Two-Eyed Seeing Application in Research Analysis: An Integrative Review

Abstract

Background

Research approaches used to understand Indigenous people in Canada have predominately used Western approaches and have not reflected Indigenous ways of knowing, protocols, or worldviews. The landscape of research involving Indigenous people is changing with a growing number of Indigenous scholars reclaiming and revitalizing Indigenous knowledge. Two-Eyed Seeing provides a framework whereby conscious and deliberate conversations and research approaches are determined prior to and throughout the research process by the research team to guide a balance of each knowledge. However, Two-Eyed Seeing approaches or methods used during data analysis within the literature remains sparse necessitating this integrative review.

Purpose

To review the literature where Two-Eyed Seeing has been applied and to identify the approaches or methods used during data analysis and discuss the implications for research with Indigenous communities worldwide.

Methods

The five-stage approach outlined by Whittemore and Knafl (2005) was used to guide this integrative review.

Results

A total of 321 articles were reviewed from four databases, yielding 32 articles.

Conclusions

This integrative review is novel in that it is the first review known to specifically explore the use and application of a Two-Eyed Seeing framework during data analysis. Five main themes are presented including (1) Indigenous community member involvement with analysis, (2) Co-Learning during data analysis, (3) Visual or symbolic conceptualizations to guide analysis, (4) Statement acknowledging Indigenous knowledge during data analysis, and (5) Sharing of Traditional stories to guide data analysis. Additionally, five Two-Eyed Seeing approaches less commonly used during data analysis are provided.

Introduction

Indigenous communities worldwide have endured research by “outsiders” or non-Indigenous researchers who have a limited knowledge of the lived experience of Indigenous communities (Kovach, 2009). Research approaches used to understand Indigenous people in Canada have predominately used Western approaches and have not reflected Indigenous ways of knowing, protocols, or worldviews (Kovach, 2009; Thambinathan & Kinsella, 2021). Additionally, experiences of historical trauma resulting from the Indian residential and day schools as well as other racist colonial policies have contributed to the erasure of Indigenous knowledge and Indigenous research methods (Hyett et al., 2018). The landscape of research involving Indigenous people is changing with a growing number of Indigenous scholars reclaiming and revitalizing Indigenous Knowledge (Kovach, 2009; Hyett et al., 2018). The aim of this paper is to explore how decolonizing research approaches, specifically, the Two-Eyed Seeing framework, known as Etuaptmumk, has been applied during the data analysis phase of health research.

Etuaptmumk, is a word in the Mi’kmaq language meaning “the gift of multiple perspectives” (Marshall, 2004). In the English language, Etuaptmumk is known as Two-Eyed Seeing. Two-Eyed Seeing is rooted in rich Mi’kmaq traditions and reflects overarching concepts that exist within diverse Indigenous communities with distinct knowledge systems sharing ontological insights (Bartlett et al., 2012). For instance, Indigenous philosophies recognize interconnectedness and relationships and avoid a narrow focus on discrete elements unrelated to the whole (Ermine et al., 2004; Martin, 2012). This approach is rich with Indigenous ancestral history and was described by the late Mi’kmaq Spiritual Leader, Healer, and Chief, Charles Labrador, of Acadia First Nation, “Go into the forest, you see the birch, maple, pine. Look underground and all those trees are holding hands. We as people have to do the same” (Bartlett et al., 2007, p. 2). This wisdom was conceptualized and proposed as “Two-Eyed Seeing” in 2004 by Mi’kmaq Elders Albert, and Murdena Marshall, from Eskasoni, a First Nation in Cape Breton, Nova Scotia. It was presented as guiding principles for Integrative Science that builds on Indigenous Knowledge and methods (Bartlett et al., 2007, 2012).

The principle of Two-Eyed Seeing provides a framework whereby conscious and deliberate conversations and research approaches are determined prior to and throughout the research process by the research team to guide a balance of each knowledge (Marshall, 2004; Peltier, 2018). Two-eyed Seeing involves the researcher being aware to not allow one eye (Indigenous ways of knowing) to be dominated by the other (Western ways of knowing); rather allowing each eye to see the world that is always partial (Martin, 2012). By applying this principle, the integration of Indigenous ways of knowing is recognized as being of equal value to Western ways of knowing, where both eyes work together as they do in binocular vision (Bartlett, 2012). Bartlett et al. (2007) note, “Two-Eyed Seeing intentionally and respectfully brings together our different knowledges and ways of knowing, to motivate people, Aboriginal and non-Aboriginal alike, to use all our gifts so we leave the world a better place” (p. 14). The authors note that in a particular set of circumstances researchers may choose to call upon the strengths within Indigenous sciences or within Western sciences. This requires “weaving back and forth” between knowledges and avoids portraying the situation as “a clash of knowledges” (Bartlett et al., 2007, p. 13). According to Bartlett et al. (2012), a co-learning journey is described when applying Two-Eyed Seeing. Co-learning involves learning from each other, learning together, learning our commonalities and differences, and learning to see how to weave back and forth between our cultures’ actions, values and knowledge as circumstances require (Bartlett et al., 2012). The authors outline eight protocols for weaving Indigenous Knowledge and mainstream (Western) science guided by Two-Eyed Seeing. The eight protocols include: (1) acknowledge that we need each other and must engage in a co-learning journey, (2) be guided by Two-Eyed Seeing, (3) view “science” in an inclusive way, (4) do things in a creative, grow forward way, (5) become able to put our values and actions and knowledges in front of us, like an object, for examination and discussion, (6) use visuals, (7) weave back and forth between our worldviews, and (8) develop an advisory council of willing, knowledgeable stakeholders, drawing upon individuals both from within educational institution(s) and within Indigenous communities (Bartlett et al., 2012). This interweaving approach offers opportunity to engage in research processes to explore knowledges in ways that will offer the community the greatest benefit (Iwama et al., 2009). Furthermore, the co-learning process engages the research team to acknowledge the historical dominance of Western knowledge within research and the devastating impact of colonial policies on the erasure of Indigenous Knowledge (Iwama et al., 2009).

In 2011, Two-Eyed Seeing was adopted to guide the vision and mandate of the Canadian Institutes for Health Research and the Institute for Aboriginal Peoples’ Health (CIHR, 2015). There has been an increase in the use of Two-Eyed Seeing to guide environmental sciences (Ahmed et al., 2022, 2023; Leonard et al., 2022), program development (Dunn et al., 2022; Marsh et al., 2022; Nicholson et al., 2021), education (Acharibasam & McVittie, 2022; Heuckmann & Zeyer, 2022), social justice (Cullen & Castleden, 2022), and discussions for cultural competency (Chatwood et al., 2015; Wright et al., 2019b). Moreover, there remains variation in how Two-Eyed Seeing is applied within the literature. For example, some studies have applied a Two-Eyed Seeing approach as a research method such as involving Indigenous community members, Elders within the research process or Indigenous Advisory Committees (Carter et al., 2017; Hall et al., 2015; Wright et al., 2019a) or while following ethical research processes (Hall et al., 2015; Lavallee et al., 2009). Hall et al., 2015, reported that Two-Eyed Seeing assisted the research team as a guiding principle which aided in engaging with decolonizing research methodologies. Other studies reported the application of Two-Eyed Seeing as an Indigenous methodology (Danto et al., 2021; Marsh et al., 2015; Sylliboy, 2021). According to Marsh et al. (2015), Indigenous research approaches and the development of Indigenous methodologies guide the research agenda to respectfully represent the Indigenous population. Additionally, some studies described a Two-Eyed Seeing approach, but not specifically the approach described by Bartlett et al. (2007). For example, in a study by Kandasamy et al. (2022), a Haudenosaunee Two-Eyed Seeing approach called, ‘Two-Row Wampum-Covenant Chain Tradition’ is used to guide and honor multiple knowledges during the research process. Despite the variety of applications of a Two-Eyed Seeing framework there appears to be consistency to represent and honour multiple knowledges in an effort to benefit the community as a whole. Moreover, there remains a lack of a defined Two-Eyed Seeing approach during data analysis representing a gap within the literature (Wright et al., 2019a). This gap significantly impacts research study findings and limits the benefits to the Indigenous community. For example, data analysis solely through a non-Indigenous lens defeats the intentions of Two-Eyed Seeing to respond and resolve the inherent conflicts between Indigenous ways of knowing and analysis process of the scoping review inquiry (Chatwood et al., 2015). The variation in application and lack of a defined approach of the Two-Eyed Seeing framework especially during data analysis as well as the rapid uptake and need for Indigenous research methods has significant implications on the recognition and revitalization of Indigenous Knowledge in research and Two-Eyed Seeing.

