lecture 4 iess.pdf

Indigenous People, Health and the Environment Indigenous health status, transition, and concepts in environmental health Lecture 4 1 1 Sources of Health Information • Regular or routine data collection systems – Consists of established procedures for collecting data as they become available (nat...

Indigenous People, Health and the Environment Indigenous health status, transition, and concepts in environmental health Lecture 4 1 1 Sources of Health Information • Regular or routine data collection systems – Consists of established procedures for collecting data as they become available (national, regional) – Examples: • National vital statistics registration system of births, deaths, marriages etc • A disease notification system to collect information udner the International Health Regulations on cholera, etc. • A reporting system for cancer (Canadian Cancer Registry) – Advantages & Disadvantages: • Availability • System may not exist or may not be uniform, may be incomplete or inaccurate WHO, 1999 2 2 1 Sources of Health Information • Ad hoc data collection systems – Usually in the form of a survey to gather information that is not available on a regular basis. May include special investigative studies or merely the collection of additional information as part of a routine data collection exercise – Examples: • National (one time) survey of health personnel • Survey to estimate the proportion of children with inner ear infections in a given population • Study to investigate whether fish consumption influences overall nutritional status • An investigation of breastfeeding practices among women who registered a birth in the previous year – Advantages & Disadvantages: • Provides accurate and reliable data on a specific issue • Logistics and expenses involved WHO, 1999 3 3 Ad hoc Health Surveys in Canada www.inuit healthsurvey.ca http://www.chiefs-of-ontario.org/environment/docs/particip.pdf 4 4 2 Indigenous Health Surveys in Canada • • • Aboriginal Peoples Survey • First Nations Regional Longitudinal Health Survey (now planned as regular, mandated longitudinal survey) First Nations Regional Longitudinal Health Survey http://fnigc.ca/our-work/regional-health-survey/about-rhs.html Nunavik Inuit Regional Health Survey Qanuippitaa? How are we? (2004) Qanuilirpitaa? How are we now? (2017) http://nrbhss.gouv.qc.ca/en/depart ments/public-health/healthportraits-healthsurveys/qanuilirpitaa-2017 • • Manitoba Metis Health Survey http://www.mmf.mb.ca/docs/metis_health_status_report.pdf Ad hoc Routine 5 5 Regular – E.g. Population Information • Census of Population What is it? – Provides an indication of population size (# in given area at given time); can be used to show variation in population sizes between countries and between geographical and administrative subdivisions within a country Why do it? – Provide data for use in planning of services – Determine denominators for indices of health – Administrative and political purposes – Example: Community health survey in Canadian Census – Limitations: Only estimates, Indigenous non-participation WHO, 1999 6 6 3 Regular – E.g. Population Information • Registration of Births and Deaths What is it ? – Vital statistics: data on various vital events of human life Why do it ? – For individual documentation – For legal and civic purposes (establishing citizenship, evidence needed for social services etc) – Maintain “balance sheet” of population – Example: Vital statistics recorded by hospital and municipality – Limitations: applying definitions (live birth – neonatal death); lack of motivation to register and report; lack of complete and reliable registration system WHO, 1999 7 7 Age-Sex Pyramids • Gender ratio in population • Percentage of older Vs younger age groups • Trends in demographic change over time and for the future • Potential indication of health status issues among segments of the population over time • Identification of percent of population in ‘vulnerable’ age groups for environmental health exposures (today and in the future) Canadian Indigenous Population • Significantly younger (e.g. 19% of Cdns < 15 yrs old; 39% of Inuit; 35% of First Nations; 29% of Metis) • Smaller proportion of elderly (12% of Cdns>65 yrs old; 3% of Inuit; 4% of First Nations and Metis) • Fertility decline in Indigenous population since 1980s and earlier 8 Waldram et al. 2006 8 4 Age-Sex Pyramids AFN, 2007 (2003 data) AFN, 2007 • Indigenous population can vary depending on source of data • Different cultural groups vary widely • Age-sex pyramid can tell us about the general structure of a population and the likely health issues of importance today and in the future • NHS 2011 data – 46% of Indigenous population < 25; 29% for nonIndigenous Canadians Current Pyramids? See: https://www12.statcan.gc.ca/censusrecensement/2021/dp-pd/dv-vd/pyramid/indexen.htm 9 https://www.aadnc-aandc.gc.ca/eng/1370438978311/1370439050610 9 Measures of Morbidity • Health: a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity • Morbidity: any departure, subjective or objective, from a state of physiological or mental well-being, whether due to disease, injury or impairment • Disability: restriction or loss of ability to perform an activity in the manner or within the range considered normal for a human being WHO, 1999 10 10 5 Measures of Morbidity Critically Thinking 11 11 Difficulties of defining and measuring morbidity at the individual scale • Problems of case definition • Variation in perception of sickness among individuals, cultures and over age – may not seek medical help • Inconsistencies in diagnostic procedures • Reporting inadequacies (Access, Human error, Data aggregation/transfer) • Challenges of health care workers (time and resources)12 WHO, 1999 12 6 Difficulties of defining and measuring morbidity at the collective scale • Population structure • Population size • Reporting challenges (Human error, Data aggregation / transfer) WHO, 1999 13 13 Measures of Mortality • Crude death rate: – total number of deaths occurring in a year x1000 / mid year population • Age-specific death rate: – total number of deaths in a specific age (or age group) in a year x 1000 / mid-year population of the same age (or age group) of the population • Sex-specific death rate: – total number of deaths in a specific sex group in a year x 1000 / midyear population of the same sex group • Standardized death rate: – Rates in which allowance has been made for the composition of the population (only useful for comparison across populations) – the number of deaths per 100,000 population that would have occurred in a given area if the age structure of the population of that area was the same as the age structure of a specified standard population. WHO, 1999 14 14 7 Causes of Mortality •Excess rate of injuries and other causes of deaths with the exception of cancer •Importance of circulatory diseases, cancer and injuries has grown 15 Waldram et al. 2006 15 Measures of Mortality • Advantages and Disadvantages of crude death rate: Advantages – Measures the average risk of death in the population at large – Easy to compute – Can be used to compare relative mortality in a given area between two periods not far apart Disadvantages – Level is affected by the age and sex composition of population (therefore can only be used to compare general mortality of populations if they have same sex / age composition) – Does not consider that the chance of dying varies according to age, sex, race, occupation etc WHO, 1999 16 16 8 Measures of Mortality • Advantages and Disadvantages of age / sex specific rate: Advantages – Measures the risk of death among persons of a specific age or sex group – Easy to compute – Can be used to compare mortality among two populations of the same age / sex group Disadvantages – Does not summarize total mortality in a single figure – Does not account for differences in the population structure in term of race, occupation, religion etc. WHO, 1999 17 17 Difficulties of defining and measuring mortality at the individual scale • Problems of case definition (e.g. miscarriage, stillbirth, live birth) • Reporting inadequacies (Access, Human error, Data aggregation/transfer) • Challenges of health care workers (time and resources for reporting) WHO, 1999 18 18 9 Difficulties of defining and measuring mortality at the collective scale • Population structure • Population size • Reporting challenges (Human error, Data aggregation / transfer) WHO, 1999 19 19 Life Expectancy – An aggregated metric Waldram et al. 2006 ITK, 2007 https://www.statcan.gc.ca/pub/89-645-x/2010001/c-g/c-g013-eng.htm • • • • • The number of years that a person, at a certain age, is expected to live. Most used indices are expectation of life at birth and at 5 years of age Significant differences still exist in life expectancy between Indigenous and non-Indigenous populations Life expectancy in Inuit communities* in the late 1990s was the same as that for all Canadians in the mid 1940s There is a life expectancy gap of about 5-6 years between First Nations and other Canadians and 10-15 years between Inuit and other Canadians What might be causing this? What is your life expectancy ? 