On the move: Exploring Inuit and non-Inuit health service providers’ perspectives about family participation in care in Nunavik, a qualitative study.

Background Literature on participation in health and social services suggests that youth, and more specically Indigenous youth, are dicult to engage within health and social services. They are less likely to access services or to actively participate in decision-making regarding their personal care. Service providers play a crucial role in engaging youth based on the ways in which they seek, and maintain relationships with youthand their families. The way in which they do so will depend on various factors including their own perceptions of roles and relationships of the various people involved in the life of youth. This article analyzes Inuit and non-Inuit health and social service providers’ perspectives, experiences and expectations regarding the roles of a particular group of Indigenous youth, families and community in care settings in Nunavik, Quebec. Methods: A snowball sampling method was used to recruit participants. A total of 58 participants (39 non-Inuit and 19 were Inuit) were interviewed. All interviews focused on three broad areas: 1) participants’ current and past positions/roles; 2) participants’ perceptions of the clientele they work with; and 3) participants’ understanding of collaborations taking place within and between services (who works with whom) and community. Inductive applied thematic analyses were conducted on the entirety of relevant data and then verbatim of Inuit and non-Inuit were analyzed separately to explore similarities and differences in perceptions based on positionality. Results: We organized ndings around three themes: I) The most commonly described interventions, II) different types of challenges to and within participation; and III) what successful participation can look like according to service providers. Participants speak of the challenges for families to go towards services as well as the challenges for services providers to go towards youth and families, including personal, organisational and historical factors. Conclusion: We adopt a critical lens to reect on the key ndings in order to tease out points of tension and paradoxes that might hinder the participation of youth and families and more specically in a social context of decolonization and self-governance of services. providers to improve cultural awareness and attitudes. Inuit workers, are also parents and community members receiving services go beyond their disappointments with the current situation and see possibilities for transforming approaches and structures of care. Here we integrate Inuit and non-Inuit perspectives to reect on ways of learning from positive experiences and building on existing strengths always basing the categories around what Inuit within this study and past studies suggest should be done to improve care.

into speci c communities periodically for assessments and follow-ups. Each coast has a hospital, one in Puvirnituq and one in Kuujjuaq, where people from other communities are own for certain specialised services. For emergencies and specialised follow-ups, patients may be sent south to Montreal, approximately 1,500 km away. Health and social services for bene ciaries in Nunavik are funded approximately 30% by the federal government and 70% by the provincial [34]. Services are under provincial legislation which is different from First Nation communities across Canada that are under federal legislation [35,36]. Provincial laws in effect since 2012 have greatly in uenced the possibilities for Inuit to work as front-line workers within the institutional services [36,37]. Inuit now hold positions as administrators, secretaries, interpreters, community workers who generally accompany or translate for non-Inuit services providers. Leadership positions are open to Inuit including positions as principals within schools and certain departments in the health and social services. Many front-line workers, and all are therefore non-Inuit staff [38].
Regarding Inuit experiences and expectations of services, a recent study conducted by the Nunavik Board of Health and Social Services suggests that Inuit generally feel satis ed with the services offered by their nursing stations and hospitals [39]. However, challenges remain, especially regarding mental health and social services for children, youth and families. A lack of preventative and front-line services leads to an over-reporting of families to youth protection services [40,41]. Psychosocial di culties experienced by children and youth can quickly turn into crisis situations, yet there are currently limited specialized services for such cases [42][43][44].

Partnership Research
It is in this context that the non-Inuit research team was invited to co-develop and seek funding for an action-oriented research program with local and regional partners in the region to support community mobilization and decision-making for youth and families. A community-led organization was developed to support youth and family-oriented prevention activities. As part of this program, our local and regional partners wanted to better understand the existing institutional services and the experiences and needs of youth, families and service providers in order to better re ect on ways to support the health and psychosocial needs of families. Our partners felt that this information would help develop new strategies to improve community decision-making within community-led initiatives as well as within government-led health and social services. Speci cally, this research would not only help understand but also transform services to improve youth participation in services within their community and within the region. Together we applied for funding for different inter-related projects that would help map out the realities of the different people involved in the health and care of Inuit. The rst studies centered on the experiences of Inuit families [44], Inuit community mobilisers and Inuit service providers.
In one such study [44], fourteen Inuit parents described their perceptions and experiences with services. They spoke of the practices that they appreciate, as well as the barriers they face in accessing and using available services. Among these barriers, parents feared the consequences of using services because of concerns of being reported to youth protection services or the police. In this context with limited prevention and front-line social services, professionals and community members might signal families to youth protection as a way to ensure follow-up, regardless of the severity of a situation. In general, the study found that families' past experiences with available resources within communities in uences their decisions regarding whether or not they should seek support. Families' perceptions of service providers' ability to be caring and non-judgemental in uences families' perceptions of the adequacy of care, which in turn in uences their desire to seek support. Pro-active services, including home visits were described positively.
Then, in a more recent study, we worked with community members who are recognized for their work in health and social care in communities to identify Inuit practices and approaches in supporting youth and family wellness. Key informants spoke of values and objectives of health and social practices for Nunavimmiut. They spoke of focusing on strengths, supporting individual and collective self-determination, focusing on the interconnections between family members and with community and how land and community are locations for healing to take place [45].
Finally, with a regional Inuit committee, our research team helped design and then analyze community consultations on how communities wished to see services transformed for youth and families. Following these consultations and exposure to the results described below, the Inuk committee developed a framework for the creation of future services for youth and families. Our team helped organize the framework which was built around 6 principles including the following: Children and families should be at the center of the design and delivery of all service, Inuit should be the guides and decision makers to all services grounded in Inuit knowledge and practices, design and delivery of services should respect the rhythm and realities of Nunavik all the meanwhile supporting steps towards self-determination [46]. The various studies and consultations brought forth the voices of Inuit, their experiences and their requests regarding service providers working within the institutions. With the motivation to self-govern services there is also a recognition that non-Inuit workers have much to contribute, so long as the work is in line with these ways of knowing and doing. Yet community members recognized the gaps between institutional ways, and approaches desired by community. There is a desire to better understand this gap and to nd ways to improve the current approaches and services while Inuit slowly develop their own systems of care.
