Indigenous Health in Canada

Who Indigenous People in Canada?

In Canada, someone who self-identifies as an Indigenous person (First Nations), Inuit, or Metis, or belongs to an Indian band or nation

Factors to consider when conducting a cultural assessment:

Communication Space Social organization Time Environment control Biological Variations

Common core Aboriginal Values

Connection to the land Language relationships Spiritual ceremonies Elder teaching Balance in life

Cooperation

Cooperation is highly valued - competition within the group is rare - security in being a member of the group and in not being singled out and placed in a position above or below others

What is Viewed as Appropriate

Allow everyone chance to speak Think carefully before speaking Pause frequently and at length Being silent in unfamiliar situations Being silent when someone is emotional until they regain control Being silent when an elder is speaking Allowing your actions to speak for themselves

Health Care for Indigenous Clients

Although a wide variety of services are available to many First Nations and other Indigenous communities, these are often delivered by non-Indigenous care providers in the Western way and so may not be fully accessed by potential clients. The Indigenous population has generally noted they have experienced culturally insensitive healthcare and/or systemic racism, both subtle and overt. Many Indigenous people have had a lower standard of health care than other Canadians.

Non-status

Are not registered under the Indian Act and are represented by the Council of Aboriginal People Approx. 250, 000 are not registered

Tyendinaga Reservation-Mohawks Bay of Quinte

As of March 31st, 2016, 9, 551, of which 2,162 members live on the Territory As of 2007, have the ninth largest membership of all First Nations in Canada, and are the third largest in Ontario Health care

What was the purpose of the Indian Act?

Assimilation

3. Inclusivity

Be respectful and supportive, reflect on your won beliefs

Cultural Nursing Assessment What if clients are reluctant to answer questions?

CHNs should seek information from sources such as family members, interpreters, traditional cultural health practitioners, and educational resources

Cultural Competence

CNA CNO RNA

Health Challenges

CVD Diabetes Self-inflicted injuries Suicide Alcoholism/Substance use/misuse Lack of immunizations TB HIV/AIDS in women on the risk Obesity Smoking

What happened in 1939?

Care of the needs of First Nations and the Inuit became the responsibility and jurisdiction of the federal government of Canada

What happens when any or all the quadrants are unbalanced?

Careful listening is highly valued among Indigenous people; they have a keen sense of perception that quickly detects insincerity Historically, Indigenous people have sharp observational skills - nonverbal messages and signals, such as facial expressions, gestures, or different tones of voice are easily perceived. Time is viewed as flowing - clocks are not watched - things are done as they have to be done - this can translate into late arrivals or missed appointments

Health Challenges to be addressed

Children: self-inflected injury; mortality from injuries and trauma; mortality rates for infants; immunizations rates; infectious diseases; childhood obesity; substance abuse

DOH Physical Environment

Clean water, sewage treatment, pollution control Quality and contamination of drinking water Low-level military jet flights over hunting grounds Blocking expansion of forestry and logging Dumping nuclear waste products on or near First Nations reserves Often over-crowded, no running water, etc.

Specific DOH as per CHNC

Colonization Globalization Migration Cultural continuity Access Territory Poverty Self-determination