20 https://www.projectbiglife.ca/life-expectancy-home 20 10 What is your life expectancy? https://www.projectbiglife.ca/life-expectancy-home 21 21 Health Indicators and their Purpose Health status indicator (morbidity or mortality): Measurement of a particular aspect of the health of a population. E.g. Life expectancy, infant mortality, disability or chronic disease rate Health determinant indicator: Measurement of something that influences health. E.g. diet, smoking, water quality, income and access to health services; Social and cultural determinants - language, cultural practices and spirituality. We have been looking at some health status indicators, now let’s look at some health determinant indicators and discuss their complexity for understanding Indigenous health in Canada. NAHO, 2007 22 11 Models of Health: Determinants of Health • • • • • • • • • Waldram et al. 2006 • Genetic susceptibility • Physical environment • Personal lifestyle and behaviours • Social, economic and cultural • • • Income and social status Social support networks Education and literacy Employment / work conditions Social environments Physical environments Personal health practices and coping skills Healthy child development Biology and genetic endowment Health services Gender Culture Public Health Agency of Canada, 2004 23 23 Models of Health: Circle of Life (by Norma Kassi) 24 24 12 Health Determinants - Critically Thinking Education Status http://www.statcan.gc.ca/pub/89-656-x/89-656-x2015001-eng.htm#a7 • • • Levels of formal education are significantly different between some Indigenous Vs non-Indigenous groups Might we then expect a lower health status ? But is formal education the primary path towards knowledge and resource acquisition that influences one’s health? 25 FNIGC, 2012 25 Health Determinants - Critically Thinking Economic Status FNIGC, 2012 http://www.statcan.gc.ca/pub/89-645-x/2015001/income-revenu-eng.htm • Formal economic status is lower than average Canadian status • But is formal economic status the critical resource to get things that support good health? 26 26 13 Income and Health in Indigenous Communities Kuhnlein et al., 2014 http://www.scienceadvice.ca/uploads/eng/assessments%20and%20publications%20and %20news%20releases/food%20security/foodsecurity_fullreporten.pdf 27 27 A Life-Course Perspective • Many diseases in adulthood have their origins in early childhood and prenatal life • Some health problems extend throughout life 28 Waldram et al. 2006 28 14 History and Health Transition Cunningham and Stanley 2003 • Dislocation from lands through colonisation has contributed to the effects of newly introduced diseases on health • Now perpetuated by other forces (both internal and external forces to the ‘community’)-e.g. modernity, sedentary lifestyle, wage economy activities 29 29 Views on Culturally Specific Determinants: Indigenous Social Determinants of Health • Need to think critically about the meaning of any particular health determinant in an Indigenous context • Why? - importance of social determinants – e.g. Indicators of mental health in First Nations communities – Chandler and Lalonde, 1988 and 2004 – Alternate view on what influences health (determinants) – Shown to be valid in the BC coastal First Nations case – Still sometimes problematic to measure in a reliable way We need to be critical of the data and its reliability (ability to measure the same thing over and over again) and validity (the measures reflects what it was intended to) regardless of the source and form it is presented in 30 30 15 Things to Remember: • Health status indicators • Health determinant indicators • Their applicability / interpretation in a rural/remote Indigenous context 31 31 32 32 16 How do we examine and understand the relationship between health and environment? 