Determinants of Indigenous peoples’ health and well-being: Featured publications from the National Collaborating Centre for Aboriginal Health

Contents

I Introduction
II An Indigenous framework for understanding the determinants of health
III The impacts of trauma for Indigenous peoples’ mental health and well-being
IV Aboriginal peoples and historic trauma
V The need for Aboriginal core competencies for public health  
VI Conclusion
VII References

-- Submitted by Regine Halseth, Research Associate

I Introduction

The National Collaborating Centre for Aboriginal Health (NCCAH) is one of six National Collaborating Centres for Public Health [1] established in 2005 to promote the use of research evidence and other knowledge to strengthen public health practices, policies and programs in Canada. One of the core tenets of the NCCAH’s focus has been on the determinants of health that underlie many of the inequities in Indigenous peoples’ health. Many of these determinants have been, and continue to be, shaped by a history of colonization. This history undermined Indigenous cultures, languages, land rights and self-determination, and manifests in poorer socio-economic status and a legacy of accumulated and collective trauma that continues to have ongoing and devastating impacts on the health and well-being of individuals, families and communities. This article provides an overview of the NCCAH’s recent work with respect to determinants of Indigenous peoples’ health, the impacts of those determinants on Indigenous peoples’ mental health and well-being, and some strategies for addressing those determinants within health services provision and more broadly.

II An Indigenous framework for understanding the determinants of health

While a social determinants of health framework has been well-established as a means of understanding health inequities in Canada and abroad, [2] this framework has limitations when applied to Indigenous peoples. Colonialism has not yet been fully and consistently accounted for as a significant determinant of health, and the ways in which both “historical and contemporary colonialisms continue to bear down on all aspects of Indigenous peoples’ lives” [3] are not well understood. Additionally, Indigenous-specific determinants such as spirituality, relationship to the land, geography, history, culture, language, and knowledge systems tend to be excluded from such frameworks. [3] Further, almost nothing in the social determinants literature has been written by Indigenous peoples. In recognition of these limitations and the need to capture Indigenous peoples’ perceptions on the topic, the NCCAH embarked on an ambitious project to “expand the health determinants discussion beyond the social” and broaden the ways in which Indigenous peoples’ health is understood. [3]

The genesis of this project emerged from a conversation over breakfast in 2011 between Dr. Margo Greenwood and Dr. Charlotte Reading, leading Indigenous women scholars working broadly in the area of Indigenous [4] health and well-being, and Dr. Sarah de Leeuw, a creative writer and geographer in the Faculty of Medicine at the University of Northern British Columbia (UNBC). Collectively, they observed that a book written by Indigenous people about the determinants of health was very much needed in Canada. They drew up a list of leading Indigenous scholars, activists, clinicians and community leaders who could offer insights about the health and well-being of First Nations, Inuit and Métis peoples. As chapters began to pour in, Indigenous artists and creative writers were also invited to contribute poems, short stories and other creative works which illuminated questions about Indigenous health. These were interwoven throughout the research contributions. In 2015 this book project, Determinants of Indigenous peoples’ health in Canada: Beyond the social, was published by Canadian Scholars’ Press. All royalties received from the sale of this book are being directed to the First Nations Child and Family Caring Society of Canada, a non-profit organization that provides high quality resources to support First Nations communities to empower children, youth and families. The book, supported through the NCCAH with funding from the Public Health Agency of Canada, can be ordered through local bookstores or online through Canadian Scholars’ Press: http://www.cspi.org/books/determinants-of-indigenous-peoples-health-in-c...

