Table 3 Themes contributing to program barriers

Impacts of Colonization

 • Historical experiences such as forced removal of children and residential school experiences creating a lack of trust, fear, and trauma that impacts the ability to deliver programs in the present day [1, 49, 69, 73, 74]

 • Colonization impacts manifest in poverty, adverse living conditions such as gangs, violence, substance abuse, overcrowded housing, and low education resulting in low resources and poor health [1, 5, 15, 31, 60, 65, 68, 70, 77]

 • Infrastructure and policies do not support Indigenous family practices, creating a gap in care structure for Indigenous families [50, 53, 65]

Power and Governance

 • Power imbalances were present in three domains client-to-staff, staff-to-staff, and program-to-community [52, 61, 64, 71]

 • Power imbalances are illustrated through mandated programs, cultural knowledge extraction, the exclusion of traditional knowledge from program decision-making, and struggling to balance worldviews [1, 4, 31, 52, 59, 69]

 • Formal oral and written information delivery systems are employed within the program [28, 31, 52]

 • The lack of community-specific research creates information gaps in program design [59, 63]

 • Jurisdictional issues between levels of government create funding inequities and impede program delivery [3, 63, 69, 71]

Client and Community Barriers to Accessing the Program

 • From the client perspective, the program excludes family members; associated with stigma and high-risk participant criteria; provide inaccurate program information; offered in an unwelcoming physical space; experience with the child welfare system can create a lack of trust and deterrent from accessing available programs [1, 14, 15, 30, 61, 66, 68, 69, 77]

 • From the staff perspective, the beliefs and practices of a community are omitted in the program such as the norm of bottle-feeding versus breastfeeding and gender roles; clients suffering from mental health challenges such as depression; participants’ other obligations in the community such as demands of mothers; and client moving out of the program area [1, 22, 28, 30, 54, 71, 73, 75]

Physical and Geographical Challenges

 • Remote and rural locations create access challenges, program availability, and delivery challenges within the community [5, 15, 32, 49, 54, 69, 70, 73]

 • Elements such as weather, transportation, and roads can inhibit staff trying to reach clients and clients attempting to reach the program [15, 49, 69]

Staff

 • Staffing challenges that include understaffing, limited male staff, and very few Indigenous staff [15, 68, 77]

 • High staff workload and staff assuming multiple roles resulting in high staff burnout and turnover [32, 49, 53, 54, 64, 69, 71]

 • Staff safety concerns, such as domestic violence, crime, and dogs [3, 5, 31, 49]

 • Challenges between staff such as non-Indigenous staff racism, worker expertise not recognized, and the exclusion of team members [15, 31, 52, 61, 69]

 • Staff members may be resistant to a program [64, 65]

 • Staff lacks the necessary training resulting in the program not delivered as intended [31, 53, 68, 69, 71, 76]

 • Staff from the local community may face unique barriers not experienced by external staff, such as cultural and kinship barriers with close relationships to community members and role conflict between what the staff member must do to carry out the program (i.e., home visits) and the community norms [5, 31, 77]

 • Some program staff lacks cultural competence, which negatively impacts the client and the program delivery [29, 52, 61, 63]

Operational Deficits

 • Lack of available space and technology (i.e., computers) to deliver the program or staff to complete their work [52, 64]

 • Time and resource constraints in the form of inadequate time and funding to build relationships, meet program demands, create program materials, and foster program sustainability [30, 33, 51, 52, 55, 69, 73]

 • Fractured service networks prevented some programs from coordinating with other agencies and services, which limited the program’s reach, i.e., not extending beyond program clients to the wider community [3, 32, 49, 60, 61, 76]

 • Policies and practices such as paperwork, disconnect of priorities between program and external organizations and departments and meeting the funding body's requirements [32, 49, 63, 68, 69, 76, 79]

 • Challenges to evaluating the program such as inadequate resources and the capacity to complete program evaluations with issues to available data, data management, and evaluation designs [3, 8, 15, 29, 55, 71, 75]