33 33 Environmental Health Hazards/Benefits Model and Approach: One approach to understanding env-hlth relationships Biological Hazards: e.g. bacteria, viruses, parasites and other pathogenic organisms Benefits: e.g. traditional food species, traditional plants Chemical Hazards: e.g. toxic metals, air pollutants, solvents, pesticides Benefits: e.g. nutrients, anti-oxidants other critical elements of traditional plants, foods and other medicines Physical Hazards: e.g. radiation, temperature, sounds (noise) Benefits: e.g. temperature, sound (music) Mechanical Hazards: e.g. motor vehicle, home, agriculture, workplace injury Benefits: e.g. motor vehicle, traditional form of transportation, home, workplace (traditional and contemporary) benefits Psychosocial Hazards: e.g. stress, lifestyle disruption, effects of social change, marginalization, unemployment Benefits: e.g. stress-relief, balance, identity, cultural connection 34 34 17 Environmental Health Concepts What is a Hazard? • A hazard is a “factor or exposure that may adversely affect health” (Last, 1995) • Qualitative term expressing potential of an environmental agent to cause harm 35 Yassi et al. 2001 35 Environmental Health Concepts What is a Benefit? • A benefit is a factor or exposure that may positively affect health • Qualitative term expressing potential of an environmental agent to convey an improvement or positive effect 36 Yassi et al. 2001 36 18 Environmental Health Hazards/Benefits Model and Approach: A simple approach to use as a guide Biological Hazards: e.g. bacteria, viruses, parasites and other pathogenic organisms Benefits: e.g. traditional food species, traditional plants Chemical Hazards: e.g. toxic metals, air pollutants, solvents, pesticides Benefits: e.g. nutrients, anti-oxidants other critical elements of traditional plants, foods and other medicines Physical Hazards: e.g. radiation, temperature, sounds (noise) Benefits: e.g. temperature, sound (music) Mechanical Hazards: e.g. motor vehicle, home, agriculture, workplace injury Benefits: e.g. motor vehicle, traditional form of transportation, home, workplace (traditional and contemporary) benefits Psychosocial Hazards: e.g. stress, lifestyle disruption, effects of social change, marginalization, unemployment Benefits: e.g. stress-relief, balance, identity, cultural connection 37 37 Exposures / Relationships Routes of Exposure / Relationship • Air • Water • Land Setting • Home, work, school, community etc. Primary Physiological Processes of Exposure / Relationship • Inhalation • Ingestion • Dermal contact 38 Yassi et al., 2001 38 19 Common Environmental Hazards and Routes of Exposure • 5 categories of ‘elements in the environment’ • 3 forms of media they move through (Air, Water, Land) • 3 methods of interaction with the body (Contact, Inhalation, Ingestion) • Yassi focuses on a traditional “hazards” approach, we will add “benefits” 39 Yassi et al., 2001 39 Transition in Importance of Health Hazards • Still many of the “Traditional (historically common) Hazards” are important in the Indigenous context today (e.g. New emerging zoonotic diseases; inadequate housing; dietary deficiencies; poor drinking water) • At the same time many of the “Modern Hazards“ are increasing in importance and influencing this “health transition” • Few of the benefits have changed, but still relatively little is presented in the literature on this view Yassi et al. 2001 40 40 20 What is a Risk? • A risk is “the probability than an event will occur, e.g. that an individual will become ill or die within a stated period of time or before a given age; the proability of a (generally) unfavourable outcome.” (Last 1995) • The quantitative probability that a health effect will occur after an individual has been exposed to a specified amount of a hazard • A hazard results in a risk if there has been exposure – not if the hazard is contained or if there is no opportunity for exposure An American woman's chance of being diagnosed with breast cancer is: from age 30 through age 39 . . . . . . 0.43 percent (often expressed as "1 in 233") from age 40 through age 49 . . . . . . 1.44 percent (often expressed as "1 in 69") from age 50 through age 59 . . . . . . 2.63 percent (often expressed as "1 in 38") from age 60 through age 69 . . . . . . 3.65 percent (often expressed as "1 in 27") 41 Yassi et al. 2001 41 Which of these hazards is a greater risk to your health ? A. B. C. D. E. Living below the poverty line Smoking Being overweight Air pollution Living your lifetime near a nuclear power plant 42 42 21 © 2004 Brooks/Cole – Thomson Learning Hazard Poverty Shortens average life span in the United States by 7-10 years Born male 7.5 years Smoking 6 years Overweight (35%) 6 years Unmarried 5 years 2 years Overweight (15%) Spouse smoking Driving Air pollution 1 year 7 months 5 months Alcohol 5 months Drug abuse 4 months Flu 4 months AIDS Air Pollution 3 months 2 months Drowning 1 month Pesticides 1 month Fire 1 month