Using the Fraser’s Triangle to Examine the Social Determinants of Health in Indigenous People across Northwestern Ontario

Using the Fraser’s Triangle to Examine the Social Determinants of Health in Indigenous People across Northwestern Ontario

Dhruv Lalkiya^1,2, Vahid Mehrnoush¹, Walid Shahrour¹

¹Department of Clinical Sciences, NOSM U

²Department of Social Justice, Lakehead University

DOI: https://doi.org/10.51244/IJRSI.2025.121500091P

Received: 21 May 2025; Revised: 05 June 2025; Accepted: 09 June 2025; Published: 11 July 2025

ABSTRACT

Indigenous populations in Northwestern Ontario face persistent and disproportionate health challenges, shaped by systemic barriers and legacies of colonialism. These disparities stem from social, political, and economic conditions that influence health outcomes and access to care. The social determinants of health (SDH) provide a crucial framework for understanding these inequities, as they reflect the broader conditions influencing well-being. This study applies Fraser’s model—centering on recognition, redistribution, and representation—to examine how structural inequalities, cultural marginalization, and political exclusion contribute to Indigenous health inequities [4]. By integrating Fraser’s framework, this research underscores the need for culturally relevant healthcare solutions that prioritize social justice and Indigenous self-determination. This study emphasizes the significance of decolonizing healthcare systems and the necessity for policies that incorporate Indigenous perspectives and lived experiences. By critically examining existing structures and frameworks, the analysis contributes to ongoing efforts aimed at achieving equitable and culturally responsive healthcare for Indigenous populations in Northwestern Ontario.

Keywords: Colonialism in Healthcare, SDH, Indigenous health equity, Decolonizing Health care, Health policy and social justice

INTRODUCTION

Indigenous communities in Northwestern Ontario (NWO) face significant health disparities that stem from historical, social, and environmental factors rooted in colonialism. These disparities are shaped by the social determinants of health (SDH), which encompass the conditions in which individuals are “born,” “grow,” “live”, “work”, and “age” [7]. To analyze these determinants in the context of Indigenous populations, this research applies Nancy Fraser’s justice framework, which emphasizes the roles of economics, culture, and politics in addressing health inequities [4]. Fraser’s model of recognition, redistribution, and representation offers a comprehensive approach to understanding the systemic barriers contributing to health disparities. By examining structural inequalities, cultural marginalization, and political exclusion, Fraser’s framework provides valuable insights into the interconnected forces that perpetuate these challenges [4]. Focusing on the recognition of cultural identities, redistribution of resources, and active participation of Indigenous communities in decision-making processes, this framework offers a pathway to creating socially just and culturally relevant healthcare systems [4].

Engagement with Indigenous communities in NWO has revealed significant limitations within existing healthcare models. These observations highlight the urgent need for culturally safe healthcare approaches that incorporate Indigenous perspectives and are informed by principles of cultural competence and contextual relevance. Addressing these gaps is essential to advancing equitable and culturally appropriate healthcare practices in the region. Health equity for Indigenous populations goes beyond access to services; it necessitates dismantling colonial structures that perpetuate exclusion and inequity [9]. This research is also significant for policymakers, healthcare providers, and community leaders as it aligns with Canada’s commitments to Truth and Reconciliation, particularly its emphasis on addressing systemic inequities faced by Indigenous peoples [10].

This paper began by outlining the methodology used for selecting and evaluating sources, including the criteria for inclusion. Following this, it summarized the foundational theories that inform the study, starting with Fraser’s justice framework. This framework was then enhanced with perspectives which contribute additional dimensions of intersectionality, co-learning through Two-Eyed Seeing, and justice-based health policy reform [1], [3], [5]. Additional sources addressing SDH, Indigenous rights, and health equity in Canada were also summarized and analyzed. These theoretical foundations and complementary perspectives were evaluated to identify key themes and gaps in the existing literature. The paper conclude by synthesizing the findings into a discussion that addresses the research question and provides actionable pathways for advancing health equity and decolonization in Indigenous healthcare systems in NWO.

