Identifying Relevant Content to Inform a Comprehensive Indigenous Health Curriculum: A Scoping Review

Abstract

Purpose:

To identify the entry-level curricular content related to Indigenous health recommended for entry-level physiotherapy (PT) programs in Canada and other similar countries.

Methods:

Design: Scoping review. Procedures: Four electronic databases were searched using the terms physiotherapy, Indigenous health, entry-level curriculum, and their derivatives. Grey literature sources were hand searched and included Canadian PT professional documents, PT Program websites, Truth and Reconciliation Commission (TRC) sources, and a Google search. Data related to curriculum characteristics, methods of delivery, and barriers and facilitators to implementation were extracted from relevant references. Stakeholders reviewed study findings.

Results:

Forty-five documents were included. Documents focused on Indigenous peoples in Canada, Aboriginal and Torres Strait Islanders in Australia, and Māori in New Zealand. Canadian PT programs appeared to rely on passive teaching methods while programs in Australia and New Zealand emphasized the importance of partnering and engaging with Indigenous people. Barriers to incorporating indigenous health curriculum included an overcrowded curriculum and difficulty establishing relevance of Indigenous content (i.e., meaning).

Conclusions:

Similarities and differences were found between curricula content and approaches to teaching IH in Canada and the other countries reviewed. Strategies to promote greater engagement of Indigenous people in the development and teaching of IH is recommended.

In Canada, Indigenous is a term used to collectively recognize individuals who self-identify as Aboriginal, First Nations, Metis, or Inuit.^1,2 Indigenous views on health and wellness are shaped by the traditional knowledge and worldview of their ancestors.³ Prior to European colonization, Indigenous peoples had their own medicines and health traditions, many of which have survived colonization.^4,5 These practices focus on holistic health and concentrate not only on physical health, but also balancing the emotional and spiritual health of individuals in relationship with their communities (i.e., families and land: past, present, and future).^3–7 Indigenous health (IH) can be defined as the physical, emotional, social, spiritual, and cultural well-being of Indigenous people, not merely the absence of disease or infirmity.^8–10 This includes, but is not limited to, the considerations of IH issues including the history and legacy of residential schools, the United Nations Declaration on the Rights of Indigenous Peoples, Treaties and Aboriginal rights, Indigenous teachings and practices, health and wellbeing of First Nations people, the First Nations principles of ownership, control, access, and possession (OCAP), and the ability to access, utilize, and leverage resources, opportunities, and voice.^11–15

As of 2021, the number of people in Canada who self-identified as Indigenous was 1,807,250 – accounting for 5% of the Canadian population.¹⁶ There have been well-documented health and socioeconomic inequities between Indigenous and non-Indigenous populations in Canada as a direct and long-term result of colonization and its impact on destabilizing the determinants of IH.^17,18 Indigenous populations in Canada are on average younger than non-Indigenous Canadians, yet are burdened with a higher prevalence of illness, chronic conditions, and injury.¹⁸ Examples include higher rates of arthritis, asthma, diabetes, and obesity.¹⁸ Additionally, First Nations people living on reserves are reported to experience a 32 times higher rate of active tuberculosis while Inuit individuals have a 300 times increased rate compared to non-Indigenous Canadians.¹⁸ It is through this lens of health inequity that the health impacts of colonialism, racism, inability to pursue self-determination, health inequalities, social exclusion, and loss of Indigenous language become evident.¹⁸

The Truth and Reconciliation Commission (TRC) of Canada was established in 2008 as a result of the Indian Residential Schools Settlement Agreement (IRSSA).¹⁷ The TRC's purpose was to reveal the truth about Canada's residential school system and its legacy, in addition to promoting lasting reconciliation between Indigenous and non-Indigenous peoples in Canada.¹⁷ The TRC's final report, published in December 2015, included 94 recommendations, referred to as “Calls to Action.” These were directed at governments, educational and religious institutions, civil society groups, and all Canadians to address several areas of reconciliation.¹⁷ Of these 94 Calls to Action, eight relate specifically to Aboriginal health, including a call upon all levels of government to provide cultural competency training for all healthcare professionals (Call to Action Number 23) and a call for educational programs to offer a course to health professional students on Aboriginal health issues (Call to Action Number 24).¹⁷ Further, the final report of the National inquiry into missing and murdered Indigenous women and girls calls for justice includes a section on health and wellness (Section 3).¹⁹ Within this section, governments are called upon to establish culturally competent and responsive crisis response health teams in all communities and regions to meet the needs of Indigenous people, families, and/or communities after a traumatic event (Call to Justice 3.5).¹⁹ Cultural competency is defined as “a set of congruent behaviours, attitudes, and policies that come together in a system, agency, or among professionals and enable that system, agency, or those professionals to work effectively in cross-cultural situations.”²⁰ In healthcare, cultural competence requires an understanding of cultural issues, as well as the capacity to adapt care to culturally diverse patient populations.²⁰ The TRC outlines an expectation that strategies are put in place to ensure student physiotherapists are trained to be culturally competent practitioners.¹⁷

