Heart Disease. Aboriginal Peoples, heartandstroke.ca

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1 Heart POSITION Disease and STATEMENT Stroke Aboriginal Peoples, Heart Disease and Stroke FACTS In 2006, 1,172,790 people identified themselves as an Aboriginal * person, representing 3.7% of Canada s population, up from 3.3% in 2001 and 2.8% in From 1996 to 2006, the Aboriginal population increased 45%, nearly six times faster than the 8% growth rate for the non-aboriginal population. 1 This can be explained by both increased numbers of people self-identifying as Aboriginal in the 2006 census, and increased fertility rates. 2 Canada s Aboriginal population is also very young. In 2006, the median age for Aboriginal people was 27 years, compared with 40 years for non-aboriginal people. 2 About 40% of Canada s First Nations population lives on reserves. 1 The life expectancy for First Nations and Inuit peoples is 5 to 10 years less than for Canadians as a whole; and, infant mortality rates among First Nations on reserve and Inuit are 2 to 3 times the overall Canadian rate. 3 Heart disease, stroke, and their risk factors are threats for all Canadians, but are particularly serious for Aboriginal people, who are 1.5 to 2 times more likely to develop heart disease than the general Canadian population. 4,5 The First Nations population has higher prevalence for physical inactivity, smoking, overweight, obesity, high blood pressure and diabetes when compared with the general population, all of which are risk factors for heart disease and stroke. 4 Aboriginal peoples do not have the same access to health care as the general population and report more unmet health care needs. 6 For example, in a 2006 survey, just over half of Aboriginal people living in Canadian territories reported visiting a physician within the previous 12 months. By comparison, during the same period, roughly three quarters of non-aboriginal people living in Canadian territories reported having visited a physician. 6 * The Canadian constitution recognizes three groups of Aboriginal people: 1) Indians (commonly referred to as First Nations); 2) Métis; and 3) Inuit. In order to ensure accuracy, this Position Statement uses these specific categories only when they are used in the particular sources that we reference. Otherwise, the term Aboriginal peoples is employed in order to emphasize that there are more than 600 different Aboriginal communities in Canada. Aboriginal Affairs and Northern Development Canada. 16 March Smoking 7, poor diet 8, lower food expenditures 9, and physical inactivity 10,11 have been associated with lower socioeconomic status. Given these relationships, the disparities in the socioeconomic status of Aboriginal populations are of urgent concern: 73.4% of Aboriginal people earn less than $20,000 per year and the average income is $15,699, versus $25,414 in the rest of Canada % of First Nations adults reported income below $10,000 per year. 5 40% of off-reserve Aboriginal children live in poverty. 13 Among Canadian households of all types (including offreserve Aboriginal people), those most likely to have problems obtaining healthy foods are those with lower incomes or whose main source of income is social assistance. 4,14 Aboriginal communities and other Canadians in remote locations also face very high rates of food insecurity due to the high price, low quality and limited availability of fresh, healthy and nutritious foods. 15 A 2004 survey found that food insecurity rates ranged from 40% to 83% in isolated Aboriginal communities Research and surveillance data for Aboriginal peoples and their communities are often limited, inconclusive or contain significant gaps. 20

2 RECOMMENDATIONS The Heart and Stroke Foundation recommends that: Aboriginal Communities and Aboriginal Organizations 1. Engage community institutions and build community capacity in prevention of chronic diseases and health promotion particularly in efforts related to school based nutrition and physical activity, recreation and nontraditional tobacco use reduction. 2. Identify and promote promising practices that are relevant to diverse Aboriginal contexts and that are culturally appropriate. Examples include the promotion of healthy nutrition and physical activity in schools and communities; healthy nutrition during the pre-natal period, infancy and early childhood; smoke-free dwellings; restrictions on smoking in public places; and, where possible, fostering land based food procurement initiatives and formalizing food distribution networks. 3. In collaboration with the federal government and other partners, work to improve human resource capacity and infrastructure of nursing stations and community health centres in order to ensure the delivery of evidenceinformed, culturally appropriate chronic disease prevention and management programs. 4. In collaboration with partners including the federal government, continue to address the consequences of readily available low-price tobacco (excluding traditional tobacco use) for Aboriginal peoples. The Federal Government 1. Develop a multi-year action plan to meet the cardiovascular health needs of Aboriginal peoples and communities using a partnership approach involving Aboriginal organizations and communities as well as federal, provincial, territorial and municipal governments. This approach should respect Aboriginal values and traditional health knowledge. 