The primary aim of this research is to examine how Fraser’s (2005) justice framework can be applied to the SDH in NWO to address health disparities and promote culturally appropriate healthcare. The study seeks to advance efforts to achieve Indigenous self-determination, social justice, and decolonization within healthcare systems. By analyzing these dynamics, the research will provide practical theoretical building recommendations for creating equitable and inclusive healthcare models that prioritize Indigenous perspectives and needs.

METHODOLOGY

Literature search and source selection

The methodology for this theory-building research paper involved identifying and gathering relevant scholarship from online academic databases. Systematic search was conducted using academic databases such as Google Scholar, Omni (Lakehead), and PubMed. Additionally, precise keywords and phrases used included “Nancy Fraser Social Determinants of Health” and “Nancy Fraser health equity framework,” to locate sources that specifically applied Fraser’s (2005) theoretical framework to health equity. These keywords were chosen to focus on the concepts of recognition, redistribution, and participation and their application to health disparities. Titles and abstracts were reviewed to determine relevance, and articles that included analyses of Fraser’s model in the context of Economic, cultural, and political inequities were selected. Peer-reviewed journal articles and academic books were prioritized that explored the intersection of social justice theory and public health. To ensure the selected sources aligned with the focus of this research, articles were excluded that only mentioned Fraser’s work tangentially or applied it to unrelated fields, such as environmental or economic justice without ties to health.

Focus on Indigenous Health Disparities in Northwestern Ontario

For scholarship on Indigenous health disparities, particularly in Northwestern Ontario (NWO), similar search was conducted in the same databases, focused on keywords such as “social determinants of Indigenous health,” “health equity for Indigenous communities,” and “Northwestern Ontario Indigenous health disparities.” To contextualize the research geographically, we also searched using terms like “healthcare access in Northwestern Ontario” and “Indigenous communities NWO.” In reviewing the results, titles and abstracts were skimmed for relevance, emphasizing those that directly addressed the intersection of colonialism, health inequities, and Indigenous perspectives in healthcare. Full-text articles were analyzed to ensure they offered detailed insights into the social determinants of health (SDH) in Indigenous communities. Priority was given to sources that highlighted culturally appropriate healthcare models, social justice, and sustainability. We also looked for works by scholars recognized for their expertise in Indigenous health, ensuring the credibility and reliability of the sources.

Inclusion and Exclusion Criteria

To ensure the research was manageable and focused, the topic was narrowed to health disparities in Indigenous communities specifically within Northwestern Ontario. This regional focused search helped address a well-defined and localized issue, which is particularly relevant to the commitment to collaborating with these communities. The search was limited to articles published within the last ten years to ensure the research reflected the most current discussions on Fraser’s model and its application to health equity. Articles were selected based on their academic rigor and relevance to our research question, particularly those that emphasized Indigenous perspectives, social justice, and self-determination in healthcare. Broader discussions on global Indigenous health or SDH unrelated to NWO were excluded, as they lacked the geographic and contextual specificity required for this research.

The scholarship excluded search that lacked direct relevance to Indigenous health or Fraser’s theoretical framework. For instance, articles that focused solely on global applications of SDH or general discussions on health equity without addressing Indigenous populations or Fraser’s model were not included. Additionally, works that were not peer-reviewed or lacked a clear academic foundation were excluded to maintain the scholarly integrity of our research. Sources that discussed Indigenous health in unrelated regions, such as urban centers or non-Canadian contexts, were also omitted unless they offered transferable insights applicable to NWO. Finally, theoretical critiques of Fraser’s model that did not explore its application to health inequities were deemed outside the scope of this research.

Challenges and Justification

Several challenges emerged during the literature search. One difficulty was the limited scholarship that directly applied Fraser’s model to the health disparities faced by Indigenous populations. While Fraser’s theory is widely discussed in social justice literature, its application to Indigenous health remains an emerging area of study, requiring synthesizing insights from multiple disciplines, such as sociology, public health, and Indigenous studies. Another challenge was ensuring geographic specificity. While there is significant scholarship on Indigenous health disparities in Canada, fewer sources focused, specifically on Northwestern Ontario. Additionally, some sources were inaccessible due to paywalls, which limited the ability to review potentially relevant articles. By keeping track of search terms, refining keywords, and using delimiters like publication date, the search was streamlined and selected the most relevant sources. This iterative process ensured that our research was focused, current, and grounded in scholarship that would effectively address the research question and objectives.

