Statistics Canada (2015a) has recently estimated that one in four Canadians will be over the age of 65 by 2051, which means that the Canadian older population will become one of the most dominant demographics in the country (Public Health Agency of Canada, 2016). The projected growth of the Canadian older population also means that the prevalence of this group experiencing injuries, specifically fall-related injuries, is anticipated to increase (Hill, Pinto, Nathens, & Fowler, Reference Hill, Pinto, Nathens and Fowler2014; Peel, Kassulke, & McClure, Reference Peel, Kassulke and McClure2002). Therefore, because of the growing rate of fall-related injuries and fatalities among older Canadian (Hill et al., Reference Hill, Pinto, Nathens and Fowler2014; Registered Nurses Association of Ontario, 2005), it is clear that this population is in need of falls prevention programs (Beauvais & Beauvais, Reference Beauvais and Beauvais2014; Gillespie et al., Reference Gillespie, Robertson, Gillespie, Sherrington, Gates and Clemson2012; Hill et al., Reference Hill, Pinto, Nathens and Fowler2014; Naraynsingh, Sammy, Paul, & Nunes, Reference Naraynsingh, Sammy, Paul and Nunes2015; Registered Nurses Association of Ontario, 2005; Semonin-Holleran, Reference Semonin-Holleran2015; Statistics Canada, 2012; Stewart-Williams et al., Reference Stewart-Williams, Kowal, Hestekin, O’Driscoll, Peltzer and Yawson2015).
Recent studies have shown that falls prevention programs are beneficial in reducing falls amongst older persons (Beauvais & Beauvais, Reference Beauvais and Beauvais2014; Gillespie et al., Reference Gillespie, Robertson, Gillespie, Sherrington, Gates and Clemson2012); however, not all groups are equally vulnerable to injury. Research has shown that Indigenous peoples (i.e., First Nations, Métis, and Inuit) in Canada experience injuries at higher rates than non-Indigenous Canadians (Bjerregaard, Young, Dewailly, & Ebberson, Reference Bjerregaard, Young, Dewailly and Ebbesson2004; Public Health Agency of Canada, 2016). Moreover, the only data available on Inuit Elders in Canada emphasize their exceptionally low life expectancy in comparison with non-Inuit seniors (Public Health Agency of Canada, 2016), which provide a generalized overview of their injury rates (i.e., there is limited information pertaining to fall-related injuries among the Inuit) (Bjerregaard et al., Reference Bjerregaard, Young, Dewailly and Ebbesson2004). Given the over-representation of Indigenous peoples’ poor outcomes on almost every health measure, including injury (Loppie-Reading & Wien, Reference Loppie-Reading and Wien2009), it is reasonable to assert that Inuit Elders are also over-represented in fall-related injuries and fatalities; therefore, they are in need of falls prevention programs.
Although Inuit Elders require falls prevention programs, most programs available to Canadians are currently not culturally safe. Cultural safety is the understanding of colonization, colonial relationships, and power dynamics as they apply to individuals’ health care or research experiences (Darroch et al., Reference Darroch, Giles, Sanderson, Brooks-Cleator, Schwartz and Joseph2017; National Aboriginal Health Organization, 2008). It is an approach to health policies, programs, and services that aims to disrupt the power imbalances between researchers/practitioners/programmers and clients, to understand their influence on participants’ day-to-day lives, and to ensure that these professionals respect and acknowledge participants’ contextual, cultural, historical, and social experiences (Christensen, Reference Christensen2016; Fulcher, Reference Fulcher2001; Giles, Hognestad, & Brooks, Reference Giles, Hognestad and Brooks2015). As a result, this approach to research and practice recognizes Indigenous peoples’ culture (Smye & Browne, Reference Smye and Browne2002). Cultural safety presents current and future falls prevention researchers/practitioners/programmers with the opportunity to recognize Inuit culture and Inuit Elders’ knowledge as valuable in the creation and implementation of falls prevention practices.
In an attempt to address these areas of interest, we conducted research in Inuvik, Northwest Territories (NWT) (68°21’N, 133°43’W). Inuvik is a community 1,068 km northwest of Yellowknife and located on the Mackenzie River Delta (NWT Bureau of Statistics, 2016a). It has a population of 3,170 residents, of which 2,059 self-identify as Indigenous (NWT Bureau of Statistics, 2016b). The Indigenous populations in the community primarily consist of Inuvialuit (Inuit), Gwich’in (First Nations), and Métis peoples. Recent statistical demographic profiles of these groups are unavailable; however, Statistics Canada (2007) cited these groups as representing 38.9 per cent (Inuvialuit), 18.4 per cent (Gwich’in), and 4.7 per cent (Métis) of Inuvik’s population. The NWT Bureau of Statistics (2016b) also identified that Inuvik has a population of 359 older persons (i.e., individuals ≥ 60 years old; no breakdown by ethnicity is available). Indigenous Elders and non-Indigenous older adults therefore comprise approximately 11.3 per cent of Inuvik residents (NWT Bureau of Statistics, 2016b). For our research, we conducted research with Inuvialuit residents.
Although the older population in Inuvik is relatively small, this demographic – and its likelihood of experiencing a fall or fall-related injury – is expected to grow. Falls prevention researchers and practitioners in this community must continue to provide interventions that reduce Inuvialuit Elders’ risk of falling, but they also need to work with the Elders to determine the cultural safety of falls prevention programs. The lack of information related to Inuvialuit Elders in current Canadian falls prevention research inspired us to conduct research with Inuvialuit Elders and local falls prevention programmers (LFPPs) in Inuvik. Working with the participants, we sought to address the following questions: “What are the current falls prevention recommendations (from research participants) to decrease fall rates among Inuvialuit Elders?” and “How can falls prevention programs for Inuvialuit Elders be co-created (with research participants) to be culturally safe?”
Using post-colonial theory (Boehmer, Reference Boehmer1995; Gandhi, Reference Gandhi1998; Judd, Reference Judd1996; McEwan, Reference McEwan2009; Scott, Reference Scott2014) as a theoretical framework and thematic analysis (Braun & Clarke, Reference Braun and Clarke2006) to analyze the data from our 12 semistructured interviews with LFPPs and Inuvialuit Elders, we identified (a) recommendations for three components of falls prevention programs in Inuvik, which included environment assessment and modification, physical activity, and education for Elders and caregivers; and (b) recommended strategies for the development of a culturally safe falls prevention program for Inuvialuit Elders, which included establishing trust and rapport within the community, including both Indigenous and non-Indigenous interventions in falls prevention programs, and training others on cultural safety practices. The results from this study challenge current falls prevention practices and indicate that falls prevention researchers and practitioners should carefully consider how they develop and implement falls prevention programs for/with Inuvialuit Elders.
Literature Review
To examine the aforementioned research questions, we situated our research within four areas: Inuit health, specifically Inuit Elders’ health; the status of falls among Indigenous Elders; the falls prevention model, Behaviour Change, Education, Equipment, Environment, Activity, Clothing and Footwear, and Health Management (BEEEACH); and the need for culturally safe falls prevention programs for Indigenous Elders.
