AN EXPLORATION OF THE HEALTH DISPARITIES AMONG INDIGENOUS
PEOPLE IN CANADA AND IMPACTS OF THE COVID-19 PANDEMIC

By
Kristi Mandin
Bachelor of Arts, Kwantlen University 2010

MAJOR PAPER SUBMITTED IN THE PARTIAL FULFILLMENT OF THE
REQUIREMENTS FOR THE DEGREE OF

MASTER OF SOCIAL WORK
In the
School of Social Work and Human Services

© Kristi Mandin 2022

UNIVERSITY OF THE FRASER VALLEY
SPRING 2022

All rights reserved. This work may not be reproduced
in whole or in part, by photocopy or other
means, without permission of the authors.

ii
Approval
Name: Kristi Mandin
Degree: Master of Social Work
Title: An Exploration of the Health Disparities Among Indigenous People in Canada and
Impacts of the COVID-19 Pandemic
Examining Committee:
Dr. Margaret Coombes, Ph.D., RCSW
Senior Supervisor
Associate Professor, School of Social Work & Human Service
Dr. Amanda LaVallee, BISW, MSW, Ph.D., RSW
Second Reader
Assistant Professor, School of Social Work & Human Services
Dr. Leah Douglas, BSW, MSW, Ph.D., RCSW
MSW Committee Chair
Associate Professor, School of Social Work & Human Services
Date Defended/Approved: April 2022

iii
Acknowledgements
I am honoured to be writing this literature review on the traditional lands of the
Kwantlen, Matsqui, Semiahmoo, and Katzie First Nations. I acknowledge that as a Métis person,
I am both a settler and Indigenous person of this land and unduly benefit from resources
provided by this land that is not mine to claim but to share with the people that came before me. I
recognize that it is a privilege to have access to higher education, and I am grateful for my
acceptance into the Master of Social Work program. It has provided me with the opportunity to
learn and grow. For, even within the process of completing the literature review, I am provided
with a deeper understanding that the role colonization has played - and continues to play - in the
lives of the first peoples of this land and mine. Colonization is defined as the "subjugation of a
people or area, especially as an extension of state power” (Davis-Marks, 2022, para. 1). And
while this expresses a clear imbalance of power, this does not capture the felt sense of loss and
disconnection that removes the capacity and self-determination of entire nations of people. Nor
does it expose the nuanced, rippling effects that exist in identities – such as mine - that straddle
both the colonizer and the colonized.
This learning journey and time of growth would not have been possible without the love
and support of my family. I am so appreciative of my husband, John, and two children, who
encouraged me to follow my educational pursuits. I am honoured by their patience and
unconditional support throughout this 3-year program. It has not been an easy road, but I hope to
inspire my children to follow their dreams and not give up even in times of hardship. I would
also like to thank all the UFV professors who supported me on this long journey, especially
Margaret Coombes, for guiding and supporting me with this literature review.

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Abstract
The COVID-19 pandemic has significantly impacted the health and wellbeing of people
worldwide. However, the impact has been variable in how it effects Indigenous Peoples and
communities across Canada. Colonial discourse and policies have created negative health
outcomes, such as mental health diagnoses, substance misuse, and chronic health conditions,
transcending generations. These disparities, along with inequalities relating to social
determinants of health, including intergenerational poverty, low education rates, reduced access
to healthcare, and inadequate housing, put Indigenous Peoples at increased risk of poor health
outcomes during pandemics. This literature review examines the vulnerabilities and protective
factors unique to Indigenous Peoples which impact their health and wellbeing during the
COVID-19 pandemic.

Keywords: [Indigenous, COVID-19, Colonization, Social Determinants]

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Contents
Approval ......................................................................................................................................... ii
Acknowledgements ........................................................................................................................ iii
Abstract .......................................................................................................................................... iv
Positionality .................................................................................................................................... 1
Introduction ..................................................................................................................................... 2
Methodology ................................................................................................................................... 4
Anti-Oppressive Framework ....................................................................................................... 5
Indigenous Conceptualizations of Health and Wellness ............................................................. 6
Literature Review............................................................................................................................ 8
Canada’s Colonial Legacy .......................................................................................................... 8
Present Day Health and Socioeconomic Inequalities ................................................................ 11
Social Determinants of Indigenous Health ............................................................................ 14
Healthcare as a Social Determinant. ................................................................................. 16
Access to Clean Water and Adequate Housing.................................................................. 19
Impacts of COVID-19 on Mental Health .................................................................................. 22
Food Security and Mental Health .......................................................................................... 25
Community lockdowns and Social Distancing ...................................................................... 26
Vaccine Hesitancy ..................................................................................................................... 27
Protective Factors and Indigenous-led responses...................................................................... 30
Gaps in Literature ......................................................................................................................... 34
Implications for Social Work Practice, Policy, and Research ...................................................... 36
Conclusion .................................................................................................................................... 40
References ..................................................................................................................................... 42

1
Positionality
It is important researchers locate themselves in their research projects, as our lived
experiences are inextricably linked to our research and conducted through the lens of our own
individual worldviews (Hulko, 2009). I am cognizant that my worldview guides the questions I
ask, the knowledge I seek, and the problems I see. It is for this reason that I chose to self-locate
in this literature review. I identify as Métis and have both European and Indigenous ancestry. My
ancestors lived in the Red River region of Manitoba since the late 1600s. This part of my cultural
heritage was hidden from me for many years of my life. Consequently, I did not experience my
formative years or most of my life as an Indigenous person. I experienced no connection to my
culture. Thus, I hold a complex relationship with my Métis roots. I am aware that I have been
awarded many unearned advantages and privileges that may limit my understanding of the lived
realities of other Indigenous People today. I also understand that family shrouds and
disconnection from Indigenous culture is a colonial impact that I continue to internally process.
Discovering my Indigenous ancestry has inspired my curiosity to learn more about
historical contexts that have contributed to present-day health and socioeconomic inequalities.
As I continue to learn and unpack the violent subjugation and horrific treatment my ancestors
endured, I feel a sense of responsibility as an emerging social worker and activist to use my
voice and position of privilege in society to challenge the status quo that maintains oppression
and marginalization of Indigenous people today.

2
Introduction
In March 2020, the World Health Organization (WHO) declared a global pandemic due
to the spread of the coronavirus, impacting individuals worldwide (Jenkins et al., 2021).
However, the impact has been variable, creating increased vulnerability for the 370 million
colonized Indigenous Peoples globally (Power et al., 2020). Individuals from vulnerable
populations are the most affected by the COVID-19 pandemic and are at heightened risk for
deteriorating mental health, severe health outcomes, and mortality (Diaz, 2021). During
pandemics, Indigenous people in Canada face higher infection rates, more severe symptoms, and
death compared to their non-Indigenous counterparts. This is a result of “powerful forces of the
social, and cultural determinants of health and lack of political power” (Power, et al., p.1). To
that end, Indigenous health is disproportionately impacted by the COVID-19 virus due to health,
structural, and social inequalities resulting from historical and ongoing colonialism (Jenkins,
2021).
Indigenous Peoples live in many communities and nations across Turtle Island (now
known as North America) and are defined as three different groups, First Nations, Métis, and
Inuit (Marsh et al., 2015). Despite many similarities, Indigenous people and communities cannot
be understood as a homogenous group due to their distinct subcultures, practices, and spiritual
beliefs. Approximately 65% -80% of the Indigenous populations in Canada live in urban
communities, with the remainder of the population living in communities called reserves
(Howard-Bobiwash et al., 2021). Reserves are delineated land areas throughout Canada that are
set aside for Status First Nations people as proscribed by the Indian Act, which is a direct
outcome of colonialism. This paper will discuss issues and impacts relating to the intersection on
reserves and COVID-19.

