The overarching caregiving theme is the “Hierarchy of challenge”. Six themes capture the challenges faced by family caregivers: (one) “Caregiving is a demanding job”: yet “No one in a sense is taking care of them”; (two) difficult navigation: “I am unable to access that”; (three) delayed assessments and treatment “And I don’t know how they’re being missed”; (four) disconnected health records: “It’s kind of on you to follow up”; (five) racism, “It’s treated differently”; and, (six) social determinants of health, “A lot of these factors have been developing for the longest time”. This study provides evidence that family caregivers’ need to care for and to maintain their own wellbeing is not top of mind in policy or programs in these First Nations communities. As we advocate for support for Canadian family caregivers, we need to ensure that Indigenous family caregivers are also recognized in policy and programs.There is a dearth of research on how family caregivers are supported in First Nations. We interviewed family caregivers, health and community providers, and leaders in two Alberta First Nations Communities about their experiences of care and support for the family caregivers in their communities. We employed a qualitative, collaborative participatory action research methodology. We drew on Etuaptmumk, the Mi’kmaw understanding of being in the world is the gift of multiple perspectives. Participants in this research included family caregivers ( One in four Canadians is a family caregiver (FCG) ,2. We deDelivery of aboriginal health services and continuing care is complex ,11,12. MThe complex First Nations health and continuing care delivery systems are also challenging for the healthcare providers who work with Aboriginal people and their families ,15. SomeThe aim of this paper is to report the experience of First Nations FCGs, health and community providers, and leaders of support and care for FCGs in First Nations communities.We began by meeting representatives from two Alberta First Nations communities to understand what might be useful for them to understand about FCGs. The representatives from both communities spoke about the complexities Aboriginal FCGs face getting services and the difficulty their health providers face trying to meet FCGs’ needs. They were very concerned about the differences between what First Nations FCGs living on and off the First Nation could access.They also stressed that we needed to take a holistic, aboriginal social determinants of health approach to understand how caregiving links to larger levels of influence, such as Indigenous culture, policies , finances  services (transportation and service delivery organization) and practices. Beginning with the ceremony was important as was ensuring that we respect the space First Nations people share with us.People from two Treaty Six Cree Nations participated in this research. The Samson Cree Nation, (Cree: Nîpisîhkopâhk) is the largest of four band governments in Maskwacis in central Alberta. By the 2021 census, 3252 people live in the First Nation. The Enoch Cree Nation (Cree: Maskêkosihk) controls two reserves. The Enoch Cree Nation 135 is west of the City of Edmonton and 135A is south of the Town of Barrhead. The 2021 census population was 1825. Members of both Nations are of Cree ancestry and primarily speak the Plains Cree dialect of the Cree language group.We employed a qualitative, collaborative, and participatory action research methodology. We drew on Etuaptmumk, the Mi’kmaw understanding of being in the world is the gift of multiple perspectives ,18. The This research is the beginning of participatory action research (PAR). PAR involves researchers and participants working together to (1) understand the situation, the problems, and the strengths and (2) change it for the better. Typically, it is an iterative cycle of research, action, and reflection that seeks to raise participants’ awareness of their situation and works with them to take action. We are just beginning to work together on this research. Our goal was to build trusting relationships.This was a convenience, snowball sample. Community representatives advised community members about the research study. Community members interested in participating could contact the research coordinator or research assistant (1) by phone or email to arrange for an interview in the place and time of their choosing or (2) they could choose from posted dates when the research assistant would be in the community to conduct interviews. Participants were asked to tell others in their networks about the interviews. In these small communities where everyone knows everyone, several participants were particularly concerned about privacy.Guided by our community advisors, people were invited to share their stories in individual interviews. Community advisors, a First Nations registered nurse with training and experience conducting qualitative interviews, and the research team designed an interview guide to encourage people to tell their stories of being family caregiving or being a health or community care provider caring for family caregivers or a health or community leader. It began with a general question about caregiving in the First Nation and then about their role, experiences, and what they thought might make caregiving or supporting caregivers easier (see Interviews were transcribed verbatim and then checked for accuracy and cleaned of any identifying information. They were imported into NVIVO for data management. We used Braun and Clarke’s  thematicn = 6), health and community providers (n = 14), and healthcare and community leaders (n = 6). All FCGs identified as First Nations and providers and leaders as First Nations, Cree, Canadian, Caucasian, Filipino, and Black. All were over 21 and two were over 65 years of age. Over half of the providers currently were or had been FCGs. The roles they identified with included: family caregiver, dental therapist, community health worker, director of health, medical transportation coordinator, manager, registered nurse, licensed practical nurse, program officer, chief, manager, health policy, health services advisor, health manager, lawyer, advanced care paramedic, home care nurse, outreach coordinator, and doctor. In what follows, first, we situate the research with the participants’ descriptions of FCGs, then move to the themes.Participants in this research included FCGs  “Caregiving is a demanding job”: “No one in a sense is taking care of them”; (two) difficult navigation: “I am unable to access that”; (three) delayed assessments and treatment “And I don’t know how they’re being missed”; (four) disconnected health records: “It’s kind of on you to follow up”; (five) racism, “It’s treated differently”; and (six) social determinants of health, “A lot of these factors have been developing for the longest time”. These challenges also impact providers’ ability to care for FCGs. We place FCGs’, providers’, and leaders’ exemplar quotes side by side in We began the interviews by asking participants about “caregivers” (“Who were the caregivers in the community?”) and care receivers, (“Who needs the most care?”) and to tell us about caregiving and receiving in ‘this community’.Participants described caregiving as part of the Cree culture: “We just do it because it’s part of our nature”. They explained how it was their role to care for people needing care when called on. Both caregiving and needing care were seen as valued roles given by the creator, the caregiver’s, and the care receiver’s purposes at this time in their life. FCGs, health providers, and leaders all explained that the entire family are caregivers. The family included the immediate family, such as grandparents, parents, children and siblings, maternal and paternal aunts and uncles, cousins and other kin, as well as all people in the community. “We are all intertwined”. Building on the broad view of caregiving as part of the Cree cultural identity and aboriginal kin of all ages as caregivers, participants also included the employed health and community providers as caregivers.Despite providing a holistic view of care and caregivers, as the interviews proceeded, participants told stories of a siloed approach to care and siloed supports at all levels of influence. FCGs, health providers, and leaders all talked about the difficulty of dealing with many different levels of government including the Federal Indigenous Services Canada (ISC) and First Nations and Inuit Health Branch (FNIHB), Provincial Alberta Health, Alberta Seniors and Housing, Alberta Persons with Developmental Disabilities, Alberta Family and Community Support Services, the Health Centre in their First Nations community, Alberta Health Services hospitals, homecare, and long-term care, primary care and medical specialists off reserve, First Nations leadership and administration, as well as the programs and services offered in the community . One community leader described coping with numerous, complex systems as the “hierarchy of challenge” with ISC and FNIHB at the top, First Nations leaders “almost at the top”, and vulnerable FCGs “at the bottom”,The systems themselves are very much built on a hierarchy, a Western type of colonialist mentality. So, for whatever reason, and this has been ongoing for a number of years now, where elected leaders are almost at the top, and then the most vulnerable people who actually put us into office seem to be at the bottom. And then in-between there’s all these programs and services like this hierarchy of like challenge.