Creation of the Indigenous Support Line for health system navigation and culturally safe access to care: a quality improvement project

ABSTRACT

Indigenous Peoples face inequities in health and healthcare access due to colonial history and systems. To work towards the Truth and Reconciliation Commission of Canada’s Calls to Action and the United Nations Declaration on the Rights of Indigenous Peoples, Alberta Health Services has collaborated with a Wisdom Council of engaged Elders and Indigenous community members to tailor programmes for Indigenous Peoples. The Indigenous Support Line (ISL) was created based on the Wisdom Council’s advice to provide an Indigenous-specific concerns line, which later expanded into a telehealth line to address any health questions or access issues, including health system navigation and access to Western and Indigenous health and wellness supports. Working from an ethical space guided the process, and Indigenous ways of knowing and Western approaches were respectfully integrated throughout. The percentage of calls answered or abandoned within 10 min was tracked as a key measure for quality improvement, coupled with a patient survey to measure access, accessibility, effectiveness and safety that included several open-ended questions that were treated as qualitative data and analysed using thematic analysis. Between June 2022 and February 2024, 92.7% of inbound calls were answered or abandoned within 10 min. A total of 86 respondents completed the survey, with 100% indicating they were satisfied with the service. Qualitative findings showed respondents felt satisfied with the line and the Indigenous Listeners, were respected during their call, and felt supported to have their concerns addressed. The ISL was successful in increasing Indigenous Peoples’ access to care in a culturally safe environment.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Anti-Indigenous racism is prevalent in Canada, especially within healthcare systems, and has disastrous consequences, including deaths of Indigenous patients. Indigenous patients also face inequitable healthcare access.

WHAT THIS STUDY ADDS

• An Indigenous-designed and staffed support telephone line provides a culturally safe access point for Indigenous patients to navigate complex health systems.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• In jurisdictions where telehealth is feasible, an Indigenous-run telephone line specific to Indigenous patients may help reduce racism and improve equity in healthcare access.

Introduction

In Canada, health disparities between Indigenous Peoples (First Nations, Métis and Inuit) and their non-Indigenous counterparts are well known.1,3 Despite Indigenous populations across Canada being culturally distinct, colonisation has had negative health impacts,⁴ a phenomenon also seen across all colonised countries.5,10 Ideological racism drove forced assimilation in Canada, with the creation of laws and policies such as the Indian Act (a paternalistic federal law that governs in matters pertaining to ‘Indian’ status, bands and ‘Indian’ reserves), residential schools (government-sponsored religious schools that operated to forcefully assimilate Indigenous children into Euro-Canadian culture), the 60s scoop (mass removal of Indigenous children from their families into the child welfare system) and Indian hospitals (federally run hospitals that segregated Indigenous patients and perpetuated a system of racial discrimination) contributing to inequalities in the social determinants of health with negative emotional, spiritual, mental and physical consequences for Indigenous Peoples.^{11 12} A deep-seated mistrust of health systems for many Indigenous Peoples has resulted, which has been furthered by Western-based healthcare frameworks prioritising Western knowledge.13,16 Moreover, systemic racism and cultural biases are embedded in health policies and practices, and reports of individual racism within healthcare systems are well-documented across Canada.^{3 17 18} Deaths of Indigenous patients directly resulting from racist treatment have been reported in the media, including the deaths of Brian Sinclair and Joyce Echaquan.^{19 20}

Further challenges for Indigenous health include unequal access to healthcare, encompassing lack of physical access^{21 22}; difficulty recruiting and retaining healthcare professionals in remote and rural locations²³; higher costs, inadequate infrastructure and challenges with digital literacy²⁴; and lack of Indigenous voice in policy and funding allocation.^{23 25} Funding and access to healthcare for Status First Nations and Inuit is complex and is provided either federally or provincially depending on First Nations status, and location (on or off reserve), with Métis and non-Status First Nations having no federal funding for healthcare, increasing gaps in care for many Indigenous Peoples.^{2 26}

