Evidence synthesis – Culturally and structurally competent approaches to health research with Black communities in Atlantic Canada: a rapid review

Abstract

Introduction: Anti-Black racism is deeply entrenched in Canadian institutions and has deleterious impacts on Black populations. Black populations have resided in the Atlantic region since the late 17th century. Despite longstanding histories, Atlantic Black populations face significant inequities, including the highest rates of child poverty among Black children across Canada. Community consultations in Atlantic Canada have highlighted a desire to bring attention to these health inequities. The purpose of this review was to identify existing literature pertaining to Black health research in Atlantic Canada and highlight culturally appropriate practices.

Methods: The search strategy was developed with a librarian and focussed on health research pertaining to Black populations in the Atlantic provinces of Canada, covering eight databases. All articles were imported into Covidence for screening, with independent reviewers assessing titles, abstracts and full texts.

Results: Forty-seven studies met the inclusion criteria. Findings demonstrated the pervasiveness and impact of racism, the importance of community engagement as a key cultural consideration and the adoption of participatory action research frameworks as culturally appropriate.

Conclusion: This review revealed opportunities for improving Black health research in Canada’s Atlantic provinces. Future research warrants attention to this region and the use of culturally and structurally appropriate research approaches and methods. Recommendations include improved education on Black history and a training module within existing ethical guidelines for culturally and structurally competent research with Black communities.

Keywords: Black Canadians, racism, health inequity, cultural competency, Atlantic Canada

Introduction

The systematic inequities facing Black people have persisted since Canada’s colonization, but police brutality, global anti-racism protests and a pandemic that disproportionately affected Black communities have brought anti-Black racism into prominence.^{Footnote 1Footnote 2Footnote 3Footnote 4} Anti-Black racism in Canada is defined as “policies and practices rooted in Canadian institutions, such as education, health care and justice, that mirror and reinforce beliefs, attitudes, prejudice, stereotyping and/or discrimination towards people of Black-African descent.”^{Footnote 5} The legacy of colonialism, the Trans-Atlantic slave and historic segregation have created a social ecosystem that disproportionately disadvantages Black Canadians. This has manifested in disproportionately high rates of poverty in Black families,^{Footnote 6} limited access to education^{Footnote 7Footnote 8} and inequitable access to healthcare for Black Canadians, resulting in significant health and social disparities.^{Footnote 9Footnote 10} Despite growing recognition of the magnitude and pervasive nature of anti-Black racism and the health inequalities it has created, comprehensive, empirical research reporting on the health outcomes of Black Canadians remains limited.

Eurocentric research institutions have a long and problematic history of perpetrating harm and excluding racialized populations from research, policy and practice. The legacy of misappropriated findings, experimentation and the morbid maltreatment of Black bodies and communities (e.g. the Tuskegee Syphilis Study) have had lasting, intergenerational impacts.^{Footnote 11} Studies have found that people of African descent are more likely than age-, education- and gender-matched White people to believe that research findings will be used to reinforce negative stereotypes^{Footnote 12} or that the research itself will expose them to unnecessary risks.^{Footnote 13Footnote 14} Contemporary research and research methodologies are often exclusionary and continue to include majority White, English-speaking, affluent participants.^{Footnote 13Footnote 15} Investigators themselves have been known to assume that people of African descent will not consider participating in research, and do not put in the time or effort to make studies inclusive and safe.^{Footnote 16Footnote 17} The problematic categorization of participants by race or ethnicity without context has contributed to the perpetuation of negative stereotypes about certain racial groups.^{Footnote 18} Many standardized measures, interventions and assessments have been designed using majority-White participants and may not be appropriate to use with Black or other racialized people.

Canada has a growing and diverse Black population. As of 2021, over 1.5 million Black people were residing in Canada, comprising 4.3% of the national population.^{Footnote 19} This number is set to double by 2041, with new immigrants and refugees arriving from Africa and the Caribbean annually.^{Footnote 20} Despite Canada’s multicultural identity, discrimination against Black people is deeply entrenched and normalized in Canadian institutions, policies and practices, and is often not noticed by non-Black folk.^{Footnote 21} In fact it has been reported that anti-Black structural racism was present in most of Canada’s core institutions (e.g. health, criminal-legal, education), with ongoing negative impacts causing further marginalization for Black communities.^{Footnote 21}

Stigma and discriminatory maltreatment are experienced by Black Canadians in intersecting ways across individual, institutional and systemic dimensions. This shapes access to social and economic resources that promote health and wellness (e.g. food, housing, education and employment) contributing to chronic stress, with devastating implications for Black people’s physical and mental health. The Public Health Agency of Canada has found significant gaps in the lifespan of Black men and women: White, university-educated men had life expectancies 14.2 years higher than those of Black men without a high school education; and White, university-educated women had life expectancies 10.3 years higher than those of Black women without a high school education.^{Footnote 9Footnote 22} Black Canadians were significantly more likely than White Canadians to report diabetes and hypertension.^{Footnote 23Footnote 24}

