Introduction
Traumatic brain injury (TBI) is a serious consequence of intimate partner violence (IPV) that is often overlooked or misdiagnosed. IPV-related TBI can have debilitating long-term effects on a survivor’s overall function and independence, and may masquerade as a number of other physical, social, and mental health issues that prevent survivors from receiving appropriate intervention by health and community professionals. Research and guidance for professionals working in this community is limited and intersections of cultural identity can further complicate what is already a complex issue. In the case of First Nations, Inuit, and/or Métis women in Canada (referred to collectively hereafter as Indigenous women), the challenges are broad, multidimensional, and, for the most part, left entirely unexplored.
IPV encompasses physical, sexual, and emotional abuse, and other controlling behaviors, inflicted by an intimate partner (World Health Organization [WHO], 2016). The most common injuries are from battery to the face, head, and neck, a pattern of violence that leaves women survivors vulnerable to TBI (Sheridan & Nash, Reference Sheridan and Nash2007). A subset of acquired brain injury, TBI is defined as “an alteration in brain function or other evidence of brain pathology, caused by an external force” such as a blow or injury to the head, severe rotation of the neck, or acceleration/deceleration movement (Menon, Schwab, Wright, & Maas, Reference Menon, Schwab, Wright and Maas2010, p. 1638). Classifications of severity are typically assessed through tests measuring loss of consciousness, post-traumatic amnesia, and post-incident deficits. TBI is a leading cause of disability worldwide and is more prevalent than breast cancer, spinal cord injury, HIV/AIDS, and multiple sclerosis combined (Haag et al., Reference Haag, Caringal, Sokoloff, Kontos, Yoshida and Colantonio2016). While brain injury caused by lack of oxygen through strangulation is technically classified as anoxic or hypoxic injury, resultant challenges closely resemble TBI and both conditions are treated in the same manner (Cullen & Weisz, Reference Cullen and Weisz2011). As such, we, along with others, have chosen to include IPV-related strangulation injuries with TBI (Campbell et al., Reference Campbell, Anderson, McFadgion, Gill, Zink, Patch and Campbell2018; Kwako et al., Reference Kwako, Glass, Campbell, Melvin, Barr and Gill2011; St. Ivany & Schminkey, Reference St. Ivany and Schminkey2016; Valera et al., Reference Valera, Cao, Pasternak, Shenton, Kubicki, Makris and Adra2018).
Exposure to TBI through IPV tends to be long-term in nature; women are typically hit multiple times before calling police, repeatedly attempt to leave the abuser before permanently leaving, and are at the highest risk of being murdered at the point of separation or on reporting (Banks, Reference Banks2007; Car, Reference Car2000). Repeated trauma to the head can cause brain tissue degeneration, resulting in symptoms such as fatigue, depression and mood changes, memory loss, confusion, aggression, impaired judgment, difficulty with everyday tasks, and can lead to dementia and other chronic health conditions (Langlois, Rutland-Brown, & Wald, Reference Langlois, Rutland-Brown and Wald2006). Women who are exposed to IPV are twice as likely to experience depression and nearly twice as likely to have challenges with substance use (WHO, 2017). These circumstances are exacerbated for Indigenous women living in remote areas where safe spaces and transportation options are severely restricted, further preventing them from leaving an abuser. While TBI among professional athletes and military personnel has captured significant public attention (St. Ivany & Schminkey, Reference St. Ivany and Schminkey2016), TBI as a result of domestic violence or IPV remains less known and understudied, despite preliminary indications suggesting prevalence rates between 35% and 74% (Goldin, Haag, & Trott, Reference Goldin, Haag and Trott2016; Kwako et al., Reference Kwako, Glass, Campbell, Melvin, Barr and Gill2011).
