Health Inequalities and Social Determinants of Aboriginal Peoples’ Health PDF 2009

health inequalities and social determinants of Aboriginal Peoples’ Health Charlotte Reading, PhD Fred Wien, PhD NATIONAL COLLABORATING CENTRE CENTRE DE COLLABORATION NATIONALE FOR ABORIGINAL HEALTH DE LA SANTÉ AUTOCHTONE © 2009, 2013 National Collaborating This publication is available for download For further information or to obtain Centre for Aboriginal Health (NCCAH). at: www.nccah-ccnsa.ca. All NCCAH additional copies, please contact: This publication was funded by the NCCAH materials are available free and can be and made possible through a financial reproduced in whole or in part with National Collaborating Centre contribution from the Public Health Agency appropriate attribution and citation. for Aboriginal Health of Canada. The views expressed herein do All NCCAH materials are to be used 3333 University Way not necessarily represent the views of the solely for non-commercial purposes. To Prince George, BC, V2N 4Z9 Public Health Agency of Canada. measure the impact of these materials, Tel 250 960 5250 Fax 250 960 5644 please inform us of their use. Email: [email protected] The NCCAH uses an external blind www.nccah-ccnsa.ca review process for documents that are Citation: Reading, C.L. & Wien, F. (2009). research based, involve literature reviews Health Inequalities and Social Determinants This document is or knowledge synthesis, or undertake an of Aboriginal Peoples' Health. Prince an update of the Health Inequalities assessment of knowledge gaps. We would George, BC: National Collaborating original design: and Social Determinants of Aboriginal Peoples’ Health like to acknowledge our reviewers for Centre for Aboriginal Health. Charlotte Loppie Reading Ph.D. University of Victoria Fred Wien Ph.D. Dalhousie University their generous contributions of time and expertise to this manuscript. La version française est également disponible au www.nccah-ccnsa.ca sous le titre Inégalités en matière de santé et 2009 déterminants sociaux de la santé des peuples autochtones. Table of CONTENTS 1. Introduction...................................... 6 2. Social Determinants of Aboriginal Health................... 7 2.1 Socio-Political Context............................ 8 2.2 A Holistic Perspective of Health....................... 8 2.3 Life Course: Child, Youth and Adult.................... 8 2.4 A Note on the Adequacy of Aboriginal Public Health Data...... 9 3. Proximal Determinants of Health........................ 10 3.1 Health Behaviours............................... 11 3.2 Physical Environments............................ 12 3.3 Employment and Income.......................... 13 3.4 Education.................................... 15 3.5 Food Insecurity................................ 17 4. Intermediate Determinants of Health..................... 18 4.1 Health Care Systems............................. 18 4.2 Educational Systems............................. 19 4.3 Community Infrastructure, Resources and Capacities......... 20 4.4 Environmental Stewardship......................... 20 4.5 Cultural Continuity............................. 21 5. Distal Determinants of Health.......................... 22 5.1 Colonialism.................................. 22 5.2 Racism and Social Exclusion........................ 23 5.3 Self-Determination.............................. 24 6. Conclusion...................................... 25 6.1 Putting It Together: The Integrated Life Course and Social Determinants Model of Aboriginal Health (ILCSDAH)... 26 Appendices....................................... 27 References........................................ 31 3 list of tables Table 1: The Well-Being of Inuit, First Nations and Other Canadian Communities, 2001........ 11 Table 2: Self-Reported Smoking by First Nations Adults On-Reserve, by Aboriginal Adults Off-Reserve, and by Non-Aboriginal Adults in Canada (%)..................... 11 Table 3: Mothers Smoking During Pregnancy, First Nations On-Reserve and Canada, 2002-03 (%)......................................... 11 Table 4: First Nations Adults On-Reserve Who Live in a Smoke-Free Home, 2002-03.......... 12 Table 5: Repairs Required for Dwellings Located On-Reserve (2002-03) and for Canada (2003) (%)........................................ 12 Table 6: Percentage of Inuit, Métis, First Nations and Non-Aboriginal People Living in Crowded Dwellings, Canada, 2006.................................. 12 Table 7: Selected Labour Force Characteristics for the Aboriginal Identity Population in Canada, 15 Years and Over, 2001 Census (%)............................ 13 Table 8: Selected Income Characteristics of the Aboriginal Identity Population in Canada, 15 Years of Age and Over, 2001 Census........................... 14 Table 9: Percentage of Those Reporting Fair or Poor Health by Household Income Among Off-Reserve Aboriginal and Non-Aboriginal Peoples, Canada, 2000/01........ 14 Table 10: Percentage of Those Experiencing a Major Depressive Episode in the Past Year by Household Income and Off-Reserve Aboriginal Status, Canada, 2000/01....... 15 Table 11: Highest Level of Schooling Attained by the Aboriginal Identity Population in Canada, 15 Years Of Age and Over, 2001 Census......................... 16 Table 12: Prevalence of Food Insecurity, by Level and Selected Characteristics, Household Population, Canada Excluding Territories, 1998-99 (%)............... 17 Table 13: Health Care Utilization and Access, Household Population Aged 15 or Older, by Off-Reserve Aboriginal Status, Canada and the Northern Territories, 2000-01 (%).... 19 Table 14: Barriers to Accessing Health Services, First Nations Adults Living On-Reserve, 2002-03... 19 Table 15: Connection to the Land.......................................... 20 4 Table 16: Percentage of First Nations People Who Have Knowledge of an Aboriginal Language, by Age Groups, Canada 2001 and 2006.......................... 20 Table 17: Percentage of Inuit Population Who Reported Inuktitut as Mother Tongue and Home Language, and Knowledge of Inuktitut, Canada and Regions, 1996 and 2006..... 21 Table 18: Percentage of the Métis Population with Knowledge of an Aboriginal Language, by Age Groups, Canada, 2006...................................... 21 Table 19: Percentage of First Nations Adults Living On-Reserve Who Consider Traditional Spirituality and Religion Important in Their Lives.......................... 21 Table 20: The Impact of Residential Schools on First Nations Adults Living On-Reserve, 2002-03... 23 Table 21: Instances of Racism Experienced by First Nations Adults On-Reserve and Perceived Impact on Level of Self-Esteem, 2002-03................................ 24 Table 22: Self-Determination Indicators by Feelings of Depression and Sadness for First Nations Adults Living On-Reserve, 2002-03 (%)................................ 24 Appendices Table 23: Most Frequent Long-Term Health Related Conditions Among First Nations Children Living On-Reserve, 2002-03........................................ 27 Table 24: Most Frequent Long-Term Health Related Conditions Among First Nations Youth Living On-Reserve, 2002-03........................................ 28 Table 25: Frequently-Occurring Long-Term Health Conditions of First Nations Adults Living On-Reserve, and Other Adults in Canada (%)........................ 28 Table 26: Body Mass Index, Household Population 15 years of Age and Over by Off-Reserve Aboriginal Status, Canada, 2000-01 (%)......................... 28 Table 27: Adults 15 Years of Age and Over Who Have Suffered a Major Depressive Episode in the Last 12 Months by Off-Reserve Aboriginal Status (%)............... 