesis=1&oclc_number=2890582 89

      Indigenous Women expressed that an ideal lifestyle program would provide motivation and promote accountability, while also accommodating the competing demands women often experience between family and work.

      Jones EJ, Peercy M, Cedric Woods J, et al. Identifying postpartum intervention approaches to reduce cardiometabolic risk among American Indian women with prior gestational diabetes, Oklahoma, 2012-2013. Prev Chronic Dis. 2015;12(4):1-12. doi:10.5888/pcd12.140566

      Effective program delivery, according to participants, would encompass a sense of social support and encourage family participation.

      Jones EJ, Peercy M, Cedric Woods J, et al. Identifying postpartum intervention approaches to reduce cardiometabolic risk among American Indian women with prior gestational diabetes, Oklahoma, 2012-2013. Prev Chronic Dis. 2015;12(4):1-12. doi:10.5888/pcd12.140566

      ,

      Sanguins J. Living well: Understanding the experience of diabetes and cardiovascular disease in First Nations peoples. Ph.D. University of Calgary (Canada); 2006. Accessed via Proquest.com. Alternative link: https://central.bac-lac.gc.ca/.item?id=NR19577&op=pdf &app=Library&is_thesis=1&oclc_number=2890582 89

      Extending education programs over longer periods of time would ideally provide maximum benefits to women and positively impact their ability to ‘live well’.

      Sanguins J. Living well: Understanding the experience of diabetes and cardiovascular disease in First Nations peoples. Ph.D. University of Calgary (Canada); 2006. Accessed via Proquest.com. Alternative link: https://central.bac-lac.gc.ca/.item?id=NR19577&op=pdf &app=Library&is_thesis=1&oclc_number=2890582 89

      Moreover, the integration of cultural elements was highly valued by women participating in health promotion programs.
      • Ziabakhsh S.
      • Pederson A.
      • Prodan-Bhalla N.
      • Middagh D.
      • Jinkerson-Brass S.
      Women-centered and culturally responsive heart health promotion among Indigenous women in Canada.
      Ziabakhsh et al. also reported that women-only groups felt safer for participants sharing and discussing sensitive issues and fostered a sense of community and connectedness to one another, as many were going through similar challenges.
      • Ziabakhsh S.
      • Pederson A.
      • Prodan-Bhalla N.
      • Middagh D.
      • Jinkerson-Brass S.
      Women-centered and culturally responsive heart health promotion among Indigenous women in Canada.
      Participants expressed that the peer-support approach to managing CVD/s was empowering because the flow of knowledge was reciprocal and the discussions were inspiring.
      • Ziabakhsh S.
      • Pederson A.
      • Prodan-Bhalla N.
      • Middagh D.
      • Jinkerson-Brass S.
      Women-centered and culturally responsive heart health promotion among Indigenous women in Canada.
      Jones et al. found the introduction of technology, including the option to opt-in to programs that use text-messaging to provide support or facilitate online sessions with a life coach, was suggested by participants as a potential solution to accommodate the busy lives of Indigenous Women.

      Jones EJ, Peercy M, Cedric Woods J, et al. Identifying postpartum intervention approaches to reduce cardiometabolic risk among American Indian women with prior gestational diabetes, Oklahoma, 2012-2013. Prev Chronic Dis. 2015;12(4):1-12. doi:10.5888/pcd12.140566

      Other facilitators identified by participants included role modelling healthy behaviours in the family, social support, nutritional education, and access to activity-related services that offered childcare.

      Jones EJ, Peercy M, Cedric Woods J, et al. Identifying postpartum intervention approaches to reduce cardiometabolic risk among American Indian women with prior gestational diabetes, Oklahoma, 2012-2013. Prev Chronic Dis. 2015;12(4):1-12. doi:10.5888/pcd12.140566

