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Aboriginal Women’s Health: Forgotten in Healthcare

The Social Ecological Model (SEM) is a multilevel model of health and the initial theory, developed by Bronfenner, is illustrated by nesting circles that place the individual in the center surrounded by various systems (Kilanowski, 2017). The SEM can be used to explain challenges in Canada in meeting the health needs of Aboriginal women. The model suggests that health is affected by the interaction between the characteristics of the individual, relationships, community and society. Ecological models assume that multiple levels of influence exist and are interactive; reinforcing that to create sustainable health improvements, all factors must be targeted simultaneously (Golden, 2012). The SEM model can be used to understand the disparities in health that Aboriginal people face in the 21st century. Aboriginal women are even worse off than their male counterparts as they have experienced violence, discrimination, sexual harassment and oppression (Boyer, 2017).

Socio-Ecological Model

The definition of health has different meaning for many people around the world. The World Health Organization defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” and has been criticized for its lack of adaptation to chronic disease as well as cultural, social and emotional contexts (Huber, 2011). In Aboriginal cultures, good health is a state of balance and harmony involving body, mind, emotions and spirit linking each person to family, community and the earth in a circle of interdependence (Boyer, 2017). Diversity as well as the social determinants of health (SDOH) must be considered when assessing health of Aboriginal people. SDOH are defined as factors that influence health outcomes and are closely linked to health equity (Edwards & Cohen, 2012). These determinants have a direct impact on the health of individuals and populations and support lifestyle changes and behaviours. Improving the context of health of Aboriginal women in Canada can only be achieved by addressing SDOH as they impact Aboriginal women directly via relationships, organizations, community and society.

A disproportionate burden of health and social suffering upon Aboriginal populations of Canada are a result of social, economic, cultural and political inequities (Adelson, 2005). Aboriginal women in particular are vulnerable and face challenges on many levels. The individual level of health in the SEM is closely interdependent on relationships, community and society and it is challenging to decipher where one level begins and another level ends. As demonstrated in the chart below, Aboriginal people report poorer health, higher smoking rates, increased rates of infectious diseases, obesity, chronic conditions and experience more food insecurity than their non-Aboriginal counterparts (Statistics Canada, 2015). A lack of knowledge of health options, symptoms and prevention can lead to further ill health. Individual choices including behaviours such as substance abuse, smoking and eating habits are influenced by the contextual circumstances of life. Stress in turn can further exacerbate existing health problems. Recognizing the importance of Aboriginal women’s health is critical as improving their health can have lasting effects on children, families and communities.

Relationships are important influences on Aboriginal women as family and social networks surround each individual. These relationships can be supportive and nurturing or conversely violent and stressful and negatively impact health. The literature describes the suffering Aboriginal women endure as a result of domestic violence as well as violence in communities and society at large (Halseth, 2013). This may begin early in life and carry through in adult relationships. A culture where health care is inconsistent or inaccessible can impact outcomes of chronic diseases such as diabetes, cancer or mental health. Aboriginal women also face unique health challenges in relationships, family dynamics, community and government systems as they face multiple levels of discrimination and disadvantage on the basis of race, gender and class (Sampa, 2014).

The communities in which Aboriginal people live may be on or off reserve. In the province where I reside, Newfoundland and Labrador (NL), there are 3 distinct Aboriginal groups including First Nations, Inuit and Southern Inuit (formerly known as Metis). Statistics Canada reported in 2011 that 3% of the Aboriginal identity population in Canada live in NL and make up 7% of the total population of the province. Cultural experiences in these communities are variable. For example, in Labrador there are 5 Inuit communities and one First Nations community that are remote; and one First Nations community and 10 Southern Inuit communities that are considered rural. These rural and remote communities are faced with additional challenges of social disadvantage such as economic viability of communities, employment opportunities, inconsistent access to health professionals and education levels. Thirty-one % of First Nations people living on a reserve in NL lived in crowded homes (more than one person per room) while the comparable figure for the non-Aboriginal population was 1% (Statistics Canada, 2016). Poverty rates of Aboriginal women are double the rates of other Canadian women (Halseth, 2013) and they continue to lack access to basic needs such as affordable housing, healthy foods such as fresh fruits and vegetables and safe drinking water. Many Aboriginal communities have issues with access to safe drinking water and waste water entering communities (Government of Canada, 2018). These basic needs individually and cumulatively affect the health of Aboriginal women, their families and communities.

Canadian society has had a profound influence on the health of Aboriginal women as they were faced with colonialism, racism and social exclusion as their way of life was overtaken by settlers. A patriarchal social structure eroded Aboriginal cultural values and gender roles (Halseth, 2013). In NL, the erosion of cultural language and identity is apparent as the ability to converse in an Aboriginal language has decreased significantly for Inuit as well as First Nations living off reserve (see chart below, Statistics Canada, 2011). The Canadian government's Indian Act discriminated against Aboriginal women from 1869 to 1985 as they lost of their treaty and Aboriginal rights should they marry a partner without status until Bill C-31 amended the Indian Act to remove the discrimination and bring the Act in line with the Canadian Charter of Rights and Freedoms (Boyer, 2017). The federal government has acknowledged the impacts of colonization and the impact of residential schools on Aboriginal men, women and children as the Truth and Reconciliation Commission of Canada recognized the cultural erosion of Aboriginal people and made 94 calls to action (Truth & Reconciliation Commission of Canada, 2015). View the powerful video at the end of this blog post as Chief Robert Joseph shares his experience as a residential school survivor and the importance of truth and reconciliation in Canada (CBC, 2018). The Commission acknowledged the appalling impact on women and called on the government to conduct a National Inquiry into Missing and Murdered Indigenous Women and Girls. The following picture depicts the REDress project and the video explains the history of the project designed to create awareness for all Canadians of the impact of Missing and Murdered Indigenous Women and Girls.

