Reduction of Family Violence in Aboriginal Communities: A
Systematic Review of Interventions and Approaches
1
Beverley Shea, Amy Nahwegahbow, and Neil Andersson
Abstract
Many efforts to reduce family violence are documented in the published literature. We conducted a
systematic review of interventions intended to prevent family violence in Aboriginal communities.
We retrieved studies published up to October 2009; 506 papers included one systematic review, two
randomized controlled trials, and fourteen nonrandomized studies or reviews. Two reviews discussed
interventions relevant to primary prevention (reducing the risk factors for family violence), including
parenting, role modelling, and active participation. More studies addressed secondary prevention
(where risk factors exist, reducing outbreaks of violence) such as restriction on the trading hours for
take away alcohol and home visiting programs for high risk families. Examples of tertiary prevention
(preventing recurrence) include traditional healing circles and group counselling. Most studies
contributed a low level of evidence.
Background
The United Nations Population Fund (UNPA) lists sixteen forms of violence directed against
women. The most common are repeated assaults, physical and psychological, within families
(UNPA, 2010). Family violence can include action that “endangers the survival, security or
well-being of another person (College and Association of Registered Nurses of Alberta, the
College of Licensed Practical Nurses of Alberta, and the College of Registered Psychiatric
Nurses of Alberta, 2008). The Royal Commission on Aboriginal Peoples (RCAP) considered
the infrastructure of family violence as “the serious abuse of power within family, trust or
dependency relationship” (RCAP, 1996).
It is not only women who suffer. Infants in violent families experience adverse effects along
with their mothers, and abuse of boys is common (Boy and Salihu, 2004). The term “family
violence” reflects this suffering of all members of the family (including the perpetrators), and
the children of these families are at increased risk of developing personality disorders, mental
health problems, poor self esteem, and low educational achievement (Bair-Merritt et al.,
2006).
Several interrelated factors contribute to high levels of family violence experienced in
Aboriginal communities. These include poor socioeconomic conditions, high rates of alcohol
and substance abuse, systemic discrimination and racism against Aboriginal Peoples, as well
as the trauma and inter-generational cycle of violence resulting from the residential school
legacy, and the impact of colonialism on traditional values and cultures (RCAP, 1996).
1
Acknowledgements: We thank Jessie McGowan who designed the search strategy and conducted the literature search. This systematic
review was entirely supported by the Canadian Institute of Health Research (CIHR) Grant “Rebuilding from Resilience” Project number
84489.
PubMed Central CANADA
Author Manuscript / Manuscrit d'auteur
Pimatisiwin. Author manuscript; available in PMC 2010 November 2.
Published in final edited form as:
Pimatisiwin. 2010 ; 8(2): 35–60.
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The Aboriginal-specific literature on family violence is sparse; a brief review summarizes what
is known about the effectiveness of interventions in nonindigenous communities, and comment
on the applicability of successful interventions in Aboriginal communities. The primary focus
of this review is the relevance of initiatives to reduce family violence in Aboriginal
communities in Canada.
Methods
The term “systematic review” refers to exhaustive searching, selecting, collating, appraising,
interpreting, and summarizing data from original studies (Cook et al., 1997). These studies
may be observational or randomized trials, qualitative or quantitative. Limited to published
material, a well known difficulty of systematic reviews is that component studies are simply
too different in the way they approach a problem for the information each offers to add up.
When the quality of primary studies is poor, a systematic review can at best note the flaws; it
cannot improve the data.
There is currently no agreed classification for interventions addressing family violence. Table
1 offers a standard prevention framework (primary, secondary, and tertiary prevention)
including examples from the Human Rights and Equal Opportunity Commission in Australia
(HREOC, 2006). Tertiary prevention of family violence receives most attention and research
investment; it focuses on the protection and care of victims, and punishment and rehabilitation
of perpetrators with the intention of reducing recurrence. Secondary prevention identifies those
with risk factors and prevents their progress to overt violence through screening, counselling,
or removal of the risk factor. Primary prevention receives less research interest and public
funding; this seeks to avoid the genesis of risk factors for family violence.
In the characterization of interventions intended to reduce family violence, holistic refers to
the fullness of interventions at any one of these levels, as they include spiritual, cultural, and
other dimensions of indigenous ways of life.