This gap has been articulated by Indigenous scholar Ermine [47] who speaks of what he calls Ethical Spaces of Engagement. Intentions and experiences between non-indigenous and Indigenous peoples have been blurred and complexi ed over centuries. Ethical practice therefore requires an understanding of these experiences. By exploring the gaps and points of connection between institutional service providers and community members it becomes possible to re ect on ways of moving forward towards services that are culturally relevant and guided by Inuit.
This current study was therefore a way of exploring the realities within institutional systems of health and social services and how these realities may in uence the ability to put in place services that correspond to Inuit principles, values and needs of community members as documented previously. We were interested in barriers and facilitators that are either explicitly expressed by service providers or implicit in their discourses.
Interviews for this study were conducted with Inuit and non-Inuit service providers working for different organizations including schools, hospitals, nursing stations, youth protection services, police and more.

Methods
The methods and interview guide for this study were co-developed with Inuit partners to capture their questions and interests. The project was submitted to the Nunavik Regional Board of Health and Social Services (NRBHSS), the Kativik School Board (KSB), now called Kativik Ilisarniliriniq (KI), and the rst author's university ethics review board for approval. Two non-Inuit research assistants worked with agents from the health board and from the school board to prepare a list of service providers who represented all "levels" (front-line workers, specialists/consultants, administrators, directors) of multiple health and social service organizations. The agents distributed letters to all service directors and school principals, explaining the project and inviting their staff to participate. A snowball sampling method was used [48] to recruit participants in three communities as well as in Montreal to include service providers residing in Montreal but who y in and out of communities for consultations. A total of 54 interviews were conducted with 58 participants. Four interviews were conducted with two participants simultaneously, as decided by the participants. Participants included psychiatrists, general practitioners, nurses, social workers, school principals, teachers, student counsellors, representatives of local committees (education committee, health committee), and police o cers. Of the 58 participants, 39 were non-Inuit and 19 were Inuit. Inuit participants worked primarily as either administrative planning agents, or community workers (non-professional workers supporting social workers). Two Inuit participants were directors of services, one represented parents of children receiving intensive medical support and three were community representatives working or volunteering for the community. Interviews were conducted in English or in French by non-Inuit research assistants and lasted approximately 90 minutes. The interviews focused on three broad areas: 1) participants' current and past positions/roles; 2) participants' perceptions of the clientele (youth and their families) they work with; and 3) participants' understanding of collaborations taking place within and between services (who works with whom) and community. All interviews were audio-recorded, transcribed, and subsequently analyzed using QDA Miner, a qualitative data software.
Applied inductive thematic analyses were conducted by the non-Inuit research team. Thematic analysis allowed us to explore emerging issues and experiences in the data rather than pre-determined hypotheses [49]. The two rst authors read through the entirety of the material and extracted initial themes and their related impressions. A rst impression was the high presence of negativity. In order to determine whether this impression was a coder-bias or a phenomenon that was speci c to certain groups of participants, extracts were organized into positive, neutral and negative statements depending on the portrayed feelings. We then organized the extracts within a large matrix based on service providers' descriptions of their relationships with other service providers, youth, families, extended families, and community members. We considered each of these relationships as a type of dyad. We conducted an thematic analysis to explore emerging themes, which included perceived roles, movement (actions) of collaboration and place of collaboration. We then conducted a thematic analysis, which allowed us to explore the challenges and positive collaborations speci c to each dyad. We then separated verbatim from Inuit participants and verbatim from non-Inuit in order to highlight the experiences and perceptions of Inuit as a way of promoting their knowledge and self-determination. Making these distinctions between Inuit and non-Inuit also allowed us to explore similarities and differences in experiences and perceptions of community members and non-Inuit . In the discussion we re ect on the results with Inuit experiences as the focus. We selected participant quotations to represent each of the various themes and dynamics. To ensure participant anonymity, we made slight modi cations to the quotations as well as to participant job titles.
It is important to note that the entire process was conducted over a 5-year period involving multiple action-oriented working sessions with the local committee, as well as with a newly formed regional Inuk committee [46]. Indeed, the model and the re ections around the model were brought to both the community advisory board and the Regional Steering Committee for discussion and decision making. This speci c manuscript does not describe the decisions made by these two bodies as they are described elsewhere (46, 50.) however the results and discussions is written with the principles in mind (see discussion for a complete list of the principles).
We do not presume that this analysis captures the entirety of experiences and perceptions, however it offers a model for discussion and re ection.

Results
First and foremost, it is important to note that Inuit and non-Inuit participants spoke at times of similar experiences but also referred to very distinct perceptions and expectations. As will be observable below non-Inuit tended to speak about the many of the challenges in engaging youth and families and although the described the interest in speaking with extended family and other community members their practices rarely integrated more than the parents. On the other hand, Inuit recognized certain challenges but also put forth many ideas of how to transform approaches and services. Their focus on was striking. Moreover, Inuit spoke much less of the services per se, even if they themselves worked within the services. They were more descriptive of the roles and ways in which community can support families and children.
We organized the ndings around three themes: I) The most commonly described interventions; II) different types of challenges to and within

I) Commonly described interventions
In this section, we outline the most commonly described social interventions with youth and families. As mentioned above, service providers spoke predominantly of the di culties engaging youth and families in services. We describe 1) the various actors discussed by participants and their perceived roles, and 2) their locations and movements between locations.

