Factors Influencing the Health and Wellness of Urban Aboriginal Youths in Canada: Insights of In-Service Professionals, Care Providers, and Stakeholders

Abstract

We addressed the positive and negative factors that influence the health and wellness of urban Aboriginal youths in Canada and ways of restoring, promoting, and maintaining the health and wellness of this population. Fifty-three in-service professionals, care providers, and stakeholders participated in this study in which we employed the Glaserian grounded theory approach. We identified perceived positive and negative factors. Participants suggested 5 approaches—(1) youth based and youth driven, (2) community based and community driven, (3) culturally appropriate, (4) enabling and empowering, and (5) sustainable—as well as some practical strategies for the development and implementation of programs. We have provided empirical knowledge about barriers to and opportunities for improving health and wellness among urban Aboriginal youths in Canada.

The Aboriginal population represents 4.3% of the total Canadian population, and 46.2% of the Aboriginal population are younger than 25 years.¹ Aboriginal youths in Canada have a mortality rate that is 3 times higher than the national average. They have disproportionately higher rates of preventable chronic and infectious diseases, such as type 2 diabetes, obesity, and sexually transmitted infections, than do non-Aboriginal youths.^2–4 An estimated 73.0% of Canadian Aboriginal youths consume diets that do not meet recommended nutritional standards, and 52.0% of this population are physically inactive.³ Furthermore, the quality of life^5,6 and emotional and psychosocial well-being of this population^7–9 are affected by socioeconomic factors such as poverty and socioenvironmental factors, including the presence of violence.^10,11

Adolescence is a critical stage of physical, emotional, mental, and spiritual growth in a person’s life.¹² Therefore, it is important to understand factors affecting and ways of improving the health and wellness of the young Aboriginal population. The urban Aboriginal youth population has grown rapidly.² Socioenvironmental circumstances of urban contexts have confounding effects on the health and wellness of urban Aboriginal youths.¹³ Although several community-based health promotion studies have been conducted to address the health disparities among urban Aboriginal youths (e.g., drug prevention and nutrition intervention studies),^14,15 little is known about the complex causes of these disparities or the mechanisms for well-being among this population.

We asked the following questions to prioritize aspects for the development and implementation of health-promotion programs that are focused particularly on nutrition and physical activity: (1) What positive and negative factors influence the health and wellness of urban Aboriginal youths? and (2) What are the ways of restoring, promoting, and maintaining the health and wellness of urban Aboriginal youths? We have provided empirical data for cross-cultural comparisons of the perspectives of urban Aboriginal youths and those of professionals, care providers, and stakeholders. Furthermore, we have provided for the first time, to our knowledge, empirical knowledge regarding barriers to and opportunities for improving health and wellness among urban Aboriginal youths in Canada.

STUDY DESIGN

We used a Glaserian grounded theory approach,^16–19 which is “a general methodology of analysis linked with data collection that uses a systematically applied set of methods to generate an inductive theory about a substantive area.”^16(p16) A Glaserian grounded theory approach focuses on developing a conceptual theory by identifying the key points emerging from a series of constant comparisons among, and neutral questioning about, phenomena. From the Glaserian perspective, the theory is thus grounded in the data.

Alternatively, Straussian grounded theory focuses on a conceptual description of phenomena through a series of structured questioning. Accordingly, Straussian researchers structure data to interpret and reveal the theory.^16–20 This approach focuses on analyzing relationships among place, people, and time in specific contexts by discovering concepts that help to explain phenomena¹⁸ instead of focusing specifically on describing accurate facts related to phenomena.²¹ As a result, this methodology aims to generate conceptual theories and hypotheses through inductive, systematic, and comparative processes of qualitative research.²²

Participants

We recruited key informants from the city of Edmonton, Alberta, using a maximum variation sampling strategy (i.e., purposefully sampling a wide range of participants to ensure transferability of research findings) and a snowball sampling strategy (i.e., recruiting further relevant participants on the basis of the recommendations of initial participants).²³

The recruitment criteria included individuals who are (1) directly or indirectly interacting with urban Aboriginal youths as service professionals, care providers, or stakeholders or (2) currently holding professional positions or interacting with urban Aboriginal youths.

