Effective synthesis, dissemination, and implementation of health research findings is critical for informing patient decision-making, promoting the effective use of health care system resources, and, ultimately, improving health outcomes [1]. Over the past few years, this process known as knowledge translation (KT) has been increasingly directed toward those accessing health care (ie, patients and parents) to foster an active involvement in informed decision-making [2]. Our research group strives to improve health outcomes for children by facilitating the uptake of evidence by actively engaging health care providers (HCPs) and families in the codevelopment and dissemination of a variety of user-friendly KT tools. We integrate the best available evidence (systematic reviews [3]) with parent experiences (qualitative interviews [4]) to create a successful KT model centered within the knowledge-to-action [5] cycle. We are now exploring within local contexts how best to tailor our KT products to diverse audiences.

Our research team has developed a series of web-based videos to help parents understand how to manage common acute childhood illnesses at home and when to contact health care services. These videos have been reviewed by our pediatric parent advisory group [6]; vetted by multidisciplinary, pediatric emergency health care professionals; tested for usability by parents in remote, rural, and urban settings [7,8]; and released on the web for the English-speaking general population (freely accessible at ECHO research [9]). However, it is unclear whether these videos, in their current form, will be useful for a wider range of population.

The relatability and accessibility of KT tools require developers to understand the contexts and realities in which their viewers find themselves [5,10]. Although KT tools are meant to present health care information in user-friendly and relatable formats, they are often developed with the majority cultural communities in mind (eg, in North America, this is predominantly White, English-speaking populations). Culturally adapting KT tools for use by diverse groups offers a great potential for decreasing health disparities and increasing access to resources.

In Canada, Indigenous populations face a plethora of health disparities and unique barriers when accessing health information [11,12]. This can include a lack of access to health resources and the discontinuity of care for families, which can directly affect child health outcomes [13,14]. Unfortunately, most existing KT initiatives may not effectively engage Indigenous populations or incorporate Indigenous knowledge and practices [15-17]. In addition, there is a lack of information in the literature on how best to implement, practice, and appraise KT initiatives for Indigenous populations [18].

We sought to understand whether and how our KT tools could be adapted for use by Indigenous communities. Although frameworks to achieve cultural adaptation for health promotion programs and health interventions have been documented [19,20], guidance on how best to adapt KT products for use by culturally and linguistically diverse audiences is lacking. As the first step, we explored the opinions of HCPs who work with Indigenous communities regarding the applicability of 2 of our KT tools for use by the families they serve. We aimed to gather their perspectives on the usefulness and appropriateness of the tools as well as considerations for how best to adapt or develop KT tools in such a way that they are relatable and accessible to Indigenous communities.

Within our province, there are 45 First Nations in 3 treaty areas, representing culturally distinct and traditionally underserved Indigenous communities [21]. We engaged with several local stakeholders (researchers, clinicians, program managers, and Indigenous community members) working in Indigenous health and research to understand what approach would work best. Those early conversations helped develop the research plan and facilitated subsequent engagement with HCPs who serve Indigenous families and communities in Alberta, Canada.

Semistructured one-on-one web-based interviews were conducted with HCPs who serve Indigenous communities to discuss 2 existing child health KT videos (on croup and acute otitis media [AOM]; Multimedia Appendix 1). The videos were originally produced for the general English-speaking population. The participants were also asked to complete a short demographic survey.

Participants were eligible for the study if they were a practicing HCP serving Indigenous families in Alberta and could read and speak English. HCPs could be any health care personnel or professional interacting with Indigenous patients and families and providing care (eg, physician, nurse, or midwife). Participants were recruited from a variety of disciplines, including provincial health authorities and those working in not-for-profit organizations, local hospitals or care units, and Indigenous organizations, through a targeted recruitment effort using professional contacts and snowball sampling [22]. Purposive sampling was used to generate an in-depth understanding of the HCPs’ reflections [23]. Sample size was determined by evidence of data saturation, which was monitored through concurrent analysis of the data to assess the comprehensiveness, variation, and richness of the interviews [24].

