Women-Centered and Culturally Responsive Heart Health Promotion Among Indigenous Women in Canada

Abstract

Most women in Canada confront a combination of bio-psychosocial factors that put them at risk for cardiovascular disease. The challenge for health planners is to address these factors while contextualizing interventions that meet the specific needs of particular social and cultural groupings. The article will discuss a women-centered, group-based heart health pilot initiative designed to engage with indigenous approaches to healing. The nurse practitioners co-led the group with a representative from the indigenous community to balance women-centered practices with more traditional and culturally appropriate ones. In particular, indigenous processes, such as a Talking Circle, combined with indigenous knowledge/content were integrated into the pilot program. The project was evaluated to investigate its outcomes (how the intervention impacted the participants) and processes (how participants perceived the intervention). Evaluation involved analysis of the Talking Circle’s content, a focus group, field observations, and self-completed surveys. Most women made changes regarding their diet, some began physical activities, and others focused on better managing their emotional health. Women viewed the group as successful because it embraced both women-centered and culturally appropriate health promotion practices. The intervention created a culturally safe space for learning and transformation. The findings confirm the need for employing culturally relevant, gender-specific approaches to heart health promotion that are situated in and responsive to community needs.

Keywords

women’s health minority health health promotion community intervention community-based participatory research evaluation methods cardiovascular disease

Introduction

Preventing heart disease among women involves addressing numerous risk factors at multiple levels, including clinical, structural, and psychosocial risk factors (Greaves, Humphries, & Hemsing, 2008, p. 6). Specific subpopulations of women have been identified to be at greater risk, to have specific needs, and to face unique barriers to heart health. In British Columbia, Canada, these subpopulations include indigenous women, that is, women who identify as First Nations, Inuit, and/or Métis (Lix, Bruce, Sarkar, & Young, 2009). The Seven Sisters Healthy Heart project (Seven Sisters) was developed and piloted by BC Women’s Hospital & Health Centre (BCWH) in partnership with a nonprofit indigenous women’s health organization, Pacific Association of First Nations Women (PAFNW), to test the design and impact of a culturally relevant, gender-specific intervention for indigenous women at risk for heart disease.

A distinct challenge of population health intervention research is identifying how context contributes to program outcomes. For women, addressing “context” may include attending to the setting in which a program is offered, using peers as intervention leaders, involving women in designing the intervention, and addressing access barriers, (Hartman, Hosper, & Stronks, 2010). Addressing “context” should also be understood to encompass history and gender relations, such as the practices of colonization of indigenous people and the persistence of gender-based violence in Canada. Programs that recognize and address these aspects of context can be understood as gender- and culturally responsive health promotion interventions (Sambo, 2010; Victorian Government Department of Human Services, 2003). Practices such as creating a safe place for diverse women to engage in health-promoting activities and learning; adopting a women-centered, violence- and trauma-informed approach to programming; and adapting materials and resources to be culturally and linguistically appropriate are approaches to incorporating gender and culture in health promotion interventions (Pederson, Greaves, & Poole, 2015).

With funding from the Provincial Health Services Authority, a nurse practitioner (NP) team at BCWH embarked on a journey to understand how to deliver group-based health promotion to women at risk of cardiovascular disease. The NPs first ran a demonstration project in 2011-2012 with women in an inner-city neighborhood using group-based health education. Findings suggested that the program needed to be contextualized in order to address women’s needs and that a group-based intervention can foster a positive sense of community with a common goal to become healthier (Prodan-Bhalla, Middagh, & Ziabakhsh, 2012). The Seven Sisters project extended the practical knowledge gained offering this demonstration project and adapted the program design and content for indigenous women. This article describes the evaluation of this pilot project in which indigenous approaches were integrated into women-centered heart health education.

Background

Indigenous people’s higher health risk profile is linked to social, economic, and political inequalities in Canada (Canadian Council on Social Determinants of Health, 2013; Reading & Wien, 2009). In particular, indigenous women in Canada have higher rates of obesity, diabetes, and hypertension than nonindigenous women, which put them at a greater risk for heart disease (Atlantic Centre of Excellence for Women’s Health, 2009). Similar health challenges have been documented for indigenous women in the United States, New Zealand and Australia (Cameron et al., 2012; Oxfam Australia, 2007; Penm, 2008; Schiller, Lucas, & Peregoy, 2012), to varying degrees.

