MS#1431 Fridkin The Ripples of Meaningful Final.pdf


 
 
 
 

The International Indigenous Policy Journal 
 

Volume 10 | Issue 3  
 
 

September 2019 
 

The RIPPLES of Meaningful Involvement: A 
Framework for Meaningfully Involving 
Indigenous Peoples in Health Policy Decision-
Making 
 
Alycia J. Fridkin 
University of British Columbia, alycia.fridkin@alumni.ubc.ca  

 
Annette J. Browne 
University of British Columbia School of Nursing, Annette.Browne@ubc.ca  
 
Madeleine Kétéskw!w Dion Stout 
University of British Columbia, madeleine_dion@hotmail.com  
 
 
 
 
 
 

 
 
 
 
 
 
 
 
 
 
 

 

 

Recommended Citation 
Fridkin, A. J., Browne, A. J., & Dion Stout, M. K. (2019). The RIPPLES of meaningful involvement: A framework for meaningfully 
involving Indigenous Peoples in health policy decision-making. The International Indigenous Policy Journal, 10(3).  
doi: https://doi.org/10.18584/iipj.2019.10.3.8309  



 

 

The RIPPLES of Meaningful Involvement: A Framework for 
Meaningfully Involving Indigenous Peoples in Health Policy Decision-
Making 
 

Abstract 
Indigenous Peoples experience the greatest health inequities in Canada and other colonized countries; yet, they are 
routinely excluded from health-related policy decisions. Those advocating for Indigenous health equity are often 
left wrestling with the question: What constitutes, and what can foster, meaningful involvement of Indigenous 
Peoples in the contemporary health policy climate? Twenty (n = 20) in-depth, open-ended interviews with 
Indigenous and non-Indigenous leaders in health and health policy were conducted with a view to understanding 
what constitutes meaningful involvement of Indigenous Peoples in health policy decision-making. The analysis 
suggests meaningful involvement requires attuning to underlying power dynamics inherent in policy making and 
taking action to decolonize and transform the policy system itself. Based on these findings, the authors offer a 
framework for meaningful involvement. 

 
Keywords 
Indigenous, Aboriginal, First Nations, Indigenous health, Aboriginal health, health inequities, health, meaningful 
involvement, engagement, participation, policy, decolonization 
 
Acknowledgments 
The authors gratefully acknowledge the contributions of Jim Frankish, the research support from the Critical 
Research in Health and Healthcare Inequities Unit at the University of British Columbia’s School of Nursing, and 
the funding received from the Canadian Institutes of Health Research’s Institute of Indigenous Peoples’ Health. 
 
Creative Commons License 

 
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 4.0 
License. 



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The RIPPLES of Meaningful Involvement: A Framework for Meaningfully Involving  
Indigenous Peoples in Health Policy Decision-Making  

Health and social inequities affecting Indigenous Peoples in Canada—namely, First Nations, Métis, and 
Inuit—have been consistently documented in key public health reports over the last several decades. 
Disparities exist across virtually every health indicator, including chronic disease, HIV, injuries, 
disabilities, mental health, problematic substance use, suicide, as well as social determinants of health 
such as housing, poverty, and employment (Browne et al., 2016; Brownridge, 2008; Nelson & Wilson, 
2017). These same disparities occur in other colonized countries, including Australia (Australian 
Institute of Health and Welfare, 2015; Dwyer, O'Donnell, Willis, & Kelly, 2016) and New Zealand 
(Mitrou et al., 2014). 

The literature suggests the consistency of these health inequities is hardly coincidental; it is the result of 
a history of colonial policies imposed on Indigenous Peoples from the moment of contact with 
European settlers. Wien (1999) argued that the history of Indigenous policy in Canada “is full of 
misguided policy choices,” which have contributed to key factors affecting Indigenous Peoples’ health, 
including the erosion of Indigenous economies and subsequent widespread poverty and starvation (p. 
102). For example, the Indian Act confined First Nations Peoples to reserves, where infectious diseases 
thrived due to isolation and poor living conditions (Kelm, 1999). The residential school system played 
an equally traumatic role on the health of Indigenous Peoples. High rates of tuberculosis and untreated 
illness resulted in the death of many children, and the overall neglect, abuse, malnutrition, and 
detachment from families, language, and culture additionally contributed to the poor health of residents 
(Truth and Reconciliation Commission of Canada, 2015a). The separation of children from their 
families also had a devastating impact on Indigenous communities and continues to have traumatic 
intergenerational effects (Nelson & Wilson, 2017). The Indian Act and residential school system, two 
policies that were made in isolation of Indigenous Peoples’ perspectives or involvement, are examples of 
how a top-down approach to Indigenous health policy has contributed to health inequities between 
Indigenous Peoples and non-Indigenous peoples in Canada. 

In the contemporary policy climate in Canada and globally, Indigenous Peoples have become more 
vocal about being involved in addressing health inequities; yet, health policy decisions are largely still 
made without involvement of Indigenous Peoples, and Indigenous women in particular (Dion Stout & 
Kipling, 1998; Oliver et al., 2015), which contributes to ongoing health and social inequities (Fiske & 
Browne, 2008; Howse & Dwyer, 2016; Lavoie et al., 2016; Loppie Reading & Wien, 2009). Some 
scholars argue that Indigenous Peoples’ health and quality of life can only be improved if addressed on 
Indigenous Peoples’ own terms, and there is a growing body of evidence showing that policies co-
produced with Indigenous communities have better outcomes (Walker, Moore, & Linklater, 2011). For 
example, in the Canadian context, the Transformative Change Accord in BC, a legal agreement between 
the provincial and federal governments and the First Nations Leadership Council, led to the creation of 
a First Nations Health Authority, where First Nations Peoples are able to provide health services based 
on a First Nations perspective of wellness (Gallagher, Mendez, & Kehoe, 2015). In Ottawa and 
Winnipeg, municipal governments have worked with Indigenous communities in policy and planning 
co-production, which has been successful in fostering community acceptance and implementation 
(Belanger & Walker, 2009). Indigenous Peoples’ involvement in health policy has additionally been 



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shown to improve Indigenous Peoples’ health (Lavoie et al., 2010; Matthews, Pulver, & Ring, 2008; 
Reading & Nowgesic, 2002) as well as policy-making processes (Quantz & Thurston, 2006).  

When it comes to decision-making impacting Indigenous Peoples’ health, there can also be value in 
including non-Indigenous peoples in the process. Regan (2005) argued that decolonization cannot be a 
project for Indigenous Peoples alone, as this is essentially asking Indigenous Peoples to take sole 
responsibility for healing themselves from the impacts of colonization. Aside from the ethical 
responsibility to address inequities created by their own governments, non-Indigenous peoples are 
appropriately positioned to disrupt their own colonial processes and may be key influencers in changing 
the status quo. Non-Indigenous people often occupy influential positions in government and/or act as 
gatekeepers, and when working in alignment with Indigenous Peoples, they may be an asset in 
overcoming systemic barriers. 

