Exploring the determinants of health for First Nations peoples in Canada: can existing frameworks accommodate traditional activities?

Social Science & Medicine 55 (2002) 2017–2031

Exploring the determinants of health for First Nationspeoples in Canada: can existing frameworks

accommodate traditional activities?

Kathleen Wilsona,*, Mark W. Rosenbergb

aSchool of Geography and Geology, McMaster University, 1280 Main Street West, Hamilton, Ontario, Canada L8S 4K1bDepartment of Geography, Queen’s University, Kingston, Ontario, Canada K7L 3N6

Abstract

While much research has examined First Nations peoples’ health in Canada, few studies have explored the role of

traditional activities in enhancing health. Using data from the 1991 Aboriginal Peoples Survey (APS), this paper

incorporates a set of measures of traditional activities within a determinants of health framework for understanding

First Nations peoples’ health. Results from the analyses undertaken show that many of the determinants of health

identified in analyses of the Canadian population in general hold for First Nations peoples. While only a few statistically

significant relationships between health status and traditional activities were identified, taking into account the

limitations of the APS and other conceptual issues, we argue that there is the potential to move from the analysis of

traditional activities to a more nuanced analysis of cultural attachment.r 2002 Elsevier Science Ltd. All rights reserved.

Keywords: Aboriginal peoples; First Nations peoples; Traditional activities; Determinants of health; Canada

Aboriginal people from almost every culture believe

that health is a matter of balance and harmony

within the self and with others, sustained and ordered

by spiritual law and the bounty of Mother Earth.

Royal Commission on Aboriginal Peoples Volume 3

(1996, p. 184).

Introduction

In exploring First Nations peoples’ health in Canada

there are two distinct bodies of literature that can be

consulted.1 The first is primarily epidemiologic and

utilizes quantitative methods to examine health and

illness/disease in the context of the determinants of

health (Harris, Caulfield, Sugamori, Whalen, & Hen-

ning, et al., 1997; Hegele et al., 1997; Moffatt, 1995; for

a good review see Young, 1994). This is a significant

body of research for identifying and trying to explain

health inequalities. While important, it is flawed by the

fact that few studies incorporate First Nations peoples’

culture into analyses of health. Some researchers have

taken on the task of trying to operationalize culture with

varying success rates (Bagley, 1991; Foggin & Aurillon,

1989; Neuwalt, Kearns, Hunter, & Batten, 1992; New-

bold, 1997; Thouez, Rannou, & Foggin, 1989; Waldram,

1990; Young, 1998). The second is a body of cultural

literature, characterized by qualitative research meth-

ods, which links culture and health (Adelson, 1998;

Borr!e, 1991, 1994; Garro, 1988, 1995; Hagey, 1989;

Jilek, 1982; Waldram, 1993, 1997).2 As is often the case

with research based on qualitative methods, there is a

lack of generality to these studies.

*Corresponding author.1When using the term Aboriginal we are referring to the

descendants of the original inhabitants of Canada, as defined by

the Constitution Act 1982; Indians, Inuit and M!etis. Many

‘Indians’ prefer the terms First Nations when referring to

themselves as a collective group. Therefore we use the term

First Nations when referring to this segment of the Aboriginal

population.

2This is not an exhaustive list of the research being conducted

on the health of First Nations peoples.

0277-9536/02/$ - see front matter r 2002 Elsevier Science Ltd. All rights reserved.

PII: S 0 2 7 7 - 9 5 3 6 ( 0 1 ) 0 0 3 4 2 - 2

In 1991 Statistics Canada carried out the Aboriginal

Peoples Survey (APS), a national survey of individuals

living on reserves, in settlements and off reserve

areas who self-reported their Aboriginal identity

(Canada, 1993a). Included in this survey are questions

related to language and tradition as well as health,

lifestyle and social issues. Utilizing data from the APS

this paper explores whether measures of ‘traditional’

Aboriginal activities contribute to our understanding of

Aboriginal peoples’ health within a determinants of

health framework. Going beyond conventional mea-

sures that a determinants of health approach embraces,

a set of variables are tested which look at the importance

of traditional activities for the health of Aboriginal

peoples.