[Leader]Participants acknowledged that being a First Nations FCG was demanding work. Even though the family is important, these participants portrayed one person as the primary caregiver. FCGs spoke to being on their own as they learned about the illness or condition and as they tried to access services and support. Health and community providers and leaders concurred that FCGs were taking on complex care primarily without healthcare or community support. FCGs, providers, and leaders all talked about FCGs needing knowledge about illness and education, about the conditions the person they were caring for, as well as supports to care for and to maintain their own wellbeing. A leader pointed out that while most patients had FCGs accompanying them, there was no specific department or program with responsibility for FCGs, and there was no care specifically for FCGs. The leader hoped that training health providers would “trickle-down” to caregivers. See All participants spoke about the difficulty that both FCGs and health and community providers had navigating health and community systems. In participants’ descriptions, FCGs were responsible for learning about and managing the care receiver’s health condition, caring for, and navigating the health and community care systems. FCGs also had to advocate for and coordinate care from each health and social care provider, program, and department. All participants reported that the healthcare and home care of First Nations offered a greater range of services. They provided examples of outpatient medical services, rehabilitation, home care, and others that were more accessible and comprehensive if people moved off the First Nation. Many participants talked about how limiting First Nation’s home care to “banker’s hours”, weekdays from 9–5, was not meeting FCGs’ needs.Caregivers, providers, and leaders all talked about advocating for better services for FCGs. Notably, the FCGs participating in this research said that they were advocating for others who were afraid to or did not have the skills to advocate for themselves. Providers were aware of the system’s shortcomings so suggested navigators, a team approach, and systemic changes based on the FCG’s and patient’s needs would improve navigation. A leader connected the difficulty navigating specifically to siloed federal, provincial, and First Nation responsibility for services and supports.Every caregiver told stories of delayed diagnosis, assessments, and treatments. Caregivers of children with a variety of conditions—cerebral palsy, autism, or a cleft larynx–spoke about delayed diagnoses. The health provider who provided palliative care for her mother and then her sister talked about a “gap” in which Aboriginal people “were not being tracked” and “getting missed” from hospitals to services in the First Nation. Health providers connected delayed assessments and treatments to caregivers’ difficulty navigating the system. After discussing similar concerns as FCGs and providers, a leader related healthcare delays to the systemic racism built into funding mechanisms, which he contended left aboriginal people having to justify why they needed services and expecting to be treated differently.After two caregivers attributed some of the difficulty, they were having to access services to disconnected, inaccessible healthcare records, we explored participants’ experiences with health records and how that affected patients and caregivers. Health and community providers and leaders confirmed that different levels of government were using a variety of different health records systems. It appeared to depend on health providers to check health records from other providers who were using and coordinate continuity of care.All the caregivers related racism to how they as caregivers were treated. One caregiver grappled to find the words to describe being treated differently by health providers at the local hospital in comparison to urban hospitals, while other caregivers spoke directly to racism in being “accused” of not caring appropriately or in the way they were treated. One caregiver, several health providers, and leaders linked racist outcomes, such as the FCGs’ difficulty accessing support in a timely manner and being turned away at dental offices, to racism. The senior leader recommended talking openly about racism in the healthcare system.FCGs, health providers, and leaders all referred to upstream social determinants of health such as poverty, housing, safe water, lack of trust in the system, and experiences of racism that made caregiving more difficult. Although a health provider noted that there was no place in the policy for health transfer policies for FCGs, she observed that not supporting FCGs was not an isolated problem. She estimated the “intermingling” of issues and “convoluted” processes that prevent care for FCGs likely affected 95% of the over 600 Canadian First Nations. One leader ventured that access to programs and services was not equitable for people in poverty and that there were gaps in all programs that needed to be addressed.In these First Nations Communities, participants characterized Onakahtohkewin, the business of a caregiver taking care of someone, as a chronic unaddressed challenge that takes a backseat to acute challenges. For the most part, FCGs are not being taken care of, rather they are at the bottom of a “hierarchy of challenges”. As a health leader noted, “there is no department for family caregivers”. FCGs are not recognized in the convoluted multilevel layers of existing siloed policies and programs that dominate indigenous people’s lives. The Truth and Reconciliation Commission of Canada’s Calls to Action  are begiIndigenous FCGs, like all Canadian FCGs, are essential to support the social connections, dignity, and wellbeing of the people they care for ,25,26,27In addition to providing care, these First Nations FCGs were struggling with a much greater structural burden of care . The strNavigation was extremely difficult for these First Nations FCGs as well as the health and community providers who were trying to support them. All participants provided examples of FCGs trying to access support, however, being put on long waiting lists, told that they had to apply to another level of government for coverage, shuffled out without treatment, or missed completely. The difficulty navigating contributed to delays in diagnosis, treatment, rehabilitation, and timely access to support. Timely rehabilitation or treatment for children with cerebral palsy, autism, or other conditions is essential for them to thrive. Jordan’s Principle holds that First Nations children should not be denied access to public services while governments fight over who should pay ,35,36. AParticipants all discussed racism that ranged from being treated differently to overt discrimination in which aboriginal people were denied services. They tied unaddressed social determinants of health like poverty, inadequate housing, unsafe water, and health issues to colonial policies and systemic racism. Systemic racism is associated with inconsistent and low-quality care for indigenous people . Racism Triangulating the views of FCGs, health and community providers, and healthcare and community leaders is a strength of this study. We were surprised by the congruence in their views. The interviews were conducted by a First Nations health provider who developed a rapport with the participants to produce very rich interviews. These two communities are both Cree and have similar traditions. While they are rural, they are not remote and relatively advantaged compared to other Alberta First Nations. We expect that some of the themes would be different in other communities, particularly those that are remote, fly-in communities. Based on this and other research, we think that the FCGs’ needs receive less attention than other acute needs in most indigenous communities. FCGs are referred to as “Invisible” and “the backbone of the health system” ,41. We nThe Standing Committee on Indigenous and Northern Affairs report on the challenges of delivering continuing care in First Nations communities  stressedAlthough we did not assess these aboriginal FCGs’ health and wellbeing, worldwide, FCGs are at increased risk of deteriorating health ,43 and fThis study provides evidence that FCGs’ needs to care for and maintain their own wellbeing are not top of mind in policy or programs in these First Nations communities. As we advocate for support for Canadian FCGs, we need to ensure that indigenous FCGs are also recognized in policy and programs. There should be a department that explicitly ensures that FCGs are considered.


