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Listening to the Communities : Perspectives of Remote and Rural First
Nations Community Members on Telemental Health
Gibson, Kerri; Coulson, Heather; Miles, Roseanne; Kakekayskung, Krystal;
Daniels, Betty; O'Donnell, Susan
t he Communit i es: Per spect ives of Remot e and Rur al Fi r st Nat i ons Communi t y Member s on Tel ement al Heal t h. Rur al Heal t h: Connect i ng Resear ch and Pol i cy. Fr eder ict on, Canada, Sept ember 23-25.
Listening to the Communities:
Perspectives of Remote and Rural First Nations Community Members on Telemental Health
Kerri Gibson
Univer sit y of New Br unswi ck
Heat her Coulson
Keewayt i nook Oki makanak Tel emedi ci ne
Roseanne Miles
Keewayt i nook Oki makanak Tel emedi ci ne
Kryst al Kakekayskung
Keewayt i nook Oki makanak Tel emedi ci ne
Bet t y Daniels
Nat i onal Resear ch Council
Susan O’ Donnell
Nat i onal Resear ch Council
Summary
Telement al healt h involves t echnologies such as videoconf erencing t o deliver ment al healt h services and educat ion, and t o connect individuals and communit ies f or healing and healt h. In remot e and rural First Nat ions t here are of t en challenges bot h t o obt aining ment al healt hcare wit hin t he communit y and t o working wit h ext ernal ment al healt h workers. Telement al healt h is a service approach t hat can address some of t hese challenges and pot ent ially support First Nat ions in t heir goal of improving ment al healt h and well-being.
This paper explores t he perspect ives on t element al healt h of communit y members living in t wo rural and remot e First Nat ions communit ies in Ont ario: Mishkeegogamang and Fort Severn. Using a part icipat ory
research design, we int erviewed 59 communit y members, asking about t heir experiences wit h and t hought s on using t echnologies and t heir at t it udes t oward t element al healt h specif ically. A t hemat ic analysis of t his
qualit at ive dat a, and a descript ive quant it at ive analysis of t he inf ormat ion reveal t he diversit y of at t it udes among communit y members.
Communit y members’ perspect ives on t he usef ulness and appropriat eness of t element al healt h great ly inf luence t he level of engagement wit h t he service. Valuing Indigenous knowledge can help us underst and communit y members’ experiences of and concerns wit h t element al healt h and inf orm more successf ul and appropriat e init iat ives. We explore t he cont inuum of communit y members’ perspect ives – ranging f rom ent husiasm and embracing t he t echnology use t o hesit ancy and rej ect ion. Wit h t he invaluable support of t he Keewayt inook Okimakanak Telemedicine co-aut hors (including t he communit y t elehealt h coordinat ors), we of f er ways f orward t o address concerns ident if ied by t he communit y members.
1. Introduction
The f ocus of t his paper is communit y perspect ives on t element al healt h, using t he rural and remot e First Nat ions of Fort Severn and Mishkeegogamang as a case-st udy. Telement al healt h is a service of f ered t o t hese communit ies t hrough Keewayt inook Okimakanak Telemedicine (KOTM). KO is t he Nort hern Chief s Tribal Council in Ont ario.
By way of background, wit hin t he t element al healt h cont ext , a small body of research exist s on 1) t he
perspect ives t oward t element al healt h of ment al healt h workers who work wit h remot e and rural First Nat ions communit ies, and 2) t he experience of t element al healt h client s, but lit t le is known about t he relevancy of t element al healt h t o t he communit ies in general and how communit y members perceive t his approach t o service.
We begin t o address t his gap by act ually “ list ening” t o t he communit y members: exploring t he perspect ives of rural and remot e First Nat ions communit y members on t he usef ulness of and concerns around t element al healt h.
Self -det erminat ion is an import ant goal of First Nat ions communit ies. Given t hat t element al healt h is accessible in remot e and rural First Nat ions in Ont ario (and ot her provinces), and t hat t he KO t ribal council sees value in it (as evidenced t hrough t he est ablishment of KO Telemedicine), it seems import ant t o explore communit y members’ own t hought s and concerns about using t element al healt h. This could allow f or
increased engagement in discussion about using t he service in communit ies.
2. Telemental Health in a First Nations Context
Telehealt h, concept ualized as t he use of inf ormat ion and communicat ion t echnology (ICT) and broadband net works t o deliver healt h services and support wellness, has been a f ocus of int erest and expansion in rural and remot e First Nat ions communit ies in Canada (Healt h Canada Telehealt h St at us Report , 2004; O’ Donnell et al. , 2010; Romanow report , 2002). The lit erat ure has ident if ied t elehealt h as a t ool t o help “ f acilit at e more ef f ect ive and appropriat e delivery of healt h services” f or individuals living in remot e and rural First Nat ions who ot herwise of t en live t he realit y of inconsist ent healt h care due t o geographic isolat ion, lack of resources, and ot her challenges (Mut t it t , Vigneault , & Loewen, 2004). Tribal councils (e. g. , KO), various levels of
government , non-government organizat ions, and academic and research organizat ions have all been engaged t o some degree in t his advent ure. Recent ly, t he Assembly of First Nat ions (AFN) passed several resolut ions recognizing and at t empt ing t o address t he need f or First Nat ions in Canada t o have suf f icient broadband net works and access t o ICT (Whit educk, 2010).
Challenges of creat ing successf ul t elehealt h init iat ives in remot e and rural First Nat ions communit ies have been ident if ied (e. g. , lack of inf rast ruct ure – see Healt h Canada 2004). Yet , Mut t it t and colleagues (2004) posit t hat while t hese obst acles are not unique t o t he First Nat ions cont ext ; t he int erplay of “ cult ural, polit ical and j urisdict ional issues” can amplif y t hese challenges. Nevert heless, t here have been successf ul t elehealt h programs such as KO Telemedicine which st rive t oward communit y engagement , empowerment , and ownership (Carpent er and Kakepet um-Schult z, 2010; Mut t it t et al. ). Carpent er and Kakepet um-Schult z emphasize t he import ance of int egrat ing First Nat ions values and belief s int o an inf ormat ion t echnology healt h syst em f or rural and remot e First Nat ions. Furt her, t hey assert t hat First Nat ions ownership and cont rol of t he service is cent ral t o t he success of t he init iat ive.