Actors and their perceived roles
Five core groups of actors emerged as essential partners with different roles and responsibilities for effectively providing services to youth and their families: a) service providers; b) youth; c) parents; d) extended families; e) the community.
Service providers. Service providers are described as having to share information with other professionals. They are seen as having to communicate with parents in order to obtain consent to offer services to youth who are under the age of 14. Service providers feel that they often take the rst steps in initiating contact and follow-up.
Youth. Service providers do not describe youth as having a particular role or responsibility. Youth are often described for their willingness to receive services, their behaviours, symptoms and family contexts.
Parents. Service providers describe parental involvement as essential in the service delivery process. Parents are sometimes described as potential coordinators of services. A non-Inuit doctor explains that parents can have a bene cial impact on the continuity and coherence of services as they can relay information from one service to another: "What goes best in paediatrics is when the parents are able to take on the role of kind of coordinating the care, it's really when it goes well. Yeah, for coordinating and also for speaking for the child. Like, "You sent me for that specialist but that wasn't the one I needed. What I needed was this". So when there's that kind of empowerment and ability, then those really go best".
Service providers also described how parents can support professionals in nding solutions for youth. A non-Inuit teacher offers an example: "The parents came in for a meeting and we discussed the plan with the parents and [they] gave us their feedback about how it (the plan) would affect their children and some ideas were put forward".
Extended family: Service providers described the role of extended family members as support systems for parents when they are not physically or emotionally available. In fact, extended family is considered the rst placement option when children must be removed from the immediate family environment. A non-Inuit Crown attorney emphasized how extended family can also be a source of information for service providers: "Family members will get involved most of the time, to help to nd a solution for the child to be protected. Maybe they'll take the child home and then this way the parents will maybe get a break for a while because sometimes it's di cult for them. And family members will also help me understand the situation a little bit better by giving me input." Community Finally, service providers often described "community" as a necessary and needed collaborator for effective care and more speci cally for prevention. Service providers spoke of their desire to have community members guide their work and "mobilize" around health and social issues.
An Inuk driver for the clinic spoke about the supporting role that community must play for a young girl with behavioural issues: "She needs hope. How do we give hope? It's a community thing so we just need the people now to be better role models. We need to do our best and hope that she does her best, and that the community speaks to her and we need to hope that everyone will do their best (to help)." The words of an Inuk participant explain how communities can take on this leadership role: These words also serve as a reminder that research might be a tool, but ultimately the process needs to be in the hands of Inuit.
Within commonly described interventions, these ve groups of actors are reported as having distinct yet highly connected roles and responsibilities: In order for the service provider to work with the youth they must interact with parents; for parents to be supportive towards their children and youth, service providers feel that they need support from extended friends and family, who is turn require the support of community. However, services providers rarely describe interactions with extended family or with community representatives or organisations.

Locations and movements
The physical locations of services and of those seeking services played an important role in service provider narratives about the role of participation in care. Children and youth often met with service providers inside organisations such as youth protection o ces, nursing stations, and schools. Parents were at times described as partners within the services, although mostly described as being di cult to reach and outside of services.
Service providers used a variety of action verbs including go to, come to, send, and call that imply the need for movement when speaking of their attempts to collaborate with families and communities. Service providers generally described their movements and actions towards families and youth as attempts to invite youth and parents to come see them, or asking parents for consent to work with the youth. They describe using email, letters, and phone calls, or at times going directly to their homes. However, they also spoke of feeling uneasy going to peoples' home, especially if they know that the family has di cult psychosocial dynamics. At times they will ask a colleague from another service to accompany them. They describe the movements and actions from services towards community to sometimes include individual consultations with particular members of the community, such as the mayor or an elder.
Regarding youth and families, very rarely do service providers speak of active steps taken by youth towards services. Instead, youth were described as being "picked up" by service providers "But of their own will? Would youth come consult themselves? Teens? Because they aren't doing well? No! The same person explains that youth will be brought to services during a suicidal episode, and according to her perceptions at least three quarters of these youth will not continue the proposed follow-up. Similarly, an Inuk rehabilitation o cer explains: The parents usually they don't call me, when I meet them it's because their son or daughter has been arrested, and then that's when they're going to say "can you help my child, can you try to convince him to listen to me, going back to school….`.
Generally speaking, youth seem to be understood as passive agents within health and social service interactions. Many non-Inuit service providers place a stronger emphasis on the role of parents. While the importance and potential of other actors such as extended family and community are recognized by service providers, there seems to be a disconnect between the locations of services and the locations of actors, and questions about how agency and who is moving towards whom are perceived.

II) Challenges to and within encounters
Service providers' narratives about patient involvement in care emphasized two inter-related challenges to making connections with youth and families: 1) Challenges that inhibit the use of services by youth and families (as understood by service providers); and 2) Challenges that impact service providers' ability and desire to go towards youth, families and communities.

1) Inhibitors to going towards services, according to service providers
In this section we identify four broad factors that in uence families' use and perception of services: a) colonialism; b) service provider's attitudes; c) fear, stigma and discomfort; d) limited service mandates.
Colonialism. For Inuit participants, historical considerations were more prominent in their explanation of di cult encounters. They spoke of the impact of forced sedentarism on families as well as the trauma carried on from generation to generation. I think that many parents have issues that they never healed from when they were young. I think it was passed from generation to generation starting with the years where Inuit were forced to be sedentary.
Only a few non-Inuit participants spoke of how colonial histories in uence how families might interact with services.
