“I feel safe just coming here because there are other Native brothers and sisters”: findings from a community-based evaluation of the Niiwin Wendaanimak Four Winds Wellness Program

Abstract

Background

Urban Indigenous populations in Canada are steadily growing and represent diverse and culturally vibrant communities. Disparities between Indigenous and non-Indigenous peoples’ experiences of the social determinants of health are a growing concern. Under the guidance of the West End Aboriginal Advisory Council (WEAAC), Parkdale Queen West Community Health Centre (PQWCHC) launched the Niiwin Wendaanimak Four Winds Wellness Program that seeks to enhance health and community services for homeless and at-risk Indigenous populations in Toronto.

Objectives

A process evaluation was carried out to (1) assess the collaborative service delivery model; (2) identify service gaps and issues for homeless and at-risk Indigenous populations; and (3) develop recommendations for how non-Indigenous organizations can provide culturally responsive services for Indigenous populations.

Methods

In consultation with the WEAAC, a thematic analysis of qualitative data collected from 2 focus groups with community members who access the Niiwin Wendaanimak program and 17 key informant interviews with staff and peers was conducted.

Results

The Niiwin Wendaanimak program bridges teachings of inclusivity and the practice of harm reduction to create a non-judgemental space where community members’ dignity and autonomy is respected. Strengths of the program include Indigenous leadership and access to activities that promote wellness and community building.

Conclusions

As a non-Indigenous service provider, PQWCHC is meeting the needs of homeless and at-risk Indigenous populations in Toronto. Program strengths, system gaps, and challenges including policy recommendations were identified.

Introduction

Urban Indigenous1 populations in Canada are steadily increasing in number and represent a diverse and culturally vibrant community. With over 70% of the Indigenous population in Ontario living in urban areas, disparities in social determinants of health such as income insecurity, unemployment, decreased food availability, and inadequate housing are a growing concern (Environics Institute 2010; Firestone et al. 2014). Indigenous communities and their governing organizations in Canada have identified the fundamental role of colonization, racism, social exclusion, and a lack of self-determination as key drivers of the alarming disparities in Indigenous and non-Indigenous peoples’ health (Allan and Smylie 2015; Loppie Reading and Wien 2009).

Of the 5523 estimated number of homeless people sleeping outdoors and in emergency shelters, Violence Against Women shelters, and in health and correctional facilities in Toronto, 16% self-identify as Indigenous (City of Toronto 2013), although this is likely to be an underestimate given limitations of the methods, particularly around how Indigenous people were asked to self-identify in this point in time count. Overall, Indigenous people are overrepresented in the homeless population who are sleeping outdoors and tend to be younger than the non-Indigenous homeless population (City of Toronto 2013). Recent data from the Our Health Counts Toronto study, which generated population-based health and health care access data among Indigenous people in the city, found that 27% of Indigenous adults were homeless (living on the street, in a homeless shelter, or couch surfing) (Well Living House and Seventh Generation Midwives Toronto 2018).

Studies like the Urban Aboriginal Peoples Report and the Toronto Aboriginal Research Project (TARP) have highlighted a number of issues that contribute to homelessness among Indigenous people in the city, including addictions and substance use, a lack of affordable housing, challenges with accessible transportation, racism, and lateral violence (Environics Instute 2010; McCaskill et al. 2011). Indigenous homelessness, as articulated and understood by the community itself, extends beyond colonial definitions of homelessness as a lack of physical housing structures, but includes “individuals, families and communities isolated from their relationships to land, water, place, family, kin, each other, animals, cultures, languages and identities” (Aboriginal Standing Committee on Housing and Homelessness 2012). Reframing the discussion around Indigenous homelessness must include but is not limited to the recognition and acknowledgement of historic and ongoing displacement, spiritual and cultural disconnection, relocation and mobility, and a lack of access to stable shelter and housing (Thistle 2017).