Telement al healt h is a ment al healt h service approach which uses videoconf erencing t o connect t hose engaged wit h t he service f or a variet y of act ivit ies, including (but not limit ed t o): support groups and group t herapy, assessment s, individual t herapy, and psycho-educat ion. Since t he mid 1990s it s use in Canada and in First Nat ions communit ies across Canada has been growing (Healt h Canada, 2004). Telement al healt h has been conceived as a vehicle f or connect ing remot e and rural communit ies t o ment al healt h services where ot herwise access t o cert ain resources wit hin t heir own communit ies would not be possible (Gibson, Kakepet um-Schult z, Coulson & O’ Donnell, 2009; Healt h Canada; KO, 2002; KORI 2008). Indeed, increased
access t o services, client sat isf act ion, and decreased cost s have been ident if ied as benef it s t o t element al healt h in Indigenous communit ies (Gibson, Kakepet um-Schult z, Coulson, & O’ Donnell; KO 2002; KORI 2008).
For inst ance, t he KO t elepsychiat ry pilot proj ect (KO, 2002) was a ground-breaking vent ure t hat sought t o connect cert ain rural and remot e First Nat ions communit ies in nort h west ern Ont ario wit h psychiat ric services. A driving f orce behind t he proj ect was t he obj ect ive of supplement ing current ment al healt h services and reducing wait t imes. At t hat t ime (and arguably st ill t oday) ment al healt h client s in t he communit ies were of t en dependent on ext ernal regional services wit h limit ed presence in t he communit ies, and/ or t hey were of t en required t o leave t heir home communit y t o receive care. Current ly, bot h in-person (again, as provided by ext ernal regional services, and cert ain in-communit y resources) and t element al healt h services are available in KO communit ies (KO - ht t p: / / healt h. knet . ca/ ). Ot her service providers have also opt ed f or t his modif ied model of service delivery. For example, Brasf ield and Clement (2007) describe how a st ress and anxiet y clinic in Brit ish Columbia works wit h a variet y of remot e and rural First Nat ions, harnessing t he ut ilit y of t element al healt h and incorporat ing in-person visit s t o allow f or great er cont inuit y of care.
A report by t he Assembly of First Nat ions (AFN) st at es t hat : “ For Aboriginal people, an int egral component rest oring balance and wellbeing t o communit ies, involves communit y empowerment as well as individual well-being. To t his end, healt h and social services delivery must be under Aboriginal cont rol, and services
delivered by t rained Aboriginal people. The ult imat e expression of an Aboriginal Healt h syst em t hat embodies bot h individual and communit y empowerment is self -government . ” (AFN, 1998, p. 20).
Perhaps an excellent example of an ehealt h/ t elehealt h proj ect t hat f ollows t his creed is t he Fort Chipewyan proj ect (Gideon, 2006). Specif ically, remot e First Nat ions in Albert a are working t oget her using
videoconf erencing t o provide t radit ional medicine t o Aboriginal communit ies. This proj ect st art ed out wit h a t ypical healt h and physiot herapy f ocus, and has evolved int o “ t ele-spirit ualit y, ” connect ing spirit ual
Indigenous leaders t o various communit ies. Indeed, according t o Gideon, Aboriginal leaders view e-healt h as a t ool and a means t o improve “ access t o, and cont rol over, healt h services. ” Furt her, t element al healt h and eHealt h in general in First Nat ions has been t out ed as having t he pot ent ial t o f acilit at e a new environment t hat is healt hy, empowering, and key t o social change (Gideon). Indeed, t he Assembly of First Nat ions has proposed a st rat egy f or increased broadband net work connect ivit y which could help support t hese init iat ives (Whit educk, 2010). However, t he success of any communit y’ s t element al healt h init iat ive will depend on how t he t ool is engaged wit h. Theref ore, it is crit ical t hat First Nat ions be involved in t he development of healt h, ment al healt h, and t element al healt h policies.
3. Participation in Previous Studies on Telemental Health in First Nations
It appears t hat no research or lit erat ure exist s on First Nat ions communit y members’ perspect ives on
t element al healt h, or even on communit y perspect ives on t he broader area of t echnologies f or ment al healt h services or t echnologies in general.
Wit hin t he Canadian cont ext , t here are a handf ul of st udies t hat have explored t he experience of First Nat ions t element al healt h client s (KO, 2002; RVH, 2006). As ment ioned earlier, a t elepsychiat ry pilot proj ect was conduct ed in Nort hern Ont ario in 2001. According t o t he evaluat ion (KO), t element al healt h client s report ed high levels of sat isf act ion wit h t he service: “ almost all t he client s indicat ed t hat t he psychiat rist had helped t hem wit h t heir emot ional problems, and t hat t hey would recommend t he service t o people t hey care about who have emot ional problems. ” In addit ion, client s f ound it benef icial t o have access t o t he opport unit y of receiving ment al healt h services in t heir home communit y wit hout t he requirement f or t ravel. It was also concluded t hat , “ In cont rast t o west ern cult ural expect at ions, t he dist ance creat ed by not being f ace-t o-f ace wit h t he psychiat rist appears t o have helped cl ient s f eel comf ort able wit h t he psychiat rist . ”
Advancing a f ew years and moving t o East ern Canada, during 2004 and 2005 t he Mawi – Wolakomiksult ine proj ect (Maliseet f or “ t oget her, let ’ s have good healt hy minds” ) was underway in New Brunswick (RVH, 2006). This part nership proj ect f ocused on ext ending t element al healt h and t eleaddict ions t o f ive First Nat ion
experiences wit h t elehealt h. Underst andably, many client s report ed f eeling somewhat uncomf ort able wit h t he t elehealt h set -up at f irst ; however af t er t hey became engaged in t he session t hey report ed f eeling as if t hey were in t he room wit h t he provider. Specif ically, according t o t he evaluat ion, 96% of t he client s report ed being sat isf ied wit h t he t elehealt h session, 89% report ed ease of communicat ion during t he session, and 82% of t he client s report ed t hat t hey pref erred t he t elehealt h sessions t o t ravelling t o t he urban cent er f or services.