Data Collection

Data consisted of face-to-face semistructured interviews, field notes, and memos.^19,23,24 The primary data were 30- to 60-minute interviews. The key informants answered open-ended questions such as “What do you think positively or negatively influences health and wellness of urban Aboriginal youths?” and “What might be done to improve health and wellness of this population in the short and long term?” We inductively generated these questions on the basis of research questions (i.e., we did not generate them on the basis of preexisting theories), and interviewers were free to explore, probe, and ask questions that would elucidate and illuminate the phenomena related to health promotion for urban Aboriginal youths.²³

We did not audio record interviews to respect the culture and preference of some key informants (i.e., some participants with Aboriginal ethnicity were not comfortable being audio recorded because of cultural restrictions). Instead, we selectively recorded interview notes using a theoretical sampling technique,^16,18 which is a decisive data sampling method involving delimitation of data on the basis of interviewees’ responses without audio recording and transcribing the interviews.^16,18

The Glaserian grounded theory approach involves simultaneous data collection and analysis and is a valid and economical way of collecting data.^16,19 Four trained interviewers conducted the interviews, with 2 interviewers administering each interview: one as an interviewer and note taker and the other as a type recorder. The interviewer and note taker wrote down the key points of interviewees’ responses, and the type recorder typed them as accurately as possible during interviews. At the end of each interview, the paired interviewers crosschecked the accuracy of their notes and transcripts and then theoretically sampled significant information emerging from each interview. We recorded sampled information in interview notes in narrative form.^25,26

The interviewers kept field notes to record the contexts of interviews and preliminary observations about interviewees’ responses.²⁴ We used memos to note possible emerging codes and their conceptual relationships during the processes of collecting and analyzing data.¹⁹ We used field notes and memos as supplementary evidence to the interview data.²³

Data Analysis

We used NVivo, version 10 (QSR International, Burlington, MA) to code, conceptualize, categorize, and theorize data. Following the analytical method used in Glaserian grounded theory,^16,17,19 analysis began with repeated readings of data, which allowed researchers to become immersed in the data.²² We then employed 3 phases of open, selective, and theoretical coding.²² Open coding refers to the first level of coding, in which researchers label and assign meanings through line-by-line reading of the interview notes.¹⁶ Then we selected the most commonly occurring codes as central concepts during the selective coding phase.¹⁶

In the final theoretical coding phase, researchers gradually sorted, merged, and clustered selected concepts into groups according to evident relationships (i.e., theme and subtheme categories).¹⁶ These processes continued until theoretical saturation occurred—that is, researchers reached a stage at which we identified no further concepts during data collection and no theories emerged from data analyses.¹⁹

Trustworthiness

Establishing trustworthiness is critical to enhancing and demonstrating rigor in qualitative research.²⁴ We employed triangulation, that is, the use of multiple methods (i.e., interviews, field notes, and memos), multiple data sources (i.e., 53 participants with diverse backgrounds and expertise), and multiple interviewers and analysts.^23,24 Peer debriefing among interviewers and analysts occurred at various phases during the study to validate emerging codes, concepts, categories, and theories.²⁷

In cases of disagreement, we thoroughly studied memos for further analysis; this process allowed us to monitor researcher biases.¹⁶ We also corroborated trustworthiness through expert audit reviews (i.e., we obtained external credibility confirmed by experts in relation to research processes and findings) and member checks (i.e., we acquired participants’ affirmation about analyzed concepts and theories).^23,24,27

We stored data in separate locking filing cabinets and password protected all electronic data.

FINDINGS

Key informants (n = 53) with diverse backgrounds and expertise participated in the study. Detailed descriptions are presented in Table 1. The key informants identified positive and negative factors that may influence the health and wellness of urban Aboriginal youths and provided practical suggestions for the development and implementation of intervention programs for this population.

TABLE 1—

Description of Key Informants (n = 53): Edmonton, Alberta, Canada, 2012–2013

Characteristics	No. (%)
Age group, y
18–29	8 (15.1)
30–50	25 (47.2)
≥ 51	20 (37.7)
Gender
Male	17 (32.1)
Female	36 (67.9)
Education level
≤ high school diploma	7 (13.2)
Some postsecondary	7 (13.2)
College diploma or university degree	21 (39.6)
Masters or PhD	18 (34.0)
Ethnicity
Aboriginal Canadian	8 (15.1)
Non-Aboriginal Canadian	34 (64.2)
European	3 (5.7)
Asian	5 (9.4)
African	2 (3.8)
Prefer not to say	1 (1.9)
Ethnicity of responsible youth group
Aboriginal youths	44 (83.0)
Immigrant youths	6 (11.3)
General youth population	3 (5.7)
Work sector
Private	1 (1.9)
Public	18 (34.0)
Not-for-profit or voluntary	34 (64.2)
Primary focus
Health	19 (35.8)
Education	17 (32.1)
Aboriginal	2 (3.8)
Academic or research	3 (5.7)
Social, human, or community services	12 (22.6)

Factors Perceived to Contribute to Health and Wellness

As opportunities for health promotion, key informants identified (1) established resources, (2) the benefits of urban contexts, and (3) the potential of urban Aboriginal youths. Some participants did not refer to any positive factors during the interview, as they felt there were no positive factors or they were not able to recall any.

Established resources.