For several years, a number of service agencies in Toronto have been reporting an unprecedented rise in the number of deaths among their clients, many of whom were vulnerably housed (Toronto West End Agencies 2015). A recent count of homeless deaths by the city confirms increasing numbers, particularly among individuals under 40 years of age and linked to overdose (Toronto Public Health 2018). Collaborating health and social service organizations serving the Indigenous community in Toronto reported that the average age of death among their clients was 37 years, compared to 75 years for the average Torontonian, and found that the cause of death was tied directly to issues arising from homelessness, physical abuse, and/or substance use, and existing chronic health conditions (Shah et al. 2008). Addressing overdose among Indigenous people who use drugs has been identified as a priority in the city of Toronto, with Toronto Public Health’s Overdose Action Plan (Acting Medical Officer of Health 2017). As evidenced and in response to the Truth and Reconciliation Commission of Canada, First Nations, Inuit, and Métis peoples require Indigenous-specific approaches to health and health promotion (Indian and Northern Affairs 1996; J. Smylie et al. 2016; Truth and Reconciliation Commission of Canada 2015a).

Parkdale Queen West Community Health Centre (PQWCHC) is an accredited Community Health Centre and a member of the Association of Ontario Health Centres (Parkdale Queen West Community Health Centre 2018). As a community-based health and wellness service organization, PQWCHC is working to improve the health and well-being of individuals and communities who are at risk and/or face barriers to accessing high-quality health care services and supports. PQWCHC has been providing services to Indigenous clients in the Bathurst and Queen community for over 40 years. In September 2015, PQWCHC in partnership with West Neighbourhood House Meeting Place Drop-in (WNP) and Evangel Hall Mission (EHM) and with support from the Toronto Central Local Health Integration Network (LHIN) launched a collaborative project with the goal to enhance health and community services for homeless and at-risk Indigenous populations in the downtown mid-west Toronto area. The Niiwin Wendaanimak Four Winds Wellness Program (Niiwin Wendaanimak program) is guided by the West End Aboriginal Advisory Council (WEACC), which is comprised of service providers, Elders, Indigenous service users, and other community leaders concerned with enhancing services in the West End and with a mandate to provide guidance, oversight, and advice for the program. The objectives of the Niiwin Wendaanimak program are to improve primary and harm reduction services for Indigenous populations, to identify and develop pathways to care for Indigenous adults and youth, particularly those who are homeless, living in poverty and at-risk of homelessness, and to provide Indigenous culturally specific healing and psychosocial support which integrates recognition of the chronic trauma caused by genocide and colonization. At the time the Niiwin Wendaanimak program was initiated, there were few Indigenous-specific organizations in the city that were actively providing harm reduction services.

In February 2016, PQWCHC hired a team of researchers at the Well Living House (WLH) to carry out a process evaluation of the Niiwin Wendaanimak program. At the core of WLH work is a commitment to uphold both Indigenous ways of knowing and doing and mainstream academic knowledge and expertise to advance the health of Indigenous infants, families, and communities. WLH is located within the Centre for Urban Health Solutions of St. Michael’s Hospital and co-governed by St. Michael’s Hospital (SMH) and an Indigenous Grandparents Counsel (Well Living House 2017).

Through a process evaluation, we aimed to assess the Niiwin Wendaanimak program delivery model and Indigenous approach to providing culturally safe, relevant, and sustainable housing supports and mental health services for Indigenous people living in Toronto.

Methods

Using a community-partnered approach (Smylie et al. 2011a, 2013) that aligns with wise practices for conducting Indigenous health research and evaluation (Cavino 2013; Estey et al. 2008; First Nations Information Governance Centre 2014; Lafrance and Nichols 2010; Smylie 2011; Smylie et al. 2011b), we implemented a process evaluation of the Niiwin Wendaanimak program. This involved initial meetings with PQWCHC and the WEAAC, during which a Memorandum of Understanding between PQWCHC and WLH was established to guide and inform the work. The WLH upholds Indigenous ethical standards (Ball and Janyst 2014; First Nations Centre 2004) that ensure balanced relationships between Indigenous and allied community research partners, academics, and additional governmental, data, and public health stakeholders throughout the research process, while maintaining rigour and policy relevance. Approval from the Research Ethics Board at SMH was also obtained.