State of Inuit Elders’ Health
With Canadian citizens generally living longer, healthier lives, it is not surprising that Canada’s population is considered one of the healthiest in the world (Public Health Agency of Canada, 2016). In fact, it has been reported that almost 90 per cent of Canadians believe that they are in good to excellent health, which highlights that these residents indeed experience exceptional overall health (Public Health Agency of Canada, 2016). However, despite evidence of these positive national health trends, Indigenous peoples in Canada fare much worse than non-Indigenous Canadians. As indicated by recent studies, Indigenous peoples experience some of the greatest health inequalities in the country. Researchers have argued that this population experiences higher rates of chronic diseases (e.g., diabetes, cardiovascular disease), communicable diseases (e.g., tuberculosis), physical inactivity, and mental health issues (e.g., drug abuse, addiction, and suicide) than non-Indigenous peoples (Health Canada, 2012; Somogyi, Barker, MacLean, & Grischkan, Reference Somogyi, Barker, MacLean and Grischkan2015). Because of these high rates, Indigenous peoples’ health inequalities have therefore become an area of interest for many health researchers and government organizations. Yet, information related to Inuit health is rather limited and under-studied.
Studies have found that the Inuit population experiences some of the highest mortality and health disparity rates in Canada (Statistics Canada, 2012). Regarding maternal, fetal, and infant health, researchers have found that the Inuit have much higher teenage pregnancy, pre-term births, stillbirths, and infant mortality rates than the national averages (Cameron, Reference Cameron2011; Luo et al., Reference Luo, Senécal, Simonet, Guimond, Penney and Wilkins2010). In terms of communicable diseases, scholars have indicated that the Inuit have higher rates of sexually transmitted infections (e.g., chlamydia, human papillomavirus), meningitis, and especially tuberculosis (Cameron, Reference Cameron2011; Hamlin-Douglas, Coutlee, Roger, Franco, & Brassard, Reference Hamlin-Douglas, Coutlee, Roger, Franco and Brassard2008; Health Canada, 2016; Steenbeek, Tyndall, Rothenberg, & Sheps, Reference Steenbeek, Tyndall, Rothenberg and Sheps2006). For chronic diseases, such as diabetes, cancer, cardiovascular disease, and respiratory disease, researchers have also found that Inuit rates are increasing in comparison with those of non-Indigenous Canadians, and have also predicted that they will only continue to increase (Cameron, Reference Cameron2011; Circumpolar Inuit Cancer Review Working Group, 2008; Dewailly, Chateau-Degat, Ékoé, & Ladoucer, Reference Dewailly, Chateau-Degat, Ékoé and Ladoucer2007; Tait, Reference Tait2008). Lastly, with regard to injury, evidence suggests that the Inuit are among the most susceptible to experiencing serious health problems as a result of intentional and/or unintentional injuries (Bjerregaard et al., Reference Bjerregaard, Young, Dewailly and Ebbesson2004). Intentional injuries include those sustained during interpersonal or self-inflicted incidents such as family violence and assault, whereas unintentional injuries are often accidental, such as drowning, motor vehicle accidents, or accidental falls (Bjerregaard et al., Reference Bjerregaard, Young, Dewailly and Ebbesson2004).
Although the body of literature on Inuit health is growing, to date it has focused on Inuit youth, young adults, and middle-age adults (Somogyi et al., Reference Somogyi, Barker, MacLean and Grischkan2015), and as a result, very little is known about Inuit Elders in relation to these health disparities. Despite this limitation, there is research currently available that provides a “snapshot” of Inuit Elders’ overall health status. For example, according to the Public Health Agency of Canada (2016), Inuit Elders are very unlikely to reach national life expectancies. That is, non-Indigenous males and females are expected to live to 79 years old and 83 years old, whereas male and female Inuit Elders are only expected to live to 64 years old and 73 years old respectively (Public Health Agency of Canada, 2016). Researchers have also agreed that Inuit Elders’ health and well-being are affected by the previously highlighted negative health measures; however, because of the lack of studies on health disparities specific to elderly Inuit individuals, these are predictions of their health status at best (Public Health Agency of Canada, 2016; Somogyi et al., Reference Somogyi, Barker, MacLean and Grischkan2015). Aside from generally poor physical health outcomes, researchers also indicated that social factors (e.g., isolation and lack of socialization with family, friends, and community members), as well as cultural and historical factors (e.g., colonization and acculturation), have progressively worsened the health and longevity of Inuit Elders in Canada as well (Kral, Reference Kral2012; Kral, Idlout, Minore, Dyck, & Kirmayer, Reference Kral, Idlout, Minore, Dyck and Kirmayer2011; Richmond, Reference Richmond2009; Somogyi et al., Reference Somogyi, Barker, MacLean and Grischkan2015).
Although the above-mentioned studies provide researchers with a better understanding of the overall health status of Inuit Elders, information pertaining to their experiences with injury, specifically fall-related injuries, is lacking. There is also scant research on Inuit Elders’ fall rates and fall-related injury rates, revealing the need for studies that examine this information. Indeed, in order to develop and implement falls prevention programs that successfully reduce occurrences of falls among Inuit Elders, it is important for researchers and practitioners to consider the cultural dimensions of Elders’ health, and for them to recognize and respect the implications that these dimensions may have on Elders’ perceptions of falls and falls prevention programs.
Status of Falls for Indigenous Elders
According to the Public Health Agency of Canada (2016), the nation’s population has officially exceeded 36,000,000 people. Of this 36,000,000, approximately 5,800,000 comprise Canada’s elderly population (i.e., individuals ≥ 65 years of age) (Public Health Agency of Canada, 2016). Although these 5,800,000 seniors have access to various health services and programs – all of which have extended the longevity and quality of lives of these elderly individuals – health issues associated with aging have significantly affected this population. In addition to Canadian older adults experiencing higher rates of chronic illnesses, such as arthritis, cancer, cardiovascular disease, diabetes, and dementia (Public Health Agency of Canada , 2016), fall rates among this population have been increasing as well. Recent evidence has shown that almost half of Canadian older adults who experience a fall will likely sustain an injury (Herman, Gallagher, & Scott, Reference Herman, Gallagher and Scott2006). Scott, Wagar, and Elliott (Reference Scott, Wagar and Elliott2011) also found that falls account for upwards of 85 per cent of all injuries that result in Canadians 65 years and older being hospitalized. It is evident that falls prevention programs are therefore needed in order to reduce and prevent falls among older Canadians.
Although literature on fall rates, fall-related injuries and fatalities, and falls prevention for older adults in Canada is growing, similar information pertaining to Indigenous Elders in Canada is significantly lacking. Firsthand accounts of Indigenous Elders’ experiences of falling and their engagement with falls prevention programs are also missing from injury prevention literature, which makes it challenging for researchers and practitioners to understand the scope and nature of falls amongst this population. Moreover, data regarding fall risk factors that either directly or indirectly influences older Indigenous adults’ likelihood of experiencing falls continue to be unavailable as well.