Although it is well recognised that equitable access to culturally safe healthcare is needed for Indigenous Peoples, the development, implementation and evaluation of such approaches are not standardised, have not been widely implemented and often do not meaningfully involve Indigenous Peoples.²⁷ In response, a team of predominately Indigenous staff from the Indigenous Wellness Core (IWC) within Alberta Health Services (AHS) and partners developed and implemented an Indigenous Support Line (ISL), a toll-free telephone line specifically for Indigenous patients to address concerns about racism and cultural safety, and to improve health system navigation and access. The specific aims of this quality improvement study were twofold: (1) assess if the ISL is leading to quick and easy access to AHS supports; and (2) assess patient experiences with the ISL.

Methods

Strategy development

The IWC is a provincial programme of AHS that regularly partners with Indigenous Peoples, communities and stakeholders to innovate the health system and provide accessible, culturally appropriate health services for Indigenous Peoples in Alberta.²⁸ In partnership, the IWC provides healthcare services to Indigenous patients that honour their culture, beliefs and identities. As part of this process, the IWC collaborates with a Wisdom Council made up of Indigenous Elders, Knowledge Keepers, leaders, health workers and community members. Taking direction from the Truth and Reconciliation Commission of Canada’s Calls to Action²⁹ and the United Nations Declaration for the Rights of Indigenous Peoples,³⁰ the Wisdom Council guides AHS system priorities and strategies for Indigenous health and wellness. In particular, the Wisdom Council advises on adaptations to programmes and services to meet Indigenous needs, identifies healthcare gaps and strategies to address them, and integrates ethical space³¹ into the healthcare system (see online supplemental material).

The Wisdom Council requested a quality improvement intervention of a culturally safe telephone line for Indigenous patients to call with their concerns about racism and a lack of safety when accessing healthcare, and to provide a platform for oral stories and narratives of Indigenous patients to be expressed. Given the ongoing impacts of colonisation, Indigenous Peoples have regularly been marginalised, and their voices and perspectives silenced.^{29 30} During the development of the line, the purpose was broadened to have a primary goal of improving health system access, service support and navigation with a secondary purpose of leveraging information from the line to learn about client needs and developing new strategies to improve equity in the healthcare system. To achieve the goals, the ISL aimed to (1) build culturally safe and psychologically safe relationships with callers; (2) provide service navigation, information and referrals; (3) provide and refer to cultural supports; (4) support the management of patient concerns; (5) provide addiction and mental health supports; and (6) provide follow-up where appropriate. Indigenous Peoples took the lead in creating, designing, implementing, maintaining, running and evaluating the line, as well as aligning the line with the AHS Roadmap to Wellness³² and the wishes of the Wisdom Council. As such, the sovereignty of Indigenous Peoples, their beliefs, values and protocols were imperative to the design of the ISL.

AHS is an integrated health system managed at a provincial level, rather than having regional health authorities, allowing for a provincial approach. Alberta has approximately 284 470 Indigenous Peoples (of those that declared a single identity, 145 645 are First Nations, 127 475 are Métis and 2945 are Inuit), making up 6.8% of the population.³³ Creating an intervention that could benefit Indigenous Peoples in all areas of the province was essential to the Wisdom Council. The ISL was created using existing infrastructure for Health Link, an Alberta-wide, toll-free telephone service that provides free 24-hour-per-day nurse advice and health information for Albertans.