A process evaluation informs policy and practice through an investigation of the implementation, mechanisms of impact, and contextual factors of a complex intervention. A process evaluation framework not only measures what was delivered, but how and why outcomes were achieved (Carroll et al. 2007). Process evaluation usually requires a combination of quantitative and qualitative methods, allowing for the identification and in-depth exploration of complex and diverse pathways (Moore et al. 2014, 2015). The objectives of the process evaluation were to (1) assess the Niiwin Wendaanimak program service delivery model and (2) explore how PQWCHC, as a non-Indigenous-led organization collaborating with Indigenous communities, provides culturally safe and relevant and sustainable services for Indigenous populations. Building on the UK Medical Research Council framework for process evaluation of complex interventions (Moore et al. 2014, 2015), the dimensions of the Niiwin Wendaanimak program implementation that were assessed included the coverage or reach of supports, and the quality of services (objective 1). Understanding how staff, peers, and clients interact within the Niiwin Wendaanimak program, which supports are needed and why they are needed helped to establish the mechanisms that drive change (objective 2). To meet the overall aims of the evaluation, indicators and key foci questions were identified and co-developed through the community-partnered research approach. The evaluation was carried out in collaboration with PQWCHC and the WEAAC through a series of steps (Fig. 1). The findings presented here will focus specifically on the qualitative data collected from key informant interviews and focus groups. A full description of the evaluation, including the results from an environmental scan of literature examining relevant service delivery models of care, can be found here (Well Living House 2017).

Fig. 1.

Steps of the Niiwin Wendaanimak Program Evaluation

Recruitment and data collection

Drawing on established conversational methods in Indigenous research (Kovach 2010), the interviews and focus groups honoured the stories and knowledge of those who participated, were flexible, purposeful, and collaborative. Key informant interviews were held with members of the WEAAC, Elders, traditional knowledge keepers, peers, and staff from PQWCHC, WNP, and EHM. The participants were contacted by the research team by phone or email and invited to participate in an interview. Two members of the research team (MF and JSyrette) conducted the audio-recorded interviews. A semi-structured interview guide was used during the interviews and included questions on involvement and experiences with the Niiwin Wendaanimak program, defining cultural safety, system challenges, and reflections on Indigenous and non-Indigenous identity.

Focus group participants were clients of the Niiwin Wendaanimak program and were recruited through word of mouth and posters that were displayed at PQWCHC, WNP, and EHM. The focus groups took place in the summer of 2016 and were facilitated by one non-Indigenous and one Indigenous member of the research team (MF and JSyrette) and were audio recorded. A semi-structured focus group guide focused on experiences with the Niiwin Wendaanimak program (i.e., what works well? what could be changed or added?), experiences with other programs and services in Toronto, and their understandings of cultural safety and harm reduction. All study participants received honoraria and tokens for transportation.

Data analysis

Transcripts of the key informant interviews and focus groups were analyzed through a critical decolonizing lens (Kovach 2009; Smith 2012) that examines ongoing power structures and social systems driving inequities and marginalization of Indigenous peoples. Through an iterative approach that combined editorial and immersion-crystallization methods (Crabtree and Millar 1999; Smylie et al. 2009), three members of the research team (MF, JSyrette, TJ) coded, read, and re-read transcripts until they reached consensus on a thematic codebook. Once consensus was reached, this codebook was presented to the Niiwin Wendaanimak clients who had participated in the focus groups. An interactive, member checking group activity was administered in which the participants were given an opportunity to reflect on the themes, provide any additional thoughts or ideas which were missed, and adjust the themes according to their own experiences and interpretation.

Results

A total of 11 themes emerged from the key informant interview and focus group data. This manuscript focuses on the 5 most salient themes, across client, staff, WEACC council and peer experiences. These 5 themes represent the experiences and concepts that were described most often by the participants.