Despite this gap in knowledge, it has been postulated that fall rates among Indigenous Elders in Canada will increase. The only Canadian falls prevention study with a focus on First Nations Elders, conducted by Reading and colleagues (2011), found that fall-related injuries and fatalities are anticipated to rise because of the expected growth of the Indigenous elderly population in Canada. Reading et al. (Reference Reading, Scott, Perron, Edgar, Baba and Elliot2011) also reported that Indigenous Elders were twice as likely to be hospitalized as a result of falling than were their non-Indigenous counterparts (Reading et al., Reference Reading, Scott, Perron, Edgar, Baba and Elliot2011). These findings emphasize the need to better understand why Indigenous Elders are over-represented in Canadian fall and fall-related injury rates.
BEEEACH: A Falls Prevention Model
For many falls prevention researchers and practitioners, the adoption of a holistic falls prevention program is considered the best approach for reducing older Canadians’ fall risk and rates. According to Scott (Reference Scott2012), “the most effective fall prevention interventions [and programs] are those that use a multifactorial approach” (p. 96). These programs often include a number of recommended prevention actions, most of which are in reference to the BEEEACH model (Scott, Reference Scott2012). As a standard for current Canadian falls prevention programs, the BEEEACH model requires prevention programs to comprise the following elements: behaviour change, education (of program participants), equipment (the appropriate use of mobility aides and assistive devices), environment (in the home and public places), activity (physical and social), clothing and footwear (required for fall risk reduction), and health management (properly assessing and treating any fall contributing medical conditions) (Scott, Reference Scott2012).
BEEEACH model programs have been found to be successful in reducing fall rates and risk among non-Indigenous older Canadians (Scott, Reference Scott2012); however, no attempt has been made to understand if BEEEACH model-related falls prevention programs are relevant to Indigenous Elders in Canada. Interestingly, researchers working with Indigenous Elders seem to have disregarded the Euro-Canadian BEEEACH model, and they have instead developed their own falls prevention program requirements. Recommendations for developing Indigenous-focused falls prevention interventions and programs were established by Reading et al. (Reference Reading, Scott, Perron, Edgar, Baba and Elliot2011) (in partnership with other scholars, practitioners, policy makers, community members, and First Nations Elders). They included the following:
(1) Offering fall prevention activities at established events to increase acceptance and accessibility by older Aboriginal people
(2) Building fall prevention into existing programming with positive messaging
(3) Supporting community-defined evidence-based practice
(4) Acceptance and incorporation of culture into health care practices
(5) Environmental scan of infrastructure to support
(6) Increasing risk assessment skills of home care workers
(7) Life course approach to fall prevention practice
(8) Partnership to support skill development and education in universities and communities (Reading et al., Reference Reading, Scott, Perron, Edgar, Baba and Elliot2011, pp. 13–15).
If we take these important cues and insights from Reading et al. (Reference Reading, Scott, Perron, Edgar, Baba and Elliot2011), it is evident that Indigenous-focused falls prevention programs can, and should, be developed and implemented in the future. The issue, however, is that key information concerning Indigenous Elders who are not First Nations peoples remains absent from the literature. For Métis, Inuit, and other Indigenous populations, research regarding their fall rates and preventive programs are sparse. Additionally, understanding of the ways in which to include Métis, Inuit, and other Indigenous peoples’ culture in the development and provision of falls prevention education and interventions is also missing from the literature. Falls prevention researchers and practitioners therefore need to create programs (with Métis, Inuit, and other Elders) that are best suited to prevent possible fall-related injuries among these populations.
Culturally Safe Falls Prevention Programs for Indigenous Elders
Before highlighting the need for culturally safe approaches to research concerning falls prevention programs, it is necessary that we first distinguish among the terms cultural competency, cultural appropriateness, cultural sensitivity, and cultural safety. The first term, “cultural competency”, refers to a researcher’s ability to engage with members of a population while respecting and working within their cultural beliefs (Baker & Giles, Reference Baker and Giles2012; Giles et al., Reference Giles, Hognestad and Brooks2015). The second term, “cultural appropriateness”, describes when a researcher is capable of creating and/or sharing research and programs in a way that is “reflective of the diverse cultural and linguistic characteristics of racial and ethnic groups” (Giles et al., Reference Giles, Hognestad and Brooks2015, p. 545). The third term, “cultural sensitivity”, reflects researchers’ ability to incorporate consideration, understanding, respect, and willingness to adapt when developing knowledge and results with their participants (Foronda, Reference Foronda2008; Giles et al., Reference Giles, Hognestad and Brooks2015). Lastly, the final term, “cultural safety”, describes when researchers or practitioners are respectful of the population that they are conducting research with, and are aware of their own cultural beliefs and values because these may influence how researchers develops their “understanding of whose knowledge is privileged within research, policies, and practices” (Giles et al., Reference Giles, Hognestad and Brooks2015, p. 547).
Although all of these terms are important for researchers, it is particularly important for scholars to adopt a cultural safety approach to their own studies. In addition to the aforementioned tenets of this practice, cultural safety encourages researchers to become aware of their personal biases and dissuades them from imposing their values and beliefs onto those with whom they are conducting research (Giles et al., Reference Giles, Hognestad and Brooks2015; Ramsden, Reference Ramsden2002). Cultural safety also permits scholars to analyze how their exercise of power may influence interactions with respect to their participants (Baker & Giles, Reference Baker and Giles2012; Brascoupé & Waters, Reference Brascoupé and Waters2009; Giles et al., Reference Giles, Hognestad and Brooks2015; Ramsden, Reference Ramsden2002). Therefore, it is clear that researchers should adopt these practices, because doing so ensures that the participants engaging in the studies and programs will ultimately determine whether or not the researchers’ findings and suggested interventions are relevant and/or needed for the participants’ communities (Brascoupé & Waters, Reference Brascoupé and Waters2009; Giles et al., Reference Giles, Hognestad and Brooks2015).
Researchers and practitioners working with Indigenous peoples thus benefit from utilizing a culturally safe approach. It encourages them to examine the ways in which their cultural backgrounds influence their actions and behaviours, and the ways in which they interact with Indigenous populations (Giles et al., Reference Giles, Hognestad and Brooks2015). Indigenous peoples have greater self-determination and responsibility for studies, services, or programs that are culturally safe, because their perspectives are taken seriously and their needs are met (Giles et al., Reference Giles, Hognestad and Brooks2015; Reading et al., Reference Reading, Scott, Perron, Edgar, Baba and Elliot2011). Fortunately, there have been studies that have addressed the development of cultural safety principles in health services for Indigenous peoples (see Giles et al., Reference Giles, Hognestad and Brooks2015; Nursing Council of New Zealand, 2011); however, there is little known about culturally safe falls prevention programs for Indigenous Elders in Canada. Interestingly, Reading and colleagues’ (2011) study is the only one in Canada that focused on increasing cultural safety of falls prevention programs. It is important to note that their cultural safety recommendations were developed from discussions regarding (and with) First Nations Elders; nevertheless, these suggestions can be used to initiate conversations on how to establish culturally safe falls prevention programs for other groups of Elders, such as Inuit Elders.
To create culturally safe falls prevention programs for Elders, Reading et al. (Reference Reading, Scott, Perron, Edgar, Baba and Elliot2011) recommended that researchers and practitioners include community members’ input and opinions. By incorporating Indigenous peoples’ voices in the development and implementation process, falls prevention professionals are more likely to create successful and sustainable programs for Indigenous Elders (Reading et al., Reference Reading, Scott, Perron, Edgar, Baba and Elliot2011). Another suggestion was to include more traditional activities and culturally relevant practices into these programs; doing so could potentially elicit greater participation rates from Indigenous Elders (Reading et al., Reference Reading, Scott, Perron, Edgar, Baba and Elliot2011).