Strategy description

The line was designed so that calls are answered by Indigenous Listeners, a deliberate choice of wording by the Wisdom Council, whose primary role was to intentionally listen to callers ‘with patience, spirituality, acceptance, caring and empathy’.³⁴ Indigenous Listeners meet callers ‘where they are at’ and provide ‘warm walk-alongs’ to prevent callers from having to tell their story multiple times and potentially relive traumatic or difficult situations. Indigenous Listeners provide pertinent information to other care providers, if necessary, on behalf of callers. Indigenous Listeners were trained in Ceremony, with an Elder blessing, and reflections and sharing circles were regularly integrated into training. Education for the Listeners also included information about the Indigenous communities being served, anti-racism and patient concerns training, trauma-informed care, and the foundational importance of Indigenous oral stories. Calls are answered between noon and 20:00, Monday to Friday (excluding statutory holidays). A phased rollout of the ISL was implemented, with service first available to AHS’ North Zone on 3 June 2022. It was expanded to the South Zone on 1 May 2023, and the Central Zone on 9 August 2023 through AHS operational funding. The line was promoted through social media, community engagement, town halls, promotional items, newsletters, brochures, poster distribution, phone calls and a webpage. The ISL was meant to be a starting point, with Wisdom Council members indicating that more work would be needed in the future, such as expanding the hours of operation, expanding the line to be operational in each Zone and having Indigenous Listeners from each Zone to enhance cultural responsiveness.

Measurement

Evaluation and improvement strategies were developed and initialised before the project launch, with a plan to complete an initial 3-month assessment to reflect, assess barriers and facilitators, review quality improvement findings and make necessary adaptations to the line. A combined quantitative and qualitative quality improvement study was conducted using call volume, the percentage of calls answered or abandoned within 10 min, and post-call survey data. A quality improvement group met weekly to discuss operational issues, real-time performance metrics and caller survey responses to optimise operations and improve efficiency using the Plan, Do, Study and Act (PDSA) cycle approach.³⁵ A weekly quality improvement meeting brought together members of the operational team and evaluation team (made up of primarily Indigenous staff), and the Indigenous Project Director. During these meetings, the group reviewed successes, identified challenges and implemented real-time changes to address any issues. Regular check-ins with the Wisdom Council also helped identify adaptations to improve the ISL and refine the evaluation plan. The team identified key performance metrics that were regularly monitored to assess performance and signal the need for quality improvement, and based on the outcomes the Wisdom Council expected to achieve: acceptability, safety and effectiveness. Standards for QUality Improvement Reporting Excellence 2.0 guidelines were followed.³⁶

Targets for key metrics included a service level target of 95% of calls within 10 min answered or abandoned (instances where callers disconnected before their call is answered by a Listener). This target is much higher than call centre benchmarks, however the team knew it would be important to consistently answer calls quickly to help build trust with Indigenous callers. A nine-question client satisfaction telephone survey was also developed to assess perceived accessibility, effectiveness and safety (table 1). Most callers over 18 years of age were offered the opportunity to participate, except those in acute health crisis. Initially, callers were asked if they consented to a follow-up call within a week to assess their experience and help improve the service. Three attempts were made to reach callers. Initial volume of survey responses was low; thus, we refined our process and callers were instead asked to take a ‘warm walk-along’ to an independent surveyor who collected a survey immediately after the call.

Table 1. Client satisfaction survey questions.

Survey question	Response type	Target
Overall, were you satisfied with the service?	‘Yes’/‘no’	75%+ ‘Yes’
Did the team help you to address your concern/reason for your call?	‘Yes’/‘no’	75%+ ‘Yes’
Did you feel respected by the person you spoke to?	‘Yes’/‘no’	75%+ ‘Yes’
Would you use the Line again?	‘Yes’/‘no’	75%+ ‘Yes’
Would you recommend the Line to a friend or family member?	‘Yes’/‘no’	75%+ ‘Yes’
If this Line was not available, what would you have done?	‘Gone without care’, ‘called Health Link’, ‘seen a physician or visited a clinic’ or ‘other’	N/A
What do you think we could improve about the Line?	Open-ended qualitative	N/A
What did you like about the service?	Open-ended qualitative	N/A
Is there anything else you would like to share about your experience?	Open-ended qualitative	N/A

Analysis

Inbound calls and the times to answer the calls (and the times that callers abandoned the call without it being answered) were measured and recorded as a percentage of calls answered or abandoned within 10 min in Microsoft Excel. Survey data was made accessible through a Tableau dashboard after data entry. Simple percentages were calculated for survey responses to questions one through six. For the open-ended survey questions an iterative thematic analysis approach was used that included data familiarisation, generating codes, constructing themes, revising themes, defining themes and subthemes, and producing a report.³⁷ The ISL leadership team and the Wisdom Council were presented with findings at regular intervals, and were regularly consulted for feedback on the findings and interpretation of the data.