In the Canadian context, Indigenous health policy is a complex environment. Historically, the federal 
government is responsible for providing health services and benefits to First Nations who are registered 
with the federal government as a “Status” First Nations person. For all other Indigenous Peoples, 
including non-Status First Nations, Métis, and Inuit, health services are provided in the same way as they 
are for the rest of the non-Indigenous population: financed by the national health insurance plan and 
administered by the provinces or territories. In addition, there are numerous policies, legislation, and 
agreements between different levels of governments, including Indigenous government organizations, in 
different parts of the country. This jurisdictional complexity has created many gaps and ambiguities in 
relation to who is responsible for Indigenous Peoples’ health, and further contributes to the complexity 
of decision-making (National Collaborating Centre for Aboriginal Health, 2013). 

There have been significant efforts and initiatives to involve Indigenous Peoples in health policy 
decision-making in Canada, including the Indian Health Transfer Policy in the 1980s (O'Neil, 1993), 
the Royal Commission on Aboriginal Peoples in the 1990s (Royal Commission on Aboriginal Peoples, 
1996; Wien, 1999), the Kelowna Accord in the 2000s (DiPenta, 2006; Durbin, 2009; Patterson, 2006), 
and the Truth and Reconciliation Commission in 2015 (2015b). Each of these policy initiatives resulted 
in recommendations or calls to action, which include involving Indigenous Peoples in health policy 
decisions; yet, it is not clear what such involvement might look like nor what steps are needed to get 
there. Furthermore, Indigenous Peoples are becoming increasingly involved at high levels of decision-
making (i.e., being engaged as a partner at senior government tables). What is not clear is how 
Indigenous leaders see these experiences and if they believe the nature of their involvement is actually 
meaningful or influential. As Indigenous Peoples continue to become more prominent in mainstream 
policy systems, there is a need to explore Indigenous involvement from the perspectives of both 
Indigenous and non-Indigenous peoples with lived experience at health policy decision-making tables. 

Recognizing the need for clarity on what meaningful involvement looks like in the specific context of 
Indigenous health, the purpose of this article is to offer a framework and practical insights for 
meaningfully involving Indigenous Peoples in health policy decision-making. Drawing on findings from 
a qualitative study that explored Indigenous and non-Indigenous policy leaders’ perspectives on what 
constitutes, and what can inform, meaningful involvement of Indigenous Peoples in health policy 
decision-making, we articulate a new conceptualization of meaningful involvement rooted in seven key 



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elements. These findings have implications for policy making in other sectors and jurisdictions 
internationally. 

Literature Review: Indigenous Involvement in Health Policy 

For hundreds of years, Indigenous Peoples have been engaged in conversation with governments in 
order to resist oppressive policies and practices. However, throughout history and to the present day, the 
nature of engagement has remained largely colonial. Indigenous–government relationships are 
characterized by the domination of Eurocentric systems, whereby structural relations of power permeate 
engagement efforts (Coulthard, 2014). In policy domains such as treaty negotiations, land claims, 
natural resource extraction, and child welfare, Indigenous leaders have consistently demonstrated how 
inequitable power relationships restrict and define the terms of engagement, resulting in a widespread 
skepticism about the effectiveness of government engagements (Blackstock, 2011; Coulthard, 2014;   
Diabo, 2014; Palmater, 2014). Even when Indigenous Peoples are engaged with the explicit aim of 
autonomous decision-making or self-determination, such as self-government negotiations, the end result 
is often another iteration of colonialism and forced government dependence (Irlbacher-Fox, 2009). 

In the context of health policy, Indigenous Peoples’ involvement often occurs through processes that 
further perpetuate Indigenous Peoples’ exclusion from decision-making. For example, governments 
commonly use community consultations as a method for gathering Indigenous Peoples’ input on health 
issues, and in doing so tend to construct Indigenous Peoples as empowered and engaged citizens on one 
hand, while simultaneously undermining their power to make decisions on the other (Fiske & Browne, 
2008). Community consultations have resulted in the frequent failure of governments to include 
community input into policy decisions, which can devalue and delegitimize Indigenous Peoples’ 
perspectives and foster cynicism about the false promises of inclusion (Fiske & Browne, 2008; Howse & 
Dwyer, 2016; Lavoie et al. 2015; McConaghy, 2000; Smye & Browne, 2002). Government-initiated 
engagement processes have also been found to have harmful effects on Indigenous Peoples. These 
include misinterpretation of the priority issues (McConaghy, 2000; Smye & Browne, 2002), 
misappropriation of Indigenous knowledges (Rains, Archibald, & Deyhle, 2000), and political 
manipulation of Indigenous Peoples’ input for solutions that may not align with community priorities 
(LaRocque, 2010). These critiques expose how discourses on involvement, such as “consultation,” can 
become rhetoric that promotes the self-interests of governments and fails to address community issues 
of concern (Davidson, 2008; McWilliams, 2004). 

Considering the ways Indigenous Peoples are typically involved in policy decision-making, Indigenous 
leaders have called for new terms of engagement. The United Nations Declaration of the Rights of 
Indigenous Peoples (UNDRIP; United Nations, 2007) outlines a vision for Indigenous Peoples’ 
engagement on issues that affect them, including Indigenous Peoples’ rights to determine their own 
priorities and to be actively involved in developing health and social programmes. Countries such as 
Canada have since endorsed the UNDRIP and have mandated implementation (Indigenous and 
Northern Affairs Canada, 2017). In the realm of research, Indigenous scholars have also developed 
policies and guidelines for involving Indigenous Peoples, such the OCAP® Principles, which declare the 
need for Indigenous ownership, control, access and possession of data, and were developed as an 
expression of Indigenous self-determination in research (First Nations Information Governance Centre, 



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2019). Initiatives such as UNDRIP and OCAP® are relevant for thinking about how Indigenous Peoples 
could be more meaningfully involved in research and policy. 

Research Design and Methods 

In response to Indigenous Peoples’ repeated calls to be meaningfully involved in health policy decision-
making (Coulthard, 2014; Lavoie, Boulton, & Gervais, 2012; Matthews et al., 2008) and the gaps in the 
literature on how this can be achieved, this study aimed to provide further clarity into how meaningful 
involvement of Indigenous Peoples in health policy decision-making might be conceptualized, and 
further, how this could be achieved. The specific research objectives were: 

a. To explore, from the perspectives of leaders and decision-makers in Indigenous health and 
other areas of Canadian health policy, what constitutes meaningful involvement of 
Indigenous Peoples in health policy decision-making; and  

b. To develop recommendations for meaningfully involving Indigenous Peoples in health 
policy and decision-making processes in Canada and beyond.  

To address these objectives, 20 in-depth, open-ended interviews with leaders and decision-makers in 
Indigenous health and other health policy areas in Canada were conducted. The study was qualitative 
and exploratory in nature, and the focus of the interviews was on exploring participants’ experiences in 
health policy decision-making related to Indigenous Peoples’ health as well as these leaders’ perspectives 
on what constitutes meaningful involvement. The study received ethical approval through the 
University of British Columbia’s Behavioral Research Ethics Board (BREB). In accordance with current 
Canadian guidelines on research involving Indigenous Peoples (Government of Canada, 2017), this 
research was designed to focus on an issue of major priority to Indigenous Peoples, and the lead 
investigators included Indigenous (Dion Stout) and non-Indigenous (Fridkin & Browne) scholars with 
extensive experience on the research topic. Fridkin was the primary researcher and lead the data 
collection, analysis, and writing, and Dion Stout and Browne provided direction on the overall research 
study, including participant recruitment, data analysis, and interpretation of findings.  

