Canadian Health Libraries’ Responses to the Truth and Reconciliation Commission’s Calls to Action: A Literature Review and Content Analysis

: Introduction: As part of the Truth and Reconciliation Commission of Canada’s (TRC) final report on the history and legacy of residential schools in Canada, 94 calls to action were identified. Of those, 7 are health-specific. The objective of this research paper is to determine how Canadian health library websites are responding to these calls to action. Methods: The authors conducted an initial literature review to gain an understanding of the context of Indigenous health in Canada. A content analysis of Canadian health library websites was conducted to track mentions of the TRC and online responses to the need for Indigenous-focused resources. Results: The results of content analysis indicated few online responses to the TRC’s calls to action from Canadian health libraries. Only 33 per cent of Canadian health libraries had content that was Indigenous-focused, and only about 15 per cent of health libraries had visible content related to the TRC’s calls to action. Academic and consumer health libraries were more likely to have both TRC- and Indigenous-focused content. Discussion: Nuances related to the research question resulted in some challenges to research design. For example, website content analysis is an imperfect indicator of real-world action. Limitations in research design notwithstanding, visibility is an important part of conveying commitment to the TRC, and the information available indicates the Canadian medical community is not living up to that commitment. Conclusion: Canadian health libraries need to do more to show a visible commitment to the TRC’s calls to action.


Introduction
The Truth and Reconciliation Commission of Canada (TRC) was officially established on June 2, 2008 as a product of the Indian Residential Schools Settlement Agreement (IRSSA). The tasks of the TRC were to hear, read, and record the experiences of residential school survivors, to unmask the truth of the painful, traumatic, and deeply racist history of residential schools in Canada. The intention for this information-and memory-gathering was to lay the groundwork to true and lasting reconciliation. The TRC released its findings in a final report on December 15, 2015, which included 94 calls to action. There are 7 recommendations specifically related to the provision of healthcare (Calls to Action 18 through 24; see Table A1 in the Appendix), though there are several other recommendations that are related to determinants of health (such as child welfare, education and employment, and sports and physical activity). Most of the 7 healthcare-specific calls to action are directed to government, but 3 (22 to 24) contain recommendations that the larger medical community can, and must, help realize. These 3 recommendations are as follows: 22. We call upon those who can effect change within the Canadian health-care system to recognize the value of Aboriginal healing practices and use them in the treatment of Aboriginal patients in collaboration with Aboriginal healers and Elders were requested by Aboriginal patients. 23. We call upon all levels of government to: i. Increase the number of Aboriginal professionals working in the health-care field. ii. Ensure the retention of Aboriginal health-care providers in Aboriginal communities. iii. Provide cultural competency training for all health-care professionals. 24. We call upon medical and nursing schools in Canada to require all students to take a course dealing with Aboriginal health issues, including the history and legacy of residential schools, the United Nations Declaration on the Rights of Indigenous Peoples, Treaties and Aboriginal rights, and Indigenous teachings and practices. This will require skills-based training in intercultural competency, conflict resolution, human rights, and anti-racism [1].
It has been 2 years since the final report was made publicly available. In that time, have Canadian health libraries responded to these healthcare-related calls to action in an explicit way? If so, in what ways have they responded?

Background
It is impossible to discuss Indigenous 1 health in Canada without linking current issues to Canada's history and legacy of colonization, as the TRC makes clear. According to oral traditions, prior to first contact the original inhabitants of the land that would become Canada enjoyed a high quality of health due to an active lifestyle and a diverse, balanced diet [2], which was maintained by their own thriving systems of healthcare, including holistic knowledge of medicines, and a variety of health practitioners and healers [3]. Interactions with European colonizers had an immediate impact on Indigenous health, beginning with the transmission of foreign diseases which quickly overwhelmed communities who were unfamiliar and underprepared to handle such epidemics [2]. Subsequent colonial programs and 1 When referring to the diversity of Indigenous groups in Canada this paper will use the terms "Indigenous" or "Aboriginal," which encompass the various first inhabitants of the land, including First Nations, Inuit  institutions created by the state to forcibly dispossess Indigenous peoples of their land, rights, and culture, produced (and continue to maintain) the conditions that have caused the disparities between Indigenous and non-Indigenous health that we see today [4].
These conditions of social, economic, cultural and political inequity, often referred to as determinants of health [3,5], are at the root of the "disproportionate burden of ill health and social suffering" experienced by Aboriginal populations across Canada [4]. A report published by the National Collaborating Centre for Aboriginal Health (NCCAH)/Centre de collaboration nationale de la santé autochtone (CCNSA) describes a poor overall picture of health among Aboriginal peoples in comparison to the non-Aboriginal population, especially in the following areas: "maternal, dental and infant health; child health; certain communicable and non-communicable diseases; mental health and wellness; violence, abuse and injury; and environmental health" [5]. Though data collection on the state of Indigenous health in Canada is far from comprehensive (due to the lack of information gathering initiatives on Non-Status, nonregistered, off-reserve, or urban Indigenous people, and the inconsistencies of "ethnic identifiers" in data collected from different Aboriginal groups [3,6]), the widely-accepted medical consensus is that "Aboriginal people continue to experience a consistently lower level of health than do non-Aboriginal peoples" [5].
Indigenous peoples experience health inequity, not only due to systemic inaccessibility to underlying determinants of health (such as clean drinking water) and barriers to accessing healthcare services and medical resources [7,8], but also due to the lack of culturally appropriate care [5]. This disparity lies at the crux of Calls to Action 22 to 24: valuing Indigenous healing knowledge as a medical resource, integrating cultural healing traditions and community practices into care plans for Aboriginal patients, and providing non-Aboriginal medical professionals with the necessary information, education and training to develop their cultural competency, are all elements that would contribute to the increase in availability of culturally appropriate care for Indigenous peoples. These areas all require the commitment and active participation of Canadian health libraries and librarians to accomplish.