The first section of this paper discusses the general

health status of First Nations peoples in Canada,

documenting their lower levels of health, as compared

to the non-Aboriginal population. The second section

summarizes the different conceptualizations used to

explore the determinants of health. In the third section,

the data used in this study are outlined as well as the

methods employed in the analysis. The fourth section

describes the results of the research. In the final section,

we reflect on how taking into account the limitations of

the APS and other conceptual issues might move research

on First Nations peoples’ health beyond the dichotomy

which now exists between epidemiological and cultural

studies to a more nuanced analysis of cultural attachment.

The health of First Nations peoples in Canada

It is a well known fact that First Nations peoples in

Canada suffer from a poorer quality of life, as measured

by mortality and morbidity, as compared to their non-

Aboriginal counterparts (Enarson & Grzybowski, 1986;

Hammond, Rutherford, & Malazdrewicz, 1988; Young,

1991).3 The average life expectancy of Registered

Indians is approximately six years less than the overall

Canadian population (Canada, 1998).4 In 1990, the life

expectancy of male and female Registered Indians was

66.9 and 74.0 years respectively. In contrast, the life

expectancy for the total male and female Canadian

population was 73.9 and 80.5 years (Canada, 1996a).

Mao, Moloughney, Semenciw and Morrison (1992) note

that Registered Indians living on reserves suffer higher

mortality rates from coronary heart disease, suicide and

cirrhosis as compared to the rest of the Canadian

population. The infant mortality rate among Registered

Indians is approximately two times higher than for

Canadians generally (Canada, 1996a).

Research on morbidity shows that a much higher

proportion of First Nations peoples suffer from certain

illnesses than do non-Aboriginal Canadians. Enarson

and Grzybowski (1986) examined differences in tuber-

culosis rates across the country for three groups; Inuit,

registered Indians and others of mainly European

origin. Their findings showed that tuberculosis rates

were 16 times higher among Registered Indians and 24

times higher among Inuit as compared to the third

group. Mao et al. (1992) showed that the stroke rate for

Registered female Indians is 2 times higher than for non-

Aboriginals. While rates of infectious diseases among

Aboriginal peoples are declining, rates of chronic

illnesses are on the rise. Research by Young, McIntyre,

Dooley, and Rodriguez (1985) and Evers, McCracken,

Antone, and Deagle (1987) documents the very high

rates of type II Diabetes in the Aboriginal population as

compared to the non-Aboriginal population. According

to 1991 figures the disability rate for Aboriginal peoples

was 31% as compared to 13% for the non-Aboriginal

population (Ng, 1996).

The preceding examples represent only a small subset

of the differences in health status which distinguish First

Nations peoples from the remainder of the Canadian

population. Since First Nations peoples suffer from

lower levels of health as compared to their non-

Aboriginal counterparts, this begs the question ‘What

determines First Nations peoples’ health?’ Given the

importance of this question there are two goals we seek

to address in this paper. Firstly, to understand the

determinants of health for First Nations peoples within

the context of a social determinants of health frame-

work. Secondly, given the uniqueness of First Nations

peoples’ health status as well as their cultural system of

beliefs, this paper further enhances our understanding of

the ‘conventional’ social determinants of health by

3As Waldram et al. (1995) state, there is no convenient single

source of mortality data for Aboriginal people living in Canada.

The Medical Services Branch (MSB) collects vital statistics

based on its administrative regions. However, it only serves

75% of the on-reserve registered Indian population. As a result,

individuals living off-reserve and the non-status population are

unaccounted for by MSB. Mortality figures for Registered

Indians are also obtained from the Indian Register. However,

late reporting of births and deaths adversely affects the quality

of this information (Waldram et al., 1995). The Canadian

Census is another source from which health information can be

obtained. However, the refusal of Indian bands to participate in

the Census has resulted in incomplete enumeration. Further,

since ethnic status within the Census is based on self-

identification, the failure of individuals to identify with any of

the three Aboriginal categories results in inaccurate population

counts.

4While the term ‘Indian’ is generally inappropriate, we use it

for reasons of clarity only in two circumstances. First, it is used

when discussing the results of other studies that have employed

this term. Second, since the term ‘Indian’ is utilized within the

APS, we use it when referring to our analysis of the APS.