The analysis and research design were informed by a theoretical framework rooted in perspectives that 
are attuned to issues of equity and relations of power within social and political structures. We included 
Indigenous and decolonizing perspectives, which focus on disrupting the dominance of Eurocentric 
perspectives, foregrounding Indigenous histories and narratives, and advancing Indigenous justice 
agendas (Battiste, 2009; Battiste & Youngblood Henderson, 2000; Denizen, Lincoln, & Smith, 2008; 
Ermine, 1999, 2007; Regan, 2005; Rigney, 1999; Smith, 1999; Turner, 2006). We further developed our 
analysis from critical theoretical perspectives such as postcolonial feminism, which focuses on disrupting 
“race-thinking” and drawing attention to how colonialism, race, ethnicity, culture, and gender shape 
inclusion, exclusion, and inequities (Anderson, 2000; Asher, 2017; Browne, Smye, & Varcoe, 2007). 
These theoretical perspectives shaped every aspect of the research, including the development of the 
research questions and methodology. For example, decolonizing perspectives were used to orient the 
research objectives towards issues of relevance and interest to Indigenous Peoples, and critical 
perspectives such as postcolonial feminism, intersectionality, and cultural safety were used to focus the 
analysis on the underlying power inequities that shape policy processes and Indigenous Peoples’ 
inclusion, as well as Indigenous Peoples’ experiences of safety at the policy decision-making table.  



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To capture a range of perspectives and insights on meaningful involvement in various policy contexts, 
we recruited participants who were working in positions related to Indigenous health across a range of 
governmental, organizational, and policy levels, paying attention to gender diversity. Both Indigenous 
and non-Indigenous participants were interviewed for two reasons:  

a. To explore a range of perspectives and experiences related to Indigenous Peoples’ 
involvement in policy, based on the recognition that socio-political positioning influences a 
person’s experiences and perspectives; and  

b. To include a sample that was somewhat reflective of the population of people working in 
Indigenous health policy settings, which includes both Indigenous Peoples and non-
Indigenous peoples. 

The sampling strategy involved a combination of purposive and convenience sampling (see Barbour, 
2001; Thorne, 2008). The research team identified people in their social networks who met the 
inclusion criteria, would have good insight on the research topic, and were positioned to provide insight 
on “what is happening and why it is happening” in the context of Indigenous health policy (Thorne, 
2008, pp. 89-91). These individuals were invited to participate in an interview. The study participants 
were leaders, decision-makers, or experts with significant experience working in Indigenous health or 
public health policy. Participants were located in geographic locations across Canada and held a range of 
leadership positions, including directors (n = 11), senior leaders (n = 6), managers or team leads  
(n = 2), and professors in health disciplines (n = 1). Half of the participants (n = 10) self-identified as 
Indigenous, approximately half self-identified as White, Euro-Canadian, and/or European (n = 9), and 
one (n = 1) self-identified as having mixed Indigenous and European ancestry. Approximately half of 
participants self-identified as women (n = 11) and half identified as men (n = 9). The age range of 
participants was between 47 and 76 years, with a mean age of 57 years. Participants were highly educated 
with many participants (n = 15) who had completed a graduate degree at the time of the interview and 
approximately half (n  = 9) who had professional designations in nursing, medicine, dentistry, or law.  

The interview guide was developed at the outset and further refined in response to emerging themes and 
insights gained from conducting the interviews. The questions were open-ended and exploratory in 
nature and sequenced with the intent of evolving from an information-based conversation to an in-depth 
discussion.  

Data collection and analysis were guided by a research team comprised of Indigenous and non-
Indigenous researchers with extensive experience in Indigenous health policy research in Canada. The 
study was conducted between 2012 and 2015 and ethical approval was provided throughout this time 
period.  

The interview and field note transcripts were organized using NVivo qualitative data analysis software, 
which included coding each transcript based on a codebook of topic-based codes developed from an 
analysis of initial reflections and subsequent readings of the data. A thematic analysis involving an 
inductive process of systematically reading and re-reading the data alongside the development of an 
evolving coding structure supported a more in-depth thematic analysis of emerging themes and insights. 
Subsequent levels of analysis involved articulating new conceptualizations arising from the data, which 



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were informed by the guiding theoretical perspectives and research questions (Richards & Morse, 2007; 
Thorne, 2008).  

To establish trustworthiness of the data, two participants were invited to dialogue with the primary 
researcher with respect to the analysis and the key elements of meaningful involvement identified 
through the research. Since the purpose of these follow-up discussions was to get an overall sense of the 
relevance of the analysis and the representation of the findings, and whether or not they resonated with 
participants, as opposed to assessing the accuracy of how each participant’s views were captured in the 
analysis, efforts were made to solicit meaningful feedback from a few select participants rather than 
systematically reviewing the findings with each participant. In particular, two Indigenous participants 
with extensive policy experience who were working in Indigenous health leadership roles within a large 
organization provided critical feedback and indicated that the overall thrust of the findings resonated 
with their experiences and represented a coherent account of the complexity of meaningful involvement 
in policy making. 

Findings 

The findings are organized into three sections:  

a. Wrestling with uncertainty, describing participants’ questioning on how to involve 
Indigenous Peoples in various settings;  

b. Attuning to power dynamics, drawing on participants’ lived experiences at the decision-
making table to illustrate the ways power inequities play out in policy and decision-making 
processes; and  

c. Perspectives on meaningful involvement, outlining participants’ insights on what has 
worked, what has not, and what is needed for involving Indigenous Peoples in more 
meaningful ways.  

Wrestling with Uncertainty: Immobilized by Sensitivity to “Doing the Wrong Thing” 

Participants recognized the need to meaningfully involve Indigenous Peoples and reflected on the 
challenges. Many non-Indigenous participants wrestled with the question of how to meaningfully 
involve Indigenous Peoples in the face of historical and ongoing colonization. One non-Indigenous 
participant explains:  

Well I think that one of the big issues, of course, is the whole issue of [colonization] . . . How it 
also shapes the policies that we have in this country . . . [H]ow do you back away from a colonial 
sort of attitude . . . in relationships and build a trusting relationship between the Aboriginal and 
non-Aboriginal communities so that we can be working together on these public health issues? 
(P08)  

In wrestling with questions such as these, the participants echoed LaRocque’s (2010) stated belief, “the 
majority of non-Native peoples in our country want to be fair and caring, not just replicating a history 
full of mistakes and some malefaction . . . Nevertheless, our encounter is informed by colonization” (p. 
14). Some Indigenous participants discussed the good intentions on the part of non-Indigenous people 
working in policy to find ways of involving Indigenous Peoples in more meaningful ways; yet, despite 



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such intentions, the historical and ongoing nature of colonialism was identified by both Indigenous and 
non-Indigenous participants as a significant stumbling block to working together.  

