Alexander First Nation Members’ Views of Their Relationships With Community Pharmacists: A Qualitative Study Protocol

Abstract

Background: Indigenous Peoples face inequities in health and social determinants of health due to colonization. Pharmacists must create relationships with Indigenous Peoples because the patient care process depends on it and because relationality is essential to Indigenous Peoples. Pharmacists are well-positioned to provide care due to their accessibility and medication knowledge. Despite the need for a focus on decreasing health inequities, little research within pharmacy in Canada has focused on Indigenous perspectives. This research explores Alexander First Nation (AFN) members’ views of their relationships with community pharmacists in Alberta, Canada, regarding trust, expectations of pharmacists, and willingness to discuss traditional medicines. Methods: General principles of Indigenous research and Ethical Space informed the study design. Community-based participatory research (CBPR) was used, and the research was collaboratively designed with the Alexander Research Committee (ARC). Conversation methodology incorporates a long history of oral tradition with the Indigenous research principles of respect, relevance, and reciprocity. Inclusion criteria were AFN members living in Alexander or outside Alexander who had interacted with a pharmacist as an adult. Qualitative data were collected through one-on-one semi-structured interviews as conversations. Inductive thematic analysis was used to analyze the data. Rigor was ensured by hiring an AFN research assistant, member checking, thematic saturation, an audit trail, and reflexivity. Discussion: An equitable partnership with the ARC was developed using CBPR, which supported Indigenous ways of knowing and doing to be incorporated into the research design and data interpretation. Consequently, the study results will provide information about building relationships with pharmacists that can be delivered back to AFN in a way that respects local First Nation perspectives and is meaningful to community members. Our results will also enable us to provide pharmacists with information about creating mutually beneficial relationships, from a First Nation perspective, necessary for positive Indigenous health outcomes.

Keywords

community pharmacists indigenous health community-based participatory research indigenous methodology

Background

Indigenous Peoples have inequities in social determinants of health and health outcomes due to current and historical colonial practices. Because the institutional health systems have been built on a Western knowledge framework, the healthcare system continues to discriminate against Indigenous Peoples at an ideologic (Canadian Medical Association, 2021), systemic (Phillips-Beck, 2020; Reading, 2018), and individual level (Phillips-Beck, 2020). Calls to address these inequities have come globally with the United Nations Declaration for the Rights of Indigenous Peoples (United Nations, 2006) and at a federal level. The Truth and Reconciliation Commission of Canada (2015) has 94 Calls to Action, with seven providing recommendations to address Indigenous health inequities. Healthcare professionals have been tasked with working to address Indigenous health access, anti-Indigenous racism, and health outcomes.

Pharmacists are well-positioned for community care due to their accessibility, medication knowledge, and expanding scope of practice within Canada. Provision of care requires a relationship with the patient, so understanding what helps build relationships has been examined. Within Canadian pharmacy research, there has been a description of factors that build trust in a patient-pharmacist relationship (Gregory & Austin, 2021), assessment of pharmacist communication styles (Guirguis, 2011; Murad et al., 2014; Nusair et al., 2018), and patient experiences with pharmacist care. Experiences of patients with different health conditions (Al Harmarneh et al., 2018; Idowu et al., 2021) and complex care needs (Davenport Huyer et al., 2021) have been described in different pharmacy settings (Crespo & Tyszka, 2017; Munro et al., 2021).

Despite increased research from a patient perspective and the requirement for Indigenous health inequities to be addressed, First Nations, Métis, and Inuit (FNMI) people in Canada, collectively referred to as Indigenous Peoples, have largely been left out of this work. Within Canada, FNMI have collectively been referred to as Aboriginal historically and more recently as Indigenous (Government of Canada 2024). Each First Nation also has their own name with their own language. Little research has focused specifically on Indigenous populations and their relationships with pharmacists despite inequities in health for Indigenous Peoples that could be reduced through the development of relationships that are built on trust and communication. For example, one Canadian qualitative study has described the integration of a pharmacist into a healthcare centre on a First Nations community once a week (Erker et al., 2021). Another Canadian study used focus group methods and explored Two-Spirit individuals' experiences accessing and receiving care in community pharmacies (Pirlot, 2023).