Ethical considerations

The Alberta Innovates ‘A Project Ethics Community Consensus Initiative’ (ARECCI) screening tool was used to determine the level of risk of the project, the types of ethical risks and the appropriate type of ethics review.³⁸ The ARECCI score was 17, placing within the category of somewhat more than minimal risk, requiring a second opinion review completed by an individual without a vested interest in the outcome and trained to complete ethical project reviews. The second opinion reviewer provided feedback and suggestions and identified minimal ethical risk. To protect participants who provided survey information, the call data was not linked to the client satisfaction survey, the participant gave informed consent, the call Listener was not the same person asking the survey questions, and quotes were captured in a non-identifying fashion. Callers under 18 years of age or people in acute health crisis were also not asked to participate in the evaluation process.

The Wisdom Council was involved and made decisions at all stages of the project, providing ethical counsel, and ensuring our work moved forward in culturally and community appropriate ways. Although this was not a research project, best practices for meaningful and effective Indigenous research helped to inform the overall health innovation approach, including the principles of community-based participatory research,^{39 40} and the Tri-Council Policy Statement on the Ethical Conduct for Research Involving First Nations, Inuit and Métis, which emphasise mutually beneficial partnerships based on relationships and trust, Indigenous control and leadership, and Indigenous Ways of Knowing.⁴¹ Finally, we were guided by the concept of ethical space (see online supplemental material), where humility towards both Western and Indigenous Ways of Knowing was embraced.³¹

Results

Between June 2022 and February 2024, the ISL received 2657 inbound calls and placed 4655 outbound calls. Among clients that provided information on their biological sex, 63.5% were female and 36.5% were male. Among clients that provided information on their age, 5.7% were aged 12–24 years, 46.1% were aged 25–49 years and 48.2% were aged 50 years or older. AHS Zone breakdown of the total inbound calls was as follows: 44.4% North Zone, 25.6% Edmonton Zone, 11.0% Calgary Zone, 9.1% South Zone, 5.8% Central Zone and 4.1% unknown/out of province. The total percentage of all inbound calls answered or abandoned within 10 min was 92.7%. The percentage of inbound calls answered or abandoned within 10 min fluctuated over time (figure 1), with the 95% benchmark being met for 10 out of the 21 months of the line operating. The leadership team intervened to hire more staff as part of the PDSA cycle to bring the percentage of calls answered within 10 min closer to target levels, even as call volume continued to increase.

Figure 1. Percentage of inbound calls answered or abandoned within 10 min over time.

A total of 86 callers answered the survey questions. Of those, 100% answered that they were satisfied with the service, 98% felt satisfied that their reason for calling was addressed, 98% felt respected by the Listener, 98% would use the line again and 99% would recommend the line to a friend or family member. All of these rate responses were above the target (75%+). According to the survey, 23% of callers would have gone without care if the ISL was unavailable, 14% would have called Health Link and 7% would have seen a physician or visited a clinic.

Qualitative findings supported the quantitative findings, with four key interrelated themes representing the respondent’s interactions with the ISL: having a positive experience; getting the support needed; feeling safe and cared for; and going above and beyond. The findings also indicate suggested areas of improvement for the line.

Respondents had overwhelmingly positive, beneficial and enjoyable experiences when interacting with Listeners. Respondents described feeling that the line was ‘lovely and different [from other healthcare experiences]’, that ‘everything was done professionally’ and that ‘there was nothing better they could have done’. Many respondents explained feeling grateful to finally have a place to call where they know they will be heard, understood, and that they will receive support. One respondent mentioned, ‘[I’ve been] seeking resources since I was young and wasn’t able to obtain much info until I stumbled across this line’. Another respondent noted,

I am overwhelmed and excited because it gives me hope … I am still overwhelmed that when I call, someone will listen to me and that’s a struggle for me in every other support network. I’m still pleasantly shocked that I’m getting a response and getting results. This is helping a community of people as through me, I’m the go between with the people on the streets and my experience has affected a community and people I know.