Although these recommendations can initiate the process of developing and implementing a culturally safe falls prevention program for Indigenous Elders, it is important to note that these suggestions were created in partnership with First Nations Elders. The issue with this is that the recommended strategies for establishing a culturally safe falls prevention program may only be applicable and relevant to First Nations Elders, meaning that the ways in which Inuit Elders determine the cultural safety of their programs is missing from falls prevention literature. Therefore, we sought to address this gap in falls prevention research by working with Inuvialuit Elders.
Theoretical Framework
This research was informed by post-colonial theory. As a theoretical framework, post-colonial theory encourages scholars to better understand individuals’ past, present, and lasting experiences with colonialism (i.e., the egocentric and capitalistic venture that allowed dominant Western nations to claim new territorial settlements, develop their resources by exploiting others, and govern the inhabitants of occupied lands) (Boehmer, Reference Boehmer1995; Gandhi, Reference Gandhi1998; Judd, Reference Judd1996; McEwan, Reference McEwan2009; Scott, Reference Scott2014). This theory also advances the understanding of how colonialism significantly influenced the colonizer’s and the colonized’s perspectives of each other and their social worlds (McLeod, Reference McLeod2000), as well as encourages scholars to critique dominant colonial discourses, while simultaneously addressing issues such as race, ethnicity, and gender (McEwan, Reference McEwan2009; Scott, Reference Scott2014). Postcolonial theory thus acknowledges and represents the formerly colonized and exposes the cultural, political, and economic damage experienced by these individuals as a result of colonization and its legacies (Gandhi, Reference Gandhi1998; Scott, Reference Scott2014).
Colonial discourses, values, and power have profound impacts on Indigenous peoples (Battiste, Reference Battiste1998; Coleman, Battiste, Henderson, Findlay, & Findlay, Reference Coleman, Battiste, Henderson, Findlay and Findlay2012; Kelm, Reference Kelm2004). This is a significant issue because the dominant Eurocentric ideals of non-Indigenous Canadians continue to frame the nation’s legislation and policies towards education, employment, health care, language, and knowledge, which has resulted in Indigenous cultures remaining absent from these areas of the government (Battiste, Reference Battiste1998; Coleman et al., Reference Coleman, Battiste, Henderson, Findlay and Findlay2012; Kelm, Reference Kelm2004). It should be noted that the Canadian government has made some (albeit often incredibly flawed) attempts to recognize and respect Indigenous peoples’ rights; however, little has been done to facilitate decolonization. According to theorists, decolonization is the long process of undoing colonialism (Crawford, Reference Crawford2002; Smith, Reference Smith1999). It separates Indigenous peoples’ knowledge, traditional practices, and research processes from the colonizer’s power and predominant Western discourses; it has Western policy makers, practitioners, researchers, and others respect Indigenous peoples’ knowledge in order to better understand the concerns within their social world; and it has these professionals work with Indigenous peoples to mutually develop potential, and appropriate, solutions (Crawford, Reference Crawford2002; Smith, Reference Smith1999). Decolonization strategies therefore ensure that Indigenous knowledge is accepted, and provide Indigenous peoples with the opportunity to exercise their power.
It is important to recognize that decolonization is a two-way street. Although Indigenous peoples may seek to rid their lives of some or all Eurocentric practices, non-Indigenous peoples, too, have to change. As a result, decolonization involves bidirectional change (Battiste, Reference Battiste1998; Coleman et al., Reference Coleman, Battiste, Henderson, Findlay and Findlay2012). Importantly, however, it is impossible for decolonization to occur without Indigenous peoples playing a leading role in this process (Battiste, Reference Battiste1998; Coleman et al., Reference Coleman, Battiste, Henderson, Findlay and Findlay2012; Kelm, Reference Kelm2004). Therefore, Indigenous peoples’ leadership of decolonization processes ensures that Indigenous peoples are able to address their world-views and concerns through a lens that accurately represents their perspectives (Battiste, Reference Battiste1998; Coleman et al., Reference Coleman, Battiste, Henderson, Findlay and Findlay2012; Kelm, Reference Kelm2004; Smith, Reference Smith1999). An additional decolonization strategy that could assist Indigenous peoples in having their knowledge represented and used in current scholarly literature would be to have both Indigenous and non-Indigenous scholars acknowledge the “colonial shadow” that has been, and continues to be, cast on studies related to Indigenous peoples (Battiste, Reference Battiste1998; Coleman et al., Reference Coleman, Battiste, Henderson, Findlay and Findlay2012; Kelm, Reference Kelm2004). By acknowledging this colonial shadow, Indigenous peoples can provide direction for the steps that should be taken in order to mitigate these effects. Decolonization strategies are necessary because they enable Indigenous peoples (with or without the assistance of non-Indigenous peoples) to develop strategies that may help them recover and/or strengthen their cultures and languages, as well as make it possible for Indigenous peoples to use their knowledge to overcome the disadvantages they currently face in Canadian society (Battiste, Reference Battiste1998; Coleman et al., Reference Coleman, Battiste, Henderson, Findlay and Findlay2012; Kelm, Reference Kelm2004).
Methodology
Participatory action research (PAR) is a methodology that enables “researchers [to] work in partnership with communities in a manner that leads to action for change” (Baum, MacDougall, & Smith, Reference Baum, MacDougall and Smith2006, p. 854). PAR is used as a reflective process among scholars and their participants in order to better understand (and, it is to be hoped, improve upon) the factors that significantly impact individuals’ everyday lives (Baum et al., Reference Baum, MacDougall and Smith2006). To facilitate this process and promote participation and action among participants, researchers must also advocate for those being researched to be actively involved in the study (i.e., participants should be considered research partners, and have the power to provide suggestions and make decisions throughout all stages of the research process) (Baum et al., Reference Baum, MacDougall and Smith2006). By following the aforementioned tenets, researchers and participants can thus co-identify important issues, promote open dialogue and community participation, and bridge gaps in knowledge and practice between researchers and communities (Baum et al., Reference Baum, MacDougall and Smith2006; Maguire, Reference Maguire1987; Wallerstein & Duran, Reference Wallerstein and Duran2010).
Similar to other methodologies, PAR also comes with a set of challenges. As it is heavily dependent on participation, researchers utilizing PAR need to include as many individuals of interest as possible in their study to ensure that a collective representation of the group’s concerns is presented (Baum et al., Reference Baum, MacDougall and Smith2006). However, if the majority of individuals cannot participate in the research, or choose not to, researchers may have an exceedingly difficult time collecting the data necessary for their research. To address this challenge for our research, the first author (J.S.F.) established a local advisory board. The board was composed of a group of stakeholders who live in Inuvik. The board was composed of three individuals (names are used with permission): Crystal MacPhail, a regional occupational therapist for the Inuvik Regional Hospital’s Rehabilitation Department; Delores Harley, the Elders coordinator for the town’s local friendship centre, Ingamo Hall; and Shannon O’Hara, the Inuit research advisor for the Inuvialuit Regional Corporation. The advisory board members not only helped the first author to recruit participants and better understand the inner workings of their community, but they also provided the first author with great guidance to ensure that our research and the practices we used were the most appropriate for Inuvialuit Elders. The advisory board also supported the use of PAR for this research.