Intergenerational Effects of the Residential Schools Experience

1. Alcohol and drug abuse 2. Fetal Alcohol Syndrome (FAS) and Fetal Alcohol Effect (FAE) 3. Sexual abuse 4. Physical abuse 5.Psychological/emotional abuse 6. Low self-esteem 7. Dysfunctional families and inter-personal relationships 8. Parenting issues such as emotional coldness, rigidity, neglect, poor communication, and abandonment 9. Suicide and threat of suicide 10. Teen pregnancy 11. Chronic, widespread depression 12. Chronic, widespread rage and anger 13. Eating disorders 14. Sleeping disorders 15. Chronic physical illness related to spiritual andemotional traumas 16. Unresolved grief and loss 17. Separation anxiety 18. Fear of personal growth, transformation, and healing 19. Unconscious internalization of residential school  behaviours such as false politeness, not speaking out, passive compliance, excessive neatness etc. 20. Patterns of paternalistic authority linked to passive dependency; misuse of power to control others; community social patterns thatfoster whispering in the dark but refusing to stand with andsupport those who speak out or challenge the status quo 21. Breakdown of social cohesiveness that holds families and communities together, such as trust, common ground, shared  purpose and direction, a vibrant ceremonial and civic life, co- operative networks and associations working for the common good etc. 22. Disunity and conflict between individuals, families, and factions within the community 23. Flashbacks and associative trauma; certain smells, foods,  sounds, sights, and people trigger flashback memories anxiety  attacks, physical symptoms, or fear e.g. the sight of a certain type of boat or vehicle, especially containing a social worker or RCMP (who used to help round up and remove children), the sight of an old residential school building etc. 24. Educational blocks - aversions to formal learning programs that seem "too much like school", fear of failure, self-sabotage,  psychologically-based learning disabilities etc. 25. Spiritual confusion involving alienation from one's own spiritual life  and growth process, as well as conflicts and confusion over religion 26. Internalized sense of inferiority or aversion in relation to society and authority figures

Indigenous Values, Attitudes, and Behaviours

1. Cooperation 2. Harmony 3. Modesty 4. Dignity & Autonomy

Cultural Safety incorporations the following:

1. Cultural awareness 2. Cultural sensitivity 3. Cultural competence

Communication

1. Ethic of Non-interference 2. Anger not be shown 3. Respecting praise and gratitude 4. Conservation - Withdraw tactic 5. Notion that time must be right

ANAC Core Competencies for Cultural Safety

1. Post-colonial Understanding 2. Communication 3. Inclusivity 4. Respect

Legal Wave

1st Wave Control of the Indigenous population was undertaken that suppressed legal rights

Why focus on Aboriginal culture? (Health)

2-3X more chronic disease 6X rate of suicide Living in poverty Past history - trust is very difficult People will avoid coming to the hospital; when they do come they are very sick

Where do Indigenous people live?

21.0% of Canada's Indigenous people live in Ontario Almost 78% of Indigenous people do not live on reserves. They live in urban centres and rural communities, small towns, large towns, villages There are hundreds of different Indigenous groups in Canada, and they are very different from each other in language, customs, traditions, beliefs, ceremonies

Administrative Wave

2nd Wave A reserve system was created to isolate Indigenous people & claim their land

Ideological Wave

3rd Wave The residential school system with the goal of assimilation

Cultural Nursing Assessment

A systematic way to identify the beliefs, values, meanings, and behaviours of people while considering their history, life experiences, and social and physical environments CHNs must conduct a cultural assessment for all clients (individual, families, or communities) when they first come in contact with them

Provincial & National Organizations

Aboriginal Nurse's Assoc. National Aboriginal Health Organization (NAHO) Aboriginal Healing & Wellness Strategy National Collaborating Centre for Aboriginal Health Assembly of First Nations

Cultural awareness

Acknowledgement of differences

Historical Factors which Impact Current Client Relationships Colonialism:

Advanced the belief that one race is superior to another This belief has been part of Indigenous history since the federal government first tried to assimilate/eliminate the Indigenous culture. It is still a prevalent force with many Indigenous people today. It is because of colonialism that many Indigenous people feel very uncomfortable accessing health care in white organizations; they may come to the first appointment but it can be difficult to get them to return.

What are some wise practices for culturally safe health care?

Create non-invasive dialogue of your client does not self-identify - "Where are your people from?" This will tell you a lot - northern communities were hit hard by residential schools, treaties, Sixties Scoop etc. - may give you some idea of level of acceptance of white people Indigenous clients may appear to be "unengaged"; eye contact can be difficult if trust has not yet been fully established. Indigenous clients may need to have more than the standard number of people (extended family, an elder etc.) with them during health care appointments or interventions; in communities where Indigenous populations are significant, this is more likely to be accommodated. Make your workplace place look Indigenous -friendly. Hang a dream catcher, a Metis sash, some Inuit art etc. Be sure that clients know your space is culturally safe, non-judgmental and supportive, no matter what they are dealing with If you know the First Nations from which your clients come, visit their websites, get to know their traditions, their history etc. Clients may be very stoic. Learn about traditional medicines and practices - ask questions - you may see medicine bags etc. Your clients may ask to smudge etc. - learn about these things. Give clients opportunities to be part of any decision-making. The loss of power among Indigenous eople makes them feel...powerless. Offer options/choices whenever possible. A little input goes a long way. Be well-versed in the Medicine Wheel in case you may be able to use this model to guide a client toward wellness. Attend Indigenous events and gatherings.