29 Table 28: Percentage of First Nations Youth Living On-Reserve Who Report Feeling Sad, Blue or Depressed for Two Weeks or More in a Row......................... 29 Table 29: Importance of Keeping, Learning or Relearning an Aboriginal Language, by Age Group, Métis Identity Non-Reserve Population 15 years of Age and Over, 2001 (%).......... 29 Table 30: Who Helps Aboriginal Children Learn an Aboriginal Language, Canada, 2001 (%)...... 30 Table 31: Residential School Attendance for Aboriginal Adults Living Off-Reserve, and for First Nations Adults Living On-Reserve............................ 30 Health Inequalities and Social Determinants of Aboriginal Peoples’ Health 5 1. introduction This paper uses available data to describe examining potential trajectories of health health inequalities experienced by diverse across the life course. Aboriginal1 peoples in Canada. The data are organized around social determinants Data from diverse and often limited of health across the life course and provide literature is provided to support claims evidence that not only demonstrates made by the authors of this paper and important health disparities within others about health disparities among Aboriginal groups and compared to non- Aboriginal peoples and the degree Aboriginal people, but also links social to which inequalities in the social determinants, at proximal, intermediate determinants of health act as barriers to and distal levels, to health inequities. addressing health disparities. Additional The Integrated Life Course and Social tables have been included in the Determinants Model of Aboriginal Health appendices to further support data and is introduced as a promising conceptual discussion presented in the text. framework for understanding the relationships between social determinants and various health dimensions, as well as 1 The term ‘Aboriginal’ refers to individuals who identify with at least one Aboriginal group, i.e. First Nations (North American Indian), Métis or Inuit, and/or those who report being a Treaty Indian or a Registered Indian as defined by the Indian Act of Canada and/or who are members of an Indian Band or First Nations (Statistics Canada, 2008, ). 6 2. social determinants of aboriginal health Beyond a small number of seminal reports, Social determinants influence a wide range little is known about the distinct influence of health vulnerabilities and capacities, of social determinants of health in the health behaviours and health management. lives of Aboriginal peoples. Yet, it is clear Individuals, communities and nations that the physical, emotional, mental and that experience inequalities in the social spiritual dimensions of health among determinants of health not only carry an Aboriginal children, youth and adults additional burden of health problems, but are distinctly, as well as differentially, they are often restricted from access to influenced by a broad range of social resources that might ameliorate problems. determinants (1-12). These include Not only do social determinants influence circumstances and environments as well diverse dimensions of health, but they as structures, systems and institutions also create health issues that often lead to that influence the development and circumstances and environments that, in maintenance of health along a continuum turn, represent subsequent determinants of from excellent to poor. For the purposes health. For instance, living in conditions of of this report, the social determinants low income have been linked to increased of health have been categorized as illness and disability, which in turn distal (e.g. historic, political, social represents a social determinant, which and economic contexts), intermediate is linked to diminished opportunities to (e.g. community infrastructure, resources, engage in gainful employment, thereby systems and capacities), and proximal aggravating poverty (17-20). (e.g. health behaviours, physical and social environment) (13-16). 7 Researchers and those responsible for care. The contemporary outcome of the specifically the ways in which health is the development of health policies have colonial process can be seen in political, perceived and addressed (25-27). reached tentative consensus about an social and economic domains (4-5). extensive list of social determinants that influence the health of individuals, For First Nations, Inuit and, to a lesser 2.3 Life Course – Child, Youth communities and populations. What extent, Métis peoples, the colonial and Adult remains less well articulated are the process has resulted in diminished self- mechanisms and contexts through which determination and a lack of influence in Health is not only experienced across social determinants influence health. policies that directly relate to Aboriginal physical, spiritual, emotional and mental Similarly, aside from health care systems, we individuals and communities (22). All dimensions, but is also experienced over know relatively little about the role social Aboriginal groups have suffered losses of the life course. A life-long trajectory of determinants of health play in addressing land, language and socio-cultural resources. health begins during gestation, with the ill health. Researchers are just beginning to Racism, discrimination and social exclusion health profile and social determinants map out the complex interconnections that also represent shared experiences among affecting the health resources for pregnant exist and are demonstrating those linkages Aboriginal groups, with Métis peoples women (28). Early child development empirically (21). often experiencing exclusion from First follows, in which the circumstances of Nations and Inuit groups as well (1-5). the physical and emotional environment impact not only children’s current health, 2.1 Socio-Political Context Aboriginal peoples differentially but sets the groundwork for future experience economic disadvantage; vulnerabilities and resiliencies (29-34). The impact of social determinants is Métis tend to experience higher levels of manifest differently among the distinct socioeconomic status than First Nations, In as much as social determinants impact Aboriginal groups in Canada, which who fair generally better than Inuit peoples children, youth and adults in similar are themselves distinct from other (23). In general, remote communities, ways, they tend to manifest as different Indigenous groups globally. Among whether they are Métis, Inuit, or First health issues in each life stage. Initially, Aboriginal peoples, there are a number Nations, suffer from a lack of economic the early years can be conceptualized as of similar historical and contemporary development that might help to ameliorate two, overlapping, phases of early and late social determinants that have shaped health problems related to socioeconomic childhood. The outcome of early and the health and well-being of individuals, status (24). late child development is first evident in families, communities and nations (1-3). adolescence, when social determinants Historically, the ancestors of all three continue to impact the distinct elements Aboriginal groups underwent colonization 2.2 A Holistic Perspective of adolescent well-being. Like childhood, and the imposition of colonial institutions, of Health adulthood can be viewed as two, integrated, systems, as well as lifestyle disruption. phases which distinguish elderhood as a life However, distinctions in the origin, form Indigenous ideologies embrace a phase that has specific vulnerabilities and and impact of those social determinants, as holistic concept of health that reflects health potentials (35-36). well as the distinct peoples involved, must physical, spiritual, emotional and also be considered if health interventions mental dimensions. However, it is the Social determinants not only have are to