Wîcohkamakew – A qualitative description of parents, perinatal clinic staff, and mentor Elders experiences of a Nêhiyawi (Cree) community-derived Elders Mentoring Program: Findings from the ENRICH study

Background: Responding to concerns over perinatal health risks and adverse outcomes, a community-based participatory research (CBPR) partnership was established in collaboration with a large Nêhiyawi (Cree) community in Alberta and university-based researchers. An Elders Mentoring Program was designed and implemented to provide additional support for pregnant women and their partners. Our objective was to understand the collective experiences of those involved in the Program. Methods: We conducted a qualitative description with the principles of CBPR as an over-arching framework. A total of 14 qualitative interviews were conducted with parents utilizing the Program, perinatal clinic staff helping to facilitate the Program, and mentor Elders that engage with parents as part of the Program. Community Advisory Committee meeting notes were also used as data. All qualitative data was analyzed using content analysis. Results: The Program helps pregnant women and their partners by fostering enhanced support networks as well as improved cultural security within the clinical environment and learning among healthcare staff. A sense of intergenerational fulfillment and enjoyment among those involved in the Program was common, and was underpinned by genuine, collaborative relationships Conclusions: Successful implementation of a community-derived prenatal Elders Mentoring Program is possible with significant community collaboration.

the research project. Staff from a neighboring Primary Care Network (PCN) and local health/social services departments, as well as other community members and Elders, were also invited to inform some of the CAC meetings as needed.
The idea of an Elders Mentoring Program was conceived within the initial CAC meetings. It was known from administrative data provided by the Alberta Perinatal Health Program that high risk pregnancies and adverse pregnancy outcomes occurred with significantly more frequency in the community than provincial averages (unpublished). In addition, the CAC expressed serious concerns over the health of pregnant women within the community.
"We need to act now… the community is starving for this" (Elder) was the sentiment from our very first meeting. The CAC agreed there was no time to waste and that a communityderived and strength-based solution was needed immediately, with the goal of support expecting parents.
To this end, a Program was conceptualized where Elders can interact with pregnant women and their partners in the clinical setting to provide support, and ultimately to "protect every grandchild" (Elder). Each year there are roughly 300-350 births within Maskwacîs, and the majority of pregnant women from the community receive prenatal services off-reserve from the PCN in a neighbouring community where the care team is made up of primarily non-Indigenous care providers. Collaboration with the PCN was initiated and the Elders Mentoring Program was born as a potentially effective and pragmatic means to reach parents that builds on the strengths within the community.
After piloting this approach for approximately three months, the Program was expanded and re-launched. Initially, several 'meet and greet' lunches were held for clinic staff and Elder mentors to discuss the Program functioning and develop relationships. The Program was advertised within the PCN and also within the community. In March 2016, Elders began attending the PCN for half day sessions on approximately one out of two specific prenatal clinic days each week. In April 2017, with the Program was further refined such that Elders began attending each prenatal clinic day for half day sessions; approximately 30% of pregnant women from the community were exposed to the program each month at the PCN.
Elders engage with parents within the waiting area by striking up conversations, offering their support, handing out program flyers, providing healthy snacks and beverages, conducting cultural activities and displays, speaking about their experiences and traditional ways of pregnancy and childbirth, and initiating draws for free traditional moss bag infant carriers and gift cards to local stores. Those seeking additional Elder support have the option of speaking privately in a separate room. Elders voluntarily offered their support 24 hours per day and are primarily accessible by telephone.

Methods
We used qualitative description to understand the experiences of those involved in the Elders Mentoring Program. The CAC determined it was essential that the direct and unadulterated voices of those included in the Program were portrayed, and qualitative description fit well. Qualitative description is frequently used when a preliminary descriptive summary of a phenomenon is needed [14], and stays close to the words of participants to generate rich and straight descriptions with 'low-interference' data interpretation [15]. The CAC also felt a descriptive summary of the experiences of those involved in the Program could encourage future research in this area that is more theorybased.