Foundational Theory building

Fraser’s Theory

To address the persistent health disparities faced by Indigenous communities in Northwestern Ontario (NWO), this research builds on Nancy Fraser’s justice framework, which supports different approaches to social justice and offers a multidimensional model incorporating “redistribution”, “recognition”, and “representation”. Redistribution focuses on addressing inequities in the allocation of material resources, such as healthcare, housing, and education, which are essential for improving health outcomes [4]. For Indigenous communities in NWO, redistribution means equitable access to healthcare services and resources, acknowledging the chronic underfunding and infrastructure gaps in remote regions (Fraser, 2005). Recognition emphasizes the value of cultural identity and the need to combat the devaluation of Indigenous knowledge, traditions, and practices [4]. This aspect is vital in addressing the marginalization of Indigenous perspectives in mainstream healthcare systems and fostering culturally appropriate care [4]. Representation highlights the importance of including marginalized voices in decision-making processes, ensuring that Indigenous communities have agency and autonomy in shaping their healthcare policies and practices [4]. While comprehensive, Fraser’s framework can be enhanced by integrating additional perspectives to account for the complex and intersectional realities of health inequities.

Intersectional Approach

Intersectional health justice approach emphasizes how overlapping social identities—such as race, gender, class, and disability—interact with systemic power structures to create compounding barriers to equitable healthcare access [3]. By incorporating intersectionality to Fraser’s work, this framework better reflects the diverse experiences within Indigenous communities and ensures healthcare solutions address specific and compounded oppressions [3]. For instance, Indigenous women and those with disabilities often face unique challenges that amplify exclusion from healthcare systems (Borras, 2021). This perspective enhances Fraser’s dimensions by ensuring the framework captures the intersecting layers of marginalization present in NWO communities [3].

Two-eyed seeing Approach

The “Two-Eyed Seeing” approach, offers a culturally grounded perspective that complements Fraser’s recognition dimension. Two-Eyed Seeing advocates for integrating Indigenous and Western knowledge systems to address complex health disparities through mutual “respect” and “collaboration” [1]. By valuing Indigenous traditions and knowledge systems alongside modern scientific approaches, Two-Eyed Seeing ensures healthcare solutions are both culturally appropriate and scientifically rigorous [1]. This approach bridges the gap between traditional healing practices and contemporary medicine, fostering co-learning and collaboration between Indigenous and non-Indigenous communities [1].

Transformative Approach

Further strengthening the framework is the work of Gilboe and Curran, who argue in The Role of Justice in Addressing the Social Determinants of Health that justice plays a critical role in addressing health disparities by advocating for systemic legal and social reforms [5]. Their work aligns with Fraser’s transformative dimension, emphasizing the need for structural changes to tackle inequities and integrate human rights into health policies [5]. They stress the importance of empowering marginalized communities to create sustainable, community-led health equity solutions [5]. This justice-based approach provides practical insights into addressing the systemic barriers that contribute to health inequities in Indigenous populations [5].

Reimaging Medical Education Approach  

Insights from Reimagining Medical Education: The Future of Health Equity and Social Justice also contributed to expanding Fraser’s Framework [2]. This work highlights the importance of reimagining medical education to prioritize equity and cultural competence in training healthcare professionals [2]. There was emphasize for the need to integrate social justice and cultural sensitivity into healthcare curricula to prepare providers to address systemic barriers [2]. Additionally, it was argued that for “diversifying healthcare leadership” it was important to reflect the lived experiences of marginalized communities [2]. These perspectives enhances Fraser’s representation dimension by emphasizing the importance of equipping healthcare professionals to engage with and support Indigenous communities effectively, fostering long-term systemic change [2].

By understanding these perspectives, this research proposes an expanded justice framework for addressing Indigenous health disparities in NWO. Transformative approach involves addressing structural inequities by reallocating resources and closing gaps in healthcare access [4],[5]. Recognition incorporates Indigenous knowledge and traditions into healthcare systems through culturally appropriate practices like Two-Eyed Seeing [1]. Representation emphasizes empowering Indigenous communities to lead decision-making processes and fostering diverse healthcare leadership [2], [4]. Incorporating intersectionality ensures the framework is inclusive of the overlapping identities and experiences of individuals within Indigenous populations, while the emphasis on reimagined medical education supports the development of culturally competent healthcare professionals [2], [3]. Together, this expanded framework not only addresses the systemic barriers created by colonialism but also lays the foundation for equitable, culturally relevant, and community-driven healthcare solutions for Indigenous communities in Northwestern Ontario.