be successful. For example, while the interrelatedness of these dimensions that differential impact on health across the mechanisms and impact of colonization is perhaps most noteworthy. It has become life course, but the ensuing health issues as well as historic and neo-colonialism widely accepted in mainstream health may themselves create conditions (i.e., are similar among all Aboriginal groups, literature and, to some extent practice, determinants) that subsequently influence particular policies such as the Indian Act that a ‘silo’ approach to the prevention and health. For instance, poverty is associated have been patently deleterious to the lives treatment of ill-health fails to address the with increased substance use, which can and health of First Nations people. First complexity of most health issues. This is lead to stressful family environments and Nations are unique in their relationship particularly true for Aboriginal peoples, diminished social support, which are with the Canadian government with who have historically been collectivist linked to, among other things, depression respect to provisions made under the in their social institutions and processes, (37-38). Indian Act of 1876, which included health 8 Physical environments such as crowded · Fragmented in the sense that individual geography (for example, on and off- housing conditions have been associated surveys do not comprehensively include reserve), and jurisdiction (for example, with stress in all three age groups (23). all Aboriginal groups. Over time, the provincial and federal). However, for adults, these conditions can APS, for example, has become less · The use of substandard data sources and also indirectly contribute to substance inclusive. It is still quite valuable for the methodologies. For example, infant overuse and parenting difficulties, which off-reserve population, but for the most mortality rates for First Nations persons may result in poor school performance part is not carried out on-reserve. The living on-reserve are based on vital among youth and children. This particular FNRLHS is quite good for the on-reserve registration data of uneven quality from interaction of life-stage health begins with population but does not include First four Western provinces combined with a social determinant, which contributes to Nations off-reserve, Inuit or Métis people. data collected from nursing stations the creation of an environment for youth · Often the pieces do not add together in in other parts of the country. The and child development. If a less-than- that different authorities are responsible resulting figures are deemed to be an optimal environment is present, children for different surveys and methodologies underestimate, a statement that is based and youth will not only face obstacles to differ. Even if a concept is measured in on comparisons to other data available optimal physical, emotional, intellectual, more than one survey, questions may not for certain regions but collected and spiritual development, but the be worded in the same way, and thus the according to a higher standard. difficulties they encounter will also likely results are not comparable. · The failure to include culturally relevant create additional stressors for families and · Important gaps in the survey health measures reflecting Indigenous communities. In this case, youth substance information base remain. Statistics perspectives. over-use and violence as well as behaviour Canada routinely completes surveys problems in children have been linked to on a whole host of issues, dealing with These data limitations impose at least over-crowded living conditions (39). subjects like activity limitations, time two limitations for this paper. First, they use, adaptation to new technologies, mean that we are seldom able to report the aging population and transition comparable data for all the different 2.4 A Note on the Adequacy of to retirement, public safety and the Aboriginal groups on the same dimension. Aboriginal Public Health Data victims of crime. However, First Nations While this is possible using the census, persons living on-reserve are almost which also permits comparison with the Compared to the situation a few decades always excluded from the surveys, and rest of the Canadian population, it is ago, there has been a significant increase the coverage of Aboriginal people living usually not possible with other data sources. in the quantity and quality of Aboriginal off-reserve (including Métis and Inuit) Secondly, it means that we must avoid health data. The Aboriginal Peoples may be too sparse for detailed analysis reporting some kinds of data, such as infant Survey (APS) (40), for example, which (especially at geographic units below the mortality rates or adult death rates, that was introduced by Statistics Canada in national or provincial/territorial level). would normally be included in this kind 1991, marked a significant step forward of report as outcome measures, but which, even though the number of health-related Other kinds of public health data are also in the case of Aboriginal people, may be questions is limited in this general-purpose problematic. Smylie and Anderson (2006) unreliable and lack external validity (44). survey. Additionally, the First Nations (44) have worked with vital registration, Regional Longitudinal Health Survey health services, surveillance, and infant/ In short, while considerable progress on (FNRLHS) has provided a wealth of new child health data. They identify the Aboriginal public health data has been information for the on-reserve population following issues, among others: made, what we have remains far short of beginning in 1997 (41-43). the standard of data available for other · The lack of accurate and complete Canadians. On the assumption that a As far as health survey information is identification of Aboriginal persons high quality health information base is an concerned (we will turn to other types of and, indeed, the fact that Aboriginal important cornerstone for health research data below), there are still important gaps affiliation is often not asked at all. and for evidence-based public policy, this and challenges which limit what we can do · The fragmentation of data resulting is an issue that should be of concern to the in this paper. Available data are: from the fact that health systems differ Public Health Agency of Canada. according to Aboriginal ethnicity, Health Inequalities and Social Determinants of Aboriginal Peoples’ Health 9 3. proximal determinants of health According to the United Nations Human space to relax (47-48). In many cases, these Development Index, which measures conditions act as a stressor, which increases health through longevity, educational the likelihood of behavioural and learning achievement, and adult literacy, First difficulties in children and adolescents, as Nations people in Canada rank 68rd in well as substance abuse and other social the world (45). Likewise, the Community problems among adults (23, 49). Similarly, Well-Being (CWB) scale for First Nations, family violence, which is experienced developed by Indian and Northern Affairs at one time or another by almost three- Canada, which measures education, labour quarters of on-reserve First Nations force participation, income and housing, women (50-51), directly impacts all family indicates that Aboriginal communities dimensions of health, especially women’s represent 65 of the 100 unhealthiest health, with a resultant negative impact Canadian communities (46). on the physical and emotional health of children. According to the model presented in this report, proximal determinants of health The mechanisms through which proximal include conditions that have