We developed a protocol to summarize and evaluate the intervention studies in indigenous
communities. Initial literature scans identified published systematic reviews as a means of
summarizing several hundred studies. We extracted relevant reviews of intervention studies
conducted in Aboriginal and non-Aboriginal communities at this stage. Beverley Shea and
Amy Nahwegahbow assessed all publications to identify relevant studies and included these
in the review. We searched for primary studies published up to and including October Week
3 2009 using MEDLINE, PsycINFO, HealthSTAR, North American Indian Biographical
Database, Violence and Abuse Abstracts 2001–2004, EMBASE, Global Health, and the
Cochrane Library. Search terms varied by database.
2
We did not limit the searches by study type. Beverley Shea and Amy Nahwegahbow read the
full text of these studies. We confined our literature retrieval to studies that provided qualitative
and quantitative estimates of prevention. Formal assessment of randomized trials used the
SIGN 50 instrument (SIGN, 2010) and non-randomized studies relied on the Effective Practice
and Organization of Care instrument (EPOC 2010). However, the broad range of the other
study types required an informal approach to quality assessment and precluded any attempt at
data pooling.
2
KW=(domestic violence) or (family violence) or (elder abuse) or KW=(child abuse) or (spous* abuse)and KW=(therap* or treatment* or prevent*) and KW=(native or aborigin* or eskimo or inuit or indigenous or indian); Global health: TX (Domestic violence or family violence or elder abuse or child abuse or spous* abuse) and TX (therap* or treatment* or prevent*) and (aborigine* or indigenous or Inuit* or Eskimo* or Indian or Indians or First Nation*); Native Health Database: (Domestic violence or family violence or elder abuse or child abuse or spous* abuse) and (therap* or treatment* or prevent*)
Shea et al. Page 2
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Results
The search yielded 506 citations up to October 2009. Combinations of search terms identified
a smaller number of potentially relevant titles from each database: MEDLINE (93), EMBASE
(26), and CENTRAL (28), psychINFO (96), Global Health (16), North American Indian
Biographical Database (70) Violence and Abuse Abstracts (6). There was considerable overlap
between the retrieval lists for these databases. Beverley Shea and Amy Nahwegahbow
examined all titles and identified 27 articles describing school and community-based
interventions aimed at decreasing family violence (see Figure 1). We excluded 12 studies that
did not describe or test interventions to prevent family violence in Aboriginal communities
(Appendix 1). A key inclusion criterion was that studies involve an indigenous population,
whether the intervention was at individual or community level. One of eleven studies in the
single systematic review (Whitaker et al., 2006) included Aboriginal participants (Table 2).
We identified two randomized controlled trials (RCT) of interventions in indigenous
communities (Duggan et al., 2004; Duggan et al., 2007) and fourteen nonrandomized studies
(Tables 3 and 4). These interventions include: community injury prevention (role modelling,
life span focus, accessibility, acceptability and active participation), restriction on the trading
hours for take away alcohol, home visiting, parenting, traditional healing circle and group
counselling provided in an Aboriginal health setting. The methodological quality of the two
RCTs was 60% (Duggan et al., 2004) and 66% (Duggan et al., 2007) while that of the other
studies ranged from 29%–45%.
Studies in Nonindigenous Communities
Table 2 lists nine systematic reviews that together summarize much of the large literature on
the prevention and reduction of family violence in non-indigenous communities. Despite the
international importance of the subject, few high quality intervention studies appear in the
literature. Every systematic review and task force report concludes with a call for more and
better studies on family violence.
Two RCTs in the review by Andersson and colleagues (2008) point to promising ways to reduce
interpartner violence in Africa: a randomized controlled trial of income enhancement and
gender training resulted in reduced gender violence and HIV risk behaviours (primary
prevention), and a trial of a participatory learning program reported a reduction of male risk
behaviours.
Other interventions that one might expect to help in practice have not done so in well conducted
studies. Screening female patients by health professionals, for instance, increased referral for
counselling but did not reduce subsequent episodes of abuse. The creation of temporary
sanctuaries for women does not have a lasting effect on occurrence of family violence unless
combined with postshelter advocacy and counselling. There is no evidence that early childhood
visits, though beneficial in other ways, reduce the rates of subsequent assaults on mothers and
children. Abuse is well established by the time detection occurs and interventions at this stage
are probably insufficiently powerful to change the behaviour of perpetrators (Table 2).
Studies in Indigenous Communities
Eight studies described interventions relevant to the prevention of family violence in
Aboriginal and indigenous communities (Table 3). We found no published reports of these
interventions tested in a controlled setting. We also identified six quantitative studies (Table
4) that examined prevention including role modelling, life span focus, accessibility,
acceptability and active participation; secondary prevention such as restriction on the trading
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hours for take away alcohol, home visiting programs (healthy start program) and parenting;
and tertiary prevention including traditional healing circles and group counselling.