      Evaluation of Engagement of Indigenous Peoples in Health Research

      Incorporation of Indigenous methodologies and Indigenous ways of knowing into research is a crucial component of generating results that are meaningful, and genuinely representative of the perspectives of Indigenous participants. Providing context when reporting on Indigenous health outcomes is necessary to avoid perpetuating stigma and researcher bias.
      • Hyett S.
      • Marjerrison S.
      • Gabel C.
      Improving health research among Indigenous Peoples in Canada.
      To effectively assess the level of engagement of Indigenous people within each of the included articles, the framework for Indigenous engagement in health research developed by Hyett et al. was employed in this review.
      • Hyett S.
      • Marjerrison S.
      • Gabel C.
      Improving health research among Indigenous Peoples in Canada.
      Considerations for successful engagement in Indigenous health research included: historical context, present-day context, ethical guidelines and protocols, Indigenous methods and methodologies, community-based research, deficit-versus strength-based research and research allyship.
      • Hyett S.
      • Marjerrison S.
      • Gabel C.
      Improving health research among Indigenous Peoples in Canada.
      Specifically, Hyett et al.’s framework defines historical context as whether authors took the initiative to develop relationships and learn about the history of Indigenous health research, and present-day context as whether authors engaged Indigenous scholars, organizations or communities in every stage of the project.
      • Hyett S.
      • Marjerrison S.
      • Gabel C.
      Improving health research among Indigenous Peoples in Canada.
      Upon evaluation of the included articles, 5 articles did not make an explicit effort to explore historical context, however a total of 9 articles did provide present-day context. All of the included articles did provide information on the ethical guidelines that informed their research to varying extents, and many researchers (n=8) incorporated Indigenous methodologies into their practice. Community-based research was defined as ways in which research methods could restore ownership, power and control to Indigenous Peoples. In this review, although all of the included articles focused on amplifying Indigenous Women’s perspectives, only half (n=5) discussed whether they integrated community perspectives into the research design at any or all stages.
      Deficit-versus strength-based approach was a marker for whether research had the potential to stigmatize the Indigenous community, and also assessed if the research acknowledged strengths, talents and skills of the community. Lastly, research allyship entailed assessing whether researchers developed relationships with Indigenous people to which they were accountable for. Following these criteria, a detailed assessment of each of the included articles with respect to the categories mentioned above, can be found in Supplemental Table S4.

      Significance of Findings

      Traditionally, heart health for Indigenous Women was viewed wholistically—considering the physical, emotional, and spiritual dimensions of health within the context of one’s family, community, and nation.

      Diffey, L., Fontaine L., Schultz, ASH. Understanding First Nations women’s heart health. Published online 2019:32.

      Lifestyle has been shown to play a significant role in CVD/s manifestation, however it is evident that there are many disruptions to traditional ways of living and healing as a result of colonization, apparent in the perspectives of Indigenous Women across the included articles. In accordance with our findings, Vallesi et al. reported that in Australia, colonization prompted a major shift away from traditional diet and hunter-gatherer lifestyles and facilitated exposure to alcohol.
      • Vallesi S.
      • Wood L.
      • Dimer L.
      • Zada M.
      In their own voice”—Incorporating underlying social determinants into Aboriginal health promotion programs.
      The disproportionate burden of CVD/s for Indigenous populations can generally be attributed to the loss of Indigenous identity and family, and collective trauma experienced from residential schools inflicted by colonization.
      • Vallesi S.
      • Wood L.
      • Dimer L.
      • Zada M.
      In their own voice”—Incorporating underlying social determinants into Aboriginal health promotion programs.
      Health disparities between Indigenous and non-Indigenous people continue to grow in Canada and globally, despite an expanding body of health research attempting to address these inequalities. Amongst 378 full-text articles from our search of the literature that reported on Indigenous Peoples’ heart health, we found that only 10 articles included the perspectives of Indigenous Women. While biometric data adds to the classification of rates and risk factors of CVD/s, there is little research on the unique set of risk factors that matter most to the heart health of Indigenous Women, which can be identified by attending to their lived experiences.

      Conklin A, Lee R, Reading J, Humphries K. Promoting Indigenous women’s heart health: lessons from gatherings with Elders and Knowledge-Holders. Published online August 30, 2019. doi:10.14288/1.0380719

      Sanguins notes a continued lack of understanding of the cultural perspectives that First Nations People have about CVD/s.