In 2019, an integrative review was conducted by Wright et al., in response to a lack of a clear application of procedures for researchers using a Two-Eyed Seeing approach. The authors identified inconsistencies with the interpretation and application of Two-Eyed Seeing in research and outline six key attributes and application procedures for consideration by researchers choosing to apply Two-Eyed Seeing to their work. The six key attributes include: (1) authentic relationships, (2) reciprocal research, (3) relational accountability, (4) Indigenous involvement, (5) Indigenous methodology, and (6) Western researchers deferring to Indigenous leadership. The research by Wright et al., 2019a, has significantly contributed to the foundational literature surrounding the application of a Two-Eyed Seeing framework described by Bartlett et al. (2007). However, the authors note significant variation and a lack of a defined approach during data analysis in the literature when a Two-Eyed Seeing framework is applied.

The purpose of this paper is to review the health literature where Two-Eyed Seeing was applied and to identify the approaches or methods specifically used during data analysis and discuss the implications for research with Indigenous communities. This article will contribute to the greater body of literature around the application of Two-Eyed Seeing in health research. To guide this integrative review the approach outlined by Whittemore and Knafl (2005) will be used and involves five stages: (a) problem identification, (b) literature search, (c) data evaluation of quality, (d) data analysis, and (e) data synthesis. Given that (a) problem identification has been clearly outlined previously, the following four stages (b-e) will be described.

Methods

Literature Search

A systematic search of the literature was completed to identify published research articles which were publicly available. The research problem, the lack of published literature to guide the application of Two-Eyed Seeing during the analysis phase of health research conducted with Indigenous communities, inspired, and guided the search for this integrative review. The following databases were used, OVID Medline, CINAHL, Web of Science, and PubMed using the search terms “Two-Eyed Seeing” or “Etuaptmumk”. Other search terms were not used given the specific area of research and limited contribution to additional relevant articles. Articles were included if they: (1) were published in English between 2007 and June 2023, (2) related to the health of Indigenous communities, and (3) described the application of a Two-Eyed Seeing framework during the analysis phase of research. Once duplicate articles were removed; all article titles and abstracts were reviewed for relevancy. Finally, a full-text review of remaining articles was completed, and articles were removed if they did not meet the inclusion criteria (see Figure 1).

Figure 1.

Prisma chart. Search strategy.

Data Evaluation of Quality

Thirty-one of the selected articles were primary research including 27 qualitative articles, three quantitative articles, and one mixed methods article. Additionally, one scoping review was included. These articles were critically appraised for quality using a relevant tool from the Critical Appraisal Skills, 2018a, 2018b library of appraisal tools. Mixed methods studies were appraised using the tool developed by Pluye et al. (2011). See Table 1 for Critical Appraisal of Primary Studies.

Table 1.

Critical Appraisal of Primary Studies.