a direct determinants influence health are not well impact on physical, emotional, mental or articulated in the literature. However, spiritual health. For example, in conditions some researchers have made tentative of overcrowding, which are most suggestions, which seem to be supported profoundly experienced among the Inuit by the epidemiology of Aboriginal health. people, children often have little room to Beyond creating minimal capacity to study or play, while adults have no private meet basic survival needs (i.e. poverty), Canadian communities. However, analysis Table 1: The Wellbeing of Inuit, First Nations and Other of the CWB Score over time shows that Canadian Communities, 2001 the score improves for all three types of Community Type Avg CWB Score 1991 Avg CWB Score 2001 communities. It also shows a small degree Inuit 0.63 0.69 of convergence over the course of the 1991-2001 period. First Nations 0.58 0.66 Other Canadian Communities 0.77 0.81 3.1 Health Behaviours Source: Senécal & O’Sullivan, 2006 (134), pp. 7 & 13. Health behaviours represent a well- Table 2: Self-Reported Smoking by First Nations Adults On-Reserve, by recognized proximal determinant of health. Among Aboriginal peoples, the most Aboriginal Adults Off-Reserve and by Non-Aboriginal Adults in Canada (%) relevant health behaviours include the over Smoking Status First Nations On-Reserve Aboriginal Off-Reserve Non-Aboriginal or misuse of alcohol, which is related to Daily 46.0 41.5 22.1 increases in all-case mortalities (41, 55), and excessive smoking, the health effects Occasional 12.8 9.9 4.4 of which are clearly expressed in high Sources: For First Nations adults on-reserve, the data source is the Regional Health Survey, 2002-03, as reported in rates of heart disease and increasing rates Health Canada, 2006 (135), p. 29. For Aboriginal off-reserve and non-Aboriginal adults, the data source is the Canadian of lung cancer (41, 56-58). Poor prenatal Community Health Survey, 2000/01, as reported in Tjepkema, 2002 (136), p. 8. care as well as drinking and smoking during pregnancy have also been linked to Table 3: Mothers Smoking During Pregnancy, First Nations poor physical, emotional, and intellectual On-Reserve and Canada, 2002-03 (%) development among Aboriginal children Smoking Status First Nations Mothers On-Reserve All Canadian Mothers (59-61). Finally, lack of exercise and poor Smoked During Pregnancy 36.6 19.4 diet has been associated with the epidemic of Type II Diabetes among First Nations Smoked >10 cigarettes per day during 15.0 5.3 adults and increasing rates among First pregnancy Nations youth (62-63). These health Smoked in third trimester 32.2 17.2 behaviours must be considered within the socio-political context of Aboriginal Sources: Data for First Nations mothers living on-reserve comes from the First Nations Regional Longitudinal Health peoples’ lives lest an individualistic Survey. Data for Canadian mothers is from the National Longitudinal Survey of Children and Youth 1998-99. Both are reported in First Nations Centre, 2005 (141), p. 248. perspective predominate the analysis. Aboriginal adults2 are more than twice as likely to smoke cigarettes as other adults unfavourable proximal determinants can Some research suggests that health in Canada (Table 2). We know from contribute to stressors that in turn can outcomes are influenced by the types of other data as well that the rate of smoking generate or exacerbate health problems communities or neighbourhoods in which has declined substantially in the non- (52). Moreover, individuals acquire one lives. Indian and Northern Affairs Aboriginal population but has remained personal skills and resources for coping Canada has created a Community Well- relatively stable among Aboriginal adults. with health challenges and developing Being index which results in a composite The implications of such high levels of health behaviours throughout life. These score for a community based on the smoking for lung and other kinds of skills and resources help people deal with characteristics of its residents – specifically cancers, and for breathing problems, challenges as well as cope with illness their income, education, housing quantity are serious. and injury (53-54). When proximal and quality, and labour force characteristics determinants of health do not support (participation and employment rates). First Nations mothers living on-reserve control over the basic material resources Table 1 reveals that the Community Well- are almost twice as likely to smoke during of life, choice, which is key to health, is Being Score for First Nations and Inuit pregnancy compared to Canadian mothers denied (17, 19). communities is well below that of other generally, and this pattern continues for 2 The Aboriginal Peoples Survey defines adults as those 15 years of age and over. In the Regional Health Survey, adults are considered to be 18 years of age and over. Health Inequalities and Social Determinants of Aboriginal Peoples’ Health 11 Table 4: First Nations Adults Table 5: Repairs Required for Dwellings Located On-Reserve (2002-03) On-Reserve Who Live in a and for Canada (2003) (%) Smoke-Free Home, 2002-03 Type of Repairs Needed Dwellings On-Reserve Canadian Dwellings Smoke-Free Status of First Nations Adults Major Repairs 33.6 7.5 Home On-Reserve (%) Minor Repairs 31.7 26.9 Live in a Smoke-Free 47.6 Home Regular Maintenance Only 24.0 65.6 Do Not Live in a 52.4 Sources: Data for dwellings on-reserve were derived from First Nations Centre, 2005 (141), p. 44. Data for Canadian Smoke-Free Home dwellings were derived from Statistics Canada, 2006 (137). Source: First Nations Centre, 2005 (141), p. 109. Table 6: Percentage of Inuit, Métis, First Nations and Non-Aboriginal People Living in Crowded Dwellings, Canada, 2006 smoking more than 10 cigarettes per Housing Condition Inuit Métis First Nations Non-Aboriginal day and smoking in the 3rd trimester of Living in Crowded Dwellings 31 3 15 3 pregnancy (Table 3). Living in Dwellings in Need of 28 14 28 7 More than half of First Nations adults Major Repairs living on-reserve are subjected to tobacco Source: 1996 and 2006 Census as reported in Statistics Canada, 2008 (138). smoke in their home from one or more smokers (Table 4). Aboriginal peoples living in remote rural of Canadian dwellings. Other data from and reserve communities face considerable the First Nations Regional Longitudinal 3.2 Physical Environments food insecurity related to challenges Health Survey reveal that almost half of acquiring both market and traditional the respondents indicated there was mold Physical environments play a primary role foods (70-71). The cost of transporting or mildew in the home in the 12 months in determining the health of populations. market foods to remote communities preceding the survey (41). Among Aboriginal peoples, physical means that healthy, nutritious food is not environments that are largely detrimental affordable to most families. Poverty not With the exception of the Métis, to health have been imposed through only limits the extent to which individuals Aboriginal people in Canada are much historic dispossession of traditional and families can access market foods more likely to live in crowded4 housing territories as well as current reserve or but also makes the costs associated with conditions than are non-Aboriginal settlement structures. The most pervasive contemporary hunting out of reach for Canadians (Table 6). This is especially outcomes of these structures include many (72-77). Finally, poor sanitation and the case for the Inuit who are 10 substantial housing shortages and poor waste management, unsafe water supplies, times more likely to live in crowded quality of existing homes (64-65). Lack of and