Compelling evidence has shown that high-intensity interval training (HIIT) is associated with substantial increases in physical fitness. However, little is known about whether and how individuals experience these adaptations over time. The purpose of this study is, therefore, to explore how physically inactive young adults subjectively experience physical fitness and its development as they start to exercise and how these experiences relate to different intensity domains  as well as to training modes  and their sequential administration .Thirty-one inactive participants completed a 15-week two-period sequential exercise intervention in which they first trained for six weeks in a HIIT or a MICT group and subsequently switched training modes. Interviews using the biographical mapping method were conducted at the end of the intervention to assess participants’ exercise- and fitness-related experiences over the past weeks. To assess experiential patterns, we conducted a reflexive thematic analysis.We developed three themes that represent the temporal and processual character of starting to exercise after a prolonged period of inactivity: (1) Inactive young adults are not all the same when starting to exercise; (2) Developing physical fitness is a multi-faceted and individual experience; and (3) Feeling physically fit (or not) fosters large-scale effects.Our results show that, in retrospect, participants mostly deemed HIIT to be more effective than MICT. Our findings also emphasize that physical fitness is a complex and subjective experience that manifests in various ways over time. The idiosyncrasy of physical fitness experiences reiterates the necessity for individually tailored exercise prescriptions instead of one-size-fits-all approaches. At t. At t3)]cipation .In recent years, one topic of debate in the discussion on PA and exercise promotion has been the question of whether high-intensity interval training (HIIT) may be a viable option for public health purposes, in contrast, for example, to more traditional moderate intensity continuous training (MICT) programs , 8. Comp2max) for various age groups and samples over time . The prntensity , 20. Thentensity , 20. Int2.2.nHIIT–MICT = 16 and nMICT–HIIT = 15)  so that participants had exercised either in the sequence HIIT–MICT or MICT–HIIT and were able to comparatively evaluate their experiences on the effectiveness of both training modes. Strictly speaking, our participants can, therefore, not be described as inactive anymore. Instead, they started to exercise regularly after a prolonged period of inactivity and must therefore be considered to be formerly inactive.The data relevant to this sub-study was collected at the end of the exercise intervention  and a vertical intensity scale (ranging from zero to ten) and which is displayed for participants on a large touchscreen using the bioMAP-software , 40. To t0) for a biographical life span analysis and before they switched training modes (t1) for a retrospective evaluation of the first training period. All participants gave their consent to audiotape the interviews. After the interviews, HG took field notes and filled out a protocol sheet for documentation purposes. The interviews ranged from 21 to 65 min .HG conducted all interviews in an office at the Institute of Sports Science. Participants were already familiar with the procedure since the same method was used at baseline  and modes  and their different sequential order , we conducted a reflexive thematic analysis , a approach  to assesgitimacy  of our dgitimacy  of a givgitimacy  and Smitgitimacy , we deciWe consider our topic to be worthy, given that current public health initiatives seem to fail to sustainably motivate people to be more active, as indicated by an evidently low prevalence in global PA-levels , 5. A moAdditionally, we tried to achieve coherence by deriving our research questions from previous literature and current observations on the phenomenon of PA, exercise, and physical fitness and by aligning our methods with our research interests. In addition, from coding to theme development and refinement to drafting the final report, HG regularly met with JJ and AT, who served as “critical friends”, and presented his ideas. The aim of these interactions was not to reach a consensus on particular instances but to discuss possible interpretations, challenge each other's perceptions, receive feedback, and, thus, increase reflexivity .3.As a result of our reflexive thematic analysis, we developed three overarching themes: (1) Inactive young adults are not all the same when starting to exercise; (2) Developing physical fitness is a multi-faceted and individual experience; and (3) Feeling physically fit (or not) fosters large-scale effects. These themes represent the temporal and processual character of starting to exercise after a prolonged period of inactivity, building up an exercise routine and potentially improving physical fitness, and experiencing the behavioral and experiential implications of feeling fit or not see . The fol3.1.This theme describes how inactive young adults who start to exercise within a structured exercise intervention setting differ in how they rate their initial levels of physical fitness concerning both exercise and everyday life activities, how they perceive themselves as sportive or athletic, and the expectations they have towards an exercise intervention with regard to physical fitness. In this regard, inactive young adults are not a homogenous group and hold disparate perceptions and expectations.3.1.1.Most participants rated their exercise-related physical fitness levels relatively low at the beginning of the study and explained this mainly by an extended period of physical inactivity, which was expected and consistent with research that shows that a dose-response relationship between PA and fitness exists , 54. OneOn the other hand, physical fitness concerning everyday activities was generally perceived as higher. Most participants argued that they had no trouble mastering their everyday life and had no impairments considering physical functioning . This finding is in line with the participant inclusion criteria of our study, as participants had to be healthy and capable of sustaining a physically strenuous exercise intervention for a prolonged period. Further, this finding aligns with previous research indicating that healthy adults generally score relatively high in questionnaires related to health  and associated subscales related to physical functioning –57. Howe3.1.2.While previous physical inactivity was considered the main reason for low levels of exercise-related physical fitness, a few participants offered deeper explanations that related to their self-perception as active or inactive persons arguing that they were not athletes or jocks. Describing herself, one participant said, “I was at the beginning, so, I was very unathletic. I would say at a 3, simply because I was or am not necessarily the sport cannon, except for going shopping or so” . Similarly, another participant elaborated, “I would say (.) so. I’m not an athlete, but in everyday life it's alright” . However, not seeing themselves as athletes or exercisers might be closely related to the explanation mentioned above of being insufficiently active. In this regard, research on exercise identity, for example, has shown that levels and pursued types of exercise are closely linked to the extent that individuals identify with exercise as an integral part of their self-concept , 59. Thu3.1.3.become [emphasis added] more athletic” , while another participant argued, “Well, I expected to feel [emphasis added] a bit fitter” . These statements might reflect two different understandings of physical fitness. On the one hand, “being” or “becoming” fit might relate to a factual, physiological state that is measurable but may or may not be explicitly experienced . “Feeling” fit, on the other hand, might relate to a sensation that is actually perceived, for example, in the way that exercise sessions become easier or that participants can walk and cycle faster in their everyday life . However, participants might have also referred to more tangible outcomes, such as weight loss, which is often mentioned as an outcome expectation of exercise adoption . Another participant went into more detail,“That I have an incentive to overcome my weaker self, or rather that it is simply the case that I have a firm commitment and it doesn’t