3
Indigenous Peoples across Canada are disproportionately affected by socioeconomic and
health inequalities, such as intergenerational poverty, housing issues: higher rates of underlying
medical conditions and comorbidities; poor mental health, increased rates of domestic violence;
and lower life expectancy compared to non-Indigenous people (Bratina, 2021). Historical and
ongoing colonialism creates a negative impact on social determinants of health for Indigenous
people and communities. Lavalley et al. (2020) assert that “Indigenous health cannot be
understood outside the context of colonization” (p. 2); therefore, to understand present-day
health inequalities, colonial roots must be examined. As such, this literature review examines the
connection between colonial discourse and policies to understand the health and socioeconomic
inequities among Indigenous people in Canada. Moreover, how Indigenous health from a holistic
lens has been impacted during the COVID-19 pandemic. The questions I use to guide this review
are: How are Indigenous Peoples health and wellbeing being affected during the COVID-19
pandemic? Why do Indigenous people experience social and health disparities that increase their
risk to pandemics? What protective factors and Indigenous-led responses have been implemented
to mitigate the negative effects of the pandemic?
To understand the socioeconomic and health disparities faced by Indigenous people
today, this paper begins with developing a historical reference to better contextualize present-day
health and socioeconomic disparities unique to Indigenous people. The analysis then explores
physical and mental health disparities among Indigenous and non-Indigenous people in Canada
during the COVID-19 pandemic. The literature in this review is examined through a two-eyed
seeing lens, which draws from both Indigenous and Western perspectives and is an Indigenous
form of analysis. This approach elevates Indigenous conceptualizations of health and wellbeing
as they expand beyond the Western biomedical model. Additionally, a strength-based lens is

4
used to explore protective factors and Indigenous-led responses utilized to protect Indigenous
Peoples and communities during the COVID-19 pandemic.
Methodology
This literature review uses a thematic review of existing qualitative and quantitative
literature. The main source of data is derived from recent and relevant peer-reviewed journals
from the past ten years (2012-present). However, due to the recent nature of the COVID-19
pandemic, most of the literature used is from the last two years (2019-2021). Furthermore, data
collection is gathered from multiple sources, including google scholar, government websites, and
The University of the Fraser Valley (UFV) library where I searched and selected peer-reviewed
journals from the PsycINFO, Wiley Online Library, and Indigenous studies portal databases. To
ensure this review includes Indigenous voices, prioritization is given to available research from
the Indigenous studies portal database, First Nations Health Authority (FNHA) and Indigenous
Services Canada (ISC).
Specific keywords and phrases such as: COVID-19; Indigenous health and COVID-19;
social determinants of health; impacts of COVID-19 on health; and colonization in Canada were
used to narrow the literature to specific themes relevant to the research topic. The majority of the
research in this review focuses on studies and data collected on Indigenous people living in
Canada. However, due to limited research available, this review expands its parameters to
include research from Australia, New Zealand, and the United States.
One gap identified during the research process is the limited data and research on
Indigenous populations in Canada. There is even less when considering research that is produced
by Indigenous people and their communities. This is due to the domination of western
knowledge and methodologies in academic and mainstream research. Indigenous research is

5
often viewed as “lacking credibility” (Baskin, 2019, p. 327). As a result, this review may lack
valuable research that did not make it to publication. Due to limited research on Indigenous
populations, the bulk of the literature in this review focuses on First Nation communities and
their unique experiences during COVID-19.
Although this review includes quantitative methodologies, it bears noting that qualitative
methods are more compatible with Indigenous knowledge and worldviews as they allow for
storytelling and give space for holistic and organic production of knowledge. Storytelling as a
vehicle for knowledge creation can include social location and is an asset to providing contextual
origins. This is another limitation, as many of the researchers in this review did not locate
themselves in relation to the populations and communities they were researching. According to
Baskin (2019), Indigenous “researchers tend to identify themselves within their research projects
and publications”; therefore, it can be assumed that most of the researchers in this review are
non-Indigenous and considered outsiders to the people and communities involved in the research
(p. 326).
Anti-Oppressive Framework
During the collection of data and literature, an anti-oppressive framework was chosen to
identify how external power structures operate and impact social conditions and health among
Indigenous people. This lens was critical to understanding how oppression, racism, and
discrimination operate and affect the health and wellbeing of Indigenous people across
generations. Moreover, an anti-oppressive lens was important to understand why Indigenous
people face health disparities that increase their risk during a pandemic.
Anti-oppressive practice involves fighting for social justice and challenging the structural
and social power imbalances within our society that create and maintain oppression and

6
inequality. According to Larson (2008), anti-oppressive practice recognizes the power
imbalances that exist within a capitalist and paternalistic society and involves “working toward
the promotion of change to redress the balance of power” (p.41). Thus, literature by Indigenous
researchers was included to ensure Indigenous voices and knowledge were amplified in this
literature review.
Social workers must be cognizant of the power imbalances that exist within our society
and how social structures create and maintain many inequalities for Indigenous people in
Canada. This process begins with looking inward. Echoing Hulko (2009), our greatest “tool in
social work” is the use of self as it makes clear the “everyday dialectics of oppression and
power” (p.45). Being aware of our worldview and the population or cultural group we are
researching is of utmost importance in mitigating these imbalances and reducing harm and
further oppression.
Indigenous Conceptualizations of Health and Wellness
Prior to colonization, Indigenous people and communities had well-established and
functioning health systems based on a holistic framework and mutual responsibility to one
another (Barnabe, 2021; Vukic, 2011). Following first contact with settlers, Indigenous health
systems and ways of knowing were dismantled and replaced with Eurocentric western
paradigms, grounded in a biomedical approach seeking scientific explanations to understand
illness, disease, and mental health-related issues. The conceptualization of health from an
Indigenous perspective is different from the current mainstream healthcare system, which views
health through a biomedical model (Kim, 2019). Indigenous ways of knowing or understanding
health, healing, and wellness are based on a holistic approach, whereby healing and wellness go

7
beyond the absence of illness and focus on finding balance and connection to the wider world
(Vukic, 2011).
An Indigenous wellness model includes the mental, emotional, physical, and spiritual
aspects of a person in connection to their land, community, and extended families. From this,
health is achieved through the balance between physical, mental, emotional, and spiritual
wellness (Vukic, 2011). It is also important to recognize that although Indigenous Peoples have
shared worldviews and knowledge, the concept and understanding of health and wellness differs
among the many different Indigenous cultures (FNHA, 2021). This paper includes research on
how the COVID-19 pandemic affects First Nations, Métis, and Inuit People across Canada.
However, the bulk of the research focuses on First Nation people on reserves in British
Columbia. Therefore, First Nation Peoples wellness can be defined in the following way:
Mental, Physical, Emotional, and Spiritual balance is at the core of First Nations and
Aboriginal worldviews and ways of life. In most First Nations and Aboriginal cultures,
there are teachings that give expression to these concepts, such as following the ‘Red
Road’ as a means to achieving balance. It is the movement towards balance in all four
quadrants of a person’s holistic health that is the underpinning of this path forward
towards the achievement of ...wellness. (FNHA, 2013, p.11)
An understanding of Indigenous conceptualizations of health and wellbeing was
necessary for the analysis of literature in this review. A holistic framework was used to examine
the literature and how mental, emotional, physical, and spiritual health and wellbeing have been
impacted due to the COVID-19 pandemic. As such, research on all aspects of Indigenous health
(mental, physical, emotional, and spiritual) and has been integrated throughout this literature
review.

8
Moreover, an analysis of social determinants of health was included in this review to
further understand how health is impacted by social conditions and inequities within our society,
rather than just focusing on biological and environmental factors. The social determinants of
health framework was developed to meet the health needs of specific populations, such as
Indigenous people (Bethune et al., 2019). Analysis of social determinants and impact on
Indigenous health was included in this review as it broadens health beyond the biomedical model
and conceptualizes health in a way that is complementary with Indigenous ways of knowing and
worldview.
Literature Review
Canada’s Colonial Legacy
Prior to Canada becoming an official country, Indigenous people lived on Turtle Island
for thousands of years. Since first contact with European settlers, Indigenous People have been
displaced from their lands and been subject to oppressive, white, western, and patriarchal
constructs. The Constitution Act of (1867) gave the federal government authority over “Indians
and lands reserved for Indians”, which continues at this time (Klasing, 2016). The Constitution
Act of, 1867, specified, that matters of Indigenous people, including health and their territories,
exclusively fell under the jurisdiction of the federal government. In addition, the Act outlined
that health care and services for the non-Indigenous population fell under provincial jurisdiction,
resulting in ambiguity regarding government responsibility for health care services for
Indigenous people (Lavoie et al., 2016). This ambiguity persists today and plays a significant
role in creating disparities in health care and health outcomes between Indigenous and nonIndigenous Peoples in Canada.