Although the participants displayed an acute awareness of the impact of colonialism on Indigenous and 
non-Indigenous encounters in policy decision-making, their interviews reflected an uncertainty about 
how to navigate these dynamics. This is illustrated in a debate within a health policy advisory group, 
which one non-Indigenous participant describes: 

[W]hen the [group] first formed, one of its goals was to pay special attention to Aboriginal 
Peoples’ health. That was part of their mandate from the beginning and they never did it. There 
were endless arguments about, how are we going to incorporate that? Would we have Aboriginal 
representation in the [group]? If we did that, do we need it at all levels of the [group], not only 
at the general [group’s] table but at the expert groups as well? Who would you choose? Who’s 
credible? How would you keep this from being political? This argument went on and on and on 
and no-one could come to a conclusion. (P19) 

P19 continues to share an analysis of what underlies such debates: 

[I]n Canada people who work in health who haven’t worked with First Nations people aren’t 
comfortable working with First Nations people . . . [They] are very reluctant to make decisions 
because they want to be very sensitive that they don’t do the wrong thing. And in being so 
sensitive to doing the wrong thing, they never do the right thing. Because they feel so timid and 
cautious. (P19) 

Like P19, other Indigenous and non-Indigenous participants explained how there is often a hesitancy to 
include Indigenous Peoples in decision-making that arises from a variety of fears, including making the 
wrong decisions, crossing jurisdictional boundaries, and receiving backlash from Indigenous 
communities. Several participants discussed the tendency for decision-making between Indigenous 
Peoples and non-Indigenous peoples to be uncomfortable, and some participants explain that this 
discomfort stems from the legacy of colonialism and the history of tensions between Indigenous Peoples 
and governments. These discussions illustrate how the “psychology of colonialism lingers” in policy 
settings, (LaRocque, 2010, p. 6), and how policy decision-making environments may be illustrative of 
what LaRocque (2010) described as “the contested ground upon which we, the Canadian colonizer–
colonialist and Native colonized, have built our troubled discourse” (p. 3).   

Although non-Indigenous participants wrestled with these uncertainties of knowing how to include 
Indigenous Peoples, some Indigenous participants reiterated the need to find ways of working through 
these challenges. As one Indigenous participant asserts, “Aboriginal representation . . . [is] extremely 
difficult to do . . . at a policy meeting table, but it has to be [done]” (P17). In referring to Indigenous 
representation as “extremely difficult to do,” this participant may be reflecting some of the challenges 
with representation that the non-Indigenous participants described above, such as trying to determine 
who should be included and how, and considering the colonial context that continues to permeate 
Indigenous and non-Indigenous relationships. Drawing from LaRocque’s (2010) assertion that both 
Indigenous Peoples and non-Indigenous peoples “are challenged to attend to decolonization while 
keeping with our respective legacies,” and that ending Indigenous Peoples’ marginalization in society 
must be a “collective aspiration” (p. 14), the interviews highlight the need for insight on how to foster an 



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environment where Indigenous Peoples and non-Indigenous peoples can work together within the 
colonial context towards a common policy goal. 

Elbows Up, Shutting Down: Attuning to Power Dynamics 

Participants’ lived experiences at policy decision-making tables revealed several ways underlying power 
dynamics play out at the decision-making table. One example of this is the inherent clash of paradigms 
that can be experienced when Indigenous Peoples participate in Eurocentric decision-making processes. 
The interviews illustrate how decision-making tables are often more suited to dominant norms 
operating in government about how meetings ought to proceed. One Indigenous participant (P09) 
explains, “it’s pretty common in the Aboriginal community to find people . . . [who] are reflective. We 
want time to think about . . . things. But we’re against the clock.” P09 further explains: 

[T]he way that the meetings are run . . . you’ve got two hours, you’ve got this much agenda . . . 
you have to butt in and interrupt if you want to get something said. I’m so uncomfortable doing 
that . . . [I]t completely goes against my nature and I think this is a cultural nature that I have . . . I 
use that expression “elbows up” . . . [A]nd it’s so against my nature to be able to do it. So that is 
really, really difficult. (P09) 

Indigenous participants also discussed how common it was for them to be the only Indigenous person in 
the room and how this posed significant challenges when discussing Indigenous issues. P09 describes 
being repeatedly asked to participate in meetings and speak to issues from an Indigenous person’s 
perspective: 

I have to have a little bit of their knowledge plus Aboriginal knowledge, right? . . . It’s hard to be 
an expert in everything, which is their expectation of me. And so it’s easy for them [the people at 
the table] to shut me down because they have more specific knowledge in their specific area than 
I do. (P09) 

These dynamics create a situation where even though an Indigenous person is invited to participate in 
meetings to provide expertise on Indigenous health, a hierarchy of knowledge systems creates an 
environment that makes it easy for Indigenous individuals to be shut down at the table.  

The interviews further suggest that Indigenous Peoples are uniquely implicated when participating in 
decision-making on Indigenous health issues, in that they are socially and politically located in the centre 
of the policy problem. Indigenous participants explained how they often have to actively strategize on 
ways of bringing up the tough issues, such as racism, and how this can be exhausting, isolating and 
painful. Reflecting on some participants’ observations that Indigenous individuals will stop coming to 
meetings, P09 suggests, “Maybe [Indigenous people] don’t come because it’s . . . so uncomfortable. And 
maybe they’re just not feeling strong enough to be the conveyor of that message today.” These data 
illustrate how Indigenous Peoples are inequitably positioned at policy decision-making tables, and how 
these dynamics can create situations that push Indigenous individuals away from participating in the 
process altogether.  

These findings may shed light on recent situations in Canadian politics where Indigenous leaders have 
resigned or stepped down from leadership positions due to intense public and political pressures, 



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bullying, or government refusal to adhere to their recommendations (see Atleo, 2014; Scott, 2019). 
When examining such situations in light of the analysis discussed in this article, Indigenous leaders’ 
resignations can be understood within the context of policy environments that are often uniquely violent 
towards Indigenous Peoples who participate in them. Considering these effects, a key factor enabling 
meaningful and sustainable involvement of Indigenous Peoples in health policy decision-making, is the 
way in which processes of involvement mitigate the effects of underlying power inequities. This includes 
recognizing and addressing power dynamics that contribute to Indigenous Peoples’ withdrawal and 
resignation from decision-making, and that ultimately foster Indigenous Peoples’ exclusion. 

The Tokenism Paradox: Perspectives on Meaningful Involvement 

In sharing their perspectives on what constitutes meaningful involvement, participants provided many 
insights on how to involve Indigenous Peoples in meaningful ways. For example, several participants 
described how there was a tendency for Indigenous individuals to be involved in decision-making in 
tokenizing ways, which some participants described as problematic. One Indigenous participant (P12) 
explains how Indigenous involvement often takes the form of “someone holding a feather or having an 
Elder come to do an opening prayer,” which can have, “deep spiritual meaning [for Indigenous Peoples], 
but have very superficial effects on White people.” While commenting on the tendency for Indigenous 
Peoples to be primarily included in cultural ways, another Indigenous participant shares: 

I worry that there’s a danger of us [Indigenous people] tokenizing ourselves by putting [culture] 
as the number one thing that you can do. It’s easy to do, it costs you five minutes at your 
meeting, you don’t have to spend any money and, “Oh there we’re done. We included 
Aboriginal people.” (P09)  

Dion Stout (2008) suggests although Indigenous cultural practices are often important to Indigenous 
Peoples’ identities, “this view becomes too narrow when it suggests that no one has to work hard on the 
non-cultural (social, political, economic) aspects of our lives” (p. 11). Inviting Indigenous Peoples to 
participate solely in cultural ways may thus perpetuate the construction of Indigenous Peoples as 
primarily cultural beings and undermines the broad range of perspectives and knowledges Indigenous 
Peoples may contribute to policy development and decision-making.  