More research on the relationships, which includes trust, respect, and transparency, between pharmacists and Indigenous Peoples using Indigenous methodologies is necessary to begin to address the aforementioned health disparities. Indigenous methodologies have been integrated into research, so Indigenous ways of knowing, values, and ways of doing and being can shape the research and outcomes. Relationality is at the centre of Indigenous worldviews, which extends beyond relationships with other people, including connections with the land, the cosmos, and ideas (Wilson, 2008). Indigenous methodologies must create knowledge to be used by Indigenous individuals, families and communities, prioritize community concerns, have a researcher invested in the community, and promote community action that can help decolonize communities (Gaudry, 2015).

Strength-based and desire-based (Tuck, 2009) approaches have been developed in response to health research that has been traditionally deficit-based, (Hyett et al., 2019). Deficit-based research with Indigenous Peoples can cause harm by leading to stereotyping and stigmatization and can lead to a lack of responsiveness to community needs (Hyett et al., 2019). Strength-based approaches identify and support individual or environmental strengths, motivations, and protective factors in people’s journeys to well-being (FNIGC, 2020). Health issues within Indigenous populations are identified, but rather than concentrating on deficits, the focus is on a solution incorporating Indigenous definitions of well-being (Hyett et al., 2019). Desire-based research allows and understands the complexity of Indigenous Peoples’ issues and highlights not only what is broken but also wisdom and hope (Tuck, 2009).

Research to address health inequities must actively include Indigenous collaboration. Concerns have been expressed with past research of Indigenous communities because of “parachute” research (Castleden et al., 2012, p. 161), where researchers have come into communities to obtain information and leave without community input, benefit, or outcome in mind (Castleden et al., 2012). This type of research has harmed Indigenous communities (Cochran et al., 2008; Smith, 2012), and subsequently there has been a reluctance to be involved in research due to its negative connotation. More recently, Community-Based Participatory Research (CBPR) has been used with Indigenous communities as it is collaborative, involves power-sharing, and is developed with community benefit in mind (Allen et al., 2021; Cargo & Mercer, 2008; Kyoon-Achan et al., 2018, 2021; Waddell & Robinson, 2017). Therefore, it is congruent with Indigenous worldviews and concepts of Indigenous research, including respect, reciprocity, relevance, and responsibility (Kirkness & Barnhardt, 1991). CBPR can be decolonizing when implemented as a research approach for Indigenous health and wellness. “Decolonizing research is a process of conducting research with Indigenous communities that places Indigenous voices and epistemologies in the center of the research process” (Datta, 2018, p. 11). CBPR adopts a decolonizing approach because 1) the community is involved in shaping the research and raising Indigenous voices (Curran et al., 2018; Jernigan, 2010; McLane et al., 2021; Rasmus, 2014); 2) it allows Indigenous views on health and wellness to be voiced, centred, and utilized within health research (Kyoon-Achan et al., 2021; Sanchez-Pimienta et al., 2021; Tobias et al., 2013; Waddell et al., 2017); 3) it can be used to create Indigenous health programs, creating desire (strength)-based research (Allen et al., 2021; Hulen et al., 2019; Kyoon-Achan et al., 2018), and 4) to build capacity (Gokiert et al., 2017; Jernigan, 2010; Kyoon-Achan et al., 2018; Sanchez-Pimienta, 2021; Tobias et al., 2013).

Research Objective and Setting

The main objective of this study is to explore First Nation members’ views of their relationships with community pharmacists, specifically areas of trust, expectations of pharmacists, and willingness to share information about traditional medicines with pharmacists. In order to achieve this objective in an equitable way, we used a CBPR approach with an Indigenous lens and Ethical Space as a framework to partner with the Alexander Research Committee (ARC) in Alexander First Nation (AFN). Exploring these perceptions collaboratively with members of AFN is valuable as relationship building is essential for patient-centred care models of pharmacy, relationships are fundamental in Indigenous worldview (Wilson, 2008), and centering Indigenous voices can be decolonizing.

