Evidence about art-based interventions for Indigenous people: a scoping review protocol

Introduction

Indigenous people experience a unique set of social, political and economic inequalities that negatively affect their physical health, mental health and wellness.1–4 In Canada, the colonial structures aimed at assimilating them into dominant European cultures continue to impact the lives of Indigenous individuals and communities to this day.5 6 The ancestral land appropriation and the forced displacement, the devastating legacy of the residential schools, the removal of children by child welfare services, the high rates of poverty and the systemic racism in the health and social services detrimentally affect Indigenous health and wellness to this date.7–9 Thus, Indigenous Canadians face disproportionate rates of diabetes type II (eg, 17.2% among First Nations individuals living on-reserve compared with 5% in the general population), cardiovascular diseases (11.5% among Indigenous people compared with 5.5% among non-Indigenous people), mental health issues (eg, 38% of fair/poor mental health among Indigenous people compare to 23% among non-Indigenous, during the pandemic of COVID-19), substance abuse (eg, 35% of abusive alcohol use among Indigenous compare to 23% among non-Indigenous), mortality as well as significantly reduced life expectancy (eg, First Nations live an average of 9.3 years less than the general population).10–16 The effects of colonialism and structural disparities had particularly salient consequences for certain vulnerable groups. For example, compared with the general population, suicide rates among First Nation youth are 5–6 times higher and 11 times among Inuit youth.17–19 Similarly, Indigenous women and girls, a group disproportionately affected by violence, abuse and trauma,20 21 are roughly between 4.5 and 7 times more likely to be the victims of homicide than non-Indigenous women and girls, depending on the year.22 23 The limited availability of culturally appropriate services and interventions with which to address these issues remains a pressing concern for Indigenous people.24 25

A broad body of research points to the benefits of the arts and creativity for different groups of people in situations of vulnerability, not just in terms of enhancing health and wellness,26–28 but also of enriching the social dimensions of life.29 30 Of these studies, a growing number has focused on the healing potential of art-based interventions for Indigenous people in countries with colonial histories such as Canada,31–34 Australia,35–40 New Zealand,41 the USA42–50 and Israel.51 Several see the use of art as a healing tool as consistent with the holistic, relational character of Indigenous worldviews in which art and life are inseparable.33 35 40 43 47 52

There is ample documentation on the application of Western therapeutic approaches—art therapy, narrative therapy, play therapy, social work therapy, counselling and so on—to working with Indigenous people. In these instances, the aims have been to foster community wellness35; promote the expression of identity and connection with cultural and spiritual values42 43; engender a sense of community among transgender and two-spirit Indigenous people in addition to raising awareness of their existence48; foster recovery from historic trauma and the residential schools legacy31; help control recreational tobacco use46; reduce stress for cancer survivors and their families44 and support peaceful end-of-life transitions in hospice care facilities.41 Certain culturally sensitive interventions have combined Western forms of healing, including art therapy, with Indigenous approaches, for example, using American Indian Medicine in conjunction with art therapy to restore wellness52; combining the Medicine Wheel and 12-Step Programme with drumming to treat substance use disorders53 and using art therapy, body mapping and storytelling in conjunction with traditional Indigenous ceremonies to promote empowerment among Indigenous women.32 Some authors suggest that the arts situate the therapeutic process beyond the biomedical and individually focused perspectives, thus fostering relationships of trust, reduced power imbalances, enhanced communication between Indigenous persons and non-Indigenous therapists and culturally safe healing environments.41 54 55

Other studies have explored interventions for Indigenous people that use art as a form of therapeutic outreach that ventures beyond standard Western disciplinary approaches. These include culturally adapting Western visual art forms to Indigenous realities to support recovery among Indigenous people living with mental health37; using break dancing to promote the expression of identity and cultural belonging among Indigenous youth45 and enhancing wellness among marginalised urban Indigenous youth through a process of embodied reflexivity using applied theatre.33 Still, other interventions have explored the healing potential of Indigenous art forms. These include beading in digital spaces34; drumming, dancing and regalia-making to strengthen identity, community connections and resilience49; cultural dancing to improve hypertension control and cardiovascular disease risk50; didgeridoo playing and traditional singing to improve asthma management38; painting and storytelling to enhance recovery after traumatic brain injury36; cultural-specific therapy to lower incidences of suicide and self-harm among incarcerated persons39 and storytelling to release traumatic experiences.47 Several of these interventions were created by artists or cocreated between artists and researchers.36 38 45 49