A non-Inuit nurse explained the irony of the colonial situation that Inuit must contend with: "They lived in igloos and they had their traditional way of life, and then we came in and said we're gonna give you those villages and we're gonna kill your dogs. We're gonna force a different kind of food on you and we're gonna basically manage you the way we want to. Then we're gonna put you in schools, where a lot of you are gonna get it and abused and whatnot. Then suddenly we're in 2014 and we're asking: How come you guys are not taking care of you own life?" This nurse described a feeling of frustration and disempowerment in the larger social context where Inuit families are asked to trust services and mobilize healthcare plans made within a colonial system.
Service provider attitudes. Both Inuit and non-Inuit participants feel that service providers' attitudes in uence whether or not services are deemed acceptable by youth and families. Some participants described negative, and at times hostile, attitudes amongst their colleagues who act in ways that enact or reinforce colonial relations. These discriminatory attitudes can directly in uence families' abilities to trust the services. An Inuk parent described the discrimination that their family experienced, being told by a doctor that if they missed an appointment for their child who was dealing with an important medical condition that the nursing station would contact youth protection services. After denouncing the doctor, the parents never heard back from her. These experiences of discrimination fuel existing mistrust.
A non-Inuit family doctor at the hospital described some of the judgemental attitudes that she has observed among her colleagues, which she believes may impact families' comfort in using services: "I nd there are lots of people who judge quickly (…) Like, my child is half Inuk and she says that when she goes to the hospital, if she is with me, she sees a difference in how she is treated. When she isn't with me, she says that they don't always treat her nicely. I feel there can be discrimination." Some participants also felt that certain service providers interpret and label behaviours as rather than truly attempting to understand the uniqueness of a person, and the complexities and contexts within which individual actions take place. This pre-judgement becomes a barrier to deeper respect and understanding. As an example of this type of attitude, an Inuk youth protection worker described the negativity that she hears from some of her colleagues who might believe that Inuit do not talk very much or share particular aspects of their life for cultural reasons: "Some workers make conclusions like, "ahhh it's because of their culture, she can't tell me this or she can't talk." I don't know what it is but with the whole White and Inuit… I'm so over it. That's enough (blaming culture). It's the 21st century -we're gonna work together or we're not? It's time to work together, everybody. Stop blaming culture.
Indeed, these statements are not uncommon in Nunavik; non-Inuit workers feel frustrated not being able to connect with Inuit families. Interpreting these challenges as cultural differences removes any possibilities of transforming one's own practice, or of understanding tensions in a different light.
Families' fear of services, stigma associated with service use, and feelings of discomfort. Some non-Inuit service providers feel that families might see services as a form of punishment rather than as a source of support. They also feel that for some parents, seeking help through services can be stigmatizing within their community. Other parents may fear service providers taking away their children or the police getting involved in their family life. A non-Inuit child psychiatrist gave an example of a family dealing with this fear: "The mother was very traumatized by the DYP (Department of Youth Protection), so she will stay away from the (services) as much as possible; basically all that is . It's a shame because the children… they (families) need help, they have a lot of learning di culties and then they go to look for help. Sometimes a mother accepts, then she withdraws because she is so afraid (…) she remains scared that her children will all be removed again." A non-Inuit social worker described how parents might feel guilty when a service provider or teacher approaches them with a situation concerning their child, which can lead to distancing themselves from the service providers: "Well, if there is any [problem], there is tension with the family. If your child is not doing well at school, the parent feels guilty about everything, and then they close down." A non-Inuit crisis center coordinator felt that families might fear being judged by other community members by accessing particular services, for example, related to mental health.
Inuit workers remind us that in and of itself being a youth can hinder the desire and ability to get help. This position is then compounded by the fact that workers are mostly non-Inuit individuals that youth do not know and therefore feel even less comfortable seeking help or opening up. A participant says: "They close up because the workers are from another culture, they keep it all in. They need to let it out. It just explodes." Service mandates. Several service providers also described how different understandings of the role and mandate of the services could impact how patients access and use services. A non-Inuit mental health nurse shared how he responded to a situation when a youth misunderstood the role of his youth protection worker: "Often they don't understand. Like for example, I was following a youth under DYP. The youth verbalised that he hated his DYP worker but he didn't understand her role at all, what she was doing for him. Sometimes I spent time with him, telling him: Listen she wants what is best for you, she is there to ensure this, that and that. She wants to help you go back to school." An Inuk worker explains that there may be services and activities within the community for youth and families but that if people do not know about these activities and do not understand why, and where they are taking place then people will not attend. Using community radio as a means of communication as well as direct invitations are encouraged by participants.
From the perspectives of service providers, these factors that inhibit families' use of services, including colonial histories, service provider attitudes, families fear of services, and misunderstandings about service provision mandates, create barriers from families 'moving towards' or accessing services. At the same time, a range of factors also inhibit how service providers engage with youth and families.
2. Factors that in uence service providers' ability and desire to go towards youth, families and communities Service providers identi ed six factors that constrain them from reaching out to and engaging with youth and families: a) Parental consent; b) lack of resources within the community; c) language; d) culture; e) mismatched timing; f) challenges of being from the community.
Parental consent. Participants spoke of legal challenges to truly engaging youth and families in service provision. In order to provide services to youth under 14, parental consent is legally required. Consent is also required to share information with other service providers. Service providers described a strained dynamic where they either feel dependent on parents until they either receive consent to provide services to youth (or instead chose to use the institutional power of youth protection services to oblige service provision. A non-Inuit social worker from the nursing station, who also worked at a local school, described the challenges to obtaining parental consent: "I always try to get consent from parents, especially when the youth is under 14 and well, sometimes they refuse. You cut the grass under my feet, I can't do anything. Sometimes I work in collaboration with DYP and then they might be able to get a consent from parents after trying very hard. I have to send a paper, they have to sign it, and then I never see the parents. They sign, I have the paper, we invite parents to come meet, again with pressure from the youth protection and often the parents won't show up." Consent is essential in order to ensure parents are decision-makers in a process of care for their children however consent requirements seem to construct and formalize particular types of relationships between service providers and families.