Data generation
Two key sources of data where drawn upon, including CAC meeting notes and interviews with those connected to the Program. The data were generated beginning with our first CAC meeting in June 2014 and ending with the last qualitative interview in October 2017.
Since the beginning of our CAC, detailed meeting notes were taken and were used as data.
After the expanded program was operational for over a year, qualitative interviews were carried out between March and October 2017. Participants for this qualitative study were recruited using purposeful sampling to capture the perspectives of parents utilizing the Program, perinatal clinic staff helping to facilitate the Program, and mentor Elders that engage with parents as part of the Program. RTO carried out one-on-one semi-structured interviews with participants. The interviews were conducted in English, lasted up to 60 minutes, and were audio-recorded and transcribed verbatim. Participants were prompted to discuss their experience in being involved with the Program. All of the interviews were conversational and participants were encouraged to discuss any other information they felt was relevant.

Data analysis
Data analysis took place concurrently with data generation. RTO analyzed all the data using qualitative content analysis [16] and Atlas.ti qualitative computer software.
Transcripts were read and re-read separately, and persistent concepts and core patterns were highlighted and categorized. The categories were similarly read and re-read, and were then carefully described in draft findings. The categories were also considered together to identify any common threads. To help refine the categories and reduce redundancy, initial findings were discussed with the CAC and members of the research team. Data collection and analysis ended when no additional insight emerged, and when the categories were well defined by the CAC.

Ethics
During the CBPR process, and design and implementation of the program, ethical issues were addressed at several levels. Ethical approval from the University of Alberta Research Ethics Board was acquired which adheres to the Tri-Council Policy Statement -2 Research Involving the First Nations, Inuit and Métis Peoples of Canada [17]. Prior to the development of the research protocol, community approval from key stakeholders and Elders was obtained. The CAC was involved at all stages of the project, providing ethical counsel and ensuring the research moved forward in a culturally and community appropriate way. A research agreement between members of the CAC was developed and signed that outlined the purpose, overall approach, roles and responsibilities, research methods, ethical issues, dissemination strategies, and data ownership. For qualitative data generation, an information letter detailing the project was reviewed with potential participants, and written informed consent was provided prior to data collection.

Rigor
Strength and rigor were maintained by adhering to the approaches of authenticity, credibility, criticality and integrity of data collected [18,19]. Authenticity meant taking careful consideration of the voices of participants, and was reached by purposeful sampling, participant-driven data generation and precise transcription. Credibility meant depicting a truly insider point of view, and was reached by researcher reflection on the believability of the findings and CAC review. Criticality meant being questioning of our work, and was reached by reflection on the critical appraisal of decisions made during the research process and the inclusion of CAC throughout. Integrity meant honesty and integrity in our work, and was reach by peer review and reflection on researcher bias.
Rigor was further enhanced by relying upon the CBPR process and frequently seeking advice from the CAC. Finally, RTO kept a reflective personal journal throughout the research process, paying particular reflexivity to the role of being a non-Indigenous father and researcher interpreting the voices of Indigenous parents, healthcare staff, and Indigenous Elders. Reflexivity helped ensure the principles of CBPR were relied upon throughout and that the authentic voice of the participants was presented.

Results
Notes from 23 CAC meetings were included in the analysis. Six parents (five mothers and one father), four clinic staff, and four Elders took part in interviews, for a total of 14 interviews. The average age of parents was 22 years (range 17 -34), of clinic staff was 39 years (range 30 -49), and of Elders was 66 years (range 57 -79). The average number of children per parent participant was three (range 1 -8). Vivid personal reflections related to their recent experiences with the Program were shared by all of the participants.
Although their stories were distinct, there were many similarities related to their experiences with the Program which are detailed in the following categories: Enhanced Support Networks, Improved Cultural Security and Learning, and Intergenerational Fulfillment and Enjoyment.