Methods

Researcher Perspective

Reflexivity throughout the research process is also essential in understanding researcher values, interests, and self-insights. It creates an understanding of methodological decisions through the process. Knowing and acknowledging that we have unconscious bias creates a requirement in CBPR to have a First Nation lens throughout the research design and process. Absolon and Willett (2015) describe the importance of locating within research to show intentions of doing responsible, accountable, and beneficial work for the community. As this project was conducted as part of a thesis for a Masters degree, AR and CS, as the student and supervisor, respectively, will locate themselves. AR is an Inuvialuk pharmacist who has never lived within her homeland due to colonial practices. Growing up in Treaty 8 territory, AR was surrounded by Dënésułiné, Cree, Tłichǫ, Dene, Gwich’in, Métis and Inuit, who did not grow up in ceremony or protocol due to colonial practices. AR was surrounded and supported by an Indigenous community and experienced the lens as a majority rather than a minority. Moving to Treaty 7 and then Treaty 6 territory demonstrated how different relationships are between Indigenous and non-Indigenous people within Alberta compared to home. A reflection back to earlier years demonstrates the inequities Indigenous Peoples face due to assimilation practices, but also resilience and strength. As AR has Métis/Inuvialuit children and has worked within the health profession for 18 years, there is an understanding now more than ever of the reasons to educate others on Canada’s history, its impacts, and the resilience of Indigenous Peoples. Understanding perspectives on relationships with pharmacists from members of one First Nation is a first step towards improving these relationships, supporting Indigenous resilience, and moving towards wellness. CS is a clinician scientist, settler, academic and pharmacist of mixed European ancestry born in Treaty 6 within Canada.

Collaboration With Alexander Research Committee

The research was conducted in partnership with the Alexander Research Committee (ARC), established in 2008 (Gokiert et al., 2017). ARC comprises Alexander First Nation (AFN) community members representing education, recreation, Elders, health, and University of Alberta academics who have been involved in many co-designed and implemented research projects with ARC (Genius et al., 2015a, 2015b; Gillies, ARC et al., 2020; Gillies, Blanchet et al., 2020; Gillies et al., 2018; Hanbazaza et al., 2015; Lopresti et al., 2020; Lopresti et al., 2021; Lopresti et al., 2022; Murray et al., 2017; Triador et al., 2015). Guiding Principles developed by ARC describe how ethical, respectful research is conducted within AFN. The Guiding Principles serve as a research agreement and “outline how committee members should function together, the rules of research conduct, and the fact that the community is the primary beneficiary of any and all research” (Gokiert et al., 2017, p. 2). As outlined by the Tri-Council Policy Statement Ethical Conduct for Research Involving Humans Chapter 9 (Canadian Institutes of Health Research et al., 2022), the Guiding Principles address mutual expectations, outline ethical protections such as informed consent and confidentiality, and describe community member involvement. ARC is involved in research (design, data collection and management, analysis and interpretation), knowledge translation, the protection of restricted knowledge, and conflict resolution (Alexander Research Committee, 2022). Collaborating with ARC promotes relevant, respectful, reciprocal, and equitable research and allows ethical issues to be discussed. Approval to proceed with research in AFN was granted by the ARC and the Director of Health in AFN as a verbal agreement. ARC has the Chief and Council’s consent to approve research within the community, and an Alexander member of ARC regularly updates the Chief and Council regarding the research. Research design, including research objectives, framework, and methods, was developed with ARC in monthly meetings. The project adhered to the First Nation’s principles of Ownership, Control, Access, and Possession (OCAP©) (First Nation Information Governance Centre, n.d; Schnarch, 2004). The University of Alberta Research Ethics Board Study ID Number Pro00121453 granted ethics approval.

Incorporating the Framework of Ethical Space

Willie Ermine developed the idea of Ethical Space initially described by Poole (1972), where two worldviews come together and can “represent a location from which a meaningful dialogue can take place between communities towards the negotiation of a new research order that ethically engages different knowledge systems” (Ermine, 2000, p. 122). Reconciliation is an approach required to correct the Indigenous - Western relationship imbalance., and Ethical Space is a framework that can be used to address health research (Brunger et al., 2014; Greenwood et al., 2017; Nelson & Wilson, 2018; Peltier et al., 2019; Sinclaire et al., 2021; Vukic et al., 2012). This space is created by differing worldviews and is “a neutral zone between entities or cultures.” (Ermine, 2007, p. 202). Ethical Space encompasses recognizing the differences in language, knowledge systems, values, social and political systems and how these can impact interaction and agreements. It is a place for conversation between different cultures and ethical engagement where different underlying values and assumptions are recognized, and there is an understanding of how they influence our decisions (Ermine, 2007). Ethical Space is a place for partnership and creating different ways of thinking in a space that addresses power imbalances (Ermine, 2007). Ethical space was required in this research as it is the space created and navigated by the research group with Indigenous methodologies and Western methodologies.