Health promotion initiatives are often developed for mainstream populations, yet many researchers and practitioners have suggested that Western biomedical approaches may contradict indigenous approaches to health and healing (Arnold & Bruce, 2005; Mundel & Chapman, 2010; Smye & Browne, 2002). Many indigenous health practices embrace a perspective that encompasses physical, emotional, mental, and spiritual well-being simultaneously. Therefore culturally responsive health services need to operate between the two paradigms, embracing elements of both biomedical and indigenous knowledge (Dion-Stout, 2015; Reading & Reading, 2012).

Heart health promotion initiatives have also, for the most part, ignored women or applied a model of intervention derived from research with men (Pederson, Izadnegahdar, Humphries, & Young, 2014). Gender-responsive health promotion is not just health promotion with women but rather an approach that is grounded in the context of women’s lives, with attention to the social, economic, cultural, and political contexts in which they live (Reid, Pederson, & Dupéré, 2012).

Examples of initiatives in which indigenous approaches are intergraded into gender-responsive approaches are scarce. Traditions of the Heart program, targeting Alaska Native women (Witmer, Hensel, Holck, Ammerman, & Will, 2004), which included traditional elements (e.g., the Talking Circle) still resorted to using standard mainstream message of eating less and moving more without incorporating any culturally specific messaging. In a household-based health intervention on a Canadian First Nations Reserve, indigenous peer counselors worked with families to improve healthy eating and exercise (Anand et al., 2007), yet neglected to attend to the mental and spiritual aspect of their well-being, which is particularly important for Aboriginal women (National Collaborating Centre for Aboriginal Health, 2013). Similarly, in a Kitchen Garden project targeting a First Nations community in British Columbia, participants engaged in healthy eating through tending to an organic garden, cooking, and feasting (Mundel & Chapman, 2010), an approach firmly rooted in cultural practices but limited due to its sole focus on healthy eating. Although elements of gender and culture are present in each of these interventions, due to the gaps stated, they are only partially grounded in gender and indigenous approaches.

The Seven Sisters project was piloted as a gender- and culturally responsive model to promote heart-healthy activities among indigenous women. This project not only builds on previous research by using traditional indigenous processes and traditions (e.g., Talking Circle) but also integrates indigenous knowledge into mainstream health promotion messages and practices and promotes a holistic approach to heart health among women. This article describes the Seven Sisters pilot intervention, the study outcomes (how the intervention impacted the participants), and the processes that contributed to them (how participants perceived the intervention).

Method

Intervention

The Seven Sisters intervention was informed by indigenous healing perspectives, transcultural nursing, and feminist theories of health and illness. The indigenous healing movement (Ross, 1996) is marked by the principles of reconnecting to spirituality, healing the broader community, shifting the focus from illness to wellness, and transforming the self in the mental, emotional, physical, and spiritual realms. Transcultural nursing (Leininger, 1978, Maier-Lorentz, 2008) links culture and care practices and promotes cultural competency in the care environment. Feminist theorists have challenged the gender-blind nature of much of health promotion initiatives, noting that health promotion has typically been silent about aspects of diversity, including racialization (Daykin & Naidoo, 1995; Doyal, 2001; Reid et al., 2012).

Taking a broader community approach, this project engaged indigenous women leaders and Elders as champions of heart health who would simultaneously learn about and try to improve their own personal risk factors while contributing to shaping the healthy living practices of their community members. This approach reflects the indigenous value that wisdom comes from Elders and leaders. Elders represent a culturally relevant resource for health promotion in indigenous communities (Varcoe, Bottorff, Carey, Sullivan, & Williams, 2010). Therefore, targeting indigenous leaders/Elders for health promotion, especially women who often take on guardian roles, would potentially have a broader community impact, although this potential ripple effect was not investigated herein.

Seven Sisters ran as a 2-hour, weekly women-only group for 8 weeks during October to November 2012. Sessions were held at the PAFNW’s premises; sessions started with a Sacred Blanket ceremony and Talking Circle facilitated by the Cultural Lead, an indigenous woman representative from the PAFNW, followed by an educational component (discussion involving all participants) led by the two female NPs (and at times guest speakers) addressing various topics related to heart health. Group components and tasks performed by the Cultural Lead and NPs are outlined in Tables 1 and 2.