The WHO estimates that one in three women throughout the world will experience IPV in their lifetime (WHO, 2017). In the Canadian context, rates of self-reported spousal violence ranged from 4% to 8% across provinces, and it is a significant cause of physical injury to Canadian women aged 15–44 (Statistics Canada, 2016). The reported numbers of Indigenous women victimized by violence in Canada are two to three times higher than non-Indigenous women (Brennan, Reference Brennan2011; Brownridge et al., Reference Brownridge, Taillieu, Afifi, Chan, Emery, Lavoie and Elgar2017). Fifty-nine percent of Canadian Indigenous women report injury as a result of IPV versus an estimated 42% rate reported by non-Indigenous women survivors (Statistics Canada, 2016). Further, more Indigenous women report that the violence included being beaten or strangled than their non-Indigenous counterparts (Brennan, Reference Brennan2011). Researchers from Université Laval and Saturviit Inuit Women of Nunavik found that 74% of the 108 Inuit women surveyed in seven Nunavik (Northern Quebec) communities had experienced violence in the home (Saturviit Inuit Women’s Association of Nunavik and Université and Laval, 2015).
Studies conducted in Ontario, Canada, have identified that the structure of rehabilitation and discharge processes for Indigenous clients with acquired brain injury living in reserves or in remote communities are of great concern. Accessibility of services has been identified as a challenge and at the same time, the communities were identified as an important source of social support. Consultations with First Nations elders and traditional healers identified the importance of spirituality, conflicting notions of fixing illness or injury versus living with wellness, working collaboratively in addressing brain injury, and the need for financial support for traditional healing as important in providing culturally safe and responsive services. These studies, however, did not explicitly address brain injury in the IPV context (Keightley et al., Reference Keightley, King, Jang, White, Colantonio, Minore and Longboat-White2011a, Reference Keightley, Kendall, Jang, Parker, Agnihotri, Colantonio and Bellavance2011b). Given the challenges of supporting TBI among Indigenous populations in Canada, the elevated rates of violence and injury experienced by women exposed to IPV and the increased level of physical assault among Indigenous women in Canada, it is important to understand the unique context and service needs of these diverse, and distinct, groups of women.
It is difficult to estimate the impact of this issue and provide appropriate care for survivors without adequate means to measure and understand the correlation of TBI and IPV, particularly within the context of Indigenous populations. Whereas there are distinct bodies of literature examining IPV and TBI, respectively, relatively few studies directly address the correlation between them, and even fewer consider the issue as it relates to Indigenous women. During a recent scoping review conducted by the authors (Haag, Jones, Joseph, & Colantonio, in press), 42 articles considering the intersection of IPV and TBI were identified. Of those, only three articles focused on Indigenous populations, all of which reported on women in the USA. However, while all three articles (Linton, Reference Linton2015; Linton & Kim, Reference Linton and Kim2014; Linton & Perrin, Reference Linton and Perrin2017) explore TBI as a result of violence in Native Americans, other forms of interpersonal violence as well as those caused by an intimate partner are included in the sample, making it difficult to get a clear picture of the unique challenges of IPV-related TBI. In an effort to begin to address this gap in knowledge and understanding, we conducted preliminary consultations with key stakeholders representing First Nations and Inuit populations in Canada, seeking to identify barriers and facilitating factors for TBI-sensitive service provision for Indigenous women exposed to IPV. The remainder of this paper will present the findings of those consultations and highlight implications for practice and recommendations for future research.
Method
As part of a larger national stakeholder consultation process to develop a TBI educational toolkit for IPV service providers, input from Indigenous stakeholders was specifically sought to allow for insights into unique challenges and strengths related to this population. As this subgroup of participants was not the main focus of the project, and it is smaller in number; however, the experiences and contributions were unique and warranted separate consideration here, particularly in light of the overall dearth of information noted above. Interviews with three IPV service providers and a focus group of eight participants supporting First Nations women were conducted, along with a focus group with seven women supporting and advocating for Inuit women in Canada. It should be noted that many of these participants were themselves Indigenous and community leaders, and the interview and focus group sessions were designed to enable participants to provide reflection and observations on the experiences of the women and families with whom they engage as well as their own first-hand knowledge.
The IPV service providers who participated in this consultation offer front-line support, including counseling and shelter services to Indigenous women in urban centers as well as rural communities. Some of those advocating for Inuit women were leaders from communities across Nunavut, including remote communities with little access to direct service. These advocates worked in both policy development and provided formal and informal front-line counseling and crisis support services. Critically important to note is that many of the advocates were also IPV survivors and brought lived experience to the consultation process.