Colonialism (mid-1500's on)

Created shame for Canada's Indigenous people - less value, "bad", heathen, savage etc. Host community taken over by newcomers and marginalized

What is culture?

Culture is a way of life of a group of people - the behaviours, beliefs, values, and symbols that they accept, generally without thinking about them, and that are passed along by communication and imitation from one generation to the next Culture is the sum of total of the learned behaviours of a group of people that are generally considered to be the tradition of that people and are transmitted from generation to generation Culture distinguished the members of one group or category of people from another

Residential Schools

Cultures in collision Reports of physical, sexual, emotional abuse Last one closed 1996 Government issued an apology Human Right Violation

Effects to consider that impact health

Disease Colonialism Assimilation Residential Schools Investigations (Truth and Reconciliation Report) Government Apologies

Common experiences in Healthcare

Don't trust Feel unsafe Feel they are being judged Miscommunication Racism Misunderstood

Intergenerational Trauma

Effects are still felt today - high representation of Indigenous people in corrections facilities, kids in foster care, communities in crisis, missing and murdered Indigenous women May not even be aware of why things are the way they are Sixties Scoop - started in 60s - ongoing

Black

Emotional: Relationships, Empowerment, Cooperation, Struggle

What is Viewed as Inappropriate

Express strong emotions in public or with people you don't know Ask forceful, direct questions of people you don't know well Speak for other people Directly tell someone they are wrong Always be the first person to speak or be in control of the conversation Interrupt others Ask direct personal questions of someone you just met Pay attention to only a few at a gathering Constantly make eye contact Be excessively polite

DOH Social Supports & Community Networks

Family is usually large and extended Wholeness, connectedness are valued Traditional values

Colonization (3) Waves

First contact between Indigenous people & Europeans 1st Wave: Legal Wave 2nd Wave: Administrative Wave 3rd: Ideological Wave:

Cultural competence

Focuses on the skills, knowledge, and attitudes of service providers

Cultural Characteristics that may Impact Health Care

For Indigenous people, the concept of health centers around balance and harmony within and among the mental, emotional, spiritual, and physical aspects of individuals If a problem occurs, the Indigenous person believes that the necessary balance or harmony has somehow been destroyed ***Therefore, a focus on addressing just the physical problems may not be compatible with the beliefs of Indigenous patients

Stories

Fort Albany Moose Factory Attawapiskat Compare to more economically stable reserves - Clarence Louie, Sagkeeng etc.

Indigenous population very low

Gov't was happy about this - wanted them gone by death, intermarriage, or assimilation

Health Challenges to be addressed continued...

HIV/AIDS Heart disease, stroke and diabetes Healthy lifestyle and eating habits

Harmony

Harmony within the group - many Indigenous people have a low ego level and strive for anonymity - social harmony more important than task orientation - needs of the group are considered over those of the individual

A vulnerable population

Higher birth and infant mortality rates Shorter life spans Higher incidence of circulatory diseases and tuberculosis Higher suicide and injury rates (Inuit 6-11 X higher, aboriginal youth 5-6 X higher) Higher rates of TB (8-10X higher) Higher diabetes rates (2-5 higher) CV risk (3-5 X higher)

2. Communication

Identify significance

Relationship of European settlers with Indigenous people

If we think metaphorically of Canada's history as having 10 chapters, it is only in Chapter 10 that "white men" (starting with European explorers) have been involved. In Chapters 1 to 9, only the Indigenous peoples lived in our country. -friendly one at first - partners in trade and exploration; Europeans relied on Indigenous people for survival skills. -Europeans needed Indigenous people for military alliances -Indigenous people came to be viewed as irrelevant or obstacles to settlement and growth of the nation -Indigenous people became "wards" of the government - marginalized in and by Canadian society

Indian Act 1856 What did it give to the government?