2. In collaboration with Aboriginal communities and organizations, work to improve human resource capacity and infrastructure of nursing stations and community health centres in order to ensure the delivery of evidence-informed, culturally appropriate chronic disease prevention and management programs. 3. Ensure that nursing stations and health centres in reserves/ aboriginal communities have the ability to respond to on-site medical emergencies (e.g., providing access to lifesaving Automatic External Defibrillators (AEDs), Cardiopulmonary Resuscitation (CPR) Training, etc.). 4. Improve screening, surveillance and monitoring systems within Aboriginal health service agencies by ensuring that all clinical, research, survey and federally managed data are available locally. 5. Provide financial, research and policy support to foster the growth of local food procurement initiatives and to improve food distribution networks. 6. Continue to support and improve the Nutrition North Canada program to ensure access to more affordable, healthy food in remote communities. 7. In collaboration with Aboriginal communities and organizations, provide economic and job diversification opportunities. These measures could help to address the social determinants of health and to reduce the widespread availability of inexpensive tobacco. 8. Work in collaboration with Aboriginal peoples/ communities, governments and researchers to improve both the quality and availability of Aboriginal health information by: advancing the development and application of First Nations-, Inuit-, and Métis-controlled health information databases that link with national databases; and, including more accurate representations of Aboriginal peoples in periodic versions of the Canadian Health Measures Survey, and encouraging/supporting Métis and Inuit organizations in developing and carrying out health surveys of their respective populations.

3 Provincial/Territorial Governments 1. In collaboration with Aboriginal peoples/communities, governments and researchers, improve the quality and availability of Aboriginal health information (see Recommendations-Federal Government for further detail). 2. Work with partners including organizations and communities as well as federal, provincial, and municipal governments to provide and improve culturally sensitive, evidence-informed health services and programs for Aboriginal peoples. Healthcare Providers and Healthcare Systems 1. Improve inter-organizational and inter-professional collaboration to ensure a continuum of care between community-based and regional health authorities. This may require working with professional organizations to define professional practice in working with Aboriginal peoples, and also helping to provide necessary training. 2. Improve access to care for Aboriginal people by making effective use of inter-professional teams employing cardiovascular disease management tools, community and home care services and telehealth/e-medicine technologies. 3. Provide culturally sensitive care by recruiting Aboriginal people to health careers and ensuring that all health providers working with Aboriginal people have the required cultural knowledge and skills. 4. Respect traditional health knowledge and where appropriate, recognize and incorporate traditional healers and elders in health care. 5. Strengthen the Aboriginal health workforce by providing chronic disease management training, intercommunity mentoring and exchange, as well as more dedicated bursaries and seats in medical and nursing faculties. BACKGROUND INFORMATION The research, evidence and recommendations contained in the Canadian Heart Health Strategy and Action Plan (CHHS- AP), released in 2009, form the foundation of this position statement. The CHHS-AP was developed through a two-year process of review and analysis of existing research, as well as consultations with more than 1500 stakeholders and experts from across Canada. Aboriginal cardiovascular health was among the six identified priority themes, and also constituted one of the overarching priorities of the CHHS-AP. Aboriginal Peoples, Heart Disease and Stroke It is important that the historical context in which non- Aboriginal people settled and developed the traditional territories of Aboriginal peoples (what is now Canada) be acknowledged. In particular, the current socioeconomic conditions of Aboriginal peoples and their associated effects on health are understood to be, to a significant degree, attributable to elements of this process. 21 Therefore, it is incumbent on Canadian society and governments at all levels to work to improve the social determinants of health for Aboriginal peoples. Political, social, and economic changes experienced by Aboriginal people, including urbanization and westernization are thought to have resulted in more sedentary lifestyles and more calorie dense/nutrient poor diets, contributing to the increase in the prevalence of heart disease In addition, a higher percentage of Aboriginal people fall into categories of low socioeconomic status, and report poor access to medical care. These factors are important social determinants of cardiovascular disease among Aboriginal people. 25 When comparing Aboriginal groups to the general Canadian population, Aboriginal peoples have higher prevalence rates in all major age-sex groups for heart disease and stroke and other chronic diseases. 26 While the overall rates of heart disease and stroke have declined in Canada 27, they are increasing among Aboriginal peoples. 5 Chronic diseases in general are also a growing cause of mortality and morbidity among Aboriginal peoples. 28 Within this context, it is worth noting that the Aboriginal population is the fastest growing population group in Canada. 29 In addition, children make up a higher proportion of the Aboriginal population (one third) compared to the general population (19 per cent). 30 Aboriginal children make