There are 15 accredited PT programs across Canada which are all administered at the graduate level (i.e., students receive a professional Master's degree upon completion). Physiotherapy (PT) education in Canada is guided by the Physiotherapy Education Accreditation Canada (PEAC), and they are responsible for determining the entry-to-practice milestones that PT programs in Canada must adhere to.²¹ In 2020, PEAC published an updated accreditation standards document for Canadian PT programs. Criteria 5.4 and 5.5 of the standards section directly address social justice, human rights, equity, diversity, and inclusion.²² Section 5.4 states “The program demonstrates a commitment to relational accountability to Indigenous Peoples and their communities,”²² while Section 5.5 takes a broader approach and states “The program demonstrates a commitment to educational and healthcare environments that are justice-driven and anti-oppressive.”²² The document includes examples that indicate fulfillment of these criteria, including evidence of opportunities for students to learn from Indigenous educators and Elders, as well as providing education on intersectionality and its impact in healthcare.²²

While there has been a review of cultural safety curricula in Canada²³ and an examination of the changes that Canadian physiotherapy curricula are undergoing in relation to Indigenous peoples and their communities,²⁴ and a review of the PT Program curricula in Australia and New Zealand exists,²⁵ currently no review exists summarizing the current Canadian PT entry-level curriculum content and comparing it to those in other countries. Therefore, the purpose of this scoping review is to identify entry-level curriculum content related to IH recommended for PT programs in Canada and other similar countries. Specifically, we will address the following research questions: (1) what IH curricular content is recommended for Canadian entry-level PT programs?; (2) What IH curricular content is recommended for PT programs outside of Canada?; (3) What learning activities are used in teaching IH content?; and (4) What are the barriers and facilitators to incorporating IH curricular content into PT programs? This information is important for educators when considering the scope of current IH curriculum and the strategies required to improve IH content in entry-to-practice PT curriculum.

Methods

The scoping review methodology was informed by the recommendations of Arksey and O’Malley²⁶ and utilized the six stages outlined by Levac et al.²⁷ The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) guided the reporting of this review.²⁸ Indigenous stakeholders were included throughout the scoping review process. Individuals who identify as Indigenous were engaged not only as an author, but as a consultant that provided suggestions throughout the process and also as part of the stakeholder group that provided feedback on the findings/results. The review was registered on the Centre for Open Science's OSF Registry (https://osf.io/4caer).

Search strategies

The search strategy for this scoping review was derived with the help of a Health Sciences Librarian. We retrieved peer-reviewed literature from four established databases (CINAHL, EMBASE, EMCARE, and OVID Medline) and grey literature. For the peer-reviewed literature, keywords were identified based on relevant terms related to the topic and were adapted to each database. The keywords used related to the terms: “physiotherapy” or “physical therapy,” “Indigenous Health,” and “entry-level curriculum.”

Sources of grey literature were comprised of national professional documents including Physiotherapy Education Accreditation Standards for Canada (PEAC), the 2019 National Physiotherapy Entry-to-Practice Curriculum Guidelines from the Canadian Council of Physiotherapy University Programs (CCPUP), and all Canadian PT regulatory bodies’ position statements and resources about IH. Canadian PT programs’ websites were searched for online curriculum materials regarding IH, as well as sources regarding the Truth and Reconciliation Commission (TRC). Additionally, the World Physiotherapy guidelines for minimum entry-level requirements for programs across the globe, and the national accreditation standards for the PT curriculum in other select countries were retrieved and examined. External links and resources contained within the grey literature were also accessed for review. Within these sources and websites, search terms associated with “Indigenous Health,” or “Aboriginal Health” were included. Lastly, a Google search was conducted using the search terms “physiotherap*” or “physical therapy,” “curriculum” or “entry-level,” and “Indigenous Health” on the American, New Zealand, Australian, and Canadian Google platforms. Beyond website content, search results were limited to files in a PDF format, and only results from the first three pages of each Google search were included in the review.

Eligibility criteria

To be included in this review, documents needed to address the concepts of (i) IH, (ii) in PT education, and (iii) within an entry-level program or curriculum. Curriculum was conceptualized to include the range of competencies that the student was required to successfully demonstrate by the end of their PT education program. Search results were limited to documents written in the last 10 years (i.e., January 2012–February 2022) and published in English. Grey literature sources were gathered from Canada, United States (US), Australia, and New Zealand (NZ). These countries (US, Australia, and NZ) were chosen as comparators as they have similar PT standards, population demographics, income status to Canada,²⁹ and they have somewhat similar colonization histories.³⁰

Process for selection

All references found during the search were uploaded into the Covidence software (https://www.covidence.org) and duplicate studies were removed. At the first phase of screening, authors (JG, CG, WS, SK, CH, BD) independently conducted title and abstract screening in duplicate using the Covidence platform. If either reviewer selected “include” at this stage, the reference was moved forward to full text screening. Full text screening was conducted independently by the same authors in duplicate. Disagreements were resolved through discussion or consultation with an expert third reviewer (PM, JST).

The grey literature search consisted of three steps. In Step 1, authors (JG, CG, WS, SK, CH, and BD) were assigned a specific set of the identified websites to search. In Step 2, a random 20% of each subset of websites was reviewed in duplicate by a different reviewer who was blinded to the results of the initial review. In Step 3, full texts of included records from all grey literature sources were screened by the six reviewers in duplicate to ensure they met the criteria for inclusion. Lastly, the reference lists of all included records from both the peer-reviewed and grey literature sources were examined to identify any additional literature that was relevant.