9
This gave way to the insidious Indian Act (1876), race-based legislation that endures in
Canada. Through the Indian Act, the Canadian government created the reserve system, outlawed
traditional practices and ceremonies, and stripped Indigenous Peoples’ freedom and selfgovernance (Eni et al., 2021). According to Harding and Jeyapal (2018), the Indian Act,
“enforced systemic racism across numerous social and political realms to ensure the oppression
of Indigenous groups” (p.124). Consequently, this led to the disruption of oral histories and
cultural ceremonies and healing practices. This also created many of living conditions
Indigenous people experience today, such as overcrowded and poor living conditions, food
insecurity, and a lack of access to healthy foods and traditional medicines (Datta, 2018; Eni et
al., 2021).
Many other colonial policies were created and implemented following the Indian Act,
which aimed to create further assimilation and cultural disconnection. This was achieved through
mass removal of children from Indigenous families and communities through residential schools
and sixties scoop. Starting in 1874, Indigenous children were forcefully taken from their families
and communities and placed in residential schools and non-Indigenous foster homes (Kolahdooz,
2015). A total of 130 residential schools operated in most Canadian provinces, with the last one
closing in 1996. The schools were mandated by the Federal government and operated by
Christian churches to assimilate Indigenous children into Eurocentric worldviews to eliminate
the “Indian problem” (Barker et al.,2019, p. 249).
The implementation of residential schools involved forced removal of Indigenous
children from their families and communities to ensure they were raised “outside the influence of
their parents, extended family, and culture” (Nutton & Fast, 2015, p. 839). The Truth and
Reconciliation Commission (TRC) of Canada has recognized the deaths of 3200 children who

10
attended residential schools. However, the Chief Commissioner has estimated the death toll to be
over 6000 (Lavesque & Theriault., 2020). For many of the children who lost their lives while
attending these institutions, their deaths were due to preventable disease and maltreatment. To
date, this has been understood as cultural genocide of Indigenous People. However, when
considering the degree of mortality, the wider term of genocide applies as well. The stark reality
is that the children who attended residential schools in Canada had the same odds of perishing as
a soldier in the Second World War (Lavesque & Theriault., 2020).
While attending residential schools’ children were subject to racism, neglect, cultural
shaming as well as sexual, physical, and emotional abuse (Bombay et al., 2020; Eni et al., 2021).
This linchpin created cultural and spiritual disconnection and familial breakdown resulting in
attachment disruptions and a major catalyst for intergenerational trauma among Indigenous
people and their communities. According to Pearce et al. (2018) “a powerful mechanism of
colonization in Canada was the residential school system” (p. 2) which had lasting and
detrimental impacts on health and mental wellness among Indigenous people.
Family breakdown and cultural disconnection continued through the mass removal of
Indigenous children during the “sixties scoop” (Bombay, 2020). This continued the removal of
thousands of Indigenous children from their communities and families; and rather than
residential schools, children were placed non-Indigenous households. The force of Indigenous
children into the residential school system and white, strangers’ households - per the “sixties
scoop” - is associated with many of the barriers faced by Indigenous people today, such as
poverty, addictions, family dysfunction, and poor mental health (Bombay, 2020). Due to the
cyclical nature of trauma, families of residential school survivors continue to be impacted by this
colonial policy. According to Kim (2019), literature shows a link between colonization and

11
intergenerational health disadvantage for subsequent generations, even for those who did not
directly live through the enactments of the policy. The residential school and reserve system
policies have created a low socioeconomic status for Indigenous Peoples, which expands across
generations, impacting Indigenous health and wellbeing.
Present Day Health and Socioeconomic Inequalities
Numerous policies and government inactions create an unsteady foundation from which
Indigenous People are meant to thrive. This includes those that erode familial and community
ties and remove the provision of basic needs. It causes Indigenous vulnerability and is from a
disadvantaged state that compounds existent issues in Indigenous lives even while Indigenous
people remain resilient in order to self-determine and survive (Kim, 2019). However, policies
that target children and separate them from their families, culture, and communities continue to
exist. Indigenous children are overrepresented in the child welfare system today and represent
52.2% of all 14 years of age and younger in care, despite only representing 7.7% of children in
Canada (Bombay, 2020). The alarming reality these numbers reveal is that, at present, there are
currently more Indigenous children and youth who have been removed into government care
than there were at the peak of the residential school era (TRC, 2015; as cited in Waldock, 2020).
Currently, Indigenous people are overrepresented in Canadian federal prisons. Indigenous
women are the fastest-growing incarcerated population, representing 41% of the federal prison
population, despite only accounting for 4% of the female population in Canada (Murdocca,
2020). Compared to non-Indigenous people, they lose “6-9 times more years of life” due to
incarceration (Ryan, 2020, p. 972). The percentage of women in federal prison has increased by
60% over the last ten years (Grekul, 2020). Many Indigenous women in federal prisons are
“surviving” the effects of colonization and “gendered racial violence”, including historical

12
trauma, inadequate mental health supports, poverty, physical, sexual, and psychological abuse, as
well as a disconnection from culture and community (Murdocca, 2020). Murdocca (2020) asserts
that incarceration further exacerbates intergenerational trauma as Indigenous people are
separated from their children, land, culture, and communities, which “is uniquely harmful to
them” (p. 32). Incarceration of Indigenous men and women is another ongoing colonial
mechanism to assimilate and control Indigenous people through familial and cultural disruptions
and thus the most recent form of cultural genocide of Indigenous Peoples. Many times, when
parents are incarcerated, children are placed in the child welfare system, creating further
attachment disruptions for both the child and the parent. This contributes to unhealthy
Indigenous families and communities. Moreover, it is a continuation of colonial tools to separate
Indigenous children from their parents and communities (Murdocca, 2020).
There have been some recent changes through the creation of legislation to address the
overrepresentation of Indigenous children in care. In 2019, the government of Canada introduced
Bill C-92, An Act respecting First Nations, Inuit, and Metis children, youth, and families (Hahn
et al., 2020). The legislation intends that Indigenous communities have sovereignty in the
creation and implementation of child-welfare policies and laws. Moreover, the Act allows
Indigenous people and communities full or partial jurisdiction over child and family services.
Thus, it addresses colonial imposition as a prime source of intergenerational trauma and reasserts
decision power in the hands of Indigenous Communities. This allows Indigenous communities to
define what is in the best interest of the Indigenous child and heal attachment and cultural
disruptions. Bill C-92 creates a path forward to improve the health and wellbeing of Indigenous
children and youth today as well as generations to come. This Act is addressing the Truth and

13
Reconciliation Commission of Canada #4 call to action which, “calls upon the federal
government to enact Aboriginal child-welfare legislation” (TRCC, 2015, p.5).
Another egregious example of human rights violations contributing to systemic injustice
across the country is the water crisis. Many First Nation people living on reserves do not have
access to clean and safe tap water and adequate sanitization, despite Canada having the world’s
third-largest renewable freshwater supply (Mike & Cheung, 2019). The water crisis is deeply
rooted in colonial policies and discriminatory legislation that continues to deprive Indigenous
Peoples of fundamental human rights and equitable access to essential resources. First Nations
Health Authority (2021) concluded that in British Columbia (B.C.), as of October 31, 2021, there
were eight boil water advisories, four water quality advisories, and nine do not consume
advisories for a total of twenty-one drinking water advisories in effect across nineteen First
Nation communities and twenty-one water systems across the province. The B.C. data is one
example of a more significant water crisis that persists across the country. The federal
government has failed to take appropriate action to provide equal protection through legislation.
As a result, First Nations people residing on reserves live in conditions comparable to an
underdeveloped country. The federal government is legally responsible for infrastructure onreserve and continually fails to allocate necessary resources and funds to address harmful
conditions (Palmater, 2019).
Colonialism is at the root of many adverse social determinants of health experienced by
Indigenous Peoples and disrupts protective determinants of health, such as traditional governance
and cultural continuity (Richardson & Crawford, 2020). Approximately one-quarter (24%) of
Indigenous people living in urban areas across the country experience poverty, which is almost
double the rate of the non-Indigenous population (13%) (Mashford-Pringle et al., 2021).

14
Moreover, some of the health inequalities Indigenous people in Canada experience today are
high rates of respiratory and heart disease, diabetes, poor mental health, substance use, and
reduced life expectancy compared to non-Indigenous people, which all increase their
vulnerability to COVID-19 (Kim, 2019; Ndumbe-Eyoh et al., 2021). In addition, despite
Indigenous Peoples only representing 4.3% of the total population in Canada, they have a life
expectancy 12 years lower than the national average.
Social Determinants of Indigenous Health
Social determinants of health are a framework to meet the health needs of populations,
including the diverse Indigenous people and communities living in Canada. As previously noted,
this framework is more consistent with an Indigenous worldview as it moves beyond a
biomedical model, which focuses solely on our physical being in relation to our health. The
framework includes factors such as employment, gender, income, and education; furthermore, it
includes how they impact health and wellness (Bethune et al., 2019). The World Health
Organization (WHO) defines social determinants of health as “the conditions in which people are
born, grow, live, work and age” (Richardson & Crawford, 2020, p. 1). These conditions are
created through the execution of policies, which in turn create many inequalities due to an
unequal distribution of resources, power, and wealth.
Indigenous people experience a greater burden of physical and mental health issues due
to inequalities related to social determinants of health (housing, education, access to healthcare
and services, socioeconomic status, etc.), which place Indigenous people at greater risk of poor
health outcomes resulting in increased risk during pandemics (Lawal, 2021; Ndumbe-Eyoh et al.,
2021; Power et al., 2020; Tremblay, 2021; Turpel & White-Hill, 2020). These health disparities
are well documented. During the H1N1 pandemic in 2009, Indigenous Peoples accounted for