Lack of resources within the community. Service providers perceived a lack of resources as a challenge to setting up alternative services that would better respond to people's needs, for example, related to emergency housing, in-community alcohol and drug rehabilitation services, psychotherapy, and nancial assistance. One non-Inuit youth protection worker, a specialist in clinical activities, explained how the lack of resources for children who are signalled under youth protection directly impacts the chain and quality of services that health workers can provide for youth: "There is a lot of placement and there are very speci c protocols and frameworks on when to put a child in and what to try, how to do it, and how to prioritize and what to do with it… The law can be rigid. But here, unfortunately, we do not have foster families. So we end up placing [youth] in places that are not necessarily better, or place with Whites who will eventually go one day. And I do not judge, but that's it anyway. So we take children, we take them away [from their families] and they lose all contact because the Whites who speak Inuktitut are not many." Service providers, like this youth protection worker, described feeling frustrated and discouraged that they do not have more adequate resources to develop/implement comprehensive solutions/plans that better meet the needs of the youth and family they work with.
Similarly, Inuit workers who describe feeling irritated with the types of services offered in their community explain that the nature of services is greatly in uenced by the low number of human resources compared to the needs. An Inuk service provider explained: "But another thing too is that I totally know and understand what their situation is about how overwhelmed [non-Inuit workers] are, but you know a lot of the times is that they don't set themselves up for success either. I just know for a fact that all these people are so overwhelmed because there's a giant work load as soon as they come in to work and it's hard for them to keep up. It's like everyone is just thrown under the bus. So, there's no time for them to think about prevention, they don't have the time to think about counselling, they don't have time to just do recreational activities." Language. Non-Inuit participants identi ed language as a major impediment to developing positive interactions with families. Communication challenges seem to create frustrations for both service providers and family members who feel that their exchanges are limited when they would like to go further. A non-Inuit psychoeducator explained: "One of the problems I have, it's Inuktitut. I do not speak Inuktitut, because the problem I have is when you have young people, when you get into the emotions, it's all in Inuktitut. They spit it to you and you would have to understand what is said. There are young people who know I do not speak Inuktitut, but sometimes I get a sentence in Inuktitut and they are discouraged that they do not know how to say it in French or in English." Non-Inuit service providers rarely speak Inuktitut. At times they will have learned a few basic words. Moreover, for many service providers English is a second language. In these cases, both the family and the worker are exchanging in a second language. This is challenging in any situation, but particularly tedious when speaking about emotions and relationships. As will be described below, language is yet another reason for non-Inuit workers to work in collaboration with Inuit workers or other community members.
Culture. Some participants spoke of the ambivalence and complexities related to non-Inuit learning about and from Inuit culture. On one hand, some participants remarked that these efforts may be perceived as a form of respect. On the other hand, participants suggested that these efforts can also be perceived as "wanting to be Inuit." Participants described how community members can limit non-Inuit access to cultural activities, and general interactions with these individuals if they are perceived as not being authentic in their attempts to learn, or if they are view as attempting to appropriate traditional activities. A non-Inuit nurse explained: "There are some (non-Inuit) who will be able to speak Inuktitut (…) They always come up with Inuktitut sentences in the meetings. Then Inuit will tell me: damn they annoy us (...). But it was only after a few years that I started hearing that. In the beginning you think . But now, collaboration for me ... It's about being yourself." Cultural challenges also emerge when people have different and often incompatible expectations. A non-Inuit social worker offered examples like school teachers expecting youth to attend classes every day and all day and social workers hoping youth attend prevention sessions on a regular basis, whereas families might feel that activities such as hunting, camping or staying at home are most helpful for the youth.
Inuit participants spoke of the importance of cultural sensitivity training for non-Inuit workers and the interest of integrating Inuit and non-Inuit workers in the same training so as to ensure shared learning and the ease of working together.
Mismatched timing. From the perspectives of service providers, families use services at times and in ways that are inconsistent with the way services are delivered. Indeed, service providers report that families often ask for help when they are in a precarious situation. However, because of the lack of resources, families often only receive help when the situation becomes critical. A planning o cer at Youth and Family Services described the situation of a family who had been asking youth protection services for support because they were concerned that their teenager was engaging in drug use and sexualized behaviors, yet they did not receive any services. In a moment of crisis, one family member hit the teenager. Youth protection services then got involved and placed the child in foster care. In another example shared by an intervention worker, a parent called the police to ask for help to deal with their teenager who was heavily intoxicated. Yet the police did not see themselves as having a mandate or a role in this situation. In these two examples, families reached out for help but could not access these services at the moments they were needed the most.
Furthermore, many service providers described their impression that in times of crisis, families expected services to take charge of a situation and of their children, relegating their parental responsibilities entirely. A non-Inuit psychiatrist described how youth can end up hospitalised alone in Montreal: "Sometimes, youth that are hospitalised, their parents don't come to see them. We have to run after the parents. The social services try to reach the parents. The youth is a minor and doesn't have family around. We have extended family who might be there a bit and that is really helpful. Or else, they end up alone." In a contrasting example, a non-Inuit social worker explained how families might show up in times of crisis: "People call when they are having a big issue, big distress, crises, they are really upset. They aren't able to keep their child, not able to keep their elderly parent, or not able to deal with alcohol problems of a family member. It's pretty much what we deal with. Yes, we offer support, but it stops there. Because if people don't take things into their own hands, well the problem just starts all over again. Me, I try to show the cycle of dependence. I try to show ways out, ways of a rming oneself, how to face our own problems." Family members may seek services on different occasions or may stay at home feeling that the resources are not helpful. If the situation spirals into a crisis, families may either feel the need to go back for support or end up forcefully receiving court-ordered services. This spiral has multiple repercussions. In the moment when services are offered or available, the family may have already fallen into feelings of hopelessness and disengagement towards the situation.