III The impacts of trauma for Indigenous peoples’ mental health and well-being

Indigenous people are more likely than other Canadians to experience traumatic events in their lifetimes. [5] Many of these traumatic events have their roots in the devastating and ongoing impacts of colonialism, including abuses experienced at residential schools, loss of lands, culture, languages, and self-determination, which have created stressful living conditions including poverty and violence. However, little is known about the mental health status of Indigenous peoples. The NCCAH has been working to address some of this knowledge gap by producing a series of three papers on the mental health of Indigenous peoples (http://www.nccah-ccnsa.ca/444/Post-traumatic_stress_disorder_(PTSD)__anxiety_and_depression_among_Aboriginal_peoples_in_Canada.nccah) . The papers, produced by Sherry Bellamy and Dr. Cindy Hardy from UNBC, focus on post-traumatic stress disorder (PTSD), anxiety and depression.  

The first paper, entitled, Post-traumatic stress disorder in Aboriginal people in Canada: Review of risk factors, the current state of knowledge and directions for further research, reviews the potential risk factors for PTSD in Aboriginal people, and provides an overview on the current knowledge about PTSD in Aboriginal peoples, including prevalence, health impacts, resilience and treatment options within an Aboriginal context. The second paper, Anxiety disorders and Aboriginal peoples in Canada: The current state of knowledge and directions for future research, reviews the limited but relevant literature on anxiety and Aboriginal peoples in Canada, including the prevalence of anxiety and the multiple risk factors for the development of anxiety disorders amongst Aboriginal children, youth and Aboriginal people living in urban centres. It also discusses Indigenous and Western models of mental health wellness, associations between anxiety and adult outcomes such as alcohol use and depression, links between physical health and anxiety, resilience factors in Aboriginal populations, and the assessment, diagnosis and treatment for Aboriginal people suffering from anxiety. The final paper in this series, Understanding depression in Aboriginal communities and families, provides a brief summary of the symptoms of depression, discusses depression across cultures, and presents what is known about the prevalence of depression among Aboriginal peoples in Canada. Selected risk factors for depression are considered within the historical and contemporary experiences of Aboriginal peoples, including colonization, forced assimilation, disrupted relationships and connections to family, and exposure to abuses. The paper concludes with an examination of some health consequences related to depression, and a discussion on Western and Aboriginal approaches to healing.

All three papers in this series call for more research in a number of areas related to mental health and Aboriginal peoples, including the prevalence, stressors, risk factors and health implications of PTSD, anxiety and depression; the cultural factors that foster resilience in Aboriginal communities; and opportunities for interventions that honour Aboriginal holistic values and traditions, promote resilience, heal families and communities, improve collective health and well-being, and reduce the environmental factors that perpetuate trauma within communities. The papers also provide links to resources for Aboriginal peoples seeking help for and/or information about PTSD. Some of these links include:

  • National Network for Aboriginal Mental Health Research: a database for mental health promotion, prevention and intervention models and programs for Aboriginal people (http://www.namhr.ca).
  • Za-geh-do-win Aboriginal Mental Health Services/Support Directory: a Directory of First Nations mental health services within Ontario (http://www.za-geh-do-win.com/PDF/The%20Key.pdf).
  • PTSD Association provides resources for people suffering from PTSD as well as their family, friends and coworkers. Its website provides access to PTSD research articles, a checklist for symptoms of PTSD, information on coping strategies, and web links to further resources for PTSD (http://www.ptsdassociation.com/coping-strategies/2015/7/15/trauma-and-th...).

IV Aboriginal peoples and historic trauma

One of the most devastating and enduring forms of colonialism on the health and well-being of Indigenous peoples has been the imposition of the residential school system. Residential schools were designed to assimilate Indigenous people into the dominant society by forcibly removing children from their families, communities and culture, and educating them in the dominant society’s values, skills, culture, religion and language. Many Indigenous students experienced a host of abuses, including physical, sexual, emotional, psychological and spiritual abuses. These have been documented over a five year period in a recently released report by Truth and Reconciliation Commission of Canada (TRC). [6] The severe trauma experienced by these students during the residential school years has accumulated over time and been passed to subsequent generations, with devastating impacts on the health and well-being of individuals, families and communities through high rates of family violence, addiction, suicide, and mental health disorders. [7]  