Despite the growing interest in the healing potential of art-based interventions, few literature reviews—and, to our knowledge, no scoping reviews to date—have focused on the role of art and creativity in fostering Indigenous health and wellness.55 56 To fill this gap, our proposed review will map studies about existing interventions and how they have benefited different dimensions of the lives of people in this group.

Objectives

This review will scope the literature with a view to obtaining a comprehensive list of art-based interventions apt to tangibly benefit Indigenous physical and mental health and wellness. This process constitutes the first step in a research programme involving working with Indigenous artists to codesign a pilot art-based intervention aimed at improving mental health and wellness among members of this group. Working with an Indigenous research partner, who will be hired as a consultant throughout the study period, we will identify culturally appropriate indicators to evaluate such interventions.

The collected information will also expand knowledge among community organisations and health practitioners as to how art-based interventions stand to benefit Indigenous people as well as how to assess their impact, thus facilitating their incorporation into practice.

Protocol design

The review will be conducted based on the Arksey and O’Malley57 methodological framework and the subsequent enhancements proposed by Levac et al.58 The framework recommends six stages: (1) identifying the research question; (2) searching relevant studies; (3) selecting the studies; (4) charting the data; (5) collating, summarising and reporting the results and (6) consulting with key stakeholders to validate findings.

Stage 1: identifying the research question

The research team has defined the following research question: ‘What art-based interventions have been used with Indigenous people to date and what effects do they have?’ To develop this question, we used the Population, Concept and Context criteria recommended by the JBI Manual for Evidence Synthesis.59 We have also maintained an open approach to the question in order to generate breadth of coverage as suggested by Arksey and O’Malley.57 For the purposes of this review, ‘art-based intervention’ is defined as ‘an action or set of actions that involve an art medium or discipline, whose overall goal is to improve the emotional and psychological wellness as well as the physical and/or mental health of a person or group of persons’.60 Since there is no one universal definition of ‘Indigenous person’—a term that can vary widely depending on geographic and sociohistorical context—we have used the United Nations proposal61 as the basis for our definition: ‘Those who have a historical continuity with precolonial societies and who consider themselves as distinct from the dominant sectors in their societies that now prevail on all or part of their ancestral lands.’ Both definitions have helped us clarify our focus to establish an effective search strategy as suggested Levac et al.58 The research question and overall search strategy will be reviewed and validated by a research librarian and coauthor of this protocol (DP), as well as by the Indigenous person with intervention experience who is to be our research partner.

Stage 2: searching relevant studies

To identify the relevant studies, a comprehensive search of the literature will be conducted using the academic databases APA PsycINFO, Embase, MEDLINE(R) ALL, ERIC, International Bibliography of the Social Sciences, National Criminal Justice Database (NCJRS), Social Services Abstracts, Sociological Abstracts, Anthropology Plus, Art Full Text, Atlas Religion Database with AtlaSerial, Bibliography of Indigenous Peoples in North America, CINAHL Complete, Criminal Justice Abstracts, Gender Studies Database, Social Sciences Abstracts, Social Work Abstracts, Web of Sciences Core Collection and Érudit. Various grey literature sources (eg, OpenGrey, the Grey Source Index, ProQuest Dissertation & Theses Global, Literature Report, Google Scholar) will also be searched. Our aim in searching such a wide range of databases is to include studies that cover art-based interventions with diverse Indigenous populations of varying genders, age groups and geographic locations. Any additional articles found through cherry-picking will be listed in the final review.