Service providers spoke of feeling frustrated when situations ended in crisis when they thought that the crisis could have been prevented. This frustration was at times accentuated by service provider attitudes that stereotypes about Inuit. For example, a non-Inuit service worker articulate the belief that Inuit are not : "In general, health services are very well received by the population. Typically, the Inuit population is a population that lives from day to day. So when we talk about curative health care, yes they are engaged, they come to seek this care. Less when we talk about prevention, it is not necessarily a population that will be compliant with prevention programs or come for their medical appointments. If it is beautiful that day, they will go shing and then hunt. They will not come to their appointments. Then I say that we are not adapted to this reality." These stereotypes and frustrations may be felt and heard by other service providers as well as by the families who may feel judged or misunderstood. An Inuit elder explained the challenges of navigating obscure bureaucracies and of having a genuine community voice within services: "Even if we meet and talk and say what we need as a people, there are too many other things that in uence decision-making, things we cannot see. So in the end we don't feel heard, we don't feel understood. What is the point?" Mismatched timings between the moments when services are needed (before breaking point) the moments when services are offered (at the breaking point), as well as the tendency towards generalization, seems to impact both service providers' and families' perceptions of one another, limiting their ability to truly collaborate towards a common goal.
Working and being from the community. Both Inuit and non-Inuit workers speak of the challenge that Inuit workers face working in their own community. Working with youth and parents who are also relatives or neighbors can be socially and professionally complicated. Inuit workers feel that they should be offered counselling and guidance in their work to help deal with these realities. They feel that the lack of social support and counselling is an inhibitor to their ability to consistently provide the care they would want to offer to their community. An Inuk worker explains: "You know what, I worked out of passion, out of love and I did this for my community. I felt like I was making a positive impact, and then my friend (also working for community services) said, 'it wasn't worth being shut-out (by community member) for 15$ an hour.' It wasn't worth family disowning them, or not feeling safe to go in public. Both Inuit and non-Inuit service providers describe a range of factors that affect their ability and desire to moving youth and families. Service providers might speak to each actor but rarely together and services providers and family members occupy distinct spaces within the community making it di cult to meet. From seemingly procedural factors such as the bureaucracy around consent, miscommunications around language, and mismatched timing around when services are requested or needed and ultimately offered, to deeper structural issues related to a lack of resources within communities and culture, each of these areas represent barriers or hurdles to youth and family participation, as perceived by service providers.

III) Building on strengths
Despite the multiple challenges above, many Inuit participants and a few non-Inuit service providers described successful encounters with youth and families as well as speci c ingredients or approaches that they felt would lead to more positive and meaningful participation of youth, families and communities. We organized these success factors around 5 categories: a) developing trusting relationships; b) informal encounters; c) reaching out to extended family and community; d) responding to the right needs; e) attitude and care from service providers. Here, it is important to note that Inuit participants speci cally spoke of trusting relationships and the role of community members in supporting the wellbeing of youth. Inuit also speak of ways of training non-Inuit service providers to improve cultural awareness and attitudes. Inuit workers, who are also parents and community members receiving services go beyond their disappointments with the current situation and see possibilities for transforming approaches and structures of care. Here we integrate Inuit and non-Inuit perspectives to re ect on ways of learning from positive experiences and building on existing strengths always basing the categories around what Inuit within this study and past studies suggest should be done to improve care.
Developing trusting relationships. Non-Inuit participants spoke of service providers who have lived in a community for many years and who have established a trusting relationship with families. They felt that when this was the case, families would mobilize in their care and proactively seek help. A non-Inuit child psychiatrist described how her ongoing relationship with and commitment to the community helps build trust and collaboration: "I've been there for a few years. [Families are] starting to recognize me, they greet me. Then they'll come to the airport and then they'll tell me "you know my daughter, such, such thing". It is in the long term that the relationship is established and then the collaboration is done".
After having received training from an Indigenous organisation, a non-Inuit nurse re ected on what she learned through the training: "Often when Inuit go towards services, it's because they are in crisis and they just don't have any other choice. But, would they really just go when they are in crisis if they felt that they had strong trusting relationships and if services were adapted? I don't think so because I know people who have good relationships with workers and they don't just go when they are in crisis." When a relationship has been di cult to establish with a patient or family, some service providers spoke of building on another service provider's trusting relationship by asking the colleague to speak with the family for them or to accompany them in their meeting with the family. This approach was particularly relevant with Inuit colleagues. For example, an Inuk youth protection worker describes how she has collaborated with her non-Inuit colleagues: "Literally for every intervention. I heard so many [of my colleagues], like "it's impossible to get to this mother, it's impossible to go to this house" 'cause they are alone, you know? Like, we discussed before, you should have an Inuk with you every time you go to someone's house. So I follow to people's houses just to go translate and it usually works." Another Inuit psychosocial worker described playing a similar role: "When I was in charge of this service, we had caseloads and we had waiting lists and everything. But we could work much faster and quicker with Inuit families because we're Inuit. I had an assistant who was also Inuit, and elderly experienced people working with us as community workers and going to visit families and knocking on doors and working with the police. So it was much more community-oriented." Community involvement and Informal encounters Inuit workers wished that non-Inuit workers be more involved in the community to get to know the families and create that trust that is essential for clinical care.