Primary Prevention: Reduction of the Risk Factors for Family Violence
Qualitative publications on primary prevention—Relevant to primary prevention,
Kiyoshk (2003) discussed interventions that integrated spiritual practices and ceremonies into
psycho-educational group counselling models. Their “Change of Seasons model” included a
28 session psycho-educational group counselling approach that sought to integrate cultural
healing methods for Aboriginal men. Spiritual practices and ceremonies included smudging,
the talking circle, and the sweat lodge. The author claimed their model was accepted by
Aboriginal clients “because it fits with their community’s spiritual beliefs and worldviews”
and proposed that “Systems Thinking” could be applicable to Aboriginal communities. The
description offers no evidence of impact on family violence.
Oetzel and Duran (2004) summarized several studies on the determinants of and interventions
for intimate partner violence (IPV) in American Indian and/or Alaska Native (AI/AN)
communities. Using a social ecological framework that identified proximal and distal risk
factors, they described multilevel interventions that addressed a variety of determinants
including age, gender, socioeconomic status, alcohol, European colonization, and
infrastructure. “While the social ecological framework makes intuitive sense, there are few
multilevel interventions to address IPV and none in AI/AN communities.” They offered no
quantitative evidence of impact.
Secondary Prevention (Stopping the Risk Factors Becoming Violence)
Qualitative studies and reviews on secondary prevention—Holkup et al. (2007)
described the Family Care Conference (FCC), an elder-focused, family-centred, community-
based intervention for the prevention and reduction of elder abuse. The intervention involved
inviting family members, family-nominated supportive community members, a spiritual
leader, and relevant health and social service providers to attend a meeting in which individuals
bring forward their concerns about the welfare of the elder. The authors claimed that families
accepted and appreciated their intervention, and attributed its success to the community’s long
history of respect for elders and preference for mediation over confrontation:
Drawing on the values of interdependence and reciprocity among Native American
kin, the FCC provided a culturally anchored and individualized way to identify a frail
elder’s care needs and to find solutions for meeting those needs from among family
members and available community resources.
The report did not provide quantitative measures of impact in reducing elder violence.
Norton and Manson (1997) described a family violence program in an urban US Indian health
centre that provided a range of services for American Indians including counselling, crisis
housing, and transportation to appointments. To increase participation, the program used home
visits and a weekly family violence group that incorporated traditions and values (talking
circles, sharing of meals). The home visits tended to build an emotional connection with the
counsellor. A weekly domestic group provided an informal atmosphere for sharing problems
and concerns over a potluck dinner. Though not supported by numeric data, the authors reported
that
Many of these women were able to build a relationship with the counsellor, and benefit
from active participation in a family violence program. Home visits significantly
enhance care and the effectiveness of counselling.
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Willmon-Haque and Bigfoot (2008) reviewed the published literature on poverty and historical
trauma, including a discussion on oppression and hegemony (authority and power). They
described research on violence and the resulting trauma, suicide, family violence, and post-
traumatic stress disorder. Since very young children can also be affected by traumatic events,
the authors called for early intervention and awareness of family violence. Recent efforts to
influence mental health care provided to AI/AN children and families included: training in
advocacy and community mobilization, increasing community capacity, promoting culturally
relevant services, enhancing knowledge and awareness on the issue, and involving
communities in research.
Quantitative studies of secondary prevention—Brewin and Coggan (2004) evaluated
the Ngati Porou Community Injury Prevention Project (CIPP) in a predominantly Maori rural
community on the east coast of the North Island of New Zealand. Participants included Maori
selected at a forum (tribal gatherings, language nests, and sports venues). The CIPP used the
World Health Organization (WHO) Safe Community Model for injury prevention, which
acknowledges that community injury problems are best addressed by those who live in that
community. Two activities addressed family violence: 1) identify and affirm traditional Ngati
Porou care and protection practices for whanau (families) through 22 education sessions,
information packs, and ongoing training to resource people; 2) coordinate and implement
regional programs to address family violence and child abuse to tie in with national campaigns.
The initiative included a gathering on emotional and physical violence, and a family violence-
free concert to raise awareness. Community surveys indicated that the proportion who
encountered threatening situations outside the home decreased (pre 73%, post 66%) and there
was a small increase in those who always/mostly walk away from a threatening situation at
home (pre 27%, post 31%). There was a significant increase in awareness of injury prevention
among Ngati Porou whanau (pre 17% and post 25%).
