12 Social and Structural Determinants of Indigenous Health

Determinants of Indigenous Health

Health is being increasingly recognized as much more than an individualistic, biomedical concept; rather, it is also determined by social circumstances and contexts. These social determinants of health involve the conditions under which people live and work, and include diverse factors, such as income, education, stress, social marginalization, and food security (Wilkinson & Marmot, 2003). Deficits in the social determinants of health are considered the major underlying reasons for health inequities and inequalities between populations (WHO Commission on Social Determinants of Health, 2008).

In the ‘Western’ world, using a social determinants lens is considered a relatively new and innovative approach to health and wellbeing.  However, Indigenous peoples throughout the world have always known that health is a holistic concept that extends beyond individual behaviours and genetics (de Leeuw, Lindsay, & Greenwood, 2015). Social determinants of health in an Indigenous context also include unique structural determinants, such as history, political climate, economics, and social contexts. These determinants are premised on the importance of relationships, interconnectivity, and community (Reading, 2015).

So it is very ironic that simply being Indigenous has been suggested to be a significant social determinant of health (Mikkonen & Raphael, 2010). For example, in Canada, Indigenous people¹ are ranked lower in almost every direct, or proximal (Krieger, 2008), determinant of health than non-Indigenous Canadians. Approximately 33% of Indigenous adults aged 25 to 54 reported having less than a high school education compared to nearly 13% of the non-Indigenous population. The median total income of the Indigenous population for the same age cohort was reported to be just over $22,000, compared to over $33,000 for the non-Indigenous population (Statistics Canada, 2015). Indigenous Canadians are described as being three times more like to experience food insecurity (Health Canada, 2017). These deficits are facilitated by intermediate determinants of health, such as government programs and policies on health care, education, and justice (Krieger, 2008). Multiple adverse health outcomes resulting from these deficits include, but are not limited to, elevated rates of: infant and young child mortality, infectious diseases, malnutrition, tobacco use, accidents, interpersonal violence, homicide, suicide, obesity, cardiovascular disease, diabetes, and diseases caused by environmental contamination (Gracey & King, 2009). For example, the age-standardized rate for diabetes is 17.2% for First Nations individuals living on-reserve, compared to 5.0% for other Canadians (Public Health Agency of Canada, 2012). The prognosis for those who suffer ill-health is also worse; First Nations people with cancer have a significantly poorer 5-year survival than their non-Indigenous peers (Withrow, Pole, Nishri, Tjepkema, & Marrett, 2017). However, it is important to remember that these statistics, while important for identifying inequitable population circumstances, capture only a symptom-heavy aspect of Indigenous health. Determinants of Indigenous health also include positive, affirming and health promoting factors, as described below.

Underlying these proximal and intermediate determinants of health are the continued effects of colonialism, often considered to be the most important foundational or distal determinant of health for Indigenous Peoples (Krieger, 2008; Richmond & Ross, 2009).  In Canada, the symptoms of colonialism largely stem from the devastating Indian Residential School system, occurring from 1892 to the mid 1990’s, that aimed to eliminate the ‘Indian’ in Indigenous populations by destroying families, culture, and language (Beavon & Cooke, 2003). Health issues faced by Indigenous Peoples are a multiplicative product, rather than additive sum, of cultural wounds resulting from colonialism; beyond individual impact, such wounds impact the entire community and ways of life (Chandler & Dunlop, 2015). These historical contexts are a structural determinant of health that is considered to be a key etiologic factor underlying high rates of illness, disease, and mortality in Indigenous populations (King, Smith & Gracey, 2009).

Addressing Inequities – Moving Forward

Addressing inequities resulting from shortfalls in the social determinants of health is an ongoing problem, particularly for Indigenous populations. However, Indigenous scholars and researchers have identified several areas for positive change. First, health policy-makers need to adopt a structural approach to addressing health inequities concerning Indigenous Peoples rather than continuing to myopically focus on proximal determinants and effects, despite the obvious lack of impact. Failing to address the underlying root causes of disparities (such as a lack of resources for healthy child development, fair and equitable employment opportunities, and differential exposures to harmful environments), perpetuates the structural inequities that are impacting future generations (Reading, 2015).

Second, we need to change the focus to individual and community strengths (what Indigenous Peoples need to succeed), as opposed to the more traditional focus on problems (where and why they have failed) (Anderson, Pakula, Smye, Peters, & Schroeder, 2011). Strength-based approaches are premised on empowering Indigenous Peoples to create social change (Kana’iaupuni, 2005). This is consistent with viewing social determinants of health as ‘health promoting’ (as opposed to ‘health demoting’) factors that are influenced by political ideologies, public policies, societal recognition and outrage, and the ability of individuals and communities to effect change (World Health Organization, 2011). Using a health promotion lens shifts the focus from a pathogenic approach that emphasizes factors related to disease and illness to a salutogenic model that stresses positive, salutary factors that support people’s health and well-being (Antonovsky, 1994; Becker, Glascoff, & Felts, 2010).

Finally, in the spirit of a strength-based approach, we need to promote, encourage, and enable people to experience positive determinants of health in a culturally appropriate way, and accept these as legitimate health determinants. In an Indigenous context, these include activities on the land, language, traditional means of sharing and passing down knowledge, and connectivity to people and communities (Loppie Reading & Wien, 2009).  Providing opportunities for Indigenous-led research and recognizing Indigenous traditional knowledge as valid encourages deeper investigation into these important structural determinants of health. Research we have conducted with northern Indigenous youth has demonstrated the inextricable link they make between connection to the land and health, and the value they attach to relationships honed through traditional activities (Lines & Jardine, 2018).