15
27.8% of all hospitalizations, 21.9% of all ICU admissions, and 17.6% of all deaths, despite only
representing 4% of the population in Canada. According to Power (2020), during the H1N1
pandemic, First Nations people were three times more likely to be hospitalized and six and a half
times more likely to require intensive care. Similar disparities have been documented during the
COVID-19 pandemic. On March 17, 2021, the First Nations Health Authority (2021) stated that
First Nations people tested positive for COVID-19 at double the rate compared to the nonIndigenous population in British Columbia. Data from the same time also reveals the median age
of death for First Nation people who were hospitalized due to COVID-19 is 11 years younger
than the provincial average. Approximately half of First Nation people who were hospitalized are
under 55 years of age comparatively the rest of the population in B.C. who were hospitalized are
under 66 years of age. Moreover, the median age of death among First Nations who died from
COVID-19 was 18 years younger than the rest of the population in B.C (67 years old for First
Nations and 85 for the remainder of the provincial population).
A central theme across multiple research studies is colonization's impact on social
determinants of health and how this is associated with increased vulnerability to COVID-19.
Several studies indicate that susceptibility to the pandemic is associated with colonial policies
that have ensured Indigenous people have reduced access to adequate, culturally safe health care,
clean water, and healthy food (Jenkins et al., 2021; Levesque & Thériault, 2020; Mosby, 2021;
Ndumbe-Eyoh et al., 2021; Power, 2020; Richardson et al., 2020; Tremblay, 2021). This is
problematic as Power (2020) asserts that health outcomes are “determined by levels of secure
housing, employment, comorbidities, functional literacy, food security, access to running water,
access to healthcare and technology” (p.1).

16
Recent research has also revealed that the COVID-19 pandemic has impacted mental and
spiritual health for Indigenous people due to disruptions in family and community connectedness
and cultural teachings (O’Keefe et al., 2021; Power et al., 2020). Some of the losses experienced
during the pandemic have been extensive due to the loss of Elders or knowledge keepers,
isolation from friends and extended family, and the cancellation of ceremonies and community
events. Kim (2019) asserts that disruptions in cultural identity and continuity can affect the
health and wellbeing of Indigenous people. This points to a diminishment of ground gained by
Indigenous Peoples in recent years to revive the Indigenous cultures and share Indigenous
knowledge to heal colonial harms.
Healthcare as a Social Determinant. According to Horill et al. (2018), access to
healthcare is considered a social determinant of health. Due to historic and ongoing colonialism,
Indigenous people in Canada do not experience equitable access to culturally safe health
services, and the COVID-19 pandemic has exacerbated these inequalities (Saint-Girons et al.,
2020; Tremblay, 2021; Turpel & White-Hill, 2020). In 2022, the Indian Act of 1876, continues to
give the federal government authority and financial responsibility for status First Nations and
their lands, which leaves Indigenous organizations and social service and healthcare agencies
grossly underfunded and in jurisdictional disputes (Turpel & White-Hill, 2020). In a 2016
survey, one in ten First Nations living in Northern territories and on-reserve reported they did not
receive adequate access to care to meet their health care needs in the last year (Saint-Girons et
al., 2020). According to Levesque and Thériault (2020), health disparities faced by First Nations
people result from discrimination and underfunding of public health services, especially on
reserves. In addition, due to anti-Indigenous racism and poor quality of care in many health care
settings, many Indigenous people avoid seeking care to address their mental and physical health

17
needs (Levesque and Thériault, 2020; Tremblay, 2021; Turpel & White-Hill, 2020). According
to Duran (2019) another issue contributing to the underutilizing of healthcare services is at
present, our current healthcare system is failing to meet the needs of Indigenous people as they
do not incorporate traditional, spiritual, and healing methods (Duran, 2019; Marsh et al., 2015).
Mashford-Pringle et al. (2021) assert that anti-Indigenous racism in health care continues to be a
significant problem for Indigenous peoples.
A report by Turpel and White-Hill (2020) highlighted the Union of the BC Indian Chiefs’
concerns regarding Indigenous people avoiding going to the hospital and seeking other health
care services due to ongoing racist, unethical, and discriminatory treatment by healthcare
professionals, as well as “broader racist incidents” associated with the COVID-19 pandemic
(Turpel & White-Hill, 2020). The concern of health care avoidance during the pandemic came
from data collected from the COVID-19 Speak Survey. Data from this survey revealed that 39%
of First Nations and Métis respondents were avoiding health services and two times more likely
than the non-Indigenous population in B.C. to avoid emergency care. In addition, data showed
that First Nations were ten times more likely to avoid counseling services (22% compared to
11%) compared to the B.C. population (Turpel & White-Hill, 2020, p.92).
A quantitative study by Turpel and White-Hill (2020) contends that First Nation
respondents reported experiencing greater difficulties accessing their doctors and emergency care
during the pandemic. One of the biggest disruptions in care reported was mental health services,
such as counseling and traditional wellness, as First Nations were over two times more likely to
experience a disruption in these services compared to the non-Indigenous population in British
Columbia. According to Asmundson et al. (2020) many Indigenous people living in rural and
remote communities have not had access to mental health services despite the added stress which

18
has resulted from the COVID-19 pandemic. In response to these concerns, the First Nations
Health Authority established virtual physician and mental health services during the COVID-19
pandemic.
In British Columbia Telehealth (also referred to as Virtual Care) has been implemented to
deliver holistic health care, educational and wellness services to First Nations people and
communities (FNHA, 2022). This service addresses issues related to health care access as it
provides health care services to First Nations living in remote or rural areas. This service
includes First Nations Virtual Doctor of the Day program, which virtually provides rapid access
to doctors. Moreover, this service is delivered by doctors who identify as Indigenous, as well as
doctors who are trained to adhere to principles and practices of cultural safety and humility. To
address barriers and access to mental wellness and substance use services First Nations Virtual
Substance Use and Psychiatry services have been made available at no cost. Similarly, to the
Doctor of the Day, all services are being offered by health care professionals trained in cultural
safety and humility. Additionally, due to common underlying causes of addiction, healthcare
workers for this service are also trained in trauma-informed care (FNHA, 2022).
Due to the COVID-19 pandemic, many health care services have moved to virtual
platforms. Access to healthcare services is critical for maintaining good health and wellness
during the COVID-19 pandemic (Mashford-Pringle, et al., 2021). Thus, it is imperative that all
Canadians have equitable access to devices and reliable high-speed internet. Indigenous
participants in a recent qualitative study declared that many remote First Nation communities do
not have adequate bandwidth resulting in unstable internet, creating barriers to accessing virtual
healthcare. Furthermore, it negates the accessibility of the previously mentioned Virtual Doctor
services created specifically to engage and support Indigenous people. Investment to improve

19
internet infrastructure and provide devices to access essential services, such as virtual physicians
and mental health services, were identified as solutions to address the concerns raised in this
report (Mashford-Pringle, et al., 2021).
Other identified barriers in accessing virtual health services on reserves highlighted in the
Mashford-Pringle et al. (2021) report are accessibility to devices, having a safe space to access
health services, and anti-Indigenous racism in healthcare. Participants shared that some
individuals do not have cell phones or devices to access the internet, further limiting their ability
to access health services. Many participants in this report also identified feeling skeptical about
utilizing telemedicine services due to fear of experiencing stereotyping and healthcare that is
culturally unsafe. Another barrier identified in this study relating to accessing virtual care during
the pandemic is the lack of private space to discuss private health matters due to overcrowded
housing.
Access to Clean Water and Adequate Housing. From the start of the pandemic, public
health leaders have encouraged physical distancing, cleaning of communal surfaces, and hand
washing to be the most effective approach at reducing transmission of COVID-19 (Levesque &
Thériault, 2020; Mashford-Pringle et al., 2021). However, in the beginning of the COVID-19
pandemic many First Nations communities were experiencing issues related to accessing
healthcare resources required to follow public health recommendations, such as COVID-19
testing kits, medications, hand sanitizer and disinfectant spray and other protective equipment
(Mashford-Pringle, et al., 2021). One of the barriers which impacted access to supplies was lack
of reliable internet (Ineese-Nash, 2020). Communities without access to high-speed internet had
a difficult time accessing federal funding which led to delays in accessing essential supplies,
such as Personal Protective Equipment (PPE) and COVID-19 testing kits. Delay in such supplies