Qualitative Research (Critical Appraisals Skills Programme, 2018a)
Author Number of Participants	Clear Purpose Location	Appropriate for Qualitative Research	Appropriate Design for Research Question	Recruitment Method Fitting	Data Collection Fitting Question	Relationship Between Researcher and Participants Considered	Ethics Considered	Rigor in Data Analysis	Clear Results	Valuable Results
Bruner et al., 2019Indigenous youth between the ages of 15 and 25 (n=99)	To understand Indigenous youth development within the context of sport and physical activity through the voices, stories, and experiences of Indigenous youth.	Yes	Yes-Methodology not described in the article	Yes-Student researchers and research coordinators contacted local youth, Indigenous organization and community leaders from their networks and programs-Recruitment posters	Yes-Thirteen sharing circles	Yes-Involved indigenous youth researchers	Yes-Institutional Ethics Review boards of three participating universities, the office of Indigenous Initiatives of one of the Institutions-Research license was obtained from the Nunavut Research Institute to conduct a sharing circle	Yes-Research team re-engaged with governing circle to present results of analysis process for feedback and comment-Consensus building- not described.	Yes-Ten main themes-Emerging themes were oriented visually; Indigenous Symbolic Analysis (McNiff, 1998) via Medicine Circle framework.	Yes-This is the first study to examine experiences of indigenous youth in sport and physical activity using Two-Eyed Seeing.-Shared stories about Indigenous youth development within sport and physical activity
Cabrera et al., 2015First Nation community members, British Columbia  (n=48)	To explore the impact and interplay of medicalization with the Nation’s knowledge and approaches to wellness in relation to early onset familial Alzheimer disease.	Yes	Yes-Methodology not described in the article	No-Secondary data analysis	Yes-Semi-structured focus groups	No-Not described in the article	Yes-Nation’s ethics protocol-University ethics board	No-Not described in the article	Yes-Understanding of disease is medicalized/Western, but approach is bother Western and Indigenous	Yes-Validates presence of both views for those who require this proof in order to value different perspectives of health and wellness
Carter et al., 2017First Nations men  (n=3)	To explore practices that support positive First Nations identify and provide suggestions for practicing culturally safe care.	Yes	Narrative methodologyIndigenized Lieblich et al. approach	Yes-Indigenous advisory group recruited	Yes-Interviews, use of symbol-based reflection	Yes	Yes-University ethics board-Indigenous Advisory board	Limited-Lacks detailMember checking	Yes-Strengths-based approach of contributing factors to living a balance life	Yes-Nurses should practice culturally safe care and may use symbols to elicit meaning from patients and help to better understand perspectives
Clark, 2014Inuit participants and key informants (n=14)	To act as an initial needs assessment to identify future design priorities for evaluating electronic health program delivery to Inuit throughout Canada.	Yes	No specific design described in the article	No-Not described in the article	Yes-Focus groups and interviews	No-Not described in the article	Not applicable-Needs assessment	No-Not described in the article	Yes-Three themes related to improving the accessibility of electronic personal health information for Inuit	Yes-Shaping the electronic health record to the benefit of Inuit patients, respecting language, and contributing to well-being
Danto et al., 2021Indigenous individuals involved with land-based programs in Mushkegowuk Territory (n=3)	To identify shared and distinct features across land-based approaches to healing in different communities within Mushkegowuk Territory through interviews with individuals directly involved with land-based programs.	Yes	Two-Eyed Seeing approach incorporating Indigenous methodology	Yes-Authors invited three participants	Yes-Semi-structured interviews	No-Thought it was indicated that previous research with two different communities in northern Ontario	No-Not described in the article	Yes-Participants were invited back for a second meeting after common themes were articulated.	Yes-Three broad themes were derived.	Yes-Land-based approaches heal disconnections
Galway et al., 2022Fort William reserve, an Anishinaabe community (n=22)	To explore the connections among climate change, land, and health, drawing on the perspectives of Elders, knowledge keepers, and community members with close ties to the land in Fort William First Nation	Yes	Two-Eyed Seeing approach-no specific design described	Yes-Project lead identified and invited participants “knowledge holders” to participate	Yes-Semi-structured interviews-conducted conversationally to ensure space for other ideas and stories to emerge	Yes-Positionality statement included and referenced supplementary material for other authors	Yes-University Research Ethics Board-Community First Nation Chief and Council	Yes-Analytical framework was developed-Reflective note taking	Yes-Five themes and 20 sub-themes relating to the intersection of climate change, land, and health In the data	Yes-This research has highlighted the importance of centering land when exploring the links between climate change and health
Hall et al., 201512 NNADAP and YSAP treatment centres in Canada*number of participants was not indicated	To develop a culturally based measurement tool to gauge the effectiveness of cultural interventions in First Nations alcohol and drug treatment in Canada.	Yes	Two-Eyed SeeingStorytelling and knowledge gardening methodology	No-Not described in this article.	Yes-Storytelling circles	No-Not described in the article	No-Not described in this article.	No-Not described in this article.	Yes-Suggest three steps for research and policy to forefront Indigenous governance under the guidance of Two-Eyed Seeing and in support of cultural renewal	Yes-Contributed to the Indigenous research and policy literature which is lacking documentation about how Indigenous communities and research teams are benefitting from Two-Eyed Seeing.
Hatala et al., 2020Plains Cree First Nations and Metis  (n=38)	To explore Indigenous youth meaning-making processes and engaging with land and nature in an urban Canadian context.	Yes	Modified Grounded Theory methodology and Two-Eyed Seeing	Yes-Purposeful and snowball sampling methods	Yes-Four sessions of community engaged photo taking data collection-Follow up talking circle interviews	No-Not described in the article	Yes-University Research Ethics Board-Community Advisory Research committee	Yes-Emerging themes were checked with youth participants-Major themes were vetted by the Community Research Advisory Committee via peer debriefing	Yes-Three main themes and processes were outlined.	Yes-Indigenous youth connections with land and nature may be a hidden strength or source of resilience and wellbeing.
Jacklin et al., 2020Consultations with Expert Anishinaabe language group (EALG) (n=11)Ad-hoc-consultations with an Indigenous Elder, a Community Advisory Council and KICA (number not specified)Piot studies with Indigenous older adults (n=15)Focus group consultation with health care professionals (n=7)	To adapt the Kimberly Indigenous Cognitive Assessment (KICA) for use as a brief cognitive test with Anishinaabe populations in Canada.	Yes	Community-based participatory research approachTwo-Eyed Seeing approach	YesRecruitment completed by the community-based researcher via purposeful sampling. Recruitment for the health professional group interviews by the health directors via purposeful sampling.	Yes-Focus group review for Pilot and Health care professionals.	No-Not described in the article	Yes-University Research Ethics Board-Manitoulin Anishinaabek Research Review Committee	Yes-Review with Community Advisory Council (CAC) and Expert Anishinaabe Language Group (EALG)	Yes-Planning, Analysis and Development of the Canadian Indigenous Cognitive Assessment (CICA) was outlined.	Yes-Developed a modified version, Canadian Indigenous Cognitive Assessment of the KICA (Kimberly indigenous Cognitive Assessment) for brief cognitive assessment that is culturally safe and appropriate for use with Anishinaabe older adults in Canada.
Kurtz et al., 2017Phase 1:Indigenous Bachelor of Science in Nursing New Graduates  (n=9)Phase 2:Indigenous health and human resources leaders, nurse educators and nursing students’ Indigenous new graduates, Indigenous and non-indigenous nurses, managers, and other decisions makers from regional health authority  (n=35)	To examine Indigenous nurses’ transition from education to practice and their career development experiences.	Yes	Indigenous methodologyTwo-Eyed Seeing approach	No-Not identified in the article	YesPhase 1-Individual telephone interviews Phase 2-One-day invitational research forum to discuss case scenarios -Talking circles guided by an Elder (opening and closing, talking circle protocols	No-Not described in the article	Yes-Education al and health institute ethics approvals	Yes-Indigenous methodology guided by Elders, research team members, and participants	Yes-Broad discussion outlining process of methodology and mutual benefits within decolonizing methods.	Yes-A collective vision for respectful, inclusive, and culturally safe strategies for education, practice, and policy change was co-created via use of Indigenous methodology.
Latimer et al., 2020First Nations Children and Elders (n=188)Health professionals (n=32)	To gather the healthcare experience, pain perspectives, and the strategies to improve the healthcare encounter for First Nations children and youth and health providers from four First Nations communities.	Yes	Community-based, participatory action methodology embedded in the Two-Eyed Seeing approach	Yes-Convenience sampling using word of mouth and signed placed in the schools and health centres	Yes-One-to-one interviews and conversation sessions	No-Not described in the article	Yes-Mi’kmaq Ethics Watch, a regional Mi’kmaw ethics process coordinated through Cape Breton University (CBU) in Nova Scotia, and by the Mi’kmaq Confederacy of Prince Edward Island from PEI Mi’kmaw communities-IWK Health Centre Research Ethics Board	Yes-Relational approach was established-Themes were reviewed by elder advisors-Member checking-Knowledge gardening	Yes-Discussion pertaining to pain expression, care experiences, and the strategies to improve the healthcare encounter.	Yes-The FIRST (family, Information, Relationship, Safe-Space, and Two-Eyed treatment) approach during the healthcare encounter.
Martin, Thompson, Ballard (2017)Little Saskatchewan First Nations (LSFN) Elders and key informants such as health care providers, family caregivers, and community leaders. (n=15)	To describe the merits and challenges of using Two-Eyed Seeing to guide a collaborative research project with a First Nations community in Manitoba, Canada that has suffered from human-made flooding.	Yes	Two-Eyed Seeing, participatory, critical ethnography	Yes-Purposive sampling	Yes-Interviews	Yes-Interviews conducted by First Nations individual in local language	Yes-University and community ethics approvals	Lacks detail-Data analyzed by research team and community advisory board	Yes-Victims of flood displacement still feeling drift and attempting to rebuild community	Yes-Call to government to create better relationships with First Nations communities to provide equitable support to victims of flooding
Martin et al., 2018Younger and Older youth living in NunatuKavut as well as key informants who work directly with youth and are familiar with issues facing youth. Inuit youth (n=86)Caregivers (n=22)Key Informants (n=13)	This article aims to elucidate Southern Inuit understanding of oral health and to theorize how efforts to address oral health crises might balance both Indigenous and non-Indigenous perspectives about oral health issues.	Yes	Yes-Methodology not described in the articleParticipatory framework and integrated knowledge translation (IKT)	Yes-Purposive sampling technique	Yes-Focus groups-Key informant video interviews	No-Not described in the article	Yes-University Ethics board-Chief and Council	Yes-involvement of a Community advisory board-multiple sources for data collection	Yes-Two major themes are provided.-Four subthemes are provided related to a First Nations experienced of forced displacement.	Yes-Creation of a video that documented both Elders’ experiences and health outcomes stemming from a flood which devastated a First Nation community.-suggestion to incorporate Two-Eyed Seeing into water management, disaster management , and health care service policies and programs.
Pilarinos et al., 2023Participants self-identify as Indigenous, accessed healthcare services within the urban region of Vancouver Coastal Health (n= 26)	To better understand the health care experiences and perspectives on culturally safe health care practice among Indigenous peoples.	Yes	Yes-Two-Eyed Seeing and Sharing Circle methodology	Yes-Convenience sampling technique	Yes-Two sharing circles	No-Not described in the article	Yes-University Ethics board	Yes-via sharing circles and ongoing discussions with research team and reflexivity.	Yes-Two major themes were identified	Yes-Findings from this study highlight discrimination, prejudice and racism experienced by Indigenous peoples assessing health care in Vancouver. -Study participants point to promising practices to increase Indigenous self-determination and leadership in health care.
Quinn 2022Indigenous former youth in child welfare care of the Ontario government  (n=7)	To explore the experiences of intergenerational trauma, cultural connections, and identity among Indigenous former youth in child welfare care of the Ontario government.	Yes	Yes-Indigenous research methodology, not described.-Traditional Grounded Theory and Constructivist Grounded Theory	Yes-purposive sampling and theoretical sampling techniques	Yes-semi-structured interviews	No-Not described in the article	Yes-University Ethics board	Yes- Sustained engagement with participants and community stakeholders-Reflexivity- prolonged community engagement with participants, Elders, agency advisors, and community stakeholders; the use of cultural protocols; and authenticity the author brought to the research-Member checking-Feedback interviews-Self-reflective process of bracketing-Triangulation of data	Yes-Overarching theme of “Transforming trauma into Triumph” consisting of three categories.	Yes-Outlined protective factors that mediated negative life trajectories. -Identify critical ingredients for well-being for children involved with the child welfare system
Rand 2016Inuit women  (n=21)	To create a dialogue with Inuit women to address the lack of information available to inform programming to improve the sexual health of Inuit women, their families, and their communities in the Canadian Arctic.	Yes	Community-based participatory research and Two-Eyed Seeing No specific design methodology described	Yes-Community feast, information session, advertising-Purposive sampling	Yes-Storytelling sessions	Yes-Author is past member of community with long-term relationships within community	Yes-Community advisory board oversaw entire research project -University and community ethics approval	Lacks detail -Participatory analysis with participant -Inductive thematic analysis	Yes-Five major themes depicting experiences and perceptions of Sexually Transmitted Diseases/Human immunodeficiency virus including strategies for holistic support	Yes-one of few studies of this topic with Inuit communities.-Results support future research and health programming strategies.
Sam et al., 2022Indigenous adolescents from the Providence Health Care’s inner city youth program, Vancouver British Columbia (n=8)	To identify end-user preferences for a tablet-based mental health app used in a primary care clinic serving Indigenous youth.	Yes	Indigenous methodology of Two-Eyed Seeing	Yes-Purposive sampling via University communications.	Yes-Two design circles	No-Not described in this article.	Yes-University Ethics board	No -not described in this article.	Yes-Results highlighted the importance of collective Indigenous storytelling about accessing integrated primary care for mental health needs.	Yes-Co-creation of persona stories to identify integrated primary care access parries to mental health services.
Shirvastava et al., 2020Care providers, administrators, and patients from Four Cree communities  (n=74)	To explore participants perceptions about primary health care conceptualizations, culturally based approaches, and experiences of oral care services at an organization using a “Two-Eyed Seeing” Indigenous framework.	Yes	Anthropological analysis	Yes-Purposive sampling; maximum variation and snowball sampling	Yes-Individual interviews-Focus groups	No-Not described in this article.	Yes-University ethics board approval-Research Committee of the Cree Board of Health and Social Services of James Bay	No-Not described in this article.	Yes-Three factors are identified related to primary oral health care including Cree perception of primary health and oral health care, cultural safety, and health provider-patient communication and the role of silence.	Yes-Provides definitions of Primary health care within the Cree language which promotes individual and collective autonomy.
Stelkia et al., 2021Fraser River peopleFirst Nations Knowledge Keepers (n=4)Youth (n=5)	To explore how connections to land, water, and territory relate to health and wellness, by being on the land and in community with Sto:lo Knowledge Keepers and youth from the Fraser Salish region of British Columbia.	Yes	YesMethodology not described in the article	Yes-Purposive sampling	Yes-Sharing circle	No-Not described in this article.	Yes-University ethics board	Yes-Sharing preliminary findings with members of the Fraser Salish Regional Team and broader research team.-Preliminary findings were shared with participants for feedback and validation.	Yes-Three themes were identified relating to how connection to the land, water, and territory influence the health and wellbeing of participants.	Yes-Findings can be used to inform the development of an indicator for connection to land, water, and territory as a measurement of ecological wellness for First Nations Populations Health and Wellness Agenda in British Columbia.
Sylliboy et al., 2021Qualitative (n=20)Quantitative (n=70)	To understand a Two-Spirit coming out process.	Yes	YesQualitative studyCommunity-based, community-led study	Yes-Purposive sampling	Yes-Guided interviews-Focus groups or talking circles-cross-sectional analysis of self-reported experiences to promote a more in-depth understanding	Yes	Yes-University ethics board -Mi’kmaw Ethics Watch	Yes-stories maintained as a collective unit of stories to keep the integrity of the stories’ spirit-Indigenous Advisory committee	Yes-Stories are shared about the resiliency among Two-spirit people and the cultural awaking of the coming out process.	Yes-First study is the only current community-based evidence about coming out experienced of Two-spirit people in Atlantic Canada.-Shares that Two-spirit people come out in intervals or phases, especially trans people.
VanEvery et al., 2022Youth (n=21)Elders/knowledge-keepers (n=6)Clinicians (n=6)	To understand how Indigenous youth describe, experience, manage pain and hurt and how they seek care.	Yes	YesCommunity base, participatory action research guided by Two-Eyed Seeing and Medicine Wheel frameworks	Yes-Convenience sampling	Yes-one-on-one interviews or small group conversations	Yes	Yes-An Indigenous Ethics Review Board and the partnering pediatric health care setting.	Yes-	Yes-Three main themes are described related to important clinical strategies for Indigenous youth to balance their health and reduce pain.	Yes-Provides an acronym LISTEN that encompasses the three main thematic areas; Language, Individual, Share, Teachable moments, Engage, and Navigate.
Vorobyova et al., 2022Adults > 50 years of age (n=27)Indigenous (n=7)	To explore perceptions of cultural safety in Older Adults Living with HIV (OALHIV) receiving home and community care (HCC) services.	Yes	Yes-Qualitative research, not specified	Yes-Convenience sampling	Yes-semi-structured phone interviews	No-Not described in this article.	Yes-University ethics board	Yes-researchers with lived/living experience were involved in coding and interpretation. -On-going reflexivity, peer examination, and member-checking	Yes-Three themes were identified relating to cultural safety in older adults living with HIV	Yes-Identified that cultural safety was important but lacking.
Ward et al., 2023The Samson Cree Nation and the Enoch Cree Nation bother located in Alberta.Family caregivers (n=6), health and community providers (n=14), and healthcare and community leaders (n=6)Total (n=26)	To report on family caregivers’, providers’, and leaders’ recommendations to support First Nations family care givers and care providers to sustain care.	Yes	YesParticipatory Action Research (PAR)	Yes-Convenience snowball sample	Yes-semi-structured interviews	No-Not described in this article	Yes-University ethics board	Yes-Indigenous community members involved with research process and analysis.	Yes-Four types of support were described.	Yes-Four recommendations to support providers were provided.
Wekerle et al., 2022Health care and social service providers (HSSPs) (n=21)	To understand and describe the perspectives of Six Nations of the Grand River community members on the relevance of an educational module to support HSSPs to provide physically and emotionally safe care to Indigenous families affected by family violence.	Yes	Qualitative description, Two-Eyed Seeing and Two Row Wampum approaches	Yes-Purposeful sample. Directors and leaders were asked to share the study information with their staff and posting on notification boards as well as snowball sampling.	Yes-Semi structured one-on-one interviews	Yes-Researchers reflexivity and positionality provided.	Yes-University and Community Ethics committees	Yes-Indigenous community members involved with research process and analysis via advisory group.	Yes-The Creating Safety education module was identified as having elements consistent with Indigenous experiences and values, and supportive of Indigenous peoples seeking care from HSSPs for family violence related concerns.	Yes-The Creating Safety module may be used as an educational adjunct to Indigenous-focused, cultural safety training that can support HSSPs to provide physically, emotionally, and psychologically safe care to Indigenous peoples who have experienced family violence.
Whiting et al., 2018Health care providers from Eagle Moon Health Office of Regina  (n=8)	To explore the perspectives/experiences of collaboration of select Saskatchewan health professionals practicing across these diverse services to understand the concept from their perspectives.	Yes	Interpretive description	Yes-Purposeful, non-random, six members of team, two from joint initiative	Yes-Semi structured interviews and observation	-Briefly noted in limitation section-Author known to participants and non-Indigenous	Yes-Although Two Eyed Seeing note threaded throughout study design	Lacks detail-Member checking	Yes-Seven themes	Yes-Description of use of Two-Eyed Seeing in collaborative relationship/initiatives
Whitty-Rogers et al., 2016Mi’kmaq women with a history of Gestational Diabetes Mellitus (GDM) during pregnancy  (n=9)	To explore and gain insight into the experiences of Mi’kmaq women with GDM in 2 First Nations communities in Nova Scotia. Furthermore, to explore how these experiences have been shaped by a variety of SDOH and existing health policies.	Yes	Participatory Action Research and Two-Eyed Seeing -Hermeneutic phenomenology	Yes-Purposive snowball sampling	Yes-One-to-one conversation and talking circle	Yes-Long-standing relationship with community	Yes-University and Community Attention to relational ethics	Yes-Member checking with participant, all authors completed analysis	Yes-Four themes related to experiences of gestational diabetes	Yes-Nursing implications clear to ensure adequate education, relational support, and advocate for funding to minimize barrier to health care
Wright et al., 2019cIndigenous mothers (n=19)Primary Care Providers (n=5)	To explore the experiences of Indigenous mothers who select and use early childhood development (ECD) services.	Yes	Interpretive DescriptionAnd Two-Eyed Seeing as a guiding framework	Yes-Purposeful sampling, theoretical and snowball sampling approaches	Yes-Individual interviews-Discussion group	Yes-Notes on contributors’ section, following the article.	Yes-Hamilton Integrated Research Ethics Board, Mohawk College Research Ethics Board, and the McMaster University Family Medicine Program.	Yes-Triangulating findings with multiple data sources and literature.-Building authentic relationships with members of the Indigenous community prior to embarking in the research-Collaborative data analysis with the First Nations research assistant-Member-checking with participants	Yes-Three themes that depict the care provided by both mainstream and Indigenous-led services-Four themes that relate to the strategies used by Indigenous-led programs	Yes-Describe that holistic care, facilitated by a wrap-around approach and the building of long-term, trusting relationships is an important way to meet the numerous social inequities experienced by some indigenous mothers and infants.
Wright et al., 2019dIndigenous mothers (n=19)Primary Care Providers (n=5)	To explore the phenomenon of how Indigenous mothers select and use acute care services (ACS) for their infants.	Yes	Interpretive DescriptionAnd Two-Eyed Seeing as a guiding framework	Yes-Purposeful sampling, theoretical and snowball sampling approaches	Yes-Individual interviews facilitated by ecomaps-Discussion group	Yes-Section for Positioning of the Researchers	Yes-Hamilton Integrated Research Ethics Board, Mohawk College Research Ethics Board, and the McMaster University Family Medicine Program.	Yes-Triangulating findings with multiple data sources and literature.-Member-checking with participants	Yes-Results outline how Indigenous mothers select acute care services to meet the health needs of their infants.	Yes-First study to explore how Indigenous mothers living off-reserve in urban areas experience accessing acute health care for their infants in Canada.
Wright et al., 2019eIndigenous mothers (n=19)Primary Care Providers (n=5)	To understanding mothers’ experiences of how they select and use health care- primary health care- for their infants.	Yes	Interpretive DescriptionAnd Two-Eyed Seeing as a guiding framework	Yes-Purposeful sampling, theoretical and snowball sampling approaches	Yes-Individual interviews facilitated by ecomaps-Discussion group	Yes-Section for Reflection of the researcher-Notes on contributors’ section, following the article.	Yes-Hamilton Integrated Research Ethics Board, Mohawk College Research Ethics Board, and the McMaster University Family Medicine Program.	Yes-Triangulating findings with multiple data sources and literature.-Member-checking with participants	Yes-Three stages are provided regarding how indigenous mothers access primary care providers for their infants.	Yes-First qualitative study to ask Indigenous mothers living in Canadian urban centre how they select and use primary health services to care for the health needs of their infants. -Need for primary care information sharing and collaboration with Indigenous organizations in the community.-Primary care that integrates culturally safe, TVIC and Family Centered Care (FCC) models is an effective way of improving access to care and promoting interactions between primary care providers and Indigenous mothers and infants.
Wright et al., 2020Indigenous mothers (n=19)Primary Care Providers (n=5)	To describe how Family Centred Care (FCC) can be uniquely adopted for the care of Indigenous infants and families in the NICU setting through the application of culturally safe and trauma-informed care principals.	Yes	Interpretive DescriptionAnd Two-Eyed Seeing as a guiding framework	Yes-Purposeful sampling, theoretical and snowball sampling approaches	Yes-Individual interviews-Discussion group	Yes-Section for Situating the Researchers	Yes-Hamilton Integrated Research Ethics Board, Mohawk College Research Ethics Board, and the McMaster University Family Medicine Program.	Yes-Triangulating findings with multiple data sources and literature.-Member-checking with participants	Yes-Three major themes are described to better meet the needs of Indigenous mothers and infants admitted to a neonatal intensive care unit (NICU)	Yes-Strategies are provided to better address the historical, cultural, and social factors impacting the lives of Indigenous mothers and infants.
Wright, VanEvery, Miller, 2021Indigenous mothers (n=19)	To provide an initial understanding of Indigenous mothers livening in an urban city in Ontario, Canada use of the internet, web-based apps, and social media to support the health of their infants.	Yes	Interpretive DescriptionAnd Two-Eyed Seeing as a guiding framework	Yes-Purposeful sampling	Yes-Individual interviews-Discussion group	Yes	Yes-Hamilton Integrated Research Ethics Board, Mohawk College Research Ethics Board, and the McMaster University Family Medicine Program.	Yes-Member-checking with participants	Yes-Four theme are identified regarding how Indigenous mothers used web-based sources of information to meet the health needs of their infants.	Yes-First study to discuss Indigenous mothers’ use of web-based resources to support the health of their infants.-Web-based modalities are likely an excellent way to reach mothers with important health education related to parenting ad infant health. -Health care providers have an important role in teaching web-based health literacy skills to parents and providing reliable sources of information to parents.
Rowan et al., 2015Articles (n=19)	To identify and map literature on cultural interventions in addictions treatment, and describe the nature, extent, and gaps in literature.	Scoping review.	Two-Eyed Seeing approach and Scoping review framework	Scoping review framework.	Not applicable	Not applicable	No-not mentioned.	Yes-involvement of an Ad Hoc review group, led by an Elder.	Yes-Two-eyed Seeing contributed differently at each stage of the scoping study.	Yes-This paper adds to the collective work on augmenting the methodology of scoping studies.