The NCCAH explored the topic of intergenerational trauma through two reports written by William Aguiar and Regine Halseth (http://www.nccah-ccnsa.ca/430/aboriginal-peoples-and-historic-trauma.nccah). The first, Aboriginal peoples and historic trauma: The processes of intergenerational transmission, provides an overview of the existing knowledge on trauma, how it is defined and how it must be conceptualized within the context of Aboriginal peoples in Canada; the characteristics and patterns of behaviour that are typical of Indigenous families living with intergenerational trauma; as well as the psychological, physiological and social processes by which trauma can be transmitted through the generations. It concludes by calling for holistic healing strategies that are implemented not only within the health domain, but within other domains like education as well.

The second report, Addressing the healing of Aboriginal adults and families within a community-owned college model, presents one model of healing through the education domain, using the Blue Quills First Nations College (BQFNC) as a case study. The report provides an overview of the history and legacy of the residential school system, including the social and psychological effects which perpetuate conditions of disadvantage such as the current educational gap between Aboriginal and non-Aboriginal peoples. It explores the impacts of trauma on learning, how expressions of trauma manifest in the classroom, and the factors considered important by researchers for improving the academic achievement of Aboriginal victims of trauma. The report then highlights the unique educational philosophy of BQFNC, and discusses how its holistic learning and programming have the potential to disrupt the intergenerational transmission of trauma within families who are descendants of survivors of Canada’s residential school system.

V The need for Aboriginal core competencies for public health  

Given the profound impact that colonialism has had on Indigenous peoples, culturally relevant models of health care are critical for improving their health and well-being. This requires that public health practitioners have a range of knowledge, skills and attitudes that are vital for providing culturally relevant health services to First Nations, Inuit and Métis peoples. These core competencies must not only address issues that are similar for all cultural minorities, including cultural safety, power, inequity, and incorporation of non-Western knowledge systems of healing, but must also include competencies specific to Aboriginal people, including an understanding of the connections between land and Indigenous health, as rooted in cultural practices and worldviews, traditional approaches to health and healing, the historical and socio-political context for Indigenous peoples’ health, and use of traditional languages. [8]

To date, there have been no core competencies developed for public health practitioners working with Indigenous communities. Given the cultural and socio-economic diversity of Indigenous groups and the lack of infrastructure and data to support Indigenous health, the development of these competencies is challenging. [8] The NCCAH has been working with Indigenous health experts from Canada, Australia, New Zealand, and the United States to develop such core competencies through CIPHER: Competencies for Indigenous Public Health, Evaluation and Research collaboration. The implementation of such core competencies could lead to improvements in academic curriculum, training programs, professional certification, health services planning and policy development, and evaluation standards, and ultimately improve the quality of care Aboriginal people receive. [8] As part of this project, the NCCAH produced the report, Review of core competencies for public health: An Aboriginal public health perspective (http://www.nccah-ccnsa.ca/Publications/Lists/Publications/Attachments/14...) Written by Dr. Sarah Hunt, a Post-Doctoral Fellow with the NCCAH, the report reviews and analyzes the seven categories and appendices of the 2007 Public Health Agency of Canada’s Core Competencies for Public Health in Canada 1.0 (http://www.phac-aspc.gc.ca/php-psp/ccph-cesp/pdfs/cc-manual-eng090407.pdf) within an Aboriginal public health framework. The review identifies systemic factors related to colonialism, recognition of Indigenous Knowledge, and First Nations, Inuit and Métis health governance as issues that are currently missing from the 2007 competencies, and provides recommendations for how to address these issues within the current document.