Despite participants’ criticisms of the tendency for Indigenous individuals to be involved as, in one 
Indigenous participant’s words, “token Indians” who are “not allowed to do anything” (P16), the 
interviews also suggest tokenism may present an opportunity for involvement. One Indigenous 
participant explains: 

We cannot become . . . complicit with the appetite for tolerance . . . [But] in some spaces, that 
tokenism is a giant step forward. However . . . we can’t stop there . . . [Y]ou’ve got to start where 
they’re at, but it doesn’t mean you’ve got to expect less. Like prayer today, [but] how about next 
year we do something really radical, you know, besides a prayer. (P12) 

The perspective shared by this participant seems paradoxical: On the one hand, tokenism is problematic 
in that it can perpetuate the view that simply inviting an Indigenous person to the table is enough, or that 
Indigenous Peoples only need to be included for the purpose of fulfilling presumed ideas about infusing 
meetings with a cultural element; yet, on the other, tokenism can be viewed as a potential opportunity 



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10 

for Indigenous Peoples to have a seat at the table, especially when Indigenous Peoples have not been 
involved at all. When the fear of tokenism is used as justification to not include Indigenous Peoples at all, 
the tokenism paradox can be a helpful perspective in weighing the costs of tokenism versus the status 
quo of zero involvement.  

Importantly, several participants spoke about the need to move beyond tokenism in order to involve 
Indigenous Peoples in more influential ways. One participant who identified as being of mixed 
Indigenous and European ancestry explains:  

[Y]ou can’t just think that in some kind of band aid way you get an Indigenous person to the 
table and it’s gonna have any kind of influence. Because there’s such a risk of tokenism and such 
a risk of [thinking], now we’ve included Aboriginal people so therefore this . . . must be a better 
policy, not necessarily . . . [J]ust because you’re Aboriginal doesn’t mean that you think outside 
of the dominant way of thinking. You know you can have somebody at the table that’s just as 
capable of saying, “Oh, Aboriginal people should just pull up their socks as their Euro Canadian 
counterparts.” (P01) 

In addition to critiquing the assumption that including one Indigenous person will lead to better 
decisions, the findings highlight the need to involve Indigenous individuals who view Indigenous issues 
with an analytical lens that challenges dominant ways of thinking, and who are attuned to the structural 
forces that shape health and health inequities.   

The interviews also emphasized the need to focus on relationships between Indigenous and non-
Indigenous parties involved in decision-making. Participants spoke about tensions that exist as a result of 
colonial dynamics and shared examples of what has helped to build trust and good working 
relationships. One non-Indigenous participant (P06) explained how this process incited a shift in 
relationship between the parties, which resulted in the Indigenous group moving from an advisory role 
to becoming a partner in decision-making. Other participants talked about the nature of partnership 
required for Indigenous Peoples and non-Indigenous peoples to work together effectively. As this 
participant, who identified as Indigenous, describes:  

[Y]our players also have to be [engaged in] reciprocity [which] is very much . . . about 
personality. It’s the notion that you are true partners. When I talk about reciprocity . . . I mean 
very much the notion of having the right attitude, being committed to it, knowing that each are 
giving something and . . . both [government and Indigenous] partners are winning in this. (P20) 

These findings point to the attitudes and sense of commitment among those involved as a significant 
factor in overcoming the stumbling block of historical and ongoing colonialism, reconciling 
relationships, and working together in ways that are different from the past. 

In their discussions on what enables meaningful involvement, several participants spoke about the 
impact of formalized agreements between Indigenous and non-Indigenous parties. One Indigenous 
participant explains: 

We are attached to the [provincial agreement], if we didn’t have that we would have flat burnt 
out, we never would have gone anywhere . . . The business case [is] not good enough when it 



Fridkin et al.: The RIPPLES of Meaningful Involvement  

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11 

comes to Aboriginal issues. You have to have something really powerful to force people because 
if we didn’t have that, it wouldn’t happen. (P12) 

As in the example above, several Indigenous participants talked about the importance of formalized 
agreements as key documents that held governments accountable to including Indigenous Peoples and 
confirming that Indigenous Peoples’ voices were heard. Another Indigenous participant shares: 

We’re not advisors in our own health, we are decision-makers . . . that's in the principles of the 
agreement. So whenever someone at the table says something like “we’re not allowed to change 
the form, we’re not allowed to change the policy, [or] we can’t do it like that,” the principles of 
the agreement [allow us]. (P17) 

The participants explained that effective formal agreements are not merely symbolic gestures of 
government commitments to including Indigenous Peoples and addressing Indigenous health issues; 
they are legal documents that hold governments accountable to fulfilling their commitments. Both 
Indigenous and non-Indigenous participants also shared how agreements have often led to establishing 
protocols and ways of working together that enable better participation. These findings resonate with 
the findings in Cheema’s (2007) study, which show that “multi-directional accountability relationships” 
are a key factor in supporting the meaningful participation of Indigenous Peoples in health policy and 
planning (p. 29). 

Indigenous participants explained how the agreements enable access to high-level decision-making 
tables that are typically inaccessible, which create situations where Indigenous Peoples have the ear of 
decision-makers. Similarly, a non-Indigenous participant explained that the influence of “champions” at 
senior levels of government has been helpful in pushing forward Indigenous health agendas (P06). 
These data suggest that the involvement of high-level decision-makers may not only have an impact on 
the potential of decision-making processes to effectively change policy, but that this can facilitate 
Indigenous issues getting on the policy agenda. In this way, the interviews reveal how legislating 
Indigenous involvement can be a way of leveraging power: It compels those in power to take Indigenous 
Peoples’ agendas seriously. 

The data demonstrate that involving Indigenous Peoples in policy decision-making in more meaningful 
ways requires change at a deep structural level. One Indigenous participant explains, “really what we’re 
talking about is change,” and further clarifies, “I’m talking about change that goes to the guts of the 
organization [in] how they think and how they act, and that requires doing things in a different way” 
(P12). Although participants emphasized the challenges of trying to achieve this kind of structural 
change, they also reiterated the necessity for working towards this goal, as one Indigenous participant 
asserts, “This change has to come . . . We can no longer say it can’t be done” (P16). The findings 
emphasize the need to articulate ways of disrupting the status quo approach of policy decision-making 
and achieving structural change, as this is needed to foster Indigenous Peoples’ involvement at a more 
meaningful and influential level.  

	  



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Discussion: What Constitutes Meaningful Involvement? 