Quantitative Research (Critical Appraisals Skills Programme, 2018b)
Author Study Design Number of Participants	Clear and Focused Question Location	Acceptable Recruitment?	ExposureAccurately measured?	Outcome Accurately Measured?	Considered Confounding Factors?	Adequate Follow Up?	Results Precise?Believable?	Applicable to Local Population?	Results fit with other evidence?	Study implications
Hunt et al., 2018Single-group quasi-experimentTime-series designFirst Nations Youth playing recreational hockey, their parents, and coaches (n=41)	To begin to understand concussion in youth hockey in a First Nations Community in Canada and to determine the impact of a novel concussion education workshop.Northern Ontario First Nation community	Yes-Posters and emails to hockey coaches	-Previous exposure to concussion.-Initial knowledge assessed via survey prior to intervention	-Post- intervention survey immediately and at six months	Yes-Loss to follow-up (individuals more likely to have experienced concussion)-Survey question may not have been culturally appropriate-Validated with four youth (most participants adults)	Six months, might have also repeated at one year to see if knowledge retained	-High level of knowledge prior to intervention did not seem to influence knowledge retention-Not powered to show statistical significance-Results are believable	-Data from northern First Nations community in Ontario. No necessarily applicable to other groups/populations	Yes	-Further research need to determine whether workshop intervention is effective-Further work to integrate Indigenous ways of knowing into concussion education and prevention is required
Jaworsky, 2023Saskatchewan Indigenous 18 years of age or older and initiated combination antiviral therapy (ART) (n=276)	To bring light to the difficulties of those who are furthest away from HIV care in Saskatchewan. To better understand the impact of distance to HIV care on HIV outcomes in Saskatchewan.	Yes-Retrospective study	Yes-a Positive Partnership Score (PSS) was used to measure how well an individual receives guidelines-based HIV care.	-Two variables of distance from HIC care.-1) closet available HIC specialist care and 2) shortest driving distance between the participants’ location of residence and the site where they were enrolled.	-Not indicated.	No follow up.	Yes-descriptive statistics used as well as linear regression models.	-Data from Indigenous community in Saskatchewan initiated combination ART.	Yes.	-the research demonstrated that distance from HIC care in Saskatchewan was associated with poorer quality of HIV care highlighting a need for better care rural HIV care.
Tarasuk et al., 2021Individual who had injected drugs six months prior to recruitment and who met the minimum age to provide consent (determined by site). (n=2383; 997 identified as Indigenous- FNIM)	To describe the prevalence of human immunodeficiency virus (HIV), hepatitis C and associated risk behaviours among Indigenous participants.	Yes-Participants were recruited from settings where prevention, testing and treatment services are provided for HIV and hepatitis C	-Survey questionnaire administered to individuals who has injected drugs six months prior to recruitment and who met the minimum age to provide consent.	-Survey questionnaire	Yes-Consideration of certain risk behaviours being over or underrepresented given small numbers of participants who identified as Metis and Inuit as well as those gender identity was transmasculine or transfeminine.	No follow up.	-All Indigenous participants completed a questionnaire and 88.78% provided a biological sample. -Results are believable.	-Data from fourteen sentinel sites in Whitehorse, Yukon, British Columbia, Saskatchewan, Manitoba, Ontario, New Brunswick, Newfoundland, and Quebec. No application to other groups/populations	Yes	-Ongoing engagement in the interpretation of surveillance findings among Indigenous participants through Indigenous-specific networks can contribute to the resilience of Indigenous peoples and communities. -Development of knowledge products that will disseminate the Indigenous-specific results contextualized to be most relevant for uptake by stakeholders in diverse settings.