Another challenge of PAR focuses on the power dynamics present in research relationships (Baum et al., Reference Baum, MacDougall and Smith2006). Researchers utilizing PAR need to have participants partake in the research, as well as ensuring that participants are powerful, active agents throughout the process (e.g., have participants participate in establishing research questions, collecting and analyzing data, and more) (Baum et al., Reference Baum, MacDougall and Smith2006). For our research, the first author used two strategies to address this process. First, she utilized a self-reflective process. This author recognized that her own cultural background (i.e., she is a Euro-Canadian graduate student who grew up in Beeton, Ontario [a town 88 km northwest of Toronto]) could strongly influence the research; therefore, she reflected on her own beliefs through discussions with the second author (A.R.G.), fellow graduate students, and research participants. This process enabled the first author to examine the potential impacts of that her biases had on our research. The second strategy was to have the participants and advisory board engage in our research as much as possible, and as much as they wanted. This resulted in participants and advisory board members assisting the first author with recruitment, as well as in participants partaking in the analysis of this research (i.e., reading over their own transcripts and helping to finalize the themes). These two strategies therefore helped us challenge potential power differentials in our research, and ensured that the participants were actively involved in the study.
From September 19, 2016 to November 30, 2016, the first author lived in Inuvik. Prior to living in the community, we received approval from the Research Ethics Board at the University of Ottawa, as well as a research licence from the Aurora Research Institute (which is responsible for issuing licenses for the NWT on behalf of the Government of the NWT). In the following section, we provide an explanation of how the first author recruited the participants for our research.
Sampling
The first author used different recruitment strategies for identifying potential participants, who fell into two categories: Inuvialuit Elders and LFPPs. For Elder Inuvialuit participants, the inclusion criterion for participants was being age 55 or older (Wilson, Rosenberg, Abonyi, & Lovelace, Reference Wilson, Rosenberg, Abonyi and Lovelace2010). Because of the shortened life expectancy of Inuit (i.e., it is expected for the average Canadian male and female to live upwards of 79 and 83 years of age, respectively, whereas Inuit male and female expectancies are only 64 and 73 years of age, respectively) (Statistics Canada, 2015b; Wilson et al., Reference Wilson, Rosenberg, Abonyi and Lovelace2010), we followed other scholars who have identified Inuit Elders as being 55 years of age and older (see Collings, Reference Collings2001; Gabel, Pace, & Ryan, Reference Gabel, Pace and Ryan2016). We also selected this age criterion because older adults are at a greater risk of falling than the rest of the population, and we wanted to include individuals who were at higher risk of experiencing falls. To identify Inuvialuit Elder participants, the first author employed snowball sampling (Cohen & Arieli, Reference Cohen and Arieli2011). In total, the first author recruited eight Inuvialuit Elders (four males and four females, with ages ranging from 64 to 79 years).
The first author used judgement sampling to recruit LFPP participants (Marshall, Reference Marshall1996). According to Marshall (Reference Marshall1996), judgement sampling describes when researchers select participants based on specific criteria because it is believed that these individuals will provide information that will assist in answering these researchers’ questions. Therefore, our specific inclusion criteria were that LFPP participants be knowledgeable in falls prevention literature and have training and/or certificates in falls prevention (e.g., Canadian Falls Prevention Curriculum). We also specified that LFPP study participants had to have worked in falls prevention for at least one year to ensure that they were familiar with the area. The first author recruited six LFPP participants (one male and five females; the male participant self-identified as Pilipino-Canadian and the female participants self-identified as Euro-Canadian). LFPP participants included occupational therapists (2), long-term care workers (1), senior program coordinators (1), rehabilitation assistants (1), and community health representatives (1).
Methods
The advisory board members agreed that semistructured interviews (Fontana & Frey, Reference Fontana, Frey, Denzin and Lincoln2005) would be an appropriate research method for this project; however, to recruit participants for data collection, it was also agreed that the first author should engage with residents of the community. To that end, the first author volunteered with local Elders at the Inuvik Regional Hospital’s Elders’ Day Program and at the local Friendship Centre (i.e., a non-profit community centre and Indigenous program/service delivery organization), Ingamo Hall. Whereas the Elders’ Day Program provides daily (Monday to Friday, from 10 a.m. to 3 p.m.) activities and games for a select number of seniors in Inuvik (i.e., acceptance into the program is dependent on availability of space and its ability to cater to individuals’ needs), Ingamo Hall runs various educational, recreational, social, and multicultural activities and events for all of the town’s citizens. The first author volunteered as a program activity aide (i.e., helped run activities for elderly participants) for the Elders’ Day Program twice a week, and served as a friendly luncheon companion (i.e., ate and socialized with Elders) at Ingamo Hall once every other week.
The first author conducted semistructured interviews to better understand Inuvialuit Elders’ and LFPPs’ definitions of what constitutes a fall, to determine what current falls prevention interventions reduce Inuvialuit Elders’ falls rates, and to ascertain how these prevention programs can be co-created (with the research participants) to be culturally safe. Semistructured interviews are interviews guided by predetermined topics and open-ended questions that elicit discussions on the various influences present in participants’ everyday lives (Fontana & Frey, Reference Fontana, Frey, Denzin and Lincoln2005). Some examples of these questions included, “Do you think Inuvialuit Elders would benefit from a culturally safe falls prevention program?” and “For this kind of falls prevention program to be provided to you/Inuvialuit Elders, what do you believe should be done?”
The first author facilitated 12 semistructured interviews (10 one-on-one interviews and 2 two-on-one interviews), for a total of 14 participants. They digitally recorded and transcribed all interviews verbatim. The first author returned the interview transcripts to the participants by mail or e-mail for participant feedback; however, only one participant edited her transcript. To recognize the expert contributions and knowledge of the Inuvialuit Elders (Giles & Castleden, Reference Giles and Castleden2008), participants’ names have been included with permission.
Analysis
To analyse the data, we used Braun and Clarke’s (Reference Braun and Clarke2006) six-step thematic analysis framework. This process was supported by NVivo11, which enabled us to organize the interview transcripts. As required by Braun and Clarke (Reference Braun and Clarke2006), our first step was to familiarize ourselves with the transcripts, and to record any ideas that we had for potential themes to be used later in the analysis. Second, we identified initial codes within our data and then attached these codes to our transcripts as a way to organize the data. Some initial codes that we identified were “various falls definitions”, “traditional falls prevention interventions”, “non-traditional falls prevention interventions”, and “strategies for developing cultural safety”.
Next, the third phase required sorting our codes into potential themes (i.e., collective definitions of falls, falls prevention interventions and programs recommended based on pre-existing curricula, and steps to creating a culturally safe Inuvialuit falls prevention program). Fourth, we reviewed and refined our themes to ensure that they suited the initial context of our research. The fifth step was composed of two stages: the first author travelled back to Inuvik from April 1, 2017 to April 9, 2017 to review the potential themes with the participants, and we then precisely named and defined the themes so that they reflected the broader themes within our data. For the final step, we established two themes: the recommended solutions for preventing Inuvialuit Elders’ falls and the recommended strategies for developing culturally safe falls prevention programs for Inuvialuit Elders.
