FROM COMPLIANCE TO CONNECTION: HOW PRIMARY CARE PROVIDERS CAN
SUPPORT DIABETES CARE IN A GOOD WAY
by
Amy Rose Palumbo
B.A., Mount Allison University, 1999
B.N., University of Calgary, 2005

CAPSTONE SUBMITTED IN PARTIAL FULFILLMENT OF
THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF SCIENCE
IN
NURSING-FAMILY NURSE PRACTITIONER

UNIVERSITY OF NORTHERN BRITISH COLUMBIA
July 2025
© Amy Palumbo, 2025

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ABSTRACT
This integrative review, “From Compliance to Connection: How Primary Care Providers
Can Support Diabetes Care in a Good Way,” explores how primary care providers (PCPs) can
more effectively support diabetes self-management among Indigenous adults in Canada. Type 2
Diabetes Mellitus (T2DM) disproportionately affects Indigenous communities, a disparity rooted
in colonialism, intergenerational trauma, and systemic inequities. Historically, Western medicine
has pathologized Indigenous bodies and dismissed Indigenous knowledge, reinforcing narratives
of “non-compliance” and undermining trust in care relationships. Using an integrative literature
review methodology, 11 studies were identified through CINAHL, Google Scholar, and hand
searching. These were appraised using the Critical Appraisal Skills Programme (CASP) and an
adapted Aboriginal and Torres Strait Islander Quality Appraisal Tool. Findings were analyzed
through a culturally grounded qualitative synthesis. The review revealed that diabetes is often
experienced not only as a physiological condition, but also as a relational and psychological
disruption. Barriers to effective management included biomedical dominance, lack of cultural
safety, ineffective diabetes education, and the framing of resistance as non-compliance.
However, promising practices emerged: the integration of traditional medicine, use of culturally
resonant strategies like peer support and talking circles, and the alignment of biomedical
concepts with Indigenous worldviews. This review urges PCPs to move from authority-driven
models toward relational, culturally-grounded care. It concludes with implications for practice,
education, and research, centring Indigenous-led approaches in all aspects of diabetes care.

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TABLE OF CONTENTS
Abstract

ii

List of Tables

v

Glossary

vi

Acknowledgement

vii

Chapter 1: Introduction

1

Chapter 2: Background

2

The Burden of Diabetes: Indigenous Populations ...................................................................... 2
Role of Primary Care Providers in Diabetes ............................................................................... 6
Language Matters........................................................................................................................ 6
Research with Indigenous Peoples.............................................................................................. 7
What is Needed ........................................................................................................................... 8
Chapter 3: Methods

10

Problem Identification .............................................................................................................. 11
Literature Search ....................................................................................................................... 12
Search Strategies ....................................................................................................................... 13
Data Evaluation ......................................................................................................................... 14
Data Analysis ............................................................................................................................ 16
Chapter 4: Findings

17

Study Methodologies ................................................................................................................ 17
Diabetes: Psychological Impact ................................................................................................ 24
Challenges to Primary Care Diabetes Management ................................................................. 28
Facilitators to Diabetes Self-Management ................................................................................ 32
Chapter 5: Discussion

36

Implications for Practice: Addressing Colonial Legacies in Indigenous Diabetes Care .......... 36
Implications for Education ........................................................................................................ 44
Implications for Research ......................................................................................................... 46
Chapter 6: Conclusion

54

References

57

Appendix 1: Database Search Strategy

68

Appendix 2: Prisma Flow Diagram

69

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Appendix 3: Summary of Data Extraction

70

Appendix 4: Comparison of OCAP® and TCPS 2 Chapter 9 and CBPR Frameworks for Ethical
Research with Indigenous Peoples
81

v
List of Tables
Table 1: Methodologies of Selected Studies ................................................................................. 17
Table 2: Sample Size in Each Study ............................................................................................ 18
Table 3: Ages of Participants in Each Study………………………………………………………….. 19
Table 4: Diabetes Profile of Participants in Each Study ............................................................... 21
Table 5: Demographic Profiles of Selected Studies .................................................................... 22

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Glossary
Anti-racism: is the practice of actively identifying, challenging, preventing, eliminating and
changing the values, structures, policies, programs, practices and behaviours that perpetuate
racism. It is more than just being “not racist” but involves taking action to create conditions of
greater inclusion, equality and justice (Turpel-Lafond, 2020, p. 8).
Colonialism: occurs when groups of people come to a place or country, steal the land and
resources from Indigenous peoples, and develop a set of laws and public processes that are
designed to violate the human rights of the Indigenous peoples, violently suppress their
governance, legal, social, and cultural structures, and force them to conform with the colonial
state” (Turpel-Lafond, p. 2020)
Cultural Humility: a process of self-reflection to understand personal and systemic conditioned
biases, and to develop and maintain respectful processes and relationships based on mutual trust.
Cultural humility involves humbly acknowledging oneself as a life-long learner when it comes to
understanding another’s experience (First Nations Health Authority, 2021, p. 5)
Cultural Safety: Cultural safety is an outcome based on respectful engagement that recognizes
and strives to address power imbalances inherent in the healthcare system. It results in an
environment free of racism and discrimination, where people feel safe when receiving health
care (First Nations Health Authority, 2021, p. 5)
Racism: is the belief that a group of people are inferior based on the colour of their skin or due
to the inferiority of their culture or spirituality. It leads to discriminatory behaviours and policies
that oppress, ignore or treat racialized groups as “less than” non-racialized groups (TurpelLafond et al., 2020, p. 8).
Systemic racism: is enacted through routine and societal systems, structures, and institutions
such as requirements, policies, legislation, and practices that perpetuate and maintain avoidable
and unfair inequalities across racial groups including the use of profiling and stereotyping
(Turpel-Lafond, 2020, p. 8).

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Acknowledgement
I would like to express my deep gratitude to my supervisor, Dr. Catharine Schiller, whose
kindness, accommodation, encouragement, and thoughtful feedback guided this capstone and
helped carry me through self-doubt to completion.
I extend heartfelt thanks to the Indigenous Peoples whose knowledge, experiences, and
resistance informed this work. Although this project did not involve direct community
collaboration, I am indebted to the authors, Elders, storytellers, and community members whose
insights shaped this review. They have informed how I will carry forward with humility and a
commitment to ongoing learning as a family nurse practitioner.
To my partner, Sheldon; my parents, Ed and Rosalind; my parents’ partners and dear family,
Lorna and Bruce; my parents-in-law, Melanie and Brian; my sister-in-law, Rachelle; and my
beautiful children, Emilio and Rosa—thank you for your endless patience, space, emotional
encouragement, practical support, and intellectual companionship throughout this journey. To
my friends, especially Zamantha, thank you for your encouragement and steady presence, which
made this possible.
Finally, I respectfully acknowledge that this capstone was written and researched on the
unceded, ancestral territories of the Liǧʷiłdax̌ʷ people—the We Wai Kai, We Wai Kum, and
Kwiakah First Nations—as well as the ʔayʔaǰuθəm-speaking peoples of the Homalco, Klahoose,
and K’ómoks First Nations. I recognize that I study, live, work, and play on these lands as an
uninvited guest.

1
Chapter 1: Introduction
From the onset of colonization, Western medicine played a central role in pathologizing
Indigenous bodies, serving as a tool of control and assimilation. Medical authority was used to
justify intrusive involvement in the lives and health of Indigenous peoples, grounded in
racialized assumptions of white superiority and a baseless fear of "interracial contagion"
(Reading, 2018, p. 8). In this way, medicine became an instrument of colonization, reinforcing
systems of oppression under the facade of caring for those who were being colonized (Reading,
2018). The experiences of many Indigenous peoples with diabetes have been shaped deeply by
this history. Diabetes is experienced within a different context for Indigenous populations, which
has implications not only for biological health, but also for mental health, cultural wellness,
political power and access, community sovereignty, and the health of Indigenous lands and
traditions (Dutton, 2018, p. 8).
This integrative review seeks to center the lived experiences and voices of Indigenous
peoples with diabetes, offering a narrative that illuminates how primary care providers can more
effectively support self-management within this population. Acknowledging the profound
historical and intergenerational impacts of colonization, it is essential to recognize how these
forces continue to shape the psychological burden of a diabetes diagnosis among Indigenous
peoples, compounded by ongoing experiences of stigma, culturally incongruent care, and the
marginalization of traditional healing practices—practices that must be respectfully centred to
support holistic and effective diabetes care.

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Chapter 2: Background
The Burden of Diabetes: Indigenous Populations
This chapter provides an overview of type 2 diabetes mellitus (T2DM) and its
significance among Indigenous populations in Canada. It begins by outlining the
pathophysiological mechanisms, symptoms, and complications of T2DM. The chapter then
highlights the disproportionate prevalence of T2DM among Indigenous peoples and examines
how colonial systems have shaped these health disparities. It describes the concept of diabetes
self-management (DSM) and critiques how mainstream approaches often overlook Indigenous
knowledge and lived experience. Finally, it identifies the critical role of primary care providers
(PCPs) in addressing these gaps and sets the stage for exploring culturally appropriate,
community-informed models of care that support Indigenous health and self-determination.
Type II Diabetes
Type 2 diabetes mellitus (T2DM) is a chronic metabolic disorder characterized by
disruptions in glucose homeostasis, primarily due to impaired insulin secretion by pancreatic
beta cells, increased hepatic glucose production, and decreased insulin sensitivity in peripheral
tissues (Galicia-Garcia et al., 2020). These mechanisms lead to elevated circulating blood
glucose levels, often developing gradually and without noticeable symptoms, which is why
T2DM is commonly referred to as a “silent” disease (Wood, 2021).
Many individuals who develop T2DM also have metabolic syndrome—a cluster of
interconnected risk factors that include central obesity, insulin resistance, hyperglycemia,
hypertension, elevated triglycerides, low HDL cholesterol, and a chronic pro-inflammatory state
(Wood, 2021). Lifestyle factors such as physical inactivity, poor diet, and excess body weight
significantly contribute to the development of T2DM, and these factors are now being observed

3
in younger populations. Once considered a condition primarily affecting older adults, T2DM is
increasingly being diagnosed in children and adolescents, making it a concern across the lifespan
(Wood, 2021).
Early symptoms, when present, may include fatigue, frequent urination, excessive thirst,
blurred vision, and slow-healing wounds. Over time, persistent hyperglycemia can lead to both
microvascular and macrovascular complications, including damage to the eyes (retinopathy),
kidneys (nephropathy), peripheral nerves (neuropathy), and major blood vessels, increasing the
risk of heart attack and stroke (Wood, 2021). Importantly, the progression from prediabetes to
T2DM can often be halted or reversed through lifestyle modifications such as healthy eating,
regular physical activity, and weight loss. However, without intervention, T2DM can result in
serious and irreversible outcomes, including blindness, kidney failure, and cardiovascular disease
(Wood, 2021).
Diabetes Epidemic
Prior to the 1950s, T2DM was virtually non-existent in Indigenous populations in
Canada; in the last several decades, it has reached epidemic proportions with rates 3 to 5 times
that of the general population (Public Health Agency of Canada [PHAC], 2018; Sinclaire et al.,
2023). In the 25-year period from 1980-2005, rates increased by 10.8% in First Nations women
and 4.2% in First Nations men (Halseth, 2018). According to the Pan-Canadian Health
Inequalities Data Tool, age-standardized rates of diabetes are now 17.2% for individuals living
on reserve compared to 12.7% for First Nations living off reserve, 9.9 % among Métis, and 4.7%
among Inuit peoples, compared to 5% in the non-Indigenous population (PHAC, Pan-Canadian
Public Health Network & Statistics Canada, 2024). Prevalence is increasing with onset at a
younger age, continued higher rates amongst women, poorer disease management and worse

4
outcomes (Sinclaire et al., 2023). This disproportionate burden results from colonial processes
and structures that have dramatically altered the socioeconomic, political and cultural systems of
First Nations peoples (Halseth, 2019) that had previously combined to prevent T2DM from being
present in that population. While it is recognized that an approach grounded in reciprocal
relationships with healthcare providers that embraces diversity, tailors care to each individual’s
unique needs, addresses the social determinants of health, and honours a patient’s own priorities
is required for meaningful change for Indigenous patients (Diabetes Canada, 2025d), rates of
diabetes have continued to rise.
Diabetes Self-Management
Diabetes self-management (DSM) refers to the ongoing process by which individuals
with the disease take responsibility for managing their condition. It involves making daily
decisions and taking action to maintain healthy blood sugar levels, prevent complications, and
improve overall well-being. Effective self-management can reduce the risk of serious
complications, such as heart disease, kidney damage, nerve damage, and vision problems
(American Diabetes Association [ADA], 2024; Centers for Disease Control and Prevention
[CDC], 2023; National Institute of Diabetes and Digestive and Kidney Diseases, 2023;World
Health Organization [WHO], 2021). Key aspects of the DSM process include healthy eating,
physical activity, blood glucose monitoring, adherence to medications, healthy and effective
problem-solving, reducing lifestyle and modifiable risk factors, and implementing healthy coping
mechanisms (Diabetes Canada, 2025b). A prerequisite for DSM is Diabetes Self-Management
Education (SME), a collaborative process between patients and healthcare providers that arm
individuals with the knowledge and skills to inform decisions and increase their capacity and
confidence to apply these skills in daily life situations (Diabetes Canada, 2025c).

