Aboriginal Health Human Resources:

: A Matter of Health Emily Lecompte, PhD Candidate, Research and Policy Officer, Aboriginal Health Human Resource Initiative (AHHRI), Health Canada, Ottawa, Ontario Disclaimers: Health Canada recognizes that Inuit in Canada do not reside on-reserve but in northern communities and settlements. Further, Health Canada also acknowledges that Métis people may reside in Métis communities and settlements in Canada. Data used for this report were provided by Statistics Canada and information in this document does not reflect the above-mentioned distinctions. Please consult the Statistics Canada website for more information on data, methods, and operational definitions used for the Census. ABSTRACT This report examines the supply and distribution of Canadian health human resources based on geographic region, area of residence, Aboriginal identity, and occupation. Analyses are from the Census long form survey (20 per cent data sample) from 1996, 2001, and 2006. Statistics are used to illustrate trends in health care. In 2006, health care providers accounted for 1,012,615 people; 2.15 per cent identified as Aboriginal and of this, 46 per cent were First Nations, 48 per cent were Métis, and 2 per cent were Inuit. Upward trends are noted in registered nursing, midwifery and practitioners of natural healing, dieticians and nutritionists, and physicians. KEYWORDS Aboriginal people, health human resources, health care occupation, social determinants of health, census data INTRODUCTION The report of the Royal Commission on Aboriginal Peoples (RCAP) is a 4,000-page study on issues affecting Aboriginal persons and provides 440 recommendations. It was launched in 1991 by the Government of Canada. During the following 5 years, the RCAP analyzed different issues and released a final report in November 1996, including a section on a human resource strategy. Four objectives were outlined in order to address important issues affecting Aboriginal people: 1) Increasing the capacity and number of education and training programs that are provided by Aboriginal institutions; 2) Improving the contribution of mainstream education and training programs to the development of Aboriginal human resources; 3) Improving Aboriginal students ability to pursue education and training through financial and other supports; and 4) Improving the cultural appropriateness and effectiveness of education and training programs to meet the needs of Aboriginal students and 16 Journal de la santé autochtone, mars 2012

communities (Indian and Northern Affairs Canada, n.d.). RCAP recommended to the federal government to train 10,000 Aboriginal people in health careers (Downey, 2003) over the next decade. While progress in health care appears positive, data used for this report indicate that critical gaps in Aboriginal health human resources in Canada still exist. Increases have been noted in key health professions and assisting professions (paraprofessions) in a previous study (Lecompte & Baril, 2008). However, a key component to progress is looking at the impact of certain programs, services, and initiatives that have recently been implemented on the increasing numbers of health care occupations, and examining the demand for health services across Canada. Aboriginal Canadians and the health care system According to the 2006 Census, Aboriginal people make up almost 4 per cent (3.8 per cent) of Canada s population, with the fastest growth found among Métis people (Statistics Canada, 2008a). With growing numbers of Aboriginal peoples in Canada over time, there is also a growing need for Aboriginal health human resources and human resources in general to address the particular needs and concerns of this population in a way that is culturally competent, adequate, and efficient. Objectives The current report had several objectives: 1) To build on a previous analysis that examines labour force characteristics and Census data as a means to better illustrate and explain trends in health care occupations as they affect First Nations, Inuit, and Métis people. 2) To provide a more complete portrait of the Aboriginal and non-aboriginal workforce in health occupations using Census data collected on three separate occasions from 1996 to 2006. The following variables were analyzed in order to illustrate labour market tendencies: Aboriginal identity, geographic location, area of residence, age, gender, and health care occupation. 