Members of the research team conducted all interviews and focus groups, and signed written informed consent was obtained from all participants. Interviews and focus groups were semi-structured and lasted approximately 1 h each. Participants were asked to suggest important topics, key messages, and useful formats for an educational TBI toolkit for use by service providers in an IPV support context and to specifically consider the question of TBI screening in women exposed to IPV and potential risks and benefits to this practice. Audio recordings were taken in each setting and transcribed verbatim for thematic analysis by two members of the research team. Both are white women engaged in helping professions and come from a strengths-based perspective. One researcher generally uses qualitative research techniques while the second is more experienced in quantitative methods. Both members independently coded the transcripts and organized the codes into preliminary themes. Final themes presented here were reached by consensus through discussion and comparison of their interpretations along with consultation with other team members who were present for interviews and focus groups. It must be noted that none of the research team are Indigenous, and thus the interpretation of results was not generated from within an Indigenous worldview. A thematic analysis approach was taken as it has been established as a method for “identifying, analysing and reporting patterns (themes) within data” (Braun & Clarke, Reference Braun and Clarke2006, p. 79). It allows for a flexible approach to the analytic process in order to provide a broad understanding of an under-examined area, remaining close to the data without being confined by a single theoretical position (Braun & Clarke, Reference Braun and Clarke2006).
Research ethics approval for the larger project and this consultation was granted by the University of Toronto and Wilfrid Laurier University.
Distinctions between Indigenous groups in Canada
Work involving Indigenous populations in Canada must make the distinction between the three groups of Indigenous people, a critical point for readers of this work. First Nations, Inuit, and Métis people are culturally distinct groups, and are recognized as such by the Government of Canada. Each of these groups speaks different languages and holds different worldviews, traditions, stories, community, and governance structures, among a myriad other distinguishing facets. The Inuit people of Canada reside primarily in the Arctic and speak Inuktitut, while the more than 50 Nations of the First Nations reside across the provinces in 630 communities (Crown-Indigenous Relations and Northern Affairs Canada, 2017). Member of the Métis Nation are descended from Indigenous women and European fur traders are Michif speakers and governed by the Métis National Council (The Métis Nation, n.d.).
Findings
As this consultation was part of the larger study seeking input on content and format for a TBI educational toolkit for use in IPV support organizations, much of the discussion was focused on addressing gaps in existing TBI knowledge and ways to successfully engage in knowledge transfer within an Indigenous context. While many of the main themes from the interviews with workers providing services to women identifying as being Indigenous were similar to those providing services to settler populations, there are striking differences to be recognized. The following section of the paper will discuss those differences in general terms, along with supporting tables containing overarching themes, sub-theme concepts, and supporting comments for more detailed information. It is important to be aware that while there are similarities between the First Nations and Inuit contexts and challenges, there are also significant differences that were highlighted by the participants, not the least of which is the need for clear distinction between these populations in Canada. As such, the findings presented here note when themes are shared and when they differ. Additionally, a detailed table has been included here (see Table 1) describing themes relevant to First Nations and Inuit women and including participant comments exemplifying these themes.
Emergent themes and supporting comments from First Nations and Inuit participants
Worldview
One of the most important emergent themes to be considered is the existence, and influence, of a holistic worldview, one in which community and family are situated as key sources of support and well-being for its members. The valuing of lived experience and the voice of elders are very important. Traditional approaches to learning and teaching and health and healing reflect the underlying belief that all living beings are interconnected. This worldview is evident in the ways in which health is framed, what is identified as important learning, and how best to address these issues, with healing, not only just for the individual, but also for the family and the community being seen as the most important goal. This worldview was apparent in both the First Nations and Inuit participants’ stories and is clearly a foundational context in which all of the findings must be situated, in order to begin to understand the experiences being shared by the speakers.
Broad scale education
Another area of concern for both First Nations and Inuit participants was that of the critical need for education, including educational campaigns directed at a range of stakeholders using printed materials like flyers and brochures. Educating within the community was seen as particularly important to all of the participants, as the community is seen not only as a critical source of strength and healing, but is also directly wounded by the violence and its outcomes. Inuit participants highlighted the importance of educating their youth about the TBI–IPV intersection. On a broad scale, participants emphasized that educational interventions should target service providers in front-line positions, health care professionals in both acute and chronic capacities, and first responders including Royal Canadian Mounted Police (RCMP) officers.