Data collection:

Data were extracted from eligible studies in duplicate by six authors (JG, CG, WS, SK, CH, and BD) working in pairs. Authors extracted data using a data collection spreadsheet guided by the PRISMA-ScR.²⁸ Data collected included title, author(s), country, journal, date of publication, document purpose/objective(s), Indigenous population, and type of document (e.g., report, peer-reviewed article). Additionally, a list of main topics relating to IH and entry-level PT IH content were identified a priori and subsequently modified iteratively by the research team and an IH consultant as the scoping review progressed, along with barriers and facilitators for integration into the PT curriculum when included, and the learning activities used to teach the IH curriculum (if reported). The learning activities were categorized into active (i.e., where students engage and participate with peers, patients, or faculty) and passive (i.e., where information is received from an instructor as in a lecture).³¹

Data synthesis and analysis:

Findings were collated using descriptive statistics and a summary of themes. This process included identifying similar and unique characteristics of curriculum content, learning activities used, and barriers and facilitators to IH curriculum implementation.

Stakeholder input:

A two-page summary of results was emailed to stakeholders who were experienced with curriculum development for entry-level PT programs related to IH content and/or identified as an Indigenous person in Canada. Within the email they were also sent a link to a brief online survey in Google Forms which included four open ended questions (see online appendix 1 for questions asked). In the survey they were asked to provide feedback about the findings and offer suggestions about how to improve the curriculum of PT Programs related to IH. Two authors with experience in qualitative research (JST and PM) identified themes within the stakeholders’ responses using content analysis.³²

Results

Overall, 4,995 documents were screened for eligibility. Eighty-five documents were included for full-text examination, of which 41 were excluded as they did not meet the eligibility criteria of this review. Therefore, 45 documents were included in this scoping review. See Figure 1.

Figure 1.

PRISMA flow diagram.

Document characteristics:

Nine included documents were peer reviewed articles,^25,33–40 and 36 documents were retrieved from the grey literature.^{22,24,41–74} Twenty of the documents (43%) addressed IH topics in Canada,^{22,24,37–39,41–53,71,74} 16 (38%) addressed IH topics in Australia,^{33–35,54–58,60,62–65,69,70,72} 5 (9%) addressed IH topics in New Zealand,^{40,66–69,73} and 4 (6%) in Australia and New Zealand together.^25,36,59,61 Characteristics of the included documents are found in online appendix 2.

Indigenous populations:

Twenty documents (45%) identified specific Indigenous populations. Seven of the documents (15%) focused on the Indigenous peoples in Canada, namely First Nations, Metis, and Inuit.^{22,24,37–39,41,50} Eight of the documents (18%) focused on Aboriginal and Torres Strait Islanders,^{33–35,54,60,63,64,69} four (9%) on a combination of Aboriginal and Torres Strait Islanders and Māori together,^25,36,62,65 and one (2%) exclusively on Māori peoples.⁴⁰

Accreditation standards

National accreditation standards for PT entry-level education were included for three of the four countries examined (Canada,²² Australia,^57,61 and New Zealand^61,68,73). No specific standards were seen to relate to IH topics in the document for the United States.⁷⁵

IH curricular characteristics:

Of the 36 documents from the grey literature included in this scoping review, our search identified documents from seven Canadian academic institutions that identified IH curriculum compontents.^45–53 Curricular content topics identified in these Canadian documents included: Indigenous history in Canada, Indigenous health inequity, cultural competence, reflections about one's culture, attitude, and beliefs, social determinants of health, colonial history of Canada, and Indigenous worldviews/perspectives and ways of knowing. Our search also identified elective opportunities related to IH which provided the opportunity for students to engage with Indigenous communities. This included a placement in an Indigenous community, an elective course on IH, an elective seminar on IH, an interprofessional course about IH, and “land-based” learning experiences. See online appendix 2.

Information on 18 PT programs in Australia and New Zealand was located for the purpose of this study. Seventeen of these programs (94%),³⁶ included learning objectives addressing Indigenous or First Peoples Health and other related issues (n = 17, 80%),³⁶ or culture or cultural responsiveness (n = 9, 42%) in their curriculum.³⁶

Method of delivery

The method for delivering IH content described in the entry-to-practice PT curricula in Canada found in this scoping review included both passive and active learning activities. There were didactic sessions (n = 4, 26% of reported teaching methods in Canadian curricula),^48,49,52,74 interactive activities such as debates, field trips, and community engagement (n = 3, 20%),^44,49,52 art projects (n = 3, 20%),^37,49,74 guided self-reflection (n = 2, 13%),^49,74 clinical experience (n = 3, 13%),^47,50,51 and required readings (n = 1, 7%).⁴⁹ Similarly, the method for delivering IH content in entry to practice PT curricula outside of Canada found in this review also included active and passive strategies. Strategies included debates, field trips, and community engagement activities (n = 9, 41%),^{33,60,61,63–65,69,71,72} didactic sessions (n = 7, 31% of reported teaching methods outside of Canada),^{33,64–66,69,71,72} guided self-reflection (n = 2, 9%),^33,72 case-studies (n = 2, 9%),^35,65 required readings (n = 1, 5%),⁶⁵ and online videos (n = 1, 5%).⁶⁵ Five documents included in this review recommended the Canadian curriculum be modified to include more interactive and experiential learning strategies.^{25,36,39,55,59}

Barriers to the integration of Indigenous health content in entry-to-practice physiotherapy curricula:

Ten of the included documents (seven from the grey literature and three peer-reviewed journal articles) identified barriers to incorporating content related to IH into entry-to-practice PT curricula.^{24,25,34,36,55,56,58–60,65} The most cited barriers included curricular factors (e.g., overcrowded curriculum, difficulty establishing relevance of Indigenous content (i.e., meaning), difficulty assessing Indigenous content, scheduling challenges; n = 7, 70% of documents),^{24,25,34,55,56,60,65} program factors (e.g., inadequate resources, staffing, finances; n = 6, 13%),^{24,25,56,59,60,65} institutional factors (e.g., lack of Indigenous faculty, colonial structures within academic institutions, difficulty creating a safe learning environment; n = 4, 9%),^24,25,59,60 personal factors (e.g., student/faculty resistance, personal discomfort with subject; n = 4, 9%),^24,25,34,60 and regulatory factors (e.g., absence of clear and specific national standards; n = 3, 7%).^24,58,65

Facilitators to the integration of Indigenous health content in entry-to-practice physiotherapy curricula:

Twenty included documents discussed facilitators for achieving IH related learning objectives in an entry-to-practice PT curriculum, some of which discussed multiple facilitators. Commonly identified facilitators included: integrating additional coursework or workshops focused on IH (n = 13, 65% of identified facilitators),^{33,35,39,49,55,56,59,63,63,65,69,71,72} increased involvement of Indigenous people in teaching and course material development (n = 8, 40%),^{34,40,57,58–60,69,72} increased PT program focus on IH funding, education, and policy (n = 4, 20%),^24,47,52,71 and updated accreditation standards aimed at increasing graduate cultural capabilities in addition to their clinical capabilities (n = 1, 5%).⁵⁸

Feedback from stakeholders:

Of the seven stakeholders who were contacted, five agreed to review the summary of findings and provide comments on the results of this scoping review. Among the respondents, four stakeholders identified as an Indigenous Person, two as educators, and two as healthcare workers (three identified multiple roles). Stakeholders were surprised with the relative lack of identified contribution of Indigenous people to Canadian PT curriculum development and felt this was an area for future educational focus in Canadian PT schools. This group felt that the “partnership” (i.e., working together with Indigenous communities to create strategies for optimal IH promotion and appropriate PT services⁶⁸) and “participation” (i.e., involving Indigenous peoples on all levels of the health sector allowing for decision making, planning, development, and delivery of health services⁶⁸) are important for faculty of Canadian PT programs to explore so as to create meaningful and culturally responsive educational opportunities for PT students.

Discussion

This review highlights gaps in the curriculum of entry-level PT programs in Canada and can be used to develop a more comprehensive curriculum for future generations of Canadian physiotherapists. With this additional knowledge and skills, future physiotherapists may provide more culturally competent and comprehensive care, thereby assisting to close the large care gaps that present in many Indigenous communities in Canada.

There was a difference between the entry-level PT curriculum content related to IH identified in accreditation standards in Canada compared to those of the three other countries explored in this review. The influence of important national reconciliation documents appears to play a major role in directing the content in respective countries. In general, the national standards and content of the various PT program curricula for IH appear to be influenced by international frameworks, such as the United Nations Declaration of Indigenous Peoples (UNDRIP),⁷⁶ as well as the country-specific reconciliation initiatives.⁷⁷ For example, in Canada, the Accreditation Standards for Canadian Entry-to-Practice Physiotherapy Education Programs cite as a key influencer, the Final Report of the Truth and Reconciliation Commission (TRC) of Canada and its 94 “Calls to Action.”¹⁷ The impact of the TRC on Canadian PT curriculum content requirements was evident in our results in that Canadian PT accreditation standards and curricula both emphasize content directly related to the TRC's Final Report (e.g., the history and legacy of residential schools).¹⁷ This historical focus is consistent with Canada's model of “Truth and Reconciliation,” which prioritizes the promulgation of history (or “Truth”) as the foundation for reconciliation.⁷⁷ By contrast, entry-to-practice PT standards in New Zealand and Australia are driven by each of these country's respective reconciliation efforts, including the Treaty of Waitangi in New Zealand,⁷⁸ and Closing the Gap in Australia.⁷⁹ So, PT Program curricula in Canada features content specific to Canadian “Truth and Reconciliation,” such as the history and legacy of residential schools, while PT content in New Zealand and Australia emphasize partnership with and participation of Indigenous peoples.⁶¹ This review, therefore, reflects and highlights that Canadian PT standards stress teaching about colonial history, whereas those of Australia and New Zealand prioritize partnership with Indigenous peoples. It is interesting to note that the draft American accreditation standards (2023) includes the expectation that the curriculum addresses anti-racism, health care disparities, and the social determinants of health, which are all topics relevant to the provision of care to Indigenous peoples, however, did not explicitly identify IH and was therefore not included in this review.⁷⁵

The extent of involvement of Indigenous peoples in the development of accreditation standards and curricular content varied between Canada and the other countries explored in this review. While cultural competency and the understanding of Indigenous perspectives and worldviews were common topics found throughout the accreditation standards and many curricular documents, there appeared to be greater emphasis on the role of Indigenous people noted in countries other than Canada. For example, Australia and New Zealand emphasize an importance on three key components of Indigenous involvement: participation (involving Māori on all levels of the health and disability sector allowing for decision making, planning, development, and delivery of health and disability services),⁶⁸ partnership (working together with Māori communities on all levels of healthcare to create strategies for optimal Māori health promotion and appropriate services),⁶⁸ and protection (responsibility of the Government to ensure that Māori have the same level of health as non-Māori, while safeguarding the cultural concepts, values, and practices throughout the whole process).⁶⁸ In the New Zealand and Australia documents, there were examples of how Māori representatives from all levels of the healthcare sector are included to make decisions, develop, and evaluate the changes that are being suggested to curricula to safeguard and respect Māori values and practices. When comparing the involvement of Indigenous voices and perspectives in the creation, development, and execution of curricula and accreditation standards, there appears to be a lack of emphasis on partnerships with Indigenous populations in Canadian programs. Rudman and colleagues highlighted the importance of partnerships to develop reciprocal relations that are sustainable and to ensure that content is accurate and meaningful to Indigenous peoples.⁸⁰ A recent study by Arcobelli,²⁴ suggests that to progress reconciliation efforts in the PT profession in Canada, all PT programs should participate in authentic and reciprocal relationships with Indigenous peoples as an accreditation standard.²⁴ The inclusion of Indigenous voices to assess and provide suggestions during curriculum development, as well as in delivering IH curriculum content can be ways to progress the involvement of Indigenous peoples in entry-to-practice PT programs.^24,80