Enhanced Support Networks
Elders felt that with every pregnancy and every newborn child there is hope, and that the Program helps to foster that hope. It was recognized that all pregnant women and their partners need support, whether they are Indigenous or non-Indigenous, and that generally "the more support the better." (Clinic staff member) Some parents described having very little help and reassurance during their pregnancy, and welcomed the opportunity to get support from an Elder, through the Program. The Program was uniformly acknowledged by all participants as an opportunity for parents to receive enhanced support through their pregnancy for those that need it, first time, teenage, and younger parents especially. For instance, one first time parent expressed, "I know that maybe this Program wouldn't benefit other people, but it did for sure benefit me. I will say that." Those that tended to not engage the Program as much for in-depth support cited already having strong support systems and good access to Elders in their family and/or community.
The provision of support through the Program was multi-layered and tended to be specific to what parents were dealing with on a day-to-day basis in their lives. Elder support meant connecting on a personal level, actively listening, empowering, encouraging, validating, valuing parents as people, being non-judgmental, being kind and caring, transferring cultural and traditional knowledge, helping to mend historical traumas and foster healing, teaching parenting skills, responsibility, values, and respect, and effectively "being on their side" (Clinic staff member). Parents expressed feeling comforted knowing they could call upon an Elder if they needed to, as one described: "she would tell me that if I didn't have anybody to come with me to the labour room or if I needed her at anytime that she would be there." (Parent) The significance and importance of Elder support through the Program is illuminated in the following quotes: I connect with the person, and we laugh. I tell stories. So it's all about the human connection. We know that a person is strong enough as they are, whether they're struggling, whether they're dysfunctional, shall we say. They're still powerful. And us [Elders], we go there and try to empower them in a very positive, sacred way -you know. Supporting parents was described extensively by all of the participants as the crux the Elders Mentoring Program. There was agreement among all participants that the Program is providing a relevant support service that was previously lacking within the prenatal clinical setting. Many women from the community face unique and continuous challenges, especially during pregnancy, and these challenges often "fall through the cracks" (Elder) within the western healthcare system. Challenges parents may face within the community were described as a "stew of crisis" (Elder; see Table 1). In many instances, care providers are unable to provide the needed support to parents as they are generally not from the community and may not identify with the complexities faced by community members. Moreover, the lack of inclusion and acknowledgement of male partners during pregnancy was often identified as a gap in perinatal care. Thus, having Elders from the community that "have been there before" (Clinic staff member), understand the issues faced by young parents, accept parents "for who we are" (Parent), provide a "safe space" (Parent), and who are able to offer culturally and community-appropriate support and advice, was viewed as filling a significant gap in prenatal care, as described in the following quotes: If I put myself in that position, and I was young, and unsure of myself, maybe my home is overcrowded, maybe I don't live in a very happy environment, because when you really face the facts there's a lot of family violence. There's a lot of domestic violence. There's alcoholism, there's drug addiction, and no one is untouched by those elements. And so we have children becoming mothers in this milieu, what more important way is there then to go there when a mother is expecting and to say: 'You know what? You're going to be okay.
You're a very strong girl, and you're a good dad. You're right here and that says so much about you.' (Elder) If they [staff] have somebody in the room that really needs a little bit of guidance, it's like, 'we have an Elder. Would you like to talk to an Elder?' And they'll come in here and close the door, and they'll sit and visit. There have been days where they were like 'I'd like to talk to an Elder,' rather than one of our therapists. You know? So it's been beneficial. Even when you get that one person that's like, 'I'm so glad she was here I guess that's the closest person I had to someone being there for me, that understands.
But it was nice because um, like older -older people have their -their different ways and like their beliefs and like… Um, like they're Elders so they know, right? They know what kids shouldn't be doing and stuff and… I liked it because when I was around old people.
(Parent) I have seen a value in the Elder program. I see that the patients are maybe more willing to speak to an Elder than say, ourselves or our therapist, or our nurses, even. Even in an open space, like the waiting room area, they'll still give more information than they might in a closed door to one of our nurses. So, I see that there's value there. And I think that it's a fantastic idea. I think there's a respect for their Elder, whether it's their own family Elder, or an Elder in general. And you can see where, if they maybe weren't warm and fuzzy to say myself, they will answer that Elder's question. They have a high respect for an Elder in general... and I think once they have that attention, then the Elder couldsky's the limit… I see it, when I see the Elder sits down beside them. They put down their phones, they pay attention. It's amazing. (Clinic staff member) There could be a whole host of things identified there [with the Program] that they don't identify in, you know, a five-minute appointment with a physician. And so, it was a good opportunity to bring those supports into place… We need somebody, you know, who speaks the language and can do this in a different way than kind of the western way of, 'Holy I made a child'. It hits him, it hits him hard, you know? But nobody recognizes it.
Nobody acknowledges it… They never ask him 'are you going through postpartum depression too?' Nobody's ever asked the father that…. So I kind of think it helps them in that sense, to build a relationship that they can understand what each other is going through, and the feelings and emotions of being a parent now. And they go through the same feelings and emotions that overwhelm them sometimes. (Elder) Nêhiyawi language, utilizing traditional medicines, adhering to longstanding protocols for pregnant women, attending sweatlodges, participating in ceremonies (such as the belly button, afterbirth, and naming ceremonies), and following cultural underpinnings of love, compassion, and generosity were particularly important to encourage during pregnancy.
One Elder described culture during pregnancy as "bringing your body, your mind into calmness. It makes you see things clear… It just helps you stop and think, instead of reacting drastically." (Elder) Parents and Elders expressed worry about the risk of these cultural practices being lost due to the ongoing impacts of colonization, and felt that the Program offered a chance for cultural learning. It was believed that incorporating traditional culture into the pregnancy would not only provide a sense of healing, belonging, and identity to parents, but would be essential to the health of the fetus.
Having Nêhiyawi culture and ways of knowing genuinely incorporated into the clinical setting through the Program was thought to contribute to improving the overall sense of cultural safety for parents. The following poignant quotes reveal the importance of cultural connection in the Program: The culture was eroded. The values were also eroded. And there was nothing strong for people to live by anymore… The girl that is the mother today, that is becoming a mother