Finally, st udies on t element al healt h t hat have explored t he experience of ment al healt h prof essionals who work wit h First Nat ions will be reviewed. Recent ly, Gibson and colleagues (2009) examined t he experiences of and at t it udes t oward t element al healt h in ment al healt h prof essionals who work wit h First Nat ions. Individual int erviews wit h ment al healt h prof essionals who had experience in t element al healt h wit h remot e and rural First Nat ions client s inf ormed t he st udy. Addit ionally, t here was an online survey component . Part icipant s were ment al healt h prof essionals Canada-wide who had experience working wit h remot e and rural First Nat ions communit ies (but not necessarily t elehealt h experience). The researchers f ound t hat overall,
part icipant s in t he online survey report ed f inding t element al healt h a usef ul t ool f or connect ing wit h remot e and rural First Nat ions client s. Furt her, t here were a variet y of concerns about using t element al in t he clinical cont ext , including t he appropriat eness of using videoconf erencing wit h cert ain client s (e. g. , individuals who are experiencing psychosis), t he uncert aint y of conduct ing cert ain int ervent ions (e. g. , exposure t herapy) t hrough video, and t he need f or “ saf et y net s” and resources at client ’ s sit e. Finally, t he aut hors not ed t hat prof essionals who had part icipat ed in t he int erviews t ended t o have signif icant ly more clinical experience wit h t he t element al healt h approach, and had discovered usef ul st rat egies f or addressing t herapeut ic challenges (e. g. , relat ionship building) in t element al healt h.
An earlier st udy on t his t opic f ound t hat healt h care workers report ed experiencing increased cont inuit y and coordinat ion in t heir care f or client s and increased f lexibilit y in t heir work. In addit ion, f ront -line workers in t he communit ies report ed experienced reduced isolat ion and increased support in t heir work (KO, 2002). Finally, ment al healt h prof essionals at a clinic in Brit ish Columbia use t element al healt h wit h First Nat ions communit ies and have f ound t hat t he approach has act ually f acilit at ed comf ort and disclosure in client s (Brasf ield & Clement , 2007).
The review of background and previous lit erat ure ident if ied t he need t o underst and t he communit y
perspect ives on t his t opic, which led us t o our research quest ion f or t he st udy: What are t he perspect ives of remot e and rural First Nat ions communit y members on t element al healt h? Specif ically, what do communit y members ident if y as advant ages and concerns relat ed t o t element al healt h and it s place in t heir communit y?
4. Description of Research Method
VideoCom is a collaborat ive research proj ect exploring how remot e and rural First Nat ions communit ies are using inf ormat ion and communicat ion t echnologies. VideoCom (videocom. f irst nat ion. ca) is a part nership bet ween t hree First Nat ions organizat ions and t wo research organizat ions t hat spans t he At lant ic, Quebec, and Ont ario regions. This current st udy was conduct ed wit h t he support of Keewayt inook Okimakanak (KO), our part ner in Nort hwest ern Ont ario.
Our part ner represent at ives provided expert ise, f eedback and support t hroughout t he various st ages of t his init iat ive, including t he design of t he proj ect and measures, helping f ost er connect ions wit h t he communit ies, recruit ment , and ot her act ivit ies.
Participants. In t ot al, 59 remot e and rural First Nat ions communit y members part icipat ed. All part icipant s were over 18 years old; however specif ic age inf ormat ion was not collect ed. Part icipant s report ed holding a variet y of roles and posit ions wit hin t he communit ies, including healt h workers, t eachers, f amily members and caregivers (e. g. , mot hers), elders, leaders (Band Council members), communit y workers, part -t ime workers, t echnology support workers, and ot hers. Our sample was 56% f emale and 44% male.
Materials. The st ruct ured int erview guide had 12 sect ions; t hose relevant t o t his st udy include demographic and int roduct ory inf ormat ion and t echnologies f or communit y healt h and wellness. Specif ically, part icipant s
were asked about t heir t hought s on using videoconf erencing f or t element al healt h and counselling services in t heir communit ies.
Procedure. In aut umn 2009, in collaborat ion wit h KO, t he research t eam cont act ed 33 First Nat ions in t he
Sioux Lookout Zone in Nort hwest ern Ont ario, invit ing t hem t o part icipat e in t his init iat ive and host a communit y visit . Mishkeegogamang and Fort Severn First Nat ions accept ed t he invit at ion. The communit y Chief s appoint ed a communit y liaison t o work wit h us t o organize t he visit s.
The research t eam was welcomed int o t he communit ies in February and March of 2010. To recruit int erview part icipant s, researchers employed t he f ollowing met hods: circulat ing post ers prior t o our visit ; visit ing
communit y cent ers (e. g. , resource cent er, healt h cent er, Band of f ice) t o meet communit y members and invit e t hem t o part icipat e; advert ising t he st udy at a parallel out reach event (communit y video f est ival); and, in Fort Severn, placing an advert isement on t he communit y t elevision channel. Finally, t he “ snowball approach” was quit e ef f ect ive.
In t ot al, 56 in-person int erviews were conduct ed in t he communit ies, and t hree t elephone int erviews were conduct ed af t erwards. Int erviews last ed bet ween 20 minut es and one hour and part icipant s were given a $20 honorarium. The research prot ocols complied wit h Canadian (Tri-Council) guidelines f or research wit h
Aboriginal part icipant s, and all part icipant s (and t heir dat a) were t reat ed in accordance wit h t he et hical guidelines out lined by t he American Psychological Associat ion, and t he Research Et hics Boards of t he
Universit y of New Brunswick and t he Nat ional Research Council. The OCAP (Ownership, Cont rol, Access, and Possession) principles also inf ormed t he design of t he st udy (Schnarch, 2004).
All 59 int erview audio recordings were t ranscribed and t he t ranscript s import ed int o a qualit at ive analysis sof t ware program – NVivo. The t ranscript sect ions relat ed t o t element al healt h were coded t hemat ically f or advant ages and percept ions of usef ulness, and concerns. Typically, when perf orming a t hemat ic analysis, subt hemes and dat a are only report ed if more t han one individual has raised t he same issue, so as t o avoid “ n of 1” issues. However, since t his is new and explorat ory research, all of t he concerns of communit y members were ident if ied, even if t he point was only raised by one part icipant .
Finally, t he responses t o t he quest ion on t element al healt h were quant if ied and cat egorized int o t hree overall t ypes of responses, namely: good idea, not a good idea, and neut ral. This dat a was ent ered int o SPSS t o f acilit at e a descript ive analysis.
5. Presentation of Research Findings 5. 1 Divided Opinions
As illust rat ed in Chart 1, t he quant it at ive result s demonst rat e a diversit y of opinions, inst ead of a clear unanimous voice on t he t opic. Specif ically, 47% of t he part icipant s report ed f inding t element al healt h t o be a helpf ul and good idea, 32% report ed t hat it was not a good idea, and 21% of t he sample report ed t heir at t it ude t oward t element al healt h as neut ral or undecided.