"Because for me in my mind, as a front-line worker and a community member, the way a community member will see a front line worker is only through when there is a crisis. So a front line worker in the community member is a crisis intervener and then it's not always positive. So i would always love them to be more involved in the community. It can be by volunteering, you know, coming in to our recreation facility and volunteering and you know, play soccer, or you know be a part of a sports team." Non-Inuit participants who described positive collaborations with families spoke of using informal approaches such as "having an open door to just come and meet". A non-Inuit social worker described what this open door could potentially look like: "There's got to be an open door. You know, I was even discussing with a couple of the local staff in the school -how cool would it be if once a month, we just had like an open-door night for a few hours? Like, not parent-teacher night, not talking about report cards… we are not discussing the academics. Just come and meet the teacher. Come have a coffee, relax, you know? It doesn't have to be fancy, it doesn't have to be organised. The idea that the teacher is not this scary entity that sits in a classroom, right? That we are human beings and we're just here to help your kids." A non-Inuit teacher explained that he tends to spend a lot of time within the community, at events and just walking around chatting with people: "I guess it's also about being in the community a fair amount, so I am very close with a lot of parents. Like, I know them on a social basis. And I'll talk to them about their kids at those points, too. I think it helps sometimes." Reaching out to extended family and community. Working with extended family members such as grandparents, aunts and uncles, and cousins as well as key members of the community can also help service providers connect with the family and youth. A non-Inuit general practitioner explained: "[The] times I've seen beautiful interventions were often [with] the grandparents who know the children well, and the grandparents really have a respect here from young offenders. I think it's often them who have a lever to try to reason youth and talk to them about more emotional things." A non-Inuit psychiatrist explained the particular involvement of extended family in Nunavik: "I nd that compared to the south, the extended families really get very involved with patients (…) Aunts, cousins, there is really this sense of family that goes beyond the nuclear family. And generally it goes pretty well with them when they see that we are interested in them, that their opinions count, that we are soliciting them for that, when we thank them for their support for example. They are often really pleased. They have a collaborative mindset". On a more individual basis, a program manager, a planning o cer and a school director described trying to "go towards community" as a way of learning from community and integrating the environment they live and work in. They spoke of attempting to learn Inuktitut or trying traditional activities, going on the land, participating in community activities, and integrating themselves into the community. have to say, that their opinion counts, that they have been asked for that, that they are thanked for the support they give for the patient, for example. They are often very happy with that".
In the quotation below, a non-Inuit psychosocial worker recounted the story of a foster family and youth protection agent who respected the importance of the mother in the child's life, despite her challenges: While messaging through social media is certainly a limited form of contact, in the very di cult situation of foster care, where many parents often lose contact with their children completely, this commitment to the Inuit mother is felt as being important for the service provider.
Rethinking the role of community Inuit workers who participated in the study spoke mostly of the role of community in supporting youth and families. They spoke of community members with life experience building trusting relationships with youth to teach them. They also spoke of the importance of spaces and activities in the community where youth and families can come together with workers to do cultural activities and spend quality time together. This is seen as the foundation for wellness and to create connections with people who can offer clinical help. An Inuk complaints commissioner gave the example of a community kitchen: "There is a community kitchen that happens every Monday, Wednesday, Friday. Three times a week, going on here at school for the whole family. Sometimes I bring my children and then you can bring your children; they have animators for the children. I think little things like that can help relationships between parents and young people."

Discussion
Shifting how service providers see participation Inuit of Nunavik are currently in the process of transforming and developing services for youth and families [46]. The vision is one of Inuit as guides and decision-makers in the design and delivery of services. As Inuit are creating the foundation of these services they recognize that non-Inuit and the institutions in place play an important role in the care of youth and families [46]. Therefore, in this period of transition towards self-determination of services, Inuit and non-Inuit wonder how service providers within the existing services transform their practices to enhance engagement of youth, families, and communities. As previously published, Inuit have spoken of their desire for more community-led practices, pro-active in home approaches, and `beyond-mandate' service provision for families [44,46,50]. Inuit ask for prevention oriented approaches that are grounded in Inuit knowledge and ways and that bring families and communities together rather than treating patients or clients as individuals [44,45]. In this discussion we re ect around these principles and values to discuss how the experiences of Inuit and non-Inuit service providers can shed light on both the tensions that might hinder the ability to achieve these goals, as well as promising opportunities.
First and foremost, exploring Inuit and non-Inuit narratives separately highlights two important differences: First, while both Inuit and non-Inuit describe a variety of challenges and promising practices to support the participation of youth and families in their health and social care, non-Inuit generally tend to hold a more negative discourse as compared to Inuit who speak offer hope and ways of moving forward. Indeed, although not always the case many non-Inuit workers describe di cult experiences. In certain of these descriptions one can detect feelings of frustration, disempowerment, and feeling stuck. Unfortunately, these narratives sometimes turn towards stereotyping, discrimination and negative attitudes. Non-Inuit service providers speak of not having enough resources and time. However, some also tend to speak of Inuit as not being prevention oriented, or as engaged as the service provider wishes. Second, even if Inuit participants are both community members and workers within the systems, the promising practices that Inuit describe are very much grounded within community, as opposed to within the institutional services. Communities are seen as spaces for connecting, learning, and healing. They are also seen as potential decision-makers. There is a clear invitation for non-Inuit service providers to be more present in community life and to learn from Inuit to create trusting relationships.
Next, we discuss the content of participants' narratives around three essential components of psychosocial practices as elaborated by Inuit in previous publications: understanding historical considerations; being grounded in community and focusing on kinship [44,45,46,50].
First, despite the importance of colonization and colonialism in the development of such attitudes [12,51], very few service providers spoke of history and its potential impact on families. Colonization and traumas (loss and grief, separation of families and children, the taking away of land, loss of culture and identity impact of social inequities) still affect the way youth and families perceive services and interact with them [20,52]. The persistent remnants of colonial history can in ltrate within the health professionals-patient interactions leading to di culties in building trusting relationships [23], along with the importance for service provider to recognize the importance of culture, language, identity and place. In our view, understanding history offers a critical entry point to possibilities of relationships building and participation.