Kovach (2021) describes methodology as the theory, or belief system, and the method which are research actions. Indigenous methodologies are grounded in the framework of Indigenous ways of knowing, Indigenous ethics, Indigenous community, and experiencing self in relationship (Kovach, 2021). Indigenous research may not necessarily be Indigenous methodology if it is not embedded in Indigenous epistemology, axiology, community, and self and if the research uses Western theoretical perspectives (Kovach, 2021). Kovach describes a Nêhiyaw (Cree) framework that includes Nêhiyaw ways of knowing, decolonizing ethics, researcher preparation, research preparation, making meaning of the knowledge gathered, and giving back (Kovach, 2021). The Alexander Research Committee uses the Nêhiyaw framework, and the university researchers, despite not being Nêhiyaw, worked to understand, respect, and integrate these theoretical perspectives into this research. The research is a blend of integrating the Nêhiyaw framework with Conversation Method (Kovach, 2010), and a decolonizing Western CBPR approach and thematic analysis. Despite using the Nêhiyaw framework as much as possible within the process by integrating Nêhiyaw knowledge systems, respecting relationality, centring the research within the community, self-reflection, integrating Alexander voice to make meaning of the knowledge, and giving back by providing opportunities and shared meals, AR, CS, MM, and AJ are not Nêhiyaw and CBPR and thematic analysis are founded in Western methodologies.

Traditional protocol was followed within this research to ensure respect, trust, and honesty. Protocol usually involves the giving of tobacco, a sacred medicine, when a request to share knowledge is made, especially to an Elder or Knowledge Keeper. Accepting tobacco means a bond has been created, and a relationship is formed in respect. Respect means that sharing will be done to the best of a person’s ability with the knowledge they possess and with a responsibility to be honest in their knowledge (J Kootenay, personal communication, August 23, 2024).

Indigenous Conversation Method

Storytelling has been an essential and legitimate form of imparting knowledge and passing on tradition within Indigenous societies for thousands of years (Dean, 2010; Geia et al., 2013; Kovach, 2021). Story as part of oral tradition and teaching, is embedded within Nêhiyaw ways of knowing and doing, firmly rooting the use of story within Indigenous methodologies and as a research method. Story has been used by many researchers and described as conversation, (Fiddler, 2014; Kovach, 2010), yarning (Bessarab & Ng’andu, 2010), and storywork (Archibald & Parent, 2019) among others. Despite the differences in the Indigenous groups where story has been used, there are similarities in its principles of relationality, sharing, and the participation by both the story-teller and the person receiving the story in meaning making (Kovach, 2021). It recognizes the contribution to decolonization by focusing on the Indigenous voice, centering participants’ values in the research so they are “an active voice for their community’s needs and concerns” (Walker et al., 2014, p. 1218). It is a culturally appropriate research method for Indigenous Peoples, as it is spiritual, relational, and accountable (Bessarab & Ng’andu, 2010; Kovach, 2021; Walker et al., 2014). In addition, using story as a method is collaborative, culturally safe, relaxed, and involved in the development of knowledge (Bessarab & Ng’andu, 2010). Despite many different names for the use of story as a research method, conversation as method was chosen based on Kovach’s (2010) characteristics of a) being linked to a particular Nation way of knowing b) being relational, c) having a purpose such as decolonizing, d) involving protocol, e) being informal and flexible, f) collaborative, and g) reflexive. Conversation as a method is less of an interview and more of a sharing, a natural conversation between two people. If a participant doesn’t answer a question directly, it is the information they need to share with you. There is less of a focus on asking the semi-structured interview questions in the proper order or bringing the conversation back to the exact questions but on trying to incorporate the questions naturally into the conversation. The “interviewer” also shares about themselves while creating a relationship that forms during conversation.