There are several significant key findings that emerged from this research: 

a. Even when the importance of involving Indigenous Peoples in decision-making is realized, 
the lack of clarity on what involvement should look like can prohibit any kind of 
involvement at all.  

b. When Indigenous Peoples are involved in a decision-making process, the inherent power 
imbalances between Indigenous Peoples and non-Indigenous peoples and ongoing colonial 
dynamics shape the experience of Indigenous Peoples participating in the process and limit 
the extent of involvement.  

c. While involving Indigenous Peoples in ways that may be viewed as tokenizing can serve as a 
significant first step towards more meaningful involvement, there is a clear need to move 
beyond tokenism. Meaningful involvement requires including Indigenous Peoples in more 
than only cultural ways (e.g., providing a cultural opening to a meeting), a commitment by 
all parties to reconcile relationships and work together in new ways, and formal agreements 
that mandate the inclusion of Indigenous Peoples and assert a mutual responsibility for 
decisions made. 

A critical analysis of the data reveals that meaningful involvement is often experienced as a paradox 
where Indigenous Peoples are excluded via processes of inclusion, and that fostering meaningful 
involvement requires attuning to the underlying power dynamics inherent in policymaking and taking 
action to decolonize and transform the policy system itself. This research provides insight into Smye and 
Browne’s (2002) question of whether or not Indigenous Peoples are involved in processes that “espouse 
the benefits of reform, in the absence of real material gains for aboriginal people” (p. 52). In order to 
inform thinking on how decision-making processes can become more meaningful, less harmful, and 
more beneficial to Indigenous Peoples, we need to conceptualize meaningful involvement in a way that 
considers how colonial dynamics shape the experience of Indigenous Peoples who are involved. 

In light of this consideration, we draw on the research findings to articulate a new conceptualization of 
meaningful involvement. The interviews point to the importance of involving Indigenous Peoples in 
ways that are not harmful and do not subsequently lead to withdrawal from process, but instead mitigate 
the multiple and sometimes covert ways racism and inequitable power dynamics play out at decision-
making tables and throughout decision-making processes. In this sense, meaningful involvement means 
challenging and disrupting the status quo; it connotes an approach to decision-making that is 
transformative and decolonizing in its aim to disrupt the systemic exclusion of Indigenous Peoples from 
policy processes. These insights gained from the research as a whole inform thinking on what constitutes 
the key elements of meaningful involvement. 

The Key Elements of Meaningful Involvement 

To articulate a new conceptualization of meaningful involvement that is attuned to underlying power 
inequities and disrupting the status quo, we describe seven evidence-informed key elements of 
meaningful involvement based on a thematic analysis of the data:  



Fridkin et al.: The RIPPLES of Meaningful Involvement  

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13 

a. Recognizing and Representing Indigenous Peoples— recognizing or acknowledging 
Indigenous Peoples and/or territories and taking efforts to have Indigenous Peoples 
represented at decision-making tables, even if tokenism seems like a false start and not a 
head start; 

b. Interrupting and Re-Imagining Relationships— actively interrupting the ways Indigenous 
Peoples and governments have historically worked together and re-defining working 
relationships based on a process of reconciliation;   

c. Preparing Agreements— establishing formal, written agreements between parties that 
articulate the nature of working relationships, mandate Indigenous involvement in the 
process, commit both parties to sharing responsibility for addressing Indigenous health 
issues, and hold parties jointly accountable for the decisions made in the process;  

d. Practicing Protocols—developing and implementing rules for Indigenous Peoples’ 
engagement in the process, as well as protocols to guide how the parties will work together 
and enact the relationships set out in formal agreements; 

e. Leveraging Power— taking efforts to foster a process that has the necessary power and 
sufficient capacity to make and implement health policy decisions, such as engaging the 
highest-level decision-makers in the process;  

f. Exerting Community Authority— taking explicit efforts to foster a process that is being 
driven by Indigenous community members, namely, Indigenous individuals who are most 
connected to and familiar with the issues being addressed and who solely represent a 
community perspective; and  

g. Shifting Social Structures— taking efforts towards addressing the systemic barriers 
impeding Indigenous Peoples’ involvement in policy, such as explicit efforts to incorporate 
Indigenous paradigms and include, support and protect Indigenous individuals in high-level 
positions in the mainstream policy system.  

While each of these key elements is rooted in the data collected for this project, they also align with 
perspectives in the literature. For example, the writings of Indigenous and non-Indigenous activists serve 
as a reminder that Indigenous Peoples’ attempts to engage with governments are still often ignored (The 
Kino-nda-niimi Collective, 2014), which highlights the importance of Recognizing and Representing 
Indigenous Peoples. Reconciling and rebuilding relationships between Indigenous Peoples and non-
Indigenous peoples have been shown to play a critical role in the way Indigenous Peoples are involved in 
decision-making (Cheema, 2007), which supports Interrupting and Re-Imagining Relationships. Walia 
(2015) and Regan (2005), among others, argue that non-Indigenous peoples have a responsibility for 
decolonizing themselves and taking action to address Indigenous justice issues, which underscore the 
emphasis on non-Indigenous peoples’ responsibility and accountability in Preparing Agreements. 
Ermine (2007) describes the need for clear rules of engagement to guide ethical interactions between 
Indigenous Peoples and non-Indigenous peoples, which is reflected in Practicing Protocols. Lessons 
learned from the creation of Indigenous health institutions have demonstrated the importance of 
working with senior government partners (Gallagher et al., 2015), which supports the ideas within 
Leveraging Power. Turner (2006) and others assert that Indigenous Peoples need to determine who 
participates in processes or dialogues, which supports the goals of Exerting Community Authority. 
Finally, Indigenous and non-Indigenous scholars have called for the inclusion of Indigenous Peoples and 
knowledges in mainstream institutions as a way of decolonizing policy systems (Fridkin, 2012; Turner, 
2006), which aligns with the objectives of Shifting Social Structures. 



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Each of these elements may be understood as existing along a continuum, where each element builds on 
the previous one so that Indigenous Peoples are increasingly influential in the process. Conceptualizing 
meaningful involvement as a continuum may help draw attention to the ways in which Indigenous 
Peoples are, and could be, more meaningfully and influentially involved. We also caution that these 
elements are not intended to represent a prescriptive list of criteria for what meaningful involvement will 
look like at every stage of every decision-making process, rather they are intended to inform thinking on 
how decision-making processes could involve Indigenous Peoples in more meaningful and influential 
ways. Table 1 further articulates what each element entails and illustrates how each could be enacted in a 
policy decision-making process. 

RIPPLES: A Framework for Meaningful Involvement 

To facilitate an understanding of how enacting these elements of meaningful involvement could 
contribute to transforming and decolonizing health policy decision-making processes, we illustrate these 
elements in relation to each in Figure 1. We refer to this framework as the RIPPLES of Meaningful 
Involvement, with RIPPLES being an acronym for the seven key elements described above: Recognizing 
and Representing Indigenous Peoples, Interrupting and Re-Imagining Relationships, Preparing 
Agreements, Practicing Protocols, Leveraging Power, Exerting Community Authority, and Shifting 
Social Structures. 