Home

Participants described a feeling of belonging at the Niiwin Wendaanimak program due to an atmosphere of acceptance and a sense of ownership in the space. Part of the safety and comfort experienced by clients was directly linked to the Niiwin Wendaanimak program being specifically for Indigenous people, both in membership and staff. As one key informant explained, “I think the reason people like and come to the program is because it actually is specifically an Indigenous program run by leadership from Indigenous populations with peers who are part of the participants themselves.”

Niiwin Wendaanimak program clients spoke of regular attendance to the program and travel across considerable distances. One client spoke of a 4-hour daily commute by foot to the area because Niiwin Wendaanimak is their home, more so than the place where they keep their possessions. Participants described a sense of belonging as being accepted and understood no matter what challenges they face and credited the sisterhoods and brotherhoods cultivated at the Niiwin Wendaanimak program for providing them the strength to overcome many obstacles. As one client explained, “…there’s a certain friendship. It’s a brotherhood or sisterhood, so to speak, between the street people.”

For many program attendees, the Niiwin Wendaanimak program is local, accessible, and situated in a neighbourhood and “territory” that has a history as a gathering place for Indigenous people well before the current health centre occupied the space. As several key informants described:

“There’s a deeper connection in the physical place itself. I think it goes down to that ancestral-level memory of our people and I think there’s different historical aspects of why this area and why these people are suffering in this area. So, it may have been the catastrophic traumatic experience of our people way, way back and you know, they’re pulling these people here for whatever reason.”

“Also, historically this corner… there’s old photos I saw a couple of years ago from over a hundred years ago where this used to be an old bank. And there were Aboriginal members sitting on the front steps of this corner of the bank. So, there’s part of it (that is) land ownership. And so I think that that’s really important for people and you hear that all the time. We’ll have new staff members come in and people take a lot of pride in the fact that they have been here for years and years and they continue to come and this is their sort of space and they take great ownership over that. So yeah, so I think that that, you know, that’s a huge part of why people come.”

Harm reduction policy

An aspect of the Niiwin Wendaanimak program and service delivery model assessed in the evaluation was its harm reduction approach. Clients of the Niiwin Wendaanimak program are trusted to use the program in the way that works for them and this autonomy is fully supported by the program staff and more broadly across programs and services at PQWCHC. Participation in any and all activities is self-directed and whether a member wishes to sit in or out of circle, they are always encouraged to come back. As explained by two key informants:

“We will help you whatever shape you are in.”

“So that holistic very client-centred view, very harm reduction-based focus which allows people to be where they’re at in whatever space they’re in and be part of the program and be respected in the program. People have let us know how important that is to them.”

The harm reduction approach means that community members have access to services and supports they critically need, which might otherwise be unavailable to them. Physical safety is supported by the distribution of Harm Reduction kits and counseling around safe use. Clients also attributed their sense of safety to the non-judgemental staff at the health centre who are trained in trauma-informed and non-stigmatizing approaches and use of language.

It was imperative that the three organizations involved in the Niiwin Wendaanimak program come up with a unified harm reduction policy. During the time of the evaluation, the WEACC developed and finalized the following harm reduction definition:

“The teaching of non-interference is a world-view that allows others to experience and learn life lessons in their own way and in their own time. This way of being is complemented by harm reduction. Earth-based cultures always used a campfire. If a child is walking toward a campfire, we do not snatch them away and slap their hand. Instead, we walk closely behind allowing the child to reach out to the fire. The child will pull the hand back when they learn that fire hurts. They learn to respect fire. This is non-interference. The rocks around the fire pit may also serve as a physical barrier, thus harm reduction. Service-wise, this means that we take a strength-based approach that is “client-centered”, as opposed to having an agent of a foreign system diagnosing and prescribing or enforcing changes that make the prescriber feel better. As with everything in life, there are always limits. When non-interference is successfully implemented, there should rarely be instances of disrespect to service providers.”

Harm reduction and Indigenous culture

Participants spoke about the importance of having access to cultural supports within a harm reduction framework. As highlighted by the quotes below, participants explained that the harm reduction approach protects the dignity and honour of community members. It is through this approach that the community can come together as a whole to strengthen the circle, not leaving anyone behind.