While our findings indicate that IH content was taught using both active and passive learning activities, Canadian programs appeared to rely more heavily on passive teaching strategies such as didactic lectures while also including some active teaching methods such as debates, field trips, community engagement, and self-reflections. Programs outside of Canada on the other hand, appeared to rely most heavily on active teaching methods such as interactive experiences, self-reflections, and case studies, while also implementing some passive strategies like didactic lectures. In a recent systematic review by Leahy and colleagues,⁸¹ active teaching methods appeared to be more effective at changing physiotherapist behaviour than passive methods. The important role of experiential learning activities is echoed in the findings of a recent scoping review conducted by Guerra and Kurtz²³ around cultural competency and safety education of healthcare professionals and students in Canada. They cite the importance of engaging members of the Indigenous community to enhance students’ understanding as well the promotion of reflection among the students in order to improve their understanding of their own cultures.²³ Further research is needed to identify the best learning activities to promotes changes in the behaviours and attitudes among student physiotherapists as they relate to IH content.

The results of this scoping review have identified a number of suggestions for the advancement of the entry-to-practice curriculum regarding IH content. Since Canada seems to have less focus on interactive and experiential learning than elsewhere in the world, we suggest that the curricula be modified to increase the number of experiential and simulation-based learning activities. Experiential learning activities place a greater emphasis on practical situations and learning through direct experiences.²⁵ This could be accomplished by incorporating clinical simulations with the use of Indigenous standardized patients. These types of experiential learning will allow students to better understand the individuals they work with, to reflect on their experiences, and to see the direct effects of their actions while receiving critical feedback.²⁵ Further, including Indigenous peoples in the creation and evaluation of curricular content is key to advancing the entry-to-practice IH PT curriculum.^56,59 Involving local Indigenous communities in designing content and as key evaluators was a major goal expressed by two documents suggesting that the recipients of care be the ones to evaluate whether students are culturally competent.^56,59 It is also suggested that PT program faculty liaise with local Indigenous communities in the assessment and development of IH learning objectives, for both in-person and online platforms.^36,59

There is a lack of research that evaluates the effectiveness of current methods used to incorporate IH curriculum content. While there were noticeable differences identified in content between Canada and other similar countries, the evidence is unclear as to which intervention would foster higher levels of cultural competency. Therefore, future research is needed to understand how various content or learning activities impact cultural responsiveness in students. Additionally, future research should focus on identifying specific learning outcomes that align with the learning objectives for the advancement of cultural responsiveness. To evaluate the complex skills and behaviours associated with developing cultural responsiveness, performance-based assessments are recommended to assess the ability of students to apply knowledge into practice.²⁵ In a recent systematic review examining the interventions, outcomes, and measures used to improve the cultural competence of healthcare practitioners, a range of outcomes were identified including self-reported tools regarding the practitioners’ knowledge and attitudes, as well as four validated measures.⁸² These authors cited the importance of reducing reliance on self-report measures, identifying valid and reliable measures to enable comparisons across programs and studies, and considering the role of tools completed by the patients.⁸² Therefore, to be confident that students have advanced in the development of cultural responsiveness, future research should explore the development and validation of measures used with both students and practitioners to assess this construct.^25,36

There are several limitations within this scoping review. Firstly, only documents published in English within the last 10 years were included in this review. This timeline includes the years of the COVID-19 pandemic (i.e., starting March 2020) and it was not clear if our search results related to curriculum content and methods of teaching were impacted by changes to publishing and posting practices (i.e., the grey literature) influenced by the pandemic. Additionally, grey literature searches were limited to include only Canada, Australia, New Zealand, and the US. This potentially excludes a subset of data available on IH-related curricular content that is written in other languages or published in another countries. Further, our search strategy only identified a very small number of documents from specific PT entry-level programs that described IH, and there are an increasing number of health professional programs across Canada delivering IH curriculum through an interprofessional and/or an integrated curriculum^83,84 (i.e., including student PTs) which our search did not identify. We acknowledge that our search strategies of the identified databases and grey literature sources may have limited the identification of these curriculum documents and others which described IH content. Furthermore, for those that were identified, there was a lack of detail about the specific learning objectives and the method of delivery. For example, we did not identify specific information on trauma and violence-informed care in PT curriculum, which is an important component of IH. Therefore, it was difficult to identify exactly what IH content is currently being taught, and how programs may differ from one another. However, a strength of this review is the inclusion of Indigenous stakeholders in planning, conducting, and reviewing results, which gives credibility to the findings of this review.