5. 2 Advantages of Telemental Health
Usefulness. Communit y members ident if ied t element al healt h as being pot ent ially very usef ul in t heir
communit ies. Telement al healt h was seen as a t ool t o enable 1) great er cont inuit y of ment al healt h care f or communit y members, and 2) great er access t o ment al healt h services overall, as demonst rat ed by t he quot es below. The f irst quot e also underlines t hat t rust in t he service and t he t echnology is crucial:
“ I t hink t hat act ual l y woul d be r eal l y good (t el ement al heal t h). . . Of cour se, i f peopl e wer e comf or t abl e wit h it wher e we woul d have a pl ace in t he social pr ogr am, maybe, or in t he heal t h cent r e wher e . . . You know, say if somebody had a counsel l or in Sioux Lookout t hat t hey r eal l y need t o t al k t o because t hey'r e exper i encing f l ashbacks or t hey'r e exper i enci ng a ki nd of a di p i n t he r oad, t hey coul d go t her e and int er act wit h t hat counsel l or and t hey coul d see t hem on t he video and j ust go back and f or t h and be abl e t o over come what ever i t is t hat 's bot her i ng t hem at t hat t ime… I t hi nk t he f ir st t hing is t hat peopl e need t o know t hey can t r ust t he ser vice, it 's conf ident i al . Because, of cour se, you know t hat in heal ing, t he f i r st t hi ng t hat needs t o be r est or ed and t he har dest t hi ng t o be r est or ed is t r ust …. If peopl e know t hat t hey can t r ust t he syst em t o honour t hem — t heir heal ing — I t hink peopl e woul d be apt t o use i t . . . You need t o be abl e t o have i t accessibl e. If somet hing does happen . . . Li ke our r esour ce cent r e i s supposed t o be 24/ 7, so peopl e can go t her e anyt i me i f t hey need hel p” - Mishkeegogamang part icipant
“ I t hink it woul d be a r eal l y good i dea because…say t his per son has ki ds and can't go out of t own f or counsel i ng…t hey coul d j ust make an appoi nt ment wit h (t he communit y t el eheal t h coor di nat or ) and she coul d do her counsel ing t her e. ”
– Mishkeegogamang part icipant
One part icipat e not ed t heir percept ion of t he lack of in-communit y ment al healt h resources and report ed t hat t element al healt h could help address t hat issue.
“ I t hink t hat woul d be a good i dea i f t her e was a ment al heal t h wor ker wor king wit h peopl e on t her e (usi ng t el ement al heal t h) because we never have a ment al heal t h wor ker her e. ”
– Fort Severn part icipant
Reductions in travel. Part icipant s not ed t hat t element al healt h could allow an individual t o remain in one’ s
home communit y when accessing cert ain ment al healt h services t hat most t imes would require t ravelling. If using t element al healt h, an individual has t he opt ion of remaining in t heir home communit y while working on increasing t heir ment al healt h, inst ead of f acing dif f erent challenges associat ed wit h leaving t heir communit y t o access services. Part icipant s also indicat ed t hat t he reduct ion in t ravel t ime and t ravel cost s would be a benef it of t element al healt h.
“ I t hink t hat 's a good idea. It woul d cut down on t r avel cost s. ” – Fort Severn part icipant
“ It (t el ement al heal t h) sur e beat s…f l yi ng back and f or t h. ” – Fort Severn part icipant
“ Wel l , it (vi deoconf er enci ng) woul d make st uf f a l ot easier f or peopl e, because most of t hem don't r eal l y want t o l eave home t o go out t her e (out si de of t he communit y t o access ser vices). It 's a l ot easi er f or t hem j ust t o st ay wher e t her e's a vi deoconf er ence set . ”
Client comfort/ facilitation of disclosure. Communit y members comment ed on how t element al healt h (as
opposed t o in-person sessions) may act ually allow ment al healt h client s t o f eel more comf ort able, and t alk more openly. This f inding has also been document ed in t he lit erat ure (Brasf ield & Clement , 2007; Gibson, Kakepet um-Schult z, Coulson, & O’ Donnell, 2009; KO, 2002)
“ Per sonal l y, I went t hr ough t hat (t el ement al heal t h) mysel f . I was i n counsel l ing and at t hat t i me, I wasn't ver y comf or t abl e wit h seeing l i ke f ace-t o-f ace, i n per son, unt il we st ar t ed going on
Tel emedicine. So I got a l it t l e mor e comf or t abl e sayi ng what I want ed t o say. ”
– Fort Severn part icipant
“ I t hink t hat 's why kids l ike Facebook so much, because t her e isn't t hat f ace-t o-f ace int er act i on. And I f i nd a l ot of peopl e, especi al l y in t he communit y, t hey t end t o wear t heir hoods up t o kind of hi de t hei r ident it y. And by usi ng Facebook, t hey can do t hat , even t hough i t 's comi ng f r om t hem, t hey can st il l say what t hey want wi t hout having someone kind of t al k back t o t hem. So I t hi nk wit h vi deo t hat def init el y pl ays out t oo. They can somewhat st il l hide t heir ident i t y and st il l be br aver t han what t hey woul d nor mal l y be. ”
– Mishkeegogamang part icipant
5. 3 Concerns/ Disadvantages of Telemental Health
In addit ion t o t he posit ive at t it udes t oward t he use of t element al healt h, communit y members also voiced a variet y of concerns about it – ranging f rom problems wit h t he t echnology, t o t he appropriat eness of accessing ment al healt h services over videoconf erencing, among ot her import ant issues.
Concern about the appropriateness of using videoconferencing. Several part icipant s were wary about t he
appropriat eness of using videoconf erencing f or accessing ment al healt h services. Part icipant s who voiced t hese concerns of t en not ed t hat ment al healt h work and healing is somet hing t hat needs t o be done “ in-person. ” One part icipant explained t hat t he import ance of human cont act was imbedded in First Nat ions cult ure, and j ust because t he service approach may benef it cert ain st akeholders, does not mean t hat it is appropriat e.