K. Wilson, M.W. Rosenberg / Social Science & Medicine 55 (2002) 2017–20312018

exploring the role of traditional activities in shaping the

health of First Nations peoples.

Conceptualizing the determinants of health

There is much discussion in the Canadian literature

surrounding the determinants of health. Many of these

documents are broad in their discussions of both health

and the determinants of health.

The 1974 Lalonde report entitled New Perspective on

the Health of Canadians was one of the earliest health

documents to identify factors, other than the health care

system (human biology, environment, life style, and

health care organization), which contribute to health

(see Lalonde, 1974, p. 31). While it is an important

document, the Lalonde report has been criticized for its

failure to acknowledge the effect of social environments

on health (Ontario, 1991). Despite this criticism, the

Lalonde report was the impetus for a sequence of

national reports that were aimed at ‘‘Achieving Health

for All’’, a phrase coined by Jake Epp and the

Ottawa Charter for Health Promotion (Epp, 1986; see

also ACPH, 1996; ACPH, 1994; Ontario, 1991; Sas-

katchewan, 1997). Epp’s (1986) paper identified

specific challenges faced in achieving health for all

Canadians: (i) reducing inequalities, (ii) increasing

the prevention effort, and (iii) enhancing people’s ability

to cope. The report attempted to strike a balance

between health promotion, disease prevention and

health care.

In 1991 the Healthy Public Policy Committee of the

Premier’s Council on Health Strategy produced a

document entitled Nurturing Health: A Framework on

the Determinants of Health. The purpose of this

document was to develop public policy initiatives aimed

at improving the health of Ontario’s citizens (Ontario,

1991). Similar to other policy documents, Nurturing

Health provided a broad look at the determinants

of health, covering a variety of factors ranging from

the physical and social environment to biological

endowment and health care. The Federal, Provincial,

and Territorial Advisory Committee on Population

Health (ACPH) produced two documents, Strategies

for Population Health: Investing in the Health of

Canadians (1994) and Report on the Health of Canadians

(1996), that identified similar key factors that influence

health. The main factors these documents identified were

living and working conditions, physical environment,

personal health practices, health services, and biology

and genetic endowment (see ACPH, 1994; ACPH,

1996).

In addition to these documents, numerous non-

governmental initiatives have outlined the ways in which

researchers can effectively study the determinants of

health. Evans and Stoddart (1990, p.1349) propose a

framework for the determinants of health that they

argue is complex and ‘‘sufficiently comprehensive and

flexible to represent a wider range of the relationships

among the determinants of health’’. They provide a

comprehensive model of the determinants of health,

which includes the social and physical environment,

genetic endowment, and health care systems. Their

discussion of the social and individual factors that

influence health tends to focus on the importance of

social conditioning as well as the dynamics of social

status and class and their inter-relationships with well

being.

Hertzman, Frank and Evans (1994) developed a

framework for discussing heterogeneities in health status

and the determinants of population health. Their

framework allows for the partitioning of the population

to define subgroups that differ in their average health

status (see p. 67). Their conceptual model is presented as

a cube with the three axes of the face of the cube

representing the key dimensions for studying hetero-

geneities in health status: (i) stages of the life cycle, (ii)

subpopulation partitions, and (iii) sources of hetero-

geneity. In terms of subpopulation partitions, Hertzman

et al. (p.75) argue that ‘‘the interesting partitions are

those which consistently demonstrate clear heterogene-

ity of health status across their subgroups in many

diverse settings’’. According to their conceptual model,

populations are partitioned by socioeconomic status,

ethnicity/migration, geography, gender, and special

populations.

The frameworks outlined above differ in their

approach to health and well being. Despite their

differing approaches, they are almost exhaustive in their

discussions and examinations of the determinants of

health. These approaches provide the conceptual frame-

work from which we explore the determinants of health

for First Nations peoples. However, we take our

analysis beyond the conventional determinants of health

outlined above by examining the role of traditional

activities in shaping health. More specifically, using

logistic regression analysis this paper examines if

measures of traditional activities that were included in

the APS further our understanding of First Nations

peoples’ health within the context of the social

determinants of health.