Conclusion

This scoping review identified the curricular content related to IH for entry-level PT programs in Canada, methods of delivery of this content, and compares those to PT programs in other countries with colonial histories such as Australia, New Zealand, and the United States. Similarities (content and accreditation standards focusing on developing cultural competency and learning about Indigenous worldviews) and differences (such as method of delivery for IH content, and the emphasis on partnering with Indigenous populations to develop, refine, and evaluate curricula) were found between Canada and the other reviewed countries. There were many barriers identified to incorporating content related to IH into entry-to-practice PT curricula (e.g.., overcrowded curriculum, difficulty establishing relevance of Indigenous content, inadequate resources). Facilitators to integrating IH education included increased involvement of Indigenous populations in teaching and course material development. Educators and those responsible for drafting accreditation standards can use this information to improve IH content in entry-to-practice PT curriculum.

Key Messages

What is already known on this topic:

Health inequities exist between Indigenous and non-Indigenous populations in Canada. The Truth and Reconciliation Commission of Canada recommends that cultural competency training and a course on Aboriginal health issues occur for all health professionals during training. In 2020, PEAC published updated accreditation standard for Canadian PT programs and included standards related to IH and equity, diversity, and inclusion. No review exists summarizing current Canadian PT entry-level curriculum content compared to other countries.

What this study adds:

Canadian curriculum content topics related to IH included Indigenous history in Canada, Indigenous health inequity, cultural competence, reflections about culture, social determinants of health, colonial history of Canada, Indigenous worldviews and ways of knowing. Both passive and active learning activities to deliver this content were observed, however, the inclusion of Indigenous peoples in curriculum development and delivery seemed to be more of a focus in countries outside of Canada. Barriers to incorporating IH into PT entry-level curriculum included an overcrowded curriculum, inadequate resources, and a lack of involvement from Indigenous Peoples.

Appendix 1. Questions Asked in Stakeholder Feedback Survey

Question 1: Did anything stand out to you from the results of this project? Question 2: How do you think project findings can be used to improve Indigenous Health curriculum in physiotherapy? Question 3: What else is needed (i.e., in research, education, practice) to improve Indigenous Health curriculum in physiotherapy in Canada? Question 4: Do you have any other comments on the value of this topic in physiotherapy?