3) To highlight cumulative tendencies in the field of heath care to better understand and predict future outcomes in the supply and demand, recruitment, and retention of health care providers as well as detecting differences in spatial trends. METHODS Data sources and material Results from the long form questionnaires (20 per cent data sample) of the 1996, 2001, and 2006 national Censuses from Statistics Canada were used. A national population census is conducted every 5 years in order to better understand trends affecting Canadians in all ten provinces and three territories. The long form of the Census questionnaire is given to one in every five Canadian households (20 per cent). During each collection period, cross-sectional data was gathered by Statistics Canada. Several variables were examined such as Aboriginal identity, geographic region, area of residence, age, gender, and type of health occupation. This study uses three consecutive periods of cross-sectional data to examine trends within health occupations over a 10-year period for Aboriginal and non-aboriginal health human resources. During 1996, 77 Indian reserves and Indian settlements did not take part in data collection, which affected the Census data quality. The number of incompletely enumerated Indian reserves and settlements decreased in 2001, when a total of 30 did not participate. In 2006, the Census counted 22 Indian reserves where interruptions to data collection were experienced. As a result, Census data has been adjusted to reflect changes in participation rates for Indian reserves and settlements by Statistics Canada (Statistics Canada, 2008a). Thus, while response rates varied over the 10-year period, the quality of Census data increased over time where the number of incompletely enumerated Indian reserves and settlements decreased. RESULTS Statistics were used to illustrate trends in Canadian health occupations over the three consecutive census periods (1996, 2001, and 2006). In 2006, Canadian workers in health occupations surpassed the million mark, with health professional and paraprofessionals accounting for a workforce of 1,012,615 people (Table 1). In this year, Aboriginal health human resource providers represented approximately 2.2 per cent (21,815 people) of Canadian health human resources (Statistics Canada, 2008b). This proportion is an increase from 1.65 per cent in 2001 (Statistics Canada, 2003a) and 1.16 per cent in 1996 (Statistics Canada, 2003b). Of the 2.2 Journal of Aboriginal Health, March 2012 17

per cent of the Aboriginal health human resource workforce, 46 per cent were First Nations, 48 per cent were Métis, and 2 per cent were Inuit (Statistics Canada, 2008b). Occupational tendencies Proportional increases can be observed in many health care occupations for Aboriginal people since Census data was gathered in 1996. In particular, increasing trends are seen in nurses, midwives, practitioners of natural healing, dieticians and nutritionists, general practitioners and family physicians, specialist physicians, and occupational therapists. A proportional increase of 130 per cent is observed for registered nurses between 1996 and 2006. Over this decade, the number of Aboriginal midwives and practitioners of natural healing increased by 230 positions or 418 per cent. Moreover, a 460 per cent increase of Aboriginal dieticians and nutritionists is observed from 1996 to 2006. Aboriginal general practitioners and family physicians have increased 246 per cent, from 65 to 225, while Aboriginal specialist physicians have gone up 300 per cent or a total of 75 positions. Over this same period, the number of occupational therapists went from 30 to 70, representing an increase of 133 per cent. In most health care occupations, the highest increases can be observed from 1996 to 2001. For example, a 340 per cent increase is observed during this 5-year period but only a 27 per cent increase is observed Table 1. Aboriginal and non-aboriginal health care workers from 1996 to 2006* Census Year Aboriginal Health Human Resources Non-Aboriginal Health Human Resources Total Canadian Health Human Resources 1996 Census 8,840 (1.2 per cent) 757,995 (98.8 per cent) 766,830 2001 Census 13,980 (1.6 per cent) 844,675 (98.4 per cent) 858,655 2006 Census 21,805 (2.15 per cent) 990,805 (97.85 per cent) 1,012,610 *Adapted from Statistics Canada, 2003a; 2003b; 2008b between 2001 and 2006. Similar tendencies are noted for previously mentioned health occupations with the exception of nursing. While the number of registered nurses increased 39 per cent from 1996 to 2001, the number further increased to 65 per cent from 2001 to 2006. On- and off-reserve tendencies The distribution of Aboriginal health human resources in Canada varies from north to south and from east to west (Table 2). In 2006, the majority of Aboriginal health human resources were located in Ontario (24.8 per cent), and 56.6 per cent were located across British Columbia, Alberta, Saskatchewan, and Manitoba. Ten per cent of Canada s Aboriginal health human resources were distributed across Quebec, and 6.14 per cent of provided health care services were in Newfoundland, Nova Scotia, Prince Edward Island, and New Brunswick, inclusively. In the northern territories including Yukon, Northwest Territories, and Nunavut, 2.34 per cent of Canada s Aboriginal health human resources services were provided. Higher numbers of Aboriginal health workers can be found working in off-reserve areas. Off-reserve tendencies from 1996 to 2006 show large increases in the number of Aboriginal health human resources for First Nations and Métis groups, however, the number of Inuit health professionals and paraprofessionals has remained stable. The number of Métis health professionals and paraprofessionals working in off-reserve areas has significantly