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Biomedical Gaps in Indigenous Diabetes Care
The effectiveness of DSM is measured by a blood test called the Hemoglobin A1C
(HgA1c), or glycated hemoglobin, which reflects an individual’s level of blood glucose control
over the prior 3-month period, expressed as a percentage (Eyth & Nalk, 2023). HgA1C is the
gold standard for assessing diabetes control within the Western model of healthcare, and if the
target level is not achieved, providers report frustration with the individual patient and place
responsibility on that person. Almost inevitably, a narrative of non-compliance will ensue
(Sinclaire, 2023). Most studies that address DSM for Indigenous populations do so from the
perspective of physicians, and those studies place their emphasis on patient factors from a deficit
perspective (Crowshoe et al., 2018). Rather than acknowledge the context for diabetes in
Indigenous populations, and the impact that this context may have on DSM, emphasis is placed
on the deficits of individuals, bodies, and behaviours.
There exists a long-standing body of Indigenous knowledge and community-driven
approaches to SME that are deeply effective and culturally resonant. These include land-based
healing, traditional food systems, intergenerational knowledge transmission, language
revitalization, and ceremony—all of which contribute to holistic wellness and self-determination
in health. Unfortunately, these Indigenous-led solutions have been rendered invisible or
delegitimized within mainstream biomedical discourse, which continues to prioritize individual
behaviour change and glucose metrics over relational and cultural approaches to health
(Greenwood et al., 2015; Hart, 2010; Smylie, 2014). This epistemic suppression reflects broader
colonial dynamics in health systems, where Western knowledge is privileged and Indigenous
knowledge systems are systematically marginalized (Reading, 2018; Smylie, 2009). Recognizing
and amplifying Indigenous approaches is essential, not only for improving diabetes outcomes but

6
also for restoring autonomy, dignity, and cultural continuity among Indigenous patients and
communities.
Role of Primary Care Providers in Diabetes
Primary care providers (PCP), such as nurse practitioners and physicians, provide
primary care. Through the provision of longitudinal, comprehensive, coordinated and personcentred care, the primary care model aims to optimize population health and minimize health
disparities across communities (WHO, 2025). PCPs treat diseases and disorders by prescribing
medication, ordering diagnostic tests, managing results, and consulting or referring to other
health professionals when needed (British Columbia College of Nurses and Midwives
[BCCNM], 2025). In the context of T2DM, PCPs are likely to be the first and most frequent
point of contact for patients, providing continuity of care with a comprehensive overview of
health issues and social supports (Diabetes Canada, 2025a; Kushner et al., 2022).
Language Matters
This paper will use several terms interchangeably to describe First Peoples who are
geographically located in what is colonially known as Canada. “Indigenous” is a collective
designation to describe First Peoples in Canada, specifically First Nations (both status and nonstatus), Inuit, and Métis Peoples (Dutton, 2018; Kesler, 2020). While it is often considered a
preferred term due to its association with Indigenous rights movements, and its use in
agreements such as the United Nations Declaration on the Rights of Indigenous Peoples
(UNDRIP), the term “Indigenous” still defines groups primarily in relation to their colonizer and
is not a word that has been derived from Indigenous language or practice (Kesler, 2020). In
recent times, “Indigenous” has been used by the Canadian government to denote the “Ministry of
Indigenous Affairs” as well as by the province of British Columbia to name the “Declaration on

7
the Rights of Indigenous Peoples Act” (Kesler, 2020; Queen’s University, 2025). “Aboriginal” is
a word used to describe the same broad grouping of peoples in the Canadian context and became
part of the legal lexicon in the Constitution Act of 1982 to replace the word “Indian.” The term
“Aboriginal” is less preferred by some due to its association with Canadian government policy,
yet it remains largely acceptable when used within a Canadian context.
Historically, the language used to describe Indigenous Peoples by institutions and in
public discourse has caused harm, failing to acknowledge how Indigenous communities identify
themselves, perpetuating colonial dominance and failing to assume a reconciliatory stance.
Conscientious language use by institutions and within public discourse is of critical importance
to acknowledge the traditional and preferred names for specific groups and to cease the
insinuation that Indigenous Peoples “belong” to Canada. For example, referring to “Canada’s
Aboriginals” as a noun implies that they belong to Canada, whereas referencing Aboriginal
Peoples of Canada as an adjective, while still overly general, is more appropriate. Authors
referenced in this integrative review used a spectrum of terms: “Aboriginal,” “First Nations,” and
“Indigenous,” according to the context of their study and the time in which their research was
conducted. It is important to acknowledge the variation in culture, language, and experience, and
to use the names that communities, regions and groups have chosen for themselves.
Research with Indigenous Peoples
Research involving Indigenous peoples has a fraught history, characterized by unethical,
exploitative practices that treated Indigenous individuals as subjects rather than human beings.
Notably, atrocities such as nutritional experimentation on children who resided in residential
schools exemplify how research was used to advance colonial agendas without consideration of
the harms being caused (Hayward et al., 2021; Reading, 2018). Indigenous communities have

8
criticized research for continuing to ignore community needs, reinforcing power imbalances,
privileging academic advancement over community benefit, and promoting stigma while
disregarding Indigenous ways of knowing and being (Hayward et al., 2021). Continuation of
these research practices that are rooted in systemic racism reinforce the marginalization and
invalidation of Indigenous voices, thereby upholding Western biomedical paradigms for diabetes
care that sustain colonial structures and ongoing harm (Sinclaire et al., 2023). Although
Indigenous peoples have consistently asserted their perspectives, their voices have often been
excluded when shaping research agendas and informing diabetes service delivery (Sinclaire et
al., 2023). In response, ethical frameworks have been developed to promote research that is
culturally appropriate, beneficial, and grounded in principles of self-determination. However, the
consistent implementation of these standards remains uneven and continues to evolve.
What is Needed
Western medicine is a bystander to the epidemic of T2DM in Indigenous populations,
who have been left to navigate complex, multilayered health and social service systems that
perpetuate a harmful colonial legacy. International, national, and provincial legislation, along
with reports and health authority agreements, have acknowledged the lack of agency as a
significant barrier to Indigenous well-being. Indigenous voices remain misrepresented and
underrepresented within the prevailing narrative of diabetes care. To effectively address this
issue, a new narrative must be developed—one that is informed by the lived experiences and
perspectives of Indigenous patients themselves.
Such an approach is essential for identifying the specific barriers within the current
healthcare framework and developing more culturally responsive solutions. We must expand and
transform our understanding of T2DM within a specific cultural context, seek alternative

9
explanations within that context, and value those stories that reveal a more favourable
construction of Aboriginal healing needs and identities to put forward a more balanced
understanding of the Aboriginal experience of living with T2DM (Barton, 2008, p. 34-35). PCPs
are integral to the comprehensive management of T2DM, being involved in diagnosis, treatment,
monitoring for complications, and the provision of continuous, longitudinal care. As pivotal
stakeholders in the healthcare system, PCPs have a responsibility to transition from passive
oversight to active leadership in addressing the growing burden of T2DM in Indigenous
populations. Their engagement is essential to driving meaningful, system-wide change.
This integrative review will discuss the diabetes epidemic and examine how current
approaches to primary care must evolve to address this issue effectively, with a focus on
delivering care in culturally appropriate and responsive ways.

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Chapter 3: Methods
According to Torracco (2016), an integrative literature review is a methodological
approach designed to generate novel insights and theoretical contributions in relation to a
specific topic. This form of review systematically evaluates, critiques, and synthesizes
representative literature in a cohesive manner, enabling the development of new conceptual
frameworks and perspectives. It is particularly suited to areas that have not undergone a recent,
comprehensive synthesis or are situated within emerging fields where existing literature may be
fragmented, contradictory, or misaligned. By addressing such gaps and inconsistencies,
integrative literature reviews offer a depth of critical appraisal that contributes to the
advancement of knowledge and fosters a deeper understanding of complex or evolving subject
areas (Torraco, 2016).
The approaches outlined by both Torraco (2016), and Whittemore and Knafl (2005), were
foundational to the development and execution of this capstone. This integrative review was
designed to critically examine, evaluate, and synthesize empirical and theoretical literature
regarding the ways that PCPs can positively impact DSM for adult patients who are Indigenous.
Given that this topic intersects with diverse domains—including chronic disease management in
primary care, Indigenous health, relational care, and cultural safety—it was evident from the
outset that the existing literature was likely to be fragmented, variably conceptualized, and
lacking a cohesive synthesis through which to address these elements. Stages 1 through 4 are
addressed below as part of this chapter. Stage 5, data analysis, focuses on interpretation of
findings, a discussion of those findings, and recommendations for practice, research, and
education; Stage 5 will be covered in subsequent chapters.

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Problem Identification
This integrative review was guided by the research question: “How can PCPs positively
impact adult patients who have Type 2 Diabetes Mellitus and who are Indigenous?” This
question was developed using the PIO (Population, Intervention, Outcome) framework, which
ensured clarity and alignment with the purpose of the review (Melnyk & Fineout-Overholt,
2023).
The population (P) of interest was adult patients who are Indigenous (First Nations, Inuit,
and Métis peoples) and living with T2DM. This population was selected in recognition of the
disproportionate burden of diabetes among Indigenous Peoples and the need to centre their
unique cultural, historical, and social experiences within healthcare research.
The intervention (I) focused on the role of PCPs and the specific ways in which their
actions, attitudes, and relational approaches influence patient experiences (Melnyk & FineoutOverholt, 2023).
The outcome (O) was the impact of PCP approaches on T2DM, which could include
engagement with care, patient empowerment, and trust in the healthcare system. These outcomes
were understood in a broad, culturally-informed sense that included relational- and communitybased understandings of health and healing that transcended Western biomedical concepts of
health.
By applying the PIO framework, this review systematically investigated the intersection
of provider behaviour and patient outcomes within a culturally-specific context, ensuring a
focused and meaningful synthesis of the literature.

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Literature Search
A comprehensive and systematic literature search was conducted for this integrative
review using the Cumulative Index to Nursing and Allied Health Literature (CINAHL) database
and Google Scholar. CINAHL is a comprehensive academic database for literature related to
medicine, nursing and allied health disciplines for peer-reviewed evidence-based topics in
medicine, practice articles, nursing and related allied health disciplines (University of Northern
British Columbia [UNBC], n.d). It was selected as the most appropriate database to identify
literature that addresses the intersecting biopsychosocial dimensions relevant to this specific
research question, areas often underrepresented in more biomedically-oriented databases. Google
Scholar is a search engine that was included in the literature search strategy due to its broad,
multidisciplinary scope and ability to capture diverse forms of scholarship, including grey
literature, policy documents, theses, and reports (UNBC, n.d.). This is particularly important
when exploring complex, socially embedded health issues, such as Indigenous experiences with
diabetes, where critical perspectives, community-based research, and culturally-grounded
knowledge may be underrepresented. While these database searches were central to systematic
literature retrieval, hand searching was also employed to ensure the comprehensive identification
of relevant literature. This process included reviewing reference lists of key articles, searching
grey literature sources, and scanning Indigenous organizational reports that may not have been
indexed in research databases. This approach aligned with recommendations for integrative
reviews that seek to include diverse sources of knowledge (Toronto & Remington, 2020;
Whittemore & Knafl, 2005).

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Search Strategies
Initial search terms were grouped by key concepts: diabetes (e.g., “Diabetes Mellitus,
Type 2,” “Diabetic Patients”), Indigenous populations (e.g., “Aboriginal Canadians,”
“Indigenous Peoples,” “Native American People”), health care quality and accessibility (e.g.,
“Healthcare Disparities,” “Quality of Health Care”), self-management (e.g., “Self-Care,” “Blood
Glucose Self-Monitoring”), and primary care providers (e.g., “Nurse Practitioners,” “Family
Physicians”). To conduct this literature search, subject headings and keywords that corresponded
to the key concepts of the research question were combined in CINAHL using the Boolean
operators “AND” and “OR”. For a full list of the search terms and combinations that were used
in this integrative review, see Appendix 1.
Google Scholar was used to search for additional literature, including grey literature and
resources that were not indexed in the CINAHL database. A simplified search string ("type 2
diabetes AND self-management AND Indigenous patients") was used for this Google Scholar
search, yielding ten additional articles that had not been previously captured. The hand searching
process described process yielded two additional articles.
Inclusion criteria for the integrative review were the following: (a) empirical or relevant
grey literature; (b) focused on Indigenous adult patients (> 18 years) with T2DM as the
population of interest; (c) related to a DSM intervention; (d) published in English; and (e)
described patient experiences with PCPs and Western medicine. Exclusion criteria were: (a) a
different population of focus than Indigenous adults with T2DM (e.g. non-Indigenous children);
(b) a study population located outside of Canada; (b) non-T2DM specific; (c) did not capture the
lived experience of participants; and (d) publication before 1999 (Toronto & Remington, 2020).