“I think the importance is that it validates their spirit. Our most marginalized people have been ostracized and booted out or paid off to get out of our communities. You know, so they’re used to rejection. So when it comes to our spiritual supports if we reject them there too, then that puts their spirit even lower than it already is. You know, so I think it’s important to validate their spirit but also to validate their right to the medicines their right to what makes them strong. Like if you deny that to them right off the hop, then why are you there to begin with?” Key Informant

“An aspect of my work that I found the most challenging and the most unique, and I still think are what sets this apart from my other program in the City of Toronto for people who are Aboriginal is you’re combining harm reduction and you’re combining spirituality and First Nation teachings and bringing them together and sort of breaking down those barriers which disallowed people who were in the throes of using to participate in their own Native culture.” Key Informant

“Harm Reduction fits with who we are as Indigenous people. It’s about love and respect. When did judgement come into the seven grandfather teachings?” Key Informant

As many participants articulated, creating spaces such as open, inclusive circles that bridge harm reduction and diverse Indigenous ways of knowing can support healing and build strength and resilience.

“A lot of our culture never stays the same, you know. A lot of people think things should always be the same and they get rigid, you know. And our culture is totally the opposite. It's about freedom, it's about flexibility and what we do in that circle. If (we’re) doing things right (we’re) giving the people in the circle and myself hope. Hope. I've been healing all my life. I had no parents; I had no one to guide me, you know, so I made a lot of mistakes learning. But what always kept me going, I always had hope that things would get better. And what saved me from my drug addiction is the culture, is the hope.” Key Informant

Cultural safety

Two key elements of cultural safety at the Niiwin Wendaanimak program emerged from the interviews and focus groups: space and knowledge.

The discussion of space acknowledged the importance of honouring an Indigenous-only time and place for the Niiwin Wendaanimak program. The presence of Indigenous people and culture in shared areas of the centre was also important. This included having Indigenous staff, displaying Indigenous artwork and hosting community events that celebrate Indigenous culture. One staff member noted that inviting the neighbourhood residents to mingle at events enhances cultural safety as this exposure can demystify culture and cultivate understanding.

“We do the circle and it’s for just Native people. And what do we do there? We honour the circle, our culture, and it gives a person a chance to share, to pray or sing.” Key Informant

The discussion of knowledge centered around the importance of learning the history and context of Indigenous people in Canada. Understanding increases accountability to the community, minimizes the power imbalance between staff and community members, and builds trust. It was frequently noted by participants that the Niiwin Wendaanimak program feels culturally safe.

“So when I say cultural sensitivity, I mean having that shared understanding and knowledge around the Indigenous population, the damages of residential schools and the impact of genocide. I think that it's damaging to have to continuously tell your story over and over and over again. And entering a space where you don’t have to do that and you can just participate is as safe as a space can get. And that doesn’t mean that (you won’t) encounter conflict but it just means there’s that pre-existing understanding which will help you navigate that conflict when it comes up.” Key Informant

“I was interested in that [access to traditional teachings and language] just because I keep hearing… not just learning about yourself but also learning about other cultures and other people. It makes it a little easier to… I don’t know, interact or reach out or make new friends.” Focus group participant

The discussions on cultural safety also highlighted existing gaps and areas where improvements could be made. Many participants cited the importance of time and space for relationship building between staff and community members to promote cultural safety. For example, one staff member explained that with adequate resources, the power imbalance could be minimized through simple social interactions. It was overwhelmingly agreed upon that the Niiwin Wendaanimak program circles should be kept Indigenous-only and that having non-Indigenous members attend made the space uncomfortable. Last, many interviewees suggested that community members would be best served by having an Indigenous counselor who understands Indigenous culture, rather than only offering counseling from a Western healing paradigm.