increased, from 2,895 in 1996 to 10,425 a decade later. The largest increase for this group is observed between 2001 and 2006, when Métis representation in health careers grew from 5,835 health workers in 2001 to almost 5,000 more just 5 years later. For First Nations people, these numbers have increased from 3,745 to 7,530 over the same period. For the Inuit, an increase of 105 positions from 1996 to 2001 can be observed, however, numbers stabilized to approximately 430 health care workers from 2001 to 2006. On-reserve populations are mostly being served by First Nations health care providers. Since 1996, the number of First Nations health human resources has increased by over 1,100 positions, from 1,435 to 2,550 over a 10-year period. However, the number of health care providers identifying as Métis and Inuit working on-reserve has decreased since 2001. Increases for both groups can be observed from 1996 18 Journal de la santé autochtone, mars 2012

Table 2. The distribution of Aboriginal health care providers across Canada in 2006* Province/Territory Aboriginal Health Human Resources Non-Aboriginal Health Human Resources Total Health Human Resources Newfoundland/ 475 (2.18 per cent) 15,770 (1.59 per cent) 16,245 (1.6 per cent) Labrador Prince Edward 30 (0.14 per cent) 4,710 (0.48 per cent) 4,740 (0.47 per cent) Island Nova Scotia 530 (2.43 per cent) 32,475 (3.28 per cent) 33,000 (3.26 per cent) New Brunswick 305 (1.4 per cent) 25,320 (2.56 per cent) 25,625 (2.53 per cent) Quebec 2,190 (10 per cent) 248,810 (25.11 per cent) 251,005 (24.79 per cent) Ontario 5,415 (24.82 per cent) 356,460 (35.97 per cent) 361,880 (35.74 per cent) Manitoba 4,035 (18.5 per cent) 39,200 (3.96 per cent) 43,235 (4.27 per cent) Saskatchewan 2,020 (9.26 per cent) 32,255 (3.25 per cent) 34,280 (3.39 per cent) Alberta 3,230 (14.8 per cent) 107,635 (10.86 per cent) 110,865 (10.95 per cent) British Columbia 3,065 (14 per cent) 126,320 (12.75 per cent) 129,385 (12.78 per cent) Yukon 105 (0.48 per cent) 870 (0.09 per cent) 980 (0.096 per cent) Northwest 285 (1.31 per cent) 765 (0.08 per cent) 1,050 (0.1 per cent) Territories Nunavut 120 (0.55 per cent) 210 (0.02 per cent) 330 (0.032 per cent) Canada 21,815 (100 per cent) 990,805 (100 per cent) 1,012,615 (100 per cent) *Adapted from Statistics Canada, 2008b to 2001, specifically from 15 to 80 health providers for the Métis and from 0 to 15 for the Inuit. Between 2001 and 2006, a difference of 30 Métis health providers and an absence of Inuit representation are observed. Gender in the workplace The predominance of specific genders can be observed across certain health careers and fields of education and training. While most health care providers are female, there is a large increase in Aboriginal health workers for both genders since 1996, a proportional increase of 139 per cent for males and 148 per cent for females (Table 3). In particular, the 2006 Census reports that 66 per cent of specialized physicians and 61 per cent of general practitioners and family physicians are male, while 94 per cent of the 288,500 registered nurses in Canada are female. These numbers are made up of Aboriginal and non-aboriginal health human resources. Further, the field of dentistry is also mostly male, with 13,145 (69%) of health workers representing this gender. Age distribution of Aboriginal and non- Aboriginal health human resources Since 1996, most of the health labour force has been between 25 to 44 years of age. While almost 50 per cent of health workers (48.6 per cent) were in this age bracket in 2006, a significant increase is observed in the age bracket of 45 to 64 years of age between the 1996 and 2006 Censuses. In 1996, health workers in this age bracket accounted for 247,735 people. Ten years later, this number rose to 416,850. In 2006, 41.16 per cent of health human resources were between 45 to 64 years of age, compared to 32.3 per cent 10 years earlier. Of those entering the health labour force, 78,740 (7.77%) were between 15 to 24 years of age in 2006 and the remaining 24,530 (2.42 per cent) were over 65 years of age. This trend can also be noted in the age distribution of Aboriginal health human resources as reported in the 2006 Census. Almost 55 per cent of Aboriginal health workers identify themselves as between 25 to 44 years of age (11,945), and 33.5 per cent of Aboriginal health workers Journal of Aboriginal Health, March 2012 19

