Situational Assessment of Digital Health in Indigenous Communities

What is the situation?

Despite Canada’s commitment to universal healthcare, Indigenous communities are still facing persistent inequities in accessing care. These inequities contribute to higher rates of chronic disease, worse health behaviours, and lower overall health expectancy (Liddy et al., 2019). Ear and hearing health is one of the more obvious examples of these disparities faced. Chronic otitis media occurs more often, earlier, and with higher severity among First Nations children when compared with non-Indigenous children (Nash et al., 2023).

Untreated or reoccurring ear infections affect speech and language development, readiness for school, social connection, and long-term wellbeing, and can lead to permanent hearing loss (Karunanayake et al., 2016). Otitis media persists as a complex and multi-faceted issue influenced by overcrowded housing, socioeconomic challenges, and historical trauma (Karunanayake et al., 2016; Nash et al., 2023). In many Indigenous communities, care is primarily delivered by nurses or community health workers without consistent access to physicians or ENT specialists (Nguyen et al., 2020). Communication barriers including low literacy and lack of culturally safe interactions further delay access to care or lead to misdiagnosis.

These gaps in accessing timely care have downstream system-level impacts including increased specialist referrals, avoidable travel to urban centres, and higher healthcare costs associated with delayed or acute presentations. Ear and hearing care in Indigenous communities is influenced by many interconnected factors including provider capability, digital infrastructure, policy frameworks, and community trust.

A consistently identified need across communities is for care to be delivered locally, by trusted, culturally safe providers. This reduces the burden of navigating complex health systems and travelling long distances. There is strong support for prevention focused approaches that promote early detection and empower both caregivers and providers with culturally appropriate education. Interventions that align with community priorities and respect Indigenous knowledge systems are essential to improving ear and hearing outcomes in a way that is truly sustainable.

What influences are making the situation better and worse?

Underlying causes and conditions run both wide and deep for this health issue. At the individual level, factors like symptom recognition and health literacy around ear hygiene influence early detection and prevention. At the interpersonal level, caregiver capacity and stigma associated with hearing aids play a role. At the community level, access to culturally safe care through a staffed clinic with effective workflows shape the quality of care delivered. Finally, at the systems level there are referral pathways, policy structures, workforce shortages, and historical trauma that all contribute to inequitable outcomes.

There are low levels of awareness within communities about early signs of ear disease and prevention strategies. Education often isn’t in language that matches the literacy of communities. Low levels of follow-up or delay in seeking care are influenced by logistical barriers in accessing care such as travel, required time off work, or childcare. There have also been many negative experiences of discrimination which produces a level of mistrust in the system and a hesitancy to seek out or continue with care.

Protective factors that move the needle are strong caregiver-child relationships, existing trust between community members and local healthcare providers, and emerging digital infrastructure that can support new models of care.

Our organization does have some strengths when approaching this health issue, we have existing eConsult infrastructure, established relationships between primary care and specialists, and we align ourselves with health system priorities around access and efficiency. There are also large weaknesses where digital literacy and infrastructure varies drastically between communities, and there’s a high risk of increasing provider workload if the workflows are poorly designed. Threats would be if we try to introduce tech driven solutions that are not community led or co-designed and mistrust if we don’t focus on relationship building first to align priorities and requirements.

What possible actions can you take to address the situation?

There is evidence from similar initiatives that prove that digital health technologies are more likely to be adopted within Indigenous communities when they are co-created from the earliest stages of development, grounded in culturally safe practices, and aligned with community identified priorities. On the other side, initiatives that introduce digital solutions after design decisions have already been made often contribute to mistrust and limited engagement.

The strongest evidence indicates that there is a huge opportunity to implement asynchronous ENT eConsults as a strategy to strengthen community based primary care in Indigenous communities. When introduced through culturally safe, respectful, and community led approaches there is a willingness and commitment from communities to engage with these digital tools. Communities need to have clear control on how their health data is being stored, accessed, and used. Issues of data governance, privacy, and ownership and crucial components to prioritize to build trust.

ENT eConsults offer a meaningful pathway toward more accessible, timely, and culturally grounded ear and hearing care. Improving outcomes requires coordinated commitment across multiple levels of the health system with Indigenous leaders guiding the process through design to evaluation. The way forward is through recognizing community strengths and supporting local care to improve long-term outcomes for Indigenous families.

References

Liddy, C., Joschko, J., Guglani, S., Afkham, A., & Keely, E. (2019). Improving equity of access through electronic consultation: A case study of an eConsult service. Frontiers in Public Health, 7, 279. https://doi.org/10.3389/fpubh.2019.00279

Karunanayake, C. P., Albritton, W., Rennie, D. C., Lawson, J. A., McCallum, L., Gardipy, P. J., Seeseequasis, J., Naytowhow, A., Hagel, L., McMullin, K., Ramsden, V., Abonyi, S., Episkenew, J.-A., Dosman, J. A., & Pahwa, P. (2016). Ear infection and its associated risk factors in First Nations and rural school-aged Canadian children. International Journal of Pediatrics, 2016, Article 1523897. https://doi.org/10.1155/2016/1523897

Nash, K., Macniven, R., Clague, L., Coates, H., Fitzpatrick, M., Gunasekera, H., Gwynne, K., Halvorsen, L., Harkus, S., Holt, L., Lumby, N., Neal, K., Orr, N., Pellicano, E., Rambaldini, B., & McMahon, C. (2023). Ear and hearing care programs for First Nations children: A scoping review. BMC Health Services Research, 23(380). https://doi.org/10.1186/s12913-023-09338-2

Nguyen, N. H., Subhan, F. B., Williams, K., & Chan, C. B. (2020). Barriers and mitigating strategies to healthcare access in Indigenous communities of Canada: A narrative review. Healthcare, 8(2), 112. https://doi.org/10.3390/healthcare8020112

Poche Centre for Indigenous Health. (2020). [Photograph of a child undergoing a hearing assessment]. Hearing Hub. https://hearinghub.edu.au/2020/06/18/indigenous-health-research-into-the-care-of-persistent-hearing-loss-is-high-on-the-agenda-for-macquarie-university/