lack of community resources represent conditions. However, there has been affordable housing has created situations physical conditions that jeopardize the some improvement over the 1996-2006 of overcrowding in First Nations and Inuit health of Aboriginal peoples (78). decade. In 1996, 36% of Inuit, 7% of communities, as well as homelessness for Métis and 20% of First Nations lived in Aboriginal people living in urban areas. The quality of the housing stock in a crowded housing conditions. Crowding Many on-reserve homes are overcrowded community has been shown to be an has been linked to a number of poor and lack appropriate ventilation, resulting important determinant of health. The poor health outcomes, including increased in excessive mold, which has been condition of dwellings located on-reserve risk of transmitting infectious diseases, implicated in several health problems is demonstrated in Table 5, which shows severe lower respiratory tract infections, including severe asthma and allergies that a third of the housing stock is in need and higher rates of injuries, mental health among Aboriginal children (66-69). of major repairs,3 compared to only 8% problems, and family tensions (23, 47-48). 3 Dwellings in need of major repairs are those that, in the judgment of the respondent, require major repairs to such things as defective plumbing or electrical wiring, and/or structural repairs to walls, floors or ceilings, etc. 4 ‘Crowding’ is defined as more than one person per room. Not counted as rooms are bathrooms, halls, vestibules, and rooms used solely for business purposes. 12 The quality of housing is also a matter of concern and the situation is deteriorating Table 7: Selected Labour Force Characteristics for the Aboriginal Identity over time for the Inuit and First Nations. Population in Canada, 15 Years and Over, 2001 Census (%) In 1996, the percentage of Inuit living in Labour Force Characteristic Inuit Métis North American Total Total Non- housing in need of major repairs stood Indian Aboriginal Aboriginal at 19% and First Nations at 26%. For the Participation Rate 62.5 69.1 57.3 61.4 66.5 Métis, there was a slight improvement over this decade. Employment Rate 49.7 44.6 59.4 48.6 61.8 Unemployment Rate 19.1 22.2 14.0 22.2 7.1 3.3 Employment and Income Source: Statistics Canada, 2001 (139). Note: Data does not include persons who gave more than one response with respect to Aboriginal identity. The literature is clear and convincing about the role of various dimensions of socioeconomic status (SES) in determining to high rates of obesity and diabetes, stressors often leads to poor mental health health. Through colonization, colonialism, and consequential poor cardiovascular and increased vulnerability to infection, systemic racism and discrimination, and renal health (79-84). Poverty is also as well as diabetes, high blood pressure, Aboriginal peoples have been denied access linked to social exclusion, low social and depression (92). In addition, suicide to the resources and conditions necessary cohesion and increased crime (85). In has been linked to poor mental health and to maximize SES (2). This disadvantage the case of Aboriginal peoples, social substance abuse, which are in turn linked is currently manifested in high rates exclusion, in turn, prevents individuals to social exclusion and poverty (93-95). of unemployment, scarce economic from pursing education and training (86). opportunities, poor housing, low literacy More profound, perhaps, is the lack of Table 7 shows significant inequalities in and educational attainment, as well as control poverty creates, with resulting the participation of Aboriginal people in meager community resources (40, 41, 47). anxiety, insecurity, low self-esteem and the economy. Aboriginal people are less feelings of hopelessness (87-91). This and likely than other Canadians to participate With respect to poverty specifically, the other forms of psychosocial stress have in the labour force (participation rate5), most widely discussed impact of poverty been linked to violence, addictions, poor and are even less likely to be employed is a lack of access to material resources, parenting, and lack of social support. (employment rate6). If they are in the such as nutrient dense food, which leads The accumulation of these psychosocial labour force,7 their level of unemployment 5 Participation rate refers to those in the labour force expressed as a percentage of the total population 15 years and over. 6 Employment rate refers to those who are employed as a percentage of the population 15 years and over. 7 ‘Labour force’ refers to those who are employed or unemployed. Health Inequalities and Social Determinants of Aboriginal Peoples’ Health 13 Table 8: Selected Income Characteristics of the Aboriginal Identity Table 9: Percentage of Those Population in Canada, 15 Years of Age and Over, 2001 Census Reporting Fair or Poor Health Income Characteristic Inuit Métis North American Total Total Non- by Household Income Among Indian Aboriginal Aboriginal Off-Reserve Aboriginal and Avg employment income 33,416 32,176 34,778 36,152 43,486 Non-Aboriginal Peoples, Canada, (full-time, year-full, in dollars) 2000-01 Avg employment income 13,795 12,837 15,386 12,866 19,383 Household Aboriginal Non-Aboriginal (part-time, part-year, in dollars) Income Level Government transfers as a 20.8 24.3 15.7 20.3 11.5 Low 34* 25 percentage of total income Middle 26* 16 Median (total) income 13,525 12,263 16,342 13,699 22,431 High 14* 9 Incidence of low income in 2000 31.2 37.3 24.5 21.9 12.4 (persons living in families, in %) Source: Data is from the 2000/01 Canadian Community Health Survey as reported in Tjepkema, 2002 (136), p. 5. Incidence of low income, in 2000 55.9 59.8 51.7 56.8 37.6 Notes: 1) *indicates significantly different from the non-Aboriginal estimate. 2) Percentages have been age (unattached individuals, in %) standardized to the Canadian population. Source: Statistics Canada, 2001 (140). Note: Incidence of low income refers to the percentage of economic families or unattached individuals who spend 20% more than average on food, shelter and clothing. (unemployment rate8) is between two total income for Aboriginal persons than it which the above table is drawn undertakes and three times higher than it is for other is for other Canadians. this kind of analysis and concludes Canadians. Among Aboriginal people, that, depending on the health outcome North American Indians are the most We have already suggested that income introduced as the dependent variable, the disadvantaged. level has a bearing on health outcomes, gap is reduced but it does not go away and Table 9 confirms that the percentage (136). This unexplained residual, as it is We have established that Aboriginal of adults, both Aboriginal and non- called, suggests there must be ‘something people in Canada are less likely to be Aboriginal, reporting that their health is else’ out there that contributes to unequal working. When they do find jobs, their only fair or poor declines substantially as health outcomes for Aboriginal people, annual earnings from employment are one moves from lower to higher income something that has not yet been identified considerably lower than they are for other levels. What the table also shows is that or satisfactorily measured. This lends Canadians. This applies when they work the gap in self-reported health between some indirect support for the notion that full-time, full-year and also when they Aboriginal and non-Aboriginal people the effects of historical trauma (e.g. lack work part-time or for a part of the year. is maintained at a statistically significant of self-determination) may indeed be Even sharper inequalities are evident level (i.e. p=.05) even when comparing a determinant of health for Aboriginal when we look at total income received individuals with the same or similar populations. in the year. Among North American household income. Indians, for example, the median total Often differences in health status observed income was $12,263 in the year 2000, Of course there are many other between Aboriginal and non-Aboriginal compared to almost twice that ($22,431) determinants of health, such as education populations can be explained by the fact for other Canadians (Table 8). Because level, geographic location, employment that the two populations differ in other of high unemployment and low earnings, status and so forth. Can the gap in health health determining respects such as income it is not surprising to see that income outcomes be explained if a large number and education. However, Table 10 – while from government transfers, such as social of the known determinants were included it only controls for one variable – suggests assistance, is a much larger component of in a multivariate analysis? The article from that there is more going on. When 8 Unemployment rate refers to those who are unemployed expressed as a percentage of the labour force. 14 Aboriginal and non-Aboriginal adults are compared at the same level of income, Table 10: Percentage of Those Experiencing a Major Depressive Episode differences in the likelihood of experiencing in the Past Year by Household Income and Off-Reserve Aboriginal Status, a major depressive episode9 continue to Canada, 2000-01 be observed. It is only in the high income Household Income Level Aboriginal Non-Aboriginal category that the difference is reduced to Low 21* 13 statistical insignificance (p=.05). Middle 13* 9 3.4 Education High 7 6 Source: Data is from the Canadian Community Health Survey, 2000/01, as reported in Tjepkema, 2002 (136), p. 7. Education, which is a component of SES, Notes: 1) Two health regions have been excluded from the analysis. 2) Household income is derived by calculating total determines health through a number of annual income and taking into account the number of persons in the household. 3) *indicates significantly different from avenues. By way of example, inadequate the non-Aboriginal estimate. 4) Percentages have been age standardized to the Canadian population. education often includes poor literacy, which affects one’s ability to acquire information about proper nutrition or healthy food preparation. Insufficient There is clear evidence of inequities in the capacity to promote education among education also diminishes the skills one distribution of resources and opportunities their children (100). Approximately might have to offer the labour market, to Aboriginal peoples in Canada. An 22% of Aboriginal youth drop out, or are often resulting in low paying jobs (96-98). example can be found in the area of ‘pushed out’, of high schools; resulting The ensuing poverty and social exclusion, education. Despite the growing number of in diminished literacy and employment, both disproportionately experienced by Aboriginal peoples, particularly women, as well as increased poverty in future Aboriginal peoples, increases the risk of who are attaining post-secondary degrees, generations (101). family instability, which often manifests in inadequate educational opportunities divorce and single parenthood (99). for most adults manifest as a lack of 9 In the Canadian Community Health Survey, a major depressive episode is diagnosed on the basis of a series of questions that measure a cluster of symptoms for depressive disorders. Health Inequalities and Social Determinants of Aboriginal Peoples’ Health 15 Table 11: Highest Level of Schooling Attained by the Aboriginal Identity Population in Canada, 15 Years of Age and Over, 2001 Census (%) Highest Level of Schooling Attained Inuit Métis North American Indian Total Aboriginal Total Non-Aboriginal Less than highschool graduation certificate 57.7 42.2 50.6 48.0 30.1 HIghschool graduation certificate only 6.2 11.9 9.0 9.9 14.2 Some postsecondary education 12.8 12.4 12.7 12.6 10.8 Trades certificate or diploma 11.1 13.6 11.5 12.1 10.8 College certificate or diploma 9.5 13.4 10.7 11.6 15.1 University certificate of diploma (below bachelor's) 0.8 1.4 1.4 1.4 2.6 Bachelor's degree 1.6 4.0 3.2 3.4 10.8 University certificate above Bachelor's degree 0.1 0.5 0.4 0.4 1.6 Master's degree 0.2 0.7 0.5 0.5 2.8 Earned doctorate 0.04 0.1 0.1 0.1 0.6 Total 100.0 100.1 100.2 100.0 100.1 Source: Statistics Canada, 2001 (142). Table 11 clearly shows how Aboriginal people are disadvantaged when it comes to the level of education attained. The percentage of Aboriginal persons 15 years of age and over who have completed less than a high school education is in the order of 50%, compared to 30% for other Canadians. Leaving school with less than high school education has been shown to significantly reduce the prospects of employment, income and other outcomes later in life, including health outcomes (16, 96). The other side of the coin is the very limited representation of Aboriginal people at the higher end of the educational continuum, especially with respect to postsecondary certificates, diplomas and degrees. Within the Aboriginal population, the Inuit are the most disadvantaged in terms of educational achievement. 16 3.5 Food Insecurity10 what they can afford to purchase. Thus, In 1998-99, Aboriginal people off-reserve persons at lower incomes are subject were almost three times more likely to Poverty has clear outcomes on health to the stress of food insecurity from a be living in households experiencing because, in part, it determines what kinds compromised diet that results when food food insecurity than was the case for all of foods people have available to them and is no longer available. Canadians (27% to 10%). Table 12 shows that this condition is strongly related to low incomes as well as single parent status, Table 12: Prevalence of Food Insecurity, by Level and Selected both of which we know from other data Characteristics, Household Population, Canada Excluding are more likely to occur in Aboriginal Territories, 1998-99 (%) households. Thus, the high prevalence of food insecurity for Aboriginal people Any Food Insecurity Any Insecurity Compromised Diet is not surprising. In the literature, food Residents of households relying on social assistance 58 53 insecurity is related to health outcomes Residents of low-income households 35 30 that include multiple chronic conditions, obesity, distress and depression (102). Lone mother with children 32 28 So far, we have discussed proximal Aboriginal people off-reserve 27 24 determinants of health as individual- Children 0-17 14 11 level determinants – that is, particular characteristics of individuals, such as Total, Canada 10 8 poverty, leading to particular individual- level health outcomes, such as stress or Source: Che & Chen, 2001 (143). obesity. Some work has been done, however, Notes: 1) Two health regions have been excluded from the analysis. 2) Household income is derived by calculating total to aggregate individual level characteristics annual income and taking into account the number of persons in the household. 3) In the Canadian Community Health Survey, a major depressive episode is diagnosed on the basis of a series of questions that measure a cluster of symptoms into community averages, and to construct for depressive disorders. 4) Percentages have been age standardized to the Canadian population. community-level well-being scores. 