identify themselves as between 45 to 64 years and are approaching the age of retirement (7,305). Encouragingly, 10.7 per cent of Aboriginal people in health occupations are between the ages of 15 to 24, and those over the age of 65 represent only 1 per cent. Limitations and implications of this report Statistics Canada appears to be making significant improvements in reaching hard-to-count populations. However, the undercounting of certain Aboriginal settlements and reserves affects our ability to make accurate predictions on spatial trends and the supply of Aboriginal and non-aboriginal health professionals and paraprofessionals. The number of incompletely enumerated Aboriginal communities and settlements has decreased from 77 in 1996 to only 22 in 2006 (Statistics Canada, 2008a). For this reason, we may only draw tentative conclusions based on the systematic analysis of Census data. Further, due to concerns over the privacy, confidentiality, and autonomy of Canadians who participate in the Census, generalizations of data cannot be made at the individual level. However, Statistics Canada has worked hard to address certain levels of generalizations that can be made, and have data from the 2006 Census available at the municipal and postal code level. Moreover, information collected by Statistics Canada is limited since we may not be able to know non- Table 3. The distribution of Aboriginal men and women in the health workforce: 1996 to 2006* Census Year Aboriginal Men Aboriginal Women 1996 Census 1,305 7,530 2001 Census 2,135 11,845 2006 Census 3,125 18,685 *Adapted from Statistics Canada, 2003a; 2003b; 2008b quantitative information affecting health care professionals and paraprofessionals. A mixed model approach may be more useful to capture the experiences and reality of health care workers in Canada. Despite these limitations, the use of Census data remains one of the most cost-effective ways of knowing quantitative information about Canadians at a nation-wide level. What is evident in this report is that recruitment and retention strategies of First Nations health care givers in on-reserve areas are effective. What we are unsure of is where the Métis and Inuit caregivers are working once they exit from working on-reserve (or northern territories or Métis communities and settlements) since there is a slight decline in Métis and Inuit health care workers in this area over time. In the future, it may be beneficial to concentrate on increasing the number of skilled, qualified, and trained Métis and Inuit health care providers to meet the needs and concerns of these Aboriginal sub-groups in these areas. For example, the Métis are recognized as the fastest growing Aboriginal population (Statistics Canada, 2008c). As these people age, they may benefit from the knowledge and skills of an Aboriginal workforce that is trained to manage, account for, and consider the broader issues and concerns at the core of certain determinants of health and illness. Exit surveys can further investigate why Métis, Inuit, or non- Aboriginal health care workers leave on-reserve sites. These surveys may help identify what motivates health workers to practice and provide health services in off-reserve areas or in other provinces or territories. Qualitative research can be used to further inquire about how to retain health care workers in on-reserve areas or even in rural or remote areas. Also, while this report identifies aging Aboriginal and non-aboriginal health care providers, it is difficult to determine the exact point when individuals plan on retiring based on Census data. However, as Aboriginal and non- Aboriginal health care workers increase in age and number, so does the general Canadian population. Although more people are working in the health care system than a decade ago, demand for particular services may be increasing. This may translate to more frequent clinic or hospital visits, and thus an increased need for skilled and knowledgeable health care staff. As certain illness and disease rates increase in 20 Journal de la santé autochtone, mars 2012

some Aboriginal groups, the need for specialized services and consultations may further increase. Therefore, a more indepth examination of the supply, demand, recruitment, and retention of Aboriginal health human resources in specific fields is strongly suggested. This would better address wait times across different regions in Canada and help direct programs and initiatives seeking to increase Aboriginal and non-aboriginal health human resources. CONCLUSION Findings from this report can help guide health human resource strategies by highlighting trends on the mix and distribution of skilled, qualified, and knowledgeable health care professionals and paraprofessionals over unique Canadian regions. These findings can also help Aboriginal, federal, provincial, territorial, and health professional associations and educational institutions to develop and implement initiatives to support Canadian health care. Research activities and programs are typically guided and driven by specific information and data and should be complimentary to policy in order to improve the health and the lives of Aboriginal people. As access to health care programs, services, information, and resources changes due to economic, political, social, geographic, cultural, and religious reasons, so will the supply and demand of health care providers who offer services and support in different areas and jurisdictions. By being aware of trends and tendencies in the health care system, we, as researchers, evaluators, analysts, and decision-makers, can translate this knowledge to various levels of governments who can then better act and respond to the unique needs and concerns of the most vulnerable citizens who use and benefit from Canada s health care services. Census data used in this report