Ethics approval for this study (Pro00085188) was received by the appropriate Institutional Review Board offices at the University of Alberta. Before the interviews, all participants were informed of the study and the study’s purpose through recruitment emails during the screening for eligibility process and at the start of the interview sessions. All participants provided informed consent before any data were collected. The anonymity, confidentiality, and secure storage of the data were guaranteed to the participants in both the written consent form and before each interview and respected. A meal or electronic gift voucher to the value of CAD $25 (US $19) was provided to all the participants before commencing the interview in recognition of their time.

Data collection and analysis were conducted concurrently to facilitate a more focused and meaningful data collection. Data management and analysis were facilitated using NVivo software (version 12, QSR International). Transcripts were read several times, coded, and analyzed using thematic analysis to identify common themes across the interviews. The thematic analysis process followed was outlined by Braun and Clark [26] and entailed familiarization with the data, initial coding, grouping similar codes together, and the development of themes and subthemes. Themes were then named and described. The interviewer (JK) regularly debriefed the study team members SAE and LH. Iterative data collection and analysis continued until data saturation was reached.

A line-by-line approach was used during the coding process. An inductive approach was used where codes emerged from the data [27]. Data were coded and sorted based on the themes that developed throughout the analysis. A focused coding approach in which similar codes were grouped together was used to elucidate patterns during data analysis. Analytical rigor and trust were promoted through continual communication with the research team and a detailed study log. Interview recordings and detailed field notes promoted confirmability of the findings. Field notes promoted reflexivity, allowing for the acknowledgment of bias, transferability, dependability, credibility, and inductive research praxis [28].

A second researcher (SAE or KSW) re-examined the transcripts and the codes to mitigate interpretive bias. All concerns were discussed until a consensus was reached.

The description and interpretation of themes were then reviewed by a fourth research team member who self-identified as Indigenous (SDL) to ensure that the language, meaning, and context of the findings were appropriately reflective of Indigenous cultures and the needs faced by Indigenous families within the scope of this study.

A total of 18 HCPs from various health professions (eg, physician, registered nurse, and licensed practical nurse) participated in the study. Participant demographics are presented in Table 1. All the participants were HCPs who served Indigenous families or communities; 83% (15/18) of the participants self-identified as female, and 39% (7/18) of the participants self-identified as Indigenous. The HCPs served Indigenous patients in rural communities (4/18, 22%), urban communities (6/18, 33%), or a mixture of both (8/18, 44%). The participants had, on average, 11 (SD 9) years of experience working with Indigenous communities.

The participants spoke about various considerations needed during the development or adaptation of KT tools to ensure they were relevant to the Indigenous communities they served. In total, 4 main themes were identified, and a summary of these themes can be found in Table 2. The participants described how addressing (1) accessibility, (2) relatability, (3) KT design, and (4) relationship building could produce more effective, culturally relevant, and meaningful KT tools.

Cultural adaptation has the potential to enhance the acceptability, uptake, and adherence to evidence-based information. Where culture represents a dynamic set of norms, values, and practices in a social sphere, cultural adaptation focuses on modifying certain aspects to enhance the fit for an individual’s cultural values, preferences, and norms [29]. Incorporating Indigenous knowledge into KT efforts has the potential to create “new knowledge, policies, and practices to address health issues in communities” [30]. Unfortunately, KT has received relatively little attention in Indigenous health contexts.

As a starting point to understanding how KT tools could be adapted or tailored to meet the needs of Indigenous communities in Alberta, we assessed the value of 2 of our existing child health KT tools from the perspectives of HCPs. From our thematic analysis, 4 key themes were identified by HCPs to consider when adapting or developing child health KT tools use by for Indigenous families: accessibility, relatability, KT design, and relationship building. Here, we present important considerations for researchers and health professionals developing or adapting KT tools for use by Indigenous populations.