Literature Review
To inform the context of the research question the authors conducted a literature review through biomedical and library and information science databases (MEDLINE, Library & Information Science Source (LISS), and Library and Information Science Abstracts (LISA)) for articles related to Indigenous health in Canada, with a focus on actions of health libraries. To limit articles to those initiatives originating as a response to the TRC's calls to action, the searches included keywords related to the Commission, or were limited to articles published in the last 3 years. The latter strategy was more effective at increasing recall than the first; though neither approach yielded many results in any of the searched databases. There have been a few scholarly articles published on the impact of the TRC on Canadian archival practices, especially with the establishment of the National Centre for Truth and Reconciliation at the University of Manitoba [9][10][11], which archived the materials of the TRC, but very few sources show up for articles about the TRC relating to Canadian libraries, and health/medical library-specific sources are virtually non-existent. From this, the authors gathered that it might be too soon to expect many indexed articles assessing the impact of the TRC on health libraries in Canada.
While the Canadian Federation of Library Associations/Fédèration Canadienne des associations de bibliothèques states as a goal the promotion of "initiatives in all types of libraries by advancing and implementing meaningful reconciliation as addressed by the Truth and Reconciliation Commission report and in the Calls to Action" [emphasis added] [12], most of the initiatives found through library and information science databases have taken place in the public library sphere. For example: the Saskatoon Public Library was the first public library to create a permanent space dedicated to truth and reconciliation [13], Edmonton Public Library has engaged its first Elder in Residence [14], and the Vancouver Public Library has initiated a number of actions (subject heading reviews, the creation of a number of resource guides, and the establishment of an online intranet "gathering space" for staff to explore reconciliation together) [15].
On the medical side, there is quite a bit of grey literature outlining the responses of medical schools and medical associations to the TRC's calls to action. Since the TRC report was published, some medical schools have built on pre-existing initiatives, such as those meant to support Indigenous students, or incorporate Indigenous knowledge and education on cultural safety into curricula [16][17][18]. Other institutions have created new goals and actions to address the TRC's calls to actions [19]. Medical associations such as the Indigenous Physicians Association of Canada (IPAC)/Association des médicins autochtones du Canada (AMAC) and the Association of Faculties of Medicine of Canada (AFMC) have also been leaders in supporting medical schools' progress in training Indigenous health professionals and developing curricula which "understand the healing power of Indigenous culture and history" [20]. While significant steps have been made on the part of Canadian medical schools, progress is uneven among different schools and there is an acknowledgement among academics and educators that existing goals remain inadequate to appropriately address disparities in Indigenous health and Indigenous medical education, and that more can, and must, be done [21,22].
From this literature review it is apparent that, while some libraries and medical schools in Canada have attempted to address the TRC's calls to action, there is little initial evidence that health libraries, which exist at the intersection of both the library and health fields, have taken action towards the realization of those objectives. The lack of indexed search results specifically related to the TRC and health libraries in a Canadian context led the authors to conclude that a content analysis of websites of Canadian health libraries would be a more direct approach to assessing visible responses to the TRC.