even come to the point, ‘Yes, but I could do something else’”. These findings are in line with Larson et al.  who foun3.2.This theme focuses on how inactive young adults do or do not experience improvements in their physical fitness when starting to exercise and how these experiences relate to particular training modes and their sequential order. The theme describes how a general feeling of physical fitness evolves across the entire intervention period independent of training mode, whether changes in physical fitness are palpable, what role exercise intensities play in this context, and the limitations a structured exercise intervention has.3.2.1.Most participants felt that their exercise-related physical fitness increased over the entire intervention period. However, some participants also indicated that they felt no or only minor changes in their fitness levels, which might be due to not achieving a personal goal, such as living up to a specific body ideal. One participant explained this non-development as follows,“Continuously the same, not so good. (8s) Maybe because I also associate a certain body image with being trained, for example, where I say that I don’t have the feeling that I look particularly trained (..) And that's why I would say it's rather low”. A few participants also indicated that, in order to feel fit, they needed to exercise regularly. However, follow-up assessments and life events or other external factors disrupted the regularity of training. Although participants had to participate in an incremental and a reference test during follow-ups, this interruption of the everyday training routine was experienced as a period of inactivity, which led to decreased feelings of fitness. One participant noted,“Because I have not trained, I have maybe somehow not felt so trained. So I would always associate this feeling of being trained with the fact that I’m also somehow in training right now, maybe”. In addition, becoming fit was not a linear experience but was impeded by disruptions, such as illness or pain, which made everyday activities particularly exhausting. This is consistent with research indicating that daily hassles and uplifts can perturbate behavioral patterns and how individuals feel , 62. HowPhysical fitness concerning everyday activities was usually rated as relatively high without much variation. Yet, some participants nonetheless experienced improvements in this regard.“So, it was really better in between with being out of breath. So, I had said at the beginning, I’m going (unintelligible) up the stairs (both grin), yes and I easily feel 50 years older. That was really a little bit better then (…). But then I hadn’t noticed it so directly. I only noticed it again now, towards the end, where I thought, ‘Ah yes, that's going quite well now’. So, that has not changed now substantially between the two blocks I would say. So that actually is much better now”. 3.2.2.Participants did not always and immediately feel improvements in their physical fitness. Several participants described that they did not feel a training effect or that changes in their exercise-related physical fitness were not palpable. In these instances of uncertainty, “objective” feedback helped most participants grasp their individual progress. When they had no sense of whether they had improved their physical fitness, the physiological assessments at follow-ups I and II provided orientation and the affirmation that they were physiologically improving. In this regard, a participant stated,“And then it was cool to see in the middle and during the diagnostics and now also on Monday during the incremental test that I have actually improved. And I had no idea how much I would somehow improve or something, so I am just happy that I have improved”. Another “objective” feedback marker was increased individual training load, which was similarly crucial to participants who could feel their progress. For them, individual load adjustments were an essential part of the training experience, as it confirmed “objectively” what they were experiencing “subjectively” and kept them motivated. One participant explained,“So, you can then already somehow see every week or every second week, ‘Okay, I’m also making a little progress here. So again, okay, again 5 Watts more and then again 5’, so, yes, this then somehow rather motivates me”. In this regard, participants were sensitive towards training adjustments. This is noteworthy, as it might not be enough for participants to feel a difference; instead, they need to see one as well . In addi“And, otherwise, in general, I would say that I expected the continuous method, uh, that I expected something different. Because the intensity always increased during the interval training, I thought it would be the same with the continuous method”. 3.2.3.Most participants experienced HIIT as more effective for their physical fitness than MICT. For them, the training effects of HIIT were more palpable, and they experienced greater increases in physical fitness in a shorter amount of time. On the other hand, MICT was mainly deemed ineffective and less beneficial, as some participants stated that they had felt no progress and that fitness improvements were not apparent despite a higher exercise volume. Comparing HIIT and MICT, one participant stated,“I just had the feeling that the interval training is more beneficial. In other words, it was also more fun for me. The other one was boring. It was so long, like an hour, it dragged on. And, yes, somehow you didn’t see the progress in the other one, exactly”. These experiences are consistent with physiological research indicating that HIIT might foster greater enhancements in cardiorespiratory fitness than MICT , 25, 64.“Well, it's just that you don’t really get tired from the training, that is, from the continuous training, and then you’re actually like you’re going for a walk, so to speak. After a walk you also wouldn’t say, ‘oh, I’m trained now’ (laughs)”. Most participants thus described MICT to be less effective and beneficial regarding their physical fitness, which they subsequently associated with less enjoyment and fun. However, a couple of participants also pointed out that they had experienced MICT to be effective nonetheless, which is in line with research suggesting that both HIIT and MICT can improve physical fitness . In partThe tendency that HIIT was considered more effective than MICT was also reflected in participants' descriptions of their fitness development across the HIIT–MICT and MICT–HIIT sequences. Concerning exercise-related physical fitness, participants who started with HIIT described a substantial increase in the first training period, while the second training period was characterized by stable or even decreasing fitness levels. For the first training period (HIIT), one participant reflected, “But then it actually went quite uphill. So, especially the interval training felt good, so that you had the feeling, ‘I’m already fit somehow’” , while other participants described the second training period (MICT) as follows, “And here I would simply draw a plateau, because (…) I don’t think that I have become significantly worse. But I haven’t noticed any major increase now either”  and “so I had the feeling that this continuous method, that I even lose progress a bit. Even if I had a higher wattage afterwards” . Only a few participants argued that physical fitness also increased in the second training period (MICT), although most of them also indicated that the rate of change was lower than during HIIT,“Yes, I also feel a bit more trained. But I have to say, that it has increased rather less steeply, because you do the same thing over and over again and you have somehow, so I think, you feel at the higher intensity more that ‘Oh now, now it's going better’. And here then rather not so fast (I: So moderately increasing), because, yes, exactly”. On the other hand, if participants started with MICT, they also reported increases in exercise-related physical fitness more often for MICT, “That definitely went up during the first training block” . Additionally, while in the HIIT–MICT sequence, the second training period resembled more a plateau and sometimes even a regression in feeling fit, the second training period in the MICT–HIIT sequence was often perceived as relatively positive as participants experienced a continuous increase or even a boost in physical fitness. One participant stated, “And then at the high intensity, it took another big swing with my training condition” .Eventually, several participants stated that their physical fitness had improved independently of the selected training modes. Those participants often described a rather linear increase in physical fitness across the entire intervention period, as indicated by the following statement,“Ah, that's really hard to tell. I actually think that they are somehow