Appendix 2. Document Characteristics

GREY LITERATURE
Author; year	Geographical Location	Document Type	Document Overview	Main IH Content Topic(s)	Learning Activity Type
Accreditation Standards
Physiotherapy Education Accreditation Canada (PEAC); 202022	Canada	PDF document	Accreditation standards of establish competencies related to Indigenous peoples in Canada	Indigenous teaching and practices Accreditation standards	NA
Physiotherapy Board of Australia & Physiotherapy Board of New Zealand; 201561	Australia & New Zealand	PDF document	Outlines physiotherapy accreditation standards relating to Indigenous health in Australia and New Zealand.	Social determinants of health of Indigenous peoples	NA
Physiotherapy board of New Zealand; 201973	New Zealand	PDF document	Accreditation Standards for Physiotherapy Practitioner Programs in Aotearoa New Zealand	Cultural competency Cultural safety Physical, emotional, social, spiritual, and cultural well-being of indigenous people	NA
Physiotherapy Board of New Zealand; 201868	New Zealand	PDF document	Provides information on the establishment of a framework of standards related to physiotherapists in New Zealand.	Social determinants of health of Indigenous peoples Treaties and Aboriginal rights	NA
Australian Physiotherapy Council; 202157	Australia	PDF document	This document outlines various criteria required in academic curricula related to IH	Curriculum Content	NA
UNIVERSITY DOCUMENTS
University of Alberta; 202245	Canada	Website	Admissions requirements to physical therapy program at the University of Alberta. States that all students admitted to the MSc PT program are required to complete a course focused on Indigenous history in Canada, as a program prerequisite.	Indigenous teaching and practices	NA
University of Alberta; 202146	Canada	Website	Lists MScPT program requirements (one course related to indigenous health as part of the MSc PT curriculum).	Truth and Reconciliation	NA
McMaster University; 202151	Canada	PDF document	Program Handbook for McMaster physiotherapy students that outlines specific academic regulations and general information related to the Program. Discusses “Northern Studies Stream” related to IH	Indigenous teaching and practices	Active (i.e., clinical experience)
University of Toronto, Department of Physical Therapy; 202148	Canada	PDF document	MScPT Student Handbook 2021-2022, highlights educational values.	Indigenous teaching and practices	Passive (i.e., didactic session with critical thinking)
McGill University; 202149	Canada	PDF document	McGill University BSc Rehabilitation Science course curriculum and required readings including: Geddes, G. (2017). Medicine unbundled: A journey through the minefields of Indigenous health care.	Racism related to interactions with Indigenous peoples Allyship related to interactions with Indigenous peoples	Active (i.e., clinical experience) and passive (i.e., lectures)
Reeder, M.; 201650	Canada	Website	Description of cultural competency in the MScPT program and process for Indigenous applicants	Voice / Acceptability (the opportunity for an individual to choose / autonomy / being the decision maker of the access points)	Active (i.e., clinical experience)
McMaster University; 202047	Canada	PDF document	MSc PT program handbook for 2020-2021. Discusses the McMaster Northern Studies Stream (NSS), which is partly meant to increase student awareness of health issues/practices/cultural related to Indigenous peoples in northern Ontario	Indigenous teaching and practices	Active (i.e., clinical experience)
University of Manitoba; 201952	Canada	PDF document	Master of Physical Therapy Program Guide. Discusses cultural safety and cultural competency education at the University of Manitoba.	Physical, emotional, social, spiritual, and cultural well-being of Indigenous people Truth and Reconciliation	Passive (i.e., didactic sessions)
University of British Columbia Department of Physical Therapy; 202153	Canada	PDF document	University of British Columbia Department of Physical Therapy Strategic Plan, including IH initiatives	Truth and Reconciliation Indigenous teachings and practices Colonialism	NA
Office for Learning and Teaching, Department of Education; 201455	Australia	PDF document	Describes design, delivery, and development and future of pre-registration interprofessional (IPE) in Australian Universities	Barriers	NA
University of Queensland Australia; 202170	Australia	PDF document	Provides recommendations for how to improve Indigenous health curriculum within Australian and New Zealand physiotherapy programs.	Truth and Reconciliation Physical, emotional, social, spiritual, and cultural well-being of indigenous people	NA
University of Notre Dame Bachelor of Physiotherapy; 202164	Australia	PDF document	Course description for the Bachelor of Physiotherapy Program.	Physical, emotional, social, spiritual, and cultural well-being of Indigenous people	Passive (i.e., didactic lecture)
PROFESSIONAL ORGANIZATION DOCUMENT
Canadian Council of Physiotherapy University Programs (CCPUP); 201941	Canada	PDF document	Describes recommended elements of academic and clinical content of an entry-to-practice physiotherapy program in Canada	Indigenous teachings and practices	NA
British Columbia (BC) Health Regulators; 202042	Canada	PDF document	Discusses the commitment to cultural safety and humility in BC. Information on how health professionals can incorporate cultural safety and humility into practice.	Declaration of Commitment to Cultural Safety and Humility Truth and Reconciliation Cultural Safety Cultural Humility	NA
College of Physical Therapists of British Columbia; 202243	Canada	PDF document	Public statement regarding college of physical therapists of British Columbia's commitment to Justice, Equity, Diversity, and Inclusion	Truth and Reconciliation Racism related to interactions with Indigenous peoples	NA
BC Health Regulators; 202144	Canada	Website	Outlines the development of a cultural safety and humility toolkit for registered healthcare professionals and discusses a cultural safety taskforce to aid in cultural safety training for healthcare professionals	Cultural safety	NA
Faraday, T.M.; 202054	Australia	PDF document	This Reflect Reconciliation Action Plan (RAP) details the steps that the Australian Physiotherapy Council will take in the next 12-month period to work towards reconciliation in Australia	Reconciliation	NA
Moore, S, et al; 201971	Canada	Book	Discusses post-colonialism, Indigenous health education, and cultural safety within Canadian physiotherapy programs	Truth and Reconciliation Indigenous teachings and practices	Passive (i.e., didactic sessions)
Indigenous Allied Health Australia; 201558	Australia	PDF document	Provides recommendations to build the capacity of both education providers and Aboriginal Torres Strair Islander communities to ensure physiotherapy education programs will best meet their needs	Indigenous teachings and practices Barriers	NA
Delany, C, et al; 201656	Australia	PDF document	Describes how physiotherapy programs in Australia and New Zealand foster relationships with Indigenous peoples and communities	Treaties and Aboriginal rights Barriers	NA
Health Professions Accreditation Collaborative Forum; 201959	Australia & New Zealand	PDF Document	Describes the role accreditation play in improving Aboriginal and Torres Strait Islander and Maori health outcomes and how to produce a culturally safe workforce.	Barriers Accreditation Standards	NA
Wyatt, K.; 201872	Australia	PDF document	Highlights institutional factors relating to Indigenous cultural safety curricula in physiotherapy programs.	Social determinants of health of Indigenous peoples	Active (i.e., field trip, self-reflection) and passive (i.e., didactic lectures)
Robinson, C, et al; 202060	Australia	PDF document	Describes cultural competence knowledge and practice amongst health and social care academics	Barriers	NA
Leaders in Indigenous Medical Education (LIME) Network; 201762	Australia	PDF document	Discusses steps taken at Australian university to develop a consensus on what to teach students regarding Indigenous health.	IH Curriculum Content	NA
Behrendt, L.; 202263	Australia	PDF Document	Focuses on the specific barriers that are preventing Aboriginal and Torres Strait Islander people from achieving their full potential in higher education, and recommends actions to improve higher education outcomes of these students.	Physical, emotional, social, spiritual, and cultural well-being of Indigenous people	NA
Spronken-Smith, R, et al; 201366	New Zealand	PDF document	Provides course overview related to IH in higher education institutions in New Zealand	Truth and Reconciliation Physical, emotional, social, spiritual, and cultural well-being of Indigenous people	Passive (i.e., didactic lecture)
Tiatia, J.; 200867	New Zealand	PDF document	An overview of the literature on Pacific cultural competence in health care	Physical, emotional, social, spiritual, and cultural well-being of Indigenous people Treatment / mistreat (injustice) in the current healthcare climate related to interactions with Indigenous peoples	NA
Thomson, E.A, et al.; 201771	Australia	Website	Highlights the application of the Charles State University system approach to collaborative course design using backward mapping.	Physical, emotional, social, spiritual, and cultural well-being of Indigenous people Truth and Reconciliation	Active (i.e., interactive session with Elders) and passive (i.e., didactic lectures)
Canadian Physiotherapy Association; 201974	Canada	PDF document	Highlights initiatives taking place across Western Canada related to implementation of Canada's truth and reconciliation report recommendations	Colonialism Physical, emotional, social, spiritual, and cultural well-being of Indigenous people Truth and Reconciliation	NA
THESIS DOCUMENTS
Arcobelli, L.M.E.,; 202124	Canada	Thesis document	Examining IH content in Canadian physical therapy curriculums	Treatment / mistreat (injustice) in the current healthcare climate related to interactions with Indigenous peoples Physical, emotional, social, spiritual, and cultural well-being of Indigenous people Barriers	NA
Te, M.; 202065	Australia	Thesis document	Discusses how entry-level PT programs deliver learning and teaching to support the development of cultural responsiveness in students and identifies gaps in the preparation of new graduates related to this topic.	Barriers	NA