We deemed established governmental supports (e.g., supportive and preventive regulations and bylaws such as the Aboriginal Urban Affairs Committee Bylaw, and financial aid such as the Post-Secondary Student Support Program) and community or institutional supports (e.g., youth-specific organizations such as the Urban Society for Aboriginal Youth, youth-specific housing services such as the Youth Emergency Shelter Society, and culturally sensitive programs, services, and activities such as the Canadian Native Friendship Centre) as positive factors contributing to or maintaining the current health status of urban Aboriginal youths.

Other educational opportunities with a positive impact included health-related educational programs (e.g., cooking and nutrition classes, health-related information, and school physical education programs at schools), organized sports and physical activity opportunities in community or school settings (e.g., Edmonton Native Ball Association Sports), and educational transitioning programs (e.g., Aboriginal university and college entrance programs and Aboriginal students liaison services).

Finally, some respondents observed that current personal relationships (e.g., with peers, members of families, the members of Aboriginal communities such as Elders, and in-service professionals such as personal mentors) could positively affect health and wellness. One key informant working with multiethnic youth groups explained,

If all their friends make healthy choices, it becomes a cool culture among them. Stable family can also provide proper guidance, or Aboriginal Elders who consistently reinforce their health in all aspects can promote their healthier lifestyle. They might find some positive role models among them.

Benefits of urban contexts.

Some interviewees perceived that the urban contexts could support the promotion of healthy lifestyles for this population. Compared with youths in remote Aboriginal communities (e.g., traditional lands of First Nations people such as Yukon, Northwest Territories, and Nunavut in the Northern Canada; reserves, that is areas set aside for the use and benefit of a First Nations government called a band; and nonreserved rural settlements such as villages and hamlets), those in the urban setting (e.g., city, town, and conurbation) would have much easier access to the health care system (e.g., hospitals, walk-in clinics, and public health centers with government-supported health care coverage), the emergency support system (e.g., police, fire rescue services, emergency medical care services, and hotlines such as violence and sexual assault hotlines), and healthy and seasonal foods (e.g., charities such as the Food Bank, supermarkets, and major food retailers). Those in the urban setting also would benefit from greater employment options and more educational opportunities (e.g., public and Catholic schools, Aboriginal schools, postsecondary schools, cultural education programs, and scholarship programs).

One participant, who worked at a government office as a health-related officer for Aboriginal populations, stated,

Living in a city gives a lot more, like better opportunities for employment and education. There are more doctors around and more access to sports programs and recreational facilities. The city has everything more than reserves.

Potential of urban Aboriginal youths.

We also discussed the value of the unique cultural and traditional backgrounds, experiences, skills, and knowledge of urban Aboriginal youths as positive factors affecting health and wellness. Some respondents predicted a positive response to the implementation of culturally appropriate health-promotion programs because of the uniqueness of the Aboriginal youth population.

One participant working with Aboriginal youths at a community organization remarked,

Traditionally, the Aboriginal way of life was really healthy. Hunting and fishing are extremely active. Some of the kids still have a sort of link to those traditions. It’s about how to bring out those traditions and how to link between them.

Factors Perceived to Have a Negative Impact

Various contextual factors that might undermine the health and wellness of urban Aboriginal youths are summarized in Table 2. We categorized these factors as natural–environmental, personal and familial, sociocultural, socioeconomic, socioenvironmental, and sociopolitical. We also considered a lack of, or the inappropriate application of, currently available resources as negative influences on the health and wellness of urban Aboriginal youths.

TABLE 2—

Contextual Factors Perceived to Have a Negative Impact: Edmonton, Alberta, Canada, 2012–2013

Context	Factors
Sociohistorical	Colonial policies (e.g., residential schooling)
	Transgenerational trauma
Sociocultural	Disconnection from Aboriginal culture
	Sense of lost culture
Sociopolitical	Racial discrimination and marginalization
	Stigmatization
Socioeconomic	Poverty
	Economic inequality
	Limited financial literacy
Personal and familial	Negative circumstances
	Unhealthy lifestyles
	Negative past experiences
	Limited basic life skills
	Limited health-related education and knowledge
	Absence of sense of belonging and familial relationships
Natural–environmental	Cold climate
	Challenge of acquiring food from nature
Socioenvironmental	Discouraging built-in environment
	Inappropriate living environment (e.g., housing conditions)
	Inaccessible resources (e.g., unaffordable programs)

Key informants highlighted sociohistorical factors that negatively affect the health and wellness of urban Aboriginal youths. They identified the colonial policy of residential schooling as a primary event that contributed to the cycle of trauma transmitted through Aboriginal generations. One participant, who was an educator of Aboriginal youths, explained the negative impact of transgenerational trauma:

Residential schools brought painful experiences to many Aboriginal people. Aboriginal children were separated from their parents, put into the assimilation facilities, and lost the sense of belonging and culture. As these children grew up, they experienced mental, social, and physical trauma and became the parents or grandparents of today’s youth. Unfortunately, the trauma seems to be passing on intergenerationally. Aboriginal youth see themselves as victims and refuse our supports and are missing their opportunity to make things better.