Expect ed dif f icult y wit h building t rust over video was not ed as well. The quot es below demonst rat e t hese concerns:
“ I r eal l y coul dn't speak on behal f of Mi shkeegogamang, but f or mysel f , I t hink i t 's an i nappr opr i at e use of t he video t echnol ogy. I t hink i t unnecessar il y r emoves t he psychi at r ist as a human car egiver . . . or a psychol ogi st . And I don't t hink t hat you can ever r eal l y f ul l y gain r appor t wit h somebody t hat you see on scr een. It doesn't mat t er how good t he t echnol ogy i s. It coul d be a pl asma TV. It doesn't mat t er . Ther e needs t o be some l evel of human cont act i n or der t o f ul l y wi n somebody's t r ust and t o make some usef ul changes…”
– Mishkeegogamang part icipant
“ That (t el ement al heal t h) woul d be al r ight , but I t hink you'r e bet t er ser ved wit h t hat wit h somebody i n communit y … because you got t a bui l d some t r ust t her e. ”
– Fort Severn part icipant
“ It 's easi er f or ser vice pr ovi der s 'cause it 's cheap. It doesn't cost a l ot of money and you can pot ent i al l y r each mor e peopl e and save a l ot of cost and money. But t hat 's not our Fir st Nat i ons peopl e ei t her . Our cul t ur e r eal l y means t al ki ng t o somebody f ace-t o-f ace in your own l anguage and t hen using…cul t ur al st uf f . Mor e and mor e we'r e sor t of de-per sonal i zi ng our cit i zens. You know, f or a physical diagnosis, or in an emer gency, t hat 's f i ne (t el eheal t h). ”
– Mishkeegogamang part icipant
“ For counsel l ing… it woul d be bet t er i f t hat per son's t her e. You know what I mean, (mor e) comf or t i ng. ” – Fort Severn part icipant
One part icipant not ed t heir pref erence f or leaving t he communit y f or t reat ment , despit e t he percept ions by some ot her part icipant s t hat leaving t he communit y was an inconvenience.
“ Wel l , I t hi nk it 's bet t er if you go out . Go out of t own. ”
- Fort Severn part icipant
Anot her part icipant raised t he point t hat if t element al healt h is being used, t he ment al healt h prof essional would not be t here in-person t o see what environment t he individual is act ually living in. This part icipant explains t he issue below, and also appears t o be quest ioning t he ut ilit y of using t element al healt h when people are missing t he very basic necessit ies.
“ How do t hey (per son connect ing wit h cl ient t hr ough t el ement al heal t h) act ual l y get t o know t hat per son? Like, wit h j ust seei ng t hem and t al king and t hat , how do t hey know, unl ess t hey'r e her e t o exper i ence what t hat per son i s goi ng t hr ough, and what t heir condit ions of t hei r house and t hei r wat er s and t hings l i ke t hat . Because t her e's t ons of Nat i ves t hat don't even have r unni ng wat er , and t hey don't have hydr o, and t her e coul d be l ike 20 peopl e l i ving in one r oom. And if t hey don't have t hat in t hei r house, t hen how woul d vi deoconf er encing hel p t hat par t icul ar f amil y?”
– Mishkeegogamang part icipant
Some part icipant s comment ed on how developing a relat ionship over videoconf erencing could be dif f icult and perhaps not appropriat e, but t hat meet ing “ in-person” f irst could help address t his issue.
“ Pr obabl y j ust f or f ol l ow-up but not f or i ni t i al visit s . . . Pr obabl y f ol l ow-up wil l wor k, once t hey've al r eady est abl i shed t hat r el at ionshi p wi t h a per son. ”
– Mishkeegogamang part icipant
Privacy and security issues. Communit y members raised some valid and import ant concerns about privacy,
securit y, and conf ident ialit y. Some part icipant s not ed t he dif f icult y of achieving privacy in t he of f ice set t ing where t he videoconf erence unit was locat ed. Ot her part icipant s voiced concern over who would be able t o access and view t heir privat e video session while it was t aking place, and what exact ly would be happening wit h t he video t ransmission.
“ I t r ied it and I didn't f eel comf or t abl e t al king on t her e because I f eel l ike a (st af f per son) woul d hear what you'r e sayi ng…she cl osed t he door but I st il l didn't f eel comf or t abl e wit h it . ” – Fort Severn
part icipant
The last part icipant was asked if her experience of t element al healt h would have been dif f erent if she could have accessed it wit hin her own home, and t he f ollowing was said:
VideoCom int erviewer: “ …If you had it in a mor e pr ivat e pl ace, l ike in your own home, woul d t hat be
bet t er ?”
Fort Severn Part icipant : “ Yeah, f or me i t woul d be. ”
Safety concerns. Some part icipant s also voiced concern around t he saf et y of t element al healt h, and what
would happen if an individual was in a crisis or was unsaf e and t he ment al healt h worker was only connect ed t hrough video at a dist ant sit e. This part icipant discusses how in a t ime of crisis t hey would pref er t o be wit h someone in-person.
“ I t hi nk t hat i t 's j ust so imper sonal usi ng t echnol ogy. That 's j ust my per sonal opi ni on. If I was goi ng t hr ough a ment al heal t h cr i sis, I'd pr ef er t o have someone t her e t o t ouch me or j ust t o say, it 's okay, r at her t han doing it over t he vi deo. ”
Interference with capacity building. One part icipant raised an import ant point of considerat ion – could
t element al healt h det ract f rom capacit y building in t he communit y, since t he t ypical west ern set -up involves connect ing a client wit h a t herapist who is elsewhere?
The f ollowing individual report ed concerns around t he use of t element al healt h and when asked if t element al healt h would be more appropriat e f or helping wit h t he cont inuit y of in-person, regional services, t he
part icipant had t his t o say:
“ I don't t hink it (t el ement al heal t h) shoul d be used i n t he ment al heal t h f i el d. Secondar il y, I don't t hi nk t her e shoul d be any r egional ser vices --- because I t hink we need t o buil d a capaci t y i n each
communit y. We need t o have our own ment al heal t h counsel ing in t he communi t y. ” – Mishkeegogamang part icipant
Problems with the technology. A minorit y of part icipant s report ed act ual personal experience wit h
t element al healt h (please not e t hat t he part icipant s were not asked whet her t hey had personally used t he service, but some described t heir experiences spont aneously). Of t hose who did, one part icipant not ed t hat she f ound it posit ive and helpf ul but not ed an issue wit h using t he t echnology. Fort unat ely, she also not ed t hat she did not perceive t he t echnical issues t o det ract f rom her overall posit ive experience:
“ I wish it [ t he i mage t r ansmit t ed by video] woul d j ust st op f r eezi ng. That 's about it . ”
– Fort Severn part icipant
5. 4 Ambivalence/ Uncertainty
Some part icipant s were unf amiliar wit h t he concept of t element al healt h; anot her part icipant recognized how it might not be appropriat e f or everyone, but t here are likely some people who would f ind it usef ul f or
accessing support .