4 up 5.6 per cent of all children in Canada, while the total Aboriginal population makes up only 3.3 per cent of all Canadians. 30 The future health and well-being of Aboriginal children is of great concern. Cardiovascular Disease Risk and Socioeconomic Factors The crisis in Aboriginal peoples health is heavily influenced by social disparities, 31 including an extremely poor standard of living for many Aboriginal people in Canada. 32 Lower socioeconomic status has been consistently associated with smoking, poor diet, significant differences in food expenditures, overweight, and physical inactivity. 11 Cardiovascular disease, obesity, tobacco use and diabetes are all more prevalent in Aboriginal communities. Moreover, material deprivation, unhealthy living conditions (e.g., poor housing, inadequate food supply), and poor access to health care services predispose people with low socioeconomic status to the development of numerous health conditions including chronic diseases and the adoption of risk behaviours (e.g. physical inactivity, poor diet, smoking, excessive alcohol use, substance abuse) throughout life. 20 Not only do absolute material conditions matter, but how people feel about themselves and their circumstances can profoundly affect their well-being. 20 Lack of control over life circumstances creates stress which is thought to contribute to the development of a variety of diseases and conditions, notably, cardiovascular disease and insulin dependent diabetes. 20 A particular area of concern with respect to cardiovascular health is a lack of access to healthy and nutritious food resulting from a combination of low-income, high food costs and limited access. This a common problem for many Aboriginal people, particularly in remote communities. 33 As part of a comprehensive approach to addressing this problem (including the continuation of subsidies to support the transport of nutritious foods to remote communities and making improvements to food distribution networks) providing support for the growth of local food procurement initiatives holds significant promise. Research indicates that, where possible, the harvesting and consumption of land based foods have many potential benefits in terms of nutrition, physical activity, food literacy, and the preservation of culture. 34 Health Care Disparities, Inadequacies and Information Gaps With certain exceptions, the federal government is responsible for health care services provided in First Nations and Inuit communities; provinces and territories are responsible for health care services that Aboriginal peoples receive in hospitals and outside their home communities; and, provinces and territories also fund some services provided in Aboriginal communities. Jurisdictional issues can affect the capacity to improve heart health for Aboriginal peoples. For example, inter-jurisdictional administrative challenges can impede the delivery of seamless care between jurisdictions delaying services and causing severe hardships for those needing treatment. 4 Many Aboriginal groups do not have access to basic physician services and report more unmet health care needs. The proportion of Inuit who have seen a physician or other health professional in the past year is the lowest among all Canadians. 35 A substantial number of Aboriginal people may only be able to access care when they are close to death, thereby missing any health benefits of regular monitoring and management. 20 For example, although First Nations living on-reserve are at a higher risk of mortality from heart attack, they are less likely than Canadians in general to receive routine early testing for heart disease risk, such as cholesterol testing. 4 Diagnosis may be delayed because many Aboriginal people may not be familiar with the signs and symptoms of disease. Poor access to healthcare services results in delayed treatment and rehabilitation. 20 Accurate, timely information and methods to share data are essential to improving health and health services for Aboriginal peoples. Research and surveillance data for Aboriginal peoples including First Nations, Métis and Inuit communities are often limited, inconclusive or contain significant gaps. For example, much of the evidence has been gathered from First Nations populations that may or may not reflect a Métis or Inuit context. Relatively little research exists that specifically addresses cardiovascular treatment, management or modifiable risk in Canadian Aboriginal communities, with the Inuit and Métis being particularly disadvantaged. The limited evidence which is available reveals much variation in risk and rates of disease between and within Aboriginal communities.