Atlantic Canada is a geographic region of Canada that comprises four provinces: New Brunswick (NB), Nova Scotia (NS), Prince Edward Island (PE) and Newfoundland and Labrador (NL). Atlantic Canada is home to a historic Black community known as the African Nova Scotians (ANS) or indigenous African Nova Scotians.^{Footnote 25} This distinct population has a unique history, with an ancestral lineage dating back to the late 17th century. After that time, thousands of formerly enslaved Black Loyalists arrived in Nova Scotia in 1783, followed by the Jamaican Maroons and other Caribbean immigrants in the 19th and 20th centuries.^{Footnote 26} In contrast to other regions, these historic Black populations have predominately resided in Atlantic Canada for over four hundred years and have a history and culture specific to the region. This review uses the term “Black” as a collective term for all people of African descent, but recognizes the greater discussion that needs to continue regarding culturally appropriate identifiers.^{Footnote 27}

Though ANS have resisted extensive racial and colonial violence, centuries of maltreatment have contributed to intergenerational trauma, health inequalities and barriers to healthcare access that remain today.^{Footnote 1Footnote 28} For example, the Atlantic provinces have reported the highest rates of child poverty among Black children in the country (40% in NS, 41% in NL, 37% in NB and 33% in PE), compared to the non-Black national average of 17%.^{Footnote 29} Moreover, Black men in Nova Scotia are six times more likely to experience street checks by police than their White counterparts. Additionally, anti-Black racism in the Nova Scotian education system has affected African Nova Scotian children aged as young as 18 months.^{Footnote 7Footnote 30Footnote 31}

Community consultations with ANS and other Black communities in Atlantic Canada have highlighted a desire to bring attention to the health inequities facing their communities. Yet, they also report mismanagement of Black health data and the over-researching of their communities. This is consistent with existing evidence documenting how the researchers and health practitioners have caused undue harm to Black communities through insensitive, inappropriate and unethical research.^{Footnote 11Footnote 14Footnote 32} Common examples of repeated and ongoing harm in research include reporting research results in a manner that reinforces negative stereotypes, failing to consult with communities consistently and meaningfully and conducting research that does not align with community needs. While the renewed awareness of anti-Black racism is welcomed, novel research conducted with Black communities must be conducted in a way that promotes their best interests and safety.

The purpose of this review was to identify existing literature pertaining to culturally and structurally competent Black health research in Atlantic Canada. The objectives of this rapid review were twofold: (1) to identify and document available literature pertaining to Black health in Atlantic Canada; and (2) to describe the research topics, methodologies, methods and reporting techniques employed in studies that examined Black health in Atlantic Canada. The findings of this review will be useful for informing future research with Black communities in and beyond Atlantic Canada. The concept of culturally and structurally competent research was recommended to us by a Black health community organization. The term combines the familiarity of cultural competence (i.e. sensitivity and responsiveness to racial, ethnic, gender-based and sociodemographic differences and preferences) with the less familiar structural competence (i.e. sensitivity and responsiveness to the impact of forces at the societal, policy, socioeconomic and individual levels).^{Footnote 33} Thus, culturally and structurally competent research is sensitive to both Africentric ways of knowing and the macrosystems that influence Black populations.

Methods

A rapid review was conducted to develop timely and culturally adept synthesis of the current state of research on Black health in Atlantic Canada. This review was conducted in accordance with guidelines outlined by Tricco et al.^{Footnote 34} The search strategy was developed in collaboration with a health science librarian at Dalhousie University. The search was conducted in July 2022 and was performed in eight databases: MEDLINE, Embase, CINAHL, Cochrane, PsycInfo, Scopus, Sociological Abstracts and Social Services Abstracts (full search strategy available on request from authors). The criteria for inclusion followed the mnemonic PCC—representing the population, concept and context.

Eligibility criteria

Population

While ANS constitute a significant portion of Black people in Atlantic Canada, this review included studies with participants of African descent. Search terms included Black, Black-Indigenous, African Nova Scotian, Black Scotian, African descent, Black descent, African. Studies that included multiple populations in Atlantic Canada alongside an analysis of Black populations were included; however, only the sub-analysis of Black Canadians in the Atlantic region was considered.