20
is problematic as, “time can be the deciding factor of community-wide transmission or
mitigation” (Ineese-Nash, 2020, p.1).
There are specific vulnerabilities for Indigenous people living on reserves and urban
areas across the country. For example, many communities on reserves do not have the autonomy
and resources to implement recommended public health recommendations, such as frequent hand
washing due to being deprived of their basic human right to clean water. Additionally, many
people on reserves cannot physically distance or isolate themselves due to overcrowded housing
and lack of assets like community buildings to temporarily house those who are infected
(Levesque & Thériault, 2020; Mashford-Pringle, 2021; Ndumbe-Eyoh et al., 2021). Poverty and
poor health have been identified throughout literature as risk factors for pandemic severity and
negative health outcomes among Indigenous people. Poverty impacts Indigenous Peoples’ ability
to respond to COVID-19 due to multiple factors and will be discussed further in this literature
review (Power, 2020).
Despite recent efforts and Trudeau’s Liberal government’s promise to end all long-term
drinking water advisories that affect First Nations reserves across Canada by March 2021, this
crisis persists (Mike & Cheung, 2019). As of 2020, there were at least sixty-one long-term
drinking water advisories in effect, as well as several short-term advisories. As a result, some
First Nation communities lack the resources necessary to implement public health
recommendations to mitigate the spread of COVID-19 in their households and communities. In
addition, there is an increased risk of water-borne diseases due to consuming and using
contaminated water (Levesque & Thériault, 2020).
A further issue emerges from the literature in the high prevalence of First Nations living
on reserves in both overcrowded housing and homes in need of major repairs, as both are

21
associated with poor health outcomes (Lawal et al., 2021; Levesque & Thériault; MashfordPringle, et al., 2021; Power et al., 2020). According to Levesque and Thériault (2020), in
Canada, one-quarter of First Nations on reserves live in crowded housing conditions, and 44.2%
live in homes requiring major repairs. During a pandemic like COVID-19, overcrowded housing
with poor air circulation increases the spread of the virus as individuals are not able to follow
physical distancing recommendations. The inability to physically distance and stop the spread of
COVID-19 is problematic due to the high rates of chronic health conditions among Indigenous
people like asthma and diabetes, which are significant risk factors. Inadequate and limited
housing is sadly associated with increased violence during the pandemic (Levesque & Thériault,
2020; Power et al., 2020).
Housing shortages on reserves and in urban areas for low-income First Nation families
put women and children at heightened risk of violence and abuse due to overcrowded housing
and public health recommendations that promote isolation (Asmundson et al., 2020; Jenkins,
2021; Levesque & Thériault, 2020; Power et al., 2020). First Nations women and children are
disproportionately affected by physical, domestic, and sexual violence due to intergenerational
trauma “induced by sexist and patriarchal colonial laws and policies” (Levesque & Thériault,
2020 p.386). Risk increases as women and children must often remain in an abusive environment
due to a lack of safe housing and shelters options on reserves. A study by Jenkins (2021)
revealed that Indigenous people in Canada were two times more likely than non-Indigenous
people to report fear of physical and emotional domestic violence, which is associated with
“persistent adverse mental health outcomes” (p.10), especially for women.

22
Impacts of COVID-19 on Mental Health
Canadians are experiencing deterioration in mental health and coping due to the COVID19 pandemic (Jenkins, 2021). There have been several surveys examining the impacts of the
pandemic on mental health among Canadians, and these studies confirm that mental health is
worsening in Canada. For instance, in April 2020, a survey concluded that 50% of Canadians
reported deteriorating mental health during the pandemic, with over 40% identifying feeling
anxious and/or worried. Additionally, in May 2020, Statistics Canada found a 14% decline in
individuals who identified their mental health as “very” good or “excellent” (p.2), compared to
the same survey conducted in 2018.
There are studies conducted around the world which have used standardized
questionnaires to gather information about the impacts of the COVID-19 pandemic and mental
wellness (Ahmed et al., 2020; Mazza et al., 2020; Wang et al., 2020; Zhang et al., 2020). Lawal
et al. (2021) concluded there is an association between worsening mental wellness and the
pandemic. Specific risk factors found to be associated with depression during the pandemic are
age (21-40 years), alcohol use/misuse, gender with the highest risk among females, having prior
medical issues, specific health issues and comorbidities, quarantine, and financial costs
associated with having to quarantine, and exposure to COVID-19 news (Lawal et al., 2021).
Also, anxiety and depression increased during the pandemic, and with identified risk factors,
such as age (20-46 years), detachment, prior medical issues, experiencing stressful situations,
specific physical health issues, self-disclosure of poor health status, being affected by quarantine
and the financial burdens associated with time spent in quarantine, family and friends affected by
COVID-19, and exposure to COVID-19 related information and news. Many factors that were

23
found to be correlated with anxiety and depression during the COVID-19 pandemic have also
been associated with increased stress (Lawal et al., 2021).
Countries around the world have revealed similar findings regarding the impact of the
pandemic on mental health (Jenkins, 2021). For example, in March 2020, research from Italy
supports these findings that impacts were higher among certain groups or demographics, such as
women, those living in poverty, and people with pre-existing medical conditions. A 2020 study
conducted in the United States by Fitzpatrick and colleagues, had similar findings to the study in
Italy. It concluded that adverse mental health impacts were more likely among women, families
with children, individuals experiencing unemployment, and people who identified as a visible
minority (Fitzpatrick et al., 2020).
The mental health impacts due to the COVID-19 pandemic are being documented
around the world as people are experiencing increased levels of “stress, worry, anxiety, and
depression” (Jenkins, 2021, p.10). In addition, the pandemic contributes to widening mental
health inequalities, especially among individuals with pre-existing mental and physical health
issues. As previously noted, Indigenous people in Canada experience disproportionate effects on
their mental wellness during the COVID-19 pandemic due to multiple pre-existing
socioeconomic and health inequalities. (Lawal et al., 2021).
Due to colonial discourse and policies, Indigenous people in Canada prior to the
COVID-19 pandemic experienced disproportionate rates of mental health issues compared to
non-Indigenous people (Lawal et al., 2021). According to Asmundson et al. (2020), there is a gap
in mental health research as population data comparing Indigenous and non-Indigenous people
using the same methodologies does not exist. However, data is available demonstrating the stark
mental health disparities impacting Indigenous people. For example, the suicide rate among First

24
Nations is two times higher than the general population and three times higher among Indigenous
youth. The suicide rate among Inuit people is approximately nine times higher than nonIndigenous people living in Canada. In addition, Indigenous youth are at increased risk of suicide
ideation and attempt if they had a parent or grandparent that was a residential school survivor
(Carrier et al., 2022; Turpel and White-Hill, 2020). First Nations people also face
disproportionate rates of substance overdose-related health outcomes (Turpel & White-Hill,
2020). Data from January1, 2020 to October 31, 2020, revealed the rate of overdose related
deaths among First Nations living in B.C. were 5.5 times higher compared to the non-Indigenous
population within the province (Turpel & White-Hill, 2020).
According to O’Keefe (2021), a recent survey of 14,000 Indigenous Peoples (15 years of
age and older) showed that 60% of participants indicated their mental health worsened following
physical distancing protocols. Data from the same survey also revealed that nearly 50% of
Indigenous women and approximately 33.3 % of Indigenous men described most of their day as
“quite a bit” to “extremely stressful” (p.2). A report by Turpel and White-Hill (2020) reveals
that 52.1% of Métis and 50.3% of First Nations people in a survey rated their mental wellness to
be slightly or much worse than prior to the COVID-19 pandemic.
A quantitative study by Lawal et al. (2021) explored the differences in depression,
anxiety, and stress, among different ethnic groups in Canada during the COVID-19 pandemic.
The findings of this study indicate that anxiety, depression, and stress have increased in the
general population during COVID-19 and are associated with certain risk factors, such as
individuals with Indigenous ancestry. The study found that participants who self-identified as
Indigenous reported higher levels of anxiety, depression, and stress compared to other ethnic
groups in Alberta, Canada. Stress was reported by 90% of participants that identified as

25
Indigenous. Anxiety and depression were also reported by over 50% of Indigenous participants
(Lawal et al., 2021).
Food Security and Mental Health
Another theme is the impact of food security on mental health. The link between food
security and mental and physical health is well documented, as food insecurity is associated with
an increased risk for mental distress (Friel et al., 2014; Jenkins, 2021; Turpel & White-Hill,
2020). Statistics from 2017 reveal that 38% of Indigenous people 18 years and older living in
urban areas experienced food insecurity (Mashford-Pringle et al., 2021). Comparatively, food
insecurity affects 43% of First Nations living off-reserve and 31% of Métis people. Inuit people
experience the highest rate of food insecurity in Canada. An Inuit health survey reported that
70% of all Inuit adults are food insecure, “representing the highest documented food insecurity
rate for any aboriginal population in a developed country” (Saint-Girons, 2020, p.7). MashfordPringle et al. (2021) pointed to potential gender differences when it comes to food insecurity
during the COVID-19 pandemic, as Indigenous women 18 years and older experienced higher
rates of food insecurity (41%) compared to Indigenous men (34%). This being so, no further
research expounds on the topic of gender-based disparity during the COVID-19 pandemic in
relation to Indigenous people.
Income and food security have been associated with increased stress impacting mental
health, especially for those with low income and experiencing food insecurity prior to entering
the COVID-19 pandemic. Turpel and White-Hill (2020) found that 41% of First Nations
respondents indicated having difficulty meeting their basic household needs during the
pandemic, compared to 32% of the non-Indigenous population in B.C. Moreover, 31% of First
Nations reported feeling stressed about food running out before they had funds to purchase more.