      Sanguins J. Living well: Understanding the experience of diabetes and cardiovascular disease in First Nations peoples. Ph.D. University of Calgary (Canada); 2006. Accessed via Proquest.com. Alternative link: https://central.bac-lac.gc.ca/.item?id=NR19577&op=pdf &app=Library&is_thesis=1&oclc_number=2890582 89

      While the biophysiological processes of CVD/s are well documented in First Nations communities, the experiences of how First Nations Peoples ‘live well’ with CVD/s have not been well investigated,

      Sanguins J. Living well: Understanding the experience of diabetes and cardiovascular disease in First Nations peoples. Ph.D. University of Calgary (Canada); 2006. Accessed via Proquest.com. Alternative link: https://central.bac-lac.gc.ca/.item?id=NR19577&op=pdf &app=Library&is_thesis=1&oclc_number=2890582 89

      and as this review has found, continue to be under investigated since Sanguins’ 2006 findings. It is noted that in response to existing poor data practices including the conceptualisation of data items to reporting of data about Indigenous People, an Indigenous Data Sovereignty movement has emerged. Indigenous data sovereignty is described as “grounded in Indigenous understandings of sovereignty that challenge dominant data sovereignty discourse and current practice” and is supported by the United Nations Declaration on the Rights of Indigenous Peoples (UNDRIP).

      Lovett R, Lee V, Kukutai T, Rainie SC, Walker J. Good data practices for Indigenous data sovereignty. In: Daly A, Devitt K, Mann M, eds. Good Data. Native Nations Institute. 2019:26-36. Accessed April 14, 2022. https://nni.arizona.edu/publications-resources/publications/published-chapter-books/good-data-practices-indigenous-data-sovereignty

      Half of the articles included in this review (n=5) linked mental and emotional health to CVD/s outcomes in participants’ experiences. In a supporting study by Ong and Weeramanthri, researchers found that stress and worry were perceived as a direct cause of heart disease which made managing heart health more difficult.

      Lovett R, Lee V, Kukutai T, Rainie SC, Walker J. Good data practices for Indigenous data sovereignty. In: Daly A, Devitt K, Mann M, eds. Good Data. Native Nations Institute. 2019:26-36. Accessed April 14, 2022. https://nni.arizona.edu/publications-resources/publications/published-chapter-books/good-data-practices-indigenous-data-sovereignty

      This finding complements the notion that emotional and mental health are linked to CVD/s outcomes, as identified in this review. Further, chronic stress paired with a perceived lack of control over one’s thoughts and actions has been linked to poor health outcomes.
      • Ong M.A.
      • Weeramanthri T.S.
      Stress and worry are central issues for indigenous heart attack survivors in the Northern Territory.
      Gender roles and expectations for Indigenous Women was another recurring theme amongst half of the included articles (n=5). Common barriers to preventive behaviours were linked to gender roles and expectations, including competing priorities, exhaustion, childcare and caregiver duties, and financial and geographic constraints.
      • Fontaine L.S.
      • Wood S.
      • Forbes L.
      • Schultz A.S.H.
      Listening to First Nations women’ expressions of heart health: mite achimowin digital storytelling study.
      • Medved M.I.
      • Brockmeier J.
      • Morach J.
      • Chartier-Courchene L.
      Broken heart stories: understanding Aboriginal women’s cardiac problems.

      Conklin A, Lee R, Reading J, Humphries K. Promoting Indigenous women’s heart health: lessons from gatherings with Elders and Knowledge-Holders. Published online August 30, 2019. doi:10.14288/1.0380719

      ,
      • Ziabakhsh S.
      • Pederson A.
      • Prodan-Bhalla N.
      • Middagh D.
      • Jinkerson-Brass S.
      Women-centered and culturally responsive heart health promotion among Indigenous women in Canada.
      ,

      Sanguins J. Living well: Understanding the experience of diabetes and cardiovascular disease in First Nations peoples. Ph.D. University of Calgary (Canada); 2006. Accessed via Proquest.com. Alternative link: https://central.bac-lac.gc.ca/.item?id=NR19577&op=pdf &app=Library&is_thesis=1&oclc_number=2890582 89