Many respondents described getting the support they needed from the line in a thorough and timely way. Respondents often felt better after calling the line, were satisfied with the line and the Listeners, felt supported to have their concerns addressed and experienced a sense of relief after reaching out to the line. One respondent reflected, ‘it helped me exactly how I needed’. Listeners were knowledgeable and informative, able to answer inquiries, provided detailed information, and connected callers to appropriate resources. Another respondent described their Listener as ‘so helpful, a tremendous help. I felt relieved, and the Listener was able to help me connect to the right sources’. Respondents also appreciated the ease, smoothness and speediness with which they were able to connect with the line and subsequent supports and resources. Importantly, respondents expressed valuing how Listeners would call them back to check-in and follow-up to ensure their concerns were addressed and supported. As one participant noted, ‘I like how personal the service is and really liked how the line continues to follow up’.

Feeling safe and cared for when interacting with Listeners was mentioned as a unique benefit of the line and something that respondents seek when accessing the health system. Respondents felt like they had an advocate and someone ‘on my team’. Terms regularly used to describe the Listeners included ‘non-judgmental’, ‘positive’, ‘respectful’, ‘polite’ ‘safe’, ‘calm’, ‘comforting’, ‘genuine’, ‘friendly’, ‘understanding’, ‘compassionate’, ‘validating’, ‘gentle’, ‘responsive’, ‘open-minded’ and ‘kind’. One responded noted, ‘the Listener made me feel like a human and I truly appreciate speaking with her’. In particular, having Indigenous Listeners that ‘came from an Indigenous perspective’ was seen as a strength of the line, as respondents felt a level of trust and cultural safety was established that was akin to family and/or someone they already knew. The line was described as ‘filling in gaps [in care]’ that was not previously available to many respondents. Having a safe place to call for Indigenous community members, staffed by Indigenous Listeners, was viewed as crucially important and necessary. A respondent described, ‘the Listeners are Indigenous, and they understand. They understand the history and so they know where they are coming from. The Listeners don’t judge and they there to help no matter what. Being Indigenous, they have cultural sensitivity’.

Listeners were frequently described as ‘going above and beyond’ for callers, and doing everything they could to help. Oftentimes this included little gestures that went beyond caller’s regular healthcare experiences and expectations, such as: holding on the line with callers as physician appointments were booked, speaking with unit managers and other health system staff to advocate on the behalf of callers, checking and re-checking after the call ended to see if anything else was needed, taking the time to stay on the line to answer all of the caller’s questions, and making space to talk about traditional Indigenous healing practices. Respondents mentioned recommending the line to friends, family members and other community members. One respondent noted, ‘with the hardship dealing with [health issues], I would like to see this pilot project always being there for the Native people. [It is a] wonderful line and I will promote this line’.

Respondents had some recommendations for potential improvements of the line: advertising more widely across the province; making the line available 24/7 to meet the needs of community members—especially for those in crisis; ensuring the line is sustained in the long-term; and the possibility of texting or emailing with Listeners was also mentioned, as well as enhanced connections to viable mental health treatment programmes.

Discussion

Importantly, the implementation of the ISL supports the health commitments of Truth and Reconciliation Call to Action 20, which is a call to the federal government to recognise and address the distinct health needs of First Nations, Métis and Inuit.²⁹ The line addresses cross-jurisdictional issues for First Nations, Métis and Inuit patients and specifically supports Calls to Action 22 and to value Indigenous healing practices and increase Indigenous professionals and train healthcare providers in cultural competency. The creation of the line is in alignment with the United Nations Declaration for the Rights of Indigenous Peoples,³⁰ specifically as Indigenous Peoples led the development and the line focuses on increasing access to health services.