Concept

The concept under study was health as it relates to Black communities in Atlantic Canada. The World Health Organization’s definition of health is “a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity.”^{Footnote 35} The review includes social determinants of health, referring to the range of personal, social, economic and environmental factors that influence population health, such as socioeconomic status, racism, working conditions, physical environments and access to healthcare.^{Footnote 36}

Context

This review considered studies that explored the health of people of African ancestry in the four provinces of Atlantic Canada (New Brunswick, Nova Scotia, Prince Edward Island and Newfoundland and Labrador). The total population of the Atlantic region is 2.41 million.^{Footnote 37}

Types of sources

This rapid review considered studies that utilized a variety of research designs, encompassing both qualitative and quantitative data. These included experimental and quasi-experimental study designs, analytical observational studies, descriptive observational study designs, phenomenology, grounded theory, ethnography, and participatory action research. Commentary, opinion and perspective articles were also included in an effort to capture a breadth of research and varying ways of disseminating research. Evidence synthesis articles were not included but reference chaining was used to identify articles for inclusion.

Screening, study selection and extraction

All articles were imported into Covidence (Veritas Health Innovation, Melbourne, AU), an online evidence synthesis tool, and were assessed in detail against the inclusion criteria by two independent reviewers. Any disagreements that arose between the reviewers at each stage of the selection process were resolved through discussion or with a third reviewer. The data extraction process was carried out in Covidence. For consensus purposes, two independent researchers extracted the data. The data extraction tool contained fields for purpose and objectives, location of study, population, health dimension, research design, theoretical framework used, data collection and analysis methods, key findings, community engagement techniques, cultural considerations and recommendations.

Results

Three thousand, seven hundred and fourteen (3714) articles were retrieved, and 1169 duplicates removed. Two thousand, five-hundred and forty-five (2545) titles and abstracts were screened by two independent reviewers for assessment against the inclusion criteria. A total of 169 full text articles were reviewed. The results of the search are presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews (PRISMA-ScR) flow diagram (Figure 1).^{Footnote 34}

Figure 1 : Descriptive text

Identification of studies via databases

• Step 1: Identification
  • Records identified from databases (n = 3714)
    • Records removed before screening:
      • Duplicate records removed (n = 1169)
• Step 2: Screening
  • Records screened against title and abstract (n = 2545)
    • Reports excluded (n = 2376)
  • Reports sought for retrieval (n = 169)
    • Reports excluded (n = 122)
      • 72 wrong population
      • 21 full text not available
      • 12 wrong concept
      • 10 wrong study design
      • 5 wrong context
      • 2 duplicates

This resulted, in the Included step, in n = 47 studies being included in the review.

• Step 3: Included
  • Studies included in review (n = 47)

This rapid review included a total of 47 studies. Two of the studies were published prior to the year 2000, 27 were published between 2000 and 2014 and 18 were published from 2015 onward. Of the studies that met the inclusion criteria, almost all were from Nova Scotia (n = 44).^{Footnote 25Footnote 38Footnote 39Footnote 40Footnote 41Footnote 42Footnote 43Footnote 44Footnote 45Footnote 46Footnote 47Footnote 48Footnote 49Footnote 50Footnote 51Footnote 52Footnote 53Footnote 54Footnote 55Footnote 56Footnote 57Footnote 58Footnote 59Footnote 60Footnote 61Footnote 62Footnote 63Footnote 64Footnote 65Footnote 66Footnote 67Footnote 68Footnote 69Footnote 70Footnote 71Footnote 72Footnote 73Footnote 74Footnote 75Footnote 76Footnote 77Footnote 78Footnote 79Footnote 80} Only one study from each of New Brunswick,^{Footnote 81} Prince Edward Island^{Footnote 82} and Newfoundland and Labrador^{Footnote 83} met the inclusion criteria. 

Findings are presented in three sections that cluster the stages of the research cycle. The first section, “Designing and implementing research with Black populations,” outlines frequently used approaches and theoretical models, and common features of the target populations, recruitment and data collection and analysis. The second section, “Findings and recommendations of the available research,” describes common findings and recommendations of included studies. Finally, section three, “Considerations outside of Eurocentric approaches to research,” highlights the importance of considering culture and community engagement in research with Black populations. Each section provides a narrative synthesis of extracted data.

Designing and implementing research with Black populations

Included studies focussed on varying areas of health and included mental health,^{Footnote 40Footnote 45Footnote 49Footnote 55Footnote 58Footnote 78Footnote 80Footnote 82} sexual and reproductive health,^{Footnote 43Footnote 46Footnote 54Footnote 56Footnote 57Footnote 59Footnote 65Footnote 71} racism,^{Footnote 39Footnote 41Footnote 47Footnote 52Footnote 68Footnote 69Footnote 71Footnote 81} food security^{Footnote 42Footnote 66Footnote 67Footnote 79} and palliative care.^{Footnote 62Footnote 75Footnote 77} Table 1 provides an overview of research approach; research design; theory, frameworks or models; recruitment and sampling; data collection; and data analysis. Research approaches designated as “other” in Table 1 include articles that do not fall under the traditional qualitative-quantitative dichotomy—for example, viewpoint articles, perspective articles and opinion articles.