The REDress Project

REDress project Retrieved from google images, March 3, 2018

The SEM model demonstrates many impacting levels that affect the context of one’s health journey. Health equity is lacking in Canadian health care as there as there is a disproportionate burden of disease in Aboriginal communities which stems from historical relationships with government, discriminatory practices and an underrepresentation of Aboriginal people (women, in particular) in policy decision making (Sampa, 2014). A downstream approach that targets individual behaviours will not bring about sustainable change. Health promotion in Canada has been largely based on individual lifestyle change and reducing personal risk factors (Schrecker, 2013) yet health promotion messages including anti smoking campaigns, drunk driving legislation, diet and exercise promotion are better received from more advantaged sectors of society (Glouberman & Millar, 2003). SDOH are modifiable as they can be affected upstream by public policy and a desire for change from communities, and all levels of government. If we relate this to the SEM model, all levels surrounding Aboriginal women such as relationships (direct and indirect) community influences and society as a whole must be impacted to modify SDOH to create lasting change. New and innovative ways of accessing health care (tele-health and remote patient monitoring), support of education and employment initiatives, and the provision of culturally safe care and policies are required to improve the health and well-being of Aboriginal women.

In conclusion, I want to highlight that the First Nations Holistic and Planning Model (NCCAH, 2018) and the Medicine Wheel should be used in tandem with the SEM to gain a greater understanding of cultural identity and define health as it is meaningful for Aboriginal women. Previous initiatives and policies designed to improve Aboriginal women’s health have failed as economic, cultural and social marginalization continue. Governments on all levels must co-design strategies that address revitalization and recovery of Aboriginal culture and traditional ways of knowing including concepts of spirituality, connectedness and reciprocity to the land and all life, self-reliance, and self- determination to advance health equality and outcomes (NCCAH, 2018). Aboriginal women, families and communities have shown tremendous strength and resiliency to overcome barriers to health; however, there is still more work to be done (Halseth, 2013). A strong desire for change on an individual, community and societal levels must be present to achieve health equity for all Canadians.

References

Adelson, N. (2005). The embodiment of inequity. Canadian Journal of Public Health. 96(2)45-60. Retrieved from http://pubs.cpha.ca/pdf/p24/22247.pdf

Bharmel, N., Derose, K.P., Felician, M., Weden, M.M. (2015). Understanding the Upstream Social Determinants of Health. Rand Health. Retrieved from https://www.rand.org/content/dam/rand/pubs/working_papers/WR1000/WR1096/RAND_WR1096.pdf

Boyer, Y. (2017). First Nations, Metis and Inuit women’s health: a rights-based approach. Alberta Laew Reviw. 54: 3. 611-635. Retrieved from https://www.albertalawreview.com/index.php/ALR/article/view/764

Edwards, N. & Cohen, E. (2012). Joining up action to address social determinants of health and health inequities in Canada. Health Care Management Forum. 25: 151-154.

CBC. (2018, December 18). Namwayut: we are all one. Thruth and Reconciliationin Canada. [Video file]. Retrieved from https://www.youtube.com/watch?v=2zuRQmwaREY

Golden, S. (2012). Social ecological approaches to individuals and their contexts: twenty years of health education and behaviour health promotion interventions. Health Education & Behaviour. 39(3)364-372. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/22267868

Kilanowski, J. (2017). Breadth of the socio-ecological model. Journal of Agromedicine. 22(4), 295-297. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/28742433

Halseth, R. (2013). Aboriginal women in Canada: gender, socio-economic determinants of health,a nd initiatives to close the wellness gap. Prince George, BC: National Collaborating Centre for Aboriginal Health. Retrieved from https://www.ccnsa-nccah.ca/495/Aboriginal_Women_in_Canada__Gender,_socio-economic_determinants_of_health,_and_initiatives_to_close_the_wellness-gap.nccah?id=77

Huber, M. (2011). Health: How should we define it? British Medical Journal, 343(7817), 235-237. Retrieved from https://doi.org/10.1136/bmj.d4163

National Collaborating Centre for Aboriginal Health (NCCAH) (2018). Social determinants. Retrieved from https://www.ccnsa-nccah.ca/28/Determinants.nccah

Sampa, J. (2014). Evidence for equity: public health examples from Aboriginal women in Canada. Health Law Review. 22(2), 28-39. Retrieved from http://0-eds.a.ebscohost.com.aupac.lib.athabascau.ca/eds/pdfviewer/pdfviewer?vid=2&sid=76f5e9f4-754d-4a8d-858b-8f30368795b3%40sessionmgr4008

Statistics Canada. (2015). Health at a glance. Retrieved from http://www.statcan.gc.ca/pub/82-624-x/2013001/article/11763-eng.htm

Statistics Canada Retrieved. (2016). Aboriginal Peoples: Fact Sheet for Newfoundland and Labrador. Retrieved from http://www.statcan.gc.ca/pub/89-656-x/89-656-x2016002-eng.htm

Truth & Reconciliation Commission of Canada. (2015). Truth & reconciliation commission of Canada: calls to action. Retrieved from:

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