      A recent Australian-based study by McBride et al. notes that in addition to such barriers, current health programs and services available to women are rarely based on family and community approaches, and ultimately fail to build on the role of women within society.
      • McBride K.F.
      • Rolleston A.
      • Grey C.
      • Howard N.J.
      • Paquet C.
      • Brown A.
      Māori, Pacific, Aboriginal and Torres Strait Islander Women’s Cardiovascular Health: Where Are the Opportunities to Make a Real Difference?.
      Women’s responsibilities within their family and community structures can make it difficult to access health services, therefore, it is important to develop services that are flexible to the needs of women.
      • Medved M.I.
      • Brockmeier J.
      • Morach J.
      • Chartier-Courchene L.
      Broken heart stories: understanding Aboriginal women’s cardiac problems.
      ,
      • Jones E.J.
      • Appel S.J.
      • Eaves Y.D.
      • Moneyham L.
      • Oster R.A.
      • Ovalle F.
      Cardiometabolic risk, knowledge, risk perception, and self-efficacy among American Indian women with previous gestational diabetes.
      ,

      Sanguins J. Living well: Understanding the experience of diabetes and cardiovascular disease in First Nations peoples. Ph.D. University of Calgary (Canada); 2006. Accessed via Proquest.com. Alternative link: https://central.bac-lac.gc.ca/.item?id=NR19577&op=pdf &app=Library&is_thesis=1&oclc_number=2890582 89

      ,
      • Sanguins J.
      • King K.M.
      Diabetes and cardiovascular disease in first nations women - the Opaskwayak Cree Nation experience.
      ,
      • Vallesi S.
      • Wood L.
      • Dimer L.
      • Zada M.
      In their own voice”—Incorporating underlying social determinants into Aboriginal health promotion programs.
      Structural changes to services can include CVD/s rehabilitation programs that are offered at home or at multiple geographic locations and during a variety of times to accommodate the schedules of Indigenous Women.
      • McBride K.F.
      • Rolleston A.
      • Grey C.
      • Howard N.J.
      • Paquet C.
      • Brown A.
      Māori, Pacific, Aboriginal and Torres Strait Islander Women’s Cardiovascular Health: Where Are the Opportunities to Make a Real Difference?.
      With distance posing a barrier to accessing health services, and a potential lack of availability of Indigenous Women during standard hours for health programs and appointments, telehealth is suggested by McBride et al. to deliver timely care and improve health outcomes.
      • McBride K.F.
      • Rolleston A.
      • Grey C.
      • Howard N.J.
      • Paquet C.
      • Brown A.
      Māori, Pacific, Aboriginal and Torres Strait Islander Women’s Cardiovascular Health: Where Are the Opportunities to Make a Real Difference?.
      With regards to Indigenous Women’s understanding of their heart health and health literacy, it is apparent from this review that many Indigenous Women are unaware that they are at an elevated risk for CVD/s. According to McBride et al., the primary contact for women seeking information on how to reduce their risk for CVD is their HCP.
      • McBride K.F.
      • Rolleston A.
      • Grey C.
      • Howard N.J.
      • Paquet C.
      • Brown A.
      Māori, Pacific, Aboriginal and Torres Strait Islander Women’s Cardiovascular Health: Where Are the Opportunities to Make a Real Difference?.
      Clear, two-way communication between an HCP and a patient is important for the patient to make informed decisions regarding their health. Otherwise, having a limited understanding of one’s heart health can affect decisions to seek care and exacerbate cardiac conditions further.
      • Artuso S.
      • Cargo M.
      • Brown A.
      • Daniel M.
      Factors influencing health care utilisation among Aboriginal cardiac patients in central Australia: a qualitative study.
      Many patients expressed that they do not feel they need to seek health services following major cardiac events, a view further perpetuated by a lack of cardiac education and sub-optimal communication between HCPs and patients.
      • Artuso S.
      • Cargo M.
      • Brown A.
      • Daniel M.
      Factors influencing health care utilisation among Aboriginal cardiac patients in central Australia: a qualitative study.
      Therefore, improving health literacy approaches should be a top priority for all healthcare systems, and can be achieved by reducing the complexity and barriers to accessing health services, as well as supporting educational programs that provide resources free of charge.
      • McBride K.F.
      • Rolleston A.
      • Grey C.
      • Howard N.J.
      • Paquet C.
      • Brown A.
      Māori, Pacific, Aboriginal and Torres Strait Islander Women’s Cardiovascular Health: Where Are the Opportunities to Make a Real Difference?.
      Strategies to improve language barriers or knowledge gaps, for example, could include the introduction of interpreters and culturally relevant resources to create a safer environment for patients.
      • McBride K.F.
      • Rolleston A.
      • Grey C.
      • Howard N.J.
      • Paquet C.
      • Brown A.
      Māori, Pacific, Aboriginal and Torres Strait Islander Women’s Cardiovascular Health: Where Are the Opportunities to Make a Real Difference?.
      Additionally, efforts to improve health literacy amongst American Indians (AI) in the United States found that culturally relevant public education campaigns developed in consultation with tribal partners increased awareness of the warning signs of heart attack and stroke in AI communities.
      • Oser C.S.
      • Gohdes D.
      • Fogle C.C.
      • et al.
      Cooperative strategies to develop effective stroke and heart attack awareness messages in rural American Indian communities, 2009-2010.
      Findings from this review indicate that healthcare utilization for Indigenous populations is shaped by experiences with the healthcare system and relationships with HCPs, further impacting health literacy. In a supporting study, Artuso et al. found that central Australia, Aboriginal and Torres Strait Islander cardiac patients were likely to delay receiving care after a cardiac event due to intercultural communication challenges with HCPs.
      • Artuso S.
      • Cargo M.
      • Brown A.
      • Daniel M.
      Factors influencing health care utilisation among Aboriginal cardiac patients in central Australia: a qualitative study.
      This supports an important subtheme in this review, particularly for Aboriginal women, that HCPs inability to speak local Indigenous languages enhanced patient’s fear, as they were not familiar with what the HCP was saying and therefore could not make informed decisions.
      • Artuso S.
      • Cargo M.
      • Brown A.
      • Daniel M.
      Factors influencing health care utilisation among Aboriginal cardiac patients in central Australia: a qualitative study.
      This poor channel of communication can happen when culturally safe services are unavailable and can lead to misinterpretation of critical health information on both sides.
      • Artuso S.
      • Cargo M.
      • Brown A.
      • Daniel M.
      Factors influencing health care utilisation among Aboriginal cardiac patients in central Australia: a qualitative study.
      An Australian report found that only 0.05% of doctors are Aboriginal women, posing a barrier to Aboriginal women seeking female practitioners and culturally appropriate health services.