14
Articles needed to be published in the English language due to limitations in translation
and interpretation resources, and English is the language spoken by the author of this integrative
review. The required date range (i.e. after 1999) was chosen to balance the inclusion of relevant
literature with the need to reflect more recent ethical standards and research methodologies.
While the initial search strategy had been designed to include articles that focused on Indigenous
populations both inside and outside Canada, a sufficient number of articles within the Canadian
context were retrieved, thus enabling a focus on the cultural, historical, and health system within
a single country. The experiences and perspectives of Indigenous peoples in Canada have been
shaped by a distinct history, specific healthcare policies, and unique sociopolitical conditions that
differ from those present in other countries. A focus on Canada-based literature only allows for a
more specific understanding of the barriers, facilitators, and culturally specific factors that
influence diabetes care and self-management among Indigenous populations in Canada.
Following the application of the inclusion and exclusion criteria, a total of 61 studies
were imported into Covidence for screening (Covidence, n.d.).
After the removal of five duplicate records, the abstracts of the remaining 56 articles
were reviewed by the author for relevance to the research question. Based on this screening, 37
articles were excluded. Of the 19 full-text articles assessed for eligibility, eight were excluded as
they did not meet the inclusion criteria. A total of 11 articles have been included in the final
integrative review (see Appendix 2 for the PRISMA diagram).
Data Evaluation
All of the studies included in this integrative review employed a qualitative methodology,
with one study (LaVallée & Howard, 2011) incorporating a mixed methods design. To critically
appraise the methodological and cultural rigour of the 11 included studies, two complementary

15
tools were used and applied to each study: the Critical Appraisal Skills Programme (CASP,
2024) tool for qualitative research and the Aboriginal and Torres Strait Islander Quality
Appraisal Tool (Harfield et al., 2018). The CASP tool provided a structured, rigorous, wellestablished framework for assessing the methodological quality of qualitative studies, focusing
on elements such as research design, data collection, ethical considerations, and the coherence of
findings. This tool ensured that each study included in this integrative review met foundational
standards of credibility, relevance, and transparency in qualitative inquiry (CASP, 2024). It was
selected for its ability to support a more nuanced and in-depth evaluation of methodological
quality in qualitative research (CASP, 2024).
The Aboriginal and Torres Strait Islander Quality Appraisal Tool (ATSI QAT) was
adapted for use in evaluating research involving First Nations, Inuit, and Métis peoples in
Canada. While originally developed for the Australian context, the tool's emphasis on Indigenous
governance, cultural protocols, relational accountability, and community benefit makes it highly
relevant for assessing the ethical and cultural dimensions often overlooked in conventional
appraisal frameworks (Harfield et al., 2020). This 14-item tool foregrounds Indigenous ways of
knowing and being, evaluating whether a particular study has been guided by Indigenous
priorities, has used appropriate cultural protocols, and has meaningfully engaged the Indigenous
community represented in the research study throughout the research process (Harfield et al.,
2020). Used together, these two tools enabled a robust and culturally respectful appraisal of the
literature by ensuring that both scientific and community-based ethical standards were being
considered.
In the case of the mixed methods study by LaVallée and Howard (2011), while
quantitative elements were included, the study was fundamentally qualitative. The use of

16
quantitative data was limited in scope and not intended to meet standards of quantitative rigour.
Therefore, a mixed methods analysis was not appropriate.
Data Analysis
Given the focus of this integrative review on the ways that PCPs could positively impact
the DSM experiences of Indigenous patients, a qualitative synthesis approach was employed to
analyze and interpret data across 10 diverse qualitative studies and one mixed methods study that
was primarily qualitative in design and intent. The aim was to identify recurring patterns,
themes, and conceptual insights related to diabetes care contexts. Following the principles of
integrative review methodology outlined by Whittemore and Knafl (2005), data from the
included studies were extracted, organized, and coded. Key findings related to the research
question were highlighted. Given the focus on Indigenous populations, particular attention was
paid to the cultural context of each study, and data were analyzed with an awareness of
historical, social, and political contexts. The final themes reflect recurring concepts and ideas
across studies (see Appendix 3).

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Chapter 4: Findings
The following is a synthesis of findings drawn from the literature to answer the question,
“How can PCPs positively impact adult patients who have Type 2 Diabetes Mellitus and who are
Indigenous?” Study Methodologies
Each of the 11 studies in this literature review employed a range of qualitative
methodologies to explore the lived experiences of Indigenous adults in Canada with T2DM.
While one study employed a mixed methods approach, combining qualitative and quantitative
methodologies, its approach was fundamentally qualitative (LaVallée & Howard, 2011).
Collectively, these studies emphasize the value of context, agency, storytelling and lived
experience in generating meaningful insights for the construction of a new narrative regarding
diabetes self-management for Indigenous communities (Table 1).
Table 1
Methodologies of Studies Included in Integrative Review
Study

Type

Barton et al. (2005)

Narrative inquiry

Barton (2008)

Narrative inquiry

Bruyère and Garro (2000)

Narrative inquiry

Dutton (2018)

Community-based participatory research

Gregory et al.(1999)

Naturalistic inquiry

Hernandez et al. (1999)

Grounded theory

Johnson et al. (2022)

Responsive interviewing

Kulhawy and Wibe (2018)

Qualitative descriptive analysis

LaVallée and Howard (2011)

Mixed methods

18
Pilon et al. (2019)

Grounded theory

Sherifali et al. (2012)

Qualitative descriptive analysis

Across the studies, sample sizes ranged from 4 (Barton, 2008) to 138 participants
(LaVallée & Howard, 2011), with most studies including a majority of women. Table 2 provides
details of the demographic breakdown in each study. Female participants outnumbered males in
nearly all studies (Barton et al., 2005; Barton, 2008; Bruyère & Garro, 2000; Dutton, 2018;
Hernandez et al., 1999; Kulhawy-Wibe et al., 2018; LaVallée & Howard, 2011; Pilon et al.,
2019; Sherifali et al., 2012), and one study included participants who identified as Two-Spirit
(LaVallée & Howard, 2011).
Table 2
Sample Size in Each Study
Study

Number of Participants

Gender

Barton et al. (2005)

N=8

w = 5, m = 3

Barton (2008)

N=4

w = 3, m = 1

Bruyère and Garro (2000)

N = 22

w = 12, m = 10

Dutton (2018)

N = 10

w = 7, m = 10

Gregory et al. (1999)

N = 20

w = 12, m = 8

Hernandez et al. (1999)

N = 10

w = 6, m = 4

Johnson et al. (2022)

N = 10

w = 4, m = 6

Kulhawy-Wibe et al. (2018)

N=5

derived from larger study
n = 78, w = 61.5% of
larger study participants,
m = 38.5%

LaVallée and Howard (2011)

N = 138

w = 106, m = 30, 2S = 2

19

Pilon et al. (2019)

N = 22

w = 13, m = 9

Sherifali et al. (2012)

N = 24*

w= 85.5%, m= 14.5%

Total
N = 273
Note. N=total sample size, w= female participants, m= male participants, 2S= 2 spirit
participants, *=average number of sharing circle participants per session (4 sessions total)
Participants across the studies ranged in age from 18 to 83 years, with most falling within
their 30s and 70s. One study focused specifically on Elders (Barton, 2008), although the authors
did not define a specific age range associated with that honourary title. Some studies reported an
age range (Gregory et al., 1999; Hernandez et al., 1999; Johnson et al., 2022) while others
reported only a mean age (Kulhawy-Wibe et al., 2018), and one study did not provide age data at
all (Barton et al., 2005). Notably, LaVallée and Howard (2011) included a large and diverse
sample of participants aged 18 to 79, with nearly half under 45, thereby offering insight across
multiple life stages.
Table 3
Ages of Participants in Each Study
Study

Age Range of Participants

Barton et al. (2005)

Unspecified

Barton (2008)

Elders (age range unspecified)

Bruyère and Garro (2000)

25 - 73 years old

Dutton (2018)

40 - 79 years old
Not stated = 2
40 - 49: n=1
50 - 59: n=3
70 - 79: n=4

Gregory et al. (1999)

28 - 68 years old

20
Hernandez et al. (1999)

32 - 75 years old

Johnson et al. (2022)

35 - 70 years old

Kulhawy-Wibe et al. (2018)

Mean age = 56.1 (age range unspecified)

LaVallée and Howard (2011)

18 - 79 years old
18 - 29: n=10
30 - 39: n=18
40 - 49: n=35
50 - 59: n=36
60 - 69: n=28
70 - 79: n=9

Pilon et al. (2019)

45 - 78 years old
Mean = 61 years old

Sherifali et al. (2012)
34 - 83 years old
Note. Age classes are provided as presented by the authors.
All 11 studies included in this integrative review explicitly involved participants
diagnosed with T2DM. One study (Johnson et al., 2022) indicated the inclusion of individuals
with T2DM in the article title but then provided no further details about time since diagnosis or
the treatment regimen used. Another study (Sherifali et al., 2012) included both individuals
living with T2DM and those living with, or caring for, someone with the condition. LaVallée and
Howard (2011) included a mixed sample of participants with T2DM, prediabetes, gestational
diabetes, and Type 1 diabetes. Reported time elapsed since participant diagnosis of T2DM varied
significantly, ranging from less than one year to over 32 years.
Treatment regimen details were inconsistently reported. In 8 of the 11 studies, the type of
diabetes treatment being used by each participant was not specified (Barton et al., 2005; Barton,
2008; Bruyère & Garro, 2000; Dutton, 2018; Johnson et al., 2022; Kulhawy-Wibe et al., 2018;
LaVallée & Howard, 2011; Pilon et al., 2019). Two studies described a range of treatment
approaches being utilized by participants, including diet modification, oral medications, insulin

21
therapy, and lifestyle management (Hernandez et al., 1999; Sherifali et al., 2012). One study
noted that its participants were receiving treatment for T2DM but did not specify the type
(Gregory et al., 1999).
Table 4
Diabetes Profile of Participants in Selected Studies
Study

Diabetes
Type

Time Since
Diagnosis

Additional
Criteria

Barton et al. (2005)

T2DM

5 to 20 years prior

Barton (2008)

T2DM

Unspecified

Bruyère and Garro (2000)

T2DM

Unspecified

Dutton (2018)

T2DM

1 to 20 years prior

Gregory et al. (1999)

T2DM

<1 to 32 years prior
Mean 10.4 years

Receiving
Treatment
(not specified)

Hernandez et al. (1999)

T2DM

2 to 32 years prior

Receiving
Treatment
Diet; n = 1
Oral; n = 4
Insulin; n = 5

Johnson et al. (2022)

T2DM

Unspecified

Kulhawy and Wibe (2018)

T2DM

Unspecified
Mean 12 years

LaVallée and Howard (2011)

T2DM
Pre-diabetes
Gestational diabetes
T1DM

<5 to 20+ years prior
<5 years = 49%
6-10 years = 25%
11-19 years = 12%
20+ years = 14%

Pilon et al. (2019)

T2DM

5 to 30 years prior
Mean 17.4 years

Sherifali et al. (2012)

T2DM

Unspecified

Receiving
Treatment
(not specified)
Lifestyle, Oral
and Injection

22
The studies included participants from several Indigenous communities across Canada.
The following Indigenous communities were represented within this integrative review: First
Nations (Barton et al., 2005; Barton, 2008; Bruyère & Garro, 2000; Hernandez et al., 1999;
Johnson et al., 2022; Kulhawy-Wibe et al., 2018; Pilon et al., 2019; Sherifali et al., 2012), Métis
(Dutton, 2018; LaVallée & Howard, 2011), and individuals with multiple Indigenous identities
(Dutton, 2018; Gregory et al., 1999; LaVallée & Howard, 2011). Participants resided in various
regions across Canada, including British Columbia (Barton et al., 2005; Barton, 2008), Manitoba
(Bruyère & Garro, 2000; Gregory et al., 1999), Ontario (Hernandez et al., 1999; Johnson et al.,
2022; Pilon et al., 2019; Sherifali et al., 2012), Alberta (Kulhawy-Wibe et al., 2018), and the
Northwest Territories (Dutton, 2018). Some studies focused on specific First Nations, such as the
Nuxalk (Barton et al., 2005; Barton, 2008), Opaskwayak Cree (Bruyère & Garro, 2000), Siksika
(Kulhawy-Wibe et al., 2018), and Dene (Dutton, 2018), while others involved urban Indigenous
populations or multiple communities. Participants included Elders, traditional medicine
practitioners, and healthcare administrators, reflecting a wide range of roles and cultural
perspectives within their communities.
Table 5
Demographic Profiles of Selected Studies
Study

Demographics

Geography

Barton et al. (2005)

Nuxalk Nation = 8

Bella Coola, BC

Barton (2008)

Nuxalk Nation = 4

Bella Coola, BC

Bruyère and Garro (2000)

Opaskwayak Cree Nation = 22

The Pas, MB

Dutton (2018)

Dene Métis = 7
Dene = 1
Cree = 2

Fort Smith, NWT

23
Gregory et al. (1999)

Urban Aboriginal = 20
Primarily Cree

Winnipeg, MB

Hernandez et al. (1999)

First Nation Community = 10
(details not provided)

Southwestern ON

Johnson et al. (2022)

First Nations = 10
(details not provided)
Involved in traditional medicine = 3
Elders = 5
Healthcare administrators = 2

Sioux Lookout,
ON

Kulhawy-Wibe et al. (2018)

Siksika Nation = 5

95 km East of
Calgary, AB

LaVallée and Howard (2011)

First Nations = 127
Métis = 9
Multiple Indigenous identities = 2

Toronto, ON

Pilon et al. (2019)

7 First Nations communities = 22
(details not provided)

Northern ON

Sherifali et al. (2012)

First Nations community members
Hamilton, ON
(details not provided)
Living with T2DM = 19
Caregiver of someone with T2DM = 5
Note. AB = Alberta, BC = British Columbia, MB = Manitoba, NWT = Northwest Territories,
ON = Ontario.
This integrative review found that diabetes is experienced not only as a physiological
illness but also as a profound psychological and relational disruption, shaped by
intergenerational trauma, colonial histories, and ongoing systemic inequities. Central to these
findings are themes of fatalism, denial, and a sense of inevitability. Yet, within this landscape of
fear and resignation, many participants also described a movement toward self-determination,
resilience, and cultural reclamation. The studies illuminate how challenges such as paternalism in
healthcare, ineffective communication, and knowledge gaps intersect with opportunities for
culturally-grounded diabetes care, which includes the integration of traditional ways of knowing
and being, and peer support. These findings frame diabetes not only as a medical condition but as

24
a reflection of broader social, historical, and spiritual realities that must be addressed through
both clinical and cultural approaches.
Diabetes: Psychological Impact
Fatalism
Several studies documented that participants perceived their development of T2DM as an
inevitable result of being Indigenous; authors referred to this belief system as ‘fatalistic’ because
these participants viewed important parts of their life journey as being out of their control
(Bruyère & Garro, 2000; Dutton, 2018; Gregory et al., 1999; Kulhawy-Wibe at al., 2018;
Johnson et al., 2022; Pilon et al., 2019). However, other studies in this integrative review
revealed that some participants held a more nuanced understanding of the trajectory of this
illness. While some individuals first expressed a sense of inevitability about their diagnosis, they
later came to understand diabetes as a condition shaped more by their own personal choices and
behaviours (Barton et al., 2005; Dutton, 2018; Johnson et al., 2022; LaVallée & Howard, 2011;
Pilon et al., 2019). This latter perspective highlighted a distinct shift over time from fatalism to
self-determination.
Inevitability. A recurring theme across multiple studies was the perception of T2DM as
an inevitable, uncontrollable, and ultimately fatal condition. Gregory et al. (1999) found that all
participants had close family members affected by diabetes and had witnessed its devastating
effects, reinforcing a belief that the illness was beyond the control of both individuals and
healthcare providers. This belief fostered an even more pervasive sense of fatalism and fear.
Similarly, Johnson et al. (2022) reported that participants not only expected to develop diabetes
but also anticipated that they would experience severe complications, such as amputations, as
part of their disease trajectory.