PEER REVIEWED JOURNAL ARTICLES
Author; year	Geographic Location	Indigenous Population identified	Methods	Main IH Content Topic(s)	Results/Conclusions
Oosman, S, et al.; 201939	Canada	Indigenous peoples in Canada (Metis)	Qualitative interviews with Physiotherapy students on perceptions of the impact of a practicum in a Metis community had on their learning in cultural humility and cultural safety	Indigenous teachings and practices	Practicum experience supported learning and development of cultural humility. Findings were categorized into three main themes: (1) realizing Métis community strengths, (2) learning from experiences and shaping future practice, (3) prioritizing relationships. Providing MPT students with exposure to IH contents should be a curricular consideration for MPT programs.
Muir-Cochrane, E, et al.; 201735	Australia	Aboriginal and Torres Strait Islanders	Design of virtual teaching and learning resources (guided learning journey's) Qualitative focus groups and interviews to explore students perceptions and experience of the guided learning journey's	Social determinants of health of Indigenous peoples	Positive changes were demonstrated for in students’ cultural competence, empathy, and attitudes after the implementation of a virtual teaching and learning resource. Use of authentic cases (case studies) is useful in preparing students to work with diverse populations.
Hojjati, A, et al; 201838	Canada	Indigenous peoples in Canada	Qualitative study exploring perspectives on postcolonialism and IH content that rehabilitation students in Canada should learn during their education programs.	Colonialism Allyship related to interactions with Indigenous peoples	Rehabilitation has much to offer people adversely affected by colonization and a post-colonial lens has unique and productive contribution to make to the field of rehabilitation.
Kickett, M, et al.; 201434	Australia	Aboriginal and Torres Strait Islanders	Outlines course guidelines for a course that is mandatory for all first-year health science students across 22 different healthcare disciplines, including physiotherapy. Uses qualitative data to describe student feedback	Privilege related to interactions with Indigenous peoples Racism related to interactions with Indigenous peoples Barriers	Overall satisfaction was high (94%) with implemented course. Challenges existed regarding teaching content to such a large group of interprofessional students and ensuring consistency between tutors in tutorial groups.
Bolton, J, et al., 201833	Australia	Aboriginal and Torres Strait Islanders	Qualitative study using student feedback on a second year MScPT course in Australia which included an active field trip to a museum highlighting IH issues	Allyship related to interactions with Indigenous peoples Social determinants of health of Indigenous peoples	A well planned culturally framed activity was identified by students as a preferred setting to traditional lectures. Students were able to connect content to their future role as a PT. Feedback highlighted a need for more information on IH prior to and following the sessions.
Came, H, et al.; 202140	New Zealand	Māori	Critical examination of 18 regulated health practitioners competency documents to determine compliance with te Triti	Treaties and Aboriginal rights	Most professions were not meeting obligations as a Crown Tiriti partner. Physiotherapy scored as the 4th top profession in adherence to the 5 te Tiriti documents (PT competency documents in PT are ahead of many regulated health professionals). Suggestions to upholding treaty are given.
Te, M, et al.; 201936	Australia & New Zealand	Aboriginal and Torres Strait Islanders and Māori	Cross-sectional study (survey using web-based, self-report questionnaire) aimed to evaluate the level of self-perceived cultural responsiveness of entry level PT students during training	Treatment / mistreat (injustice) in the current healthcare climate related to interactions with Indigenous peoples Allyship related to interactions with Indigenous peoples Barriers	PT students who are ‘dogmatic’ in their thinking have lower self-perceived cultural responsiveness scores. Physiotherapy educators need to understand how cultural responsiveness can be fostered over time. Educators should assess dogmatism to identify at risk students, design educational interventions and facilitate open-mindedness, self-awareness, and dispel biased and prejudiced thinking to support culturally responsive practice.
Garneau, A, et al.; 202137	Canada	Indigenous peoples in Canada	Literature review to identify practices and challenges associated with integrating equity and social justice in undergraduate/ health profession education	Allyship related to interactions with Indigenous peoples	Three interrelated components of the integration of equity and social justice were identified:  1) Adopt critical pedagogical approaches that promote indigenous epistemologies  2) Partner with Indigenous populations Engage educators on critical pedagogical approaches and health equity issues
Te, M, et al; 201925	Australia & New Zealand	Aboriginal and Torres Strait Islanders and Māori	Qualitative Interviews with PT programs to collect information on how entry-level PT programs in Australia and NZ design curriculum to foster the development of cultural responsiveness in PT students	Social determinants of health of Indigenous peoples Barriers	All programs were integrating educational content and approaches related to culture or cultural responsiveness. Variability was present regarding structure, teaching, and assessment methods used. Most programs relied on didactic teaching methods and implicit assessment methods.