Natural radiation 8 days Medical X rays 5 days Oral contraceptives 5 days Toxic waste 4 days Flying 1 day Hurricanes, tornadoes 1 day Living lifetime near nuclear plant Ranking of Risks Comparison of risks people face, expressed in terms of shorter average life span 43 10 hours 43 Vulnerability / (‘at risk’) ; Sensitivity ; Resilience ; Adaptive Capacity Sensitivity Sensitivity is the degree to which a system is affected, either adversely or beneficially, by an external stressor stimuli. The effect may be direct or indirect. Resilience Amount of change a system can undergo without changing its original state (‘bounce back’). Adaptive capacity The ability of a system to adjust to an external stress to moderate potential damages, to take advantage of opportunities, or to cope with the consequences. Vulnerability The degree to which a system is susceptible to, or unable to cope with, adverse effects of an external stress or stimuli. Vulnerability is a function of the character, magnitude, and rate of stress to which an individual or population is exposed, its sensitivity, and its adaptive capacity. V = f (E,A) 44 Adapted from IPCC 2001 44 22 Vulnerability, Sensitivity, Resilience, Adaptive Capacity Health Status External force / stimuli (Exposure) Time 45 45 Vulnerability, Sensitivity, Resilience, Adaptive Capacity Health Status External force / stimuli (Exposure) Sensitivity Time 46 46 23 Vulnerability, Sensitivity, Resilience, Adaptive Capacity Health Status External force / stimuli (Exposure) Time 47 47 Vulnerability, Sensitivity, Resilience, Adaptive Capacity Health Status External force / stimuli (Exposure) Time 48 48 24 Vulnerability, Sensitivity, Resilience, Adaptive Capacity Health Status External force / stimuli (Exposure) Resilience Time Adaptive Capacity – the ability of the system to draw on its resources and respond or act (reactively or proactively) 49 49 Sources and Suggested Reading • • • • • Adelson, N. 2005. The embodiment of inequality: Health disparities in Aboriginal Health, CJPH: 96(2): S45-S61. Bramley et al. 2005. Disparities in Indigenous health: A cross-country comparison between New Zealand and the United States. American Journal of Public Health, 95: 844-850. Chandler, M., and C. Lalonde. 1998. Cultural continuity as a hedge against suicide in Canada’s First Nations, Transcultural Psychiatry: 1-20 Chandler, M.J., and C. Lalonde. 2004. Cultural continuity as a moderator of suicide risk among Canada’s First Nations, In, Kirmayer, L., Va;askakis, G (Eds), The Mental health of Canadian Aboriginal peoples: Transformations, Identify and Community, UBC Press. Cunningham, C and Stanley, F. 2003. Indigenous by definition, experience or world view. British Medical Journal, 327: 403-404 • • Dumont, J. 2005. First Nations Regional Longitudinal Health Survey: Cultural Framework. Durie, M. 2004. Understanding health and illness: research at the interface between science and indigenous knowledge. International Journal of Epidemiology, 33:1138-1143 • • First Nations Regional Health Survey http://fnigc.ca/our-work/regional-health-survey/about-rhs.html First Nations Information Governance Centre online data: http://fnigc.ca/dataonline/chartslist?term_node_tid_depth_1=1&term_node_tid_depth=2&keys= • Fleming, J and Ledogar, RJ. 2008. Resilience, an Evolving Concept: A review of literature relevant to Aboriginal research, Pimatsiwin, 6(2): 7-23. Furgal, C, Garvin, T and Jardine, C. 2010. Trends in the Study of Aboriginal Health Risks in Canada. International Journal of Circumpolar Health, 69:4: 322-332 Ring, I. and Brown, N. 2003. The health status of Indigenous peoples and others. British Medical Journal, 327:404-405 • • • Young, T.K. 2003. Review of research on aboriginal populations in Canada: relevance to their health needs. British Medical Journal, 327: 419-422 50 50 25 Seminar - Movie & Questions Look in Seminar Folder – Film and questions “The Last Days of Okak” to examine the topics of sensitivity, vulnerability, resilience – Feel free watch and discuss with a classmate; individual response assignments must be submitted though to the link on Blackboard – Due Oct 31st through Blackboard – if you need an extension please contact me Reminders: – Assignment #1 – due unless you have an agreed upon extension – Assignment #2 – available in the Assignments folder as of Friday Oct 20th. Due Nov 14th. Being posted with video explanation – watch and start working on it after you have completed and submitted Assignment #1 51 51 26