Mixed Methods Research (Pluye et al., 2011)
Author Study DesignNumber of Participants Type of Mixed Method study	Clear Qualitative and Quantitative Research Questions	Qualitative		Quantitative (descriptive)			Mixed Methods
		Are sources relevant to address research question?	Consideration given to how findings relate to context and researchers’ influence?	Sampling strategy relevant to address the quantitative research question?	Sample representative of population?	Are measurements appropriate?Acceptable response rate?	Research deigns relevant to address the qualitative and quantitative research questions?	Integration of qualitative and quantitative data relevant to address research question?	Limitations associated with integrations?
Marsh et al., 2015Aboriginal peoples living in Northern Ontario, Canada. (n=24)Qualitative withDescriptive Quantitative	To explore whether incorporating Aboriginal traditional healing practices into Najavits’ (2002a) Seeking Safety treatment model was a feasible, suitable, and beneficial approach for Aboriginal women and men suffering from intergenerational trauma and substance use disorders. Quantitative research question not specifically identified.	Yes	Yes	Yes	-Use of pre and post survey using t-test for bivariate comparisons followed by qualitative thematic analysis	-Measurements included baseline questionnaire, three scales, and an end-of-session questionnaire -appropriate-Response rate included all participants for scales and 16 or 24 participants for the	Not described in article.	Not described in article.	Not described in article.