Results
Based on our analysis and supported by feedback from our participants, we identified two main themes that related to our research objectives of understanding the nature of falls among Inuvialuit Elders in Inuvik, NWT, and determining if and how falls prevention programs can be adapted and made culturally safe for this population: (a) the recommended solutions for Inuvialuit Elders’ falls included the assessment and modification of an Elder’s environment, participation in physical activity, and educating the Elder and his/her caregivers on falls prevention strategies; and (b) the recommended strategies for developing culturally safe falls prevention programs for Inuvialuit Elders was composed of falls prevention researchers and practitioners establishing trust and rapport within the community, including both Indigenous and non-Indigenous interventions in falls prevention programs, and training falls prevention professionals on cultural safety practices.
Recommended Falls Prevention Solutions
Discussions with both Inuvialuit Elders and LFPPs indicated that the current falls prevention solutions offered to the elderly residents of Inuvik, NWT are relatively similar to the components of the BEEEACH model. We therefore analysed and framed the recommended solutions in relation to the BEEEACH model; and with the assistance of our participants, we determined which components of this model should be included in a falls prevention program for Inuvialuit Elders.
Environment (Assessment and Modification)
Ten participants (one male LFPP, four female LFPPs, two male Inuvialuit Elders, and three female Inuvialuit Elders) agreed that the assessment and modification of environmental hazards should be an integral component of any falls prevention programs tailored for Inuvialuit Elders. As one LFPP, Jenel, explained, many Elders in Inuvik, NWT, are at higher risk of experiencing fall-related injuries or fatalities because of the conditions of their indoor (e.g., overcrowding, trip hazards such as throw rugs, or ineffective and/or lack of assistive living devices) and outdoor environments (e.g., extremely low temperatures in the winter, relatively consistent snowfall, or icy surfaces). To address these risk factors, the participants argued that environmental hazard assessment and modification interventions can also be used to reduce Inuvialuit Elders’ fall and fall-related injury rates. The following are examples some of these participants provided:
They most often fall when they stand up from the bed [in Inuvik Regional Hospital’s Long-Term Care Centre]. We put floor mats. Mats in order to provide some sort of suspension when they fall, so they don’t break their hip (Jenel, LFPP).
You gotta have that rubber mat [in the bathtub] to protect you. Or I always put a towel under—just make sure you don’t trip on it or anything. But that rubber mat is best. It’ll keep you from falling. And always make sure you’ve got that handle—that safety handle [grab bar] (Jean, 80 years old, Inuvialuit Elder).
[In the winter, have someone] clear their steps [of snow and ice] for them. Also provide Elders with kitty litter, just to sprinkle on their steps [to reduce their risk of slipping and falling] (Crystal N, LFPP).
(Physical) Activity
Participants (three female LFPPs and one male Inuvialuit Elder) also indicated that physical activity interventions should be included in falls prevention programs. LFPP participants felt that programs that incorporated exercise and fitness had the greatest likelihood of reducing Inuvialuit Elders’ overall falls risk. As Susan (LFPP) explained, an “exercise program that you can apply with any population [is good] because [a LFPP] can explain to them exactly what the exercise is for, what it is benefitting, and how it can help them [build strength and reduce their likelihood of experiencing a fall]”.
Education (for Elders and Caregivers)
The last component that Inuvialuit Elder and LFPP participants considered to be a falls prevention program requirement was education. They (two female LFPPs, one male Inuvialuit Elder, and three female Inuvialuit Elders) agreed that the purpose of education for fall prevention was to increase Elders’ awareness about the importance of preventing a fall, to ensure that prevention was indeed possible, and to promote learning effective strategies to prevent falls, such as conducting personal safety checks of their surroundings and being mindful of personal limitations. However, these participants also identified the need for caregivers (i.e., long-term care/home care staff, family members responsible for the care of parents/grandparents) to be given this prevention education as well. As Chelsey (LFPP) explained: “Sometimes the homecare staff don’t identify that the [older] person could benefit from interventions like a home assessment. They need to be taught these [falls prevention] techniques.” Juanita (LFPP) further highlighted this issue and stated: “I think family awareness is a big one…I think it comes down to education and educating families [on falls prevention].”
Recommended Strategies for Developing a Culturally Safe Falls Prevention Program
After developing and considering these population-specific recommendations, the participants of this study also made it evident that these prevention programs can be made culturally safe for Inuvialuit Elders as well. The following are the recommended strategies that participants suggested for the development of a culturally safe falls prevention program for Inuvialuit Elders.
Establishing Trust and Rapport within the Community
The majority of the participants (one male LFPP, four female LFPPs, four male Inuvialuit Elders, and four female Inuvialuit Elders) agreed that establishing trust and rapport with Inuvik’s residents was integral to developing a culturally safe falls prevention program. Both LFPPs and Inuvialuit Elders indicated that falls prevention professionals who engage in community capacity building and promote open dialogue are more likely to gain a better understanding of Inuvialuit Elders’ falls risk and rates. Jenel (LFPP) explained: “If we wanted to make a culturally safe falls prevention program, I feel like a big element is trust. You need to develop that rapport with them…you [should] also include locals [in the discussion and development of a culturally safe falls prevention program]. You can have them put their input on what they think would be great for them.”
Participants also felt that prevention researchers and practitioners who make an effort to build relationships with Inuvik’s Inuvialuit Elders also give the community’s older adults opportunities to actively develop, implement, and refine their falls prevention program. The LFPPs and Inuvialuit Elders further indicated that providing the community’s Inuvialuit Elders with chances to openly share their suggestions and opinions could result in Elders’ developing a sense of ownership in reducing their rates of falling and fall-related injuries. As reiterated by local Inuvialuit Elder Albert (74 years old) explained: “Participating in the decision-making [regarding the development of a culturally safe falls prevention program]…it is so important, that participation.”
Including both Indigenous and Non-Indigenous Interventions in Falls Prevention Programs
Participants (one male LFPP, five female LFPPs, four male Inuvialuit Elders, and three female Inuvialuit Elders) widely agreed that the incorporation of Indigenous and non-Indigenous interventions can assist falls prevention researchers and practitioners in making their programs more culturally safe for Inuvialuit Elders. Many of the participants voiced how modern, non-Indigenous falls prevention interventions (e.g., generic muscular endurance and cardiovascular exercise programs, as well as mobility aides such as metal canes, walkers, and wheelchairs) have reduced Inuvialuit Elders’ experiences of falling and maintained their independence; however, both LFPPs and Inuvialuit Elders also indicated the benefits of traditional, Indigenous prevention interventions. As Crystal N (LFPP) noted, including elements of Inuvialuit culture, such as traditional mobility aides (e.g., walking sticks) and traditional cultural activities (e.g., going out on the land, trapping, “jiggling”/fishing), into falls prevention programs “can only benefit them that much more.” Chelsey (LFPP) agreed and also stated, “there would be a better uptake and a more wide-reaching effect for Inuvialuit Elders [if falls prevention programs had culturally relevant interventions].” The following statement from Albert (74 years old, Inuvialuit Elder) succinctly summarized the participants’ opinions towards the desire to include non-Indigenous and Indigenous interventions in falls prevention programs: “I think that anything helps, you know?”