Data and methods

The APS is a national survey of individuals who self-

reported their Aboriginal identity, living on reserves, in

settlements and off reserves (Canada, 1993a). The

observations in the APS are drawn from the Aboriginal

population of Canada based on responses to two

questions in the 1991 Canadian Census. To be selected

for the APS, individuals had to indicate whether: (i) they

K. Wilson, M.W. Rosenberg / Social Science & Medicine 55 (2002) 2017–2031 2019

had Aboriginal origins (North American Indian, Inuit,

M!etis); and/or (ii) they were registered under the Indian

Act of Canada. Those individuals selected for the APS

were then asked whether: (i) they identified with an

Aboriginal group; and/or (ii) if they were registered

under the Indian Act. If an individual answered in the

affirmative to either of these questions, they were asked

to complete the remainder of the survey.5

The total sample size of the APS is 36,635 persons

who reported having Aboriginal origins and/or being

registered under the Indian Act. Of that total sample

size, 25,122 individuals report identifying with their

Aboriginal origins and 11,513 do not. The sample size

may under-represent some groups because of their

refusal to participate in the 1991 census or the APS.

The results of the APS are unavailable for those

communities that were incompletely enumerated in the

1991 Census (Canada, 1995a). In total, 78 reserves and

settlements were incompletely enumerated in the census

and 181 were incompletely represented in the APS

(Canada, 1995a).

The APS groups Aboriginal identity into three

categories; North American Indians, M!etis and Inuit.

This analysis explores the determinants of health for

only those individuals identifying themselves as regis-

tered North American Indians (a sub-sample size of

16,249). North American Indians who are not registered

under the Indian Act or who did not indicate their

registration status within the APS are excluded in the

analysis. Only those who self-reported themselves as

registered North American Indians were chosen for

analysis because they, unlike their non-status counter-

parts and the M!etis, receive both standard medical

services as well as non-insured medical services such as

eye care, dental care and drugs through the First

Nations and Inuit Health Branch (FNIHB) of Health

and Welfare Canada.

The APS is divided into eight thematic sections and

also contains standard sociodemographic information

for each individual (see Table 1). The breadth of

questions included in the APS provides the opportunity

to examine the relative importance of traditional

activities in relation to more conventional measures of

the determinants of health (e.g., age).

Based on the variables included in the APS, the

dependent variable in the logistic regression models is

self-assessed health status, with individuals reporting

their health as excellent, very good, good, fair or poor.

Due to the low response rate in some of the categories,

individuals reporting their health as excellent, very good

or good are combined into a ‘healthy’ category while

individuals reporting their health as fair or poor are

combined into an ‘unhealthy’ category. Approximately

86% of the population fall into the healthy category

while 13% fall into the unhealthy category. This

distribution is similar to what is found in other national

and provincial surveys of the non First Nations

population (Canada 1994–95, 1996–97; Ontario, 1990;

Qu!ebec, 1987, 1992–93).

Building upon the frameworks presented earlier in the

paper, the determinants of health included in this study

can be divided into five categories. The first four

categories represent conventional determinants of

health: demographic status, socioeconomic status, utili-

zation of health care services, and place of residence.

The fifth category includes variables that are designed to

measure attachment to traditional activities. Gender,

age and marital status are used to measure demographic

status while total income, highest level of schooling and

employment status are used to measure socioeconomic

status. A variable measuring whether or not an

individual had visited a physician in the past two weeks

measures utilization of health care services. Place of

residence is the contextual geographic variable and is

divided into four levels: reserve/settlement; Census

Metropolitan Area (CMA); other urban; and other

rural.