10 Food insecurity can refer to “any insecurity” that includes concern there will not be enough to eat because of a lack of money in the previous 12 months, as well as a “compromised diet,” which includes either the quality or the quantity of food (or both) that one would want to eat because of a lack of money. Health Inequalities and Social Determinants of Aboriginal Peoples’ Health 17 4. intermediate determinants of health While proximal determinants represent 4.1 Health Care Systems the root of much ill health among Aboriginal peoples, intermediate In order to realize the benefits of an determinants can be thought of as the advanced system of health care, Canadian origin of those proximal determinants. individuals must have physical, political For instance, poverty and deleterious and social access to those services; this is physical environments are rooted in a lack often not the case for Aboriginal peoples of community infrastructure, resources (103-104). The federal system of health and capacities, as well as restricted care delivery for status First Nations environmental stewardship. Likewise, people resembles a collage of public health inequitable health care and educational programs with limited accountability, systems often act as barriers to accessing fragmented delivery and jurisdictional or developing health promoting ambiguity (105). Moreover, current behaviours, resources and opportunities. health care services remain focused on The interaction of intermediate communicable disease, while mortality and determinants is especially evident in the morbidity among Aboriginal peoples are connection between cultural continuity increasingly resulting from chronic illness. and other intermediate determinants, Social access to health care is similarly all of which have a direct influence on limited or denied to Aboriginal peoples proximal determinants. through health systems that account for 18 Table 13: Health Care Utilization and Access, Household Population Table 14: Barriers to Accessing Aged 15 or Older, by Off-Reserve Aboriginal Status, Canada and the Health Services, First Nations Northern Territories, 2000-01 (%) Adults Living On-Reserve, Utilization and Access Canada Territories 2002-03 Contact with Health Professional in Last 12 Aboriginal Non- Aboriginal Non- Systemic Barriers % months Aboriginal Aboriginal Waiting list too long 33.2 General practitioner 76.8 78.7 58.8* 75.9 Not covered by NIHB 20.0 Eye specialist 37.9 38.0 35.3 39.1 NIHB approval denied 16.1 Other medical doctor 24.7* 28.9 15.1* 24.1 Unable to arrange transport 14.5 Nurse 16.8* 9.8 49.0* 22.0 Barriers related to First Nations % Dentist 45.2* 59.4 45.0* 53.5 specific needs Has a regular doctor 76.4* 83.9 31.1* 67.0 Felt health care provided was 16.9 Unmet health care needs 19.6* 12.7 18.4 13.6 inadequate Source: Data source is the Canadian Community Health Survey, 2000/01, as reported in Tjepkema, 2002 (136), p. 10. Service not culturally appropriate 13.5 Note: *Significantly different from the non-Aboriginal estimate. Difficulty getting traditional care 13.4 Chose not to see health professional 10.9 neither culture nor language, or the social more isolated communities, and at very Barriers related to geography and % and economic determinants of Aboriginal low levels of income, led to a number of the availability of services peoples’ health (106-110). economic barriers to accessing health care. Doctor or nurse not available in area 18.5 Another determinant of positive health Service not available 14.7 outcomes is having access to the required 4.2 Educational Systems Health facility not available 10.8 services on a timely basis. Table 13 shows different patterns of utilization of health Adequate education, which in many ways Economic Factors % care professionals, and suggests more continues to be denied to Aboriginal limited access to doctors and dentists. peoples, has a profound impact on income, Could not afford transportation costs 13.7 This is most notable in the North, where employment and living conditions. Well- Could not afford direct cost of care, 13.2 nurses play a stronger role. Also, a higher educated parents not only earn higher service percentage of Aboriginal people indicate incomes, thereby improving proximal that they have unmet health care needs. determinants of health, but they also Could not afford child care costs 7.1 pass the value of education and life-long Source: Adapted from First Nations Centre, 2005 (141), p.130. As with other Canadians, First Nations learning to the next generation (111-112). Note: Data from the Regional Health Survey is only available adults living on-reserve have difficulty Preschool programs have demonstrated for First Nations persons living on-reserve. Equivalent the most favourable ‘return on investment’ information for Métis and Inuit is not available. accessing health care services because of long wait lists (Table 14). In addition, among Aboriginal children (113). In fact, however, they are limited by needed not only has education been correlated services not being covered or approved by with optimal child development, but it retain Aboriginal high school students, the federal Non-Insured Health Benefit has also been shown to mitigate some most curricula continue to lack any focus plan and by doctors or nurses not being of the effects of poor child development on Indigenous content or learning styles available in their area. Reports that the on adult health (96). Yet, programs such (114). Finally, mainstream education health care provided was inadequate or not as Aboriginal Head Start continue to be systems pay little attention to social culturally appropriate were also frequently under-funded (34). Similarly, although determinants that might act as obstacles mentioned barriers. The fact that many the benefits of ‘culturally competent’ for Aboriginal children and youth realizing First Nations adults live in rural and curricula have been demonstrated to the most from their education (113). Health Inequalities and Social Determinants of Aboriginal Peoples’ Health 19 Table 15: Connection to the Land 4.3 Community Infrastructure, % of adults reporting on progress in renewing the relationship of First Nations persons % Resources and Capacities to the land The health of an individual and their Good progress 11.1 family is substantially influenced by the No progress 45.5 community in which they live. In the case of Aboriginal peoples, the Assembly of First % of adults reporting that they often consume traditional foods % Nations and others contend that economic Protein-based foods such as game and fish 59.3 development is a key determinant of health (115-119). Limited infrastructure Berries and other types of vegetation 21.8 and resource development opportunities Other First Nations foods such as bannock, fry bread or corn soup 42.2 have been important contributors to economic insecurity and marginalization, Source: First Nations Centre, 2005 (141), pp. 147 and 99. with subsequent deprivation among community members. In addition, inadequate social resources, in the form of Table 16: Percentage of First Nations People Who Have Knowledge of an qualified individuals who can develop and/ Aboriginal Language by Age Groups, Canada, 2001 and 2006 or implement programs, restrict Aboriginal Age groups Total On-Reserve Off-Reserve Total On-Reserve Off-Reserve communities’ access to funding. When 2001 2001 2001 2006 2006 2006 communities experience fragmented, Total all ages 30 50 14 29 51 12 under-funded programs in which the bureaucracy increases community 0-14 years 21 36 8 21 39 6 responsibility without a concomitant 15-24 years 25 44 10 24 43 9 increase in power, community-level stress and paralysis can result (120). 