Telehealth as a healthcare modality has been rising as a response to inequitable care,⁴² with COVID-19 increasing the need for virtual services and accelerating the development of telehealth services.^{43 44} This modality has excellent potential to increase care for Indigenous Peoples, particularly for the population living in rural and remote locations.⁴⁴ However, despite the rapid increase in telehealth services created for Indigenous Peoples, there is little data to support outcomes within Canada.^{42 45} Data from this quality improvement project show that a telehealth-based support line increased equitable access to care.

Attempts to decolonise health systems, reduce racism and discrimination, and improve health outcomes with Indigenous Peoples, are increasingly recommending the adoption of cultural safety and the delivery of healthcare that reduces the power differentials, necessitates healthcare staff to consider colonial policies and practices, and shows respect for Indigenous culture, identity and rights.46,48 Many innovations and interventions have been implemented to improve cultural safety and increase Indigenous health equity, including creating apps for providers,⁴⁹ adapting communication tools for First Nations patients,⁵⁰ using digital storytelling,⁵¹ creating strategies, programmes, or services in conjunction with Indigenous advisory committees.^{52 53} Cultural safety is determined from the patient or community perspective⁵⁴; and our results indicate that ISL is culturally safe, with 98% of respondents feeling respected during their interactions with Listeners.

Transformational health system innovations for Indigenous Peoples must be led by Indigenous Peoples. A scoping review of telehealth found that the most common way to work towards cultural safety was to involve the Indigenous community in developing and implementing telehealth services, to tailor services, to respect cultural values by incorporating multiple definitions of health and wellness, and to adopt traditional healing practices and Ceremony.⁴² In addition, using Indigenous methodologies, strengths-based approaches, following Indigenous protocol, acknowledging the historical and social factors impacting Indigenous health, and completing cultural competence and safety training were also important factors in creating safe telehealth services.⁴² Following these principles were crucial for the success of the ISL.

Lessons and limitations

Using the PDSA model within weekly team meetings was an innovative strength of this work and allowed for the team to make changes and adaptations quickly to improve the line’s accessibility. A thematic exploration of factors affecting the implementation of quality improvement strategies found that sharing perspectives and experiences, reflecting on local practice information and aligning care to client needs and culture were crucial.⁵⁴ The authors also showed that strengthening and building relationships, organisational support and capacity, and facilitating quality improvement by engaging in team discussion and reflection and facilitating learning were important drivers of successful quality improvement projects.⁵⁵ These concepts guided the current work and allowed for diverse perspectives of team members from many areas to shape the project, ongoing guidance from the Wisdom Council, prioritising the voices of respondents, and opportunities to gather organisational support. All of this was done in an ethical space, considering how to bring together two worldviews in a telehealth initiative designed for Indigenous Peoples.

The creation of the ISL has led to several unanticipated positive outcomes. At the system level, there is no established mechanism to gather information from Indigenous patients to impact real-time change. The ISL has provided an avenue to learn more about the needs of callers and Indigenous populations to inform quality improvements within the broader healthcare system to address cultural safety. Indigenous Listeners have noticed patterns of concerns being brought forth by callers and have directly advocated for change, such as contacting unit managers and sorting through challenges. Moreover, healthcare professionals have called into the line to learn more about Indigenous-specific supports that they can recommend to patients.

There are limitations to this study. This support line used existing call-taking infrastructure that supported callers from a large geographical area, and had the physical infrastructure and technology developed to support callers and to keep data secure. Not all provinces or states have this infrastructure, and as such the generalisability of the results of this line may be limited. Telehealth lines require a call centre with physical infrastructure and technology to keep health data private. The inclusion of pre-/post-comparison data was not possible, and the survey respondents who agreed to take part may have been those most satisfied with the line and may have been most agreeable to completing it.

Conclusion

The ISL demonstrates that culturally safe, Indigenous-led initiatives can be successfully implemented within a Western-based system when ethical space is created. The ongoing assessment of the ISL will provide information about access to care and ensure that the needs of Indigenous Peoples are being met. It will help meet the secondary purpose of leveraging information from the line to learn about client needs and develop new strategies to improve equity in the healthcare system.

Data availability statement

No data are available.