In 1856, Act gave government control over most aspects of their lives (Wards of the State)

The Perspective of Indigenous People Today

In recent decades Indigenous Peoples have experienced a revitalization of their strength and determination. Traditional ways have been restored, languages have been revived and are being taught to younger generations, the Indigenous identity has grown and flourished, and Indigenous history has been looked at with "new eyes", new appreciation, and new perspective.

Indigenous People

Include North American First Nations Metis (mixed ancestry of French & aboriginal) Inuit (NWT & Northern Quebec) The Inuit are the fastest growing group

DOH Income & Social Status

Increased rates of poverty Increases rates of unemployment Decreased life expectancy

Indigenous people may not know themselves

Indigenous clients may not be aware or fully aware of why things have happened in a particular way in their families and communities; sometimes learning about the same things we talked about today gives a sense of relief and understanding. They need to know about the generations who went before and what happened to them in order to know themselves. Clients will not necessarily realize that the way things are in their family and community is because of what happened in the past.

Indigenous Presence

Indigenous people are more likely to self-identify and advocate for themselves if there is an Indigenous presence in the facility Without this Indigenous presence, these people may look for Indigenous cultural awareness and sensitivity among the non-Indigenous staff Many barriers between Indigenous clients and their care providers come from the residential schools experience. Multi-generational trauma and feelings of inferiority and powerlessness stemming from the residential schools' experience can be easily aroused in health care situations; building trust is very important

Why is there so much attention paid to Indigenous Cultural Safety?

Indigenous people are native to Canada; we all live on their traditional lands They are a large population group and the fastest-growing in Canada (both by birth rates and by increasing numbers who self-identify) They are vital to Canada's culture and economy

Positive aspects of the Europeans

Indigenous people did benefit in some ways from involvement with Europeans, and their history in Canada is by no means completely characterized by these negative effects. European technology, for example, improved the lives of many Indigenous people in some ways. Rich and beneficial relationships were also a part of this history for some Indigenous people. Indigenous people have made tremendous contributions in many, many areas of the Canadian historical and cultural landscape.

Dignity & autonomy

Indigenous people have respect for the individual's dignity and autonomy - don't interfere in another person's affairs - believe that people are not meant to be controlled

Overview of Cultural Safety

June 2, 2015 - Truth and Reconciliation Report 94 recommendations for all of Canada Two-way process - two paths - side by side in cooperation, respect, and acknowledgement Openness is a close second Indigenous people do not want to be treated differently than anyone else - just equally Sense of belonging and sense of purpose are huge importance - also having stories heard

Culturally competent CHNs:

Know if there are specific risk factors for a given cultural population Understand their clients' non-traditional healing practices Are aware of cultural values, beliefs, and practices to guide them in delivering culturally appropriate care

1. Post-colonial Understanding

Know the historical impact & understand the legacy, concerns with equity, & access

Moved to reserves

Land and resource taken Often couldn't perform traditional roles in the community so sense of purpose compromised

Shame reinforced by residential school system

Loss of power for Indigenous people - attempt at assimilation - get rid of "the Indian in the child" Results - no parenting models, perpetuating of abuse lived and learned - addictions, violence, crime etc.