even. Although I actually thought at first that the interval training might be more beneficial, because I thought it was somehow a bit more strenuous and so. But actually, from the sensation how trained I actually feel, it was not the case”. Regarding everyday physical fitness, participants did not elaborate much on the perceived effects of the two training modes. Only a few participants described a similar tendency as for the exercise-related physical fitness development, namely, increases during the first training period of the HIIT–MICT sequence, followed by a subsequent plateau or decrease in the second training period. Similarly, a few participants described increases in their everyday fitness during the first training period of the MICT–HIIT sequence, followed by an increase or even a boost in the HIIT period.3.2.4.Some participants did not perceive the exercise intervention solely as positive. One of the main reasons was that exercising only on a bicycle ergometer was perceived to be too one-sided to improve fitness on a global level. While most participants reported increases in their physical fitness, they related these changes primarily to increased muscle mass in the upper thighs and improved cardiorespiratory fitness. However, to feel fitter on a more global scale, participants missed training other muscle groups ,“What bothered me a bit, because I come more from running, that it was concentrated only on the legs. So, the rest of the body felt so flabby (laughs) and the legs were really strong and pumped up”. This indicates that the experience of fitness and what it means to be fit or not is highly subjective and may expand on various concepts and notions of fitness, such as cardiorespiratory and muscular endurance, muscular strength, or body composition, which, however, might not be achieved by cycling alone. Although participants did not often speak explicitly about their body image, on a latent level, they still drew on socio-culturally determined body ideals, which were associated with a thin body for women and a muscular or athletic appearance for men , 67. ThiAdditionally, participants argued that the intervention period was too short and the training volume was too low in order to feel trained on a more global level,“I mean, as I said, I am (unintelligible) was and am not an athletic person and of course, somehow, in a few weeks you do not suddenly become a super athlete or at least not with 3 times a week of an adapted training”. 3.3.This theme focuses on descriptions of the effects of feeling fit (or not), especially concerning its impact on exercise experiences, how participants go about their everyday activities, and how feeling fit changes how they see themselves.3.3.1.Feeling that exercise-related physical fitness improved positively affected how participants experienced the exercise sessions. While HIIT was initially described as particularly strenuous and exhausting, several participants indicated that physical adaptations made the training sessions easier . One participant elaborated, “So at the beginning it was just, I would say very strenuous and then, of course, you also saw successes, that's why this increase at the beginning. Then it became better of course” . In particular, participants stated that they “suffered” less, were less exhausted during the high-intensity intervals, could withstand exhaustion for a longer time, and recovered faster in between intervals. A participant explained her experience as follows,“I have actually felt more trained there. With time, because you also notice how the intervals with the higher frequency, how you then become better and less exhausted”. This is in line with previous findings that suggest that despite lower training volume, for example, compared to MICT, HIIT leads to substantial improvements in exercise tolerance over time  and migh“But, yes, then it was also more fun and you also noticed that you recover faster in the recovery phases or so. So, the intervals were still strenuous, I thought, but the recovery was faster and then it was also more fun”. Consequently, a couple of participants stated that the training became more of a priority for them and that they were more motivated to train when they either felt that their fitness was improving or when the training load was increased. On an affective level, these results align with research reporting that, despite experiencing less pleasure in-task, HIIT can be equally or even more enjoyable than MICT, especially with regard to post-exercise enjoyment , 73. In A few participants described similar adaptations to MICT, which was generally perceived as not as strenuous or exhausting and might have led to less joy and pleasure during the training session as there was no apparent progress. One participant explained, “With the continuous method, it's basically the same every time. And you do not feel a great training effect” .3.3.2.Although participants generally rated their levels of physical fitness related to everyday activities as high without much variation, some still experienced changes in this regard. Several participants reported that they were able to walk faster and had improved their “cycling ability”, for example, by being able to go in a higher gear or feeling less exhausted,“So, I also notice that in everyday life, so for example I walked here again this morning and I thought, ‘oh dear, oh dear, I’m late’, because during the first week of diagnostics it took me about three quarters of an hour. And now it didn’t take me three quarters of an hour. I think it took me maybe half an hour to go the same distance”. Additionally, participants were not out of breath so quickly and recovered faster after PA.Feeling fit and being able to master demanding everyday activities more easily also led to more PA in those participants, who felt that their fitness levels increased in this regard. Especially those few who had children reported that they had more energy in their everyday life and had become more active with their kids. One participant gave a vivid example,“So, I’m imagining it. I don’t know if it's true, sure. Um, that it has already gotten better. I would increase that from 5 to 8 (…). Because the other day, I don’t remember when it was, I went out with my children. They really wanted to go out. And then we went 4.2, so we did a lap and I measured it. It was 4.2 kilometers, and after he half, they said they didn’t feel like it anymore. I was like ‘yeah, that was the first time they said they’re not up for it anymore (laughs)’  and I could still. Yes, I walked and they just rode bikes and skateboards and I walked alongside. And climbing stairs. It's getting better, so I’m still out of breath, but it's getting better. I have the feeling not that I’m getting faster, but my breath is getting better”. 3.3.3.Last but not least, feeling fit changed the way several participants saw themselves. Regular training was linked to changes in the body and appearance. The fitter participants felt, and by knowing that they were “doing something for their body”, the better and more comfortable they felt in their bodies. One participant explained, “And then, however, over the course of the training it already rose a bit. Because simply, so from the feeling, by exercising more and regularly I just felt better in my body” . In particular, a couple of participants reported increased muscle mass, which was associated with feeling powerful and capable. This is in line with research that has shown that PA and exercise interventions can positively impact individuals’ body image and self-perception . However4.4.1.To our knowledge, this is the first study to assess the processual character of fitness development in a structured exercise intervention from a subjective perspective. The methodological approach of our study can be considered a strength on several levels. First, the retrospective assessment of experiences across the intervention period using a biographical mapping method yields deeper insights, provides a contextualized understanding of exercise- and fitness-related experiences, and considers physical fitness and its development over time. Second, our research extends previous studies in that we did not solely focus on a comparison of HIIT and MICT but also compared the administration of two different sequential orders in which HIIT and MICT were prescribed , thus allowing participants to comparatively evaluate both training modes. Third, our sample presents a group that might be of particular interest to public health and PA policies since young and healthy inactive adults are a potential target group that might potentially be easy to reach as physical limitations might not yet impair the uptake of PA and exercise.Our study also has some limitations. First, as indicated by the participants, our study design was limited in that the selected training modes primarily emphasized