Several key informants mentioned that the continuing effects of this transgenerational trauma have been key contributors to the inequities in health and wellness among urban Aboriginal youths. Sociocultural aspects, including a disconnection from Aboriginal culture, have also played a significant role in determining the current health status of urban Aboriginal youths. Many of the survivors of the residential schools—the ancestors and family members of today’s urban Aboriginal youths—settled in urban areas instead of returning to their families on the reserve.^28–30

Colonial policies have negatively affected spirituality, language, traditions, cultures, and the connection to the land, which are integral to the lifestyles of Aboriginal peoples.^28,31 Many of the survivors lost their Aboriginal identities and their sense of Aboriginal community, and this sense of lost culture has been sustained for decades.^28–30

As an interviewee working with Aboriginal youths in a public organization observed,

Aboriginal culture approaches life differently than Western culture. In urban settings, you have to adjust to a new culture and new health care practices. I think the gap is huge, and we are not doing a good job at filling this gap.

The interviewee highlighted that the sense of lost culture has been embedded in the life of urban Aboriginal youths and has been passed on as a normalized and integral component of the culture among urban Aboriginal youths. Furthermore, the interviewee called attention to the root causes of health inequalities among urban Aboriginal youths and the negative impacts of the forced separation from families and Aboriginal communities.

Interviewees identified sociopolitical aspects, such as stigmatization, racial discrimination, and marginalization, as negative factors affecting the well-being of urban Aboriginal youths. According to a participant who worked with Aboriginal youths as a health-related professional,

Media is stigmatizing our kids as drunks on the street. We only hear about bad stories about kids, even though there are so many good stories. Stereotyping makes it really hard to help our youth. It’s discrimination.

The participant suggested that opportunities to promote healthy lifestyles might be restricted by stigmatizing urban Aboriginal youths. Some key informants also indicated that urban Aboriginal youths were often discriminated against and marginalized in their daily lives. One respondent working with multiethnic youth groups provided an example:

When Aboriginal kids go to a medical clinic, because of who they are and how they look, they often sit there for 5 to 6 hours, waiting to get called, whereas others get to go ahead of them. Finally they see the doctor, but they get brushed off and end up leaving the clinic with no idea what’s wrong with them or what they need to do. They are probably never coming back to see the doctor. It’s reality.

The respondent highlighted that racial discrimination and marginalization have violated the dignity of urban Aboriginal youths, and without careful attention, they may continue to contribute to health inequity among the youth population.

We identified socioeconomic factors, such as poverty, economic inequality (e.g., ethnic discrimination in employment), and limited financial literacy (e.g., the ability to budget and spend appropriately), as negative factors affecting the health and wellness of urban Aboriginal youths. Notably, most respondents indicated that poverty was a major issue for health status and health promotion for this population. One respondent working with multiethnic youth groups argued as follows:

I think poverty is the biggest barrier to health. If you are starving, you don’t care about what you are eating as long as you have something to fill your stomach. How can you sign your kids up for organized sports programs when you can hardly afford food?

Some key informants also indicated that the negative personal and familial environments of urban Aboriginal youths contributed significantly to their current health status, namely, negative circumstances (e.g., health issues, lack of hope, and self-esteem), unhealthy lifestyles (e.g., smoking, abuse of or addiction to alcohol and substances, and high-fat diet), negative past experiences (e.g., exposure to crime as an observer or victim and domestic violence), limited basic life skills (e.g., literacy, and inter- or intrapersonal skills such as resilience and communication), and limited health-related education and knowledge (e.g., nutritious cooking and safe sex).

The absence of a sense of belonging and familial relationships was perceived as a negative influence on the health and wellness of urban Aboriginal youths. One respondent, who worked with Aboriginal youths in a not-for-profit organization, noted,

Aboriginal people have left their home communities and come to big cities like Edmonton to have better opportunities but were disconnected without getting any benefits. Unfortunately, these kids get connected with gangs, because this becomes their community.

Several key informants acknowledged that Aboriginal girls in urban settings start to care for siblings or other children at a relatively young age without parenting skills. Interviewees indicated that this personal and familial situation negatively affected the health and wellness of both urban Aboriginal youths and children. These respondents noted that there might be gendered paths affecting the well-being of urban Aboriginal youths (e.g., higher risks of connections to gangs among male youths and greater disadvantages of surrogating parental roles among female youths). Because there is limited information regarding relationships between gender roles and the well-being of the youths, further investigation is required for an in-depth understanding of the gender roles in health and wellness among urban Aboriginal youths.