Tangible resources, such as access to internet, being able to afford certain medications, or having access to clean water or transportation, were key elements to consider when portraying an event or message within the KT tools. In general, remote and rural communities have greater accessibility barriers than their urban counterparts and often face challenges in relation to transportation infrastructure and internet connectivity [31-34]. In addition, a community’s ability to leverage resources, services, and providers affects the relevance and applicability of the recommendations made in a KT tool. Researchers and developers should ensure that KT tools are tailored to the intended population or community with specific accessibility barriers in mind so that the users can implement the recommendations effectively.

Accessibility barriers can also impact whether users are able to access or view KT tools. For instance, caregivers residing in remote locales with sparse internet connectivity may be unable to use web-based KT tools. Although these interviews did not reveal a preference for a particular KT format, the ideal KT format is something which is easily accessed and used by the target population. In this case, social media platforms such as Facebook were identified as an extremely effective method for distributing web-based tools to populations with internet access and have been successfully used previously to share health information with First Nations communities within our province [35].

To ensure widespread accessibility and usability, the translation of KT tools into various Indigenous languages and dialects for specific communities and linguistic groups should be considered. However, a deep linguistic approach, as referred to by Resnicow et al [36], should be used. This involves ensuring that texts are culturally relevant rather than simply providing a direct translation. Direct language translations can often lack cultural nuances; therefore, high quality translations by Indigenous translators are needed.

A community-level collaboration approach should be adopted to support the development of community-owned products that incorporate cultural sensitivity and unique linguistic needs to improve their uptake and use within the community.

Incorporating different aspects of a group’s culture appropriately into KT tools can foster engagement and increase knowledge, especially if shared through locally developed and contextualized ways [17,18]. Incorporating Indigenous cultural components, such as the medicine wheel, or practices, such as smudging, may help users to better connect with KT tools. An important caveat here is that Indigenous peoples and cultures are incredibly diverse [37], and as such, it is extremely challenging to create content that is relevant to all Indigenous groups within a single tool. However, culture has been successfully incorporated within KT efforts in the past. For instance, Laird et al [38] used a culturally safe KT approach to help Indigenous Australian caregivers manage protracted bacterial bronchitis in their children. Another study aimed to improve dementia health literacy in Canadian Indigenous communities by developing culturally appropriate fact sheets in collaboration with Indigenous organizations and Elders [39]. However, each Indigenous community has a unique culture and history; therefore, a successful approach to KT for one community may not be relevant to another. By actively engaging the community of interest, stakeholders could shape the information design and content to suit the community’s needs and preferences.

Ensuring that KT tools, specifically those that use visuals or graphics, incorporate relevant and appropriate depictions of environments and characters is important. Scenic or environmental portrayals must be relatable to KT users. Likewise, portrayals of characters within visual or story-based KT tools must also bear resemblance to the target users for optimal reception. This could involve having characters in a visual KT tool that have a similar skin complexion to that of the target audience and similar clothing items based on cultural or environmental factors or integrating customs and practices specific to that group [40,41].

Notably, those developing KT tools should avoid stereotypical or inaccurate representations of Indigenous peoples or cultures by effectively engaging with and involving the communities and tailoring the tools appropriately.

Relationship building is important throughout all aspects of the KT and dissemination process and is integral for working with Indigenous communities in a respectful and meaningful way.

Engaging with and building long-lasting mutual relationships with Indigenous communities, stakeholders, and Elders has been shown to be extremely important for working with Indigenous populations in a multitude of capacities and contexts [42-44]. A scoping review highlighted the importance of the contributions of the Indigenous Elders to well-being at the individual and community levels and the need to include Indigenous Elders in consultation and relationship-building efforts [45].