Three variables were chosen as measures of attach-

ment to traditional activities: participation in tradi-

tional activities; spent time on the land; acquired food

through hunting, trapping or fishing. Participation in

traditional activities is defined in the APS as ‘‘traditional

ways of doing things such as hunting, fishing, trapping,

storytelling, traditional dancing, fiddle playing, jigging,

arts and crafts, pow-wows, etc’’(APS, 1991). In terms

Table 1

Thematic areas included in the 1991 Aboriginal Peoples Survey

Section Theme

A Identity

B Language and tradition

C Disability

D Health, lifestyle and social issues

E Mobility

F Schooling

G Work and related activities

H Expenditures and sources of income

5The definition of the Aboriginal population differs between

the 1991 Canada Census and the 1991 Aboriginal Peoples

Survey. The Census defines the population based on Aboriginal

ancestry (i.e., persons who report at least one Aboriginal

origin). The APS selects individuals who not only indicate

Aboriginal ancestry but also consider themselves to be

Aboriginal. For example, a respondent may report in the

1991 Census that they have Inuit origin from an ancestor but

report in the APS that they do not identify with an Aboriginal

group. As such, the population counts between the 1991 Census

and the APS are different.


of spending time on the land, the APS asked respon-

dents if they spent part of the last 12 months living

on the land to hunt, fish, trap or teach traditional

ways to their children. Finally, the survey asked

respondents what amount of meat, fish or poultry

consumed in the house is obtained through hunting,

fishing, or trapping. The survey coded responses into

four categories: none, some, half, or most. For purposes

of this research, the responses are recoded into a binary

variable (i.e., no meat, fish or poultry acquired through

hunting and some, half or most acquired through

hunting).

Given the dichotomous nature of the dependent

variable (0,1), logistic regression is used to estimate all

the models. Coefficients are estimated using the max-

imum likelihood method (MLM) of estimation (Aldrich

& Nelson, 1984). The independent variables are recoded

into categorical indicator variables. One value of each

variable is chosen to be the reference category. To

produce a more reliable statistical model, in most cases,

the value chosen to be the reference category is the one

with the highest frequency (see Table 2). For ease of

interpretation, the results are discussed in terms of the

odds ratios. The odds ratio is a measure that approx-

imates how much more likely (or unlikely) it is for the

outcome, in this case being unhealthy, to be present

among those with a given attribute relative to the

reference category and controlling for all other attri-

butes.

Results

In the first part of this section, we use a series of cross-

tabulations to set the context for the logistic regression

analysis that follows. In doing so, we examine the health

of First Nations peoples by age and sex as well as

attachment to traditional activities by age, sex and place

of residence.

Fig. 1 shows that for each of the three youngest age

cohorts, a higher proportion of men report being

healthy (i.e., excellent, very good, good) as compared

to women. For adults aged 40–64 years, 74% of women

are healthy as compared to approximately 81% of men.

In addition, this figure shows that as age increases the

proportion of men and women reporting excellent, very

good or good health decreases.

Figs. 2–5 illustrate how attachments to traditional

activities vary by sex and place of residence. In Fig. 2

we see that a much higher proportion of men have spent

some amount of time living on the land in the past year

relative to women in every age cohort. Similar to the

results of Fig. 2, Figs. 3 and 4 illustrate that higher

proportions of men than women report acquiring food

through hunting, fishing or trapping as well as participat-

ing in traditional activities. The findings of Figs. 2–4 may

reflect a gender division of labour, in that spending time

on the land, participating in traditional activities and

acquiring food through hunting, fishing and trapping are

activities generally associated with male band members.

Table 2

Categories assigned to each variable (reference categories indicated by bold)

Variable groupings Categories

Health status

Self assessed health status Healthy (excellent/very good/good)

Unhealthy (fair/poor)

Demographic status

Age 15–24, 25–39, 40–64, 65+

Sex Female, Male

Marital status Single, Divorced/separated/widowed, Married

Socioeconomic status

Total income 0–9,999, 10,000–19,999, 20,000–39,999, 40,000+

Education Less than high school, High school, Post-secondary

Employment status Employed, Unemployed not in the labour force

Health care

Visited physician in past year Yes, No

Geographic

Place of residence Reserve, CMA, Other urban, Other rural

Attachment to traditional activities

Spent time living on land in No, Yes

Past year

Hunt for food Yes, No

Participate in traditional Yes, No

Activities


Fig. 5 demonstrates that attachment to traditional

activities varies by place of residence. In particular, a

much higher percentage of individuals living on reserves

report spending time on the land, participating in

traditional activities and acquiring food through

hunting, fishing, trapping, relative to individuals living

in CMAs and other urban areas. For example, 85% of

individuals living on reserves report acquiring food

through hunting, fishing and trapping as compared to

only 47% in CMAs. In addition, approximately 30% of

respondents living on reserves stated they spent time

living on the land relative to only 14% of their

counterparts living in CMAs. This may reflect differ-

ential levels of access to traditional activities between

First Nations peoples living on reserves and those living

in urban areas.