Communicating and educating the key players that are seeing these women in the communities, at a community level, like the RCMPs, like the nurses that are coming in from the South and not knowing that this is maybe some of the issues that are going on. (Inuit participant).
Participants shared that education must extend to community members at large, particularly those in a supportive capacity, such as elders or spiritual leaders. The need for both TBI and IPV education was seen as a top priority to address issues such as misdiagnosis, inappropriate supports, and gaps in key services. One First Nations participant framed education as an opportunity to “demystify” TBI in the community, and thus draw on the community’s ability to strengthen its capacity through collective learning. Another First Nations participant further clarified that the nature of the education must be strengths-based to be effective:
I think the most important piece for me is the accommodations and adaptations and for me I’m always solution-based and strength-based and I always want to look at how do we move forward from here? So it’s good to understand the context and the reality of what we’re dealing with, but also having some clear, concrete tools on moving forward I think is really quite important.
Lack of infrastructure
Complicating all of these already complex difficulties, infrastructure-based challenges were highlighted by all participants. Geographic distances, coupled with technological limitations, create barriers to service provision that are overwhelming. Hamlets in Nunavut often do not have driving routes to the nearest cities, which are frequently upwards of 150 miles to well over 800 miles away. Air travel is expensive with only a single flight per day; thus an entirely unfeasible option. Over 70% of Inuit communities have no shelter or safe houses for women. The testimony of two Inuit participants illustrates this impact in terms of logistics and the emotional toll:
In some cases, I was going to say, the first responders in some cases where are no shelters are your friends or your family, you run away to your friends or your family or even neighbours sometimes if it’s really, really bad.
It scares me too, when the woman comes to my place in the middle of the night and when the policeman are … in the town and my apartment. And vulnerable … it scares me and I’m willing to help but scary and they can damage my vehicles.
Overcrowding and insufficient housing is a significant problem in both Inuit and First Nations communities, sparking incidents of violence and reducing safe refuge options at the same time. In many communities, basic needs are a higher priority, as people struggle to obtain housing, safety, sufficient food, and clean water. In the words of one Inuit participant, “We’ve been asking for shelters forever. Instead of building shelters, saving people now we have a liquor store, you know. Priorities are wrong.” And, in the First Nations context, “some of our community are not getting their top three needs …they don’t have a safe place to sleep. They do not have adequate nutrition. They haven’t had a glass of water in I don’t know how long.”
Technological limitations in these areas are significant, resulting in a lack of communication options, as cell and land lines are not always present, leaving CB radio as the main method of summoning outside help. The following comment from an Inuit participant illustrates this reality:
I’m a volunteer helper so the whole, pretty much the whole community looks up to me and gives me a call anytime or goes on the CB, I keep the CB radio on throughout the night. It’s a good thing cause somebody would have died if I had shut the CB radio down when I went to sleep.
Large distances between communities often result in emergency calls being routed to the nearest RCMP detachment, potentially hundreds of miles away and then rerouted to a local officer. All of these steps in communication take considerable time in a situation, which can escalate and become life threatening very quickly, and as one Inuit participant shared, “every minute counts, and so people just hang up because, you know, it’s too much.”
Stigma and cultural incompetence
Systemic challenges were a common theme in both groups although there were distinct differences in how they are experienced, as outlined in the table. These challenges were associated with the ways Indigenous people are viewed by the dominant culture and arise from general societal failure to adequately prepare those working within the system to understand and communicate with Indigenous people. Generally, encounters with shame and stigma were key, because, as noted by a participant, “there’s always a spectrum of shame. There’s always a spectrum of guilt. Anger. Denial. There’s grief involved in surviving sexual violence.”
This is particularly true in regards to the issue of misdiagnosis. Discussion focused on the difficulties faced when assumptions of alcohol abuse, drug use, and/or mental health challenges were perceived as the ‘problem’, instead of violence and possible TBI, leading to inappropriate intervention and support. One participant reflected, “the RCMP have no clue that maybe she was battered and put her in the drunk tank.”