cardiorespiratory fitness development. Strength training was not included in the exercise prescription, which therefore did not meet current public health PA guidelines which usually include muscle-strengthening activities on a least two days a week . Compari4.2.Physical fitness is a complex and subjectively experienced phenomenon. Our results illustrate that participants perceive and experience physical fitness and its development in various ways. This inter-individual variance relates to what individuals associate with physical fitness; if, when, and how they feel their physical fitness improving; and how physical fitness affects their behavior and experience beyond the exercise setting itself. In a recent study on affective responses, Stork et al.  have conper se.Participants from our study mostly favored HIIT over MICT and considered it more effective. Participants notably attributed fitness improvements to the severe intensity of HIIT and reasoned that a feeling of exhaustion during or after exercise was a sign of having accomplished something. In this respect, higher intensities may have elicited a sense of achievement, while post-exercise exhaustion may have been interpreted as a sign of having actively been engaged in exercise. However, it is essential to point out that exercise intensities need to be physiologically and psychologically manageable for participants, as studies have indicated that intensities beyond a critical threshold might lead to decreases in pleasure and, subsequently, in potential exercise adherence . In addiImproving physical fitness and feeling those improvements has wide-ranging benefits related to exercise experiences and beyond. In particular, feeling fitter can change how young adults experience single training sessions. For example, physical adaptations led participants to enjoy HIIT more over time and to be more motivated for the exercise sessions. We think that palpable fitness adaptations might precede changes in affective responses to exercise. If young adults can actually feel the progress, they are making and thus experience some sense of mastery or self-efficacy, this can lead to more enjoyment and motivation. On the other hand, a lack of perceived progress might lead to less enjoyment and motivation (or even decreases) due to the experience of stagnation or monotony. To our knowledge, the iReAct-study is the first to assess and compare the prescriptions of different sequential orders of HIIT and MICT. Assessing different exercise modes in different sequential order might provide another avenue for future studies with regard to both physiological and experiential adaptations and their interrelationship.Finally, as we have pointed out, no follow-up assessments took place to assess whether participants continued to exercise and which role their experiences with HIIT and MICT might have played in this regard. Of course, for meaningful improvements in physical fitness to occur, a continued adherence to PA and exercise is required. Future research might therefore further focus on long-term behavioral patterns of PA and exercise after an intervention period has been concluded. Herewith, repeated surveys over an extended time might be especially helpful to better understand the impact an intervention might actually have on individuals' PA and exercise behaviors.4.3.Our study has implications for those administering exercise interventions in the context of both research as well as health and PA promotion. First, while there is a general tendency that young adults experience HIIT to be more effective and beneficial than MICT regarding physical fitness, not all participants prefer HIIT to MICT. Practitioners should acknowledge this and—similar to researchers—frame HIIT and MICT as alternative options in a pool of exercise opportunities rather than framing them as one vs. the other or merely highlighting HIIT as an extraordinarily potent training mode for everyone , 83. Simfeel the distinctive benefits of regular exercise.Second, researchers and practitioners must be aware that physical adaptations are not similarly palpable to all participants. In this regard, providing feedback regarding physiological progress is crucial. Adjustments in the training load require constant monitoring of individual development over time but can reaffirm to participants that they are actually making progress, promote positive emotions, keep them motivated, and, thus, increase exercise adherence. However, if participants do not improve on a physiological level and training loads cannot be adjusted, exercise professionals should equally provide feedback and offer training alternatives since participants are well aware if no adjustments occur, which might limit perceived self-efficacy and motivation. Additionally, it appears relevant to promote awareness of subjective outcomes associated with increased physical fitness, such as feeling more powerful, capable, or energized for participants to Third, it is vital for researchers and practitioners alike to be aware that structured exercise interventions have their limitations. Our results have shown that participants have a complex understanding of the concept of physical fitness, which needs to be addressed if exercise interventions should be sustainable. For participants who aim to improve their overall physical fitness and well-being, exercise interventions focusing primarily on cardiorespiratory fitness and only selected muscle groups  might be less beneficial than other modes of exercise . This requires understanding physical fitness not merely as a physiological outcome but as a subjective construction.5.In recent years, the discussion around PA and exercise promotion for public health purposes has focused, among others things, on the question of whether HIIT might be a viable option. Compelling evidence has shown that HIIT is associated with substantial increases in physical fitness. However, little is known about whether and how individuals actually experience these adaptations when they start to exercise. The objective of this study was to qualitatively assess how (inactive) healthy young adults subjectively experience physical fitness and its development throughout a structured exercise intervention in which they were prescribed HIIT and MICT in a different sequential order and how they retrospectively evaluate those experiences. Our results emphasize that physical fitness is a highly individualized and complex experience that manifests in various ways. Although participants generally seem to favor HIIT to be more effective than MICT, the idiosyncrasy of physical fitness experiences also reiterates that one-size-fits-all approaches might be misleading and that individual expectations, perceptions, and experiences need to be taken into account when administering training modes. We think that our findings can extend the knowledge about how young adults subjectively experience exercise and associated fitness outcomes and the role HIIT and MICT can play in this regard, thus strengthening vigorous exercise as a viable alternative to or an extension of moderate exercise programs, particularly in previously inactive young and healthy adults.


Owing to colonization's impacts, Indigenous Peoples in Canada face a disproportionate share of health challenges and suffer inequitable access to health care today. In recent years, an increasing number of Indigenous-led health services have emerged, which—informed by decolonial principles, including “culture-as-cure”—holistically center local Indigenous cultural, spiritual, and healing knowledges and practices. Aligned with decolonial principles, this work examines the delivery of Chinese Medicine (CM) care—an East Asian Indigenous therapeutic approach—in Indigenous communities in British Columbia, Canada.Informed by qualitative interviews with three licensed CM practitioners and one biomedical clinician working in such clinics, the work provides a descriptive account of clinical operations, and thematically explores operational successes and challenges.Four CM clinical programs were identified, all operating on First Nations reserves, including settings at multidisciplinary community health centers, a First Nation Band Council office, and a school gymnasium. Most CM care was delivered free of charge, funded variously by nonprofit agency donations and provincial government reimbursement. Three central themes emerged across the study interviews. The first, transculturalism, emphasizes the conceptual overlap between CM and Indigenous belief systems in the Canadian context, which participants described as a source of strength in building trust for CM care as a nonlocal Indigenous therapeutic approach. The second theme, Cultural Humility, characterizes non-Indigenous practitioners' respectful outlook as guests on Indigenous land, taking community members' lead as to how they might best serve. The final