Healing and wellness

Creating a space and providing support for Indigenous healing is of central importance to the Niiwin Wendaanimak program as it is common for the clients to have experienced multiple levels and forms of trauma. This approach also aligns with the Truth and Reconciliation Commission (TRC) calls to action (Truth and Reconciliation Commission of Canada 2015b). Colonization and its resonating impacts, including experiences with residential school, child, and family services and the breaking down of families are a major source of trauma. Increasingly, the Indigenous community in Toronto is coping with the grief and loss of their peers and family in addition to the high turnover of staff at health and social service organizations, which are contributing factors of complex trauma. As described by several participants, the convergence of a culturally safe Indigenous-led space with a non-interference Indigenous harm reduction approach facilitated healing.

“Now I can talk about what happened to me without breaking down, without having to cry. Why? Because I went and got help for that. I had to go to my own culture to do that.” Key Informant

“So but I heard it put really really nicely in one of the teachings and the Elder said, you know, this is a reminder for us to be humble, to recognize these warriors that are substance users because they’re doing that for us so we don’t have to. Just a reminder of what they’re giving up for the rest of us. And I thought that was so beautiful because that’s so true. It’s right in your face every day of where we could all be. And so it’s a gentle reminder to be humble and accept the gifts that you have and share them as well to help our struggling people.” Key Informant

Participants agreed that the Niiwin Wendaanimak program offered a broad and wholistic understanding of wellness. Health and wellness for Niiwin Wendaanimak program clients was improved through their access to a range of supports including, for example, access to health care, health education, housing, showers, and laundry in addition to access to medicines, ceremony, Elders, traditional healers, and counselors. Food was central to well-being within the Niiwin Wendaanimak program. The members were happy that the food offered was healthy, free, or low-priced. One key informant explained the importance of food as a way to bring the community together.

“I think because we’re putting food in their bellies, that in itself just breaks down so many resistances and people start laughing. When they’re around food they get a little bit dance-y and so I think that in itself just humanizes the experience of people coming together and that’s what we’re trying to do right across the province now is feed the people. Bring them in to feed them. That gets people through the doors and eliminates that clinical atmosphere. It just makes everything a lot more familiar and communal and comfortable. And I think that that’s huge for Four Winds [Niiwin Wendaanimak program].” Key Informant

Healthcare was another element of wellness cited by project participants. Community members explained that they access health care at PQWCHC and that the Niiwin Wendaanimak program provides an access point or connection to care. Additional wellness and social opportunities that were raised by Niiwin Wendaanimak program clients included nourishment/diabetes education, health fairs, and workshops on how to choose and prepare healthy food on an affordable budget.

Opportunities for improvement

Opportunities for program improvements were raised by program staff and clients and included: the need for traditional healers and counselors in the program who are Indigenous; a dedicated space where ceremony can take place and where community members can meet with Elders and have access to medicines; more opportunity to get out on the land; expanded roles and opportunities for peers involved in the Niiwin Wendaanimak program; and ongoing cultural safety training for all staff at Niiwin Wendaanimak partner organizations, including those who are not directly involved in the Niiwin Wendaanimak program. The evaluation highlighted a need for additional coordination among the Niiwin Wendaanimak program partners: PQWCHC, WNP, and EHM. Participants provided examples of how coordination could be enhanced across the three partner agencies, such as increased outreach support, the development of a shared understanding of roles and function across the three organizations, and more opportunities for integrated and complementary programming.

Discussion

The Niiwin Wendaanimak program works to improve stability, health, well-being, and quality of life for Indigenous peoples who are homeless and under-housed in the downtown mid-west Toronto area. Through a process evaluation, a number of strengths were uncovered as well as opportunities and recommendations for the program.

The Niiwin Wendaanimak program is a unique model where clients and staff described a feeling of home, in a welcoming, non-judgemental atmosphere, situated on a territory that has long been a gathering space for Indigenous community. Cultural safety within the Niiwin Wendaanimak program is facilitated through dedicated, Indigenous-only time and space and the relationships among staff and clients in the health centre. The presence of Indigenous people, Indigenous languages, and access to ceremony and teachings were highlighted. Relationships among clients, peers, and staff were supported through the staffs’ knowledge and trauma-informed understanding of the history and context of Indigenous peoples in Canada. This interconnection between physical spaces and relationship building has been identified as an essential component of best practices in providing culturally safe services to Indigenous people (Churchill 2015). Another strength of the Niiwin Wendaanimak program is the combination of a harm reduction approach that meets people where they are at and provides access to Indigenous knowledge, teachings, and ceremony through local Indigenous community members and Elders. Overall, there is recognition and support for individuals to choose their own path toward healing and well-being, which is consistent with emerging scholarship on experiences of historic and ongoing complex trauma among Indigenous populations (Linklater 2014) and definitions of Indigenous homelessness (Thistle 2017).