Scope and Rationale
The authors decided to focus on visible online commitment to the TRC calls to action for a variety of reasons: 1) a website is often the first public face of an entity that people encounter; 2) online content often increases accessibility, meaning that the information available on a website is usually consulted by a wider audience; 2 and 3) while visibility does not always equal action, online public statements often carry weight because websites serve as digital representations of the entity to the wider world. The authors view such statements as acknowledgement and recognition of the TRC recommendations, which is vitally important because it is an affirmation of the authority of the TRC as well as the legitimacy of the TRC's concerns. Statements of support should coincide with real action, and both should be used to reinforce each other and hold the institution accountable.
This paper takes a broad definition of 'health library' to encompass the wide range of information services that "meet the information needs of physicians, nurses, pharmacists, allied health professionals, students, patients, consumers and researchers" [23]. By including academic libraries that cater to medical and (or) health science education and training programs, hospital and health institution libraries and resource centres, libraries of professional associations for allied health professionals, and consumer health libraries, the authors hope to capture a wider picture of the responses to the TRC's calls to action thus far, as well as account for those health libraries that may belong to multiple categories. This approach does, however, pose limitations to content analysis (which will be discussed further in the "Challenges" section).

Methods
The authors used the list of Canadian health libraries and consumer health libraries provided through HLWIKI International, and the Health Science Information Consortium of Toronto's member directory to compile an initial list of relevant websites [23][24][25]. This list was then cross-referenced and supplemented with health library information from the Internet and the Libraries Canada/Bibliothèques Canada print directory [26].
The content analysis took into account the sources and statements originating within these various organizations, similar to the "internal assessment" portion of an environmental scan [27]. For this particular paper, only those libraries which had a discrete online presence (for example, a specific library page within a larger institutional website) were analysed. While most health libraries are housed within larger entities that might be implementing TRC-related or Indigenous initiatives, to focus our analysis solely on health libraries, only those actions that were specifically library-related were counted. The content analysis was intended to discover how websites made visible their commitment to the TRC, by asking the following questions: Does the health library website have specific mentions of the TRC? Do they mention Indigenous information initiatives that are in the spirit of the TRC recommendations, in particular, Call to Action 22? The authors analysed these websites for references to the TRC or to Indigenous initiatives that contain the "spirit" of the TRC calls to action.
Due to the broad definition of health libraries that was utilised, methods of analysis differed slightly depending on subcategory of health library, and website design. Websites were browsed for any library-led initiatives relating to either the TRC or specifically to Indigenous health. If there was a search option given on a health library website that allowed searching of the website itself and not the library catalogue, it was used to look for pre-determined search terms. This involved using a variety of search terms, including "TRC," "Truth and Reconciliation," "Indigenous," "Aboriginal," "First Nations" (for a full list of search terms see Table A2). If French-language websites had serviceable English facsimiles the English-language site was used for browsing. Frenchlanguage websites that did not have that option, or that only had basic English versions available, were translated using the Chrome browser Google translate function. If given the option to search the site, French translations of the same terms used to search the English sites were used (see Table A2). These translations were sourced from the French-language version of the executive summary of the TRC findings, Honorer la vérité réconcilier pour l'avenir: Sommaire du rapport final de la Commission de vérité et reconciliation du Canada, or from online translation tools [26].

Results
The authors compiled a list of 539 Canadian health libraries. Of those, 177 had no discrete online presence, leaving the authors with 362 health library websites with which to conduct content analysis for mentions of TRC-related initiatives, or library initiatives with an Indigenous focus. Of those 362 websites, 119 health libraries (around 33%) had visible Indigenous-focused initiatives, mostly in the form of subject guides on topics such as "Indigenous Health," or "Aboriginal Studies." Sometimes Indigenous content was nested under categories such as "Spiritual Health" or "Public Health." Only 56 (around 15%) made specific mention of the Truth and Reconciliation Commission. This was a far lower number than anticipated. Of those libraries that mentioned the TRC, the types of libraries that were most likely to have TRC-related content were academic libraries (n=27) and consumer health libraries (n=18). Libraries that had Indigenous content were highly represented in academic libraries (n=39), consumer health libraries (n=26), and hospital libraries (n=17). 3

Discussion
Though the content analysis for health libraries returned fewer findings of support for the TRC and Indigenous-focused resources than expected, some libraries had particularly promising approaches contributing to Call to Action 22. While most of the health library websites that contained Indigenousfocused resources did so in the form of subject guides, some libraries went beyond simply offering a single "Indigenous Studies" toolkit to encompass the totality of Indigenous issues, or including the TRC report within those Indigenous subject guides. For example, the University of Saskatchewan has a "ReconciliAction Resources" Libguide to encourage the enacting of reconciliation [29]; Dalhousie University has a subject guide dedicated to "TRC Calls to Action -Library Resources and Best Practices Subject Guide" [30], and the University of PEI has a TRC guide currently under development [31]. The Northern Ontario School of Medicine Libraries are notable for committing to using TRC-approved terminology relating to Indigenous peoples [32], and have numerous Indigenous-focused subject guides, including resources for cultural competency.
As noted in the "Results" section, academic libraries were most highly-represented among health libraries with visible TRC content. Since the most common way to incorporate TRC-related content into a health library website was through subject guides, perhaps it is not surprising that academic institutions (which usually have a significant emphasis on research resources) would include more of these types of guides than other health libraries. Consumer health libraries, which have a public-or patient-oriented focus, also have a lot of content that would be relevant to Indigenous users and health professionals supporting 3 These results are current as of July 31, 2017.
Indigenous patients. Health libraries that were underrepresented in terms of visible TRC content were resource centres (especially those in hospitals dedicated to specific health concerns) and health science libraries that primarily cater to staff. The purpose and intended audience for each health library was an important factor for whether or not that library had content relating to the TRC or Indigenous issues. In general, public-facing or academic researchoriented health libraries were more likely to exhibit a visible relationship to the TRC. This may have to do with a number of factors that are unrelated to commitment to the TRC's calls to actions, such as the capacity of the library to maintain a detailed online presence.