This framework illustrates the key elements of meaningful involvement along a continuum, which is 
represented by a series of concentric ripples. Each “ripple” radiating outwards represents a key element 
of meaningful involvement in which Indigenous Peoples are increasingly more influential. The 
progression of ripples further illustrates how a single effort towards increasing Indigenous representation 
could be seen an important first step towards more influential involvement. For example, if an 
Indigenous person is involved in a tokenizing way, although problematic, this could be a first drop in 
creating a series of ripples toward including Indigenous Peoples in ways that are non-tokenizing and, 
eventually, in ways where inclusion is at a deeper, structural level. This is the ripple effect of meaningful 
involvement; as Indigenous Peoples become increasingly influential in policy decision-making, the 
policy system itself becomes increasingly effective in addressing Indigenous health and social inequities. 

The ripples are set against a backdrop of decolonization to illustrate how the enactment of each element 
from one ripple to the next may represent a transformative shift towards decolonization of the wider 
policy system. Each effort to include Indigenous Peoples in increasingly influential ways may work 
towards disrupting a Eurocentric and colonial policy system and contribute to the advancement of 
Indigenous Peoples’ agendas and efforts towards sovereignty and self-determination. Drawing on 
Ritskes’ (2012) construction of decolonization as a goal rather an endpoint, meaningful involvement 
may be a goal to work towards rather than an endpoint to be achieved. It is a process of ongoing 
reflection and taking action to deepen the ways in which Indigenous Peoples are involved, and 
subsequently deepening the extent to which policy processes can improve Indigenous Peoples’ health 
and address health and social inequities. 



Fridkin et al.: T
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eaningful Involvem

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T
able 1. E

nacting the K
ey E

lem
ents of M

eaningful Involvem
ent 

 

R
ecognizing and 
R

epresenting 
Indigenous 

Peoples 

Interrupting and  
R

e-Im
agining 

R
elationships 

Preparing 
A

greem
ents 

Practicing 
Protocols 

Leveraging Pow
er 

Exerting 
C

om
m

unity 
A

uthority 
Shifting Social 

Structures 
Purpose 

● R
ecognize 

Indigenous 
Peoples and/or 
Indigenous 
territories and 
have 
Indigenous 
individuals 
represented in 
the decision-
m

aking process 

● C
ritically 

exam
ine the 

historical 
relationship 
betw

een 
Indigenous 
Peoples and 
governm

ents  
● R

econcile 
relationships 
betw

een parties 
● R

e-im
agine and 

re-define 
relationships 
based on 
reconciliation 

● A
rticulate and 

agree on the 
nature of the 
w

orking 
relationship 
betw

een parties 
● Establish a 

shared 
responsibility for 
addressing 
Indigenous 
health 

● A
rticulate 

specifically how
 

parties w
ill w

ork 
together in a w

ay 
that honours the 
agreed upon 
relationship 
betw

een parties 
and other 
com

m
itm

ents 
outlined in 
agreem

ents 

● Foster a process 
that has the 
pow

er and 
capacity to m

ake 
policy decisions 

● Foster a process 
that has sufficient 
capacity to fully 
im

plem
ent 

decisions m
ade  

● Foster a process 
that has the 
capacity to 
develop good 
decisions and is 
effective in 
im

proving 
Indigenous 
health 

● Foster a process 
that is driven by 
Indigenous 
com

m
unity 

m
em

bers w
ho 

are im
pacted by 

decisions 
 

● A
ddress system

ic 
barriers im

peding 
Indigenous 
Peoples' 
involvem

ent in 
the m

ainstream
 

policy system
 

O
bjectives 

● Include 
Indigenous 
Peoples in the 
process, even if 
representation 
is tokenistic and 
like a false start, 
not a head start 

● Include or 
incorporate 
aspects of 
Indigenous 
cerem

ony or 
culture 
 

● Establish a new
 

process for 
Indigenous and 
governm

ent 
groups to w

ork 
together based 
on reconciled 
relationships 

● A
rticulate or 

define the nature 
of relationships 
betw

een parties 

● Establish form
al, 

legal agreem
ents 

betw
een parties 

that m
andate 

Indigenous 
involvem

ent in 
decision-m

aking 
and hold both 
parties jointly 
accountable to 
the process and 
to decisions 
reached 

● Establish rules of 
engagem

ent or 
protocols to 
guide how

 the 
parties w

ill w
ork 

together 

● Include high-
level decision-
m

akers w
ho have 

the pow
er to 

m
ake decisions at 

the sam
e tables in 

w
hich 

Indigenous 
Peoples are 
involved 

● Involve 
Indigenous 
Peoples at the 
outset and 
throughout the 
entire process 

● Foster a process 
that uses input 
from

 Indigenous 
Peoples and 
com

m
unities to 

drive the process 
and decisions 

● Incorporate 
Indigenous 
paradigm

s into 
Indigenous 
policy decision-
m

aking  
● Include, support, 

and protect 
Indigenous 
individuals in 
high-level policy 
positions in the 
m

ainstream
 

policy system
 



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he International Indigenous Policy Journal, V

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2 

 

R
ecognizing and 
R

epresenting 
Indigenous 

Peoples 

Interrupting and  
R

e-Im
agining 

R
elationships 

Preparing 
A

greem
ents 

Practicing 
Protocols 

Leveraging Pow
er 

Exerting 
C

om
m

unity 
A

uthority 
Shifting Social 

Structures 
Exam

ples of 
Enacting 

M
eaningful 

Involvem
ent 

● R
ecognize or 

acknow
ledge 

Indigenous 
Peoples or 
traditional 
territory  

● Include 
opening or 
closing prayers 
or other 
traditional 
practices 

● Involve 
Indigenous 
Elders in 
decision-
m

aking or to 
lead traditional 
practices  

● Include at least 
one Indigenous 
person w

ho can 
represent the 
broad 
perspectives of 
Indigenous 
Peoples or the 
perspectives of 
a specific 
Indigenous 
group at 
decision-
m

aking tables  

● Each party m
eets 

on their ow
n 

prior to 
discussions 

● D
esignate a 

bridge person to 
facilitate 
com

m
unication 

betw
een parties 

● O
penly discuss 

each party’s 
interests, roles, 
and decision-
m

aking capacities 
● W

ork together 
on developing a 
process for 
Indigenous 
engagem

ent  

● Both parties 
w

ork together to 
develop w

ritten 
agreem

ents that 
articulate 
relationships 
betw

een parties 
and outline 
m

utual 
com

m
itm

ents 
● Form

alize or 
legalize 
agreem

ents to 
m

andate or 
legislate 
Indigenous 
involvem

ent and 
hold all parties 
accountable to 
the process and 
to decisions 
m

ade through 
the process 

● D
evelop and 

im
plem

ent 
protocols for 
com

m
unication 

w
ith m

edia or 
external groups 

● D
evelop and 

im
plem

ent 
ground rules to 
guide m

eetings 
or discussions in 
w

ays that 
m

itigate silencing 
and dism

issal of 
Indigenous 
individuals, such 
as designating a 
leader to identify 
and address 
racism