To conduct the search, a team with appropriate content and methodological expertise comprised of researchers in the social and health sciences, a research librarian and an Indigenous research partner will be assembled.58 This team will define the search terms and strategy. Database and other searches will combine terms from two themes/concepts: namely, ‘arts-based intervention’ and ‘Indigenous people’. The online supplemental file lists the terms that will be used in the search strategies of each database included in the study. Retrieval will be based on words appearing in the title, abstract and full text and in subject headings (MeSH, index terms, etc). No language or date limits will be applied to the search. The search strategies of all databases that will be used in the scoping review were tested on 25 April 2024. All studies thus identified will be imported into the screening and data extraction tool Covidence.

Supplemental material

Stage 3: selecting the studies

Study selection will consist of a two-step screening process conducted by two researchers: (1) a title and abstract review and (2) a full-text review. For the first step, the researchers will separately screen the titles and abstracts of all studies identified as eligible through a set of inclusion and exclusion criteria. These criteria will be tested on sample abstracts before starting the review to ensure their suitability for capturing studies on art-based interventions used with Indigenous populations. The two reviewers will meet at the beginning, midpoint and final stages of the title and abstract review process to discuss challenges related to study selection and refine the search strategy as needed.58 This dual review will also help to reduce bias in applying inclusion and exclusion criteria. All studies deemed relevant will then be put through the second step, which will involve separately reviewing the full-text articles to determine whether they meet the inclusion and exclusion criteria. Should the two researchers fail to concur on a given article, a third researcher will step in to resolve the question.

Studies will be included if they describe one or more art-based interventions that target Indigenous people. To avoid bias during the selection of the studies, we have described in detail the inclusion and exclusion criteria. For this protocol, the following inclusion criteria were identified: (1) studies about interventions based on one or more Western and/or Indigenous art forms (eg, drawing, painting, sculpture, embroidering, music, dance, singing, storytelling, poetry, visual arts); (2) studies that focus on people who self-identified or are identified as Indigenous (eg, Indigenous people, First Peoples, First Nations, Metis, Inuit, Native American People, Alaska Natives; Maori, Pacific Islander, Native Hawaiian, Torres Strait Islander People, Quechua, Aymara, Maya); (3) all types of studies (eg, design, implementation, evaluation, comparison); (4) all types of study design (eg, qualitative, quantitative, randomised control trials, case study, cohort study, quasi-experimental); (5) all sources of evidence (eg, primary research studies, letters, guidelines); (6) studies conducted in all languages; (7) studies conducted in all geographical locations; (8) studies conducted in any time periods and (9) all sources of academic publications and grey literature. In addition, the following exclusion criteria were identified: (1) studies that do not involve interventions based on one or more Western and/or Indigenous art forms; (2) studies that target only non-Indigenous people; (3) studies about interventions that use art as a method of data collection and (4) studies about antiretroviral therapy that are often referred to by the acronym ART.

Stage 4: charting the data

The research team will iteratively develop a data charting instrument to extract characteristics from the selected studies. These characteristics will include (1) publication year; (2) type of publication; (3) country in which the study took place; (4) study design; (5) theoretical approach or key concepts; (6) research sample characteristics; (6) type of art-based intervention; (7) form of implementation and duration; (7) implementation setting and (8) type of evaluation or measurement of the intervention’s outcomes. Input from the librarian and the Indigenous research partner will help ensure the instrument’s efficacy. Two researchers will independently extract data from the first 5–10 included studies and meet to determine if the data charting instrument is consistent with the research question.58 The extracted data will be compared and any discrepancies further discussed to ensure consistency. The data will be compiled in a customise data extraction template of Covidence for coding and validation. Although scoping reviews do not typically include a risk of bias assessment,62 we will also customise the quality assessment tool of Covidence (Cochrane Risk of Bias) to appraise the included studies.