Douglas (1998) considered an intervention to restrict availability of alcohol in a small town in
Western Australia (population 1,200); 63% were Aboriginal. Other programs implemented
along with the intervention included a school education program. Overall, the incidence of
crime declined. Alcohol-related presentations to the hospital and presentations resulting in
family violence decreased relative to the period prior to the intervention (odds ratio 0.43, 95%
CI 0.31–0.60). The authors reported no change in domestic violence.
An RCT by Duggan and colleagues (2004) assessed the impact of home visits in the prevention
of child abuse and neglect in the first three years of life in families identified as at-risk of child
abuse through population-based screening at the child’s birth. The study focused on Hawaii
Healthy Start Program (HSP) sites operated by three community-based agencies. The
intervention had two parts: (1) screening of medical records by paraprofessionals to identify
indicators of families at risk of child abuse and neglect; and (2) home visiting of these identified
at-risk families. The home visiting aimed to prevent child abuse and neglect by improving
family functioning in general and parenting in particular. Home visitors were paraprofessionals
working under professional supervision. Home visits included both direct services and linkage
with community resources. Direct service included providing emotional support to parents,
encouraging them to seek needed professional help, teaching about child development and
role-modelling parenting skills and problem-solving techniques. Intervention group mothers
were less likely to use common corporal/verbal punishment but this was attributable to one
agency’s reduction in threatening to spank the child. Intervention group mothers also reported
less neglectful behaviour, related to a trend toward decreased maternal preoccupation with
problems and to improved access to medical care for intervention families at one agency. The
intervention and control groups were similar on most measures of maltreatment. The program
did not prevent child abuse or promote nonviolent discipline. From the reader’s viewpoint, it
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seems the intervention could be tightened up considerably; HSP records rarely noted home
visitor concern about possible abuse.
A second RCT by Duggan et al. (2007) assessed the impact of a para-professional home visiting
program in preventing child maltreatment and reducing parental risks for maltreatment. This
focused on six Healthy Families Alaska (HFAK) programs aimed at preventing child
maltreatment by promoting positive parenting and child health and development. There was
no overall program effect on parental risks for child maltreatment or on outcomes for families
with high dose home visiting. Home visited mothers did report using mild forms of physical
discipline less often than did control mothers, although the groups were similar in their use of
more severe forms of physical discipline. Mild physical assault of the child was less common
in the HFAK group only in the subgroups of multiparous mothers and for those not in a violent
relationship at baseline. These positive findings must be balanced against deficiencies of the
study: home visitors discussed parental risks for maltreatment in less than one half of active,
risk-positive families; most risk-positive families were not referred to community services
raising an issue of viability of the intervention.
The systematic review by Whitaker et al. (2006) included one study involving First Nations
youth (Wolfe et al. 2003). This dating violence prevention program included middle or high
school students with behavioural outcomes including conflict in adolescent dating relationship
inventory (perpetration and victimization), healthy relationships skills, adolescent
interpersonal competence questionnaire (emotional support, negative assertion, self-
disclosure, conflict management, conflict resolution, trauma symptoms (trauma symptom
checklist) and hostility. Interventions consisted of education about healthy and abusive
relationships, conflict resolution and communication skills, and social action activities. Only
8% of participants were First Nations youth; the positive results declared by the study may
also apply to them, but this is not presented in subgroup analysis.
Tertiary Prevention (Reduction of the Worst Effects or Recovery from Family Violence)
Qualitative studies on tertiary prevention—Heilbron and Guttman (2000) report
interviews with five women exposed to traditional Aboriginal healing practices and the sharing
of beliefs in the therapy process for First Nations and non-Aboriginal women survivors of child
sexual abuse. A counselling group combined a traditional “healing circle” with conventional
cognitive therapy. The intervention involved weekly group meetings over a ten-week period
for approximately two hours per session. The healing circle provided a spiritual framework for
addressing problems in the group, and may have influenced participants in several ways:
spiritual focus heightened participant motivation for confronting issues; participants felt
empowered to speak; they felt comfortable and supported; the ceremony was conducive to
encouraging a warm, caring, and relaxed environment; and a safe, supportive and spiritually
nurturing environment was encouraged. The sharing of Aboriginal teachings and stories in the
group may have provided personal meaning for the First Nations women and enabled them to
develop a stronger devotion to Aboriginal healing methods:
At first she blamed herself for the abuse that occurred. It was through aboriginal
teachings that this woman learned she was not to blame.