 and/or 
racialized sexism

 
at the table 

● Sign agreem
ents 

betw
een parties 

by the highest 
levels of all 
parties, such as 
m

inisters, C
EO

s, 
or chiefs 

● Include the 
highest-level 
decision-m

akers 
at the sam

e tables 
as Indigenous 
Peoples and/or 
leaders 

● Include the 
highest-level 
decision-m

akers 
from

 
governm

ents or 
policy 
institutions that 
have access to a 
large pool of 
resources 

● A
llocate 

sufficient 
resources for a 
full com

m
unity 

engagem
ent 

process 
● Establish and 

im
plem

ent a 
rigorous process 
for using 
com

m
unity input 

to set priorities 
and drive the 
process 

● Include 
com

m
unity 

m
em

bers at every 
stage of the 
decision-m

aking 
process and at 
the highest levels 
of decision-
m

aking 

● U
ndertake efforts 

to build 
Indigenous 
policy decision-
m

aking capacity 
and experience 
(e.g., 
internships/ 
m

entorships) 
● T

ake efforts to 
build 
governm

ent 
capacity and 
experience in 
w

orking w
ith 

Indigenous 
Peoples and 
paradigm

s (e.g., 
cultural safety 
training)  

● C
reate high-level 

policy positions 
for Indigenous 
Peoples  

● C
reate structures 

to support and 
retain Indigenous 
leaders 

● R
ecognize 

Indigenous 
Peoples’ 
know

ledge, 
experience, and 
expertise in 
hiring criteria 
 



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R
ecognizing and 
R

epresenting 
Indigenous 

Peoples 

Interrupting and  
R

e-Im
agining 

R
elationships 

Preparing 
A

greem
ents 

Practicing 
Protocols 

Leveraging Pow
er 

Exerting 
C

om
m

unity 
A

uthority 
Shifting Social 

Structures 
 

R
ole of 

Indigenous 
Peoples 

● Bring 
Indigenous 
traditional or 
cultural 
perspectives to 
the process 

● A
dvise, provide 

input, or inform
 

the discussion 
even if not 
participating in 
the actual 
decision-
m

aking (e.g., 
advisory 
com

m
ittee 

m
em

ber) 
 

● Provide input 
into developing 
new

 relationships 
and processes for 
w

orking in 
partnership w

ith 
governm

ents 

● D
evelop 

agreem
ents in 

partnership w
ith 

governm
ents 

● Share 
responsibility for 
decision-m

aking 
as per 
agreem

ents 

● D
evelop 

protocols in 
partnership w

ith 
governm

ents 
● Fully participate 

in discussions 
and processes as 
per agreem

ents 
and protocols 

● Influence and 
participate in 
decision-m

aking 
at the highest 
levels of 
governm

ent, 
including 
decisions on 
spending or 
resource 
allocation 

● D
rive the 

process, 
including setting 
the agenda and 
determ

ining w
ho 

is involved in the 
process 

● D
eterm

ine the 
policy issues and 
decide on policy 
solutions 

● Integrate 
Indigenous 
paradigm

s into 
policy discourses 

● Influence policy 
through taking 
on high-level 
positions in the 
m

ainstream
 

policy system
 

w
hile 

m
aintaining 

autonom
y in 

decision-m
aking 

 

A
spirational 

O
utcom

es 
● Indigenous 

Peoples are 
present and 
involved in the 
process and 
have som

e 
input into 
decision-
m

aking 

● Indigenous 
Peoples are seen 
as partners in 
decision-m

aking 
and recognized 
as respected, 
legitim

ate leaders 
and contributors 
to the process 

● Indigenous 
People’s rights to 
be included in 
the process are 
recognized, 
protected, and 
upheld by all 
those involved in 
decision-m

aking 

● Indigenous 
Peoples feel safe, 
heard, and 
“em

pow
ered” 

through 
participating in 
decision-m

aking; 
harm

ful, stressful, 
or painful 
experiences 
associated w

ith 
participating are 
reduced  

● Indigenous 
Peoples have 
increased 
influence and 
control over 
policy decisions 
im

pacting 
Indigenous 
Peoples’ health 

● Indigenous 
com

m
unity 

m
em

bers are 
valorized as 
experts in their 
ow

n health and 
w

ellness 
● Indigenous 

Peoples’ 
experiential 
know

ledge is 
valued and seen 
as integral to the 
decision-m

aking 
process 

● Indigenous 
Peoples are seen 
as integral and 
respected leaders 
and have 
increased access 
to health policy 
decision-m

aking 
positions 

● Indigenous 
know

ledge is 
recognized as a 
legitim

ate form
 

of know
ledge and 

valued as an 
integral part of 
health policy 
decision-m

aking 



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  Figure 1. The RIPPLES of Meaningful Involvement 
 
 
The RIPPLES of Meaningful involvement is offered as framework to inform policy, research, and other 
decision-making processes with respect to how Indigenous Peoples could be more meaningfully and 
influentially involved in a policy or decision-making process. This framework is not intended to be a 
“one-size-fits-all” model for how Indigenous Peoples should ideally be involved in every process. 
Instead, it is intended to be a heuristic device to stimulate further thinking and discussion on ways of 
meaningfully involving Indigenous Peoples in policy decision-making. We explicitly note that the 
intention of the RIPPLES framework is not to introduce a new dominant discourse or way of thinking 
about meaningful involvement that should remain unchallenged, unmodified, or withheld from further 
refinement, but to offer a starting place, or perhaps in some contexts a continuing place, for thinking 
about how more meaningful involvement could be realized and fostered. 

Limitations of the Research 

Consistent with the aims of qualitative inquiry, this study aims to make sense of and provide insight into 
a complex social problem (Leung, 2015). This has implications for the generalizability of the findings, in 
that the perspectives gleaned from the data are not intended to make inferences about meaningfully 
involving Indigenous Peoples in every health policy decision-making context; rather, the findings aim to 



Fridkin et al.: The RIPPLES of Meaningful Involvement  

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5 

provide insight into the broader question of how to foster meaningful involvement. In addition, while 
aligned with the overall paradigm of research in which all knowledge is considered to be socially 
constructed and imbued with inherent bias, the purposive sampling strategy may have contributed to 
recruitment of participants who share a similar set of experiences or perspectives, which could limit the 
range of experiences and perspectives that inform the findings. 

Conclusion 

To continue moving towards decolonization and more meaningful and influential involvement of 
Indigenous Peoples in health policy, efforts are needed to confirm that attention is paid to assessing and 
improving processes of involvement. This research may inform directions for future research, including 
investigating ways of evaluating and monitoring how Indigenous Peoples are involved in health policy 
decision-making and measuring the transformation towards meaningful involvement, particularly from 
the perspectives of Indigenous individuals who are involved in the process and also those who are 
impacted by the decisions. This research may inform future studies that aim to build on the findings, 
such as studies exploring rules for engagement or protocols that effectively counter racism and the 
silencing and dismissal of Indigenous Peoples at the decision-making table. Future studies could result in 
the development of indicators for meaningful involvement based on this framework, or applied tools for 
guiding health policy leaders in designing decision-making processes that foster and adopt more 
meaningful and influential involvement of Indigenous Peoples.  

 

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