Table 1. Characteristics of included studies

Author(s) Year	Research approach	Research design	Theory, framework or model	Recruitment Sampling	Data collection	Data analysis
Adjei et al.Footnote 83 2018	Qualitative	Multifaceted research design	Critical race study	Existing networks Purposive	Semistructured interviews (one-on-one and focus group)	Qualitative analysis
Aziz et al.Footnote 82 2022	Mixed methods	Cross-sectional study	NA	Local media (newspapers and radio) and community networks (notice boards and social networks) Representative	Surveys (with qualitative, open-ended questions)	Statistical analysis (independent sample t tests, ANOVA, compared mean scores), content analysis
Baker et al.Footnote 81 2001	Qualitative	Constructivist research design	NA	Board members of multicultural associations assisted recruitment Purposive and snowball	Interviews (one-on-one)	Constant comparative analysis
Beagan and EtowaFootnote 39 2009	Mixed methods	NA	Everyday racism	Word of mouth Nonrepresentative purposive and snowball	Surveys and semistructured interviews	Thematic analysis, statistical analysis
Beagan and EtowaFootnote 40 2011	Qualitative	Narrative research	NA	Word of mouth Purposive and snowball	In-depth, semistructured interviews	Thematic analysis
Beagan et al.Footnote 41 2012	Mixed methods	Exploratory design	NA	Word of mouth Purposive and snowball	Interviews and surveys	Thematic analysis, statistical analysis
Beagan and ChapmanFootnote 42 2012	Qualitative	NA	NA	Advertisements and word of mouth Purposive and snowball	Semistructured, one-on-one interviews and observation	Thematic analysis
Beals and WilsonFootnote 25 2020	Qualitative	Arts based and community-based research	Intersectional Black feminist decolonizing perspectives and identity theory	Through “Proclaiming Our Roots” project Convenience	Workshops, semistructured interviews	Thematic analysis
Bernard et al.Footnote 77 2014	Mixed methods	Naturalistic inquiry and cross-sectional secondary data analysis	NA	Purposive	Secondary data analysis (survey data) of data from Racism, Violence, and Hate Study and interviews (one-on-one and focus group)	Thematic analysis
BernardFootnote 38 2020	Other	NA	Practice Principles based on Africentric theory	NA	NA	NA
Bhawra et al.Footnote 79 2021	Quantitative	Quasiexperimental (prospective cohort study)	NA	Face-to-face intercept sampling method stratified by region and type of location	Surveys	Statistical analysis (descriptive, multinomial logistic regression)
CrooksFootnote 43 2018	Qualitative	Case study	NA	NA	NA	NA
Davidson et al.Footnote 44 2001	Qualitative	Cross-sectional	NA	Database of provincial telephone numbers, systematic sampling procedures from a list of randomly selected Nova Scotian households in the database	Surveys	Statistical analysis (descriptive statistics, one-way ANOVAs, Pearson chi-square tests)
DavisFootnote 45 1964	Quantitative	Cross-sectional	NA	Students were drawn from Grades 7, 8 and 9 to correspond as closely as possible in educational level to Karon’s school children Purposive	Standardized tests	Statistical analysis
Davis et al.Footnote 46 2013	Qualitative	NA	Critical race theory	Phase 2: flyers, word of mouth and community networks Purposive	Interviews (one-on-one and focus groups)	Thematic analysis
Delisle and SweeneyFootnote 47 2018	Other	NA	NA	NA	NA	NA
EtowaFootnote 48 2005	Qualitative	Grounded theory	NA	Community organizations and existing networks Purposive convenience, theoretical and snowball sampling	Interviews (informal), observation, field notes and group meetings	Constant comparative method
Etowa et al.Footnote 49 2007	Mixed methods	Participatory action research and interpretive phenomenology	Interpretive phenomenology paradigm (Africentric paradigm)	Purposive sampling	Interviews (one-on-one and focus groups), community workshops and survey	Thematic analysis and statistical analysis (descriptive)
Etowa et al.Footnote 50 2007	Qualitative	Participatory action research	NA	Community networks Purposive, theoretical and snowball sampling	Interviews (one-on-one)	NA
Etowa et al.Footnote 51 2007	Mixed methods	Participatory action research	NA	Existing networks of community facilitators and community networks Purposive and snowball sampling	Interviews (one-on-one and focus groups) and surveys	Thematic analysis
Etowa et al.Footnote 52 2009	Qualitative	Grounded theory	NA	Theoretical sampling	Interviews (one-on-one and focus groups), interview observations and field notes	Constant comparative method