Synthesis

Indigenous communities in Northwestern Ontario (NWO) experience significant health disparities rooted in a legacy of colonialism, systemic inequities, and socio-economic challenges. These disparities manifest in limited access to healthcare services, higher rates of chronic illnesses such as diabetes and cardiovascular disease, and greater incidences of mental health challenges, substance abuse, and suicide [6]. Historical injustices, including the residential school system, forced displacement, and the systemic marginalization of Indigenous knowledge and traditions, have disrupted “community cohesion” and “intergenerational knowledge transfer” [8]. The Indian Act and other colonial policies further entrenched these inequities by stripping Indigenous communities of autonomy over their land, resources, and health systems [10].

Healthcare access in NWO is significantly impacted by geographic remoteness and systemic neglect. Many Indigenous communities must travel great distances to access essential health services, creating barriers that disproportionately affect vulnerable populations, such as elders, women, and those with disabilities [7]. Additionally, the underfunding of healthcare infrastructure in these communities perpetuates inequities. For example, clinics in remote regions often lack adequate staffing, equipment, and culturally competent care, contributing to poor health outcomes and increased reliance on emergency services [9].

These health disparities are further exacerbated by the social determinants of health (SDH), such as income inequality, unemployment, housing insecurity, and food insecurity [8]. Indigenous communities in NWO often face systemic barriers to education and employment, which limit their economic opportunities and perpetuate cycles of poverty and poor health [6]. The intersection of these determinants creates a complex web of inequities, compounding the negative impacts on health and well-being.

A critical factor underlying these disparities is the intergenerational trauma caused by colonial practices. The loss of language, culture, and land has contributed to a sense of disempowerment and alienation within many Indigenous communities [10]. High rates of mental health disorders, such as depression and post-traumatic stress, reflect the enduring impact of this trauma. For example, the residential school system not only stripped Indigenous children of their cultural identity but also instilled feelings of shame and disconnection that continue to affect future generations [8]. Despite these challenges, Indigenous communities have demonstrated resilience and agency through efforts to reclaim their cultural identity, advocate for self-determination, and establish community-based health initiatives [6].

Analyzing and supporting Fraser’s Social Justice Framework for Indigenous people

Nancy Fraser’s  justice framework, expanded with insights from intersectionality, Two-Eyed Seeing  and justice-based health policy reform , provides a comprehensive lens for addressing these health disparities [1], [3], [4], [5]. This framework incorporates redistribution, recognition, representation, and intersectionality to offer actionable solutions to the systemic inequities faced by Indigenous communities in NWO.

Redistribution

Redistribution focuses on addressing structural inequities by reallocating resources to underserved Indigenous communities. In NWO, redistribution requires significant investment in healthcare infrastructure, such as building community health clinics, increasing telemedicine capabilities, and ensuring transportation options for remote areas [4]. For example, increasing the availability of mobile health units and culturally trained healthcare workers in these regions can directly address the gap in access to essential services [7]. Redistribution also involves tackling broader SDH, such as improving housing conditions and creating employment opportunities, which are essential for reducing health disparities [8]. Addressing income inequality through targeted social programs, such as subsidies for healthy food and housing, can further enhance community well-being [6].

Recognition Dimension

Recognition underscores the importance of valuing Indigenous knowledge, traditions, and practices within healthcare systems. The Two-Eyed Seeing approach (Bartlett et al., 2012) provides a pathway for integrating Indigenous and Western knowledge systems, fostering a holistic and culturally relevant approach to healthcare. For example, incorporating traditional healing practices, such as ceremonies and land-based therapies, alongside Western medical treatments, can create more inclusive care models [1]. Recognition also entails addressing systemic racism within healthcare institutions.  Indigenous patients often experience discrimination and culturally unsafe care, which discourages them from seeking medical treatment [9]. Anti-racism training for healthcare providers and policies that prioritize cultural competence can help build trust and ensure respectful care [5].