      Her Heart. Aboriginal and Torres-Strait Islander Women’s Cardiac Health. 2020. https://herheart.org/aboriginal-torres-strait-islander-cardiac-health-information/

      Negative past experiences, language barriers, perceived racism, and a lack of cultural awareness from HCPs contribute to Indigenous Participants’ mistrust in the healthcare system.
      • Artuso S.
      • Cargo M.
      • Brown A.
      • Daniel M.
      Factors influencing health care utilisation among Aboriginal cardiac patients in central Australia: a qualitative study.
      Trauma associated with residential schools, experimentation, and separation from family has led Indigenous Peoples to ascribe high levels of CVD/s mortality to HCPs mistreatment due to mistrust.
      • Artuso S.
      • Cargo M.
      • Brown A.
      • Daniel M.
      Factors influencing health care utilisation among Aboriginal cardiac patients in central Australia: a qualitative study.
      This mistrust was identified as being rooted in the dominance of the biomedical model that places a high degree of power into the hands of HCPs and takes away from that of the patient.
      • Artuso S.
      • Cargo M.
      • Brown A.
      • Daniel M.
      Factors influencing health care utilisation among Aboriginal cardiac patients in central Australia: a qualitative study.
      Given that HCPs are often responsible for the distribution of appropriate knowledge, providing a diagnosis, and prescribing CVD/s medications, effective communication strategies are essential to support the self-management approaches for Indigenous Women living with or at risk for CVD/s.

      Downey, B., Nepinak, C., Cooper, N., Prince, C., Smylie, J. Strengthening health literacy among Indigenous people living with cardiovascular disease, their families and health care providers. 2013:31. https://bccewh.bc.ca/

      HCPs need to be aware that incorporating Indigenous People’s perspectives ultimately contribute to improve health outcomes.
      • Mbuzi V.
      • Fulbrook P.
      • Jessup M.
      Indigenous cardiac patients’ and relatives’ experiences of hospitalisation: A narrative inquiry.
      Listening to the stories of participants may assist HCPs in the identification of crucial aspects relating to cultural values and beliefs, undiagnosed symptoms, and past experiences that could support culturally safe continuity models of cardiac care throughout one’s journey to healing.
      • Mbuzi V.
      • Fulbrook P.
      • Jessup M.
      Indigenous cardiac patients’ and relatives’ experiences of hospitalisation: A narrative inquiry.