Cultural competency was identified as a significant issue by both groups, although with some differences as outlined below, with language and literacy being of concern. The lack of native speakers in first responder positions and competent translators in health care and throughout post-violence support structures was seen as a critical problem. One participant noted, “you can’t really communicate with the health personnel or the RCMP because [for an] Inuktitut speaking person, that’s it. And there’s no readily available interpreter around.” Increased funding to address these challenges was discussed by participants from both groups, who identified the need for financial support for education, diagnosis, adequate and culturally sensitive treatment, and the development of sustainable community-based supports.
Silencing through systemic violence
Interestingly, each group also communicated one overarching theme that was entirely separate from the other. For the Inuit women, the theme of silencing was discussed at length, a theme that was recognized as significantly bolstering family-based violence within their communities. Many women do not report family violence as being a part of their daily life, as they see no point in asking for assistance where there is none to be had. The standard response of physically removing women from the community to address issues of safety and medical care, required because of service gaps in remote communities, is often seen as more traumatic, as families and communities are torn apart, a practice that is in direct conflict with the worldview described above. This knowledge that current conditions may well result in a significant impact on her children, spouse, and extended family, along with the community, as the family is fractured by her removal for safety and medical care, tends to silence women, and leave them exposed to continued violence.
Service provision models
First Nations participants expressed concern over current service provision models within their communities and the prevalence of settler practices that do not take traditional approaches into account. Discussion focused on issues of trust, resulting from historic systemic patterns of violence and abuse. Traditional healing practices need to be valued and supported within the settler medical model and community involvement needs to be fostered. Elders and traditional healers need to be included in all aspects of health and healing within their communities. As one participant shared:
I think coming from an Indigenous perspective when we talk about our healing, our culture comes first. So I think if there were a toolkit, I think implementing healing practices in a traditional sense. Bringing in elders for these women who need this healing is important so they know they’re supported.
Importantly, survivors need to be recognized as the owners of information about their bodies and responsible for their own health and well-being. As one participant stressed to the research team:
So when I hear that you know something and you’re not telling somebody, you’re not holding people able to be responsible for their own life. I find that highly offensive. The information really belongs to her and I think absolutely that she should know. Absolutely that she should have that information.
Discussion
As stated in the opening of this paper, there is limited literature that looks at the intersection of IPV and TBI, regardless of ethnic and cultural position, and only a very few look within an Indigenous context. This lack of information presents a host of challenges including the difficulty of situating the findings of this consultation within existing knowledge. Findings, however, reflect a congruence with the existing literature on Indigenous people’s engagement with a range of colonial structures – and the resultant experiences of structural and cultural violence – which is a direct affront to community health, safety, and integrity (Akter, Davies, Rich & Inder, Reference Akter, Davies, Rich and Inder2019; Kronfli et al., Reference Kronfli, Lacombe-Duncan, Wang, de Pokomandy, Kaida, Logie and Loutfy2017; Patrick, Reference Patrick2016). It is this larger picture of colonial violence in which IPV, TBI, and their intersection are situated, which shapes Indigenous women’s experiences of the injury and its aftermath.
Despite the dearth of literature exploring the intersection of TBI and IPV, some comparisons can be made with the few studies to explore either TBI or IPV within an Indigenous context in Canada, where themes such as challenges to post-injury care, issues of cultural competency, and need for education and screening were also present. Studies examining post-injury transition back to community living report that TBI survivors from Canadian First Nations have a more difficult time than those from settler populations (Keightley et al, Reference Keightley, Ratnayake, Minore, Katt, Cameron, White and Colantonio2009; Keightley et al., Reference Keightley, King, Jang, White, Colantonio, Minore and Longboat-White2011a). Many of the emergent themes discussed here reflect challenges with existing services, such that women are also likely to experience lower success rates with community reintegration post-injury. Exacerbating these challenges is the identified lack of sustainable funding to address these deficits in service delivery and safe housing for survivors, a finding also reported by Keightley and colleagues in both of their 2011 studies. The combined effect of this may well be an even larger health care crisis, as the inability of women to protect themselves from ongoing exposure to violence will not only increase the likelihood of sustaining a TBI, but may well result in more severe and lasting damage.