Table 1

Components of the Seven Sisters Group

Component	Time Allotted, Minutes	Description and Objective(s)
Check-ins	5-10	There were weigh-ins, blood pressure checks, and private time with NPs.
Welcome and informal circle	5	Welcome was followed by a song/drumming and prayer, led by the Cultural Lead—as a grounding exercise and creating a welcoming environment for indigenous women.
Sacred Blanket ceremony	5-10	Cultural Lead performed the ceremony by placing sacred items on a blanket reflecting themes of the day. For example, on the week that connectedness was the theme a wheat grass weave symbolizing connectedness was placed on the blanket. The Blanket ceremony allowed the Cultural Lead to incorporate symbolism and traditional teachings into the group.
Talking Circle	40-50	Led by the Cultural Lead, a feather was passed around from one woman to another, each taking turns to speak. This provided an opportunity for all women (including the facilitators) to freely discuss issues around health and well-being, to share their personal stories, and to provide teachings (sharing what they have learned on their life journeys).
		This form of teaching is consistent with traditional teachings where one only shares of oneself as opposed to telling others what to do.
Breakfast and educational component	30-35	Women moved from the circle to the breakfast area to eat nutritious food as a group. This provided an opportunity for women to feast together and for the NPs to demonstrate healthy eating. Each week a certain topic was covered (led by the NPs) over and after breakfast. In some weeks guest speakers also attended the group and provided further information on the weekly topics. Cultural Lead also participated in the weekly topic discussions by providing insights from an indigenous perspective and/or leading special activities/ceremonies (e.g., rock ceremony—see Table 2)
		Integration of Indigenous Knowledge: The Cultural Lead ensured the NPs were aware that it was important for them to participate in the feast (as a sign of respect and to create unity), since in the first week the NPs wanted to use the breakfast time to do facilitator preparation.
Weekly assignments and gifting	5	Before closing the women were given weekly assignments (e.g., using herbs in sacred ways) and a gift from the last week’s assignment was presented to the woman who needed the most encouragement. This was to motivate women and to show a sign of respect. Each woman received some form of a gift throughout the 8 weeks—either as part of the weekly assignments or a gift or a token (e.g., sacred herb) passed on as part of the Sacred Blanket ceremony.
		Integration of Indigenous knowledge: Initially weekly assignments were treated as “challenges” with the intention of providing gifts to those who had done the best in the challenge; this was revised to “assignments,” eliminating the atmosphere of competition, with gifts given to the women who needed the most encouragement—this follows the indigenous value that everyone should win.
Closing prayer	5	Women held hands in a circle and the Cultural Lead shared a prayer before the women to create closure prior to the women leaving the group space.
NP time (if needed)	After the formal closing	This further provided opportunities for women to approach the NPs and talk to them in private.

NOTE: NP = nurse practitioner.

Table 2

Themes, Topics, and Key Messages/Activities in the Seven Sisters Group

Session	Theme/Topics	Emergent Themes From Talking Circle	Key Messages/Activities
Week 1	“Am I at risk?”: Risk factors	• Introductions/getting to know one another	• Having more than one risk factor substantially increases chances of developing heart disease
		• Breaking down barriers or pretenses	• Everyone has a unique heart health profile and most women have at least one risk factor
		• Breaking down barriers or pretenses	• Cardiovascular health is important to women’s overall health
Week 2	“Connectedness”: Rite of passage, healthy relationships	• Culture is prevention	• Healthy relationships and social connectedness with family is important for heart health
			Integration of indigenous knowledge
			• Creating awareness of the link between health and connection with one’s cultural practices; rituals like the Taking Circle form the foundation for heart health
Week 3	“Holy smoke”: Smoking cessation	• Tobacco is also holy and is important in ceremony and indigenous culture	• Smoking is a very important risk factor
			Integration of indigenous knowledge
			• Mainstream health care message of tobacco being harmful was altered to tobacco can be used ceremonially
			• Message was that modern-day cigarettes are different from traditional tobacco and can cause addiction; limiting tobacco usage was stressed as opposed to eliminating its usage
Week 4	“Getting moving”: Exercise	• Change is a journey	Train for wellness rather than for fitness
		• It’s okay to take small steps	Walking is as effective as other forms of exercise (e.g., running, aerobics, etc.)
		• It’s okay not to be perfect	• Small spurts of exercise throughout the day is a good way to start, but a sustained amount of exercise (20 minutes or more) achieves an aerobic state
			• 23 Hours Video—a film with the focus on making time to fit exercise into one’s life
			• Pedometer was given out to everyone
Week 5	“It’s a beautiful world”: Depression	• Create light out of darkness	• Depression is a powerful and important factor in women’s heart health
			• Women can be affected by depression in various degrees and different ways
			Integration of indigenous knowledge
			• Seed ceremony—women took seeds representing their depression, anxiety, and stress. These seeds were later planted into a community garden to represent transformation and growth (creating light out of darkness). This activity replaced the way the traditional depression screening/assessment tool was used by the NPs.
Week 6	“Food and foodies”: Nutrition, label reading	• There is no one right way	Purchase oils that are unrefined and cold-pressed
		• 80/20 rule—eat right 80% of the time	• Save on cost by buying in bulk and storing or sharing with friends and family
			• Packaged cookies were handed out and food labels were reviewed
			Integration of indigenous knowledge
			• Eat foods that are closest to nature; this sometimes translates to eating more fatty foods (e.g., grease); this message contradicts mainstream food guideline to omit or limit animal fat and use unsaturated fats. However, traditional diet and foods were combined with messages of watching portion size to ensure good health.
Week 7	“Journey to peace”: Trauma, internal voices (wise vs. trickster)	• Everyone has a wise voice and a trickster voice, identifying these can empower you	• Link between trauma and health
		• Gain strength from the wise voice	• Everyone has trauma
			• Intergenerational trauma is apparent in indigenous culture
			Integration of indigenous knowledge
			• Identifying where your trauma was experienced will show you where you are struggling along the medicine wheel (emotional, physical, spiritual, or mental).
			• Internal voices were indigenized as trickster and wise voices. The message was that identifying the trickster voice gives one power over it
			• Rock ceremony—putting wise energy and thoughts into your rock to serve as reminder to ground you into wise voices rather than trickster voices
Week 8	Feast/evaluation	• Stories of transformation