Several interviewees highlighted that natural–environmental factors could affect lifestyle among urban Aboriginal youths. The climate of Edmonton, where the key informants were recruited, is cold, with average winter temperatures of −10.4°C in January, and the topology of the city is flat.³² One interviewee, who worked with multiethnic youth groups as a health-related professional, stated, “Winter in Edmonton is really cold and long. This Northern climate really limits our outdoor physical activities for almost half of the year. Even gardening is available just for a few months.” Another interviewee, who worked with Aboriginal youths as a health-related educator, described the challenge of acquiring food from nature within the city: “We don’t have a sea or big mountains here in Edmonton. There is no big lake or river for fishing, which means that there is no food from nature if you are in Edmonton.”

Although the key informants identified factors perceived to contribute to the health and wellness of urban Aboriginal youths (e.g., established resources and the benefits of urban contexts), they also highlighted the socioenvironmental factors that negatively affect the well-being of this population (i.e., insufficiency and inappropriateness of the existing resources). These included a discouraging built-in environment, an inappropriate living environment, and inaccessible resources.

One respondent, who worked with Aboriginal youths as a health and nutrition professional, described the unhealthy urban built-in environment: “There is only a 7-Eleven [a convenience store] where you can buy a Slurpee and a bag of potato chips. Walmart and Superstore [major retailers] are too far away for kids to go.” The respondent emphasized that urban Aboriginal youths had greater exposure to fast food outlets and fewer resources for reaching supermarkets or major food retailers. This limited access to, and choice of, healthier and nutritious foods may be a contributing factor to the higher prevalence of obesity among urban Aboriginal youths.³³ Accordingly, ways of promoting the accessibility of healthy foods should be examined thoroughly to develop and implement future policies and actions regarding the urban built-in environment.

Another interviewee, who worked with Aboriginal youths as an educator, commented on how an inappropriate living environment affected the health of urban Aboriginal youths:

Living on the street is very stressful. It literally affects all the youths’ choices. Kids would choose housing rather than food when it’s −30°C outside. Once they have a somewhat safer place to stay, then there needs to be food on the table. These are the basics.

Studies have indicated that homelessness and inadequate housing quality are closely related to high-risk behaviors (e.g., domestic violence)^34–37 and higher mortality rates.³⁸ Further investigation would increase the understanding of urban Aboriginal youths’ living environment and its impact on health outcomes.

Finally, the majority of the key informants indicated that the socioenvironmental resources currently available were lacking or were inappropriately utilized. The resources included accessible and affordable programs, facilities, and transportation. A participant who worked in a social service organization described one situation as an example:

The society provides many programs, but [they] are neither easily accessed nor affordable. I see programs are being allocated unevenly throughout the city. Some neighborhoods have so many, whereas some others have none. A lot of these kids live in a less advantaged neighborhood and have younger siblings to take care of because parents are working day and night. How would these children access programs if their parents can’t give them a ride? Who will look after their little brothers and sisters while they play outdoor soccer?

The participant stressed a lack of awareness regarding the established resources in urban contexts and called attention to the need to identify strategies to increase urban Aboriginal youths’ uptake of these existing resources. Accordingly, specific suggestions for developing and implementing health promotion programs were offered.

Practical Suggestions for Promoting Health and Wellness

Key informants recommended 5 approaches for developing and implementing intervention programs aimed at promoting the health and wellness of urban Aboriginal youths. These approaches were

1. youth based and youth driven,

2. community based and community driven,

3. culturally relevant and appropriate,

4. enabling and empowering, and

5. continuous and sustainable.

Key informants also discussed the practical implications of and provided suggestions for each approach. Summarized findings are presented in Table 3.

TABLE 3—

Practical Suggestions for Promoting Health and Wellness Among Urban Aboriginal Youths: Edmonton, Alberta, Canada, 2012–2013

Approaches	Practical Suggestions
Youth based and youth driven	Understand personal life contexts of the youths
	Value the opinions, perspectives, and insights of the youths
	Address the needs and aspirations of the youths
	Involve youths in program planning and implementation
Community based and community driven	Value the inputs, perspectives, and insights of the community
	Ensure community involvement in program planning and implementation
	Share established knowledge among communities and organizations
Culturally relevant and appropriate	Avoid stereotypes and stigmatization
	Acknowledge the diverse and complex culture of the youths
	Provide engaging and relatable information and programs
	Increase the availability of cultural and traditional program options
Enabling and empowering	Mentor to be resourceful, resilient, self-supportive, and self-motivated
	Develop positive self-identity
	Build critical thinking abilities
	Provide experiential and practical learning opportunities
Continuous and sustainable	Build programs on existing resources, knowledge, and expertise
	Establish long-term relationships with the youths
	Connect with influential and relatable role models
	Advertise and promote existing resources

Youth based and youth driven.