25
Among Nehinawin Cree participants, Bruyère and Garro (2000) observed a striking
linguistic distinction that underscored this sense of helplessness. Instead of using ponipimatsiw
(“he quits living”), which implies agency and intent, participants used nipw (“he dies”), a term
typically reserved for animals. This shift in language reflects a broader cultural narrative that
positions diabetes as something outside of human control. Kulhawy-Wibe et al. (2018) further
described the emotional toll of this perception, with several participants describing diabetes as a
“death sentence.” Such fatalistic beliefs were accompanied by distress, denial, and withdrawal
from care, complicating efforts to engage patients in self-management. Similarly, both Dutton
(2018) and Pilon et al. (2019) found that a sense of inevitability was a persistent undercurrent
throughout their interviews. Many participants viewed diabetes as genetically determined and
unavoidable—an outcome they had long anticipated. These findings reveal that for many
individuals who are Indigenous, diabetes is experienced not simply as a chronic illness but as a
looming and inescapable threat.
Self-Determination. Barton et al. (2005) documented, that prior to participating in the
study, one participant had experienced a shift in their understanding of T2DM—from viewing
the illness as an inevitable fate to recognizing the role of personal agency in its management.
This shift had been catalyzed by a peer living with diabetes who had encouraged the participant
to take responsibility for their health by adhering to medication and monitoring dietary choices.
As a result, the individual had relinquished their “sick person” identity and embraced a more
proactive and empowered approach to living with the disease. Dutton (2018) also challenged the
notion of fatalism and passive surrender to diabetes and emphasized that while the participants
experienced distress, they did not passively surrender to their diagnosis and were able to adapt
and embrace self-management in their own unique ways. A participant in LaVallée and

26
Howard’s (2011) study described T2DM as a teaching tool rather than a death sentence and
explained that diseases such as diabetes represented human beings out of balance with creation.
Where previously, Elders would have made sure that everyone ate and that food distribution was
balanced in accordance with the calendar of nature, this flow has been lost; however, all of the
knowledge needed to take care of diabetes was still there for Indigenous peoples to use.
Participants in Pilon et al.’s (2019) study challenged the notion that diabetes was the
result of fate, instead linking it to the disruption of traditional diet and lifestyle that had occurred
with colonization. While it was recognized that there was no returning to the way things were,
this was not viewed as a reason to accept the consequences of a poor diet and unhealthy lifestyle.
One participant remarked, “So to me it’s the way you live, just because your parents have
diabetes doesn’t mean you have to have diabetes…it’s the way we live, I would say, it’s up to
you to prevent it” (Pilon et al., 2019, p. 261). A participant in Johnson et al.’s (2022) study
expressed that Anishinaabe1 people were being guided by the negative and destructive things
they had been told, including that they had no control over diabetes. This was a sentiment that
deeply influenced their approach to the disease yet what they needed to understand, based on the
teachings of the ancestors, was a “sense of control and belief in oneself” (p.55)
Denial
Denial was identified as a significant barrier to diabetes self-management for participants. It was
also cited as a limiting factor in study recruitment.
Part of the Process. Denial was a common coping response in the aftermath of a diabetes
diagnosis. Dutton (2018), Hernandez et al. (1999) and Sherifali et al. (2012) found denial to be

1

Also spelled Anishnaabe, Anishinaabeg, and Anishnawbe, depending on regional and community preference.
Multiple spellings are used in this capstone to honour the diversity of languages, dialects, and identities within
Anishinaabe nations.

27
part of the process of coming to terms with diabetes. Participants in Hernandez et al.’s (1999)
study described denial as pushing the diagnosis out of their mind, avoiding taking medications
and the daily responsibility of diabetes until they reached a turning point and recognized that
diabetes was something they could no longer ignore (Hernandez et al., 1999). According to one
participant in Sherifali et al.’s (2012) study, denial, accompanied by anger, depression and fear,
was an initial barrier to reaching out for emotional support and assistance; however, in the words
of a second participant, once you became able to move through denial, you were “halfway there”
in terms of effective diabetes self-management (Sherifali et al., 2012, p. 179). Similarly, a
participant in Dutton’s (2018) study described their journey with diabetes as moving through
denial to acceptance and effective diabetes self-management (p. 74).
Effect on Study Recruitment. Dutton (2018) and LaVallée and Howard (2011) reported
denial of a diabetes diagnosis to be a factor that impeded the recruitment of participants into their
respective studies. Due to high rates of denial, depression, and distress associated with diabetes
diagnosis in Indigenous communities, the University of Toronto Health Sciences Research Ethics
Board (REB) recommended limiting the recruitment of participants for Dutton’s (2018) study to
voluntary only. Non-voluntary recruitment, which would have involved approaching participants
about their diabetes when they were not in a state of acceptance, was seen as compounding a
participant’s distress about their diagnosis. As a result, recruitment for that study occurred
exclusively through participants reaching out to the researcher themselves and requesting to
participate. While the author agreed with the decision ethically, it led to a smaller-than-ideal
sample size. LaVallée and Howard (2011) found that 34.2% of participants (n = 138) in their
study were categorized as being in denial, or having been in denial in the past, about having

28
diabetes. However, the authors also noted that, while this number was significant, the actual rates
of denial were likely underrepresented.
Challenges to Primary Care Diabetes Management
Paternalism in Healthcare
Paternalism is present when those in a position of authority restrict the freedom and rights
of those who are subordinate to them (Oxford English Dictionary, n.d.). Several studies reported
paternalism as a barrier to feeling safe in the healthcare system, and likened PCPs to authority
figures encountered in residential schools. Other studies emphasized PCP ignorance about power
dynamics and the impact they had on caring for Indigenous patients.
Power Imbalance
According to several authors, PCPs embodied an approach to diabetes care that was
reminiscent of authority figures in residential schools (Dutton, 2018; Pilon et al., 2019),
characterized by control and unilateral decision-making (Barton, 2008). Participants felt judged
and perceived as dirty and non-compliant by their provider and feared what would happen if they
did not do what they were told (Dutton, 2018). One storyteller described being berated for
bringing up the use of traditional medicines for diabetes and was told “take this and that’s it” in
reference to Western medicine, and “if you mix anything with it, that’s your problem and not
mine” (Pilon et al., 2019, p. 262). Another participant in the same study described that diabetes
care options were either very limited or had been imposed upon them, while traditional
medicines were forbidden.
Participants in Gregory et al.’s (1999) study described both distressing and positive
interactions with healthcare providers. The negative experiences included being berated and
threatened that death would occur if the rules of diabetes care were not followed. Positive

29
experiences consisted of being offered advice and information with permission to accept or reject
it.
Lack of Contextual Understanding
A lack of awareness and appreciation among healthcare providers of power imbalances in
the provider/patient relationship created a significant barrier to effective diabetes care for
Indigenous patients (Dutton, 2018; Johnson et al., 2022; Kulhawy-Wibe et al., 2018). In addition
to this disconnect, Indigenous patients felt that their lived experiences, particularly the lasting
trauma of residential schools, were misunderstood or dismissed by those providing care (Pilon et
al., 2019). Together, these dynamics contributed to a broader sense of mistrust and disconnection
regarding clinical encounters.
Biomedical Diabetes Paradigm
According to participants in 5 of the 11 studies, PCPs viewed diabetes as being in
individual bodies, as an exclusively physiologic phenomenon, with focus placed on blood
glucose levels, medications monitoring, diet, and weight loss, whereas participants viewed
diabetes through the lens of collective experience and historical processes (Barton, 2008; Dutton,
2018; Pilon et al., 2019; Bruyère & Garro, 2000). LaVallée and Howard (2011) found that 42.3%
of participants completely or very much agreed that PCPs were too concerned with statistics and
prescribing medications.
Non-Compliance
A recurring theme across the reviewed literature was the mischaracterization of
Indigenous peoples as “non-compliant” within the context of diabetes care (Dutton, 2018;
Gregory et al., 1999; Kulhawy-Wibe et al., 2018; Pilon et al., 2019). Participants described that
this label was often applied when they did not adhere to prescribed regimens—such as

30
medication use, dietary restrictions, or weight loss—yet these instances of non-adherence
occurred within coercive and prescriptive clinical encounters that left little room for dialogue or
shared decision-making (Dutton, 2018; Pilon et al., 2019. The label of non-compliance was
experienced not simply as a clinical judgment but as a continuation of colonial stereotypes rooted
in the residential school era—stereotypes that painted Indigenous peoples as disobedient, dirty,
or uneducated (Dutton, 2018). This stigmatizing perception discouraged many from seeking help
or engaging in self-management practices, as it reinforced feelings of shame, powerlessness, and
marginalization within the healthcare system (Kulhawy-Wibe et al., 2018).
Diabetes Education Delivery
Several authors found that the delivery of diabetes education by PCPs was either
ineffective or non-existent, and many participants reported that their need for information to
empower themselves to manage their own illness remained unmet. Others reported that when
diabetes education was high quality, it helped them move from a place of ignorance and fear to
feeling empowered to manage their diabetes.
In four of the 11 studies, ineffective communication emerged as a central barrier to
diabetes education for Indigenous patients. Barton et al. (2005) and Gregory et al. (1999) both
reported that participants experienced healthcare encounters as rushed, with limited explanation
and little time for teaching and learning, which created barriers to learning about and
understanding diabetes. One participant reported that healthcare providers often did not take the
time to explain medical information thoroughly and this participant felt they were being
perceived as unwilling to listen (Gregory et al., 1999). Hernandez et al. (1999) and Dutton
(2018) noted persistent confusion and misunderstandings amongst participants despite repeated
interactions with their provider.

31
In contrast, when providers took the time to explain the condition and treatment options
in detail (Dutton, 2018), participants reported feeling less stress, reduced anxiety, and improved
capacity for self-management. One participant valued the approach of their provider, where they
felt able to maintain transparency about any skepticism and a decision to refuse pharmaceutical
treatments, yet still access provider support (Dutton, 2018).
Knowledge gaps
Knowledge gaps about the cause of diabetes, the disease process itself, and how to
manage it were widespread amongst study participants. Gregory et al. (1999) found that 11 of
their 20 study participants could not explain the cause of diabetes and 14 of their 20 study
participants were unable to explain what diabetes was. Hernandez et al. (1999) and Barton et al.
(2005) found a lack of knowledge and tentativeness of understanding; individuals were unable to
correlate symptoms of feeling unwell, a lack of energy, and poor eyesight to long-term diabetes
complications such as heart and kidney damage (Barton et al., 2005). One participant in the
Hernandez et al. (1999) study had been on insulin for 6 years yet monitored their blood sugars
and took insulin in a way that was incongruent with effective and safe diabetes management.
Participants in Dutton’s (2018) study described how, without the health literacy to
understand diabetes, individuals fell through the cracks. One participant reported that several
close friends who admitted not understanding their illness, and who simply took whatever pills
the PCP prescribed, had died because they did not know how to navigate the healthcare system
or ask for things that they needed. Kulhawy-Wibe et al. (2018) described diabetes knowledge
gaps as a major source of stress for individuals. While there was a desire to do something,
participants were paralyzed by not knowing what to do and not feeling empowered to act
(Kulhawy-Wibe et al., 2018).

32
Facilitators to Diabetes Self-Management
Traditional Healing Practices
Traditional medicines and knowledge played a significant role in healing and care of
diabetes for Indigenous peoples and was viewed as a vital component that should have been
integrated into their treatment, providing cultural relevance, holistic support, empowerment and a
way to address the historical and social context influencing health (Johnson et al., 2022;
LaVallée & Howard, 2011; Pilon et al., 2019; Sherifali et al., 2012). Traditional healing practices
to address diabetes included traditional foods and medicinal plants (Barton et al., 2005; Bruyère
& Garro, 2000; Dutton, 2018; LaVallée & Howard, 2011), and ceremonial practices such as
healing circles, smudging, and sweat lodges, all used to feel calmer and manage diabetes (Barton
et al., 2005; Johnson et al., 2022; LaVallée & Howard, 2011). Elders were sought to provide
healing, understanding, and advice about living with diabetes (Gregory et al., 1999; Johnson et
al., 2022). Healing practices encompassed a wide array of beliefs, ceremonies, and relational
systems rooted in worldviews where wellness arises from balance—physical, emotional,
spiritual, and communal. Johnson et al. (2022) highlighted the importance of the ceremonies that
were described by Anishinaabe participants in Sioux Lookout, Ontario, such as smudging and
sweat lodges, which are guided by spiritual protocols and involve sacred medicines like sage and
sweetgrass. These practices serve to symbolically and spiritually cleanse negative energies and
restore kindness and relational harmony, reinforcing motivation for self-care and holistic wellbeing.
Traditional medicines, referred to as ininiwimuskiki in the Nehinawin Cree language, are
vital expressions of Indigenous healing knowledge. Bruyère and Garro (2000) explained that, for
many Indigenous people, healing is considered to be inseparable from spirituality and the

33
sacredness of all life. Diabetes, in this context, is not merely a physiological condition but a
disruption in spiritual and communal balance, requiring responses that are holistic, culturally
grounded, and spiritually engaged. Cultural activities such as berry picking and fishing are also
recognized as meaningful components of wellness. Barton et al. (2005) and Barton (2008a)
describe how these land-based practices are used to facilitate physical activity but also to
strengthen cultural identity and self-determination.
There were significant challenges associated with using traditional medicine due to
knowledge being lost (Bruyère & Garro, 2000), lack of access to those medicines, particularly in
urban settings (Gregory et al., 1999; LaVallée & Howard, 2011), lack of experience in seeking
help from traditional healers or Elders for diabetes (LaVallée & Howard, 2011), and Western
institutions undermining traditional medicines and sacred knowledge of Indigenous peoples
(Johnson et al, 2022).
Integrate Culture with Biomedicine
Several authors found that when biomedical concepts could align with existing cultural
frameworks, diabetes self-management was successful and led to wellness amongst study
participants. Through the analysis of study data translated from Nehinawin (Cree language),
Bruyère and Garro (2000) gained a nuanced understanding of the ways in which Western
biomedical knowledge of T2DM could be integrated into existing cultural frameworks and
patterns of Nehinaw thought. For example, the biomedical understanding that exercise helps to
metabolize sugar so that it does not become “stuck” somewhere in the body and cause damage is
congruent with the Nehinaw framework that “ancestors worked hard,” giving it relevance.
Incorporating traditional foods and boiling them rather than frying was strongly accepted, as this
was what the ancestors did.

