The First Nations Health Authority (FNHA) is the first and only first nations health authority in Canada. FNHA is run in collaboration with the BC Ministry of Health and Health authorities. FNHA was established by the need to have a health care system that fully recognizes the cultural needs that are unique to first nations people of British Columbia. This includes recognizing the gaps in access and culturally safe health care for first nations communities. The FNHA has a vision: Healthy, Self-Determining and Vibrant BC First Nations Children, Families and Communities. This vision helps to inform the FNHA’s perspective on health and wellness. Below is a visual depiction of the multilevel approach to health and wellness.
(First Nations Health Authority Healing Through Wellness, 2021)
Looking at this picture you can see the five rings of the perspective. I want to focus on the fifth ring in the circle with the Environmental, Social, Cultural and Economic determinants of health. I am going to break down these determinants of health and discuss them in terms of chronic disease management. Looking through research papers and reports I saw that one of the most prevalent diseases that effects many first nations people and communities is Diabetes Type 2. I think that its important to understand what diabetes is and how it effects the body.
” Diabetes is a disease in which your body either cannot produce insulin or cannot properly use the insulin it produces. Insulin is a hormone produced by your pancreas.
Insulin's role is to regulate the amount of glucose (sugar) in the blood. Blood sugar must be carefully regulated to ensure that the body functions properly. Too much blood sugar can cause damage to organs, blood vessels, and nerves. Your body also needs insulin to use sugar for energy.”
(Canadian Diabetes Association, 2021)
Type 2 diabetes usually develops in adulthood but can develop in adolescence, it can sometimes be managed through diet and exercise but often also needs medication management. Some of the risk factors for developing type 2 diabetes are obesity, a diet high in processed and refined foods and lack of exercise.
Let’s take a closer look at the social determinants of health in the FNHA wellness model about Type 2 Diabetes, starting with Environment.
“Environmental determinants include the land, air, water, food, housing, and other resources that need to be cared for and considered to sustain healthy children, families and communities. Safety and emergency preparedness are critical components.”
(First Nations Health Authority Healing Through Wellness, 2021)
One of the risk factors for some first nations people living on reserve is the “walkability” factor in terms of grocery stores. Many first nations people who live on reserve do not have access to a walkable supermarket or grocery store. At best there may be a convenience store that does not sell a selection of health food but highly processed options. Lack of transportation often leaves people with little choice then to make food choice from the local corner stores.
“Individuals living in a highly walkable environment are likely to walk more, thereby reducing the risk of obesity. Similarly, having supermarkets close by can encourage a healthy diet, and dense neighborhoods can facilitate access and use of local amenities, social activities, and physical activity. In contrast, limited access to supermarkets may motivate visits to convenience stores and fast-food outlets that in turn increase the odds of unhealthy food intake. These environment shaped choices and behaviors can regulate calorie intake and burning that influences obesity risk, β-cell dysfunction, and insulin resistance.”
(Dendup, 2018)
The environment also includes the shelter you live in and the food that you can afford to eat. First nations living on reserve have historically lived in subpar housing including, overcrowding, mold riddled homes and lack of properly insulated homes that drive up the price for heating. This leads to homes that need major renovations and upgrading which only increases the cost for individuals living in those homes. This leads to choices that need to be made in terms of food and nutrition and shelter. We also cannot leave out the idea of colonization of the first nations people and how this has affected their traditional ways of living off the land. The introduction of highly processed, less nutritionally dense foods from the outside influence of colonizers has led to greater risk factors of developing type 2 diabetes such as obesity and lack of exercise.