Training Others on Cultural Safety Practices
The remaining recommendation was the need for cultural safety training among falls prevention researchers, practitioners, and programmers. Because of their lack of cultural safety education and understanding of Inuvialuit culture, participants (two female LFPPs, two male Inuvialuit Elders, and one female Inuvialuit Elder) indicated that falls prevention researchers, practitioners, and programmers have done a disservice to the Inuvialuit falls prevention program recipients. Susan (LFPP) explained: “I don’t think we’re doing enough to educate people about what the culture is, what it means to be a part of that culture, and how we can effectively work with it. I think people think they’re doing it, but I don’t see it…I don’t think [falls prevention programmers] have bought into cultural sensitivity [and safety] as much as they could have or could.”
Juanita (LFPP) agreed, stating “implementing [Inuvialuit] culture into [falls prevention programs] is going to get their attention and participation way better than if we’re putting our culture onto them.” Training was therefore deemed necessary by the participants as a means to prevent falls prevention professionals from imposing their values and beliefs onto Inuvialuit Elders participating in their programs.
Discussion
In this study, LFPPs and Inuvialuit Elders identified BEEEACH model-related falls prevention solutions that reduce Inuvialuit Elders’ risk of falling and strategies, which can be used to make current falls prevention programs in Inuvik more culturally safe for Inuvialuit Elders. This study makes an important contribution to better understanding how falls prevention researchers, practitioners, and programmers can develop and implement a more culturally safe program, which would enable falls prevention programs to be more respectful and inclusive. In the next section, we discuss the recommended solutions and strategies identified by the participants and the ways in which these findings support or challenge existing literature. We also identify potential steps that can be taken to improve the cultural safety of falls prevention programs for Inuvialuit Elders, and areas of future research.
Not All Components of the BEEEACH Model are Relevant for Falls Prevention Programs in Inuvik
Environmental hazards applied to Inuvialuit Elders in this study in the context of their experiences with falls and fall-related injuries. Both LFPPs and Inuvialuit Elders argued that the current conditions of Inuvialuit Elders’ indoor and outdoor environments increased their fall risk and rates. The participants also indicated that assessments and modifications of these environments (conducted by LFPPs) could be effective strategies for reducing Inuvialuit Elders’ likelihood of injury. These findings support research related to the environmental category of the BEEEACH model, which implies that both indoor and outdoor fall risk contributors need to be assessed – and, if need be, modified – in order to reduce older adults’ risk of experiencing fall-related injuries or fatalities (Canadian Mortgage and Housing, 2011; Gallagher & Brunt, Reference Gallagher and Brunt1996; Gallagher & Scott, Reference Gallagher and Scott1997; Scott, Reference Scott2012; Simpson, Lamb, Roberts, Gardner, & Evans, Reference Simpson, Lamb, Roberts, Gardner and Evans2004).
In addition to the assessment and modification of Inuvialuit Elders’ indoor and outdoor environments, LFPPs and Inuvialuit Elders indicated that including physical activity in falls prevention programs can also serve as an effective strategy for reducing falls and fall-related injuries. The participants (three female LFPPs and one male Inuvialuit Elder), however, emphasized that falls prevention programs should specifically include exercise and fitness components. Interestingly, this finding supports evidence related to the BEEEACH model as well, which stresses that exercise and fitness is beneficial for community-dwelling seniors and can significantly reduce their risk of falling (Gillespie et al., Reference Gillespie, Gillespie, Robertson, Lamb, Cumming and Rowe2005; Scott, Reference Scott2012; Sherrington et al., Reference Sherrington, Whitney, Lord, Herbert, Cumming and Close2008).
Lastly, both LFPPs and Inuvialuit Elders indicated that education was another effective strategy for decreasing the likelihood of Inuvialuit Elders experiencing a fall. They (three female LFPPs, one male Inuvialuit Elder, and three female Inuvialuit Elders) argued that educating those at risk of falling (i.e., Inuvialuit Elders), as well as those who assist Elders in their day-to-day lives (i.e., long-term care/home care staff, family members responsible for the care of parents or grandparents) should be a key component of Inuvialuit Elders’ falls prevention programs. This finding is parallel to research that supports the BEEEACH model’s education recommendations; that is, providing falls prevention education to older adults and caregivers is considered a key component of falls prevention programs (Robertson & Gillespie, Reference Robertson and Gillespie2013; Scott, Reference Scott2012; Tzeng & Yin, Reference Tzeng and Yin2014; Williams & Hadler, Reference Williams and Hadler2015).
It is evident that some of the BEEEACH model recommendations for mitigating falls (i.e., assessments and modifications of environments, inclusion of physical activity, and falls prevention education for all) were similar to the participants’ recommendations. This was particularly interesting because the participants of this study – to a certain extent – subscribed to the BEEEACH model; a falls prevention model that was created in relation to the experiences of non-Indigenous seniors only. Although the participants indicated that only specific components of the BEEEACH model were relevant to falls prevention for Inuvialuit Elders (i.e., the need for falls prevention researchers and practitioners to address the environmental, physical, and educational categories of the model has been deemed appropriate for Inuvialuit Elders), the selected categories of the BEEEACH model may be further evidence of falls prevention programs reinforcing colonial, non-Indigenous falls prevention knowledge and practices. Arguably, the entire BEEEACH model (and its respective recommendations) enforces the assumption that the model’s recommended falls prevention solutions work for all Canadian seniors. The BEEEACH model also does not provide opportunities for non-dominant populations, such as Inuvialuit Elders, to refer to their traditional knowledge regarding falls and falls prevention. Participants, such as Shirley and Albert, referred to oral stories of safety (including those relevant to falls and fall-related injuries) and explained how participating in traditional activities, such as being on the land, trapping, hunting, and fishing can assist Elders in maintaining their physical health, which is believed to be needed to prevent experiencing a fall. Therefore, by strictly abiding by the model, current and future LFPPs working with Inuvialuit Elders are at risk of upholding colonial discourses on what is considered a fall-related hazard and what falls prevention practices should be used.
Because both LFPPs and Inuvialuit Elders agreed that some components of the BEEEACH model should be included in Inuvialuit Elders’ falls prevention programs, we are not suggesting that future LFPPs should completely avoid referring to the model for falls prevention recommendations. Instead, we argue that these LFPPs need to consult Inuvialuit Elders prior to determining which strategies would be most effective in reducing the Elders’ likelihood of experiencing a fall. Doing so will provide Inuvialuit Elders with the opportunity to exercise their power in determining which components of the BEEEACH model would actually assist them in reducing their likelihood of falling, as well as minimizing the chances of LFPPs’ implementing a falls prevention program based on stereotypical assumptions and using a “checklist approach” to culture (Giles et al., Reference Giles, Hognestad and Brooks2015; Nursing Council of New Zealand, 2011).