26
A cross-sectional survey from May 2020, examined how the pandemic has impacted mental
health among certain populations and found that 1 in 5 participants reported worrying about
having enough food required to meet the needs of their household. This was intensified among
specific groups, such as Indigenous people and those living in poverty (Jenkins et al., 2021).
Community lockdowns and Social Distancing
Another issue of concern that arose in the literature is the effects community
lockdowns/isolation have on mental wellness and physical wellbeing for Indigenous people
(Howard-Bobiwash et al., 2021; Jenkins et al., 2021; Mashford-Pringle et al., 2021; Power et al.,
2020; Turpel & White-Hill, 2020). There is minimal research in this area thus far; however,
according to a qualitative study by Mashford-Pringle et al. (2021), participants expressed
concern regarding the mental and emotional wellbeing of people in their communities due to
difficulties accessing cultural practices due to public health and lockdown measures. This is
problematic as for many First Nation people across Canada, feasting, potlaches, and other
cultural practices play a significant role in the spiritual and cultural wellness of their
communities (Smith et al., 2021).
Substance misuse and overdose of lethal substances is also a theme in the literature. Prior
to the COVID-19 pandemic, provinces across the country faced an opioid crisis, which has only
been exacerbated since the pandemic (Asmundson et al., 2020; Turpel & White-Hill, 2020).
There has been a substantial increase in fatal substance overdoses, specifically on reserves during
the pandemic as travel was limited to and from remote communities, which made the supply of
these substances inaccessible (Mashford-Pringle et al., 2021).
The Emergency Response Benefit (CERB) was identified as having a negative impact on
mental health and substance use in certain communities (Mashford-Pringle et al., 2021). The

27
CERB was extremely helpful for some individuals as it provided income to help them meet their
basic needs, such as providing food for their families and communities. However, that income
was used to purchase illegal substances and alcohol for some individuals. The CERB provided
by our federal government was a protective factor for some individuals, and for others, it created
more harm. Some Indigenous participants in a qualitative report shared they were encountering
“a doubling of opioid-related and fentanyl-related overdoses” in their communities (p.9).
Turpel and White-Hill (2020) examined the correlation between COVID-19 and mental
wellness among Indigenous Peoples residing in B.C., Canada, and found First Nations and Métis
experience higher rates of stress resulting from isolation caused by the pandemic. According to
this study, 50.3% of First Nations people reported their mental wellness to be “slightly or much
worse than it was before” the COVID-19 pandemic. In addition, 26.7% of First Nations rated
experiencing stress during the pandemic that was “quite or extremely significant” (p.88).
Vaccine Hesitancy
Vaccine hesitancy among Indigenous people and communities is an issue that emerged in
the literature, however there are limited studies in this area (Mosby & Swidrovich, 2021;
Muhajarine et al., 2021; Ochieng et al., 2021). According to Mosby and Swidrovich (2021),
many Indigenous leaders have been vocal regarding their support for vaccination; however, some
Indigenous people have expressed opposition and hesitancy for the COVID-19 vaccine. A
previous Chief of the Assembly of First Nations National named Matthew Coon expressed grave
concern regarding the vaccine in a social media post, writing, “Mistassini is now the
experimental rats of this experimental vaccine” (p.2).
This being so, vaccine hesitancy and refusal have been linked to distrust of the Canadian
medical system due to the past medical experimentation on Indigenous Peoples (Mosby &

28
Swidrovich, 2021). Several instances are well documented and remembered by Elders where
Indigenous people were subjected to medical experimentation and abuse. For example, nutrition
experiments took place in several Cree communities and residential schools in the 1940s,
producing scientific knowledge through the starvation of Indigenous people, many of which
were children. There are many other documented examples of medical experimentation on
Indigenous Peoples, such as the twelve-year trial for the bacilli Calmette-Guerin vaccination to
treat tuberculosis, the forced sterilization of Indigenous women, and other “experimental surgical
and drug treatments” were given without informed consent (Mosby and Swidrovich, 2021, p.3).
According to Mosby and Swidrovich (2021), vaccine hesitancy was seen during the
H1N1 pandemic and can be linked to Indigenous Peoples' experiences with colonization and past
pandemics. Moreover, negative perception of the H1N1 vaccine and pandemic was worsened by
problematic public health interventions and lack thereof. For example, during the H1N1 outbreak
in 2009, the federal government delivered body bags to 4 First Nation reserves in Manitoba
instead of sending supplies, such as hand sanitizers, antivirals, and care kits. This story spread
across Canada, causing further distrust among Indigenous communities and Nations. Indigenous
people were identified as a group to receive the H1N1 vaccine among all the groups identified as
a high risk. Focusing on “Indigeneity alone meant that many were left feeling like guinea pigs”
(p.3).
Muhajarine et al. (2021) examined COVID-19 vaccine hesitancy/refusal among adults
living in Saskatchewan and found Indigenous respondents were 2.4 times more likely to refuse a
COVID-19 vaccine and 1.7 times more likely to be vaccine-hesitant compared to non-Indigenous
participants in the study. In addition, specific sociodemographic variables were associated with
vaccine hesitancy and refusal, such as poverty, gender (women being more hesitant), and

29
Indigeneity. Moreover, level of education was strongly correlated with vaccine hesitancy/refusal
as respondents with less than a professional degree were more resistant and unsure of the
COVID-19 vaccine. This study also revealed vaccine hesitancy was associated with maskwearing, as those who reported being vaccine-hesitant were less likely to wear a mask in public
spaces (Muhajarine et al., 2021).
Vaccination rates among Indigenous Peoples and communities have varied throughout
the pandemic across Canada. According to First Nations Health Authority (2021) as of July 20,
2021, 81% of people in B.C. (12 years and older) received their first dose of a COVID-19
vaccine, whereas the vaccine rates among First Nations people as of July 16, was just above
64%. During this time there is no data available regarding vaccine rates among Métis and First
Nations people living in urban areas, as Indigenous Services Canada (ISC) research is limited to
First Nations living on reserve. Due to gaps in research and sampling it is unclear how many
Indigenous people in Canada have been vaccinated compared to the non-Indigenous population.
Indigenous peoples tend to distrust the current healthcare system and government
leadership pertaining to pandemics and vaccines (Lavesque & Thériault, 2020; Mosby &
Swidrovich, 2021; Muhajarine et al., 2021). This is problematic as like previously mentioned
they are at a greater risk of severe infection and adverse health outcomes if they contract the
COVID-19 virus due to inequalities resulting from historic and contemporary colonial structures
(Levesque and Thériault, 2020; Power et al., 2020). To address vaccine hesitancy and protect
community members, First Nations and the Métis Nation used different mechanisms to
encourage their community members to get vaccinated, such as leadership by Elders, social
media sites and radio (Muhajarine et al., 2021).

30
Elders play a vital role in reducing vaccine hesitancy in their communities by educating
and encouraging members to protect themselves through vaccination and by leading by example
(Muhajarine et al., 2021). As of July 2021, vaccination rates were the highest among Indigenous
Elders, 60 years of age and older (FNHA, 2021). During this time, 84% of Elders 70 years and
older were fully vaccinated. In addition, several Indigenous organizations and community
leaders addressed vaccine hesitancy collaboratively by removing barriers such as access to
transportation by creating their own vaccine clinics in partnership with Indigenous Services
Canada and provincial health authorities. These clinics made the vaccine accessible and
convenient as they delivered doses to reserves and remote communities.
Protective Factors and Indigenous-led Responses
Since first contact with European colonizers, Indigenous people have been exposed to
various viruses and diseases that have devastated their communities. This knowledge has been
used to inform their response to pandemics like we are currently experiencing (Mashford-Pringle
et al., 2021; Neeganagwedgin, 2020; Turpel & White-Hill, 2020). Indigenous peoples and
communities “have a wealth of knowledge, practices, language, and culture, which includes
time-tested responses to crises” (Neeganagwedgin, 2020, p.1). Mashford-Pringle et al. (2021)
identified that surviving past pandemics (e.g., Smallpox, Spanish flu, SARS-1, H1N1) has built
resiliency in Indigenous communities and is a source of pride which has led to leadership in both
their communities and organizations. Successful leadership was identified as being “fundamental
for delegating funding and services to First Nations, Inuit, and Métis communities” (p.10).
Since the beginning of the COVID-19 pandemic, Indigenous people in Canada have
taken immediate action to protect the wellbeing and safety of their communities and nations
(Diaz et al., 2021; Mashford-Pringle et al., 2020; Neeganagwedgin, 2020). Communities and