Determinants of Health: Social and Community Factors

Loss of the ancestral language means that grandparents and grandchildren find it difficult to communicate, limiting social support networks Educational and empowerment opportunities are limited in Inuit communities, which increases poverty, yet Inuit people pay 50% more for groceries than residents of southern Canada

Red

Mental: Understanding, Awareness, Perspective, Leadership

Modesty

Modesty is emphasized

Intergenerational (2)

Occurs when the effects of trauma are not resolved in one generation When trauma is ignored and there is no support for dealing with it, the trauma will be passed on to the next generation What people learn to see as "normal" when they are children will be passed on to their own children E.g., Children who learn that physical or sexual abuse is "normal" and who have not deal with the feelings that come from this may abuse their own children in the same way

Status

The act was amended in 1985 to restore status to people who had lost it: Marrying a man who did not have Status Enfranchisement (until 1960, one could vote in federal elections only by renouncing their status) Having a mother and paternal grandmother who did not have status before marriage (these people lost status at 21) Being born out of wedlock of a mother with status and a father without

First Nationals Health Care Delivery

Non-Insured Health Benefits are provided to approximately 749, 000 eligible First Nations and Inuit people. Coverage includes prescription drugs, vision care, dental services, medical supplies and equipment, and medical transportation, when these benefits are not provided through private or provincial/territorial health insurance plans

"Wards of the state"

Not what Indigenous people wanted but no choice Health problems due to extreme poverty, and 5 cheap white foods provided by Gov't - Rice, lard, flour, sugar, salt Diabetes, heart issues, overweight, high blood pressure

Yellow

Physical: Action, Skills, Sustainability, Health

Emotional/West

fall, reason, emotional response, black/blue, sharing, animal/medicine

Indigenous Values, Attitudes, and Behaviours Continued...

Placidity valued, as well as ability to remain still Silence is comfortable - feelings of discomfort are frequently masked in silence to avoid embarrassment of self or others When ill at ease, Indigenous people remain silent - inwardly determining what is expected of them Indifference to work ethic - with nature providing for one's needs, little need existed to work just for the sake of working - adherence to a rigid work schedule traditionally not an Indigenous practice Talking for the sake of talking is discouraged in Indigenous society - many Indigenous people find small talk unimportant - ideas and feelings conveyed through behaviour rather than through speech Careful listening highly valued in Indigenous society - keen sense of perception that quickly detects insincerity Sharp observational skills - nonverbal messages and signals, such as facial expressions, gestures, or different tones of voice easily perceived Most Indigenous people are pragmatic - prefer common sense, practical solutions - concrete rather than the abstract or theoretical solutions Nature - cooperative way of life which functions in balance/harmony with nature If a problem occurs, the Indigenous person believes that the necessary balance or harmony has somehow been destroyed. Spirituality: Religious aspects in all areas of life - religion is an integral part of each day; it is a way of life.

Historical Factors/ Eras which impacted/Impact Indigenous People in Canada

Pre-history/history (First Contact) Disease Wars Fur Trade Assimilation (Government attitudes) Colonialism Reserves/Treaties Residential School System/IntergenerationalEffects Investigations (RCAP and Truth and Reconciliation Reports) Apologies

The 60's Scoop

Prompted by changes in the Indian Act Many children were taken and placed in non-aboriginal foster or adoptive homes Western trained workers came into reservations & intervened in situations where they thought "abuse" was occurring Caused many children who weren't in abusive situations to be removed because workers had little understanding of cultural practices Felt a sense of rejection, isolation and disconnect with their traditions

Cultural sensitivity

Recognition of the importance of respecting difference

Facts

Represented by the Assembly of 1st Nations 750, 000 live on reserves

Truth & Reconciliation

Schools Language Abuse Loss of identity Estrangement from family

Recent efforts by "Indigenous" and non-Indigenous leaders have focused on:

Self-government and self-determination

DOH Education

Some schools on reservations Lack of qualified teachers who speak ancestral language in some cases Initiatives to encourage post secondary education

The Medicine Wheel: Balance Between Universe and 4 Aspects of Self

Spiritual/North Physical/East Mental/South Emotional/West Wheel is circular to help align forces in nature Mesh with seasons, stages of life, elements of nature, ceremonial plans, animals

White

Spiritual: Dignity, Values, Connection, Reflection

Physical/East

Spring, vision, yellow, kindness, eagle

Indian Act

Status, Treaty, or People of 1st Nations are Indigenous people registered under the 'Indian Act'

Mental/South

Summer, knowledge, red, honesty, tree

Colonization What was lost?