34
Barton et al. (2005) found that outdoor activities such as fishing or berry picking for
exercise led to significant amounts of weight loss for patients. While Barton (2008a) found that
participants viewed medical care as the most appropriate treatment for diabetes, they also used
traditional medicinal, spiritual, and ceremonial purification practices. While aches, pains, fatigue
and feeling unwell were treated with Western medicines, they were also treated with traditional
medicine in the form of traditional foods, spiritual and ceremonial practices, and healing circles.
Combining these modalities led to finding harmony between being diabetic, being Aboriginal,
and being well.
Peer Support
Engaging with other individuals living with diabetes through healing or sharing circles
was consistently identified as a meaningful and supportive practice. Six of the 11 studies
emphasized that talking circles function as culturally resonant spaces that promote diabetes
management by facilitating health education, emotional connection, lifestyle change, and
community engagement (Barton et al., 2005; Gregory et al., 1999; Harnandez et al., 1999;
Johnson et al., 2022; LaVallée & Howard, 2011; Sherifali et al., 2012). Johnson et al. (2022)
highlighted that receiving diabetes support within a culturally safe environment helped
participants restore their sense of balance and control, reconnect with ancestral understandings of
health, and foster kindness and positive energy. Similarly, LaVallée and Howard (2011) reported
that 75% of study participants found sharing circles to be “completely” or “very much” helpful.
These gatherings combined ceremony and cultural teachings with diabetes education, which
many described as transformative. Participants reported feelings of empowerment, hope, and
support, along with a reduction in fear and frustration, and gained practical strategies for selfmanagement.

35
Barton et al. (2005) found that healing circles provided a space where individuals could
seek the wisdom and experience of others living with diabetes. In Sherifali et al.’s (2012) study,
a participant who attended four culturally grounded sharing circles featuring smudging, prayer,
traditional teachings, and social connection reflected that such gatherings were not only
supportive but could serve as a foundation for community-based health initiatives involving
healthy eating and physical activity. Likewise, participants in Gregory et al.’s (1999) study
valued learning from other Indigenous people managing diabetes, while Hernandez et al. (1999)
noted that peer learning and role modelling reflected a traditional First Nations approach to
knowledge sharing and community care.

36
Chapter 5: Discussion
The studies included in this integrative review focused on three main themes: the
psychological impact of diabetes, challenges of primary care diabetes management, and
facilitators to diabetes self-management. This chapter will discuss the significance of the
findings in the context of primary care provision and discuss ways to include them in practice,
education, research, and policy.
Implications for Practice: Addressing Colonial Legacies in Indigenous Diabetes Care
While colonization is often viewed as a historical event, PCPs must recognize that its
structures and impacts remain deeply embedded in today’s healthcare system. These ongoing
colonial influences continue to shape the experiences of Indigenous peoples, including their
access to and engagement with diabetes care. By acknowledging both the historical and presentday effects of colonization, PCPs can better understand the systemic barriers Indigenous patients
face. This awareness can guide providers to use their sphere of influence to support more
effective diabetes self-management. By using a more nuanced approach to understanding patient
history, a commitment to relational practice, and shifting perspective to reimagine what
meaningful diabetes care can look like, PCPs can collaborate with Indigenous patients to cocreate pathways to wellness, ones that promote health rather than manage decline.
Recognizing the Enduring Impact of History
Recognizing the enduring impact of colonization is essential to understanding current
challenges in diabetes care for Indigenous patients. Findings revealed that many PCPs lacked
awareness of how profoundly colonial histories continue to shape Indigenous experiences of
health care (Johnson et al., 202). This lack of historical consciousness often manifested in
clinical interactions that unknowingly reproduced colonial dynamics. Providers frequently

37
adopted prescriptive and authoritative communication styles, presenting diabetes management as
a rigid set of rules rather than a collaborative process. Medication regimens were imposed with
minimal explanation, and expectations were enforced with implicit or explicit threats, leaving
patients feeling silenced, disrespected, and powerless (Barton, 2008; Dutton, 2018; Gregory et
al., 1999; Pilon et al., 2019). These encounters contributed to a deep sense of mistrust and
emotional withdrawal.
Even when providers acted with good intentions, the lingering legacy of colonialism
created barriers to open dialogue and trust. Many Indigenous patients bring to each clinical
encounter an acute awareness of the historical power imbalances between themselves and
representatives of Western institutions, including health care professionals. These power
differentials, rooted in histories of cultural suppression, forced assimilation, and systemic
exclusion, continue to shape perceptions of safety and engagement in care (Crowshoe et al.,
2019). Without a deliberate effort to acknowledge and address these dynamics, therapeutic
relationships remain compromised, hindering effective, long-term diabetes management.
Towle et al. (2006) emphasize the importance of expanding the concept of “patient
history” beyond biomedical metrics. In the context of diabetes, this means a departure from
exclusive focus on measures such as HgA1c levels and medication adherence. Recognizing
patients’ personal histories within the broader context of collective historical trauma offers a
more holistic understanding of their diabetes health behaviours. Though rarely discussed openly
in clinical spaces, these historical experiences continue to inform how Indigenous patients
interpret provider behaviour and engage with medical advice (Kirmayer et al., 2003).
Building relational trust requires moving beyond disease-focused frameworks for
diabetes and instead viewing the patient as a whole person. This involves understanding patients’

38
stories not only in the context of illness but within the continuity of their lived and inherited
experiences (Crowshoe et al., 2019). When providers make the effort to listen deeply and engage
authentically, patients are more likely to feel seen, respected, and supported (Towle et al., 2006).
In turn, this relational approach can begin to counteract the effects of historical trauma, creating
space for healing, empowerment, and meaningful collaboration in diabetes care (Crowshoe et al.,
2019; Towle et al., 2006). Exploring patients’ perspectives on previous adverse experiences and
centring their priorities within the plan of diabetes care fosters an effective health care
relationship where a space to discuss issues such as denial and fear can exist.
Relationship as Medicine
Several studies have shown that relational approaches grounded in humility, empathy,
and respect can rebuild trust and foster meaningful engagement in diabetes care. When PCPs
took a genuine interest in their patients' lives and approached with humility rather than a
prescriptive or top-down approach, relationships became therapeutic (Jacklin et al., 2017). One
participant, for example, felt honoured when a provider admitted their limited understanding of
diabetes and asked to be taught (Jacklin et al., 2017). Relational gestures—such as calling
patients at home or involving family members in diabetes care planning—were also seen as
culturally resonant expressions of empathy. These practices were closely linked to increased
patient trust and improved perceptions of the healthcare system (Jacklin et al., 2017). Taking less
professional distance and objectivity to share aspects about oneself to enact a more reciprocal
relationship with patients (Crowshoe et al., 2019). Relationships develop over long periods of
time and add depth to the PCP-patient interaction (Gibson et al., 2015). By understanding the
PCP–patient relationship as a form of medicine, as described by Walker and Behn-Smith (2020),
healthcare encounters can shift from being transactional to more meaningful and healing. This

39
relationality is not a soft add-on to biomedical care—it is the foundation upon which sustainable
diabetes self-management is built. It is an approach to care that may be particularly valuable in
addressing the psychological impacts of diabetes, especially among populations affected by
systemic and historical trauma.
Diabetes Education
Rushed clinical encounters that allowed no time for patients to ask questions or absorb
information from their PCPs were identified as a significant barrier to effective diabetes
education (Barton et al., 2005; Gregory et al., 1999). This lack of time and engagement
contributed to ongoing confusion and psychological distress, as patients remained uncertain
about the etiology of diabetes and the strategies required for its effective management (Dutton,
2018; Hernandez et al., 1999; Kulhawy-Wibe et al., 2018). Towle et al. (2006) emphasize that
time is an essential enabler of trust. Without adequate time, appointments feel rushed or
transactional, leaving Indigenous patients to feel dismissed or unseen, reinforcing feelings of
marginalization. Approaching diabetes education at a slower pace, in a more relational way,
creates space for patients to process information, integrate it into their lived experience, and ask
questions to confirm their understanding (Crowshoe et al., 2018b; Gibson et al., 2015). In the
context of diabetes education, devoting time to patient relationships, rather than focusing
exclusively on biometric targets, is recommended by the Diabetes Canada Clinical Practice
Guidelines Expert Committee. The committee asserts that poor success in diabetes selfmanagement reflects health service limitations, where care is approached in a way that is socially
and culturally irrelevant to the context of Indigenous peoples (Crowshoe et al., 2018b).

40
Non-Compliance: Indigenous Resistance in Diabetes Care
The findings from the selected studies challenge the dominant narrative of noncompliance as a patient deficit and instead call for a re-evaluation of how historical trauma
shapes health behaviours. Behaviours often labelled as non-compliance, such as missed
appointments or selective engagement, can be viewed as feedback, highlighting how the system
itself continues to fall short in providing culturally responsive, equitable care. These findings
underscore the enduring influence of colonial remnants in diabetes care and their profound
implications for clinical practice. The persistent framing of Indigenous patients as non-compliant
reflects a colonial logic that reduces complex health behaviours to individual failure,
disregarding the structural and historical forces that shape them (Crowshoe et al., 2018; Dutton,
2018). Rather than interpreting non-adherence as a lack of responsibility or motivation, it should
be understood as a protective or necessary response to a healthcare system that continues to
marginalize Indigenous voices and exclude Indigenous knowledge systems.
Clinicians are called to develop critical consciousness—a process of sustained selfreflection that involves recognizing how personal biases, institutional norms, and the legacy of
colonialism may influence interactions with patients (Kumagai & Lypson, 2009). This requires
shifting the clinical gaze away from reductive notions of “non-compliance” and toward an
understanding of how structural factors such as racism, poverty, intergenerational trauma, and
the ongoing impacts of colonial control inform health behaviours and access to care. By
acknowledging and addressing these broader determinants, providers can work to redistribute
power within the clinical relationship, which in turn fosters a culturally safe, relational approach
to diabetes management. This shift not only enhances trust and engagement but is essential to
advancing equity in diabetes care. Providers must frame diabetes care as a space for

41
empowerment rather than compliance. Such actions are essential to challenging the colonial
narratives that render diabetes as inevitable and Indigenous patients as passive recipients of care
(Crowshoe et al., 2018; Jacklin et al., 2017).
Integrating Traditional Medicine
Findings from the reviewed studies underscore the importance of integrating Indigenous
cultural frameworks with biomedical approaches as key facilitators of effective diabetes selfmanagement (Barton et al., 2005; Barton, 2008; Bruyère & Garro, 2000; Dutton, 2018; Gregory
et al., 1999; Hernandez et al., 1999; Johnson et al., 2022; LaVallée & Howard, 2011; Pilon et al.,
2019; Sherifali et al., 2012). A notable example of such integration is the Aboriginal Diabetes
Wellness Program (ADWP), which has been operated by the Capital Health Regional Authority
in Edmonton, Alberta, since 1995 (Toth et al., 2005). The program was established through
collaborative partnerships involving Indigenous communities, governmental bodies, academic
researchers, and local healthcare providers, with guidance from Indigenous Elders. The ADWP
combines conventional biomedical care with traditional Indigenous healing practices, guided by
principles of cultural respect and inclusion. Its design reflects a deliberate effort to contextualize
biomedical information within culturally relevant frameworks, thereby enhancing accessibility,
engagement, and effectiveness for Indigenous participants. For instance, nutrition and lifestyle
counselling are adapted to include traditional foods such as wild game, Bannock, roots, and
berries, alongside culturally meaningful activities like hunting and dancing. Additionally, the
program is tailored to address the unique social and geographic contexts of Indigenous peoples
living in both rural and urban settings, acknowledging and responding to the diverse realities that
shape their health experience (Toth et al., 2005).