Etowa et al.Footnote 53 2012	Other	NA	Participatory action research	NA	Surveys	Statistical analysis and thematic analysis
EtowaFootnote 54 2012	Qualitative	Feminist participatory action research	NA	NA	Interviews (one-on-one and focus groups)	Thematic analysis
Etowa et al.Footnote 55 2017	Mixed methods	NA	NA	Purposive, snowball sampling	Surveys, interviews (one-on-one and focus groups) and community workshops	Qualitative and quantitative analysis
Evans et al.Footnote 56 2005	Qualitative	Participatory action research	NA	Community networks (organizations and leaders)	Interviews (focus groups)	Thematic analysis
Gahagan et al.Footnote 57 2011	Mixed methods	NA	NA	Flyers, existing networks (community and healthcare services contacts)	HIV surveillance data and interviews (in-depth, semistructured, one-on-one)	Thematic analysis and statistical analysis (descriptive)
Jean-PierreFootnote 58 2021	Qualitative	Cross-sectional	Cultural trauma	Word-of-mouth, email, posters Snowball sampling/respondent-driven sampling	Interviews (one-on-one and focus groups)	Thematic analysis
Johnston et al.Footnote 59 2003	Quantitative	Cohort study	NA	Mailing letters Sample derived from a provincial database	Data registry	Statistical analysis (two dimensional cross-tabulations and chi-square tests, logistic regression)
Kisely et al.Footnote 60 2008	Quantitative	Retrospective cohort study	NA	NA	Administrative databases	Statistical analysis (incidence rates, descriptive statistics)
LeBrasseurFootnote 74 2022	Mixed methods	Participatory action research	NA	Existing networks (to form advisory committee)	Survey (digitally map-based)	Literature review, descriptive analysis
MaddalenaFootnote 61 2005	Qualitative	Case study, reflexive ethnography	Feminist ethics	Mail survey Purposive sample	Interviews, surveys and document review	Discourse analysis, thematic analysis, reflexive ethnography and ethnography
MaddalenaFootnote 76 2010	Qualitative	Case study	NA	Purposeful sampling	Interviews (one-on-one, in-depth)	Discourse analysis, thematic analysis, reflexive ethnography and ethnography
Maddalena et al.Footnote 75 2010	Qualitative	Case study	NA	Purposeful sampling	Interviews (one-on-one)	Thematic analysis and discourse analysis
Maddalena et al.Footnote 62 2013	Qualitative	NA	Naturalistic inquiry and participatory action research	Through local community church Purposeful and snowball sampling	Interviews (focus groups)	Thematic and discourse analysis
NourpanahFootnote 63 2019	Qualitative	Ethnography	NA	NA	Interviews (ethnographic)	Narrative analysis
NyikaFootnote 64 2022	Qualitative	Photovoice	Critical race theory–social constructivism framework	Invitations through school staff (principals, vice principals and support staff) Purposeful	Photovoice and interviews (one-on-one and focus groups)	Thematic analysis
Paynter et al.Footnote 65 2022	Qualitative	NA	Community-based research	Email to past doula training participants	Semistructured interviews	Thematic analysis
Ristovski-Slijepcevic et al.Footnote 67 2008	Qualitative	NA	NA	Community based organizations, community contacts and public notices	Interviews, observations	Thematic analysis
Ristovski-Slijepcevic et al.Footnote 66 2010	Qualitative	NA	NA	Community-based organizations and public notices Purposive and snowball sampling	Part of a family-oriented food study (described elsewhere), interviews, shopping trip, participant observation	Critical discourse analysis
TaylorFootnote 80 2022	Qualitative	Grounded theory	Straussian grounded theory	Social media, community organization email lists Purposeful and snowball sampling	Interviews	The data were analyzed using techniques specific to Straussian grounded theory
WadeFootnote 78 1973	Quantitative	Cross-sectional	Maslow’s Theory of Needs	Existing network, letter to school Random sampling	Standardized tests and surveys	Theoretical analysis
WaldronFootnote 68 2015	Other	NA	NA	NA	Workshops	NA
WaldronFootnote 69 2018	Other	NA	NA	NA	NA	NA
WaldronFootnote 70 2018	Other	NA	NA	NA	NA	Sociospatial analysis
WatsonFootnote 71 2009	Qualitative	Ethnography	Interdisciplinary, problem-oriented approach	Direct requests at educational classes	Observations and interviews (one-on-one)	Thematic analysis
WeerasingheFootnote 72 2012	Qualitative	NA	Cultural health capital framework	Contact information obtained from community organizations	Surveys, interviews and discussions	Theory-driven coding and inductive coding
Wong et al.Footnote 73 2005	Other	NA	NA	Project assistants were used for recruitment, existing networks	Interviews (focus groups) and surveys	NA