31
leaders worked collaboratively, finding ways to keep their communities safe by utilizing
available resources and finding ways to mitigate COVID-19 and its impacts on depression, food
security, and isolation (Mashford-Pringle, et al., 2021; Neeganagwedgin, 2020). In some
community’s Indigenous leaders worked towards an immediate transition from in-person to
online health platforms to avoid communication disruptions for their community members. Other
ways in which Indigenous people have responded is through seeking guidance and knowledge
from Elders, protecting Elders and seniors, sharing food and resources, community-led
shutdowns, and connecting to their ancestral land and cultural practices. However, it should be
noted that pandemic preparedness and response varied across communities and Nations
(Mashford-Pringle, et al., 2021; Neeganagwedgin, 2020).
Elders and knowledge keepers are essential in First Nation communities and families as
they play a major role in educating future generations and passing on traditional practices,
knowledge, language, and culture (Mashford-Pringle et al., 2021; Neeganagwedgin, 2020; Rowe
et al., 2020). However, not all seniors in Indigenous communities are Elders. Elders are leaders
in Indigenous communities as they support and guide their communities. Moreover, Elders are
traditional knowledge keepers and leaders “who possess talents or knowledge that they pass onto
future generations” (Mashford-Pringle et al., 2021, p.6). Elders are protective factors in
Indigenous communities as they play a significant role in educating future generations through
oral transmission and ensuring cultural continuity (Neeganagwedgin, 2020).
Indigenous Elders and seniors are disproportionately affected by COVID-19 as they have
an increased risk of experiencing severe illness and adverse health outcomes if they contract the
virus. They face even greater vulnerability due to the high rates of chronic illness and
comorbidities among their age demographics. Over eighty-four percent of Indigenous

32
Elders/seniors 55 years or older have at least one long-term chronic health condition (First
Nations Information Governance Centre, 2020). Considering the essential role of Elders and
knowledge keepers in Indigenous communities, any loss is significant (Mashford-Pringle et al.,
2021). Thus, protecting grandparents and Elders from coronavirus is imperative to protect
cultural identity and continuity. As such, many Indigenous peoples from rural, urban, and remote
communities worked collaboratively to protect Elders from COVID-19 (Mashford-Pringle et al.,
2021; Neeganagwedgin, 2020). They were provided with daily meals and isolated from those
who were considered a risk due to potential COVID-19 exposure. In addition, Elders with
underlying health conditions and comorbidities which put them in a high-risk category had
limited visitors to protect their health and wellbeing. Alternatively, to in-person visits,
socialization with Elders was done virtually (Mashford-Pringle, et al., 2021).
Youth are also important in Indigenous communities as they represent the future (IneeseNash, 2020; Mashford-Pringle, et al., 2021). COVID-19 has provided an opportunity for many
Indigenous youth as many have returned to the land to support themselves and their communities
(Ineese-Nash, 2020). Many Indigenous youth have been fulfilling their roles as helpers in their
communities, “guiding the way forward and forging new potentialities outside of the singular
colonial existence” (p.1). For example, in some communities, youth have demonstrated
leadership, resiliency, and creativity during the COVID-19 pandemic (Ineese-Nash, 2020;
Mashford-Pringle, et al., 2021). Some of the ways they have supported their communities are
through facilitating activities for children and other youth while adhering to physical distancing
measures. Leadership initiatives were created to increase the social health of families and
communities using social media platforms, such as Facebook and Instagram. Additionally, it was
reported that some youth led educational discussions on social media platforms. A few

33
participants identified that these initiatives reflected “Indigenous ways of knowing through the
use of human, animal, and land characters and illustrations” (p.7).
Another way Indigenous communities responded to the pandemic and protected their
communities and Elders is through action by implementing community-led lockdowns (IneeseNash, 2020; Mashford-Pringle, et al., 2021; O’Keefe et al., 2021). Many of the community
lockdowns that were implemented were before provincial and territorial orders and exerted by
sovereign authority. The immediate lock down response was implemented to protect the health
and safety of community members by limiting the transmission of infectious disease from
outside sources (Ineese-Nash, 2020). Some rural First Nation communities partnered with local
police services to assist with keeping non-community members from entering the area. In some
Indigenous communities in Canada, physical barricades were created to ensure non-residents
could not enter their communities (Mashford-Pringle, et al., 2021).
During the COVID-19 pandemic, Elders and community members found innovative
ways to enhance community connections, foster relationships, and build an online community in
response to in-person connections being limited (Mashford-Pringle et al., 2021;
Neeganagwedgin, 2020). At one university in Canada, where Elders could no longer engage with
students face to face, they provided individual counseling through text and hosted virtual circles
to share traditional knowledge with students. Indigenous communities were able to support one
another in various ways, including sharing of food and stories and virtual/physically distanced
cultural activities, such as pow wows. In addition, Indigenous communities connected via social
media to feature culture through “song and dance” (Neeganagwedgin, 2020, p.407).
Prior to colonization and displacement from their traditional lands, Indigenous people
learned and lived on the land (Neeganagwedgin, 2020). Closures of schools, mandates that

34
promote isolation, and community lockdowns have provided opportunity for Indigenous people
and communities to “engage with land-based pedagogy” (p. 407). As such, during the COVID19 pandemic many Indigenous peoples are connecting to the land to find guidance, foster
healing, and enhance cultural learning. According to Mashford-Pringle et al. (2021) Some
Indigenous communities assisted people with connecting and reconnecting to the land in both
“old and new” ways, such as ceremonies, gardens, planting of traditional medicines, and
traditional teachings. Despite the challenges COVID-19 presented in many communities, it
provided the gift of time as lockdowns provided families with more time to spend together.
Moreover, it fostered physical, cultural, and spiritual community connectedness that are
fundamental to the wellbeing and survival of Indigenous people (Mashford-Pringle et al., 2021;
Neeganagwedgin, 2020).
Gaps in Literature
One of the major gaps in research on Indigenous health is historical research has been
“conducted on Indigenous people rather than in collaboration with them” (Carrier et al., 2022,
p.2). Indigenous knowledge tends to exist within grey literature, and this thematic review
consisted primarily of peer-reviewed journals. Thus, critical research and Indigenous knowledge
to better understand their unique experiences, strengths, protective factors, and health during the
COVID-19 pandemic may have been excluded from this review. However, it is important to
recognize in recent years there has been an increase in literature produced in collaboration with
and led by Indigenous Peoples and communities.
Despite the research, for this review taking on a holistic lens and including all aspects of
Indigenous health (spiritual, emotional, physical, and mental), most of the research available in
relation to the COVID-19 pandemic pertained to mental health. Due to the recent nature of the

35
COVID-19 pandemic, there is limited research on how the pandemic is affecting Indigenous
people from a holistic framework. A major limitation of this thematic review is it does not
include substantial research on how the COVID-19 pandemic is affecting all aspects of
Indigenous health.
Research regarding mental health during the pandemic in both Canada and other
countries concluded that women faced greater negative impacts to their mental health and
wellness during the COVID-19 pandemic. Studies on Indigenous women and the effects of
COVID-19 on health were not available, rendering them even further invisible in research and
the production of knowledge. Therefore, gender-specific studies are required to better understand
both men and women's unique realities and health during the pandemic.
Another gap is the lack of research for non-status First Nations, Métis, and Inuit people
pertaining to health and the COVID-19 pandemic, as information for Indigenous people living
off-reserve and non-status is not adequately collected. As previously mentioned, Indigenous
Services Canada (ISC) only seeks data collection for status First Nations people and excludes
non-status (Howard-Bobiwash et al., 2021). Moreover, there is no organization in Canada
releasing race-based data on the impacts of COVID-19. The Public Health Agency of Canada
reports daily COVID-19 cases and includes demographics such as gender and age but does not
include rates among Indigenous people.
Indigenous Services Canada (ISC) acknowledges there is a need to improve and expand
parameters for data collection in order to include all Indigenous Peoples in research pertaining to
COVID-19 and the impacts on health. As such, they are exploring alternative approaches that are
more inclusive. ISC has identified barriers to accurate data collection as, lack of research on
urban Indigenous populations and accessibility to Indigenous communities living in remote and