      Limitations

      While this scoping review aimed to be comprehensive in nature, the results should be interpreted considering the following limitations. First, the search strategy is limited in that not all Indigenous communities across Canada, the United States and Australia were explicitly stated in the search string, due to the fact that hundreds exist, which may have limited the perspectives captured. The search string follows a biomedical approach to defining heart health and well-being, which may have narrowed the scope and neglected articles that define heart health and well-being using Indigenous ways of knowing. Second, while all authors (Z.G., D.H., B.D.) discussed and finalized the inclusion and exclusion criteria, the final articles, and grey literature to be included in this review, a major limitation was that the title and abstract screening process was completed by one author (Z.G.) which influenced the fact that no Cohen’s kappa score was obtained at this stage. No protocol was registered for this review. Further, the decision to exclude non-English literature may have excluded relevant articles and research published in non-English speaking countries or nations. Attempts to mitigate this included the development of a search strategy for both the peer-reviewed and grey literature in consultation with a health sciences librarian with considerable experience working with Indigenous literature sources.
      Indigenous women’s voices were situated as the primary respondent perspective and only literature which included data specific to Indigenous women was included in this review. However, because research related to Indigenous women’s heart health is an emerging body of literature, some of the core themes identified in this review could be applied to both Indigenous men and women, which could be considered limiting since the objective was to focus on the experience of Indigenous women specifically. In addition, it is acknowledged that the health research community needs to create space for inclusion of Indigenous voices with respect to their experience and Indigenous knowledge. The scope for this review was to document the gap in the literature regarding Indigenous women who experience CVD/s. It is noted that critical discussion to expand on the initial review goal and convey the implications of the women’s perspectives in a way that reclaims and situates Indigenous knowledge as an important body of knowledge in relationship to the health and well-being of Indigenous women would ultimately strengthen the discussion of this review. However, with this in mind, this important issue will be discussed in depth as part of the larger study findings for the MBH project.
      Lastly, as is the case for most scoping reviews, appraising the quality of the literature was not undertaken.

      Peters M, Godfrey C, McInerney P, Munn Z, Trico A, Khalil H. Chapter 11: Scoping Reviews. In: Aromataris E, Munn Z, eds. JBI Manual for Evidence Synthesis. JBI; 2020. doi:10.46658/JBIM

      This can be considered a general limitation of many scoping reviews rather than a specific limitation of this review. However, as aforementioned, this review does evaluate the level of engagement of Indigenous communities in each of the included articles following the framework set by Hyett et al. as outlined in Supplemental Table S4.
      • Hyett S.
      • Marjerrison S.
      • Gabel C.
      Improving health research among Indigenous Peoples in Canada.

      Conclusion

      Indigenous Women across the globe have been made vulnerable by the impacts of colonization, perpetuating sociocultural and socioeconomic risk factors for chronic diseases such as CVD/s. This review found that many Indigenous women’s perspectives of heart health and well-being included the influence of lifestyle habits, gender roles, relationships, emotional and mental health, and experiences with the healthcare system, with each being affected by the lasting impacts of colonization. Factors often not considered within biomedical research, such as trauma, stress, and grief have all been identified by Indigenous women as contributors to their negative CVD/s outcomes. Residential schools have made an overall lasting negative impression on Indigenous Peoples collectively, contributing to much of that trauma and grief. Indigenous women described gender roles and expectations as impacting their ability to self-manage their heart illness, with the burden of caregiving contributing to stress and time spent away from self-care. Despite this population being at a high risk for CVD/s, Indigenous women’s perspectives on cardiovascular health and well-being continue to be underrepresented in existing literature. This significant gap warrants the need for culturally relevant research approaches and methodologies that prioritize and amplify the perspectives of Indigenous women globally, to effectively influence policy, inform culturally safe healthcare, and improve health outcomes.

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