25-44 years 33 58 17 30 56 13 45-64 years 45 71 26 39 67 21 4.4 Environmental Stewardship 65-74 years 56 79 33 50 79 26 Another key intermediate determinant 75 years + 59 83 31 52 83 24 of health that has been widely recognized Source: Statistics Canada, 2008 (138), Table 23. is environmental stewardship (1). In fact, traditional ties to the natural environment are generally acknowledged as a major resource for the superior health enjoyed by Indigenous peoples prior to European colonization of the Americas (3). Unfortunately, the past 500 years have witnessed a rapid transition from a healthy relationship with the natural world to one of dispossession and disempowerment. Aboriginal peoples are no longer stewards of their traditional territories, nor are they permitted to share in the profits from extraction and manipulation of natural resources. Finally, contamination of wildlife, fish, vegetation and water has forced Aboriginal peoples further from the natural environments that once sustained community health (2). 20 Table 17: Percentage of Inuit Population Who Reported Inuktitut as Table 18: Percentage of the Métis Mother Tongue and Home Language, and Knowledge of Inuktitut, Population with Knowledge of Canada and Regions, 1996 and 2006 an Aboriginal Language, by Age Canada Total, Inuit Nunaat Total, outside Inuit Groups, Canada, 2006 Nunaat Age Group % Inuktitut mother tongue, 1996 68 79 13 < 15 years 2 Inuktitut mother tongue, 2006 64 78 14 15-24 years 2 Inuktitut home language, 1996 58 69 4 25-44 years 3 Inuktitut home language, 2006 50 63 4 45-64 years 6 Knowledge of Inuktitut, 1996 72 84 16 65-74 years 9 Knowledge of Inuktitut, 2006 69 84 15 75 years + 12 Source: Statistics Canada, 2008 (138), Table 12. Source: Statistics Canada, 2008 (138), Figure 5. Notes: 1) ‘Mother tongue’ refers to the first language learned at home in childhood and still understood. 2) ‘Home language’ refers to the language spoken most often at home. 3) ‘Knowledge’ refers to languages in which the respondent can conduct a conversation. Table 19: Percentage of First Nations Adults Living On-Reserve The Regional Health Survey reveals that a intergenerational connectedness, which is Who Consider Traditional high proportion of First Nations adults are maintained through intact families and the Spirituality and Religion still tied to the land when it comes to food engagement of elders, who pass traditions Important in Their Lives sources, but very few believe that there to subsequent generations (121). Indicator % has been much progress made in their Traditional spirituality is very 76.4 community in renewing their relationship Overall, it appears that the percentage of or somewhat important to the land (Table 15). First Nations persons claiming knowledge of an Aboriginal language is holding Religion is very or somewhat 70.3 steady at about 30% (Table 16), but this important 4.5 Cultural Continuity masks some slight gains for the on-reserve population and some losses on the part Source: First Nations Centre, 2005 (141), p. 35. A landmark study conducted by Chandler of those living off-reserve. There is cause and Lalonde (1998) revealed that among for concern both because the off-reserve First Nations people in British Columbia, percentages are so low and because the rates of suicide (which are strongly linked knowledge of an Aboriginal language is younger age groups are much less likely to to intermediate determinants) varied quite low, and this is especially the case for report knowing an Aboriginal language dramatically and were associated with a those in the younger age groups (Table 18). compared to those in the older age groups. constellation of characteristics referred We know from other results that Cree is (See Appendices – Tables 29 & 30). to as ‘cultural continuity’ (121). Cultural the most common language of the Métis, continuity might best be described as the followed by Dene and Ojibway. Very few Use of the Inuktitut language by the Inuit degree of social and cultural cohesion speak Michif, the traditional language of is quite high, especially in Inuit Nunaat or within a community. According to the Métis, which involves a mixture of the homeland territories such as Nunavik and Chandler and Lalonde, low rates or an Cree and French languages. Nunavut where it approaches 100% (Table absence of suicide in a community appear 17). However, comparisons between 1996 to be related to: land title, self-government According to the Regional Health and a decade later suggest that the use of (particularly the involvement of women), Survey, close to three-quarters of First the language is declining. control of education, security and cultural Nations adults living on-reserve consider facilities, as well as control of the policies traditional spirituality and religion to be In contrast to the Inuit and First Nations and practice of health and social programs. very or somewhat important in their lives populations, the percentage of Métis with Cultural continuity also involves traditional (Table 19). Health Inequalities and Social Determinants of Aboriginal Peoples’ Health 21 5. distal determinants of health Distal determinants (122) have the and economic dispossession, the provision most profound influence on the health of low-level social services and ultimately, of populations because they represent the creation of ideological formulations political, economic, and social contexts around race and skin colour that position that construct both intermediate and the colonizer at a higher evolution level proximal determinants. In the case of than the colonized”(p. xviii). While Aboriginal peoples, although intra neo-colonialism detrimentally influences and inter-group differences exist, to a the health of contemporary Aboriginal large extent, colonialism, racism and peoples, historic, successively traumatic social exclusion, as well as repression events continue to affect generations of self-determination, act as the distal through what has been referred to as determinants within which all other ‘historic or cultural trauma’ (124). determinants are constructed. Historical In essence, the collective burden of a research clearly indicates a link between repressive colonial system has created the social inequalities created by conditions of physical, psychological, colonialism and the disease, disability, economic and political disadvantage for violence and early death experienced by Aboriginal peoples. Aboriginal peoples in Canada (123). According to Kelm (123), “colonization 5.1 Colonialism is a process that includes geographic incursion, socio-cultural dislocation, the Colonialism impacts the health of establishment of external political control Aboriginal peoples by producing social, 22 dramatic and devastating socio-cultural Table 20: The Impact of Residential Schools on First Nations Adults change among all Aboriginal peoples, Living On-Reserve, 2002-03 including disengagement by many from Residential School Characteristics % their ancestry and culture. Proportion of adults attending 20.3 One major dimension of historical trauma Proportion of those attending reporting a negative impact on their overall health 47.3 is the experience that Aboriginal students and wellbeing went through in attending residential Belief that parent's attendance at residential schools negatively affected the parenting they 43.0 schools, an experience that still has received as children ramifications today for the health and Most frequently mentioned elements of the residential school experience that contribute to well-being not only of the survivors, but the negative impact on health and wellbeing of survivors: also their children and grandchildren. Of the adults interviewed by the First · Isolation from family 81.3 Nations Regional Longitudinal Health · Verbal or emotional abuse 79.3 Survey, 20% are survivors of residential schools, a figure that jumps to almost · Harsh discipline 78.0

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