“ I've never hear d of t hat bef or e. Wel l , because I know t hat t her e was a gir l t aken out of t hi s communit y t his week and sent t o Sioux Lookout f or t r eat ment because she was t al ki ng about sui cide. So I know her e, t hey've al ways t aken t hem out of t he communit y t o get t hem hel p. So she's at a hospit al r i ght now. So I don't know how t hat woul d wor k. I've never hear d of t hat bef or e. But you know, i f t hey don't have anyone l ocal l y, t hat woul d be gr eat , so t hen at l east t hey have someone t o t al k t o. ”
– Mishkeegogamang part icipant
“ Ever ybody is di f f er ent . It doesn't r eal l y make a di f f er ence f or me i f it 's video or f ace-t o-f ace, as l ong as I got t he hel p t hat I needed. ”
– Fort Severn part icipant 6. Discussion and Conclusions
The remot e and rural First Nat ions communit y members who part icipat ed in t his st udy report ed a wide range of at t it udes t oward t element al healt h. Quant it at ively speaking, it was demonst rat ed t hat 47% of t he sample f ound t element al healt h t o be a good and usef ul idea, 32% did not t hink t hat it was a good idea, and 21% were undecided. Looking past t he “ numbers, ” import ant advant ages and concerns of using t element al healt h were raised. Bot h t he advant ages and disadvant ages need t o be t aken int o considerat ion when communit ies are deciding upon whet her t element al healt h may be a usef ul t ool f or t heir communit y, and whet her it may help wit h meet ing communit y goals. Furt her, concerns and barriers t o use raised by communit y members must be addressed by t element al healt h init iat ives if increased engagement wit h t he service is a goal. Pot ent ial “ ways f orward” will be of f ered in t he f inal sect ion.
Based on t he t hemat ic analysis of int erview responses, we now have considerable inf ormat ion t o help us begin t o underst and communit y members’ perspect ives on t element al healt h. To begin wit h t he advant ages of using t he approach, part icipant s associat ed t he use of t element al healt h wit h t he pot ent ial increase in access t o ment al healt h services, and an increase in cont inuit y of ment al healt h care. Part icipant s not ed t hat t he need
t o t ravel out side of t he communit y t o access resources would be reduced, as would t he t ime and cost
associat ed wit h t ravel. Addit ionally, some part icipant s also f elt t hat communicat ing wit h a t herapist t hrough videoconf erencing would f acilit at e client comf ort and disclosure. Indeed, t his same benef it has been not ed in past research (Brasf ield & Clement , 2007; Gibson, Kakepet um-Schult z, Coulson, & O’ Donnell, 2009; KO 2002). In sum, many part icipant s saw t element al healt h as being pot ent ially very usef ul f or t heir communit y.
In cont rast , however, a good number of part icipant s also f elt t hat it would not be usef ul or helpf ul f or t heir communit y. Many quest ioned t he appropriat eness of delivering ment al healt h services over video, inst ead of “ in-person. ” One part icipant quest ioned t he real benef it of using t element al healt h when some individuals in t he communit y did not have f resh wat er or ot her necessit ies. Anot her part icipant raised t he point t hat
t element al healt h (and even regional ment al healt h services) could pot ent ially j eopardize capacit y building in t he communit y since individuals are connect ing wit h individuals out side t he communit y f or support . St ill yet , ot hers were concerned about privacy issues, not ing t hat t he t element al healt h set -up t hat t hey had
experienced did not seem very privat e (i. e. sound carried out side of t he room). One part icipant who had personal experience wit h receiving t element al healt h services not ed t hat t he t echnology could be improved upon, as she had experienced t he image f reezing during her session (however, and f ort unat ely so, she did remark t hat it did not det ract f rom t he benef it of t he experience).
Finally, ot her part icipant s report ed f eelings of ambivalence and indecision about ment al healt h,
acknowledging t hat it likely wasn’ t a solut ion f or everyone but some may f ind it helpf ul. It appears t hat t his observat ion is quit e valid, especially when t aking int o account t he wide range of at t it udes t hat were
demonst rat ed.
Many of t he concerns raised by communit y members have also been raised by ment al healt h service providers (Gibson, Kakepet um-Schult z, Coulson & O’ Donnell, 2009). Wit hin t he lit erat ure, cert ain opt ions have been raised f or addressing some of t he concerns t hat were raised by communit y members. For example, mixed models of service delivery have been discussed, where videoconf erencing compliment s (inst ead of replaces) “ in-person” services (Gibson, Kakepet um-Schult z, Coulson, & O’ Donnell). Furt her, incorporat ing First Nat ions belief s, values, and t radit ional pract ices int o t elehealt h and t element al services have also been not ed as being pot ent ially helpf ul in increasing communit y accept ance and engagement wit h t he service (Carpent er &
Kakepet um-Schult z, 2010; Gibson, Kakepet um-Schult z, Coulson, & O’ Donnell). Ot her possible solut ions will be discussed in t he next sect ion.
Limitations. Wit hin t his st udy we were assessing t he usef ulness of t he approach of t element al healt h – t he
t ool of using videoconf erencing t o connect communit ies and individuals f or ment al healt h services – we were not evaluat ing t he ef f ect iveness of t he ment al healt h t herapy or any service t hat would t ranspire via t hat service. Furt her, because of t he limit ed number of part icipant s and t he nat ure of t he nonrandom and non-represent at ive sample, result s of t his st udy should not be generalized.
Future research. This st udy is a st art ing point f or exploring how remot e and rural First Nat ions communit y
members perceive t element al healt h and it s place in t heir communit y. Furt her invest igat ions are needed as First Nat ions communit ies in Canada are diverse and varied, and communit y engagement on t he t opic can help bet t er det ermine whet her t his approach t o service is a usef ul and appropriat e t ool in helping meet communit y needs and goals. It would also be highly benef icial t o have a crit ical analysis of t he role of t element al healt h in First Nat ions communit ies, wit h an explorat ion int o t he cult ural, social, polit ical and economic f act ors
involved. The import ant issues of whet her t element al healt h could int erf ere wit h capacit y building, and how usef ul it is in light of some individuals not having access t o basic resources, deserve great er at t ent ion. It appears t o be a complex issue, as t element al healt h – if owned and managed by t he communit ies and used f or support ing communit y goals – could pot ent ially support t he communit y in capacit y-building. Fut ure
7. Ways Forward
First and f oremost , any ways f orward f or communit y t element al healt h init iat ives need t o be communit y-driven and communit y-led. This will increase t he likelihood of t he init iat ives being successf ul and experiencing a higher level of engagement , and t he communit y experiencing posit ive benef it s f rom using t he t ool.