Study Setting

This research was conducted in AFN, a Cree Nation in Treaty 6 territory located 45 minutes NW of Edmonton, Alberta, Canada. The traditional area of AFN was larger than its current geographical size but was illegally reduced when treaties were negotiated. The community has approximately 1,500 people living in Alexander, with the First Nation’s total membership of approximately 2500. Alexander is a sovereign Nation that provides the community with health, education, early childhood services, and other community services. Alexander Health Services operates and manages the Kipohtakawkamik Elders Lodge and Keehewkamik Supportive Living Facilities, the Footprints Healing Centre, and Alexander HeadStart program (Alexander First Nation, 2020). A health center in the community has many healthcare professionals who work on-site or visit the community regularly, but this does not include pharmacists. No community pharmacy is in AFN, and residents use pharmacies in neighbouring communities. The closest community with a pharmacy is approximately 18 km away, with additional options 30–35 km away. A pharmacy is contracted to deliver medications to the supportive living facility in AFN. Because of negotiated treaty rights, members of AFN have some medications covered through the federal government as Non-Insured Health Benefits (NIHB) (Government of Canada, 2021), which provides certain health benefits including medications. Differences in Treaty interpretation between the Crown and First Nations have led to ongoing land, resource, education, and healthcare disputes, including the medicine chest clause in Treaty 6. From a First Nations perspective, Treaty agreements between the Crown and First Nations were held in a spiritual ceremony, upholding First Nations’ sovereign rights to healthcare. During these agreements created in ceremony, the Crown agreed to the provision of holistic healthcare for First Nations and ongoing access to traditional and Western healthcare (C Arcand, personal communication July 17, 2024).

Participants: Sampling and Recruitment

All AFN adult members living on and off the Nation were invited to participate in the study. Inclusion criteria were conversing in English to allow for the consent process, having had at least one interaction with a pharmacist as an adult, and being a member of AFN.

Convenience and snowball sampling were used to recruit participants. Convenience sampling was appropriate for this setting as this is the first pharmacy study within the Nation, and relationships were being developed. Snowball sampling was chosen to efficiently recruit more interested participants from the community (Creswell, 2013). Sampling was conducted until thematic saturation, when no new themes were identified from the conversations, and no new information or relationships emerged between the themes (Rahimi & Khatooni, 2024).

Recruitment was initiated by placing posters approved by ARC throughout the community. The poster was also uploaded to AFN’s social media pages. Posters included eligibility criteria and listed the appreciation gift for participation, participant expectations, and contact details (study phone number and university e-mail) of research team member AR. AR attended a parent conference at the school on the Nation with REB and ARC-approved posters and flyers to recruit participants. Attending a community event demonstrated relationship building and provided an opportunity to provide potential participants with information about the study. AR also spent 2 days at the Nation’s administration office, available to discuss the research and for interviews. AR spent time in the community before and during recruitment, attending social and ceremonial events such as pow-wows, medicine (plant) harvesting, and community celebrations. These combined efforts allowed researchers to reach the largest number of potential participants by reaching all members including those on social media, and people who do not have an online presence.

Interested community members contacted the researcher, and a screening process (see Appendix 1) ensured that individuals met the inclusion criteria, understood the process, and asked if they would like to include a Cree interpreter if conversing in Cree was more comfortable. If the study’s criteria were met, a meeting was arranged to provide potential participants with an information sheet and verbal information about the study and obtain consent. As recommended by ARC, in keeping with oral tradition and Indigenous epistemology, oral consent was obtained from those participants who were more comfortable giving oral consent. Written consent was available as well. Once consent was obtained, an agreed-upon time was arranged for a semi-structured, conversational interview.

Research Process and Data Analysis

Researcher AR conducted one-on-one, in-person, semi-structured interviews, as conversations, in AFN in a private space in the Nation’s administration office, health centre, or school. Conversations were held between AR and participants as this researcher developed relationships within the community, an essential component of Indigenous research (Absolon & Willett, 2015; Wilson, 2008).

A semi-structured interview guide facilitated conversation (see Appendix 2). The interview guide was based on studies examining patients’ experiences with pharmacists (Idowu et al., 2021), trust in pharmacists (Gregory & Austin, 2021), and questions specific to First Nations patients. Questions were co-developed with ARC to ensure cultural safety and respect, and questions important to the First Nation were included. Open-ended questions were used to gather information and allow participants to express their experiences in detail and in a flexible and informal conversation. Updates were made to the interview guide based on concurrent review and reading of interviews during the data collection. The interview focused on exploring prior interactions with pharmacists, expectations and trust in community pharmacists, and perceptions about pharmacist knowledge of First Nations traditional medicines and health concerns. The interview guide was piloted with one Nation member, who agreed to have the conversation be a part of the results.

Each participant received a gift card for groceries or gas and a chance to win two tickets to a sports event recommended by ARC. As required by federal legislation, the participant who won the game tickets answered a skill-testing question to claim the prize.