42
The integration of Indigenous knowledge systems with biomedical models in diabetes
care, such as ADWP, has important implications for clinical practice. Clinicians should prioritize
collaborative partnerships with Indigenous communities in program development and service
delivery, ensuring that interventions are co-designed and locally relevant. Incorporating
Indigenous ways of knowing into clinical encounters not only improves health outcomes but also
supports broader efforts toward reconciliation and the decolonization of health care systems.
Talking Circles
In the reviewed studies, connecting with other individuals living with diabetes was
identified as a helpful strategy (Barton et al., 2005; Gregory et al., 1999; Harnandez et al., 1999;
Johnson et al., 2022; LaVallée & Howard, 2011; Sherifali et al., 2012). Talking circles represent
a culturally grounded and effective approach to diabetes management among Indigenous
patients. They have been found to be an effective platform for knowledge sharing, emotional
support, and community-driven lifestyle change, while also fostering trust and connection.
Integrating talking circles into diabetes care may enhance patient engagement and contribute to
improved health outcomes.
In studies conducted by Struthers et al. (2003) and Toth et al. (2005) talking circles were
found to be an effective form of support, providing a culturally safe and effective approach to
diabetes care for Indigenous communities through sharing knowledge and experiences by
participants, providing a space for emotional support, and serving as a catalyst for participants to
make meaningful lifestyle changes, and community empowerment (Struthers et al., 2003; Toth et
al., 2005). Talking circles were found to provide a culturally grounded space where individuals
receive clear, relevant, and up-to-date information about type 2 diabetes, often filling a gap left
by previous encounters with health services (Struthers et al., 2003). Through storytelling and

43
peer dialogue, participants could build their understanding of diabetes prevention, management,
and the physical impacts of the disease in ways that are both accessible and meaningful
(Struthers et al., 2003; Toth et al., 2005).
Beyond knowledge transmission, talking circles function as a source of emotional and
psychological support (Struthers et al., 2003; Toth et al., 2005). They offer a safe environment
for participants to express grief, fear, anger, and shame related to their diagnosis, emotions that
are often silenced in clinical settings. This open sharing fosters a sense of trust, belonging, and
mutual support, contributing to participants’ emotional well-being and a sense of not being alone
in their experiences (Struthers et al., 2003; Toth et al., 2005).
Importantly, talking circles have been shown to catalyze meaningful lifestyle changes.
Participants report improvements in self-management behaviours, such as incorporating
traditional and healthier foods, increasing physical activity, and becoming more conscious of
nutrition and stress management. Some have reported weight loss, improved blood sugar control,
and enhanced overall well-being because of what they learned and experienced in the circles
(Struthers et al., 2003; Toth et al., 2005). These outcomes demonstrate the potential of talking
circles to support diabetes self-management in culturally relevant ways.
Furthermore, the collective nature of talking circles promotes community empowerment
by facilitating shared understanding, collaborative problem-solving, and culturally aligned
decision-making. Rooted in traditional Indigenous knowledge systems, the circles support a
holistic view of health that integrates the physical, emotional, spiritual, and social dimensions of
wellness (Struthers et al., 2003; Toth et al., 2005). They may also incorporate traditional healing
practices, such as prayer or consultation with Elders and medicine people, thereby restoring
balance and cultural continuity in care (Struthers et al., 2003; Toth et al., 2005).

44
Talking circles represent a powerful and practical strategy to support Indigenous patients
who are living with diabetes. They illustrate how an Indigenous led, culturally based strategy for
diabetes self-management can improve individual diabetes outcomes at the individual and
community levels. They represent a way to give agency to Indigenous-led healing modalities…
decolonizing approach to diabetes self-management and are a paradigm for change that PCPs
should be aware of. Primary care providers can support diabetes self-management for patients
who are Indigenous by expanding their understanding to recognize that Indigenous-led
approaches as effective and meaningful. Referring patients to talking circles for diabetes selfmanagement or supporting the concept in collaboration with Indigenous communities with
culture and providing a needed antidote to colonization trauma-informed care, and reconciliation.
As such, they represent a powerful, practical strategy for supporting Indigenous patients living
with or at risk of diabetes.
Implications for Education
Experiential Learning
Towle et al. (2006) found that experiential learning, such as listening directly to patients’
lived experiences, needs to be taught as a core skill in the context of biomedical education. This
type of learning helps future PCPs build trust and improve communication with Indigenous
patients, especially when care is shaped by the impacts of historical trauma like residential
schools. The authors emphasized that increasing lectures on colonial history alone is not enough;
instead, teaching relational, experience-based approaches is essential for providing culturally
safe care, particularly in managing chronic conditions like diabetes (Towle et al., 2006).
Educational outcomes related to diabetes management for future PCPs must be oriented
to valuing outcomes in diabetes care that extend beyond biometric indicators such as blood

45
glucose levels or HgA1c. Relational outcomes—such as trust, connection, and mutual
understanding—are critical, particularly when working with Indigenous patients, for whom
historical and cultural contexts deeply influence engagement with care. The Southcentral
Foundation’s (SCF) Nuka System of Care offers a transformative model of chronic disease
management in which relationship is regarded as the primary outcome of care (Southcentral
Foundation [SCF], n.d.). In this model, patients are referred to as “customer-owners,”
underscoring shared responsibility, mutual respect, and self-determination. Unlike conventional
models that emphasize measurable clinical targets, the Nuka model deliberately de-centers
biometric outcomes in favour of building and sustaining relationships as the foundation for longterm health and healing in diabetes care (Gottlieb et al., 2008).
This model has important implications for how PCPs are trained with respect to
providing diabetes care. Over 90% of SCF customer-owners reported that having a strong
relationship with their provider improves their health, and those with stronger provider
relationships experience better outcomes. SCF has surpassed the 90th percentile in Healthcare
Effectiveness Data and Information Set (HEDIS) measures for diabetes care, including annual
testing and HgA1c control as well as decreased emergency department use and increased
satisfaction with care (Gottlieb et al., 2008; SCF, n.d.). These findings emphasize the need to
reframe education for PCPs to centre on relational competence as an essential component of
effective healthcare delivery.
Traditional Medicine and Decolonizing Diabetes in Primary Care
In the educational milieu, PCPs must be taught to value and honour traditional medicines,
as a gesture of reconnection to traditional ways. Learning about Indigenous traditional medicines
and healing practices can help future PCPs understand their value and legitimacy as complete

46
systems of care, and use their knowledge to be a force of re-connection to culture (Corntassel,
2012) rather than continue to approach diabetes care in a colonial way. By valuing and
integrating traditional knowledge in their approach, PCPs can offer a more relevant, meaningful
and effective approach to diabetes care (Obomsawin, 2007). Teaching future PCPs about
traditional medicines is therefore not optional or ancillary—it is a matter of ethical practice,
reconciliation, and health equity. It fosters a decolonizing approach that moves beyond the
dominance of Western biomedical frameworks and supports Indigenous self-determination in
health care.
Additionally, this learning ensures that clinical practice aligns with broader ethical
obligations of the healthcare system. Beyond individual clinical interactions, education for PCPs
must prepare them to uphold commitments made in the Truth and Reconciliation Commission’s
(TRC, 2015) Calls to Action, particularly Call to Action #22, which urges all those who work in
healthcare to recognize the value of Indigenous healing practices and use them in treatment when
requested by Indigenous patients.
Implications for Research
Considerations for Ethical and Culturally Appropriate Research with Indigenous Peoples
The included studies reflect a broad range of ethical and culturally appropriate fulfillment of
research standards with Indigenous Peoples. In the Canadian context, frameworks such as the
Ownership, Control, Access, and Possession (OCAP®) principles and Chapter 9 of the TriCouncil Policy Statement: Ethical Conduct for Research Involving Humans (TCPS 2) are
foundational (First Nations Information Governance Centre [FNIGC], 2025; Canadian Institutes
of Health Research [CIHR], Natural Sciences and Engineering Research Council of Canada
[NSERC], and Social Sciences and Humanities Research Council of Canada [SSHRC], 2018).

47
These guidelines recognize and respond to the historical and ongoing harms caused by
exploitative and extractive research practices. They each provide a distinct yet complementary
framework that emphasizes respect for Indigenous governance, community engagement, and the
recognition of Indigenous knowledge systems. Complementing these frameworks, CommunityBased Participatory Research (CBPR) has emerged as a valuable methodological approach that
aligns closely with them. CBPR promotes collaboration, shared decision-making, and mutual
benefit by involving communities as active partners in all stages of the research process
(Castleden et al., 2012; Jagosh et al., 2012). Together, these frameworks and approaches
contribute to ethical research practices that are grounded in relational accountability, cultural
safety, and Indigenous self-determination (see Appendix 3).
OCAP®
The OCAP® principles constitute a community-driven framework and standard
developed by the FNIGC to establish a First Nations-led standard for ethical research (FNIGC,
2025). Specifically designed for First Nations communities, organizations, and researchers,
OCAP® represents the ideal benchmark for research that respects Indigenous data sovereignty
and self-determination (FNIGC, 2025; Konczi & Bill, 2024; LaVallée & Howard, 2011).
Although rooted in a First Nations context, the framework is increasingly recognized as relevant
and applicable to research involving Inuit, Métis, and other Indigenous Peoples across Canada
(Schnarch, 2004; Wright et al., 2023).
OCAP® addresses the long-standing power imbalances in research, in which Indigenous
Peoples are often over-researched, misrepresented, and subjected to harmful or culturally
inappropriate methodologies. In many cases, sensitive research data was released without
consent, leading to further stigma and mistrust (Dutton, 2018). The OCAP® principles respond

48
to this legacy by affirming that Indigenous communities own the data collected from them and
hold proprietary rights over how it is used and stored (Konczi & Bill, 2024; LaVallée & Howard,
2011). Communities have the right to control all aspects of the research process, from
determining the purpose and design of studies to selecting researchers and governing data
collection, analysis, and dissemination (FNIGC, 2025; Konczi & Bill, 2024; LaVallée &
Howard, 2011). OCAP® ensures that communities have access to data and findings in ways that
are meaningful and accessible, while the principle of possession emphasizes that data should be
physically housed within the community or an Indigenous organization of their choosing
(FNIGC, 2025; Konczi & Bill, 2024). In the context of diabetes self-management research,
applying OCAP® offers a pathway to restore trust, center Indigenous leadership, and ensure that
research is conducted in respectful, reciprocal, and culturally-grounded ways.
Highest Ethical and Culturally Appropriate Standards
Two studies included in this review (Dutton, 2018; LaVallée & Howard, 2011) describe
explicit adherence to OCAP® guidelines. Dutton (2018) reports that the study’s design,
methodology, and researcher conduct were guided by OCAP® principles, with a consistent
emphasis on community control and respect for local autonomy throughout the research process.
The study was proposed to the leadership of three local Indigenous governments in Fort Smith,
Northwest Territories – two First Nations and one Métis Council – who approved to proceed
without objections in keeping with establishing some degree of community control. The research
agreement with study participants clearly outlined limitations on data control, noting that once
stories were shared, they became part of the public domain and could not be withdrawn, even if
the participant later chose to leave the study. Anonymized stories were to be retained in the
community for up to seven years to support future community-led research, after which they

49
would be destroyed. The study did not provide specific information about long-term community
ownership or data governance.
LaVallée and Howard (2011) demonstrated strong adherence to OCAP® principles by
centring Anishnawbe Health Toronto (AHT) as the lead authority in the research process. AHT
exercised full ownership and control over the project, including researcher selection,
administration, and oversight of how data were used and shared. A formal agreement was created
to recognize AHT as the sole owner of the data and grant them final review and approval of
project documents. Access and possession were also upheld through active community
involvement in data interpretation and dissemination, with findings shared directly with
participants, the Governing Circle, and key community members, ensuring transparency,
accountability, and cultural relevance throughout the research (Dutton, 2018).
The absence of these principles in much of the literature underscores ongoing issues of
data extraction and limited Indigenous oversight in diabetes-related research. This gap highlights
the need for future scholarship to uphold Indigenous data sovereignty and prioritize communityled methodologies that are grounded in respect, accountability, and relational ethics (FNIGC,
2020).
Tri-Council Policy Statement
Chapter 9 of the Tri-Council Policy Statement: Ethical Conduct for Research Involving
Humans (TCPS 2) provides specific guidance for conducting research involving First Nations,
Inuit, and Métis peoples in Canada. It emphasizes the importance of community engagement,
respect for Indigenous governance, and the inclusion of Indigenous perspectives throughout the
research process. Furthermore, it highlights the ethical imperative of mutual respect, culturally
relevant practices, and the recognition of Indigenous knowledge systems. Researchers are urged

50
to ensure that their work benefits the community, supports capacity building, and respects
Indigenous rights to data ownership and control – all principles that are aligned with OCAP®.
Rather than approaching Indigenous peoples as subjects of research, TCPS 2 advocates for
partnership-based methodologies that reflect Indigenous self-determination and uphold ethical
integrity (CIHR, NSERC, & SSHRC, 2022).
Three studies included in this review demonstrated strong adherence to the relevant
principles of TCPS 2 (Dutton, 2018; LaVallée & Howard, 2011; Pilon et al., 2019). Dutton
(2018) outlines explicitly how the research protocol for that study was approved by the
University of Toronto Health Sciences REB and that a research license had been obtained from
the Northwest Territories government. She extensively discussed her positionality as a nonIndigenous researcher and described how she maintained transparency and reflexivity while
working with an Indigenous community, addressing power imbalances, and engaging
consistently with community advisors.
Member Checks
Member checks, also referred to as participant or respondent validation, are a critical
component of qualitative research, used to enhance the credibility and trustworthiness of
findings. This process involves returning preliminary interpretations, themes, or results to
participants, allowing them to confirm, clarify, or challenge how their experiences and
perspectives have been represented (Lockwood et al., 2015). By inviting participants to reflect on
the accuracy of data interpretation, member checks not only strengthen methodological rigour
but also promote relational accountability in the research process.
This practice is especially important in research involving Indigenous communities,
where ethical imperatives extend beyond standard academic protocols to include principles of

51
reciprocity, respect, and shared authority. Omitting member checks risks replicating colonial
power structures, in which researchers retain exclusive control over the narrative and analysis,
denying participants agency and voice in shaping how their knowledge is represented and
interpreted. Such hierarchical dynamics are inconsistent with ethical standards for conducting
research in Indigenous contexts and undermine efforts to support self-determination and
relational accountability in knowledge production.
The use of member checking and collaborative validation techniques varies across the
included studies. This has important implications for the credibility and cultural appropriateness
of the research. Several authors actively engaged in member checking or similar methods to
validate their findings and ensure the alignment of their results with community perspectives.
Dutton (2018) engaged community advisors in group analysis sessions, where transcripts were
shared and discussed to refine themes and insights. This process allowed participants to guide the
analysis and apply theoretical concepts to the lived experiences of the community. Similarly,
Hernandez et al. (1999) conducted focus groups with study participants to verify findings and
ensure that the grounded theory met criteria for fit, work, and relevance. They also presented a
verbal report of the findings to the Band Council, ensuring further community validation.
Johnson et al. (2022) used member checking of written interview summaries to confirm the
reliability of their research. Additionally, Anishinaabe elders and traditional healers were deeply
involved in the study, providing explicit permission for publication, approving the final draft,
and participating in the authorship process. This collaborative approach ensured that the research
maintained cultural accuracy and relevance. Lavallée and Howard (2011) similarly adopted a
collaborative approach by interpreting results with a diverse group of stakeholders, including
research participants and community leaders. They shared cluster maps and findings with these

52
groups for feedback, ensuring that the research process and outcomes were grounded in
community knowledge. Sherifali et al. (2012) formalized their member checking process by
presenting key findings to participants of the sharing circles, who were given the opportunity to
confirm the data’s accuracy and offer additional insights. This promoted data credibility and
helped ensure that the participants' voices were reflected in the findings.
However, some studies did not mention or use member checking explicitly, raising
concerns about the depth of participant involvement in the analytical process. For instance,
Barton (2005) and Barton (2008) did not refer to member checking, even though the latter
emphasized a narrative inquiry approach involving "co-participation and co-construction" of
stories. Similarly, Bruyère and Garro (2000) conducted interviews in the Cree language but did
not specify the use of member checks for data validation. Kulhawy-Wibe et al. (2018) used
inductive thematic analysis but did not mention member checking or participant validation. Pilon
et al. (2019) explicitly stated that participants did not engage in the analytical process, though the
researchers planned to return to the community later for input on the findings.
Lastly, Gregory et al. (1999) justify the omission of member checks through an explicit
description of how data collection was carried out by a research assistant who was diabetic,
identified as "Aboriginal," and worked in healthcare. The authors justify this choice by
positioning the research assistant's diagnosis, identity and background as qualifications that
replace the need for member checking. The research assistant was viewed as a representative of
all "Aboriginals”, which creates a dichotomy between the white authors and the "Aboriginal"
community.
These differences in methodology underscore the importance of explicitly involving
participants in the research process, especially in qualitative studies with Indigenous

53
communities. Member checking serves as a critical tool for enhancing the trustworthiness of
research and ensuring that findings reflect the perspectives and experiences of those being
studied. Assessing the presence or absence of this process offers insight into the methodological
and ethical integrity of the research in the context of research with Indigenous people and
diabetes self-management.