Remote geographical location poses an additional barrier particularly to northern communities, due to extreme distances. This health care context must be appreciated as entirely unique to this population. The Office of the Auditor General’s 2017 report on health care services in Nunavut speaks to these challenges of remote distances. While any health or emergency service access is complicated by a rural context, regardless of Indigeneity, those in Nunavut and across the North cannot be reached by road, and are subject to Arctic weather conditions preventing travel. Communities are isolated, dispersed, and air transportation is often the only method for delivering service (Office of the Auditor General of Canada, 2017). No settler communities in Canada are subject to these extreme conditions.
Challenges stemming from reduced or non-existent cultural competency were discussed at length in this study, reflecting conversations found in the broader body of literature exploring Indigenous health (Akter et al., Reference Akter, Davies, Rich and Inder2019; Kronfli et al., Reference Kronfli, Lacombe-Duncan, Wang, de Pokomandy, Kaida, Logie and Loutfy2017; Patrick, Reference Patrick2016). Both Inuit and First Nations participants expressed concerns regarding language, literacy, and an absence of recognition for the unique qualities and varied implications of the Indigenous worldview. Challenges experienced with language and literacy have also been raised by authors who note significant barriers to service provision and uptake can be directly linked to a dearth of first language speakers and translators among service providers (Keightley et al, Reference Keightley, Ratnayake, Minore, Katt, Cameron, White and Colantonio2009; Keightley et al, Reference Keightley, Kendall, Jang, Parker, Agnihotri, Colantonio and Bellavance2011b; Niemeier & Carlos Arango-Lasprilla, Reference Niemeier and Carlos Arango-Lasprilla2007). Others report similar themes arising in studies exploring the lived experiences of Indigenous survivors of IPV or TBI, noting a need for increased community involvement with service delivery (Brownridge et al., Reference Brownridge, Taillieu, Afifi, Chan, Emery, Lavoie and Elgar2017; Keightley et al, Reference Keightley, King, Jang, White, Colantonio, Minore and Longboat-White2011a, Reference Keightley, Kendall, Jang, Parker, Agnihotri, Colantonio and Bellavance2011b) and the lack of settler acceptance of traditional healing models (Keightley et al., Reference Keightley, Ratnayake, Minore, Katt, Cameron, White and Colantonio2009, Reference Keightley, King, Jang, White, Colantonio, Minore and Longboat-White2011a, Reference Keightley, Kendall, Jang, Parker, Agnihotri, Colantonio and Bellavance2011b; Puchala, Paul, Kennedy, & Mehl-Madrona, Reference Puchala, Paul, Kennedy and Mehl-Madrona2010). In the clinical case described by Puchala and colleagues, traditional methods of healing delivered by community elders to women experiencing IPV were shown to result in a significant and positive impact on harm reduction (Reference Puchala, Paul, Kennedy and Mehl-Madrona2010). This would lend support to the position proposed here that traditional healing methods may be useful for this population and should be encouraged and supported going forward.
While some of the challenges facing Indigenous women exposed to IPV and TBI are similar to those of settler women, the increased rates of violent encounters and the higher likelihood of episodes including elevated levels of violence resulting in injury, coupled with some of the unique experiences of these women, require individual consideration and a targeted approach to support design and implementation. Other authors have identified the need for further research considering the unique requirements of Indigenous women exposed to IPV (Brownridge et al., Reference Brownridge, Taillieu, Afifi, Chan, Emery, Lavoie and Elgar2017; Keightley et al., Reference Keightley, King, Jang, White, Colantonio, Minore and Longboat-White2011a, Reference Keightley, Kendall, Jang, Parker, Agnihotri, Colantonio and Bellavance2011b; Puchala et al, Reference Puchala, Paul, Kennedy and Mehl-Madrona2010) and the prevalence and impact of resultant TBI (Linton, Reference Linton2015; Linton & Kim, Reference Linton and Kim2014; Linton & Perrin, Reference Linton and Perrin2017), a call that is also supported here. Further research focused on developing educational materials targeting service providers, survivors and their families, and communities at large is critically needed. More investigation exploring the lived experiences of women exposed to IPV is needed to develop TBI-sensitive services to address this unique group of survivors. Studies focused on other areas of Indigenous health have highlighted this knowledge gap (Akter et al., Reference Akter, Davies, Rich and Inder2019; Kronfli et al., Reference Kronfli, Lacombe-Duncan, Wang, de Pokomandy, Kaida, Logie and Loutfy2017), suggesting the issues are not unique to the IPV/TBI context, but reflect a larger, systemic concern. Engaging in further consultation in order to gain a better understanding of the Indigenous worldview and the ways in which existing traditional methods of healing can be fostered and supported within the community will have significant implications for policy and health care delivery, and can make strong advances in the reduction of shame and stigma, as all Canadians move forward in the process of reconciliation.