Interviews were transcribed using Otter.ai® (https://otter.ai/) and confirmed by AR for accuracy. For member checking, AR delivered transcripts in person to participants who responded. Participants who received their transcripts were given the opportunity to review the transcripts to ensure that information was captured correctly. If participants requested a change, their edits were noted on the paper transcript, which was then changed in the electronic copy.

Inductive Thematic Analysis

Vignettes and thematic analysis have been used within Indigenous methodologies (Kovach, 2021). Western methods break data down into sections of code, category, and theme, but Indigenous worldview is very holistic (Kovach, 2021). During the analysis, information can be taken out of context (Kovach, 2021). Indigenous researchers struggle with this tension between Indigenous worldview and the Western approach of breaking people’s stories into small sections (Kovach, 2021; Simonds & Christopher, 2013). To mitigate these tensions, provide an appropriate lens, and contribute to the community, data analysis was completed with an AFN member enrolled in graduate studies. Hiring an AFN graduate student also provided reciprocity as a student gained research experience.

Identifying information was removed from the interviews before being uploaded into Google Drive for all researchers to review. Interviews were played back, and transcripts were read to familiarize researchers with the data. Memos were taken while the transcripts were reviewed. Inductive thematic analysis was used to develop a coding framework. Three researchers, AR, CS and the graduate student (JP) hired from AFN, developed a coding framework using five interviews. Codes and sub-codes were created, discussed, and retained or removed. The remaining interviews were deductively coded concurrently in NVivo® and in parallel by researchers AR and JP using the framework. Codes were added if data were not captured by the codes previously developed. Data were coded line by line and coded if it was relevant to obtain the research objective.

After coding one to three interviews, AR and JP would meet to review, discuss, and agree on all codes. The latent and manifest analysis allowed for the development of codes and themes that were both explicitly stated and allowed researchers to integrate underlying assumptions and ideas. Once all interviews were coded, four researchers (AR, JP, CS, MM) met to discuss overall themes and sub-themes. Similar codes were grouped, and in the first meeting, the coding consistency and coding process were discussed (Idowu, 2021). From these groupings, themes and sub-themes were developed. The process was iterative, and codes were reviewed throughout the process to ensure the themes and sub-themes developed were representative of the codes. The analysis was presented to ARC for input and discussion to provide an Indigenous lens. Discussion with an Elder about how to present the results was required to ensure that Cree perspectives were incorporated into the analysis. A smaller group of ARC community members met with AR to finalize themes and subthemes. AR presented the analysis process, the themes and subthemes, including how they were developed, and codes to support the findings. A graduate committee meeting was also held to discuss the themes and sub-themes.

Ethical Issues

Privacy and Confidentiality: Interviews were conducted in a private office. Confidentiality was maintained by storing all files on a VPN maintained by the University of Alberta’s Information Services and Technology. Research assistant JP did not listen to recorded interviews, received de-identified interviews, and signed a confidentiality waiver regarding the data.

Ownership, Control, Access and Possession (OCAP©): Ownership, Control, Access and Possession (OCAP©) are guiding principles for research with First Nations people (First Nations Information Governance Centre, n.d.; Schnarch, 2004). Ownership is the relationship of a First Nation community with its knowledge and data. Control is the ability of First Nations to determine all portions of research. Access is the ability for First Nations to obtain their information and data, no matter where it is stored. Possession is the ability to own and keep data. Within this research, no traditional knowledge or sensitive information will be published unless approved by the ARC, which is only for the First Nations to share. The ARC represents AFN and controls all aspects of this research, including determining the research objective, methods, analysis, and knowledge dissemination. In keeping with the principles of OCAP©, ARC will receive a copy of the thematic analysis and coding. Through discussion with ARC, it was decided that raw data would not be provided to ARC to ensure that participants felt safe disclosing health information that would potentially be identifying and may be very personal.

Tri-Council Policy Statement 2 (TCPS) Research Agreement: Chapter 9 in the TCPS 2 (Canadian Institutes of Health Research et al., 2018) recommends implementing a research agreement under article 9.11. However, they also state that it is up to each Nation to determine how research is conducted based on their own sovereignty. Prior to the research proposal being presented, and in keeping with cultural practices, protocol was given to an AFN member, which was the start of a relationship. During the first year of developing the research protocol, researchers CS and AR met with the ARC at seven monthly meetings. AR built relationships at the meetings and in the Nation during community events. On the basis of The ARC Guiding Principles verbal consent was provided for the research project. The relationship and time commitment have continued with monthly ARC meetings. For REB approval purposes, a letter of support was provided.