Data Analysis and Data Synthesis

Data was extracted from each article related to purpose, methodology, and the application of Two-Eyed Seeing during data analysis. Analysis pertaining to the application of Two-Eyed Seeing during the data analysis phase of research was completed by using constant comparison methods described by Miles and Huberman (1994). A synthesis of data is presented outlining key themes in the following results section.

Results

The initial search provided 321 articles. After removal of duplicate articles, 175 article title and abstracts were reviewed for inclusion in the review by the first author (AR). Following this initial procedure, 42 articles were identified as meeting the selection criteria. After completing a full-text review, 12 articles were excluded because they did not meet inclusion criteria. Four articles did not include the Two-Eyed Seeing framework within the data analysis phase (Chatwood et al., 2015; Lewis et al., 2021; Maar et al., 2022; Marsh et al., 2022). Two articles did not address decolonizing frameworks outlined by Bartlett, Marshall, & Marshall, 2007 (Kandasamy et al., 2022; and Milligan et al., 2022). One article did not address the health of Indigenous communities (Markham et al., 2022), and one article was a scoping review mapping the application of the Two-Eyed Seeing framework to educational programs (Shrivastava et al., 2020). Rowan et al. (2015), is a scoping review and was included because it applied Two-Eyed Seeing to its analysis process of the scoping review. It is important to note, five articles identified were derived from a single primary study (Wright et al., 2019c, 2019d, 2019e, 2020, 2021). Therefore, Wright et al. (2019c) was included to reflect the application of the Two-Eyed Seeing framework and the others were excluded. Next, after review of the references of selected articles, two additional articles were included (Martin et al., 2017; Hunt et al., 2018). Finally, author D.B., who is a member of Beaver Lake Cree Nation in Treaty Six Territory, validated the final 32 articles for full text review. The first author, A.R., completed a full review of selected articles included in this integrative review. All articles were based in Canada with the exception of one article (Jacklin et al., 2020), which was based in the United States of America. For a review of article methodologies see Table 2.

Table 2.

Themes and Sub-Themes with Associated Articles.

Themes and Sub-Themes

Five major themes, and five sub-themes emerged from the analysis and represent a synthesis of the data. Additionally, five approaches that were unique to individual articles are provided. These themes, sub-themes, and additional approaches are discussed below and can be found in Table 2.

Indigenous Community Member Involvement in Analysis

Indigenous community member involvement during research analysis involved 28 (n = 28/32; 88%) articles (Bruner et al., 2019; Cabrera et al., 2015; Carter et al., 2017; Clark, 2014; Danto et al., 2021; Galway et al., 2022; Hall et al., 2015; Hatala et al., 2020; Hunt et al., 2018; Jacklin et al., 2020; Kurtz et al., 2017; Latimer et al., 2020; Marsh et al., 2015; Martin et al., 2017, 2018; Quinn, 2022; Rand, 2016; Rowan et al., 2015; Stelkia et al., 2021; Sylliboy, 2021; Tarasuk et al., 2021; VanEvery et al., 2022; Vorobyova et al., 2022; Ward et al., 2023; Wekerie et al., 2022; Whiting et al., 2018; Whitty-Rogers et al., 2016; Wright et al., 2019). This theme was divided into four sub-themes including: (a) analysis results presented to an Indigenous advisory group for feedback and comment, (b) Indigenous community member(s) involved with coding and analysis, (c) analysis results reviewed with research participants via member checking, and (d) partnership with an Elder or Knowledge Keeper during analysis. Member checking with research participants was the most commonly used strategy to involve Indigenous community members representing nearly half (n = 15/32; 47%) of the articles (Carter et al., 2017; Danto et al., 2021; Hatala et al., 2020; Latimer et al., 2020; Marsh et al., 2015; Martin et al., 2017, 2018; Quinn, 2022; Rand, 2016; Rowan et al., 2015; Stelkia et al., 2021; Vorobyova et al., 2022; Whiting et al., 2018; Whitty-Rogers et al., 2016; Wright et al., 2019). According to Marsh et al. (2015), transparency and member checking is grounded in the Two-Eyed Seeing Indigenous decolonizing approach and Aboriginal research ethics/protocol. The second most common strategy to involve Indigenous community members was the creation of an Indigenous advisory group which represented under half (n = 12/32; 38%) of the articles (Bruner et al., 2019; Cabrera et al., 2015; Carter et al., 2017; Hall et al., 2015; Hatala et al., 2020; Jacklin et al., 2020; Marsh et al., 2015; Martin et al., 2017, 2018; Rowan et al., 2015; Tarasuk et al., 2021; Wekerie et al., 2022). Involvement of an Indigenous community member with the coding and analysis process was the next most common strategy (n = 9/32; 28%) (Bruner et al., 2019; Galway et al., 2022; Hunt et al., 2018; Latimer et al., 2020; Marsh et al., 2015; VanEvery et al., 2022; Vorobyova et al., 2022; Ward et al., 2023; Wright et al., 2019). Finally, analysis in partnership with an Elder or Knowledge Keeper was the last strategy (n = 7/32; 23%) (Clark, 2014; Hall et al., 2015; Jackline et al., 2020; Kurtz et al., 2017; Latimer et al., 2020; Rowan et al., 2015; Stelkia et al., 2021). One article identified that the Elder was part of the research team (Stelkia et al., 2021). In an article by Marsh et al. (2015), the Elders and Aboriginal advisory group provided input into the cultural components of the data to gain more accurate meaning of the analysis. Nine articles (Bruner et al., 2019; Carter et al., 2017; Hall et al., 2015; Hatala et al., 2020; Jacklin et al., 2020; Martin et al., 2018; Stelkia et al., 2021; Vorobyova et al., 2022; Wright et al., 2019c) used two of the strategies and three articles (Latimer et al., 2020; Marsh et al., 2015; Rowan et al., 2015) used three strategies to involve Indigenous community members. Overall, all but five article (Jaworsky, 2023; Pilarinos et al., 2023; Sam et al., 2022; Shrivastava et al., 2020; Sylliboy, 2021) used a strategy to involve Indigenous community members during data analysis.

Co-Learning during Analysis

Co-learning requires working together closely to understand each other’s values, perceptions, beliefs, and their knowledges. This close working process provides space for individuals to explore and listen to each other’s lived experiences (Bartlett et al., 2007). According to Roher et al. (2021), the spirit of co-learning shows a commitment to the process of conversation rather than outcomes. This process is about ensuring that the essence or spirit of the two ways of knowing (Indigenous and Western knowledge), has been respected as the research team works to balance the energies of those ways of knowing.

Three subcategories were identified which address co-learning including frequent meetings with the research team to support co-learning, prolonged engagement with research participants, and engagement in reflexivity during the analysis phase. Four articles (n = 4/32; 13%), identified frequent meetings of the research team as a key strategy during data analysis (Galway et al., 2022; Hunt et al., 2018; Martin et al., 2017; Wright et al., 2019c). Though most articles did not identify the frequency of meetings, Martin et al. (2017), state that they met every 3 months to discuss the research protocols and preliminary results. Four articles (n = 4/32; 13%) engaged in reflexivity during data analysis (Carter et al., 2017; Pilarinos et al., 2023; Vorobyova et al., 2022; Whitty-Rogers et al., 2016). Carter et al. (2017), reported that the research team engaged in dialogical reflexivity where positionality was written in a story format and openly discussed and questioned by the research team to identify how social positions, values, and ideologies affected the way the research and data analysis was conducted. Other authors reported keeping reflexive notes or journals to allow time to create space to reflect and gain perspective (Vorobyova et al., 2022; Whitty-Rogers et al., 2016). Finally, one article (n = 1/32; 3%), reported prolonged engagement with participants, during the analysis phase of research (Quinn, 2022). The authors reported that through prolonged engagement with participants the authors were able to go back and ask in later interviews about data that emerged.