NOTE: NP = nurse practitioner.

As the program evolved, the design of sessions changed. The Talking Circle, which was originally intended to be 10 minutes in length, became closer to 50 minutes long, and topic presentations (as part of the education component) were adapted to embrace indigenous practices. For example, the talk on smoking cessation titled, “Where Is the Smoke?” and intended to focus on the impact of first and secondhand smoke exposure, was transformed into “Holy Smoke,” with a focus on how herbs and tobacco can be used ceremonially. While discouraging women from active smoking, the NPs learned that some of the women used tobacco for healing and ceremonial purposes, and that therefore viewing all tobacco use as negative could alienate members of the group. This became an example of amalgamating Western medical and indigenous knowledge (Crowshoe, 2005). Other indigenous components integrated into the program are outlined in Tables 1 and 2.

The NPs also adjusted their teaching approach and became less didactic as the group progressed and as they became more familiar with the indigenous teaching perspectives (Prodan-Bhalla et al., 2015). For example, although the NPs wanted to initially engage in formal, personal goal setting with the women, it became evident that it was more important for the goals to unfold organically in the Talking Circle. In turn, the NPs and the Cultural Lead served as positive role models by authentically reflecting on their own goals, progress, and barriers to achieving them, and ways to overcome them as part of the stories they shared in the Talking Circle.

Recruitment

Indigenous female leaders were recruited by PAFNW among women formally working in the indigenous community as health advocates and/or as recognized Elders (spiritual teachers) using posters, e-mails, and word of mouth. Women were provided an honorarium ($20/session) for their participation as compensation for their time away from work and other responsibilities.

This study, conducted mainly for evaluation and program planning/development purposes, did not fall under the scope of the Research Ethics Board, as per the University of British Columbia Guidance notes, Article 4.4.1 and TCPS2 Article 2.5. However, verbal consent was gathered by the Cultural Lead from the program participants prior to participation and any data collection activities. Participants were made aware that the data will be used for evaluation and the results may be disseminated publicly. Data collection of personal information occurred in accordance with the agency’s privacy laws.

Evaluation Approach

An evaluation framework, developed in consultation with a number of stakeholders, including providers, program planners, and community partners, included questions about how the women responded to the intervention (processes) and if they were able to make positive life changes (outcomes). The impact of the intervention on the providers was also investigated (but not reported herein). A participatory and a developmental approach to evaluation was taken (Chouinard & Cousins, 2007; Patton, 2010); as the program evolved, the focus of the evaluation also changed. The Talking Circle proved to be a rich source of data, whereas initially, in the evaluation planning stage it was thought of as an introductory icebreaking exercise. As the program incorporated attention to emotional and psychological factors a qualitative approach was taken, omitting weight and blood pressure readings as outcome indicators. This developmental approach supports pilot programs that are evolving and reshaping, especially programs embedded in cross-cultural contexts, which by their very nature require fluidity and flexibility to work (SenGupta, Hopson, & Thompson-Robinson, 2004).