Participant safety: Plans were developed to deliver trauma-informed care for participants who may have had a strong emotion triggered during the conversation. The plan was for AR to stop the recording and ask if they would like the interview paused, stopped, or rescheduled. AR took trauma-informed care training in the event that she needed to provide support to participants. The ARC directed and supported AR’s guidance in providing participants with the phone numbers for different support systems within AFN if necessary.

Methodological Rigor

Rigor was contextualized with credibility, transferability, dependability, and confirmability (Lincoln & Guba, 1985). Indigenous conversational methodology allowed data collection to be conducted in a culturally appropriate way, incorporating Indigenous epistemology. Hiring an AFN research assistant and ensuring ARC was involved in the thematic analysis created credibility and cultural validity from an AFN lens. Credibility, or the trustworthiness of the data, was achieved by thematic saturation, member checking, researcher triangulation, and peer debriefing. Transferability is how applicable the findings are to other settings (Lincoln & Guba, 1985) and is done by “providing detailed thick description of the setting and participant” (Mayan, 2009, p. 102). The setting has been thoroughly described, including healthcare services for the Nation, to ensure the transferability of knowledge. Dependability is the ability to see how decisions have been made throughout the research process (Lincoln & Guba, 1985; Mayan, 2009). Two researchers (AR, JP) coded independently, checking deductively to ensure the themes explained the data and the decision process throughout the research project was documented. Finally, AR located herself in the report to acknowledge bias and situate herself in the research. Raw data, memos, and iterations of the changes during the process were saved to demonstrate how interpretations and results are derived from the data to allow for confirmability.

Knowledge Translation

Dissemination occurred throughout the research process to maintain effective communication and transparency with all members. The relationship-building phase and early results have been presented in posters and oral presentations, with an ARC member co-presenting. Ongoing plans are inclusive and will include disseminating results to the Nation through a community feast. A traditional knowledge translation approach will be taken with publications, presentations, and continuing professional development with pharmacists and pharmacy professional bodies. A videographer will create videos to bring results to community pharmacists and Nation members.

Conclusion

To date, very little research has been conducted within Canada in the field of pharmacy with Indigenous Peoples. Although pharmacists interact with Indigenous People, a Western-business model has been traditionally used. In response to the TRC, healthcare professionals need to recognize the healing practices of Indigenous People. Their knowledge must be incorporated into health care to advance health. Using Community-Based Participatory Research with the Alexander Research Committee incorporates First Nations’ ways of knowing in an equitable partnership. Having research outcomes driven by a community can develop policies and practices based on Indigenous ways of knowing respectfully and meaningfully. In addition, a rigorous qualitative study guided by Indigenous and Western methodologies will provide evidence-informed change in structure and policy. A strength-based or desire-based approach to this work will promote awareness and changes within the pharmacy profession to be more responsive, respective, relevant, and reciprocal to Indigenous Peoples in a way that honours their worldview.

Supplemental Material

Supplemental Material - Alexander First Nation Members’ Views of Their Relationships With Community Pharmacists: A Qualitative Study Protocol

Supplemental Material for Alexander First Nation Members’ Views of Their Relationships With Community Pharmacists: A Qualitative Study Protocol by Amber Ruben, Alexander Research Committee, Jeannie Paul, Mark Makowsky, Allyson Jones, and Cheryl A. Sadowski in International Journal of Qualitative Methods

Footnotes

Acknowledgments

From the University of Alberta, we would like to thank Dr. Dean Eurich from the School of Public Health for reviewing the research protocol and manuscript. We also wish to thank Dr. Nancy Van Styvendale from the Faculty of Native Studies and Dr. Arnaldo Perez Garcia from the Faculty of Medicine & Dentistry for their contributions in the form of many discussions about Indigenous and Western methodologies, respectfully. We would also like to acknowledge Dr. Jaris Swidrovich from the Leslie Dan Faculty of Pharmacy at the University of Toronto for his Indigenous academic pharmacist mentorship.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by Social Sciences and Humanities Research Council (892-2022-3112), Indigenous Wellness Core (RES0061401), Indigenous Primary Health Care and Policy Research (10028230-70000). AR was supported with a studentship from the Alberta Strategy for Patient Oriented Ressearch Support Unit.

ORCID iDs

Allyson Jones

Cheryl A. Sadowski

Supplemental Material

Supplemental material for this article is available online.

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