As Niiwin Wendaanimak program clients, peers and staff articulated, the concept of home not only refers to the dedicated, physical space for Indigenous community to come together, but also a social connectivity and feeling of inclusion. Wahkohtowin, translated to mean “all things are related” or “kinship”, is one of the basic principles of Cree Natural Law and is fundamental to understanding Indigenous relationships and community (Bear Paw Legal 2016; O’Reilly-Scanlon et al. 2004). Wahkohtowin underpins many of the teachings and experiences shared by participants with respect to harm reduction and their involvement in the Niiwin Wendaanimak program. Specifically, everyone in the circle has an important role to play and the circle is open to all, even those who are using substances or who may have been ostracized or rejected from their communities have a right to access the spiritual supports within the circle. By welcoming all relations, Wahkohtowin establishes the social protocols and context that can allow for an ethic of non-interference as described in the WEACC definition of harm reduction.

Government policies in Canada have undermined Indigenous social systems and the intergenerational transfer of Indigenous knowledge and practice (Smith et al. 2005; Truth and Reconciliation Commission of Canada 2015b), resulting in well-documented health and social inequities (Loppie Reading and Wien 2009; Smylie and Firestone 2016). The opportunities for program improvement raised by program and staff and clients reinforce urban Indigenous community priorities and mandates to break the cycle of disruption, rebuild Wahkohtowin and ways of living a good life. With an estimated 45,000–60,000 Indigenous people residing in the city of Toronto (Rotondi et al. 2017) and a high prevalence of poverty, housing insecurity, and unmet health needs, there is a growing need for coordinated health service access across Indigenous and allied providers in the city. Since the completion of the evaluation, PQWCHC has been responding to these gaps through the hiring of a mental health care worker and an outreach worker and through expanding partnerships in the neighbourhood. Overall, these recommendations strongly reinforce the TRC calls to action (Truth and Reconciliation Commission of Canada 2015b).

There were a number of limitations to the study. First, given recruitment methods, our sample of participants may not be representative of community members who are less connected to services and supports or who face barriers with mobility and could not travel to participate in the focus groups. Given that the timeframe of the Niiwin Wendaanimak evaluation was over the period of one year, qualitative data collection occurred at one point in time; therefore, we were unable to capture the change in implementation or contextual factors over time. Our findings, however, do establish a foundational basis on which future evaluations can build and has already led to the expansion of staff, services, and outreach in the community.

The Niiwin Wendaanimak program is a unique service delivery model in Toronto that is led by Indigenous staff and governed by a community council with mixed Indigenous and allied representation from peers, Elders, and local community organizations. A key recommendation for strengthening the program is through the expansion of Indigenous representation across all areas of program governance, management, and delivery, including Parkdale Queen West Community Health Centre Board, managers, and staff (e.g., front-desk staff). Evidence of local Indigenous community investment, leadership, and collective sense that the program is intrinsic to the local community has been shown to positively impact Indigenous health and well-being (Smylie et al. 2016). Opportunities for expanded Indigenous community development will build upon the social connectivity and inclusivity that the program nurtures.

The evaluation of the Niiwin Wendaanimak program has contributed to a body of evidence that links wellness and healing with integrated, community-led, and culture-based approaches (Rowan et al. 2014; Smylie et al. 2016). Ultimately, this will support the identification of collaborative strategies as well as policy and advocacy efforts that support reconciliation, strengthen partnerships, and address ongoing inequities experienced by Indigenous people.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflicts of interest.