Data Collection

Demographic and health profile data were elicited with an intake form. Participants also completed a questionnaire in the first and last sessions that included questions on diet, physical activity, and smoking. Diet questions included items such as “How many servings of fruits and vegetables do you currently eat in a day?” (Stoddard, Palombo, Troped, Sorensen, & Will, 2004). A “junk food” score was obtained by summing the number of high-fat, sugary, and high-sodium food items purchased in the past week (O’Loughlin et al., 1995). They were also asked, “How many times did you exercise last week?” (Stoddard et al., 2004); smoking was measured by asking “Do you currently smoke?” and if so, “How many cigarettes do you typically smoke in a day?” In addition, women were asked to keep weekly journals, which included their goals, their progress, and the barriers to making changes. However, due to low uptake this data collection strategy was abandoned.

All eight Talking Circles were audio-recorded, without any formal probing or interference. The lead evaluator, the first author and an evaluation specialist, conducted three field observations, during in which she participated in the Talking Circles and took detailed field notes. Observations focused on women’s experiences and the dynamics of the sessions. These observations proved valuable in data analysis and provided opportunities for the evaluator to establish rapport and become accepted as an “outsider” evaluator (Ziabakhsh, 2015).

In addition, a focus group with the women (n = 8) was held during the final session, moderated by the lead evaluator using a facilitator’s guide. Discussion covered areas such as the women’s overall experience and the potential impact of the group on their well-being (Table 3). The session was audio-recorded.

Table 3

Discussion Guide Questions

1. How did you find the components/features of the group sessions? (Probes: format, themes/topics, delivery, ambiance, group dynamic, facilitator, cultural components, etc.)

2. Did the sessions meet your expectations?

3. What motivated you to attend each week? (Probes: what did you look forward the most? The least?)

4. Did you find the messages, recommendations, and/or advice doable given your life circumstances, your roles, and your responsibilities?

5. We want to develop a health promotion model that particularly works for women. So what things, features, and/or messages in the group really spoke to you or resonated with you because of you being a woman, if any?

6. What things, features, and/or messages in the group really spoke to you or resonated with you because of your culture/values, if any?

7. What are the key things you learned from this group?

8. What are the changes you have made in your life (if any) as the result of attending this group?

9. What things and/or who helped you achieve results?

10. What and/or who made it difficult for you to make changes/stick to your plans?

11. Do you think you can maintain the changes you have made thus far—beyond this group?

12. Did you get a chance to share information, tips, and/or learnings with others (e.g., family members, clients, community members, etc.)?

Data Analysis

Descriptive analysis was done for all quantitative data using SPSS. All audio data were transcribed verbatim. Transcriptions were coded, and meaningful categories were identified. Once these categories were generated, they were examined against others and were combined to create broader themes (Rubin & Rubin, 1995). These themes were then presented to the NPs and the Cultural Lead along with supporting verbatim comments/quotes for feedback and member checking (Doyle, 2007); the Cultural Lead provided the participants with opportunities to reflect on the themes via one-on-one sessions following the program, which served as checks and validation for the themes identified. Minor revisions were made to the themes based on feedback gathered. Triangulation was also used as validity check (Curtin & Fossey, 2007), as similar themes emerged from the various qualitative data collection methods.

Findings

Participant Profile

Eight women participated regularly in the sessions, attending an average of seven sessions. The average age of the participants was 58 years (SD = 9.16; age range = 47-71). All of the women had grown children. The women in the group represented different First Nations and tribes in Canada, including Coast Salish, Haida, and Cree.

All of the women had at least one cardiac risk factor, four had two, but none had more than two. Four of the women were classified as overweight (body mass index ≥ 25). One woman had diabetes, and another was diagnosed during the course of the group as having hypertension. Four women smoked, and three had high LDL cholesterol levels. Six women reported having family members with cardiac risk factors, and four also reported having a history of trauma.

Program Outcomes

Women reported eating more healthfully as a result of their participation in the intervention. All of the women reported being more conscious of what they were eating, of food labels, and of the benefits of eating vegetables, home-cooked meals, not skipping breakfast, and eating fewer processed foods.