The overarching theme found in this study acknowledging the critical need for a broad education campaign increasing awareness and understanding in service providers, survivors, families, and communities supports findings not only in previous studies of a similar nature (Keightley et al., Reference Keightley, King, Jang, White, Colantonio, Minore and Longboat-White2011a, Reference Keightley, Kendall, Jang, Parker, Agnihotri, Colantonio and Bellavance2011b; Linton & Kim, Reference Linton and Kim2014), but also in the broader Indigenous health literature (Akter et al., Reference Akter, Davies, Rich and Inder2019). In particular, issues of timely and effective screening, the absence of a culturally competent diagnostic tool, and the persistent lack of knowledge are raised as being of ongoing concern in a study looking at IPV-related TBI in Native Americans (Linton, Reference Linton2015). The challenges in service provision and the increased risk to women’s health as a result of the scarcity of a validated TBI screening tool sensitive for use in an IPV context have been discussed by other authors, along with a call to address this gap with further research (Goldin, Haag & Trott, Reference Goldin, Haag and Trott2016).
Limitations
Despite this project being the first in Canada to explore the experiences of Indigenous women survivors of IPV and TBI, the small number of stakeholders consulted prevents the findings from being representative of all Indigenous women in Canada. It is also possible that the experiences of urban-based Indigenous women would vary greatly from those based on more remote areas and this was not reflected in the consultation. These limitations do provide clear direction for future research exploring the experiences of Indigenous women exposed to IPV and TBI, identifying barriers and facilitating factors in service provision, and developing and evaluating social and health care policy relevant to this population. Further, while many of the Indigenous women consulted were also women survivors, there is a pressing need to conduct explicit consultation with First Nations and Inuit women with lived experience to develop a robust understanding of their needs.
Conclusion
IPV resultant TBI is a serious health concern that has gone unidentified and unsupported for far too long, particularly within Indigenous populations in Canada. The lack of enquiry into the experiences of First Nations and Inuit women in Canada exposed to IPV and TBI seriously impairs the creation of effective health care policies and support services for women survivors. The multiple intersections of marginalization, shame, stigma, and colonization, coupled with significant barriers to service provision in remote communities faced by these women are such that solutions generated for urban-based settler populations are unable to address the unique challenges experienced. A widespread, multi-layered educational campaign is urgently needed to bring much needed awareness to the seriousness, prevalence, and implications of TBI among women survivors of IPV, including key arenas such as direct service providers, survivors, families, communities, health care professionals, legal professionals, child protection agencies, and Indigenous and settler government bodies. Further research is needed, done in partnership with First Nations, Inuit, and Métis communities, and focused on identifying barriers to service uptake as well as on developing creative, culturally sensitive, and community-based interventions. Such research should also focus on expanding our understanding of the lived experiences of Canadian Indigenous women exposed to IPV and TBI. Finally, specific health care needs and solutions are critically necessary in order to begin to address this gap.
Author ORCIDs
Haag Halina (Lin), 0000-0003-3256-6992
Acknowledgements
The authors would like to thank the DisAbled Women’s Network Canada and the Cridge Centre for the Family for their advice and support to the team as we embarked on this new area of investigation.
Financial support
This work was supported by the Department of Justice Canada (A.C. file number 8858055); the Canadian Institutes of Health Research Chair in Gender, Work and Health (A.C. grant number CGW-126580); and The Ontario Ministry of Health and Long-Term Care (H.H. Ontario Women’s Health Scholar Award).
Conflict of interest
Halina (Lin) Haag has no conflicts of interest to disclose. Melissa Biscardi has no conflicts of interest to disclose. Pauktuutit Inuit Women of Canada has no conflicts of interest to disclose. Noel (Natalia) Smith has no conflicts of interest to disclose. Nneka MacGregor has no conflicts of interest to disclose. Angela Colantonio has no conflicts of interest to disclose.
Ethical standards
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.
