Healing Kidney Care 

  Applying the Health Equity Framework to Indigenous Renal Inequities in British Columbia 

When evaluating renal services for Indigenous peoples in British Columbia, the Health Equity Framework (HEF) provides a foundation for developing strategies to address disparities. In Canada, "Indigenous peoples" includes First Nations, Métis, and Inuit, with over 600 distinct communities (Chaturvedi et al., 2024). While health equity is a priority in British Columbia, the social determinants approach often lacks public support and fails to tackle systemic inequities. (Government of British Columbia [BC Gov], 2025; Peterson, Charles, Yeung, & Coyle, 2021). Therefore, a multilevel model will be used called the HEF. The framework centres on Health and Education Outcomes, influenced by four intersecting spheres: Physiological Pathways, Individual Factors, Relationships and Networks, and Systems of Power (Peterson et al., 2021). Examining these spheres in relation to Indigenous populations highlights critical pathways to improving kidney care in British Columbia.  

Physiological Pathways 

Physiological pathways encompass biological, physical, cognitive, and psychological abilities that affect health outcomes (Peterson et al., 2021). There are many examples of physiological pathways to chronic kidney disease in Indigenous communities.

For example, chronic stress, historical trauma, and environmental factors contribute to higher rates of kidney disease (Park, 2021; Xu, Nie, Ding, & Hou, 2018). Early life adversities, such as food insecurity, unsafe drinking water, and exposure to pollutants, can disrupt neuroendocrine and immune system functions, increasing the risk of chronic conditions like diabetes and hypertension (Berens, Jensen, & Nelson, 2017; Vaiserman & Koliada, 2017). Further, diabetes, hypertension, and Indigenous identity are well-established risk factors for chronic kidney disease (CKD) (KDIGO, 2024). Additionally, genetic analyses have identified elevated inflammatory markers such as C-reactive protein and fibrinogen among healthy Indigenous individuals, with even higher levels observed in those with CKD compared to their non-Indigenous counterparts (Ferguson et al., 2024). These insights emphasize the need for culturally safe and trauma-informed care for Indigenous populations, considering the impact of historical trauma and environmental stressors (Chaturvedi et al., 2024). Further, action is needed to improve living conditions by ensuring access to food, clean water, and reducing pollution (Berens, Jensen, & Nelson, 2017; Vaiserman & Koliada, 2017). 

Additionally, comprehensive screening for diabetes, hypertension, and CKD is essential for early detection and management in at-risk communities (CanSolve, n.d.). Screening serves as an ideal entry point to renal services because it can prevent the progression of CKD. Early detection through screening allows for timely interventions, reducing the need for more intensive treatments and improving patient outcomes. (KDIGO, 2024). Reviewing the physiological pathways of the HEF highlights key exposures that increase the risk of kidney disease in Indigenous populations and highlights the importance of targeted strategies to address these risks. 

Individual Factors 

Health behaviours and attitudes significantly influence access to kidney resources and affect health outcomes (BC Gov, 2020; Peterson et al., 2021). Historical and ongoing experiences of culturally unsafe care have led to deep-seated mistrust in the healthcare system among Indigenous communities (BC Gov, 2020). This mistrust contributes to lower screening rates and delayed diagnosis, exacerbating disease progression (Bello et al., 2019; CanSolve, n.d.; Lavoie et al., 2023).  

To improve engagement, healthcare models must align with Indigenous perspectives on health. Community-based care initiatives, where Indigenous healthcare workers deliver services, can foster trust and encourage participation in screening and treatment programs (Harasemiw, Komenda, & Tangri, 2022). Strengthening Indigenous-led healthcare services can ensure that care delivery aligns with community values, increasing patient trust and participation (Harasemiw, Komenda, & Tangri, 2022). Supporting Indigenous care providers through funding and resource allocation will enhance the effectiveness of these model (Harasemiw, Komenda, & Tangri, 2022). Additionally, integrating holistic, culturally safe kidney care models, which emphasize community well-being and traditional healing practices, can improve long-term health outcomes (Chaturvedi et al., 2024). Creating safe environments within healthcare facilities by incorporating Indigenous artwork, language, and staff trained in culturally competent care will further enhance patient engagement and trust (Harasemiw, Komenda, & Tangri, 2022).  