Mokuau (2002) examined culturally based interventions for Native Hawaiians that incorporate
cultural values and practices, and involve Native Hawaiian participants in the design and
delivery of the interventions. This study described two culturally based interventions: The first,
ho’oponopono (“to set right”), was a family-focused holistic approach for maintaining and
restoring relationships with family members and others in a spiritual realm. It was facilitated
by a respected elder, family member, or community leaders, and included a spiritual
component. The second intervention, aloha ’aina (“caring for the land”) involved activities
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that reflect the Native Hawaiian connection to the land. For example, working in the taro field
entailed physical discipline, cognitive attention, emotional reflection, and spiritual openness.
While working, participants learned about the cultural past through storytelling by elders and
other caregivers. Participants learned values such as cooperation and reciprocity, engaged in
self-reflection on cultural identity and cultural pride, and explored their spirituality:
Native ancestors have left the United States a legacy of cultural values and traditions
that can have a powerful impact on resolving some of the issues of child abuse.
Luna-Firebaugh (2006) reported the evaluation of the Services-Training-Officers-Prosecutors
Violence Against Indian Women (STOP VAIW) Program, a partnership between the tribal
justice system and the nonprofit, nongovernmental service programs. Indian tribal
governments received financial assistance to implement strategies to address violence against
Indian women, and to develop and enhance services provided to Indian women who are victims
of violent crimes. Tribal approaches include coordination of services to ensure better response
to violence against women; enhancement of law enforcement response; innovative approaches
to tribal prosecution; new approaches to shelter; and implementation of the full faith and credit
provision of the Violence Against Women Act (with reference to protection and restraining
orders). The authors claimed that STOP VAIW programs had a significant impact in Aboriginal
communities. The program helped raise awareness among tribal leadership and the community,
as well as promote various approaches to confronting the problem of violence against women.
Most tribal communities felt that it was essential to combine “culturally compatible law
enforcement and prosecution components with victim’s assistance and outreach.” Tribes and
tribal officials, program personnel, and women were reportedly empowered by involvement
in the development and enhancement of tribal programs that address the safety of Indian
women. This supported tribal sovereignty. Across all programs, the authors claimed that the
development of coordinated community-wide responses to the problem of family violence was
successful in addressing family violence, sexual assault, and stalking. Other results they
claimed included:
• Tribal police officers and their departments were more efficient in their police work
and more thorough in their investigations.
• Fifty-seven tribes developed mandatory arrest policies that included a holding period
in their family violence codes and protocols.
• With respect to protection orders, 30% of tribes implemented a no-drop policy for the
prosecutor, and 50% allowing for victimless prosecution to occur.
• Calls for service and the number of arrests increased by more than 10 times during
the years 1995–1998. Family violence complaints increased more than 400% during
that time period.
• A number of tribal programs entered into cross-jurisdictional agreements with
surrounding law enforcement agencies, while others developed protocols and
ordinances that eased jurisdictional issues.
Quantitative studies of tertiary prevention—Becker and colleagues (2008) reported a
methodologically constrained trial; only one half of the participants completed the baseline
questionnaire and the authors only analyzed those who completed the treatment. They
examined outcomes of a 12-week “culturally influenced” group intervention for children and
adults exposed to family violence. The intervention involved 90 minutes of support through a
psycho-education children’s group provided — Haupoa meaning “make the ground soft for
planting.” A simultaneous weekly support and education group exposed parents to what their
children were learning and addressed parenting in the aftermath of family violence.
Notwithstanding the methodological flaws, the authors claimed statistically and clinically
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significant improvements in children and parent violence-related skills. Children receiving the
intervention showed improvements in internalizing and externalizing difficulties despite the
lack of direct symptom-focused intervention in these domains. More than one-half (53.2%) of
children exhibited clinically significant internalizing difficulties at pre-intervention, compared
to 21.3% at postintervention. Participants were of diverse ethnic backgrounds, most reporting
Asian or Pacific Island heritage; this cultural diversity raises questions about how culturally
appropriate the intervention could have been.
Discussion
Few studies relate to Aboriginal and indigenous communities and those that do exist contribute
only weak empirical evidence. We could not identify quantitative evidence of primary
prevention (reduction of risk factors for family violence). Most authors equate tertiary
prevention (recovery and reduction of the worst consequences) with prevention of family
violence. Our extensive search retrieved a very small number of published reports of controlled
studies.