Having explored some key relationships between

traditional activities, sex and place of residence, we

now turn to examine the complexity of these relation-

ships in the context of the social determinants of health

using logistic regression analysis.

The first model explores the determinants of health at

the national level (see Table 3).6 All of the variables are

inserted into the model, with the exception of the

variables measuring attachment to traditional activities.

In general, the relationships between health status and

the conventional determinants of health are as expected.

0102030405060708090

100

15-24 24-39 40-64 65+

Age Groups

Perc

ent

Female

Male

Fig. 1. Percentage of ‘healthy’ registered Indians by sex.

05

101520253035404550

15-24 25-39 40-64 65+

Age Groups

Perc

ent

Female

Male

Fig. 2. Spent time living on the land by sex.

0

10

20

30

40

50

60

70

80

90

100

15-24 25-39 40-64 65+

Age Groups

Perc

ent

Female

Male

Fig. 3. Percentage of registered Indians who report acquiring

food through hunting, fishing and trapping.

0102030405060708090

100

15-24 25-39 40-64 65+

Perc

ent

Female

Male

Age Groups

Fig. 4. Percentage of registered Indians who report participat-

ing in traditional activities.

0102030405060708090

100

Huntin

g/Fish

ing/T

rappin

gLan

d

Partici

patio

n

Perc

ent

ReserveCMAOther UrbanOther Rural

Fig. 5. Participation in traditional activities by place of

residence.

6 Initially, two variables measuring smoking and drinking

behaviours were included in the model to represent lifestyle.

The results showed no statistically significant relationships

between these two variables and health status. Further,

supplementary analyses explored an interaction of smoking

and drinking behaviours but they did not show a significant

relationship between the combined effects of smoking and

drinking on health status. As a result, these two variables were

removed from subsequent analyses.


With respect to demographic status, the odds ratios

indicate that the likelihood of assessing one’s health as

unhealthy increases with age. For example, compared to

those between the ages of 15–24, those aged 25–39 are

two times more likely to report being unhealthy and

those aged 65 and over are six times more likely to

report being unhealthy. Relative to those who are single,

the odds ratios show that individuals who are married

are less likely to report being unhealthy. This finding is

consistent with previous research that suggests social

support positively affects health (Bloom, 1990). Inter-

estingly, sex is not significantly related to health status.

In terms of the socioeconomic variables, the odds

ratios for income reveal that as income increases, the

likelihood of reporting being unhealthy decreases. The

odds ratio for employment status is reflective of the

‘healthy worker’ effect (see Dahl, 1993), with those

individuals not in the labour force reporting they are

more likely to be unhealthy than the employed. In terms

of education, individuals with high school education or

Table 3

Geographic Model of the Determinants of Health for First Nations Peoples

Variable 95% Confidence intervals

For exp (b)

Estimated coefficient Odds ratio exp (b) Lower Upper

Sex (Ref: Male) �0.080 0.923 0.798 1.068

Age (Ref: 15–24)

25–39 0.837*** 2.309 1.811 2.944

40–64 1.583*** 4.871 3.760 6.311

65+ 1.853*** 6.379 4.660 8.730

Marital status (Ref: Single)

Divorced/separated/widowed �0.103 0.902 0.727 1.119

Married �0.245* 0.783 0.650 0.943

Total income (Ref: 0–9,9999)

10,000–19,999 �0.082 0.922 0.782 1.086

20,000–39,999 �0.537*** 0.584 0.456 0.748

40,000+ �1.669*** 0.189 0.097 0.368

Education (Ref: Less than high school)

High school �0.687*** 0.503 0.420 0.603

Post secondary �0.612*** 0.542 0.445 0.661

Employment (Ref: Employed)

Unemployed �0.168 0.845 0.643 1.110

Not in labour force 0.597*** 1.817 1.499 2.202

Physician use (Ref: Yes) �0.718*** 0.488 0.352 0.676

Place of residence (Ref: Reserve)

CMA �0.211* 0.810 0.661 0.993

Other urban �0.123 0.884 0.742 1.053

Other rural 0.009 1.009 0.807 1.262

Constant �2.172***

Model chi-square 980.590***.