Most key informants prioritized understanding the personal life contexts of urban Aboriginal youths as a crucial aspect of a youth-based approach. An educator of Aboriginal youths provided an example: “Kids will be mad if I start to teach about how to set up a plate when they don’t even have plates to begin with. We need to make sure that the basic needs are met before tackling the other issues.” Another educator of Aboriginal youths also suggested that we need to “be aware of the dynamics of where a student is in their life,” while considering “the root of where issues arise from, such as intergenerational poverty and cultural alienation.” A youth-based approach, according to these participants, involves developing and implementing programs that address issues on the basis of the comprehensive and in-depth understanding of personal life contexts of urban Aboriginal youths.

To appreciate personal contexts and circumstances, respondents suggested listening “for” the voices of the youths (i.e., a more active way of engaging in the ideas of urban Aboriginal youths by gathering and incorporating information derived from them). According to a participant who worked in a government office as an Aboriginal health-related officer, “Many times we just assume things. We can come up with programs for kids, but it would be nice if we could get real input into health issues they face.”

Instead of approaching health promotion programs on the basis of the assumptions and perceptions of experts (e.g., in-service professionals, policymakers), the opinions, perspectives, and insights of urban Aboriginal youths should be valued. Another interviewee, who worked with Aboriginal youths in not-for-profit organizations, noted:

Aboriginal youth are often ignored. You need to let the kids know that you want them to be heard and that you want to hear what they have to say. . . . Without us realizing what is going on . . . it’s hard to come up with a program that suits this population. To improve health, I think we first need to listen to the kids and what they say about their current situation.

In addition, key informants suggested paying close attention to the needs and aspirations of urban Aboriginal youths, as this would contribute to developing effective individualized programs. As an educator of Aboriginal youths explained:

We need to identify goals, because each is different. We need to cater to different lifestyles and set goals based on those styles. So, the first thing for us to do is find out what a person’s needs are. Then we will be able to design policies and programs that will meet their needs, and we can encourage them to focus on attaining their goals.

Key informants also highlighted the importance of a youth-driven approach. According to the participants, urban Aboriginal youths should be involved not only in planning programs but also in delivering them. One interviewee, who worked with Aboriginal youths as a health and nutrition professional, provided a reason: “Having a peer-led program would be good, because youth tend to listen to their peers better than to us [in-service professionals].” The interviewee noted that this youth-driven approach would improve the uptake and level of participation in intervention programs.

Another participant, who worked with multiethnic youth groups, articulated this point:

When programs speak to the youth and resonate with them then they are more likely to be involved. So it’s important to involve the youth and let them have a voice. There has to be a way that they will be listened to and be involved in some of the decisions and some of the choices. Plant the seed, but make the idea theirs.

Community based and community driven.

Most key informants emphasized the importance of community roles in promoting the health and wellness of urban Aboriginal youths. Similar to the youth-based approach, the perspectives and insights of, and inputs from, the community should also be valued in developing and implementing programs. An educator of Aboriginal youths stated the importance of this community-based approach:

To ensure success, you need to know the politics and the needs of the community. You need to have people who know what actually happens in the community. If people in the community believe some methods are better than others, it is easier to change. The community members are the ones who say what they want to do.

Several respondents stated 1 challenge of a community-based approach: the difficulty in identifying the collective opinions of urban Aboriginal youth communities. Interviewees identified the youths’ sense of disconnection from the Aboriginal community and their limited sense of belonging in both Aboriginal and non-Aboriginal communities as the underlying factors of this challenge.

A participant working with Aboriginal youths as a health-related professional noted, “Aboriginal youth really need to see a place for them[selves] in this society. They don’t feel like they belong to the community they live in and the community where they came from.” Several participants suggested a way of overcoming this challenge in a community-based approach might be through involving Elders of each Aboriginal community in developing and implementing programs. However, further investigation is required to understand the diverse ways of identifying community opinions and to restore the sense of community and belonging among urban Aboriginal youths as a way of closing a knowledge gap in a community-based approach.

Some respondents stated the importance of a community-driven approach, that is, an approach ensuring a level of community participation in planning and implementing intervention programs. According to a government officer who worked in the area of Aboriginal health and wellness:

More support and decision-making power should be put in the First Nations communities. It is important to have Aboriginal health champions, Aboriginal professors, [and] social workers, and leaders of all sorts need to put their heads together to create the programs. There needs to be Aboriginal peoples leading initiatives and bringing people together. The community needs to hold workshops and have champions meet with community leaders to talk about issues. This might bring out subject matter that may be sensitive for our kids. Once these are established, these people should run those programs or at least be involved in running [them], so that they can keep the programs better.

Collaborative works among communities (e.g., Aboriginal communities) and organizations (e.g., educational institutions) are important aspects of the community-driven approach. Informants argued that sharing established knowledge between the groups would provide effectiveness and efficiency in developing and implementing intervention programs. One respondent, who worked with multiethnic youth groups, explained:

Different cultures can learn from each other and have a transmission of knowledge both ways. Interventions need to be linked with established cultural programs, because the established program leaders know the community already and know what barriers and strengths exist. It is important to be aware of what’s going on already with youth and what would work better for the community.