An example of a this is Kidney Check. Kidney Check is a program that addressed these physiological pathways and individual factors. Kidney Check, a Can-SOLVE initiative, is a patient centred, culturally safe program for Indigenous communities in five provinces, including British Columbia (CanSolve, n.d.). It uses screening questions and point-of-care tools to identify kidney disease risk. Developed with Indigenous partners, the program is effective (CanSolve, n.d.). Despite this, the Kidney Check and Interior Health Kidney Care Clinics are not well connected highlighting the need for stronger partnership. Strengthening this connection will enhance continuity of care and improve kidney health outcomes for Indigenous communities.

Relationships and Networks 

Relationships and networks include the many connections between people and support structure environments (Peterson et al., 2021). Strong networks are essential for improving Indigenous health outcomes. Many Indigenous patients face barriers to care, including geographical isolation, lack of transportation, and the emotional toll of being separated from their support systems when accessing treatment (Harasemiw, Komenda, & Tangri, 2022). 

Further, expanding home-based dialysis options can help patients remain in their communities, reducing disruptions to their social and cultural networks (Harasemiw, Komenda, & Tangri, 2022). This is particularly critical for Elders, whose presence and guidance are integral to community well-being (Harasemiw, Komenda, & Tangri, 2022). With this understanding, BC Renal supports a home-first approach through its publicly available It’s Better at Home video series and healthcare-focused guidelines (BC Renal, n.d., It’s better at home). Within Interior Health, my team actively utilizes these resources and promotes home dialysis modalities, recognizing their role in improving patients' quality of life.

Systems of Power 

Systems of power refer to policies, processes, and practices that determine the distribution and access to resources required to be healthy (Peterson et al., 2021). These systems, when shaped by structural bias, can create barriers to equitable care (BC Gov, 2020; Peterson et al., 2021). A critical component of addressing systemic inequities in kidney care involves improving screening processes and fostering culturally safe healthcare organizations. 

Screening is essential in kidney care to prevent CKD progression and avoid invasive treatments (KDIGO, 2024). While access to all renal services is important, pre-dialysis interventions are more impactful as they affect a broader population (KDIGO, 2024). Currently, British Columbia renal programs rely heavily on referrals from primary care providers which require multiple steps: Ordering diagnostics, reviewing results, entering referrals to the Kidney Care Clinic (KCC), and prescribing the appropriate CKD treatments (BC Renal, n.d., Best practices). A more effective system for Indigenous communities would involve active surveillance, automatic referrals for follow-up diagnostics, and stronger support for Indigenous-led healthcare services in rural areas (Harasemiw, Komenda, & Tangri, 2022). This system should monitor CKD diagnostics with automatic referrals to the KCC for those meeting criteria, reducing primary care workload (Harasemiw, Komenda, & Tangri, 2022; KDIGO, 2024). As part of their basic function, KCC would ensure correct treatments are prescribed (BC Renal, n.d., Best practices). 

Additionally, since diabetes is a primary cause of CKD, surveillance for positive diabetes diagnostic results with automatic referrals for CKD diagnostics would improve early detection (Harasemiw, Komenda, & Tangri, 2022; KDIGO, 2024). This process would reduce barriers, bypass bias, and ensure access to clinical expertise. Further, despite concerns about rural resources, Indigenous healthcare services often outperform primary care in kidney disease surveillance, highlighting their effectiveness (Bello et al., 2019). This is particularly notable given that primary care often receives more funding (Bello et al., 2019). Strengthening these Indigenous services will improve early detection and treatment, addressing kidney health needs and bridging gaps in care. 

Beyond screening, in order for any strategy to be effective, it has to be embedded in a culturally safe organization. A culturally safe organization prioritizes the representation of Indigenous health workers and ensures Indigenous partners are actively involved in decision-making processes (BC Gov, 2020). This fosters an environment where cultural perspectives are respected and valued. Additionally, cultural humility in education is essential, where healthcare professionals engage in continuous learning about Indigenous cultures, histories, and health needs, recognizing the importance of self-reflection and open-mindedness in providing effective and respectful care (Harasemiw, Komenda, & Tangri, 2022). Implementing these strategies lays the foundation for creating exceptional kidney care within a culturally safe organization.