Intergenerational Fulfillment, Enjoyment, and Collaboration
When asked about their personal experience of being involved in the Program, all of the participants repeatedly described feelings of fulfillment and satisfaction through taking part. Several clinic staff members described an enhanced sense of accomplishment in their work with the addition of Elders that were able to fill a gap in care that ultimately lead to a more cohesive and holistic clinical environment. Similarly, parents were contented after visiting with Elders in the Program and were often gratified given the opportunity to learn from Elders about pregnancy and parenting in a way they felt was relevant. Some parents discussed feeling pleased that they were able to incorporate more of "who we are as First Nations people" into their pregnancy as a result of interacting with the Elders in the Program, and that this would benefit their babies. One mother explained further that her sense of identity and that of her mother as well, was validated by talking with an Elder in the Program: Elders in particular described at length the fulfillment they felt through participating in the Program. Partnerships with clinic staff members had evolved such that they felt a part of the team. Being involved in the prenatal journey of parents to "help bring life into the world" (Elder) offered an especially strong sentiment of pleasure through giving back to their community in a meaningful way. Elders believed that their support was part of overcoming the challenges faced within the community by reconnecting parents to the "many strengths" (Elder; see Table 2) that exist also within community as well. The following two quotes help illuminate their sense of fulfillment: The feeling when a person goes to the gym and they're done and they've had a really good workout, the finish of a long project, all those feelings that surface as a result of doing something powerful and positive, that's the feeling I get.  The Elders also discussed feeling fulfilled through the Program as it contributed to their own continued healing from historical traumas they had experienced in the past as a result of colonization. Several of the Elders gave in-depth and detailed accounts of their own experiences related to colonization including residential schools, foster homes, racism and discrimination, and poverty to name a few. They described how these experiences have, in many ways, hindered their ability to carry out their roles as Elders in the community during certain times of their lives. Elders shared how the Program contributes to restoring their roles, provides a renewed purpose in life, and "gives a reason to keep on going." (Elder) Specifically, being a mentor to younger parents compelled some of the Elders to look at themselves in a more honest way, open up more to others, and make positive changes so that they were better able to care for or help others. One Elder in particular explained the personal impact of the Program: when they're here. They're good people. Yeah, really good people… The Elders enjoy there time here and so do we. We really do… It just reflects when they come in and they're just so eager and ready to help and it's nice for everyone. We like it, it's really good. (Clinic staff member) They're [mothers] beautiful. They -they're just -they're just so happy that we go and sit beside them, and introduce ourselves. And just make them feel more comfortable. At first they're kind of like -they just kind of sit there. And -because we live in a very impersonal world as well, you know? And so, they have to make up their mind -'Oh yeah, this is… Ah, there -I -I'm getting positive vibes from this person.' And then it opens them up. And we start talking. And we laugh. (Elder) She was a really, really nice lady though. It was nice to be able to just, you know, to laugh in that place. And that really made me -me the most happy… Yeah. I really enjoyed it.
She actually just came and sat down with -and I mean, just started a nice conversation.
(Parent) I said those words just for laughs, you know. For laughs, yeah. Like it's… at the moment, I don't want to kill their moment and say, 'You're going to do this, you're going to do that.' But it -you talk to them slowly and just have fun. Tell them a joke every now and then. (Elder) Reaching out to the young mothers, young parents, I just appreciate it. You know, I enjoy what I'm doing. At the clinic, I just enjoy the staff. 'Cause when I walk in there, I just introduce myself. And I tell them I'm here. The staff is really nice. I really appreciate their -you know, their acknowledgement… Oh, they all -they always say they look forward and will say to me "you can come in anytime you want to." The staff there know -they see me.