Culturally relevant and appropriate.

Most of the respondents identified the uniqueness of urban Aboriginal youth culture. Accordingly, they suggested that establishing cultural relevancy and appropriateness be one of the key aspects in developing and implementing intervention programs for the target population. Several of them pointed out that stereotyping and stigmatizing urban Aboriginal youths should be avoided to bring out the full potential of this population. As a participant from an Aboriginal community observed,

As a society, we need to change perspectives toward our kids. It really limits their potential. I have relatives who are successful, like doctors, nurses, and entertainers. This is the place where our kids can be.

Another educator of Aboriginal youths indicated how stereotyping and stigmatization marginalized this population: “If they look healthy, the government people will be scared, because it’s good business to keep them ‘down’ and maintain their conflicts. They stereotype the youth as antagonists of society.” Traditionally, some practitioners have focused only on urban Aboriginal youths’ responses to the negative personal and social life contexts, without attending carefully to the root causes associated with these individual responses. As a result, the youths were often considered antagonistic and as requiring special attention to correct individual problems; the voices of youths were often silenced and marginalized.^39,40

Several key informants indicated that acknowledging the diversity and complexity of this population’s culture should be a priority. A participant working with multiethnic groups stated:

Each Aboriginal group has unique cultural practices. You have to understand that there’s diversity within their culture. Don’t assume that beliefs align with what we think their culture is. There’s even a lot of “mixing” of youth, ethnically, and although they might relate on some aspects, they also are very unique and individual. You need to find where and what they relate to.

Interviewees also provided practical suggestions for developing and implementing culturally relevant and appropriate intervention programs to understand the meanings of health from the perspectives of urban Aboriginal youths. An educator of Aboriginal youths pointed out, “We are already in a world that’s not in their favor. You need to figure out what health looks like from their perspective.” Furthermore, several respondents stated the need for attractive and engaging programs that would “work for youths.” Examples included “some kind of incentive at the end of the program” to enhance the level of participation and “providing a short-term program” in consideration of the attendance level.

Additionally, a respondent who worked with multiethnic youth groups in the area of community development pointed out the importance of “increasing the availability of some cultural and traditional program options.” Another participant, from an Aboriginal community, emphasized the importance of Elder-informed program development and implementation as a relatable and culturally relevant approach:

There are wonderful resources for other stuff, but there is nothing for health programs based on the Aboriginal aspect. Get me an Elder from a community who can come to food classes and help create a curriculum. The more realistic for these youth, the better it will work.

Enabling and empowering.

Although the majority of the key informants indicated that the resources currently available for urban Aboriginal youths were lacking, or were inappropriately utilized, some participants perceived that this population had been overserviced. According to a participant who worked in a public organization as a health-related professional,

The urban Aboriginal population is being overserviced. So many programs have been provided. They are living in a system that creates dependency and waiting for services and programs to be provided for them.

Several respondents echoed this participant, arguing for an enabling and empowering approach. An educator of Aboriginal youths elucidated this point:

It is not just about providing services to be healthy. It should be about enabling people to make healthy choices. We need to enable Aboriginal populations to take care of themselves and be independent.

According to these participants, the self-determination and autonomy of urban Aboriginal youths were the keys to the success of health promotion programs. Therefore, youth-driven and community-driven approaches were closely linked to this approach. Using an empowering approach to allow the youths and community to independently make healthy choices promotes a successful youth-driven and community-driven approach to health promotion.

Key informants provided strategies for developing and implementing enabling and empowering intervention programs. Several interviewees stressed the importance of having hopes for the future as a key to this approach. An educator of Aboriginal youths observed:

The most important aspect is to give the youth hope. I think a lot of young people in our communities have no hope, and some of them don’t even know how to find hope. If they want to fulfill their gifts in whatever they have skills in, they first need to know what they want to do.

Some participants added that developing positive self-identity would contribute to hope. A respondent from an Aboriginal community noted, “These young people need to be encouraged to feel good about them[selves] and have self-esteem and a sense of accomplishment, to dream about their future.”

Some other interviewees identified self-motivation and self-regulation as important life skills for the development of hope. A participant who worked with the Aboriginal population in a not-for-profit organization explained the link between these factors:

It’s very hard to motivate and make people happy and satisfied with their lives. To move people out of negative situations you need a lot of counseling and support. A lot of it has to do with motivation and convincing people they are more than what they are now. It’s not a forced thing. We need to help youth assume responsibility for [their] future health and well-being.

One of the most important aspects of the enabling and empowering approach is educating urban Aboriginal youths to be resourceful and self-supportive. A key informant working with Aboriginal youths as a social service professional stated,

We need to teach them how to be resourceful, for example, about where they can actually get food. They need to be educated about what’s already available in the community and how to use these resources.