5 Opportunities for Improving the Cardiovascular Health of Aboriginal Peoples Research indicates that effective health measures for Aboriginal peoples share the following features. 4 They are: developed through partnerships and collaboration with Aboriginal communities based on a team approach designed to create capacity within Aboriginal communities created using a life course approach (see below for description) designed to focus on specific risk factors designed to provide more equitable access to care culturally appropriate created to match the needs and readiness of the people/ communities involved A life course approach views health in a holistic way - complementing Aboriginal understandings of health and well-being that include the physical, mental, emotional, and spiritual domains. 36,37 It recognizes that life experiences particularly in the early years affect habits and choices later in life and focuses on promoting health at critical life stages. At each stage of life, people receive the information, skills and support they need to make healthy choices. 4 Examples include improving fetal nutrition and birth weights; promoting healthy diets and physical activity in the early years to avoid childhood obesity and giving children information and skills to remain smoke-free. Research conducted with Aboriginal people reinforces the value of a determinants of health framework and indicates that broader social-welfare provisions must be considered in attempts to reduce disparities in health. 35 Prevailing Aboriginal perspectives and the health determinants framework share the assumption that well-being is the result of a complex interplay between people and their environment. 35 To end the cardiovascular health crisis in Aboriginal communities, Aboriginal peoples and communities must be actively engaged in developing their own cardiovascular health solutions and plans. It is clear that a multi-year action plan to meet the cardiovascular/chronic disease needs of Aboriginal peoples is urgently required. REFERENCES 1 Statistics Canada. Aboriginal Peoples in Canada 2006: Inuit, Métis and First Nations. Figure XIE July www12.statcan.ca/census-recensement/2006/as-sa/97-558/index-eng. cfm 2 Education Policy Institute. Review of Current Approaches to Canadian Aboriginal Self Identification June Publications/Lists/Publications/Attachments/123/epi-report.en.pdf 3 Canadian Institute for Health Information. Canadian Population Health Initiative. Improving the Health of Canadians Canadian Heart Health Strategy and Action Plan Steering Committee. Canadian Heart Health Strategy and Action Plan: Building a Heart Healthy Canada. Ottawa, Canada, First Nations Information Governance Centre. First Nations Regional Longitudinal Health Survey 2002/2003. Results for adult, youth and children living in First Nations communities. Ottawa, Canada, Tjepkema M. The Health of the Off-Reserve Aboriginal Population. Health Reports 2002; 13 (Suppl). Statistics Canada Catalogue No Reid JL, Hammond D, Driezen P. Socio-economic status and smoking in Canada : Has there been any progress on disparities in tobacco use? Canadian Journal of Public Health. 2010; 101 (1). 8 Darmon N, Drewnowski A. Does social class predict diet quality? The American Journal of Clinical Nutrition. 2008; 87 (5): Kirkpatrick S, Tarasuk V. The relationship between low income and household food expenditure patterns in Canada. Public Health Nutrition. 2003; 6 (6): Janssen I, Boyce WF, Simpson et al. Influence of individual-and arealevel measures of socioeconomic status on obesity, unhealthy eating, and physical inactivity in Canadian adolescents. The American Journal of Clinical Nutrition. 2006; 83 (1): Smith GD, Hart C, Blane D et al. Lifetime socioeconomic position and mortality: prospective observational study. British Medical Journal 1997; 314 (7080): Sin DD, Wells H, Svenson LW et al. Asthma and COPD among Aboriginals in Alberta, Canada. CHEST 2002; 121: Lee KK. Urban Poverty in Canada: A Statistical Profile. Canadian Council on Social Development. Ottawa, Canada, Health Canada. Income-Related Household Food Security in Canada. Office of Nutrition Policy and Promotion. Health Products and Food Branch. Ottawa, Canada, Power E. Individual and Household Food Insecurity in Canada: Position of Dietitians of Canada. 16 Indian Affairs and Northern Development. Nutrition and food security in Fort Severn, Ontario: Baseline survey for the food mail pilot project. Prepared by Lawn J, Harvey D. Indian Affairs and Northern Development. Ottawa, Canada, Indian Affairs and Northern Development. Nutrition and food security in Kugaaruk, Nunavut: Baseline survey for the food mail pilot project. Prepared by Lawn J, Harvey D. Indian Affairs and Northern Development. Ottawa, Canada, 2004.