Visual or Symbolic Conceptualization to Guide Analysis

Seven articles (n = 7/32; 22%) included a visual or symbolic conceptualization to guide data analysis (Bruner et al., 2019; Carter et al., 2017; Galway et al., 2022; Marsh et al., 2015; Rowan et al., 2015; Sylliboy, 2021; VanEvery et al., 2022). Bruner et al. (2019), used Indigenous Symbolic Analysis as described by McNiff (1998) to guide data analysis. The authors identified this as an Indigenous approach to better represent the experience shared by Indigenous participants. They used a graphic representation of the Medicine Wheel to extend the coded nodes to higher order themes with dynamic positions. Carter et al. (2017), used a Anishinaabe Symbol-Based Reflection described by Lavallee (2009), during data analysis. This method is described by the authors as eliciting rich data by asking participants to reflect on a concept and then to choose a symbol that represents that concept to them. In an article by Galway et al. (2022), authors co-created an analytical framework to support co-learning. Within this framework the authors describe creating a visualization of themes as discussions continued. Furthermore, the authors noted that this was based upon recommendations by Bartlett et al. (2012). Elders involved with the study by Marsh et al. (2015), immediately identified during thematic analysis that the themes could be depicted in a Medicine Wheel conceptual framework to further assist qualitative analysis. By depicting the results through the lens of the Medicine Wheel, the Elders identified that the Two-Eyed Seeing Indigenous methodology could be visually authenticated. In a scoping review by Rowan et al. (2015), results were placed into the four dimensions of Indigenous wellness including Spiritual, Heart/Social/Emotional, Mind/Mental, and Physical/Behavioural. The authors noted that this non-hierarchical approach during analysis was consistent with Two-Eyed Seeing. Finally, two articles (Sylliboy, 2021; VanEvery et al., 2022) used a visual conceptualization of the Four Directions of the Medicine Wheel to guide data analysis. This approach is consistent with the holistic nature of well-being (Sylliboy, 2021) and represents the symbolic balance and interconnection between physical, spiritual, emotional, and mental health (VanEvery et al., 2022).

Statement Acknowledging Indigenous Knowledge during Analysis

Three (n = 32; 7%) articles (Hall et al., 2015; Jaworsky, 2023; Sam et al., 2022; Wright et al., 2019c) of the 32 articles included a statement acknowledging Indigenous Knowledge during research analysis. In a study by Hall et al. (2015), the research team identified that participant stories would be treated as Indigenous Knowledge including complex teachings, humorous additions, historical happenings, and/or sacred tellings depending on the intent of the shared story. Additionally, Wright et al. (2019c), emphasized that a Two-Eyed Seeing framework was used to respect Indigenous Knowledge and ways of knowing during the data analysis procedure. All articles included in this integrated review report utilizing the Two-Eyed Seeing framework, which, according to Roher (2021), assists to bridge Indigenous and Western knowledges. However, these two articles specifically recognize Indigenous Knowledge within the write up on the article analysis.

Sharing of Traditional Stories to Guide Analysis

Two articles (n = 2/32; 6%) identified sharing of Traditional Indigenous stories as a strategy to guide analysis and assist with interpretation and narrative expression (Bruner et al., 2019; Carter et al., 2017). An Indigenous approach to data analysis was described by Bruner et al. (2019), whereby the research team wanted to best represent the experiences shared by Indigenous participants. One of the team members shared the story of the “Bone Woman” to help the research team understand how to apply an interpretation of a narrative expression. According to the authors, by sharing Traditional stories during data analysis, the research team was able to understand the processes of connections between emerging themes. For example, how the narrative took emotional qualities as it emerged from the data, then moved to a cognitive quest to identify themes, then to a spiritual ceremony through the drum and song, and finally to a re-creation of being and a place of renewal. In a study, Carter et al. (2017), describe telling stories of positionality and openly discussing and questioning how their social positions, values and ideologies affected the way data analysis was conducted. Though this is not Traditional storytelling, the authors describe how engaging in the act of storytelling via discussions with research team members can assist with the data analysis process.

Additional Approaches to Consider

Furthermore, some additional approaches during Two-Eyed Seeing data analysis were mentioned in individual articles. Five approaches are described including: (1) the research team involvement with cultural practices and ceremony during analysis, (2) timelines for analysis were flexible to ensure Indigenous governance, (3) collective approach to data analysis, (4) holistic review of transcripts during analysis, and (5) separation analysis between biomedical and Traditional knowledge (Cabrera et al., 2015; Carter et al., 2017; Hall et al., 2015; Sylliboy, 2021).

The first approach included a strategy where the research team was involved with cultural practices and ceremony to assist with the research process, including analysis (Hall et al., 2015). The authors describe the research team’s engagement in cultural practices and ceremony such as prayer where the research team celebrated an Indigenous worldview’s inclusion of the Creator in the research process and gift giving where the research team was gifted with a sweat lodge by the Indigenous community. The authors report that by creating this connection within the Indigenous community and research team, the research team was able to move forward with the project “in a good way” (Hall et al., 2015, p. 8).

The second approach involved having flexible timelines for data analysis to ensure Indigenous governance (Hall et al., 2015). The authors describe the limitations of Western imposed research grant timeframes and suggest overcoming these limitations by following an Indigenous-centred process of Indigenous governance. This required additional time to complete data analysis by a Western researcher and coder through a cultural lens with Elders and Knowledge Keepers. The authors describe the challenge they experienced working from a set timeline. For example, how Indigenous Knowledge including the use of prayer and involvement with ceremony was a priority during the research process for the project to develop a measure to gauge the effectiveness of cultural interventions in First Nations alcohol and drug treatment programs in Canada.

The third approach involved using a collective approach to data analysis (Sylliboy, 2021). In this study, Two-Eyed Seeing was used as a co-learning methodology whereby stories were collected from Two-spirit people and were maintained as a collective unit versus sharing individual participants’ experiences. The authors described that this approach keeps the integrity of the stories’ spirit and the collective consciousness of Two-spirit participants. Furthermore, the authors preferred this approach to maintain and respect the anonymity of the participants in the study. Additionally, the author identifies that disintegrating the stories into individual parts for analysis and coding can be viewed as disrespectful for the sake of research.

The fourth approach incorporated engaging in two primary readings of the transcripts, one for holistic content and another for holistic form using an Indigenized version of a narrative approach described by Lieblich et al. (1998) cited in Carter et al. (2017). The authors report that they decided to concentrate only on the analytic viewpoint of holism because holistic analysis aligned with Indigenous ways of knowing. Using this framework, the analysis involved interpreting sections of the transcript in relationship to all parts of the transcript and the evolving story which the authors acknowledge as influencing how data was analysed, which included always looking for strengths, abilities, and possibilities even within sections of the narrative with struggle, regression, or challenge.

Finally, the fifth approach involved separating analysis between biomedical and Traditional knowledge. One article by Cabrera et al. (2015), organized two main categories into subcategories, identifying them as either biomedical or Traditional. Biomedical knowledge included language around biomedical labels such as Alzheimer’s disease and disease progression and genetic makeup. Traditional knowledge included how knowledge about disease had been shaped by interactions and discussions with family and community members and connectedness to the land and food. The authors note that a biomedical framework dominated and often framed the knowledge and understanding of key findings; however, traditional views were given equal consideration by separating the analysis into biomedical and Traditional knowledge. This separation of knowledge was a unique method used during analysis versus the blending of knowledges via consensus.

Discussion

This is the first integrative review to focus solely on the application of Two-Eyed Seeing specifically during the data analysis phase in health research. A gap has been identified within the published literature regarding the application of a Two-Eyed Seeing approach during data analysis procedures (Kovach, 2009). This article extends on the work of Wright et al., 2019b by identifying how Two-Eyed Seeing has been applied during data analysis.

Two-Eyed Seeing is known as a guiding principle or framework that can assist with research methodologies (Iwama et al., 2009; Wright et al., 2019b). Integration of Indigenous and Western worldviews is required throughout the research process when applying a Two-Eyed Seeing framework. This does not entail taking pieces of Indigenous Knowledge and appending them to Western knowledge, it involved interweaving between the strengths of both knowledges (Bartlett et al., 2012). Failing to do so will negatively impact interpretations during data analysis and undermines the application of the principle of Two-Eyed Seeing. This, in turn, also negatively impacts the potential benefits to the Indigenous community and causes harm and mistrust within the Indigenous community (Hall et al., 2015; Smylie et al., 2003).

This review provides a synthesis of data analysis approaches for authors when applying a Two-Eyed Seeing framework. This is especially important for non-Indigenous researchers involved with research projects with Indigenous communities to prevent the erasure of Indigenous Knowledge, promote the responsivity and responsibility of working with Indigenous communities, and to create safer spaces for Indigenous communities to engage with research efforts. Finally, this research will provide researchers a more robust approach during data analysis when applying the principle of Two-Eyed Seeing.