Representation Dimension

Representation emphasizes the need for Indigenous communities to have agency and leadership in healthcare decision-making processes. Fraser argues that marginalized groups must have a voice in shaping the policies that affect their lives [4]. In NWO, this could involve establishing community advisory boards to guide the development of healthcare programs and policies, ensuring they align with Indigenous cultural values and priorities [5]. For instance, initiatives such as community-driven mental health programs have demonstrated success in addressing specific needs while fostering self-determination [10]. Participation also involves increasing representation of Indigenous professionals in healthcare leadership roles, which can help dismantle systemic barriers and advocate for culturally safe practices [2].

Intersectionality Dimension

Intersectionality addresses the compounded barriers experienced by individuals with overlapping social identities, such as Indigenous women, LGBTQ+ individuals, and those with disabilities [3]. For example, Indigenous women often face unique challenges, including higher rates of gender-based violence, which significantly impact their health outcomes [6]. Applying an intersectional lens ensures that healthcare solutions are inclusive and responsive to these diverse needs. Programs tailored to specific subgroups, such as maternal health services for Indigenous women or accessibility initiatives for individuals with disabilities, are critical for achieving health equity [3].

Educational Transformation for Healthcare professionals

Insights from Reimagining Medical Education underscore the transformative potential of education in addressing health disparities. Healthcare providers must be trained to recognize systemic inequities, dismantle barriers, and foster cultural humility [2]. Incorporating Indigenous perspectives into medical curricula and increasing the representation of Indigenous professionals in healthcare leadership are essential steps toward creating an inclusive healthcare system [2]. Educational reforms should emphasize cultural competence, social justice, and anti-racism to ensure healthcare providers are equipped to support Indigenous communities effectively.

CONCLUSIONS

This research has the potential to make a meaningful difference by shedding light on the systemic inequities that contribute to health disparities in Indigenous communities, particularly in NWO. By exploring how the social determinants of health (SDH) intersect with structural inequality, cultural marginalization, and political exclusion, this study offers a critical framework for understanding the root causes of these inequities [4], [6]. The analysis directly inform healthcare policies and practices, ensuring they are more inclusive, equitable, and culturally appropriate. Policymakers, healthcare providers, and Indigenous leaders could use the findings of this research to advocate for resource redistribution, improved access to culturally safe care, and the inclusion of Indigenous voices in decision-making processes [1], [5]. By bridging theory and practice, the research underscores the importance of combining structural and cultural dimensions in addressing health disparities. Furthermore, it emphasizes the necessity of incorporating Indigenous perspectives and knowledge systems into healthcare solutions, advancing the academic field by demonstrating the critical role of cultural recognition and self-determination in health equity [2], [6].

The conclusion of this research extends beyond academic discourse. Without understanding and addressing these systemic barriers, society risks perpetuating health inequities that hinder progress toward broader goals of social justice and equity [4]. Addressing these barriers is not only a moral obligation but also a critical step in ensuring the health and well-being of Indigenous communities and, by extension, the health of the nation. These inequities, rooted in structural and social determinants, underscore the urgency of systemic reforms that prioritize Indigenous needs and perspectives [5].This research also has the potential to inspire a shift in how healthcare systems operate, moving from reactive, one-size-fits-all approaches to proactive, inclusive systems tailored to the needs of Indigenous populations. By fostering an appreciation for Indigenous knowledge, traditions, and perspectives, this study could contribute to creating healthcare systems that are more responsive to the realities of marginalized populations [1]. This shift could lead to improved health outcomes, greater community trust in healthcare institutions, and a stronger foundation for collaboration between Indigenous and non-Indigenous peoples [9].

Finally, the findings of this research could have far-reaching implications, serving as a model for addressing health inequities in other marginalized populations and regions. The intersectional and justice-based approach proposed in this study could be adapted to other contexts, providing a roadmap for tackling structural inequities and fostering culturally competent care worldwide [2], [3]. By advancing both academic understanding and real-world application, this research has the potential to contribute to a more just and equitable future for Indigenous communities and society at large.

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   https://irep.ntu.ac.uk/id/eprint/52695
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