I think I feel better. That’s my legacy to my own kids, right, that I feel better . . . cause I’m cooking for myself . . . for the last six weeks, proper food . . . Where before . . . I’d just open a can of spaghetti. (Talking Circle)

Women reported having more servings of fruits and vegetables per day after the 8-week session (4/8 had three to four servings at Week 1 vs. 7/8 at Week 8); 1/8 women reported snacking on vegetables three to four times in the past week at Week 1, versus 4/8 at Week 8. Women also reported eating less white pasta (5/8 at Week 1, vs. 1/8 at Week 8). Women on average had purchased 5.3 junk food items (SD = 1.64) in the past week at Week 1, versus 2.3 items (SD = 0.42) at Week 8. Living alone and lacking motivation to “cook proper food for just oneself” and social pressures from family and friends to participate in social gatherings involving unhealthy foods were some of the challenges women reported facing on a weekly basis with regard to eating healthfully.

Not all of the women undertook exercise during the program as each was understood to be on an individual health journey. One woman in particular was satisfied with her health and did not feel the need to become more physically active. Two women started yoga after joining the group, while others incorporated fitness more subtly into their everyday routines. For example, some walked whenever it was possible and one woman started taking the stairs and parking her car further away and walking. Some weeks women were challenged to be physically active due to lack of time, bad weather, injuries, past trauma, or just lack of motivation. All of the women reported that they became more mindful of the importance of exercise for physical and mental well-being.

I’ve been going to yoga . . . And I’m feeling like I’m able to stand straight now. Before I was kind of curved, starting to look like an old lady . . . So I notice it’s helping me. (Talking Circle)

I even took the stairs, it’s a miracle. I think the people in my [work] were amazed I took the stairs instead of the elevator. (Talking Circle)

Among the four smokers in the group, one decided to take steps toward quitting and was prescribed nicotine replacement therapy. At the end of the 8 weeks, she had cut her consumption in half, from 15 to 20 cigarettes per day to 10 to 15. Smokers in the group provided insights regarding barriers to quitting, including fear over one’s reaction to quitting, stress, overeating, partners who smoke, and cost of nicotine replacement therapy (which at the time of the intervention was not available at no cost in British Columbia).

Women also reported that they made changes in their emotional health. One woman started grief counseling, and another woman mended her relationship with her parents. Other women reported spending more “me time” to reduce stress, and others reported trying to find the joys in their lives.

I think one of the main things [I got from the group] is gratefulness. I never really appreciate what wonderful things are going on in my life. Even the most simple thing like having my kids over for dinner. After they left the other night—I was just exhilarated . . . So finding that happiness and peace . . . I’ve just kind of always brushed it under the carpet thinking that I wasn’t worth having all that happiness and peace in my life. (Talking Circle)

Feedback on Program Design and Processes

The program participants reported that they valued the integration of indigenous cultural elements into the program format; the importance of fostering relationships between and among participants as a source of health and knowledge; and the significance of promoting positive messages about the value of taking care of oneself as a woman, but not necessarily in rigid, prescriptive ways. Together, these features and processes encouraged women’s attendance, perseverance, and engagement with the program.

The Talking Circle, which was reported to be “the best part of the group experience,” was perceived as fostering connections, spirituality, and traditional learning. The circle was depicted by some of the women as being “magical”—generating a feeling of sacredness and spirituality. Overall, the intervention was viewed as holistic and consistent with the indigenous philosophy of the connectedness of the physical and the spiritual. Women viewed this approach as pivotal for well-being.

Modern medicine has never accepted spirituality as being part of the healing process. But it has to be. That’s the only way . . . Maybe my sister wouldn’t have got diabetes if she’d known 10 years before her spiritual self, you know, the four quadrants. How to balance her life properly. I mean, those things are critical to long-term health. (Talking Circle)

Women also recognized the importance of culture in health promotion and acknowledged the cultural void in their own lives and community. The cultural focus and the integration of indigenous processes and knowledge into educational messages gave them a sense of grounding. One woman in the group referred to “culture as prevention”—which became a wisdom sound bite for the group.

It is important in making the connection between where the women come from and health, we rely on who we are to get us through the rough times. This connection is not always clear for urban Aboriginals since many have lost their culture through missionary teachings. (Talking Circle)

Women also appreciated the women-only space in which the program was offered. They reported that they felt safer sharing and discussing sensitive issues in a women-only group; they felt a sense of community, as they felt supported by and connected to one another. Sharing food (feasting) also facilitated this connection, by bringing the women together over breakfast and “heart-” healthy bonding conversation. Women also reported that they valued the peer-support approach to learning. This approach was empowering, as they were not just the recipient of teachings but also passing on their own wisdom to others. The Talking Circle provided a venue for storytelling, a traditional way of teaching and learning, in which the women “shared of themselves,” as opposed to one in which experts were “telling others what to do.”