Target populations

Varying terminology was used to describe Black populations in Atlantic Canada—for example, ANS,^{Footnote 38Footnote 40Footnote 41Footnote 77} Black^{Footnote 48Footnote 66Footnote 81} and African Canadian.^{Footnote 75} Several included studies focussed on multiple populations (e.g. Black populations and Punjabi British Columbians, White Canadians, Southeast Asian immigrants, etc.).^{Footnote 59Footnote 66Footnote 67Footnote 72Footnote 78} Studies sampled diverse Black populations at the intersections of gender, age, socioeconomic status, ability and immigration status. While some studies focussed on Black communities,^{Footnote 70Footnote 73} most focussed on subpopulations such as middle-aged women,^{Footnote 39Footnote 40Footnote 49Footnote 55} school-aged youth^{Footnote 45Footnote 78} and nurses.^{Footnote 48Footnote 52} No studies focussed on children, and four focussed on youth.^{Footnote 45Footnote 64Footnote 78Footnote 81} Three studies focussed on parents or family entities.^{Footnote 46Footnote 75Footnote 83} With respect to gender, 13 studies focussed solely on women,^{Footnote 39Footnote 40Footnote 41Footnote 44Footnote 48Footnote 50Footnote 51Footnote 53Footnote 54Footnote 55Footnote 59Footnote 71Footnote 72} while no studies solely focussed on men, and one study included, but did not focus on, gender-diverse individuals.^{Footnote 25}

Findings and recommendations of the available research

Key findings

The key outcomes and results from included studies had varying implications for Black health and associated research. The pervasiveness and impact of experiencing racism was threaded through the findings of several studies.^{Footnote 39Footnote 41Footnote 48Footnote 51Footnote 71Footnote 81} For example, racism impacted engagement in education,^{Footnote 81} had a distinct influence on occupation^{Footnote 39} and directly impacted health.^{Footnote 51} Several studies explored conceptualizations of health and health concerns. A core focus of such studies was developing an understanding of the social determinants of health that impact Black Canadians.^{Footnote 46Footnote 51Footnote 80} For example, Etowa and colleagues highlighted key determinants of health for rural Black Nova Scotian women and their families (e.g. racism, poverty, unemployment, access to health services and caregiving roles).^{Footnote 51} One study explored definitions of health.^{Footnote 53} Other studies found key health outcomes for Black Canadians, including higher likelihood of living in a food-insecure household^{Footnote 79} and higher morbidity levels associated with treated disease.^{Footnote 60}

Culture was woven through the findings of several studies. One study noted the importance of meals to ANS as a source of pride and identity.^{Footnote 42} Culture-based spirituality was also noted as a strong influence on African Canadians in Halifax.^{Footnote 77} Spirituality and religion were used as key coping mechanisms to deal with racism, as well as means of advocating for social justice.^{Footnote 41} Furthermore, a lack of access to culturally appropriate, sensitive and safe services and education was highlighted.^{Footnote 58Footnote 61Footnote 76}

Recommendations

Many studies offered valuable future directions for Black health data. The recommendations broadly fit into five categories: (1) recognizing the pervasive and real impact of racism on Black populations; (2) developing and providing education and cultural competence and safety training; (3) building partnerships with community prior to project start; (4) recognizing the importance of community-based approaches; and (5) developing a stronger research foundation.

Research conducted with Black populations is fundamentally flawed if the research team does not recognize the impacts and pervasive nature of racism. Etowa and colleagues state that it is important that “research in this area be undertaken with the recognition that race interacts with numerous other variables and experiences to determine the health of Canadian Black women and their families.”^{Footnote 51,p.72} The interactions between race and other variables and experiences denote the pervasive impact of racism on everyday lives of Black people.