54
Chapter 6: Conclusion
This integrative review has critically examined the complex landscape of T2DM amongst
Indigenous populations in Canada. It centres the understanding that the disproportionate burden
of T2DM is not merely a biological phenomenon but a deeply entrenched legacy of colonial
processes and structures that have systematically pathologized Indigenous peoples and
marginalized their sophisticated and deeply integrated knowledge systems. The prevailing
Western biomedical paradigm, with its focus on biometric outcomes and individual focus on
“non-compliance,” has proven ineffective and often harmful, failing to address the
interconnected historical, social, and spiritual facets of Indigenous health experiences.
The findings revealed that, for many individuals who are Indigenous, a T2DM diagnosis
is experienced as a profound psychological and relational disruption, deeply shaped by
intergenerational trauma and ongoing systemic inequities that frequently manifest as a sense of
fatalism and denial. Within primary care, challenges such as paternalistic approaches, a lack of
contextual understanding of Indigenous lived experiences, and the mischaracterization of “noncompliance” continue to perpetuate colonial dynamics, hindering effective diabetes management
and fostering mistrust.
Importantly, this integrative review illuminates powerful facilitators for healing and
effective diabetes self-management that emerge from Indigenous ways of knowing and being.
The integration of a diversity of traditional healing practices, including traditional foods,
medicinal plants, and ceremonial practices like smudging and sweat lodges, was consistently
identified as vital for holistic well-being and culturally relevant care. Furthermore, peer support,
particularly through talking circles, emerged as a profoundly effective and culturally resonant

55
strategy for health education, emotional connection, and community-driven lifestyle change,
fostering trust and a sense of collective empowerment.
The implications of this review are far-reaching across practice, education, and research.
For practice, PCPs are called to move beyond passive oversight to active leadership in
decolonizing diabetes care. This requires a fundamental shift from an authoritarian, compliancebased approach to one grounded in building relational trust, humility, and empathy. PCPs must
recognize and address the enduring legacies of colonialism, understand "non-compliance" as a
potential form of Indigenous resistance or a reflection of systemic failings, and proactively
support the integration of traditional Indigenous medicines and community-led modalities like
talking circles into care plans.
For education, it is imperative to train future PCPs in experiential learning and relational
competence, valuing outcomes that extend beyond mere biometric indicators to encompass trust,
connection, and mutual understanding. Educational curricula must instill a deep respect for and
understanding of traditional Indigenous medicines, aligning with the TRC’s (2015) Calls to
Action, specifically Call to Action #22, which advocates for recognizing and using Indigenous
healing practices.
For research, strict adherence to Indigenous data sovereignty principles is non-negotiable.
Frameworks such as OCAP® and Chapter 9 of the TCPS 2 are foundational for ensuring
research is culturally appropriate, beneficial, and genuinely community-led (FNIGC, 2025; TRC,
2015). This commitment is essential to counter the historical harms of extractive research and to
foster respectful, reciprocal, and ethically sound knowledge production that truly serves
Indigenous communities.

56
In conclusion, transforming diabetes care for Indigenous peoples requires a profound
paradigm shift from an individualistic, compliance-driven model to a holistic, relational, and
culturally grounded approach. By embracing Indigenous ways of knowing and being, fostering
genuine partnerships, and actively working to dismantle colonial structures within healthcare,
PCPs can move from merely managing a disease to supporting the revitalization of Indigenous
health and well-being in a good way. This journey is not just about clinical outcomes; it is about
reconciliation, reclaiming agency, and fostering a future in which Indigenous peoples can thrive
in health and spirit.

57
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Appendix 1
Database Search Strategy
Search Database
S1

CINAHL

Search Terms
("Diabetes Mellitus, Type 2") OR ("Diabetic Patients") OR
("diabetes type 2 or diabetes mellitus type 2 or diabetes 2")

Results
150,742

CINAHL

("Aboriginal Canadians") OR ("Indigenous Peoples") OR ("First
Nations of Australia") OR ("Alaska Natives") OR ("Aboriginal
Australians") OR ("Indigenous Health") OR ("Indigenous
Women") OR ("Apache (Native American People)") OR (MH
"Medicine, Native American Traditional")

CINAHL

(MH "Quality of Health Care") OR (MH "Healthcare Disparities")
OR (MH "Health Services Accessibility") OR (MH "Primary
271,025
Health Care")

CINAHL

(MH "Self Care") OR (MH "Blood Glucose Self-Monitoring") OR
(MH "Self Care Agency") OR (MH "Self Medication") OR (MH 56,177
"Self Administration")

S5

CINAHL

(MH "Primary Care Nurse Practitioners") OR (MH "Physicians,
Family") OR (MH "Family Nurse Practitioners") OR (MH "Nurse 45,815
Practitioners") OR (MH "Adult Nurse Practitioners")

S6
S7

CINAHL
CINAHL

S1 AND S2 AND S3
S1 AND S2 AND S4

152
49

S8

CINAHL
Google
Scholar

S2 AND S5

56

type 2 diabetes AND self-management AND Indigenous patients

10

S2

S3

S4

Note: MH indicates a CINAHL Medical Subject Heading (controlled vocabulary).

17,962

69
Appendix 2

70
Appendix 3
Summary of Data Extraction
Article Reference
Barton, S. S., Anderson, N., & Thommasen, H. V. (2005). The diabetes experiences of Aboriginal
people living in a rural Canadian community. Australian Journal of Rural Health, 13(4), 242–
246. https://doi.org/10.1111/j.1440-1584.2005.00709.x
Purpose and Context
-To better understand the challenges of living with T2DM for Nuxalk peoples in the remote community
in Bella Coola, BC
- N=8 initially interviewed (women=5, men=3), 4 of the participants engaged in 6 follow-up
conversational interviews (women, n=3, men, n=1)
-diagnosed with diabetes in the last 5-20 years, open to talking about their 'diabetic life stories'
-sampling= purposive, by invite from trusted members of the research team
-informed consent obtained, anonymity preserved
Type of Study and Design
Descriptive qualitative design
Strength and Limitations
Strengths:
-honours listening, learning and storytelling to generate an understanding for more culturally safe
management of diabetes
-portrays diverse responses elicited by participants and does not try to homogenize data for ease of
reporting
-consent and ethics approval obtained
Limitations:
-cultural background/positionality of researchers not described/influence of researchers on the research
not explored
-methods unclear
Relevance to Research Question
Psychological Impact
Fatalism:
-shift from seeing diabetes as inevitable to recognizing personal agency
Challenges to Primary Care Diabetes Management
Diabetes education delivery:
-communications with PCP hard to understand, encounters too rushed for teaching and learning
-provider not doing enough to explain how diabetes medications worked
-would like providers to relate in a more personal way
Knowledge gaps:
-unable to correlate symptoms of feeling unwell with long-term complications such as heart and kidney
damage
-patients took their medications but did not understand how they worked
Facilitators to Diabetes Self-Management
Integrate culture with biomedicine:
-outdoor activities such as fishing and berry picking for exercise led to significant amounts of weight
loss
Peer support:
-healing circles offered an environment where the support of others with diabetes could be sought for
their wisdom

71

Article Reference
Barton, S. S. (2008). Using narrative inquiry to elicit diabetes self-care experience in Aboriginal
population. Canadian Journal of Nursing Research, 40(3), 16–36. https://doi.org/10.1111/j.14401584.2005.00709.x
Purpose and Context
-to examine the experience of Elders living with T2DM in a remote Nuxalk community in Bella Coola,
BC
-participants selected for ability to provide a rich life story and reveal meaning in their experience of
diabetes, n= 4 (women, n=3; men, n=1)
Type of Study and Design
-Narrative inquiry based on hermeneutic phenomenology
Strengths and Limitations
Strengths:
-analysis is deep, rich, evocative and complex, conveys concepts of Aboriginal epistemology, findings
novel
-duration of the study was long (3 years of active research, 2 years of research, reflection and writing)
Limitations:
-information about methods vague, no ethics approval
-author/researcher does not describe the recruitment process or their relationship to the participants,
influence of the researcher on the research and vice versa not described
-themes not easily delineated, difficult to follow article
Relevance to Research Question
Facilitators to Diabetes Self-Management
Integrate culture with biomedicine:
-participants viewed medical care as most appropriate for diabetes treatment but also used traditional
medicine, ceremony and traditional practices
-combining modalities led to finding harmony between being diabetic, being Aboriginal and being well

72
Article Reference
Bruyère, J., & Garro, L. C. (2000). "He travels in the body": Nehinaw (Cree) understandings of
diabetes. The Canadian Nurse, 96(6), 25-28.
https://www.proquest.com/docview/232048769?fromopenview=true&pqorigsite=gscholar&sourcetype=Scholarly%20Journals.
Purpose and Context
Purpose:
-Listen to Nehinaw perspectives on T2DM and explore how First Nations people themselves
understand T2DM, illuminate challenges in providing effective transcultural healthcare
Context:
-Opaskwayak Cree Nation (OCN) near The Pas, Manitoba
- Nehinaw speakers with T2DM aged 25-73
- N= 20+2 (women = 10+2, men = 10) (+2 = pre-test volunteers who were included because their
answers did not differ from informants)
Type of Study and Design
-Narrative inquiry
-Structured qualitative interview conducted in Nehinawin (Cree language)
Strengths and Limitations
Strengths:
-interview questions reviewed and revised by an Elder
-interview conducted primarily in Nehinawawin (Cree language)-enriches understanding, provides
nuanced perspective
Limitations:
-few details about methods provided
-interview questions not shared
-no mention of ethics approval
Relevance to Research Question
Psychological Impact of Diabetes
Fatlism
Inevitability:
-death from diabetes in Nehinawin (Cree language) described in an unconventional way that implies
lack of control
Facilitators to Diabetes Self-Management
Integrate culture with biomedicine:
-biomedical understanding that exercise helped metabolize sugar was congruent with Nehinaw
framework that “ancestors worked hard” gave it relevance, boiling food rather than frying also
accepted because that is what the ancestors did

73
Article Reference
Dutton, J. (2018). Lessons from stories of diabetes self-management: Enunciating culture in health
decision-making in the third space. [Doctoral dissertation, University of Toronto]. ProQuest
Dissertations and Theses Global.
https://www.proquest.com/openview/c58c88cc60af36e9af54b9dffeb5527a/1?pqorigsite=gscholar&cbl=18750&diss=y
Purpose and Context
-Increase understanding of the factors that influence the diabetes self-management behaviours of
Indigenous peoples
Context:
-Fort Smith, Northwest Territories, population 2500, predominantly Dene-Métis, self-identified as
Indigenous, living with T2DM, over 18 years old
-n =10
Type of Study and Design
-Community Based Participatory Research (CBPR)
Strengths and Limitations
Strengths:
-study design, methods and researcher conduct followed the Tri-Council Policy Statement: Ethical
Conduct for Research Involving Humans Research Involving the First Nations, Inuit and Métis Peoples
of Canada (2014) and the OCAP guidelines
-in-depth critical analysis
Limitations:
-sample size smaller than intended
Relevance to Research Question:
Psychological Impact of Diabetes
Fatalism
Self-determination:
-author refutes notion of universal resignation to diabetes for Indigenous peoples based on literature
review (p. 22)
-participant learned to adjust their own insulin “because the doctors don’t know what’s going on”
Denial
Part of the process:
-coming to terms with diabetes required moving through denial to acceptance and effective diabetes
self-management
Effect on study recruitment:
-approaching individuals with diabetes about recruitment into study was seen as a potential cause of
distress if person was in ‘denial’ therefore deemed unethical by research ethics board
Challenges to Primary Care Diabetes Management
Paternalism in healthcare
Power imbalance:
-approach resembled authority figures from residential school, judged as dirty and non-compliant,
feared not doing what they were told
-participant correlated how people are treated and how likely they are to seek care
Diabetes education delivery:
-quality diabetes education helped to move out of fear and worry into empowerment and action with
self-mangement
Knowledge Gaps:
-without health literacy to understand one’s own health you fall through the cracks