You know, talking and ah -or they -they greet me, you know. They know who I am. And I know who they are. And we greet each other with a hug. I enjoy what I'm doing. It has helped me… And my question is to the mothers, about me being there for them, and they've said that they've enjoyed it. It has been good. Why I keep saying I enjoy is that it's a time for me to meet people, to meet these mothers. 'Cause I know some of them, you know, from the past (Elder) It was clear from the participant's stories that fulfillment and enjoyment were predicated upon the authentic relationships that were developed through the Program and the enhanced collaboration that ensued between Elders, healthcare staff, and parents. There was a belief among many of the participants that the common goal of healthier pregnancies was bringing individuals that were previously worlds apart, together, as one Elder commented: "We're talking -we're dealing about life -with life…We need to come together."(Elder). Coming together and evolving into a teamwork environment took time.
Long seeded rifts that exist between Indigenous and non-Indigenous communities were described, as were initial feelings of trepidation as the Program was implemented. The continued and consistent presence of the Elders through the Program ultimately allowed for participants to feel comfortable with one another, for stereotypes to be deflected, and for genuine and trusting relationships to emerge. The Program, and especially the relationships developed, were described as having come "leaps and bounds from the start". (Clinic staff member) These relationships were crucial in the successful functioning of the Program and sincere collaboration allowed for the positive impacts described in the aforementioned themes to ensue. Participants spoke of how the relationships between staff, Elders, and parents have grown: I was here before the whole program started. So we've kind of… grown into that… to where we are now, which is great. It's a good clinic. And again, it's -it's been kind of an ongoing -it's -it's been a process. So I think it's still just kind of a bit about progressing over time. Still just a little bit of a -of a journey, to get that to -to that place where we work great together… And now I've seen a big growth with the Elders and the staff that has improved a lot since day one. (Clinic staff member) In the beginning, it was kind of a… like a… I -I'm used to that. to name a few. Parents in our study expressed feeling more likely to trust, connect with, and talk to Elders about these issues than to a health professional who may not understand their context well. Mistrust and disconnection between pregnant Indigenous women and healthcare providers has been thoroughly described in other qualitative research [24][25][26][27], and are rooted in cumulative historical trauma, societal marginalization, paternalism, and rampant discrimination of Indigenous people [4,28]. Beyond providing a more safe and trusting space for Indigenous women and their partners to discuss and deal with their unique challenges, the inclusion of Elders also had meaningful impacts on the clinic staff members' sense of their patients' context, and of providing culturally safe care. We believe this will lead to better and more frequent interactions between patients and staff. The National Aboriginal Health Organization defined cultural safety as moving "beyond the concept of cultural sensitivity to analyzing power imbalances, institutional discrimination, colonization and colonial relationships as they apply to health care." [29] There is no shortage of research calling for improved cultural safety for Indigenous patients in healthcare settings, particularly perinatal settings [8,25,[30][31][32]. Our findings suggest that consistent Elder presence in perinatal care offers a novel opportunity for ongoing experiential and reflective cultural safety learning for staff as opposed to the often one time, limited, and unidirectional cultural sensitivity trainings typically offered that tend to focus on cultural differences [33].