Developing and providing education and cultural competence and safety training was the second most common recommendation. One study recommended ongoing education training for faculty and staff in nursing programs due to a lack of diversity and social inclusion training.^{Footnote 48} Another study suggested the need for cultural competence and safety training within curricula for childbirth educators and healthcare providers.^{Footnote 54} Jean-Pierre adopted a systems-level recommendation aimed at integrating culturally relevant and sustaining pedagogy within Nova Scotia’s education system.^{Footnote 58} Furthermore, she provides an explanation of how such integration would benefit Black learners:

Implementing culturally relevant and sustaining pedagogy across Nova Scotia may foster equitable learning environments for Black learners by providing fluency in their cultural heritage, fulfilling the long-awaited democratic promise of integrated public schools, and representing a form of civic repair where we redress the legacy of anti-Black racism in education.^{Footnote 58,p.1167-8}

Several other studies recommended cultural and structurally appropriate and competent training be implemented within healthcare and health education. Educational recommendations were mostly made for childbirth settings and professionals,^{Footnote 54Footnote 65Footnote 71} followed by nurses.^{Footnote 48}

Partnership and community were at the heart of culturally and structurally competent research throughout this review. This is reflected in the studies that recommended building community partnerships prior to commencing research.^{Footnote 51Footnote 54Footnote 62Footnote 68Footnote 69Footnote 73} Etowa and colleagues suggested that embedding community partnerships as an explicit goal can help research teams fully understand health issues and achieve improved health outcomes for Black populations.^{Footnote 51} Another study added that partnerships foster mutual respect between healthcare providers or organizations and community that, in turn, empowers communities to find their voices.^{Footnote 54} While partnerships were a core focus of recommendations to improve Black health research, one study recommended exploring mechanisms of developing partnerships to ensure effective engagement.^{Footnote 62}

Considerations outside of Eurocentric approaches to research

Community engagement

Community engagement (CE) is a process of working collaboratively with populations or groups that share specific characteristics to positively impact the health and well-being of that population.^{Footnote 84} CE operates on a spectrum from minimal involvement to community-led initiatives. CE as a spectrum was reflected in the conceptualizations expressed in the included studies in this review. For example, three studies discussed having appropriate population representation on the research team,^{Footnote 42Footnote 55Footnote 75} while others discussed community involvement in varying ways, including having community members assist in recruitment,^{Footnote 48} connecting with community organizations,^{Footnote 67} creating community advisory committees^{Footnote 46Footnote 73Footnote 74} and encouraging community leads and/or involvement throughout the entire research process.^{Footnote 51Footnote 54Footnote 56Footnote 75}

Articles often included community engagement but did not discuss the importance of the process. For example, Beagan and Etowa acknowledge the presence of “close-knit local communities”^{Footnote 40,p.287} and developed an African Nova Scotian research team, but do not touch on the reasons for adopting this method of community engagement. Further, Davis and colleagues hired an advisory committee of community members, but again, do not discuss the importance of the process of engaging community members in the research process.^{Footnote 46} Wong and colleagues touch on a “failure to identify leaders in each of the participant communities to act as cultural representatives”^{Footnote 73,p.12} as part of the reason for difficulty with recruitment and response rates.

Cultural considerations

Connecting with community arose as a key cultural consideration, and the importance of working collaboratively with community is discussed in the community engagement section above. Other key considerations were selecting appropriate theoretical frameworks^{Footnote 50Footnote 51Footnote 58Footnote 68Footnote 69Footnote 74Footnote 75} and engaging members of the Black population throughout the research cycle.^{Footnote 42Footnote 52Footnote 53Footnote 62Footnote 72Footnote 75} The theoretical frameworks adopted by included studies are outlined in Table 1. It is important to note that certain frameworks were discussed as culturally relevant and appropriate. Specifically, participatory action frameworks were frequently discussed as appropriate and relevant.^{Footnote 50Footnote 51Footnote 68Footnote 69Footnote 74} Other frameworks that were included, discussed and identified as culturally considerate were cultural trauma^{Footnote 58} and storytelling.^{Footnote 75}

Discussion

This rapid review was conducted as part of a national inquiry across three key regions in Canada (the Prairies, Quebec and the Atlantic region). The purpose of this review was to develop an understanding of the research cycle in the field of Black health in the Atlantic provinces of Canada. Specifically, key issues, opportunities and promising practices were identified to further improve the state of Black health research across the region. The results of our study suggest a dearth of literature in the Atlantic region, but also key areas for consideration to ensure that research is conducted with Black Canadians in a manner that is safe, culturally appropriate and beneficial to the community.

The lack of available literature (only 47 studies) poses a serious concern to ensuring culturally and structurally appropriate research. Trends in number of publications by year indicate that the turn of the millennium sparked an increased interest in Black health. However, the International Decade for People of African Descent—declared by the United Nations to extend from 2015 to 2024—did not result in a further, noticeable increase in interest in and generation of Black health data.^{Footnote 85} Because of the prevalence of anti-Black racism and systemic injustice, a broader foundation for this research area should be available.