VI Conclusion

Given the pervasiveness of the mental health issues existing in many Indigenous communities and the complexity of the factors which are contributing to the increased risk of mental health disorders within Indigenous populations, these NCCAH reports provide pathways to addressing health inequities. In line with the 94 Calls to Action of the Truth and Reconciliation Commission of Canada, these will require: multi-sectoral collaboration to address current socio-economic inequities between Indigenous and non-Indigenous Canadians; holistic and culturally relevant strategies which promote healing for individuals, families and communities; a revitalization of culture and language as foundational to a strong sense of identity and resilience; as well as changes at the health services provision level to improve access to health services and ensure they meet the needs of Indigenous peoples. As part of the growing movement towards reconciliation, all levels of government need to work together to change policies and programs in the areas of child welfare, education, language and culture, health, justice, and to change the nature of the relationship between Indigenous peoples and non-Indigenous peoples and governments.

VII References

  1. The other five National Collaborating Centres include the: National Collaborating Centre for Determinants of Health, National Collaborating Centre for Methods and Tools, National Collaborating Centre for Environmental Health, National Collaborating Centre for Healthy Public Policy, and National Collaborating Centre for Infectious Diseases.
  2. Commission on the Social Determinants of Health (2008). Closing the gap in a generation: Health equity through action on the social determinants of health. Geneva: World Health Organization.
  3. de Leeuw, S., Lindsay, N.M., & Greenwood, M. (2015). Introduction: Rethinking determinants of Indigenous peoples’ health in Canada. In M. Greenwood, S. de Leeuw, N.M. Lindsay, & C. Reading (eds.), Determinants of Indigenous Peoples’ Health in Canada: Beyond the Social (p. xii). Toronto, ON: Canadian Scholars Press Social determinants book.
  4. The terms ‘Indigenous’ and ‘Aboriginal’ are used here interchangeably to refer to the original inhabitants of Canada and their descendants, including First Nations, Inuit and Métis peoples of Canada as defined in Section 35 of the Canadian Constitution of 1982. The term ‘Indigenous’ is increasingly used at a federal government level, notably since the Department of “Aboriginal Affairs and Northern Development Canada” was renamed to “Indigenous and Northern Affairs Canada” in 2016.   
  5. Bombay, A., Matheson, K., & Anisman, H. (2009). Intergenerational trauma: Convergence of multiple processes among First Nations peoples in Canada. Journal of Aboriginal Health, 5(3): 7-47.
  6. Truth and Reconciliation Commission of Canada. (2015). The survivors speak: A report of the Truth and Reconciliation Commission of Canada. Accessed February 19, 2016 from http://www.trc.ca/websites/trcinstitution/File/2015/Findings/Survivors_S...
  7. Adelson, N. (2000). Re-imagining Aboriginality: An Indigenous peoples’ response to social suffering. Transcultural Psychiatry, 37(1): 11-34; Ross, R. (1996). Returning to the teachings: Exploring Aboriginal justice. Toronto, ON: Penguin Canada; and Waldram, J.B., Herring, D.A., & Kue Young, T. (1995). Aboriginal health in Canada: Historical, cultural, and epidemiological perspectives. Toronto, ON: University of Toronto Press).
  8. Hunt, S. (2015). Review of core competencies for public health: An Aboriginal public health perspective. Prince George, BC: NCCAH.

Resources

Truth and Reconciliation Commission of Canada. (2015). Honouring the truth, reconciliation for the future: Summary of the Final Report of the Truth and Reconciliation Commission of Canada. http://www.trc.ca/websites/trcinstitution/File/2015/Honouring_the_Truth_...
Provides a summary of the history of residential schools, its legacy for Indigenous peoples, the activities of the Truth and Reconciliation Commission of Canada, and summarizes its key findings and calls to action.  

Commission on the Social Determinants of Health (2008). Closing the gap in a generation: Health equity through action on the social determinants of health. Geneva: World Health Organization. http://apps.who.int/iris/bitstream/10665/43943/1/9789241563703_eng.pdf
Provides an analysis of the social determinants of health and describes the actions that must occur in order to close the gap in health equity within and between countries.