Challenges
There were some inherent challenges to researching our topic. One challenge related to our literature review searching was the use of controlled vocabularies and indexed terms related to Indigenous peoples: offensive legacy vocabulary notwithstanding, unfortunately even current terminology used to refer to Indigenous peoples within databases lags behind the evolution of culturally appropriate vocabularies in contemporary discourse [33].
From our content analysis of health libraries a few difficulties emerged. Firstly, many health libraries do not have an online presence outside of the larger institution they fall under, or they may not have an online presence at all, which makes it difficult to discover if they are responding to the TRC; they may be, but it is not immediately visible online. Secondly, there was difficulty in parsing whether initiatives from health libraries were in response to the TRC or whether they were pre-existing; although we determined that the important thing to acknowledge is that these initiatives exist, regardless of the catalyst for their implementation, recognition of the TRC as a significant national undertaking is still important, and is not being addressed to the level it should be. Thirdly, since a broad approach to the definition of health libraries was used, some health library websites intended purely for staff or intra-organization use were not accessible to public searching. Lastly, for health libraries whose services are primarily offered in French, the authors' linguistic limitations posed barriers to thoroughly analysing French-Canadian health libraries.

Next Steps
The authors recommend that future research be done to build on the findings of this content analysis. Possible avenues of inquiry include researchers fluent in French analysing French-Canadian medical school and health library websites, research into how subcategories of health libraries have responded differently to the calls to action, and further research into concrete TRC-related actions by Canadian health libraries that are not visible online.

Conclusion
It has been 2 years since the TRC released its final report and calls to action. In that time, not many Canadian health libraries have made progress in addressing the TRC's health-related recommendations. While this research paper acknowledges its limitations in assessing just how much Canadian health librarianship has responded to the TRC, given the challenges detailed above, the final assessment is that it is not clear how Canadian health libraries are engaged as visible, active participants in the processes of truth and reconciliation. Achievement of the TRC's goals requires the work of all Canadians, in every sector, but it is of vital importance in the provision of health care, which concerns matters of life and death. An article in the September issue of the Health Information & Libraries Journal has identified improving Indigenous health and library services as a key goal for health sciences libraries in Canada, following the release of the TRC report [34]. In that spirit, we encourage more Canadian health libraries to publicly declare their support for the TRC calls to action, and to commit to initiatives that directly respond to the recommendations.

19
We call upon the federal government, in consultation with Aboriginal peoples, to establish measurable goals to identify and close the gaps in health outcomes between Aboriginal and non-Aboriginal communities, and to publish annual progress reports and assess long-term trends. Such efforts would focus on indicators such as: infant mortality, maternal health, suicide, mental health, addictions, life expectancy, birth rates, infant and child health issues, chronic diseases, illness and injury incidence, and the availability of appropriate health services. 20 In order to address the jurisdictional disputes concerning Aboriginal people who do not reside on reserves, we call upon the federal government to recognize, respect, and address the distinct health needs of the Métis, Inuit, and off-reserve Aboriginal peoples. 21 We call upon the federal government to provide sustainable funding for existing and new Aboriginal healing centres to address the physical, mental, emotional, and spiritual harms caused by residential schools, and to ensure that the funding of healing centres in Nunavut and the Northwest Territories is a priority. 22 We call upon those who can effect change within the Canadian health-care system to recognize the value of Aboriginal healing practices and use them in the treatment of Aboriginal patients in collaboration with Aboriginal healers and Elders where requested by Aboriginal patients. 23 We call upon all levels of government to: i. Increase the number of Aboriginal professionals working in the health-care field.
ii. Ensure the retention of Aboriginal health-care providers in Aboriginal communities.
iii. Provide cultural competency training for all health-care professionals. 24 We call upon medical and nursing schools in Canada to require all students to take a course dealing with Aboriginal health issues, including the history and legacy of residential schools, the United Nations Declaration on the Rights of Indigenous Peoples, Treaties and Aboriginal rights, and Indigenous teachings and practices. This will require skills-based training in intercultural competency, conflict resolution, human rights, and anti-racism.