Second, a di culty that non-Inuit service providers may be experiencing in reaching out to youth is a challenge related to location and mandates within services. As Inuit service providers, and community members [45] explain, possibilities of supporting youth and families are great within the communities themselves. Various Indigenous authors remind us that community is the space where people can gain deep insight into the hearts and realities of Indigenous peoples and therefore the service providers who wish to bridge this gap must integrate community to connect with people [8,52,53]. In their article, Vicary & Westerman [52] showed that participants preferred a non-Indigenous therapist who was interested in developing a holistic relationship with them, not limited to professional settings. Inviting participation is not an event (a phone call, or an email), it is a bond and an open attitude. When "ties to place" (people relationship with spaces and places) are respected and strengthened, community participation in services can be improved [54][55][56]. Our ndings align with research exploring ways of engaging Indigenous youth in health and social services which highlights the importance of reaching out to youth, and meeting youth in their environments, perhaps with their families, and on their own time with informal interactions and trust building [8,20,52,57]. This is important to re ect upon. If service providers expect families to go towards services and participate within the institutional boundaries, then the absence of family members within the walls of the nursing station can be frustrating for the service providers. If community is seen as a space for trust building and healing, then service providers must be encouraged and supported in transforming their protocols and approaches. A few non-Inuit participants of this study suggest that positive encounters, are often described as informal, which means being exible, spontaneous and open to meet and discuss outside of institutional spaces and outside of o ce hours. A barrier that is identi ed in the current study is related to space, time, mandate and lack of resources. With regard to time and space, the position of various actors within speci c geographical locations shapes the possibilities of participation of youth.
However, for all of this to take place, as Inuit participants tell us that services require major nancial and structural transformations. Similarly, Campbell and Erbstein [53] highlighted the need for greater time and resources for intervention, for cultural changes within organizations, and for the development of particular values that underpin leadership, such as community rootedness, relationships, knowledge, and legitimacy among the staff. Adapting services to Indigenous needs and culture, particularly of youth, often requires extending beyond service mandates [53].
Third, Inuit have expressed the need to work in ways that respect Inuit kinship and strengthen interconnections [45,46]. Within the current study, service providers also identi ed a multitude of interdependent actors that play a role in the care of children and youth. These ndings contrast with the literature on collaborative care, patient-centered care, health coalitions, and youth engagement, which each tending to focus on more narrow relations, often between two actors. Collaborative care, patient-centered care, health coalitions and youth engagement scholarship each focus on the relationships between a very restricted group of actors: ie service providers connecting with patients, different types of health professionals connecting amongst themselves [58,59], community organizations connecting with institutional (formal) organizations [60]. Participants of this study suggest that youth are connected to a variety of actors who play distinct roles (parents, extended family, community), and who are codependent in the care of youth. However, our ndings suggest that these individuals may not have the opportunities to all interact with one-another due to structural realities or organizational culture. For example, focussing on parental consent to work with children, as well as on notions of con dentiality, workers have di culty building partnerships with parents and extended families. Moreover, having limited human resources and many families to work with, workers end-up having to do crisis work rather than prevention and support work. Participants who speak of being able to connect with families describe the importance of working with Inuit workers, cultural consultants, or at least, non-Indigenous professionals that have an established trusting relationship with the community over years. Interestingly, in a study conducted in Australia, Vicary [61] found that 92% of Aboriginal people in his study would not see a non-Indigenous service provider unless a cultural consultant recommended the service provider to them. Westerman [8] adds to this literature by suggesting that engaging a cultural consultant in service provision has to be done in manner that is coherent with culture and beliefs.

Conclusion
The study highlighted certain practices that are viewed by service providers as being helpful in creating this connection with families. Service providers, and more speci cally Inuit service providers speak of the importance of sensitivity and understanding of colonization, ongoing colonialism and its impacts. Service providers are encouraged by non-Inuit workers to explore approaches including asking Inuit for guidance, collaborating with Inuit workers, building relationships within the community, and advocating for structural transformations as requested by Inuit. It would seem however that many structural issues can act as an impediment to these transformations in approaches [8,53,62].Non-Inuit and Inuit Service providers might feel stuck in the exibility they can have within institutions. These various personal and organisational limitations might lead to feelings of frustration towards the system or towards the families people work with. For Inuit participants, communities seem to be spaces of opportunities. In order to reduce the gap between services and families, signi cant changes must be made so that Inuit can be decision makers of the services approaches and help guide non-inuit towards approaches that are supportive. Therefore, rather than asking how we can increase youth and family participation in health and social services, we propose a shift in perspectives. We propose the following question: How can we create spaces and processes for service providers to better see and support the existing participation of family members in the design and delivery of care? And how can we better listen to Inuit families and service providers who clearly have ideas of how to transform services and approaches?
It is important to note that the current study was conducted primarily by non-Inuit researchers. Despite having developed strong relationships with community members and having held various brainstorming and planning sessions with Inuit the way of organising and sharing information remains highly in uenced by Western ways of seeing and doing. Moreover, interviews were conducted with service providers who were interested in speaking about their experiences and perceptions. This most likely homogenizes the voices of service providers within the current manuscript.
Interviews were conducted in English by non-Inuit coordinators who were not connected with community members at the moment of conducting interviews. Although they have continued to be heavily involved in partnership research and Inuit-led initiatives the fact that they did not have long standing relationships with Inuit at the time of interviews may have limited the number of interviews conducted with Inuit. For all of the reasons, and those stated within the present article, Inuit workers and families should always be seen as the guides to their health and social care.

Declarations
Ethics approval and consent to participate: Ethics was obtained from the Comité d'Éthique de la Recherche en Éducation et en Psychologie from University of Montreal. Written consent was obtained from all participants.