Percentage of correct predictions 83.1%.

Sensitivity 12.7%.

Specificity 97.6%.

Rho 0.151.

N 6885.

*po0:05; � � po0:01; � � �po0:001:


post secondary education are less likely to report being

unhealthy, as compared to those with less than high

school education.

The results also show that individuals who have not

visited a doctor are less likely to report being unhealthy

than those who have seen a doctor. With respect to place

of residence, individuals who live in Census Metropo-

litan Areas (CMA) are less likely to report being

unhealthy, as compared to those individuals who live

on reserves. The fact that major metropolitan areas have

better and more health services (in addition to other

resources) that cannot be found on many reserves, may

explain this finding. However, this result may also reflect

a process of self-selection among migrants to cities.

Research has shown that many First Nations peoples

migrate to the city in search of education, employment

and health care (Canada, 1993b; Clatworthy, 1994).

Other statistics show that registered Indians living off

reserve enjoy higher levels of socioeconomic status as

compared to registered Indians living on reserve. For

example in 1990, the average individual income for

individuals living off reserve was $12,551 as compared to

$8,812 for individuals living on reserve (DIAND, 1995).

Similar disparities exist for education level (Clatworthy,

1994; DIAND, 1995). Therefore, the finding that

individuals living in CMAs are less likely to report

being unhealthy than individuals living on reserves may

capture a package of advantages of city life (e.g., better

housing opportunities, job opportunities, etc.) including

higher socioeconomic status.

The model chi-square is significant, which allows for

the rejection of the null hypothesis that the predictor

variables are not related to health status. To assess the

fit of this model we must examine the rho-squared value.

While the rho-squared value for this model (0.151),

appears low, analyses based on large sample sizes tend

to deflate the upper bound of the rho-squared by an

unknown amount (McFadden, 1974). The sensitivity of

this model is low (12.7%), while the specificity is high at

97.6%. Overall, the model correctly classified 83.1% of

respondents.

The second model explores the determinants of health

at the national level and includes the variables chosen to

measure attachment to culture/traditional activities (see

Table 4). Once again we see that increased age is

associated with increased odds of being unhealthy, and

higher levels of income and education are associated

with lower odds of being unhealthy. Married respon-

dents are less likely to report being unhealthy relative to

their single counterparts. In addition, those not in the

labour force have higher odds of reporting being

unhealthy as compared to the employed.

The variables chosen as measures of traditional

activities revealed some interesting findings. Individuals

who reported spending time living on the land in the

past year were less likely to report being unhealthy, as

compared to individuals who had not spent time living

on the land. Acquiring food through traditional ways

was also significantly related to health status. The odds

ratio revealed that individuals who reported that they

had not obtained any of their food through hunting,

fishing or trapping were less likely to be unhealthy

compared to those who had reported that they had. The

third proxy measure, participation in traditional activ-

ities, was not statistically significant.

The odds ratio for the hunting/fishing/trapping

variable, at first glance, is opposite to what one might

expect and therefore counter to the argument that

attachment to traditional activities are necessary for

good health. One possible explanation for this counter-

intuitive result is that the hunting variable is serving as a

proxy for a lack of resources to purchase food rather

than any form of attachment to traditional ways. To test

this hypothesis a supplementary model was examined. A

variable measuring whether an individual reported not

having enough food in the past year was added to the

model and a set of interaction effects between the food

adequacy variable and each measures for attachment to

traditional ways was also created. The direct effect for

food adequacy was statistically significant showing that

those who reported not having enough food in the past

year were two times more likely to report being

unhealthy as hypothesized. However, the interaction

effects between food adequacy and the proxy measures

were not statistically significant. While hunting, fishing

and trapping may indeed be supplementing the diets of

respondents as well as maintaining attachments to a

traditional way of life, the lack of an interaction effect

makes it difficult to interpret the hunting variable in a

clear way.