In summary, reframing our approach to addressing the most profound social determinants of Indigenous health through a structural rather than symptom perspective is necessary if we are to realize the elimination of inequities for the founding inhabitants of the Circumpolar North. Doing so from a strength-based perspective that focuses on celebrating, reinforcing and reaffirming determinants specific to Indigenous peoples’ health holds the most promise for achieving this goal.\ 

Notes

1. In Canada, Indigenous peoples refers to First Nations, Métis and Inuit peoples.

References

Anderson, J.F., Pakula, B., Smye, V., Peters, V. & Schroeder, L. (2011). Strengthening

Aboriginal health through a place-based learning community. Journal of Aboriginal Health March, 42-53.

Antonovsky, A. The salutogenic model as a theory to guide health promotion. Health  Promotion International 11(1), 11–18.

Beavon, D. & Cooke, M. (2003). An application of the United Nations human development index to registered Indians in Canada. In J.P. White, P. Maxim & D. Beavon (Eds), Aboriginal Conditions. Vancouver: UBC Press

Becker, C.M., Glascoff, M.A. & Felts, W.M. (2010). Salutogenesis 30 years later: Where do we go from here? International Electronic Journal of Health Education 13, 25–32.

Chandler, M. J. & Dunlop, W. L. (2015). Cultural wounds demand cultural medicines. In Greenwood, S. de Leeuw, N.M Lindsay, and C. Reading (Eds.), Determinants of Indigenous Peoples’ Health in Canada: Beyond the Social. Toronto: Canadian Scholars’ Press Inc.

de Leeuw, S., Lindsay, N.M., & Greenwood, M. (2015). Introduction: Rethinking determinants of Indigenous People’s health in Canada. In M. Greenwood, S. de Leeuw, N.M Lindsay, and C. Reading (Eds.), Determinants of Indigenous Peoples’ Health in Canada: Beyond the Social. Toronto: Canadian Scholars’ Press Inc.

Gracey, M. & King, M. (2009). Indigenous health part 1: Determinants and disease patterns. Lancet 374, 65-75.

Health Canada. (2017). Household Food Insecurity in Canada Statistics and Graphics (2011 to 2012). Retrieved from https://www.canada.ca/en/health-canada/services/nutrition-science-research/food-security/household-food-security-statistics-2011-2012.html?wbdisable=true.

Kana’iaupuni, S.M. (2005). Ka‘akālai Kū Kanaka: A call for strengths-based approaches from a Native Hawaiian perspective. Education Research 34(5), 32-38.

King, M., Smith, A. & Gracey, M. (2009). Indigenous health part 2: The underlying causes of the health gap. Lancet 374, 76-85.

Krieger, K. (2008). Proximal, distal and the politics of causation: What’s level got to do with it? American Journal of Public Health 98, 221-230.

Lines, L.-A. & Jardine, C.G. 2018. Connection to the land as a youth-identified social determinant of Indigenous Peoples’ Health. Revised and resubmitted to BMC Public Health.

Loppie Reading, C. & Wien, F. (2009). Health Inequalities and Social Determinants of  Aboriginal Peoples’ Health. Prince George: National Collaborating Centre for Aboriginal Health. https://www.ccnsa-nccah.ca/docs/determinants/RPT-HealthInequalities-Reading-Wien-EN.pdf

Mikkonen, J. & Raphael, D. (2010) Social Determinants of Health: The Canadian Facts; York Toronto: University School of Health Policy and Management.  Retrieved from http://www.thecanadianfacts.org/The_Canadian_Facts.pdf.

Public Health Agency of Canada. (2012) Diabetes in Canada: Facts and Figures from a

Public Health Perspective. Retrieved from https://www.canada.ca/en/public-health/services/chronic-diseases/reports-publications/diabetes/diabetes-canada-facts-figures-a-public-health-perspective.html

Reading, C. (2015). Chapter 1: Structural determinants of Aboriginal People’s health. In Greenwood, S. de Leeuw, N.M Lindsay, and C. Reading (Eds.), Determinants of Indigenous Peoples’ Health in Canada: Beyond the Social;; Toronto: Canadian Scholars’ Press Inc.

Richmond, C.A.M. & Ross, N.A. (2009). The determinants of First Nation and Inuit health. Health Place 15, 403-411.

Statistics Canada. (2015). Aboriginal Statistics at a Glance. Retrieved from https://www.statcan.gc.ca/pub/89-645-x/89-645-x2010001-eng.htm.

WHO Commission on Social Determinants of Health. (2008). Closing the Gap in a

Generation: Health Equity through Action on the Social Determinants of Health. Geneva, Switzerland: World Health Organization. Retrieved from http://apps.who.int/iris/bitstream/10665/43943/1/9789241563703_eng.pdf .

Wilkinson, R. & Marmot, M. (Eds.). 2003. The Social Determinants of Health: The Solid

Facts 2nd ed. Geneva, Switzerland: World Health Organization. Retrieved from http://www.thecanadianfacts.org/The_Canadian_Facts.pdf .

Withrow, D.R., Pole, J.D., Nishri, E.D., Tjepkema, M. & Marrett, D. (2017). Cancer survival disparities between First Nation and non-Aboriginal adults in Canada: Follow-up of the 1991 census mortality cohort. Cancer Epidemiology Biomarkers Prevention, 26(1), 145-151.

World Health Organization. (2100). World Conference on Social Determinants of Health. Rio Political Declaration on Social Determinants of Health, Rio de Janeiro, Brazil, 21 October 2011. World Health Organization: Geneva, Switzerland, 2011.