I believe for myself anyway, and maybe for others, too, that we learn from one another and I think it’s a real powerful way to do things. And, again, it creates—I agree what they’re saying, it’s a safe environment. (Focus group)

Women also acknowledged the openness of the NPs (who were not indigenous), since they approached the group not as “medical staff” but as women/sisters and participants. One woman indicated that as the group progressed, the NPs “became us.” The way the NPs interacted with the women and represented themselves was critical to creating safety and trust. It was also pivotal for the women to have the NPs as not “powering over” them but as sharing “power with them.”

They [NPs] did really well . . . they diminished that hierarchy, that perception of power . . . Like, they did want to learn from us . . . (Focus group)

Women reported that being reminded of the value of self-care was one of the most important lessons; they reflected that it was particularly valuable for them as women, because they often neglected themselves due to their responsibilities as caregivers. The women above all embraced messaging around self-care and change that allowed them flexibility. For example, messages such as change is a journey, it’s okay not to be perfect, it’s okay to take small steps (baby steps), and there is no one right way resonated with them. With this type of messaging, the women were able to set realistic expectations, not feel defeated by setbacks (and in fact come to expect them), and still perceive that a change in behavior is within reach. In other words, women liked having options, working at their own pace, and in their own time.

99% of the time most of us are caregivers in one aspect or another. Often putting ourselves on the bottom of the list . . . and if there’s time we’ll get there and if there isn’t, oh, well. Until we finally break down, right . . . it (self-care) is extremely important. (Focus Group)

You can’t push yourself 100 % of the time. And I was thinking yeah, that’s true because a lot of people try that (diet) and it doesn’t work. They decide to go off their diet completely instead. (Talking Circle)

Women also provided suggestions for improvement. A few women wanted less emphasis on the Cree traditions in the “welcome segment” (e.g., Sacred Blanket ceremony) and more opportunity to share traditions from different Nations. Yet the majority of women valued the cultural traditions regardless of their origin.

I think whatever kind of spirituality we can glean from any nation will help us. Because those will be the roots of our healing. (Focus group)

Women also disliked being weighted as part of the NP check-in, wanted a longer intervention period, and viewed the amount of paperwork (e.g., intake forms, surveys, weekly journals) required of them to be burdensome.

Discussion

The women in the Seven Sisters program reported making positive changes as a result of their participation. Consistent with the philosophy of the group, each woman described herself as being on her own health journey, and each made changes that were feasible and “right” for her at the time. Although these changes may be modest in scope, given the length of the program (8 weeks) and the philosophy of the program (“change as a journey”), the results are quite promising. The women intended to take “baby steps” toward change, an approach they viewed as more sustainable than “end goal–focused” health promotion approaches. This finding is consistent with emerging evidence of the value of recognizing that people may require a number of strategies to set and attain health-related goals (Mann, de Ridder, & Fujita, 2013) and that small changes in diet and physical activity show promise for weight management (Hills, Byrne, Lindstrom, & Hill, 2013).

Our findings suggest that this project was successful because it embraced both culturally appropriate and women-centered practices. Through the Talking Circle and the other indigenous processes, the group embraced spirituality, bringing women into what one called a “sacred space of transformation.” This holistic approach, the delivery of teachings through “sharing of oneself” versus “telling others what to do,” and the integration of indigenous knowledge in traditional health messages are the components that resonated with the women. These elements are consistent with the indigenous healing perspectives (Ross, 1996) and promising practices outlined by Reading and Reading (2012) and can be marked as culturally competent practice (Maier-Lorentz, 2008).

From the gender lens, the group-based intervention fostered closeness and a sense of sisterhood among the women. Communication and messages were also adapted to take into account women’s unique life circumstances and their role as caregivers and were delivered with a flavor of flexibility. These features of the program are consistent with the feminist and indigenous women’s health promotion approaches (Daykin & Naidoo, 1995; Dion-Stout, 2015).

Evaluation findings suggest that culturally appropriate and gender-responsive approaches are promising and highly acceptable. “Exercise more, eat less” dialogues with patients often do not take into account women’s unique life circumstances and are often ineffective (Erhardt, 2005; Hillsdon, Thorogood, White, & Foster, 2002). Rather than attending to prescriptive one-size-fits-all models of care and health promotion, program planners and health providers need to work with “women in context” (Pederson et al., 2014). This means substituting general health promotion practices with practices that are firmly grounded in the context of women’s lives with attention to women’s culture, age, priorities, challenges, and support systems (Reid et al., 2012). This may translate into incorporating cultural practices, adapting educational resources, providing trauma-informed services, adapting health messages to take into account women’s multiple roles (busy lives), fostering self-care, and creating a sense of community. The implication is that “rather than trying to find general practices that work for all women all of the time, we are willing, as health promoters, to work with particular women in their unique circumstances” (Pederson et al., 2014, p. 143).