6 18 Indian Affairs and Northern Development. Nutrition and food security in Kangi: Baseline survey for the food mail pilot project. Prepared by Lawn J, Harvey D. Indian Affairs and Northern Development. Ottawa, Canada, Health Canada. Diabetes among Aboriginal (First Nations, Inuit, and Métis) people in Canada: The evidence. First Nations and Inuit Health Branch, Health Canada. Ottawa, Canada, Reading J. The Crisis of Chronic Disease among Aboriginal Peoples: A Challenge for Public Health, Population Health and Social Policy. University of Victoria. Centre for Aboriginal Health Research. Victoria, Canada, Loppie Reading C, Wien F. Health Inequalities and Social Determinants of Aboriginal Peoples Health. National Aboriginal Collaborating Centre for Aboriginal Health Jan www. nccah-ccnsa.ca/docs/social%20determinates/nccah-loppie-wien_ Report.pdf 22 Anand SS, Yusuf S, Jacobs R et al. Risk factors, atherosclerosis, and cardiovascular disease among Aboriginal people in Canada: the Study of Health Assessment and Risk Evaluation in Aboriginal Peoples (SHARE-AP). Lancet 2001;358 (9288): Young TK. The Health of Native Americans: toward a biocultural epidemiology. New York: Oxford University Press, Wolever TM, Hamad S, Gittelsohn J et al. Nutrient intake and food use in an Ojibwa-Cree community in Northern Ontario assessed by 24 hour dietary recall. Nutrition Research 1997;17: King M, Smith A, Gracey M. Indigenous health part 2: the underlying causes of the health gap. Lancet. 2009; 374: Sytowski PA, D Agostino RB, Belanger et al. Sex and time trends in cardiovascular disease incidence and mortality: the Framingham Heart Study, American Journal of Epidemiology 1996; 143: Public Health Agency of Canada Tracking Heart Disease and Stroke in Canada. Ottawa, Canada, Smeja C, Brassard P. Tuberculosis infection in an Aboriginal (First Nations) population of Canada. The International Journal of Tuberculosis and Lung Disease. 2000; 4(10): Statistics Canada. Portrait of the Canadian Population in 2006, by Age and Sex, 2006 Census. Ottawa, Canada, Anderson J. Aboriginal Children in Poverty in Urban Communities: Social exclusion and the growing racialization of poverty in Canada June Adelson N. The embodiment of inequity: health disparities in aboriginal Canada. Canadian Journal of Public Health 2005; 96(Suppl 2): S O Neill J. Senate committee chastises Canada for its treatment of aboriginal children. Ottawa Citizen, June Kmetic A. Addressing and Enhancing Aboriginal/Indigenous Cardiovascular Health. Background Paper. Canadian Heart Health Strategy and Action Plan. Ottawa, Canada, Haman F, Fontaine-Bisson B, Batal M et al. Obesity and type 2 diabetes in Northern Canadas remote First Nations communities : the dietary dilemma. International Journal of Obesity. 2010; 34, S24-S Bartlett J. The Medicine Wheel for comprehensive development in health. Unpublished manuscript. Winnipeg: University of Manitoba, Winnipeg, Isaak CA, Marchessault G. Meaning of health: The perspectives of Aboriginal adults and youth in a northern Manitoba First Nations community. Canadian Journal of Diabetes. 2008; 32(2): The information contained in this position statement is current as of: JULY 2012.