theme, Multidimensional Healing, explores the physical, mental, and emotional healing that practitioners witnessed across their work.Despite economic and logistical challenges, study respondents expressed optimism about the potential for similar traditional medicine clinics to provide culturally resonant primary care in other underserved communities. Further research to learn about the experiences of First Nations community members receiving CM care is warranted. In the province of British Columbia (BC), this impulse is exemplified in the establishment of the First Nations Health Authority: a governmental partnership whereby First Nations communities increasingly regain control over their own health care services.1(p32)In recent years, however, an increasing number of health care programs and services have emerged in Canada, which aim to enhance primary health care access and improve health outcomes for Indigenous Peoples.2 “directed by the Indigenous communities that they are designed to serve.”1(p31) Such programs are often explicitly decolonial—that is, antiracist and culturally safe—in character,2 and based on the principle of “culture as cure,” which centers “health interventions…[that] are holistic and informed by cultural knowledge or local spiritual worldviews,”2(pE208) including Indigenous healing practices.Furthermore, an increasing number of Indigenous-led health services have arisen across Canada in recent years,4(p9)—is an essential ingredient.2For non-Indigenous and biomedical health care providers working in such settings, “cultural humility”—a commitment to righting historical wrongs by “dismantling…power imbalances” and learning about Indigenous ways of knowing and doingAligned with the aforementioned decolonial principles, the present work offers a first scholarly account of the delivery of Chinese Medicine (CM) care on First Nations reserves in BC, Canada. With reference to the voices of clinicians working in the aforementioned settings, the study aims to: (1) develop a descriptive account of clinical operations; and, (2) explore operational successes and challenges across these clinics.10 Like other Indigenous therapeutic approaches, CM is internally diverse in terms of how its core epistemic principles are enacted in practice. Following the World Health Organization's guidance, many jurisdictions (including and beyond China) have standardized a particular, historically situated codification of Chinese medical knowledge known as “Traditional Chinese Medicine” into law. In Canada, BC is one such jurisdiction, where Traditional Chinese Medicine has been a statutorily regulated profession since 1996.11 While the present work refers to interviews with licensed practitioners of Traditional Chinese Medicine in BC, the authors will preferentially use the term “Chinese Medicine” (CM) throughout (except with reference to licensing and in direct quotes) to better recognize the diverse practice approaches employed by practitioners.CM is a system of East Asian traditional (Indigenous) medicine with a pre-colonial, nonbiomedical epistemology informing the use of such traditional therapies as acupuncture and herbal medicine.12 the authors received approval from the McMaster University Research Ethics Board to conduct qualitative interviews with CM and biomedical health care professionals working in such clinics. The first author contacted the lead clinician identified in the aforementioned news article, which led to the identification of a total of four clinics offering CM care in BC First Nations communities. Using a snowball sampling strategy, the authors aimed to secure English-language telephone interviews with lead clinicians working in each of these clinics. The authors constructed a semistructured interview guide with two broad areas of focus: identification of the clinics' operational characteristics; and, inquiry into clinician experiences working in these treatment settings.Informed by a news article about the operation of CM clinics on First Nations reserves in BC, Canada,Four health care practitioners, all fluent in English, consented to participate in the study: three licensed Traditional Chinese Medicine practitioners  who were actively delivering care in BC First Nations communities; and, one biomedical health care professional . Fieldwork and preliminary analyses for the present study constituted the first author's undergraduate thesis project at McMaster University, with the second author as her supervisor. This work represents a subsequent collaboration between the two authors.13 of all interview transcripts with reference to the study aims. Thematic analysis unfolded in two primary phases: a deductive coding process aimed at identifying key operational characteristics of each of the identified clinics; and, subsequently, an inductive coding process focused on characterizing clinician experiences and contextualizing these within the study's overarching decolonial framework. All coding and analytic decisions were reviewed and finalized by both coauthors.The first author (a white-identified woman of mixed-European ancestry) conducted and transcribed telephone interviews with all respondents. Together with the second author , the first author conducted a thematic analysis14In what follows, the authors present the study findings, using verbatim interview excerpts to illustrate and theoretically interpret key emergent themes. To protect respondent anonymity, the authors have elected to use the gender-inclusive pronoun “they” in all cases; but, when explicitly relevant, identify respondents according to their professional roles and/or ethnic ancestries. Overall, this article adheres to the guidelines articulated in the SRQR Reporting checklist for qualitative study.As shown in A third semiweekly clinic (“c”), supported with funds from the Band Council and Medical Services Plan, operated as a “pop-up” clinic at a Band Council office wherein a single CM practitioner would set up (and take down) a treatment room on clinic days. There, patients received acupuncture treatments free of charge, but were asked to pay for any herbal medicines given. The fourth clinic (“d”), funded by the same nonprofit organization subsidizing operations at the two community health centers, operated on an annual basis at a school gymnasium, where 5 to 10 volunteer CM practitioners provided acupuncture, free of charge, to dozens of patients—separated with vertical dividers—over the course of a single day.What follows is an exploration of three emergent study themes—Transculturalism, Cultural Humility, and Multidimensional Healing—followed by a discussion of challenges and future visions associated with the studied clinics.When [CM practitioners] first were introduced to our community, our community had to learn about Chinese medicine and their belief system. Once we thought there are huge similarities, especially about energy, we were like “yes.” …How they've explained their medicine-work is really similar to some of our Indigenous beliefs of how one heals. It's fairly universal in a lot of Indigenous communities to move energy in order to heal someone. For our Nation, the fact that they may use a needle whereas our Nation would use, could be a feather, or cedar, or cedar bows. We are healing people and not just physically but also spiritually.Interviewed clinicians repeatedly indicated that it was not simply the technical use of acupuncture needles or herbal medicines that appeared to facilitate the acceptance of CM care within the First Nations communities served. Rather, they pointed to important transcultural similarities between the CM offered, and the beliefs held by community members. One respondent, a biomedical professional of First Nations ancestry, observes:One beautiful thing is the herb…So that's really important: the specific herbs [I use in clinic], and they [the patient] will say, “wow this works like, something that we use” … stimulati[ng] conversation that “my grandmother used to use this,” or “I am going to go and ask so-and-so what they use”—to be able to stimulate a conversation about the power and healing properties of our traditions… [People come in and we talk about] what can I do with my lifestyle to get healthier, how do I live off the land, how do I pay attention to where my food comes from? That's traditional for both of us.One of the interviewed CM practitioners, a person of East Asian ancestry, provided tangible examples of such transculturalism in action:Chinese medicine…it's an old medicine… I think that there are ways of being as medicine people that are very transcultural. The old ways are the old ways, that's what is seems to me. Whether you are here, or you are there, they kind of transcend space, time, and dimension. They just are.Another CM practitioner—also a person with East Asian ethnic origins—spoke more conceptually about the potential for “culture-as-cure” to take