Communit ies need t o have t he opport unit y t o t ailor t he use of t he t echnology so t hat it f it s t heir needs, and t he use may be dif f erent t han t he current mainst ream west ern use of t he t echnology. For example, recall t he “ t ele-spirit ualit y” Indigenous t elehealt h init iat ive t hat f ormed out of a previous physiot herapy t elehealt h init iat ive.
To keep wit h t he goal of communit y-driven ways f orward and init iat ives, t his sect ion was writ t en based on a discussion wit h t he Keewayt inook Okimakanak Telemedicine st af f , and t he communit y t elehealt h coordinat ors specif ically. We will of f er possible “ ways f orward” in t he hopes t hat communit ies and organizat ions engaging in t element al healt h wit h First Nat ions will consider t hese ideas as possibilit ies t hat could st rengt hen t heir init iat ives and address client concerns. The ideas we will discuss are not int ended t o be prescript ive, or exhaust ive.
Bef ore proposing any possible ways f orward, it is import ant t o emphasize t he impact of colonialism on Indigenous peoples in Canada. At t he same t ime, t his is not ment ioned t o posit ion First Nat ions as disempowered; f or indeed t here are self -governing, empowered and healt hy Indigenous communit ies in Canada. However, t he impact of colonialism on individual and communit y well-being, and on cult ural, social, polit ical and economic aspect s of Indigenous communit ies in Canada cannot be denied. Furt her, some
communit ies t hat are isolat ed (i. e. remot e or rural) can experience great er dif f icult y in f ost ering healt hy communit ies when conf ront ed wit h a lack of resources. Theref ore, if t he various levels of condit ions in t he communit y (cult ural, social, polit ical, economic) could be improved so t hat t he communit y was no longer in need of t element al healt h services, or all issues could be appropriat ely dealt wit h wit hin t he communit y, t hat would perhaps be ideal. However, a det ailed discussion of int ervent ions of t his t ype is out side of t he scope of t his paper. Furt her, healt hy communit ies and all communit ies always have individuals who somet imes need services.
Consequent ly, t element al healt h needs t o be a communit y’ s choice, and an individual’ s choice; it cannot be somet hing t hat is imposed. Telement al healt h needs t o be one of many opt ions (i. e. services wit hin t he act ual communit y, t radit ional medicine, in-person t herapy, et c. ) t hat an individual or communit y can use in
at t empt ing t o address goals of ment al healt h and well-being. If a communit y is int erest ed in increasing engagement in t element al healt h as a t ool f or accessing services and/ or using it f or t heir own int erest s (e. g. , t ele-spirit ualit y clinic), t he f ollowing possibilit ies could be considered.
Educat ion about t element al healt h, and raising awareness about t he approach, is an import ant f irst st ep. Even t hough part icipant s in t his current st udy lived in communit ies t hat had access t o t element al healt h, not all part icipant s were aware of it and t he maj orit y had never used videoconf erencing f or t element al healt h or any ot her act ivit y. One possible way of increasing awareness may be by having brochures about t element al healt h available in communit y healt h cent ers, t he Band Council of f ice, or ot her areas t hat display inf ormat ion in t he communit y. Int erest ed individuals can be of f ered t he opport unit y t o speak wit h t he communit y t elehealt h coordinat or (or someone else in t he communit y who is t rust ed and aware of t he service) in a conf ident ial set t ing t o discuss any quest ions or concerns t hey may have about t element al healt h. Furt her, brief videos about t elehealt h f eat uring communit y members who have f ound it usef ul and benef icial or communit y leaders discussing t he service (e. g. , t he Chief or Band Council Members, t he communit y t elehealt h coordinat or, et c. ) could help in communicat ing benef it s of t element al healt h t o individuals who may want more inf ormat ion on it . Of course, it is not being suggest ed t hat t hese videos would f eat ure any privat e or sensit ive inf ormat ion, or be about any personal t element al healt h experience.
Part icipant s raised concerns about privacy and saf et y in using t element al healt h. Increasing privacy and saf et y needs t o be a t op priorit y in t element al healt h. Resources (like a “ saf et y net , ” a counselor or cont act
healt h. Furt her, t here are a variet y of t hings t hat could be done in a healt h cent er set t ing t o help increase privacy. Ideally, t he individual who is using t element al healt h would be aware of all of t he precaut ions t aken t o ensure t heir privacy and would be asked if a suf f icient level of privacy was achieved. For example,
headphones could be used, or a whit e noise maker could be set -up out side of t he room. The room used f or t element al healt h consult s needs t o be as “ sound proof ” as possible.
Addressing issues of privacy underscores t he need f or f lexibilit y in t he set t ing of t element al healt h. Current ly, t he maj orit y of (if not all) t element al healt h sessions t ake place at t he communit y healt h cent er or nursing st at ion. Some individuals may f ear t he st igma t hat could be at t ached t o seeking ment al healt h services, and some may not f eel comf ort able going t o t he nursing st at ion f or f ear t hat t heir anonymit y will be compromised in some way. In some areas of t elehealt h home-visit s are possible, and in t his st udy one part icipant not ed t hat she would have f elt more comf ort able accessing t element al healt h f rom her home. However, using
videoconf erencing at a nursing st at ion, or at home, is not always ideal. For example, depending on t he home sit uat ion and how many people reside t here, privacy may be even more limit ed at home. Theref ore,
communit ies and organizat ions need t o be open t o increasing t he f lexibilit y of t element al healt h and engaging t he client in co-det ermining aspect s of t he set t ing t hat may be saf est and most benef icial f or t he client .
The last point t hat we will ment ion is t he necessit y t o “ t hink out side t he box. ” Using t element al healt h in t he t ypical west ern way of connect ing a client wit h a ment al healt h prof essional may or may not be usef ul f or a communit y. Inst ead, using t he t ool f or peer support (e. g. , alcoholics anonymous, quit t ing smoking groups), group work or sharing circles about cert ain issues, easing t ransit ions f rom inst it ut ions or healt h care f acilit ies, and f acilit at ing f amily visit s wit h f amily members who are out of t he communit y due t o illness, school, or ot her reasons are some possible creat ive applicat ions of t he t ool. Furt her, t elehealt h can be used t o f ost er well-being in a communit y by connect ing Elders and ot her communit y members wit h ot her communit ies t o provide t he opport unit y t o speak t radit ional languages and engage in t radit ional pract ices. In f act , t his last act ivit y is current ly of f ered by KOTM. There are endless possibilit ies, and t he communit ies and t heir leaders know t heir own int erest s and needs best .