Several key informants agreed and provided practical suggestions in this regard. Interviewees suggested providing “continuous encouragement” and “celebrating success for even small achievements” to encourage urban youths to be resourceful and self-supportive.

Additionally, some of the interviewees indicated that youths would need to be exposed to alternative options before making choices. As a respondent working with multiethnic youth groups observed, “Children actually need to have an exposure to what’s out there, like other ways of life, doing exercise, eating healthy, without necessarily telling them first these are healthy.” Furthermore, several participants emphasized the importance of building critical thinking abilities among urban Aboriginal youths by “teaching them why” they should be resourceful and self-supportive. As a participant who worked in the area of public health said, “These kids need to be taught why. It’s important to eat healthy, but they have to understand why it is important.” Additionally, some respondents highlighted that providing experiential and practical learning experiences would help this population be more self-supportive in real-world situations.

Finally, to enable and empower urban Aboriginal youths, several key informants suggested educating this population to be resilient in negative life contexts. In particular, interviewees identified resilience as an important life skill for some minority groups in the urban Aboriginal youth population, such as “those youth that have already gone down the ‘wrong road’ or are involved in gangs” and those who are “having children at a very young age without being ready to be a single mom.” However, only 1 key informant, who was an educator of Aboriginal youths, provided a specific educational strategy for becoming resilient: starting educational programs at younger ages. The respondent stated:

The older you get the more effort it will take to break bad habits. It will be more difficult to teach youth how to escape from bad things. The only thing that comes to my mind is educating them when children are younger, so at least some of it sticks with them. Or it’s better to avoid it from the beginning.

Continuous and sustainable.

Several key informants highlighted the importance of continuity in intervention programs. A participant working with multiethnic youth groups elucidated that programs should be developed through the “grassroots initiatives that are built on what we already have.” Other participants highlighted the importance of extensive collaboration with communities and stakeholders, as well as with governmental agencies, in this regard.

The majority of the participants also pointed out the importance of a sustainable approach in developing and implementing intervention programs through establishing long-term relationships with urban Aboriginal youths and through a caring and trust-building approach. An interviewee who worked in a public organization as a health-related professional observed,

Caring relationships really help. These kids need that outlet, someone who is caring and can help them through their issues and concerns. If trust is built, the youth will listen to those delivering the message.

Building on the long-term relationships, several key informants indicated that intervention programs should create a culture of healthy lifestyles and habits for urban Aboriginal youths for continuous and sustainable effects of the programs. Notably, many participants suggested that the use of role models would be an effective strategy for creating this culture. An educator of Aboriginal youths advocated the effectiveness of connecting urban Aboriginal youths with influential role models and mentors:

Aboriginal motivators who used to be on [the] street and now have made a commitment to change the children, they serve as great role models. Aboriginal youth need someone to look up to. They need examples of success. They need to see real-life people who have transformed, instead of worshipping the gangster culture.

Additionally, some key informants specified the need for relatable role models, such as Elders.

Some practical strategies were provided for the development and implementation of continuous and sustainable intervention programs for urban Aboriginal youths. Advertising and promoting existing resources were the most frequently suggested strategies. One respondent suggested sharing and exchanging information and expertise among organizations as an effective strategy, and some of the respondents suggested working collaboratively with research institutions to use existing knowledge derived from evidence-based research.

CONCLUSIONS

Fifty-three in-service professionals, care providers, and stakeholders shared their perspectives on factors contributing to the health and wellness of the urban Aboriginal youth population and provided practical suggestions for future intervention programs. The key informants felt that currently available resources, urban contexts, and the potential of this population would be an asset to health promotion. However, they also indicated that these existing resources are insufficient to fully support effective health promotion. Furthermore, they identified the complex contextual mechanisms that negatively contributed to the current health status of urban Aboriginal youths. On the basis of these identified factors, they suggested approaches and subsequent practical strategies as ways of addressing these issues.

Key informants emphasized the importance of identifying the personal life contexts of urban Aboriginal youths. They also argued that intervention programs should be predicated on the needs and aspirations of this population. However, according to the participants, voices of urban Aboriginal youths are often marginalized and excluded in health-related decision-making processes. Previous studies have likewise indicated that the perspectives and opinions of urban Aboriginal youths have not been considered when developing health-related policies and programs.^41–44 Accordingly, follow-up studies should aim to identify the perspectives of urban Aboriginal youths in the determinants of health and the strategies for health promotion.

Finally, key informants raised concerns about health-related intervention programs and research practices. They argued that these might have unexpected ramifications if responsible long-term relationships are not established. In voicing recommendations for future research and interventional practices, one participant stated,

Researchers will come and go, evaluators will come and go, but the community will be there. The community needs to have the ability to continue the program and evaluate it. It should not be for the sake of research. Don’t just walk away after a project is finished, but ask people in the community how to make programs better.