illustrate the number of Aboriginal people working in health careers over the past 10 years. Results from this report show that the recommendation of the RCAP to train approximately 10,000 Aboriginal people in allied health careers since 1996 (Downey, 2003) has been reached and exceeded. Almost 13,000 (12,965) First Nations, Inuit, and Métis people have entered health careers since 1996 (Statistics Canada, 2003b; Statistics Canada, 2008b), which has enabled the meaningful and important contribution of Aboriginal people to the delivery of health care to Canadians. The social determinants of health, as well as geography, have an impact on health care systems and access for First Nation, Inuit, and Métis people. Certain chronic diseases such as diabetes (The Canadian Press, 2009; Young, Reading, Elias, & O Neil, 2000), cardiovascular disease, and atherosclerosis continue to disproportionately affect First Nations, Inuit, and Métis people and Aboriginal communities in Canada (Anand et al., 2001) and around the world (The Canadian Press, 2009). The importance of increasing the number of Aboriginal people in health careers, in particular specialized health fields, has attracted more attention and demand in recent times. As health services and culture have been recognized as key social determinants of health (Health Canada, 1996), governmentand non-government-funded initiatives have sought to improve these indicators to improve Aboriginal health. REFERENCES Aboriginal Diabetes Initiative. (2001). Diabetes among Aboriginal (First Nations, Inuit and Métis) people in Canada: The evidence. Retrieved from http://dsp-psd.communication.gc.ca/ Collection/H35-4-6-2001E.pdf. Anand, S. S., Yusuf, S., Jacobs, R., Davis, A. D., Yi, Q., Gerstein, H., Montague, P., & Lonn, E. (2001). Risk factors, atherosclerosis, and cardiovascular disease among Aboriginal people in Canada: The Study of Health Assessment and Risk Evaluation in Aboriginal Peoples (SHARE-AP). The Lancet, 358, 1147 1153. Downey, B. (2003). Aboriginal health human resources A pillar for the future : A discussion paper for the International Network for Indigenous Health Knowledge and Development Forum. Ottawa (ON): National Aboriginal Health Organization. Retrieved from http://www.naho.ca/documents/naho/english/pdf/ pillar_for_future.pdf. Health Canada. (1996). Conceptual framework subgroup on population health. Towards a common understanding: Clarifying the core concepts of population health: A discussion paper. Cat. No. H39-391/1996E [ISBN] 0-662-25112-9. Ottawa (ON): Government of Canada Indian and Northern Affairs Canada. (1996). Report of the Royal Commission on Aboriginal Peoples. Volume 3 Gathering strength, Chapter 3 Health and healing, section 3.3 Human resources strategy. Retrieved from http://www.aadnc-aandc. gc.ca/eng/1100100014597 Journal of Aboriginal Health, March 2012 21

Lecompte, E., & Baril, M. (2008). Comparison of the 1996 and 2001 Census data for Aboriginal and non-aboriginal workers in health care occupations. Cahiers de sociologie et de démographie médicales, 48(1), 123 138. Statistics Canada. (2003a). 2001 Population 15 years and over, excluding institutional residents, by Aboriginal identity (8), sex (3), age (5) by selected historical occupations (SOC 1991) (51) showing area of residence (7), custom product. Ottawa (ON): Statistics Canada. Statistics Canada. (2003b). 1996 Population 15 years and over, excluding institutional residents, by Aboriginal identity (8), sex (3), age (5) by selected historical occupations (SOC 1991) (51) showing area of residence (7), custom product. Ottawa (ON): Statistics Canada. Statistics Canada. (2008a). Aboriginal Peoples in Canada in 2006: Inuit, Métis and First Nations, 2006 Census. Statistics Canada catalogue no. 97-558-XIE. Ottawa (ON): Statistics Canada. Retrieved from http://www12.statcan.ca/censusrecensement/2006/as-sa/97-558/p4-eng.cfm. Statistics Canada. (2008b). 2006 Population 15 years and over, excluding institutional residents, by Aboriginal identity (8), sex (3), age (5) by selected historical occupations (SOC 1991) (51) showing area of residence (7), custom product. Ottawa (ON): Statistics Canada. Statistics Canada. (2008c). 2006 Census: A decade of comparable data on Aboriginal Peoples. Ottawa (ON): Statistics Canada. Retrieved from http://www12.statcan.ca/ census-recensement/2006/ref/info/aboriginal-autochtoneseng.cfm. The Canadian Press. (2009, July 2). International study links Aboriginal health, lifestyle, local decision making. Retrieved July 23, 2009, from http://www.con-aboriginal.ca/detail.aspx?men u=17&dt=3205&app=70&cat1=211&tp=12&lk=g Young, T. K., Reading, J., Elias, B., & O Neil, J. D. (2000). Type 2 diabetes mellitus in Canada s First Nations: Status of an epidemic in progress. Canadian Medical Association Journal, 163(5), 561 566. 22 Journal de la santé autochtone, mars 2012

Your Health at Home What you can do! An Environmental Health Guide for Inuit Get your guide today! To learn more about environmental health issues and tips on how to make changes in your home, visit your local health centre or go to www.healthycanadians.gc.ca/ environment