Stage 5: collating, summarising and reporting the results

Descriptive numerical summary analysis and qualitative thematic analysis of the extracted data will be conducted.58 The inclusion criteria will provide a preliminary structure for organising and presenting the results. The conceptual categories (eg, aims, intervention duration, intervention type, study population and sample size, methodology, key findings, gaps in the research) set out in the JBI Manual for Evidence Synthesis, Section 11.3.8.159 will also inform the synthesis. The results will be presented in tables and charts accompanied by narrative summaries explaining how the findings relate to the review’s objectives and the research question. Implications for future research, practice and policy will be discussed. The 20 essential and 2 optional reporting items in thePreferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist62 will be used to enhance reporting in the scoping review manuscript, which will also be proofread by the Indigenous research partner to ensure clarity and accessibility.

Stage 6: consulting with stakeholders

As pointed out by Levac et al,58 this stage creates opportunities for the involvement of stakeholders who can provide insights beyond the relevant literature. Our Indigenous research partner, engaged throughout the scoping review process, will help to identify and involve relevant stakeholders for consultation. We will reach out to Indigenous stakeholders from diverse cultural backgrounds (including artists, organisations and art therapy groups) who can inform the research. Working with them, we will organise with them activities of knowledge translation and exchange activities (eg, the world café method and discussion groups).

Patient and public involvement

As previously mentioned, our Indigenous research partner will be involved in all stages of the scoping review process. He will review the research question and research strategy (stage 1), help define the search terms and strategy (stage 2) as well as the inclusion and exclusion criteria (stage 3), provide input on the data charting instrument (stage 4), proofread the scoping review manuscript (stage 5) and help with bringing relevant stakeholders on board for consultation (stage 6). He has already collaborated with the first author (RM-O) on knowledge dissemination activities. He will be engaged as a consultant and receive an honorarium. Furthermore, he will be a coauthor of the final article and will also be involved in the dissemination of the scoping review results (see the ‘Ethics and dissemination’section). Furthermore, we will consult Indigenous stakeholders with whom some of the authors (RM-O, MAB-W, NI-S and ERA) have previously established collaborative relationships. We will meet with them at key moments of the scoping review process to share and get feedback about the study design and search strategy, selected studies, the charting instruments, study results and knowledge dissemination strategies. These Indigenous stakeholders will be provided with monetary compensation for their time and expertise.

Cultural sensitivity

To ensure cultural sensitivity in the collection, interpretation and dissemination of data, the study will align with the Tri-Council Policy Statement (Chapter 9) for the ethical conduct of research involving Indigenous peoples.63 The involvement of an Indigenous research partner throughout the scoping review process will foster respectful engagement and maintenance of cultural integrity. The knowledge dissemination activities (see the ‘Ethics and dissemination’ section) will promote reciprocity between the researchers and Indigenous stakeholders. Moreover, our interactions with Indigenous people and organisations will be guided by the core principles of respect for individuals, concern for welfare and justice. Note that we consider certain terms that have been included in our search strategies (eg, Indian, Aboriginal, Native, Eskimo) to be inappropriate and potentially sensitive for Indigenous persons; unfortunately, most databases still use these terms to index the existing literature, leaving us with no choice but to include them.

Ethics and dissemination

This study is the first step in a research programme that involves working with Indigenous artists to codesign a pilot art-based intervention aimed at improving the mental health and wellness of Indigenous people. The scoping review will identify the specific components of documented art-based interventions that have benefited the lives of Indigenous people. These results will guide the next phase of the research, which will explore the experiential knowledge of Indigenous artists—considered experts in the healing effects of artistic creation64—to identify elements of their practices suitable for integration into the pilot. Since a scoping review consists of collecting and reviewing data from public sources, this study does not require ethics approval. However, since this scoping review is specific to Indigenous people, we will consider data sovereignty and ethics in our analysis and interpretation of the results. We will also ensure that the study findings return to Indigenous people in a way that benefits them. This will involve setting up knowledge translation activities with Indigenous artists, Indigenous organisations and art therapy groups. Furthermore, our Indigenous research partner will also put us in touch with Indigenous networks with whom we can share the scoping review article and a results summary. Lastly, this study will be published in an open-access journal to secure wider dissemination.

This post was originally published on https://bmjopen.bmj.com