In addition, interacting with Elders allowed patients ongoing opportunities to connect and re-connect to traditional Nêhiyawi cultural principles and philosophies that are pertinent to pregnancy and raising children. An accumulating body of research indicates that Indigenous patients, including pregnant women and their partners, want and need Indigenous culture and language incorporated into health care practices in a meaningful way [8,24,25,30,32]. In our study, healthcare staff also recognized the critical importance of cultural connectedness for the health and wellbeing of many of their Indigenous patients, and welcomed the opportunity for Elders to be the facilitators of culture within the clinic. Our findings add to those of others suggesting positive associations between cultural connectedness and Indigenous health, wellbeing, healing, self-determination, belonging, knowledge, empowerment and self-esteem, and identity [21,23,[34][35][36][37]. Cultural interventions in relation to mental health and addictions have been studied far more in comparison to other health conditions, particularly pregnancy-related health. For instance, in the treatment of addictions among Indigenous populations in North America, culture-based interventions have been shown to improve patient spiritual, emotional, mental, and physical wellness, as well as decrease or eliminate substance use problems in many instances [38].
Our Elders Mentoring Program also helped to fill other noted gaps in perinatal care. The Program proved particularly helpful in supporting younger and teenage mothers through their pregnancies as they may feel even more vulnerable, judged, and scared. Teenage pregnancies are typically more common in Indigenous populations [39], and research from suggests that teenage pregnancies lead to poorer obstetric and perinatal outcomes and necessitate culturally appropriate care [40,41]. Moreover, opportunities to engage with Elders in the perinatal setting were believed to lead to increased inclusion and acknowledgement of male partners during pregnancy in our study. Our previous qualitative work [9] and that of others [42][43][44] highlight the importance of including fathers more in perinatal care. The current study suggests that authentically and consistently incorporating traditional culture and Elder support into perinatal care approaches may help to support and include Indigenous men.
A key finding from our study was the sense of intergenerational fulfillment and enjoyment that the Elders Mentoring Program brought to all of those involved, and that this stemmed from relationships. This reflects the intent and benefit of CBPR approaches [11]. This finding also emphasizes the need for collaboration and partnership in attempts to improve Indigenous health, which has been suggested time and time again through recent research [11-13, 45, 46]. It is not enough to simply conduct research or provide healthcare in a "culturally sensitive way". For example, it was clear from extensive grounded theory research with health professionals that government agencies and health services and organizations need to work with Indigenous people in order to advance strategies that empower providers and staff to practice cultural safety and ultimately improve clinical interactions and patient outcomes [33]. Significant strides are now being made to make health practices and research practical and localized, rather than removed and devoid of investment. CBPR is now the accepted approach for Indigenous health-related research.
Cultural safety and partnerships with Indigenous communities are now recommended by key health organizations as means of revamping our health systems and improving Indigenous health.
Our study has limitations. Given the distinctiveness of each community, any transferability of our findings to other Indigenous populations must be approached with caution. Also, our intervention and study was carried out in a rural Primary Care Network clinic and the suitability and usefulness in other more conventional care settings was not considered.
This was our first attempt to understand the impact of a novel and community-based culturally and community appropriate way. For qualitative data generation, an information letter detailing the project was reviewed with potential participants, and written informed consent was provided prior to data collection.

Consent for publication
Not applicable.

Availability of data and material
Not applicable. The data will not be shared. Ethical approval for the study requires the data be kept in locked files, accessible only by the authors and community partners.

Competing interests
The authors declare that they have no competing interests

Funding
The ENRICH Project is funded through an Alberta Innovates -Health Solutions