A recent scoping review of participatory research methods in Indigenous health research supports this notion.^{Footnote 86} The study identified 211 articles for inclusion. Given the similarities in proportion of the population that Indigenous and Black individuals represent, and similarities in scope between the two reviews, one might expect a greater availability of research on Black health. The sparsity of available evidence may, in part, be due to the lack of mandatory race-based data collection in Canada,^{Footnote 87} community fatigue from exploitative research projects or a lack of culturally and structurally appropriate and ethical training for researchers and practitioners.^{Footnote 48Footnote 54Footnote 58}

Central to contributing to a broader foundation for Black health research in Atlantic Canada is ensuring that the design, development and execution of research is premised on cultural considerations. Our findings suggest that community engagement is an integral consideration for conducting research with Black populations and may improve project outcomes. Husbands and colleagues found that through engaging Black churches in an intervention (Black PRAISE) to promote critical awareness of HIV, congregants’ knowledge of HIV increased.^{Footnote 88} In addition to the importance of community leaders discussed by Wong and colleagues,^{Footnote 73} Black PRAISE may indicate the how crucial context is in the process of community engagement with Black populations. Integrating community engagement techniques into research has the potential to ensure culturally and structurally competent research is undertaken with Black populations in Atlantic Canada.

While community-based and participatory action research were frequently adopted, the importance of community extends beyond the adoption of a model or framework. Data governance frameworks exist that help to explain the centrality of community in Black health data. For example, the Engagement, Governance, Access and Protection (EGAP) Framework, out of Ontario, outlines engagement as the first of four core principles for data governance.^{Footnote 89} Engagement is not only a process of listening but rather ensuring the project hinges on what is meaningful to communities. This review highlights the many meaningful ways community can be engaged, from the creation of community advisory committees to the inclusion of Black researchers at the beginning of the project. Given the geographic spread and diversity of Black populations in Canada, there is a need for a framework that extends beyond Ontario and that represents the collective data ownership, governance and accessibility rights of all Black Canadians.

This review highlighted the many recommendations arising from the limited Black health research conducted in the Atlantic region of Canada. In order to develop an evidence base that informs action to address health inequities, there is a fundamental need for greater education and consideration of the histories and contributions of Black populations to the region. Currently, the Tri-Council Policy Statement “Ethical Conduct for Research Involving Humans (TCPS 2)” does not offer a module for conducting research with Black Canadians.^{Footnote 90} We recommend, to ensure and support the implementation of cultural and structural competence and safety training into services, that the federal funding agencies develop an appropriate module, created by Black communities and researchers, that will form the ethical groundwork for all research involving Black participants in Canada.

Strengths and limitations

A notable strength of this study is the rigorous search strategy adopted. The collaboration with a university librarian ensured the search strategy was comprehensive and accurate and captured all applicable and available information on the topic. Another strength is the use of a broad definition of health, enabling the capture of culturally and structurally appropriate and ethical Black health research that specific definitions might overlook.

This study also has potential limitations. Critical appraisal of literature may be of benefit to assess the trustworthiness of the study findings. Given the importance of community engagement in conducting research with Black populations, a search of grey literature might have identified key community-level data collection initiatives that exist outside the realm of published literature.

Conclusion

Findings from this study suggest there is a need for dedicated resources (e.g. a TCPS 2 chapter on ethical conduct in research with Black populations, and regional ethics frameworks for Black populations similar to the EGAP framework) to improve the state of Black health research in Atlantic Canada. There is a paucity of Black health data in the region, particularly for subpopulations including men, children and Black populations in NB, PE and NL. To maximize research participation and outcomes, particular attention should be paid to community engagement throughout the stages of the research process. A nationwide data collection and governance framework would provide an opportunity to improve the state of Black health data in the Atlantic region.

Acknowledgements

Thank you to the Public Health Agency of Canada for providing the funding to conduct this project. The research team would like to acknowledge Courtney Svab, a librarian intern, for their contributions to the development of the search strategy. We would also like to thank Melissa Rothfus, a university librarian, for providing supervision and expertise in the development of the search strategy for this review. Further, we thank Nicholas Hickens and Shirley Hodder, research assistants, for their contributions to the manuscript draft.

Conflicts of interest

This study was funded by the Public Health Agency of Canada.

Authors’ contributions and statement

• JY, ESC, KJ, BB, CS: data curation.
• JY, ESC, KJ, BB, CS: formal analysis.
• BHH: funding acquisition.
• ESC, KJ, BHH: methodology.
• JY, BHH: project administration.
• JY, CS: visualization.
• JY, ESC, KJ, BB, BHH: writing—original draft.
• JY, BHH: writing—review and editing.

The content and views expressed in this article are those of the authors and do not necessarily reflect those of the Government of Canada.

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