Creating a Culturally Safe Falls Prevention Program for Inuvialuit Elders
Although some of the BEEEACH model’s corresponding components and recommendations were suggested as elements to include in falls prevention programs for Inuvialuit Elders, the LFPPs and Inuvialuit Elders in this study also indicated that LFPPs should use a culturally safe approach to their interventions and programs. To develop a culturally safe falls prevention program tailored to Inuvialuit Elders, the participants recommended that the following strategies be included: establishing trust and rapport within the community, including both Indigenous and non-Indigenous interventions in these programs, and training others on cultural safety practices.
Regarding the first recommended strategy, the participants (one male LFPP, four female LFPPs, four male Inuvialuit Elders, and four female Inuvialuit Elders) felt that community members would be more willing to engage in falls prevention discussions and program planning if LFPPs facilitated community capacity building with Inuvik’s Inuvialuit peoples. In this vein, the participants suggested that LFPPs should not only include locals’ input in relation to falls prevention services, but also provide the target population (i.e., Inuvialuit Elders) the opportunity to actively develop, implement, and refine their own falls prevention programs. Recent studies support these findings, and highlight that researchers and practitioners who promote residents’ ability to develop, implement, and sustain their own solutions actually facilitate a culturally safe approach by furthering participants’ self-determination and improving their opportunity to exercise control in determining the cultural safety of programs that influence their health and well-being (Giles et al., Reference Giles, Hognestad and Brooks2015; Reading et al., Reference Reading, Scott, Perron, Edgar, Baba and Elliot2011).
As a second recommended strategy, the participants (one male LFPP, five female LFPPs, four male Inuvialuit Elders, and three female Inuvialuit Elders) indicated that the current falls prevention programs offered in Inuvik could become more culturally safe by including both Indigenous and non-Indigenous falls prevention interventions. Indeed, LFPPs and Inuvialuit Elders agreed that non-Indigenous falls prevention interventions were beneficial to and appropriate for Inuvialuit Elders; however, incorporating traditional activities (e.g., going out on the land, hunting, trapping, and “jiggling”/fishing) can be culturally safe interventions used to decrease Inuvialuit Elders’ likelihood of experiencing a fall. Strong evidence exists on the benefits of physical activity for reducing fall risk, and the previously listed activities can be essential to Inuvialuit Elders’ falls prevention. Going out on the land, trapping, and jiggling all have the potential to challenge Elders’ balance, as well as improve and increase their gait, coordination, flexibility, muscle strength, and endurance, thus compensating for changes to their bodies that may increase their likelihood of experiencing a fall or fall-related injury. Further, as these activities reflect Inuvialuit Elders’ cultural preferences, local falls prevention programmers could incorporate them into Elders’ falls prevention programs; meaning that Inuvialuit Elders may even be more likely to follow their falls prevention programs and decrease their likelihood of falling as well.
Additionally, incorporating other culturally relevant practices (e.g., using a walking stick as a mobility assistive device) into Inuvialuit Elders’ falls prevention programs could also help to ensure that their specific needs are met and that their knowledge becomes better represented in Canadian falls prevention research and practice (Reading et al., Reference Reading, Scott, Perron, Edgar, Baba and Elliot2011; Scott, Reference Scott2012; Smye & Browne, Reference Smye and Browne2002). Local falls prevention programmers should therefore consider including Indigenous falls prevention interventions into Inuvialuit Elders’ falls prevention programs.
The last recommended strategy for developing a culturally safe falls prevention program for Inuvialuit Elders requires that current and future falls prevention researchers, practitioners, and programmers receive cultural safety training. The participants (two female LFPPs, two male Inuvialuit Elders, and one female Inuvialuit Elder) argued that LFPPs in Inuvik are doing very little to better understand Inuvialuit culture, which has subsequently resulted in a disconnect between these researchers/practitioners/programmers and Inuvialuit Elders. In particular, the LFPPs and Inuvialuit Elders worried that Inuvik’s LFPPs are failing to learn more about what it means to be Inuvialuit, and about how Inuvialuit peoples’ knowledge and traditional practices can be effective falls prevention interventions. By excluding Inuvialuit culture and their knowledge, Inuvik’s LFPPs therefore may be at risk of upholding the normalization of whiteness (Brascoupé & Waters, Reference Brascoupé and Waters2009; Gerlach, Reference Gerlach2012; Giles et al., Reference Giles, Hognestad and Brooks2015) in falls prevention research and practice (i.e., using falls prevention interventions and programs that reflect white Canadians’ preferences and privileges instead of Inuvialuit peoples’ preferences).
The participants also reaffirmed the need for cultural safety training to prevent LFPPs from imposing their cultural values, beliefs, and biases on Inuvialuit Elders participating in their falls prevention programs. The LFPPs’ and Inuvialuit Elders’ concerns support recent studies on cultural safety, which posit that a culturally safe approach to research and practice encourages program providers to be aware of their cultural background, as well as to better understand whose knowledge is privileged in these areas of interest (Giles et al., Reference Giles, Hognestad and Brooks2015; Ramsden, Reference Ramsden2002). Inuvik’s LFPPs should therefore undergo cultural safety training in order to learn how their cultural backgrounds are influencing their falls prevention practices and programs, and to determine if they are asserting and upholding power differentials between themselves and their participants (i.e., Inuvialuit Elders).
After considering the participants’ concerns and recommendations, our findings suggest that LFPPs should provide Inuvialuit Elders with personalized falls prevention program options. By ensuring that the program is tailored to the Elder’s capacity, is reflective of their cultural background and preferences, is accessible, and includes interventions and activities they find relevant and enjoy, LFPPs may increase Inuvialuit Elders’ participation rates in falls prevention programs and, as a result, decrease their likelihood of experiencing falls and fall-related injuries or fatalities.
Conclusion
The falls prevention programs presently available to Inuvialuit Elders in Inuvik reaffirm colonial practices and support white Canadians’ ideas of falls prevention, making this area of injury prevention a potential site of colonization. Researchers and practitioners therefore need to initiate the long process of undoing colonialism by facilitating a culturally safe approach to falls prevention programs. Our findings suggest that Inuvik’s LFPPs should encourage Inuvialuit Elders’ self-determination and ability to exercise control throughout the development and implementation of their falls prevention interventions and programs, which can help to ensure Inuvialuit peoples’ histories, world-views, and knowledge are respected and accepted in falls prevention research and practice. Current and future LFPPs should take a culturally safe approach to their practices to better understand Inuvialuit Elders’ concerns within their social world (a facet of decolonization), which can help these professionals create falls prevention programs that are applicable and relevant to this population.
A culturally safe falls prevention program for Inuvialuit Elders can promote the decolonization of this field of injury prevention; however, there are some important limitations to this study. Only six LFPPs and eight Inuvialuit Elders participated in this study, meaning that this research is in no way representative of all LFPPs and Inuvialuit Elders in Inuvik. Nevertheless, it makes an important contribution to Canadian falls prevention research and practice by providing an opportunity for these participants to have a voice in documenting health disparities, such as injury, that regularly affect them.
Future studies should consider separately exploring falls prevention programs tailored to First Nations, Métis, Inuit, and other populations of Elders to determine how these programs can be made more culturally safe, and to prevent generalizing findings among Indigenous Elders.