“Colonization processes set in motion a rapid transition from a physically active lifestyle revolving around hunting, fishing and other food gathering activities and reliance on a nutritionally dense diet of traditional foods, to a more sedentary lifestyle and reliance on less nutritious manufactured foods containing substantial amounts of simple sugars and saturated fats (Haman et al., 2010). This transition has contributed to higher rates of obesity, hypertension, metabolic syndrome, and impaired fasting glucose and/or increased insulin resistance among First Nations people. “ (Halseth, 2019)
The second social determinant in the wellness model is social. The social determinants of health include housing, food, and education. “Social determinants such as security, housing, food, prevention, promotion, education, health awareness, and outreach supports, are all critical aspects of our health and well-being.” (First Nations Health Authority Healing Through Wellness, 2021) These social aspects have a significant impact on a person’s risk for developing diabetes. People living on reserve have a lack of access to grocery stores and traditional foods which can lead to food insecurities. Fresh foods can be difficult to obtain, and many times are expensive due to the remote locations for Indigenous people living in northern parts of the province. This adds more expensive to fresh produce and often spends days if not weeks on a produce truck. By the time the produce gets to the market for purchase the shelf life is noticeably short. Given the choice with an exceedingly small food budget many people choose to buy foods that have a long shelf life and will not spoil quickly. These foods are usually filled with preservatives, sugars and are highly processed. “One of the leading causes of developing type 2 diabetes is diet. Aboriginal peoples living in remote rural and reserve communities face considerable food insecurity related to challenges acquiring both market and traditional foods. The cost of transporting market foods to remote communities means that healthy, nutritious food is not affordable to most families.” (Loppie,2009)
An aspect to the prevalence of diabetes among Indigenous people is the lack of education and prevention work that has been made accessible to communities. The importance of education is often overlooked and underrated, due to the historical colonization of Indigenous people. One of the aspects of chronic disease management that FNHA is looking at focusing on in terms of diabetes, is education, early screening and treatment, health promotion and capacity building and training. “Diabetes programming aims to reduce Type 2 diabetes through health promotion and disease prevention programs, services and activities delivered by community diabetes workers and health service providers. The initiative provides training opportunities and continuing education to community diabetes prevention workers and health professionals, and increases community access and capacity to deliver diabetes prevention programs and services” (First Nations Health Authority Healing Through Wellness, 2021)
The third aspect of the health model by FNHA is culture. “ Cultural determinants include language, spirituality, ceremonies, traditional foods and medicines, teachings, and a sense of belonging.” (First Nations Health Authority Healing Through Wellness, 2021) One of the aspects of health care that has been often ignored is the aspect of culture and cultural sensitivity. Understanding how Indigenous people have been treated in Canada for many years and the colonization of an entire population of people is so important when it comes to building relationships with people in the health care system. Working from a culturally informed lens helps to build capacity and an understanding of how to better meet the needs of Indigenous people. Having had their traditional lands and ways of harvesting foods removed for so many years has led to a lack of nutrient dense foods and encouraged more reliance on western supermarkets and overly processed foods. Understanding why many Indigenous communities have a lack of trust in the mainstream healthcare system helps to aide in trying to appreciate why culture is such an important part of a person’s overall health. There have been studies conducted that have looked at the importance of culture in all aspects of health for Indigenous people. One such study, (Cultural continuity, traditional Indigenous language, and diabetes in Alberta First Nations: a mixed methods study, 2014) concluded that “First Nations that have been better able to preserve their culture may be relatively protected from diabetes.” The participants in the study, consistently recognized that the loss of their traditional ways has led to some of chronic health conditions that Indigenous communities deal with today.
The last aspect of the health model from FNHA is economic. These determinants include ways to manage, share and create balance in using available resources, making them sustainable for future generations. The economic status obviously plays a particularly important part in a person's health in terms of access to safe housing, transportation to access health care, nutrient rich healthy foods, and the ability to access private resources such as psychiatry and substance use treatment facilities. Indigenous people have had less access to post-secondary education and in turn often have lower paying employment and over all income. In a discussion paper by the Assembly of First Nations they explain how education is a powerful tool for a person’s economic future, “Further, the level of education of a First Nations person is a strong predictor of long term estimated lifetime earnings. A First Nations man with no diploma is likely to earn about $546,000 in a lifetime compared to a Non-First Nations man who could earn about $1,099,000. Comparatively a First Nations man with a university degree has the potential of earning $1,453,000 in a lifetime compared to a non-First Nations man with an earning potential of $2,227,000.” (Nations,2010) FNHA hopes to promote and empower first nations communities to tap into the natural resources of the land and take these economic opportunities to obtain more economic stability for its members.
These aspects of health and determinants of health are important for health care professionals to be aware of and work with when listening to and helping to serve all patients and the Indigenous populations of Canada. We do not all start out on the same level playing field and this need to first be acknowledged so we can address health needs effectively. I admire the health and wellness model that the FNHA has adopted. It tends to look at the person holistically and see the person in the context of health, culture, family, and all aspects of the persons physical, emotional, and spiritual needs.
References
Canadian Diabetes Association. (2021, March). Diabetes Canada. Retrieved from Diabetes Canada: https://www.diabetes.ca/about-diabetes/what-is-diabetes
Dendup, T. F.-B. (2018). Environmental Risk Factors for Developing Type 2 Diabetes Mellitus: A Systematic Review. International Journal of Environmental Research and Public Health.
First Nations Health Authority Healing Through Wellness. (2021). Retrieved from www.fnha.ca: www.fnha.ca
Halseth, R. (2019). THE PREVALENCE OF TYPE 2 DIABETES AMONG FIRST NATIONS AND CONSIDERATIONS FOR PREVENTION. Prince George: National Collaborating Centre for Aboriginal Health (NCCAH).
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