Suppression of diet, ceremonies, language, culture Loss of land Family systems Identity Crisis

Indigenous families and communities carry with them the effects of the residential school system

Survivors did not know how to show love or caring; these qualities had to be learned, but some people were not able to learn them. Survivors felt shame and told no one what happened to them. Survivors did not have parenting skills because they did not have role models and were not themselves parented. Survivors who were assimilated did not belong anywhere when they left the schools; they were emotionally and physically isolated from their home community and culture and from the "western" or "white" world. Dignity, spirit, language, and pride in culture were lost. Indigenous culture was undermined, and its foundations were weakened.

First Nations Health Status and Consequences

The First Nations and Inuit Health Branch (FNIHB) of Health Canada provides health services and support for First Nations and Inuit as a treaty right Over the past two decades, First Nations and the Inuit have been working with Health Canada to assume more local control for health services Recently, the health of the Indigenous people has improved (e.g., longer life expectancy and fewer infant deaths) CHN interventions for suicide should include knowing the determinants contributing to suicide in the community, skilful counselling, assessment, and cultural awareness

Indian Act 1850

The Indian Act defines who is considered and contains certain legal disabilities and legal rights for registered First Nations individuals (began in 1870)

What is the Indian Act of 1876?

The Indian Act of 1876 formally recognized Aboriginal heritage

Will you have Indigenous clients?

The Indigenous population is the largest and fastest growing demographic in Canada (especially the Metis) The Indigenous population is increasing at 3 times the rate of the general population (higher birth rate and more self ID)

First Nations Heathcare

The federal government provides health promotion programs and public health services on First Nations reserves and in identified Inuit communities In remote and isolated areas, where provincially or territorially insured services are not readily available, the Government of Canada provides on-reserve primary and emergency care services

What does the Indian Act recognize and affirm?

The legal validity of aboriginal treaties

What losses did the Indigenous people face?

The loss of tradition, lifestyle, and culture among the Indigenous people of Canada has been associated with colonialism Today, more than 54% of about 1.3 million Indigenous people in Canada live in urban settings

Who are Canada's Indigenous People?

There are 1.7 million in Canada who identified on the 2016 census as having Indigenous ancestry - even more not self ID Indigenous people include First Nations (status and non-status), Inuit, and Metis

Why do some Indigenous people not self-identify as being of Indigenous ancestry

They may be concerned with pre-existing attitudes and may fear racism or discrimination. Other reasons may include, but not be limited to the atmosphere in the room; not having the opportunity to self-identify; and the person's feeling that he is not "native enough" or not connected to his culture or to an Indigenous community.

True or false: The Indian Act underwent several amendments

True. Act was amended in 1985 to incorporate the Character of Rights & Freedoms

4. Respect

Understand the beliefs about access to healthcare

DOH Working Conditions

Unemployment leads to many social concerns

The Canadian Legacy

When Europeans began to arrive in Canada, there were between 500 000 and 2 million Indigenous peoples. They made a living based on the resources available to them. Over time, involvements with Europeans brought life-changing results for Indigenous people - disease, "modern" warfare, loss of a familiar way of life, loss of land, loss of the ability to make a living off the land, death, elimination of entire groups etc. Many Indigenous people live in poverty - faced with ongoing unemployment; living conditions and income levels for Indigenous communities, and for Indigenous people living off the reserves, are lower than for the rest of Canada.

Spiritual/North

Winter, action, white, strength, rock

What is reconciliation?

means addressing the socio-economic determinants of Indigenous health including disparities in income, education, employment, housing, infant mortality rates that are two to four times higher than the norm, child food insecurity, substance use, extreme poverty and social exclusion, which combined lead to higher prevalence rates for most diseases

Ideally, Indigenous people would be educated in all aspects of health care

so that they could provide services to their own people should their people wish to access these services (We are a long way from this) One of the proposed solutions to eliminate these feelings of racism is to train all front line health care professionals in the area of Indigenous cultural safety in order to ensure that Canada's Indigenous people receive the health care they need in a way that makes them comfortable enough to have an ongoing relationship with their health care providers.