This project also demonstrates that biomedical models can be integrated with more holistic approaches to risk factor reduction (Crowshoe, 2005). Mainstream health models often fail to take into account the holistic understanding of health and the central importance of spirituality in indigenous communities (Dion-Stout, 2015; Oulanova & Moodley, 2010). Throughout the project, the NPs were challenged to balance Western traditional health promotion messages with indigenous healing ways. They navigated this experience as one of colearning, acknowledging differences, and allowing both worldviews to be present (Prodan-Bhalla et al., 2015).

The implementation of such interventions is dependent on the readiness of the community to work with outside health care establishments, on the openness of providers to embrace other perspectives, on the flexibility of the funders to support interventions that may evolve within the project time frame and may not report conventional or explicit top-down success indicators (Prodan-Bhalla et al., 2015), and on having an appropriate evaluation approach. Developmental evaluation (Patton, 2010) proved to be a valuable framework as it provided flexibility to redefine indicators and methodology as the project unfolded. In particular, qualitative and verbal data collection approaches proved to be more culturally acceptable than quantitative ones.

This intervention has since inspired the project team and the management to incorporate elements of this project into an existing outpatient heart health program at BCWH and other outreach projects targeting indigenous women and girls. The project has also inspired the providers to rethink and transform their daily practices (Prodan-Bhalla et al., 2015).

There were several limitations to the evaluation. First, generalizability is likely limited. Indigenous women are diverse, and any new program needs to be adapted to meet the specific needs of women and their cultural practices. The small sample size also affects generalizability.

Selection bias may also have been at play; the women who joined the group may have been ready for “change,” though participant readiness is a prerequisite to any voluntary program. The women were also given honoraria for participation, which raises questions regarding the impact of incentives on recruitment and participation (Groth, 2010). However, the honoraria and the other “perks” in the program (e.g., breakfast) added to the women’s overall positive experience, which included feeling culturally respected; instead of being thought of as extraneous, these elements should be understood as parts of the intervention itself.

In addition, the intervention, with all its components, should be examined in its entirety. Although certain aspects of the intervention resonated more with the women (i.e., Talking Circle), no component can be singled out as the contributing factor to change. Although not a limitation per se, having a multilayer program makes replication more challenging, since the success of the intervention rested on the many fine details of the intervention content and delivery (Bell et al., 2007).

Furthermore, the impact of the program was only investigated in the short term. Further studies are needed to investigate the long-term impacts of such programming. Sustaining changes is often challenging once programs and ongoing support cease (Frieden, 2013). Future programming must also attempt to address barriers to lifestyle changes. For example, a family-centered approach to smoking maybe appropriate when women have partners who smoke, and subsidizing transportation can ease financial barriers and help with weather-related barriers.

Last, the evaluation of the project was led by a nonindigenous evaluator. Despite a participatory approach to evaluation, there are limits to what an outside evaluator can understand and claim (Price, McCoy, & Mafi, 2012). Hence, understanding of the project was shaped by the authors’ own backgrounds and the relationships they had forged with the indigenous community (Ziabakhsh, 2015).

Conclusion

Heart health promotion initiatives need to be contextualized to meet participants’ unique social, economic, psychosocial, and biological needs. In particular, health promotion initiatives need to be adapted to meet the needs of indigenous women who have unique needs and diverse perspectives on health and healing (Arnold & Bruce, 2005). Through the appropriate use of culturally relevant processes and integration of culturally relevant content, traditional information-heavy health education materials can be transformed into opportunities for dialogue, reflection, and change.

Footnotes

Acknowledgements

We wish to honor all of the women involved in the Seven Sisters Healthy Heart Pilot Project. We would also like to acknowledge that support for this project was granted by the Provincial Health Services Authority, BC Women’s Hospital & Health Centre, BC Centre of Excellence for Women’s Health, and the Pacific Association of First Nations Women. We would like to thank our Advisory Committee, led by Cheryl Davies, for their guidance. We thank Charlene King for her support and comments on an earlier draft. We also thank the Editor and the anonymous reviewers who provided very insightful comments on earlier drafts of this article. And finally, a special thank you to Glida Morgan, our Elder for the project, who provided her ongoing wisdom to our article.

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