36
isolated communities. Additional research is needed to understand health disparities and
protective factors, and responses among the diverse Indigenous cultures in Canada during the
COVID-19 pandemic. Moreover, research must be in collaboration with or by Indigenous
communities to ensure the data produced is relevant and advantageous for each community.
Implications for Social Work Practice, Policy, and Research
Many voices have brought to light the systemic inequalities faced by Indigenous people
and proposed solutions to remedy these issues, including the Truth and Reconciliation
Commission, the National Inquiry into Missing and Murdered Women and Girls, the Office of
the Auditor General of Canada, the Royal Commission on Aboriginal Peoples, and the U.N.
Declaration on the Rights of Indigenous People. (Lavesque & Thériault, 2020). However, despite
recommendations and solutions, the Canadian government has failed to take appropriate action,
which has resulted in disparities in health care, clean water and proper sanitization, and access to
adequate housing and food. These put First Nations, Métis, and Inuit peoples at heightened risk
of negative health outcome during pandemics.
Health is a well-established human right in Canada and globally, and it has been for
decades (Turpel & White-Hill, 2020, p.173). In 1946, the World Health Organization (WHO)
declared “the enjoyment of the highest attainable standard of health is one of the fundamental
rights of every human being without distinction of race, religion, political belief, economic or
social condition” (WHO, 2020, p.1). According to WHO, health is conceptualized as a “state of
complete physical, social, and mental wellbeing” (p.1) and not just the absence of illness or
disease. Indigenous people in Canada continue to face health inequalities and social inequities,
which violate basic human rights. Moreover, Indigenous ways of knowing and healing methods

37
are not always recognized in our current western healthcare system (Broadhead & Howard,
2021; Duran, 2019; Marsh et al., 2015; Turpel & White-Hill, 2020).
The Truth and Reconciliation Commission of Canada call to action #22 calls upon those
who can effect change within the Canadian healthcare system to recognize the value of
Indigenous healing practices and to integrate them in the treatment of Indigenous patients. In
addition, work collaboratively with Indigenous healers and Elders and allow them to be part of
treatment when it is the wish of a patient (TRCC, 2015). Elders’ engagement in the healthcare
system and treatment of Indigenous patients is of utmost importance as recent research has
revealed that their presence is associated with improved health outcomes (Hadjipavlou et al.,
2018; Neeganagwedgin, 2020). This call-to-action links to our social work Code of Ethics # 11,
which states “A social worker shall advocate change in the best interest of the client and for the
overall benefit of society” (BCCSW Code of Ethics and Standards of Practice, 2016, p.1).
Social workers have a duty to build practice competence in Indigenous wellness and
understand Indigenous conceptualizations of health and wellbeing. As per the BCCSW Code of
Ethics #4, “A social worker shall have and maintain competence in the provision of social work
services to a client” (BCCSW Code of Ethics and Standards of Practice, 2016, p.1). Social
workers can advocate for the integration of Indigenous ways of knowing in the Canadian
healthcare system to ensure Indigenous healing methods are respected and honoured. One of the
ways in which the path forward can address the current health disparities faced by Indigenous
people is to create a more inclusive and culturally relevant healthcare system by adopting a twoeyed seeing approach (Broadhead & Howard, 2021). The term two-eyed seeing was introduced
in the mid-2000s by an Indigenous Mi’kmaw Elder, Albert Marshall, to integrate Indigenous
approaches into our current western healthcare system, as both are of value (Broadhead &

38
Howard, 2021). By adopting a two-eyed seeing approach, we learn to see with one eye the
strengths of Indigenous knowledge and ways of knowing and the other eye with the strengths of
Western knowledge and ways of knowing. (Institute for Integrative Science and Health, n.d.).
According to Eni et al. (2021) one of the ways traditional healing methods can be integrated into
our current healthcare system is to bring back traditional medicines in hospitals for those who
wish to utilize them.
Social workers must be educated on the history of colonization and support transforming
our healthcare system to one that is culturally safe. Trembley (2021) contends that the COVID19 pandemic has made the social vulnerabilities related to systemic racism more visible, which
provides opportunity to address social and cultural health inequalities in health care. Cultural
safety should be central in all future health care initiatives for Indigenous people as it supports
autonomy and self-determination concerning their healthcare needs. However, for cultural safety
to be achieved in our healthcare system, public and government organizations must acknowledge
the impact colonialism and racism have on Indigenous wellness and accept Indigenous people’s
strengths and knowledge. Cultural safety is essentially about “dismantling colonialism and
systemic racism in the health system, promoting equity in health and empowering Indigenous
populations” (Trembley, 2021, p.2). Cultural safety aligns with social work values and ethics as
it promotes equity, social justice, collaboration, and self-determination.
Social workers have a duty to fight for social justice and challenge the structural and
social power imbalances that perpetuate inequality and oppression. One of the ways social
workers can create change is to engage in research alongside Indigenous people. Research is an
important tool in challenging the status quo and facilitating social change through policy
development. It is imperative social workers work collaboratively with Indigenous people and

39
communities to dismantle the systems that created and continue to maintain their oppression.
However, Indigenous voices need to be central to this process as they are the experts of their own
lives. Therefore, Indigenous people need to lead the path in all decolonizing efforts to address
the inequality in our current healthcare system that negatively impacts Indigenous health
outcomes (Eni et al., 2021). Decolonizing health care requires a collaborative approach between
Indigenous and non-Indigenous people to dismantle the colonial systems that dominate and
perpetuate healthcare inequalities. Indigenous people should be given autonomy and control over
their “health, health services, and systems” (Eni et al., 2021, p.2).
Advocacy efforts and policy initiatives also need to address social determinants of health
impacted by ongoing colonialism in order to close the health and socioeconomic gap between
Indigenous and non-Indigenous people in Canada (Blas & Kurup, 2010). During the COVID-19
pandemic, Indigenous leadership, self-determination, and knowledge have been protective
factors, thus it is essential these strengths are acknowledged when developing public health
approaches with Indigenous peoples and communities (Richardson et al., 2020). Indigenous
health policy is one step in addressing the health gap between Indigenous and non-Indigenous
people in Canada. However, this initiative alone will not create health equity without including
policy initiatives that also address social determinants of health (Blas & Kurup, 2010). Future
research and policy initiatives involving the path forward to alleviate these disparities should be
community-driven and controlled (Eni et al., 2021). Moreover, the path forward will require a
paradigm shift whereby Indigenous people are understood and viewed in a way that does not cast
them to the outskirts of our society. Rather than focusing on deficits, Indigenous peoples should
be understood in terms of their many strengths and resiliencies.

40
Conclusion
Due to trauma caused by years of colonial discourse, Indigenous people are
disproportionately affected by adverse health outcomes, such as chronic health conditions,
mental health diagnoses, and substance misuse. Colonialism’s overarching effect on social
determinants of health is rife with policies that contribute to a myriad of negative impacts on
Indigenous people, like displacement from land, cultural disconnection, and genocide. This in
turn, creates poor health and socioeconomic outcomes across generations and compounds
intergenerational trauma. Moreover, inequalities produced by colonialism relating to social
determinants of health include intergenerational poverty, reduced access to culturally safe
healthcare, low levels of education, and inadequate housing. It is because of these socioeconomic
inequalities that Indigenous people in Canada experience adverse physical and mental health
issues at higher rates than non-Indigenous people and put them at increased risk and poor health
outcomes during pandemics like COVID-19 (Jenkins et al., 2021; Levesque & Thériault, 2020;
Mosby, 2021; Power, 2020; Tremblay, 2021).
This paper examined the vulnerabilities and protective factors unique to First Nation,
Métis, and Inuit people within the context of their health and wellbeing during the COVID-19
pandemic. However, due to limited research on Métis people and First Nations living off-reserve,
most of the research included in this review is on status First Nation communities living on
reserve. Some of the risk factors specific to First Nations People and communities identified
throughout the literature include residing in a remote community, lack of clean water and
sanitization, overcrowded and inadequate housing, inequitable access to culturally safe health
care services, avoidance of health care services, and food insecurity. Another issue that arises in
the literature as a risk factor for Indigenous health is vaccine hesitancy.

41
There are direct associations between historical trauma, colonial policies, government
responses to past pandemics, and anti-Indigenous racism in healthcare (Turpill & White-Hill,
2020). Protective factors are vast and include community preparedness, leadership, vaccine
education, access to culturally safe and relevant health care, access to the internet, connection to
land and culture, and addressing systemic barriers were mentioned throughout the literature to
mitigate against the impacts of COVID-19. Research included in this review did not reveal if
access to reliable internet in remote communities has been addressed. However, Telehealth
(Virtual Care) was implemented to reduce barriers to health care services during the pandemic
for First Nations people living in remote locations (FNHA, 2022). Virtual care reduces barriers
to health care access as it provides some services to communities that are both culturally relevant
and safe. It can be taken from this that Indigenous people need to have sovereignty over their
communities and Nations. Indigenous peoples have a right to self-determine and to “continue to
live by Indigenous ways of being and knowing” (Mashford-Pringle, 2021, p.5). Thus, Indigenous
people need to be given control and autonomy to self-govern and make decisions in the best
interest of their communities and Nations.
To alleviate disparities, the federal, provincial, and territorial governments need to
increase funding and work collaboratively with Indigenous communities and Nations to create
Indigenized programming and supports to ensure that health care services are not just accessible
but culturally relevant and safe. Moreover, policy initiatives need to address the inequitable
access to education, healthcare, food and water, and employment opportunities on reserves to
ensure Indigenous people may have a chance at thriving again once more.

42
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