In conclusion, if communit ies decide t o engage wit h t element al healt h and f ind it rewarding, part icipat ion in t element al healt h and considerat ion of using t element al healt h will likely increase nat urally over t ime as people experience t he benef it s of it and learn t he usef ulness of it . Af t er all, even t hough First Nat ions are f orging new models f or t elehealt h delivery, t he int roduct ion of t elehealt h int o remot e and rural First Nat ions is relat ively new given t he hist ory of t he communit ies and t heir f amiliarit y wit h ot her t echnologies. One KOTM st af f aut hor recalls how a couple of years ago t he idea was raised t o use t elehealt h f or f acilit at ing First Aid and CPR t raining in remot e and rural First Nat ions communit ies; t he response was t hat it may not be possible or appropriat e. Current ly, t his t ype of t raining is now of f ered via videoconf erencing and t he init iat ive has been report ed t o be very successf ul.
Acknowledgements
First and f oremost , we would like t o t hank t he leadership and communit ies of Mishkeegogamang and Fort Severn First Nat ions f or part nering wit h us in t his st udy. In addit ion, we would like t o acknowledge t he help and support of t he communit y liaisons, Erin Bot t le of Mishkeegogamang and Tommy Miles of Fort Severn. We would also like t o t hank all 59 communit y members who t ook t he t ime t o part icipat e in t his research. Furt her, t his paper would not have been possible wit hout t he part icipat ion of t he communit y t elehealt h coordinat ors f rom Mishkeegogamang and Fort Severn First Nat ions. We also want t o t hank Keewayt inook Okimakanak, K-Net , t he KO Research Inst it ut e and KO Telemedicine f or t heir valuable support of t his proj ect . We would like t o t hank all members of t he VideoCom t eam f or t heir involvement and helpf ul f eedback along t he way. The VideoCom proj ect is f unded by t he Social Sciences and Humanit ies Research Council of Canada (SSHRC), wit h in-kind cont ribut ions f rom proj ect part ners including Keewayt inook Okimakanak (KNET, KORI, KOTM), t he First Nat ions Educat ion Council, At lant ic Canada’ s First Nat ion Help Desk, t he Universit y of New Brunswick, and t he Nat ional Research Council of Canada, Inst it ut e f or Inf ormat ion Technology.
References
Assembly of First Nat ions (AFN). (1998). An Aboriginal Healt h Inf o-St ruct ure: Crit ical Issues and Init iat ives. Ot t awa: AFN.
Brasf ield, C. , & Clement , C. (2007). Beyond t he Pilot St udies: Cognit ive Behavioral Therapy in a Remot e Aboriginal Communit y. Canadian Societ y of Telehealt h Conf erence: Telehealt h: Empowering Primary Care, St John’ s, Newf oundland and Labrador, November 4-6.
Carpent er, P. , Kakepet um-Schult z, T. (2010). Above and Beyond: Embedding Communit y Values and Belief s int o an Evolving First Nat ions IT Healt h Syst em. E-Healt h COACH Conf erence, Vancouver, May 29-31.
Commission on t he Fut ure of Healt hcare in Canada. (2002). Building on Values: The Fut ure of Healt hcare in Canada (The Romanow Report ). Roy J. Romanow, Commissioner, Final Report , November.
Gibson, K. , Kakepet um-Schult z, T. , Coulson, H. , O’ Donnell, S. (2009). Telement al Healt h wit h Remot e and Rural First Nat ions: Advant ages, Disadvant ages, and Ways Forward. Nat ional Aboriginal Healt h Organisat ion (NAHO) Conf erence. Ot t awa, November 24-27.
Gideon, V. (2006). Canadian Aboriginal Peoples Tackle E-Healt h: Seeking Ownership Versus Int egrat ion. In K. Landezelius (ed. ) Nat ive on t he net : Indigenous and Diasporic peoples in t he virt ual age (p. 61-79). Abingdon, Oxon: Rout ledge.
Healt h Canada (2004). Telement al Healt h in Canada: A St at us Report . Accessed Oct ober 1st ,
2009 at ht t p: / / www. hc-sc. gc. ca/ hcs-sss/ alt _f ormat s/ iacb-dgiac/ pdf / pubs/ 2004-t element al/ 2004-t ele-ment ale. pdf /
Keewayt inook Okimakanak. (2002). Evaluat ion of t he Keewayt inook Okimakanak Tele-psychiat ry Pilot Proj ect Report , Balmert own, Canada: Keewayt inook Okimakanak.
Keewayt inook Okimakanak Research Inst it ut e. (2008). MMW Ment al Healt h Proj ect Evaluat ion 2005/ 2006 2006/ 2007. Hasham Consult ing.
Keewayt inook Okimakanak Healt h. Accessed August 1st, 2010 at ht t p: / / healt h. knet . ca/
Mut t it t , S. Vigneault , R. , & Loewen, L. (2004). Int egrat ing t elehealt h int o Aboriginal healt hcare: The Canadian Experience. Int ernat ional Jour nal of Cir cumpol ar Heal t h, 63(4), 401-414.
O’ Donnell, S. , Molyneaux, H. , Gorman, E. , Milliken, M. , Chong, C. , Gibson, K. , Oakley, P. , Mait land, J. (2010) Inf ormat ion and Communicat ion Technologies t o Support Healt h and Wellness in Remot e and Rural First Nat ions Communit ies: Lit erat ure Review. Frederict on: Nat ional Research Council, May, 136 pages.
River Valley Healt h (2006) Telement al healt h and Teleaddict ions part nership proj ect – Mawi Wolakomiksult ine Evaluat ion Report : Frederict on, NB: River Valley Healt h.
Schnarch, B. (2004). Ownership, cont rol, access, and possession (OCAP) or self -det erminat ion applied t o research: A crit ical analysis of cont emporary First Nat ions research and some opt ions f or First Nat ions Communit ies. Jour nal of Aboriginal Heal t h, 1(1), 80-95.
Whit educk, J. (2010). Building t he First Nat ion e-Communit y. In Whit e, J. P. , Pet ers, J. , Beavon, D. , Dinsdale, P. (eds. ) Aboriginal Policy Research VI: Learning, Technology and Tradit ions (p. 95-103). Toront o: Thompson Educat ional Publishing.