In considering protective factors against suicide of Aboriginal youth, Chandler and Lalonde
(1998) considered that restoring and rebuilding community culture could be protective. The
concern for “cultural continuity” resonates with almost all the interventions described in this
review, which took into account Aboriginal beliefs and values, holistic concepts of health,
spirituality, traditional ceremonies, and healing practices. Many authors on interventions to
reduce family violence recognize that strong social support networks should underwrite
prevention efforts and change community perception about the issue of family violence.
Authors also recognized that community involvement in the development, design, and
implementation of family violence interventions should empower the community, make the
interventions better received by its members, and contribute to the overall success of the
intervention.
Despite this almost uniform recognition of the importance of cultural relevance and
participation, there is not much hard evidence of impact in reducing family violence in
Aboriginal communities. We see at least two reasons for this. First, the current literature rests
on qualitative approaches that generate insights into cultural dynamics and participant
perspectives. These studies can be pivotal to understanding what might work and how it might
work (Carriere, 2007; Olesen, 1994). With this now in hand, we look forward to a next
generation of research that start from these qualitative studies, going on to quantify the impact
of interventions that reduce family violence.
Second, mirroring the investment in nonindigenous communities in Canada and
internationally, most family violence research focuses on tertiary prevention (prevention of
recurrence). There is a growing body of work on secondary prevention (reduction of violence
outbreaks where the risk factors exist). We found only two narrative reviews relevant to if not
actually directed at primary prevention, the prevention of emergence of risk factors that could
lead to family violence. Yet this is exactly the upstream prevention where indigenous strengths
are mostly likely to play out. Two programs in Africa emphasized the importance of
participatory learning and structural interventions that change the position of women — and
therefore, their risks to family violence.
Conclusion
The causes of family violence are complex and deeply rooted. Once established, the cycle is
difficult to break. Interventions most likely to be effective are those designed to prevent family
violence rather than, once established, to reduce its frequency and severity.
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This review highlights the need for high quality research to inform interventions that reduce
family violence in Aboriginal communities. Barriers to prevention in this context include the
instability of programs, funding, and lack of capacity. Even with a potentially effective
intervention, these implementation factors will need consideration. Future research priorities
include the development and implementation of evidence-based interventions tested in
pragmatic randomized controlled trials.
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Biographies
Bev Shea has a PhD in epidemiology and is a researcher at Community Information
Epidemiological Technologies (CIET) and co-director of the Anisnabe Kekendazone (AK)
Network Environments for Aboriginal Health Research (NEAHR), administered by
CIETcanada. Over the past few years she has been working in Aboriginal health and
international research leading to the production of systematic reviews and in the areas of HIV/
AIDS and childhood immunization. She has contributed to the creation of new knowledge in
the field of quality assessment and qualitative data analysis. During the past ten years she has
worked in improving the field of systematic review methodology. She also mentors in
systematic review courses through CIET and the University of Ottawa.
Amy J. Nahwegahbow is a research coordinator with Community Information and
Epidemiological Technologies (CIET). Amy is a member of the Whitefish River First Nation
and a graduate of Trent University in the Honours Bachelor of Arts Program with a major in
Native Studies. Since 1999, she has worked for National Aboriginal Organizations such as the
National Association of Friendship Centres, the National Aboriginal Health Organization and
the Assembly of First Nations on a variety of First Nations health issues such as youth at risk,
suicide prevention, injury prevention, research ethics, environmental health and public health
issues of concern to First Nations. She has developed several toolkits for First Nations
communities on ethical research practices, the principles of OCAP, and Aboriginal health
indicators. Amy brings a broad knowledge of First Nations health and wellness issues, as well
as experience in conducting on the ground research with communities. She is pursuing her
education and a life long career in epidemiology to help improve the health, social, and personal
prospects of indigenous communities.
Dr Neil Andersson is the executive director of CIET and adjunct professor in the Faculty of
Medicine at the University of Ottawa. He has three decades of experience designing,
implementing and managing evidence-based health planning initiatives. A medical
epidemiologist, for the last 15 years he has supported training of researchers in more than 200
Canadian First Nations, Métis and Inuit communities.
www.ciet.org
Shea et al. Page 11
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Figure 1.
Flow Chart for Included and Excluded Systematic Reviews and Primary Studies: PRISMA
2009 Flow Diagram
1
1
From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred
Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS
Med 6(6): e1000097. doi:10.1371/journal.pmed1000097
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Pimatisiwin. Author manuscript; available in PMC 2010 November 2.

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Pimatisiwin. Author manuscript; available in PMC 2010 November 2.