place across systems of “old medicine, old knowledge”:…small gifts, smoked salmon…sometimes hunters invite me over to pick up some meat on the way home, just gifts that people make to be able to say thank you, and say, you know, we hope this continues. That's nice, that's beautiful.Transcultural exchange went both ways, with CM practitioners at times being “invited to the ceremonies” held on reserve, or receiving:cultural humility, emphasizing their position as guests on First Nations reserves, serving at the community's lead rather than coming in to implement a therapeutic agenda of their own:I think a lot about the concept of host and guest. I'm a guest on the land…This is an unceded territory. This is a Nation. That affects how I practice medicine. It is different to be the guest, and the Nation is the host. And within that there are a bunch of responsibilities… its everything from how one introduces oneself, it's calling your own ancestors into the land, it's acknowledging the ancestors of the land, the history of the land, it's acknowledging the relation of the history of the land with the history of that body.Interviewed CM practitioners consistently alluded to the concept of As a practitioner I have to be always respectful and follow the lead of the First Nation. I can't go in and think that TCM [Traditional Chinese Medicine] is the next big thing. I can just walk in and say, this is who I am, what can I do to help? I can't assume, I have to be respectful of the leadership, following the direction of the First Nation, their level of readiness. If they invite me into the next step, and then I am part of a team that uses allopathic medicine, traditional Indigenous medicine. …It is not to take the lead or further colonize, that is not our role.Another practitioner shared:We are fortunate that we have doctors that promote acupuncture with clients. I think it makes a difference for clients that really look to their family doctor for assurances that this is “ok” medicine.As another respondent indicated, the success of the CM care offered in a community health center setting furthermore depended on the cultural humility of the center's biomedical professionals, expressed in an open validation of a nonbiomedical therapeutic approach with community members:Ultimately, clinicians' cultural humility appeared to support a therapeutic context in which healing could safely occur. One respondent shared that the Chief of the Nation where they worked indicated in a public speech that “the community feels safer since the TCM clinic began.” Importantly, it was also from patients that practitioners reported receiving positive feedback.I have seen patients with arthritis who were in so much pain they didn't want to get out bed in the morning, [now] coming in with big smiles on their faces and hopping up on the table. A lot of elders with vertigo. Actually, two of them have told me they now go dancing. So, I see big changes to mental health, emotional health.All interviewed CM practitioners characterized their work as providing multidimensional therapeutic benefits to patients served; healing, as they described it, went well beyond physical ailments to support improvements to mental and emotional health, as well as health at the community level. One clinician explained:Chinese medicine looks at the whole person. …I do know that we have clients that have used Chinese medicine for their addiction issues. Also, I have seen success where clients decrease the amount of pain medication.Practitioners repeatedly described clinical successes in using CM to treat health concerns where “community members…haven't really found a lot of success in Western medicine in treatment,” including reductions in patient usage of “narcotics [and] opioids.” As the interviewed biomedical clinician affirmed:I have clients in the community who have not gone to Western medicine in 20 years because they have no faith in that system. And there is more than one, but I do know [one such] person goes to Chinese medicine and a Naturopath. And there are some here in the community that are actually becoming more open to that form of [non-biomedical] treatment. I mean you are looking at trauma, Indian residential schools, the way that Aboriginals were governed in this country, so there is a resistance in that older population.Respondents repeatedly reported that “once you have one person having success, then others are willing to try,” leading to greater acceptance of CM care within the broader community, with “people bringing their whole families in, from the elders to the children.” As the biomedical clinician indicated, such a context of trust building was an important component of health care work within the First Nations being served, given the legacies of mistrust for conventional biomedicine:It's not just the superficial reasons. [Patients] come to see you for lower back pain, car accident, pain management. And once it is resolved, they keep coming and we see actually a lot of problems residing under this. It can be traced back to early childhood trauma, or tragedies in their family members' [lives].CM practitioners similarly alluded to the complex, historically situated traumas that often underpinned patients' health challenges:Sometimes it is challenging with health and social situations, I have to remember to take care of myself. There are situations where I have to suck back tears because what people are telling me, the subjects get heavy.At times, practitioners found it personally difficult to bear witness to the traumatic experiences reported by those they served:I had students doing herbal foot baths and massage of the feet, and I had an elder come in during one of my community events, and he started crying because his wife died twenty years ago, and he has actually not been touched kindly in twenty years. So, if that is not a reason to do the work, and to do really humble work, then I don't know what is.Ultimately, however, all interviewed CM practitioners spoke to the gratifying character of their work, arising from the multidimensional healing that their work facilitated:I am not going in saying that the answers are all in Traditional Chinese Medicine, that was never the point of this program. It was always: these are some traditions from somewhere else, from Indigenous people somewhere else, and why can't we grow together?Despite the many successes reported, all interviewed clinicians alluded to operational challenges , the mosOur song is our spirit, we believe that [it] gives us strength…And we believe that moving energy can cause [a] person to become better. That is a belief that has been here among Indigenous people here for 10,000 years. Chinese medicine, when they told me it unblocks energy so that a person's body sings, when it was described that way, I knew that I would be able to get my people to try it. And I think [that] is partly why it is successful here. I can't speak for other Indigenous populations. That is up to each community to share their song, their spirit, their way of being. …[But] I think if more communities—you know, ours was a pilot project—if more communities were given this opportunity, I think they would really benefit from that.Ultimately, respondents tempered their vision of growing similar programs elsewhere with an emphasis on the agency of First Nations Peoples. As the interviewed biomedical clinician concludes, with reference to their own Nation:15 the epistemic premises of Indigenous medical approaches from “outsider” Nations may—as suggested in this work—be experienced as culturally resonant. Importantly, the present study findings should not be construed as a broad endorsement of the potential value of acupuncture care in Indigenous or otherwise marginalized communities; instead, the reported success of the studied clinics may be more accurately attributed to the culturally humble and resonant manner in which CM-based acupuncture was delivered. Furthermore, the voices of First Nations community members who received on-reserve CM care as patients did not form part of the current study's scope, but should certainly be heard before making grand statements as to the studied programs' ostensible advantages.The principles of transcultural exchange and cultural humility that emerged as central in the present study may provide useful parameters for similar projects in other Indigenous and ethnic minority communities detrimentally impacted by European colonization. Within such communities, where a historicized distrust for biomedicine is often endemic,9 to “improve health care outcomes and ensure access…[to] appropriate…care” for Indigenous and otherwise-marginalized communities in Canada and beyond.Nevertheless, further investigation is warranted to explore the possible contributions of nonbiomedical, traditional medicine approaches as part of a broader strategy, aligned with the Declaration of Astana,