74

Article Reference
Gregory, D., Whalley, W., Olson, J., Bain, M. G., Harper, G., Roberts, L., & Russell, C. (1999).
Exploring the experience of type 2 diabetes in urban Aboriginal people. Canadian Journal of Nursing
Research, 31(1), 101-115. https://cjnr.archive.mcgill.ca/article/view/1512
Purpose and Context
- To determine the general experience of Aboriginal people living with T2DM in the urban setting of
Winnipeg, Manitoba
- Urban dwelling Aboriginal people, status and non-status (Indian, Métis, Inuit)
-recruited from urban diabetes resource clinics
- N = 20 (women = 12, men = 8)
Type of Study and Design
-naturalistic
-person-centred face to face interviews
Strengths and Limitations
Strengths:
-aims to understand the experience of people with lived experience
-elaborate detail and justification
Limitations:
-omit member checks
-outdated language, i.e. refers to research assistant as "an aboriginal," tokenistic
-limited details about about sampling method
Relevance to Research Question
Diabetes: Psychological Impact
Fatalism
Inevitability:
-20/20 participants had immediate family members living with diabetes, felt nothing could be done to
stop them from getting it
Challenges to Primary Care Diabetes Management (Paternalism- Power imbalance):
-distressing encounters with providers, participants berated and threatened to death if rules of diabetes
not followed
-berated by care providers for not following rules related to diabetes, scared by doctor who threatened
death if rules not followed
Diabetes education delivery
-doctor visits rushed, no time for teaching and learning, mostly for looking at blood sugars and
assessing medications
-doctors don’t take the time to explain, popular perception that providers don’t want to listen
Knowledge gaps:
-11/20 participants could not explain the cause of diabetes, 14/20 unable to explain what caused it
Facilitators to Diabetes Self-Management
Peer support:
-learning from other Aboriginal people with diabetes as welcome strategy

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Article Reference
Hernandez, C. A., Antone, I., & Cornelius, I. (1999). A grounded theory study of the experience of
type 2 diabetes mellitus in First Nations adults in Canada. Journal of Transcultural Nursing, 10(3),
220–228. https://doi.org/10.1177/104365969901000313
Purpose and Context
-investigate the experience of having T2DM for First Nations adults
-large First Nations community in Southwestern Ontario
- N=10 (males = 6, females =4)
Type of Study and Design
-grounded theory, open-ended interview questions
-emergent fit mode employed: used when there is already a theory that can be extended and refined
during the research process
Strengths and Limitations
Strengths:
-data ownership shared with community
-research methodology congruent with research question
-results shared verbally with Band Council
-high level of transparency about research design, methods, and interview questions
Limitations:
-study designed to provide 'cultural context' yet impact of colonization not even mentioned
-ideas about First Nations culture not derived from study participants
-First Nations culture understood through tropes derived from non-Indigenous sources (i.e. gerontology
textbook)
-model used was designed for 'Whites with Type I diabetes'
Relevance to Research Question
Psychological Impact of Diabetes
Denial
Part of the process:
-being in denial about having diabetes led to not taking medications regularly, normalizing and
minimizing diabetes until recognition diabetes no longer something that can be ignored
Challenges to Primary Care Management of Diabetes
Knowledge gaps:
-took medications incorrectly and in a way that could be unsafe

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Article Reference
Johnson, R., Fiddler, T., Pirozek, J., Gordon, J., Sodhi, S., Poirier, J., Kattini, R., & Kelly, L. (2022).
Traditional medicine and type 2 diabetes in First Nations patients. Canadian Journal of Diabetes,
46(1), 53–59. https://doi.org/10.1016/j.jcjd.2021.05.007
Purpose and Context
-'re-tell' participants' stories and explore the role of traditional medicine in diabetes treatment
-Sioux Lookout, Northern Ontario, N = 10 (men = 6, women = 4)
Type of Study and Design
- responsive interviewing (Rubin & Rubin) where study participants are 'conversational partners' who
have an active role in determining the shape of the discussion through storytelling
-oral tradition and personal experience of participants valued
Strengths and Limitations
Strengths:
-harmonized, integrated understanding of the participants viewpoints
-culturally sensitive orientation throughout
Limitations:
-authors do not declare their own cultural backgrounds
-authors do not assess their impact on the research and vice versa
Relevance to Research Question
Diabetes: Psychological Impact (Fatalism-Inevitability):
-expectation of poor outcomes, always wondering who the next amputee in the family would be
Challenges to Primary Care Management of Diabetes (Paternalism in healthcare-Lack of
contextual understanding):
-providers being unaware of power imbalance a barrier to care for Indigenous patients, led to
disconnection and mistrust
Facilitators to Diabetes Self-Management
Peer support:
-sharing circles a way to receive support in a culturally safe manner and a chance to return to thinking
about health as the ancestors did

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Article Reference
Kulhawy-Wibe, S., King-Shier, K. M., Barnabe, C., Manns, B. J., Hemmelgarn, B. R., & Campbell, D.
J. T. (2018). Exploring structural barriers to diabetes self-management in Alberta First Nations
communities. Diabetology & Metabolic Syndrome, 10(1), Article 87. https://doi.org/10.1186/s13098018-0385-7
Purpose and Context
-highlight the structural barriers to effective diabetes self-management described by study participants.
-FN peoples with T2DM living in FN communities adjacent to a major city in Alberta, n= 5 (subset
from a larger study with 34 participants)
Type of Study and Design
-qualitative descriptive analysis
-follows phenomenological principles
-sub cohort of patients from FN communities with T2DM from a larger qualitative study
-purposive sampling via signage in physicians’ offices, pharmacies, clinical databases and a FN kidney
disease prevention clinic
Strengths and Limitations
Strengths:
-barriers elucidated
Limitations:
-sample size small even for qualitative research
-sample not fully saturated and derivative
Relevance to Research Question
Psychological Impacts of Diabetes (Fatalism- Inevitability):
-perception that diabetes was a death sentence
Challenges to Primary Care Management of Diabetes (Knowledge gaps):
- not understanding diabetes was a major source of stress, desire to do something but paralyzed by not
knowing what to do and not feeling empowered to act

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Article Reference
Lavallée, L. F., & Howard, H. A. (2011). Urban Aboriginal Diabetes Research Project report.
Anishnawbe Health Toronto. Toronto, ON. https://iportal.usask.ca/record/35183
Purpose and Context
-to gather information regarding Aboriginal cultural perspectives about diabetes and barriers to
diabetes management.
-to identify challenges that Aboriginal people living with diabetes in the Greater Toronto Area
experience.
-to uncover misconceptions and cultural nuances to identify barriers and interventions that will enable
positive health outcomes in Aboriginal people with diabetes.
-N = 138
-adults18-79 years old, male, female or two-spirit who were diagnosed with T2DM, pre-diabetes,
gestational diabetes or TIDM and identified as First Nations, Inuit or Métis
Type of Study and Design
-Governing Council selected to advise on and oversee the project
-concept mapping (using Concept Systems software)-provides both qualitative and quantitative data
-sharing circles
-questionnaire
-Anishnaabe Symbol-Based Reflection (ASBR, n=14)
-photovoice: participants given cameras to act as recorders and portray various topics related to
diabetes (n=9)
Strengths and Limitations
Strengths:
-multiple forms of assessment used so that triangulation possible
-voices of Aboriginal people living with diabetes at the centre
-authors provide elaborate detail about how they adhere to the Tri Council Policy Statement Guidelines
2 (TCPS2) chapter 9 articles 9.19
-OCAP adhered to- Anishnawbe Health Toronto is the sole and rightful owner of the data and controls
how the findings will be shared
-the results interpreted collaboratively by the research team, a group of research participants, members
of the project’s Governing Circle, the Anishnawbe Health Diabetes Education Team, healers and staff
physician
-researchers’ reflections published with the study results
Limitations:
-unable to obtain a random sample
-Inuit, Métis, two-spirit and men under-represented
Relevance to the Research Question
Psychological Impact of Diabetes (Denial- Effect on study recruitment):
-denial reported in 34.2% of study participants actual rates likely underrepresented due to recruitment
methods
Facilitators to Diabetes Self-Management
-support and companionship of sharing circles were ‘completely’ or ‘very much’ helpful for 75% of
participants
-cultural teachings can help us live well and manage our diabetes (like medicine wheel: spiritual,
emotional, physical and mental) 63.5% very much completely, 85.5% somewhat to completely

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Article Reference
Pilon, R. S., Benoit, M., Maar, M., Cote-Meek, S., Assinewe, F., & Daybutch, G. (2019). Decolonizing
diabetes. International Journal of Indigenous Health, 14(2), 252–275.
https://doi.org/10.32799/ijih.v14i2.32958.
Purpose and Context
-to explore the impact of colonization on the lived experience and perceptions about developing T2DM
for Indigenous Peoples living in the North
-7 First Nations communities in Northern Ontario
-Indigenous adults living with T2DM, N = 22
Type of Study and Design
-qualitative
-constructivist grounded theory guided by a decolonizing approach
-used elements of Community Based Participatory Action Research approach
Strengths and Limitations
Strengths:
-community consultation and approval obtained to conduct the study
-centres participant lived experience using in-depth interviews
-collaborates with communities to share the position of power and take a decolonizing approach
-quotes used to illustrate themes
Limitations:
-authors declare importance of researcher positionality in Indigenous research yet do not describe theirs
to readers
-authors acknowledge importance of addressing preconceived ideas, notions, experiences and theories
and that it is important to reflect on these throughout research process yet do not show evidence of
doing this
-no member checking described
Relevance to Research Question
Challenges to Primary Care Diabetes Management (Paternalism- Power imbalance):
-providers reminiscent of authority figures in residential school, participants berated bringing up
traditional medicines
Lack of contextual understanding
-trauma of residential school misunderstood or dismissed by providers leading to distrust,
disconnection from providers in clinical encounters
Facilitators to Diabetes Self-Management
Counter misperceptions:
-diabetes not caused by fate

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Article Reference
Sherifali, D., Shea, N., & Brooks, S. (2012). Exploring the experiences of urban First Nations People
living with or caring for someone with type 2 diabetes. Canadian Journal of Diabetes, 36(4), 175–180.
https://doi.org/10.1016/j.jcjd.2012.07.005
Purpose and Context
-Understand the lived experience of First Nations people living with (79.2%) or caring for (20.8%)
someone with T2DM in an urban setting
-Aboriginal Health Centre, Hamilton, Ontario
-self-identify as Aboriginal and 18 years of age or older, diagnosed with T2DM or caregiver for
someone with diabetes
-willing to commit to attending 4 sharing circles (focus groups)
-N = 24
Type of Study and Design
Qualitative descriptive design
Strengths and Limitations
Strengths:
-qualitative descriptive approach best method to answer the research question
-research method enabled interweaving a culturally sensitive approach and include a First Nations
Elder and Healer to elucidate findings
-data analysed concurrently and triangulated by 3 researchers and member checked with 9 sharing
circle members to ensure accuracy of findings
Limitations:
-findings may be unique to this study as participants access same services – not generalizable
-participants recruited at a social event- those unable to attend for reasons such as illness, lack of
transportation or finances not included
Relevance to Research Question
Psychological Impact of Diabetes (Denial- Part of the process):
-once you were through denial you were halfway there in terms of effective diabetes self-management
Barriers to Self-Management
-need for ongoing education, support and timely advice about diet and benefits
Facilitators to Diabetes Self-Management
Peer support:
-sharing circles a way for diabetics to get together, eat healthy food, exercise together as a community
-smudge, prayer, traditional teachings and social time valued at study sharing circle

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Appendix 4
Comparison of OCAP® and TCPS 2 Chapter 9 and CBPR Frameworks for Ethical
Research with Indigenous Peoples
Feature

OCAP®

TCPS 2 Chapter 9
Tri-Council Policy
Ownership, Control, Statement 2: Chapter 9 –
Full Name
Access, and
Research Involving the
Possession
First Nations, Inuit and
Métis Peoples of Canada
First Nations
Information
Tri-Council Agencies
Developed by
Governance Centre (CIHR, NSERC, SSHRC)
(FNIGC)
Primary
Audience

First Nations
communities and
those conducting
research with them

Researchers in Canada
conducting research
involving Indigenous
Peoples

Focus

Data sovereignty and Ethical standards for
self-determination in research involving
research
Indigenous Peoples

Core
Principles

First Nations have
the right to own,
control, access, and
possess their data

Respect for Indigenous
knowledge, community
engagement, and selfdetermination; community
and individual consent

CBPR
Community-Based
Participatory Research

Originated in public health
and social sciences; no
single governing body
Researchers and
communities across diverse
contexts, including but not
limited to Indigenous
settings
Equal partnership between
researchers and
communities throughout the
research process
Co-learning, mutual benefit,
community empowerment,
shared ownership of
research

Can be applied in any
Applies to all research
research context with
Scope
involving First Nations,
marginalized or
Inuit, and Métis in Canada underrepresented
communities
National policy guideline A flexible, values-based
A set of communityStatus
required for Tri-Councilapproach rather than a
defined standards
funded research
formal policy
Community and
Emphasizes collaborative
Requires both individual
Consent
individual consent,
decision-making, often
and, where appropriate,
Requirements with emphasis on
includes community-level
community consent
collective rights
consent processes
Primarily applies to
First Nations data
governance

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Feature
Knowledge
Sharing

Power
Dynamics

OCAP®
Emphasizes
community control
over how findings
are used or shared

TCPS 2 Chapter 9

CBPR

Encourages inclusion of
Community partners coIndigenous perspectives in own and help share research
dissemination
findings

Aims to rebalance
Encourages addressing
power in research by
power imbalances through
centering Indigenous
respectful engagement
authority

Seeks to flatten hierarchies
between researchers and
communities through
collaboration

Note. Abbreviations are as follows:
OCAP®: Ownership Control Access and Possession
TCPS 2: Tri Council Policy Statement: Ethical Conduct for Research Involving Humans,
Chapter 9
CBPR: Community-Based Participatory Research.
Information adapted from Castleden et al., 2012; CIHR, NSERC, & SSHRC (2022); First
Nations Information Governance Centre (2025) and Jagosh et al., 2012.