Relationship building entails creating long-term, sustainable partnerships with community members, stakeholders, and health professionals. Understanding community needs is required from a holistic and grassroots approach, which should only be achieved through genuine reciprocal relationships. Relationship building is also necessary to facilitate consultations with Indigenous community members, Elders, and health providers to adapt KT tools for use by their respective communities. KT tools should be codeveloped with the members of a given community to ensure that they are culturally sensitive, relevant to their needs, and accessible.

While reflecting on the enduring power dynamics of researchers engaging with Indigenous peoples [46], we believed that recruiting Indigenous community members required a sensitive process of meaningful reciprocity that was not feasible for this study. In consultation with Indigenous community representatives, it was suggested that HCPs who work with Indigenous families were well situated to comment on the available health care resources for the Indigenous communities they serve. The interviewed HCPs also provided important considerations on how to engage Indigenous patients and communities to develop relevant and impactful KT tools.

An important limitation to address is the biases that may arise from the type of qualitative research conducted in this study. Specifically, interpretive biases could arise during the interview or the data analysis and interpretation stages. To mitigate the impact of any interpretive biases, a second researcher (KSW) reviewed the data and brought forth any concerns for discussion with the primary author to reach a resolution. The findings of this study were also reviewed by one of our team members (SDL) who self-identified as Indigenous, further mitigating any interpretative biases.

Despite having a good representation from HCPs working directly with Indigenous families and communities, only 39% (7/18) of our participants self-identified as Indigenous. Even though the themes present across the interviews were similar, it is important to keep in mind that the lived experiences of HCPs who self-identify as Indigenous are distinct from those that are not. Future studies may benefit from incorporating a higher proportion of HCPs self-identifying as Indigenous or aim to recruit exclusively Indigenous participants. This may prove difficult given that Indigenous peoples have historically been underrepresented in health care–related fields [47]. It is important to recognize that given the small number of Indigenous people involved in the study, the findings are not generalizable to the broader population of Indigenous people. In addition, these findings only represent the perspectives of the HCP, and future studies should expand beyond consulting only HCPs and include the health consumers or knowledge users of the KT tool (Indigenous families). We recognize that this study is just a first step; consultations with Indigenous community members, Elders, Indigenous leaders, and other stakeholders are needed to fully understand how to best develop and adapt KT tools for use by Indigenous communities in accordance with their unique needs. Furthermore, we recognize that this study was conducted within a local context in Canada, and the findings might not be representative of all Indigenous populations, not just within Alberta but across Canada (and elsewhere). However, the croup video usability was completed at the Stanton Territorial Hospital in Yellowknife, Northwest Territories, Canada, which has a significant population of Dené people; Portage La Prairie, Manitoba, Canada, which has a significant population of Anishinaabe or Ojibwe, Cree, and Dakota or Sioux people; and the Stollery Children’s Hospital (Edmonton, Alberta, Canada). The AOM video usability was conducted in 3 rural emergency departments in Nova Scotia; the Royal University Hospital in Saskatoon, Saskatchewan, Canada; and Leduc Community Hospital, Alberta, Canada. Therefore, it is important to acknowledge that the perspectives of various Indigenous communities and Indigenous peoples may differ from the themes we have derived in this study. Future KT tool development studies may also benefit from usability testing that occurs across an increased number of locales, particularly those with significant populations of Indigenous peoples.

Developing or adapting KT products that are relevant to different cultural groups is important to enhance the reach of knowledge and ultimately improve health outcomes. On the basis of the interviews with HCPs, accessibility, relatability, KT design, and relationship building were perceived by HCPs as important considerations for adapting and developing KT tools that would meet the needs of the Indigenous communities they serve. This study is a critical first step in identifying how to adapt existing KT tools for use by culturally and linguistically diverse communities in general. This study demonstrated the importance of engaging end users (health care consumers) in the development and critique of KT products. Including Indigenous perspectives in the continuing refinement of KT tool content and delivery will increase the relevance and accessibility of the messaging for future KT efforts in this unique population.