This integrative review has outlined key approaches utilized during data analysis when a Two-Eyed Seeing framework has been applied. Five major themes with corresponding sub-themes as well as five additional approaches that were unique to individual articles are described in this paper. Table 3 demonstrates how these approaches align with the Two-Eyed Seeing principles described by the original authors (Bartlett et al., 2012).

Table 3.

Themes and Sub-themes related to original authors.

Themes	Sub-themes	Two-Eyed Seeing Protocol (Bartlett et al., 2012)
Indigenous community member involvement in data analysis	Analysis results reviewed with research participants via member checking (n=15)	Protocol #8: develop an advisory council of willing, knowledgeable stakeholders, drawing upon individuals both from within the educational institution(s) and within Indigenous communities.
	Analysis results presented to an Indigenous Advisory Group for feedback and comment (n=12)
	Indigenous community member(s) involved with coding and analysis (n=9)
	Partnership with an Elder or Knowledge Keeper during analysis (n=7)
Co-learning during data analysis	Frequent meetings with the research team to support co-learning (n=4)	Protocol #5: Become able to put our values and actions and knowledges in front of us, like an object, for examination and discussion
	Prolonged engagement with research participants (n=4)
	Engagement in reflexivity during analysis phase (n=1)
Visual or symbolic conceptualization to guide data analysis (n=7)	N/A	Protocol #6: Use visuals
Statement acknowledging Indigenous knowledge during data analysis (n=4)	N/A	Protocol #1: Acknowledge that we need each other and must engage in a co-learning journeyProtocol #3: View “science” in an inclusive way
Sharing of Traditional stories to guide data analysis (n=2)	N/A	Not specifically noted in the lessons learned by (Bartlett et al., 2012)
Two-Eyed Seeing approaches less commonly used during data analysis	Research team involved with cultural practices and ceremony to assist with research process including data analysis (n=1)	Protocol #4: Do things in a creative, grow forward wayProtocol #7: Weave back and forth between our worldviews
	Timelines for analysis were flexible to ensure Indigenous governance (n=1)
	Collective approach to data interpretation (n=1)
	Two primary readings of the transcripts for holistic content and holistic form (n=1)
	Separating analysis between biomedical and Traditional (n=1)

It is not surprizing that the most prominent theme focuses on Indigenous community member involvement during data analysis. Four sub-themes were described including: (1) research participants involved with member checking, (2) involvement of an Indigenous advisory group during analysis, (3) Indigenous community member(s) involved with coding and analysis, and (4) partnership with an Indigenous Elder or Knowledge Keeper during analysis. Future researchers should consider creating an advisory council or Indigenous advisory group. Therefore, the research team in collaboration with the Indigenous advisory group can develop and revise research protocols to include Indigenous community members throughout the research process, including data analysis. This theme encompasses “nothing about us without us” and is integral to the broader research process especially during data analysis (Herbert, 2017).

Co-learning was the second most common theme identified in this review. This too, is not surprising given that it is described directly as one of the key principles of Two-Eyed Seeing (Bartlett et al., 2012). Three sub-themes were identified for Co-Learning including: (1) frequent meetings to support co-learning, (2) prolonged engagement with research participants, and (3) the use of reflexivity during the analysis phase. These three approaches are not necessarily unique to a Two-Eyed Seeing approach. For example, other methodologies such as Indigenous Research methods suggest frequent encounters with research team members to engage in data analysis or prolonged engagement with research participants to facilitate relationship building and trust (Kovach, 2009). Reflexivity is described within qualitative methodologies to ground the authors to acknowledge their own thoughts, values, and position of power (Olmos-Vega et al., 2022). Co-learning in Two-Eyed Seeing differs from other methodologies in that it focuses on the weaving between knowledges and the growth between the researcher and the Indigenous community. Researchers applying Two-Eyed seeing during data analysis will need to work with the Indigenous community and expand upon these sub-themes. This will assist to facilitate the co-learning process throughout research and data analysis. Future research is required to understand the process of interweaving between knowledges and its application in health research.

The use of a statement to acknowledge Indigenous Knowledge during analysis was the next major theme. Directly recognizing and honoring Indigenous Knowledge during data analysis, ensures the reader that Indigenous Knowledge is valuable and contributes to the study findings in an equitable way. This approach offers transparency and accountability regarding the interpretation and analysis that was completed.

Next, the sharing of Traditional stories as a distinct strategy to use during data analysis was identified. Only two articles in this review outlined storytelling during data analysis and each study utilized varying approaches to storytelling. For example, in the article by Bruner et al. (2019), research team members shared the story of the “Bone Woman” which helped to explain the research analysis process and in the article by Carter et al. (2017), storytelling was used to assist with positionality and open discussion during data analysis. Storytelling has rich ancestral history whereby knowledge has been carried from generation to generation (Kovach, 2009). According to the Institute for Integrative Science and Health (IISH) (2022), the exchange of stories is the foundational basis for all relationships and helps Indigenous Elders to revitalize language while also connecting with children and young people in their communities (IISH, 2022). It is interesting that the two articles (Bruner et al., 2019; Carter et al., 2017) which identified sharing of Traditional stories to guide analysis in this review did not involve an Elder or Knowledge Keeper in the study protocol. This is not to imply that an Elder or Knowledge Keeper is required to engage in the sharing of Traditional stories, but rather Indigenous communities may have specific protocols when Traditional stories are shared. The IISH also note that exchanging stories enables researchers to acknowledge their agency within knowledge systems (IISH, 2022). It is therefore important for researchers to follow the guidance and leadership of the Indigenous advisory group when considering an approach of sharing stories to aid data analysis. This can help to ensure that the approach is culturally appropriate and will benefit the community where the research is completed.

Moreover, there were five additional strategies which may be considered when applying a Two-Eyed Seeing approach during data analysis. These strategies included: (1) the research teams’ involvement in cultural practices during data analysis, (2) mindfulness of timelines during data analysis. Specifically, considering the pressures of strict timelines for grant and funding agreements, (3) using a collective approach, (4) applying holistic review of data, and (5) separating data into biomedical (Western) and Traditional (Indigenous) analysis before reaching consensus. These approaches address the imbalance of opposing worldviews (the two eyes). For example, research teams participating in cultural ceremonial practices such as a drumming circle and gaining understanding of a non-mainstream worldview or analysing data using a collective or holistic lens to recognize and honour Indigenous worldviews and knowledge or ways of knowing. Iwama, et al. (2009), notes that Two-Eyed Seeing does not merge two knowledge systems into one nor does it paste bits of Indigenous Knowledge onto Western knowledge. Therefore, it is important to identify the goals of the research question and the needs of the Indigenous community before considering separating analysis between biomedical and Traditional. In the article by Cabrera et al. (2015), a reason is not outlined by the authors for this decision. Researchers wishing to apply these approaches during data analysis should consider explaining how the data analysis approach will be presented and how this presentation addresses the needs of the Indigenous community. Further research to explore approaches whereby data analysis is separated is required.

Finally, it is paramount to recognize the long-standing history of Indigenous studies and the strong alternatives to Eurocentric ways of inquiry Indigenous Knowledge offers. This study is the first known to the authors to highlight Two-Eyed Seeing approaches during data analysis. Liberda et al. (2022), state that the application of Two-Eyed Seeing goes beyond simply incorporating Indigenous Knowledge into a study design but involves active participation at all levels throughout the research process. It is therefore important to consider the Two-Eyed Seeing framework throughout all phases of the research process. Future research is needed to identify how Two-Eyed Seeing has been applied within various research methodologies as well as in other phases of the research process. Additionally, given that nearly all articles were based in Canada, future research to explore the application of Two-Eyed Seeing in other countries, especially those with similar colonial histories is needed. This integrative review builds upon the research by Wright et al. (2019b), who aimed to address the disparity of how Two-Eyed Seeing has been interpreted and applied in research. The themes and sub-themes presented in this integrative review provide a starting point to understand how a Two-Eyed Seeing approach is applied during data analysis. Borrowing from Wright et al. (2019b), researchers (Indigenous and Non-Indigenous) should thoroughly describe their approach and decisions related to the application of Two-Eyed Seeing to research with Indigenous communities. This is critical for researchers to consider for each phase of the research process to increase research integrity and to provide the greatest benefit to Indigenous communities.

Conclusion

This integrative review is novel in that it is the first review known to the authors to explore the use and application of a Two-Eyed Seeing framework during data analysis. Five themes and corresponding sub-themes are provided to assist future researchers, non-Indigenous and Indigenous, who have chosen Two-Eyed Seeing to guide their research. This research contributes to the broader literature to engage and work with Indigenous communities in a culturally responsive and informed way.