Once again the model chi-square ratio statistic is

significant. The inclusion of the cultural variables has

resulted in a slightly higher rho-squared value (0.154), as

compared to the previous model. In addition, the

specificity has increased (98.1%) while the sensitivity

(12.5%) decreased slightly. Overall, this model correctly

classified 83.8% of respondents.

It is also important to highlight the statistically

significant difference in health status observed for

those living on reserves as compared to those living in

CMAs (see Table 4). Exploring the determinants of

health by location is important because the proportion

of the Aboriginal population living in urban centres is

steadily increasing. In 1991, 44% (320,000) of the total

population was living in urban areas (Canada, 1996d)

and this figure is predicted to grow by another 43% over

the next 25 years (Kerr, Siggner, & Bourdeau, 1995).

Much of the relocation literature focuses on the

movement of whole communities. However, a smaller

body of literature, which discusses individual relocation,

argues that individuals who move away from the

reserve/community also face problems (Duck, 1993;


Redwolf, 1995; Richardson, 1993). The literature

contends that individuals who move from the reserve

to urban area face lower levels of access to their

traditional activities. As Peters (1996, p. 321) notes,

few urban Aboriginal institutions have ‘‘as their primary

mission the promotion or support of aboriginal culture

and identity’’. Despite the improved levels of socio-

economic status associated with living in urban

areas, urban migrants face diminished levels of access

to traditional activities, identity and the land, all of

which can cause psychological and emotional health

problems.

Table 4

Cultural model of the determinants of health for First Nations peoples

Variable 95% Confidence intervals

For exp (b)

Estimated coefficient Odds ratio exp (b) Lower Upper

Sex (Ref: Male) �0.084 0.920 0.788 1.074

Age (Ref: 15–24)

25–39 0.844*** 2.327 1.797 3.012

40–64 1.615*** 5.026 3.819 6.615

65+ 1.820*** 6.172 4.419 8.622


Divorced/Separated/Widowed �0.143 0.866 0.689 1.089

Married �0.257* 0.773 0.635 0.942


10,000–19,999 �0.081 0.922 0.775 1.096

20,000–39,999 �0.493*** 0.611 0.471 0.793

40,000+ �1.964*** 0.140 0.063 0.313


High school �0.715*** 0.489 0.403 0.594

Post secondary �0.551*** 0.576 0.468 0.710


Unemployed �0.236 0.790 0.589 1.059

Not in labour force 0.605*** 1.832 1.495 2.245

Physician use (Ref: Yes) �0.740*** 0.477 0.337 0.676

Place of residence (Ref: Reserve)

CMA �0.212* 0.809 0.649 1.009

Other urban �0.157 0.855 0.703 1.039

Other rural 0.043 1.044 0.825 1.320

Land (Ref: No) �0.203* 0.816 0.673 0.990

Hunt (Ref: Yes) �0.212* 0.809 0.681 0.961

Traditional activities (Ref: Yes) 0.074 1.077 0.927 1.251

Constant �2.122***

Model chi-square 904.174***.

Percentage of correct predictions 83.8%.

Sensitivity 12.5%.

Specificity 98.1%.

Rho 0.154.

N 6269.

*po0:05; **po0:01; ***po0:001:


The model results, the demographic trends and the

relocation literature all point to the need to disaggregate

the data by place of residence and run separate models

for those individuals living on reserves and those living

in CMAs. As Table 5 shows, in both locations, increased

age is associated with higher odds of being unhealthy

and those not in the labour force have higher odds of

being unhealthy. The results also show differences in the

determinants of health between the two locations. For

example, visiting a physician is only significantly related

to health status on reserves. The odds ratio shows that

individuals who have not visited a physician are less

likely to be unhealthy, as compared to those that have

visited a physician. In addition, marital status is only

significantly related to health status in CMAs and the

odds ratios reveal that relative to single respondents,

Table 5

Determinants of health for First Nations peoples by place of residence

Variable Reserve CMA

Estimated

coefficient

Odds ratio

exp (b)Lower Upper Estimated

coefficient

Odds ratio

exp (b)Lower Upper

Sex (Ref: Male) �0.045 0.956 0.796 1.148 �0.420 0.657 0.373 1.157

Age (Ref: 15–24)

25–39 0.797*** 2.218 1.574 3.125 1.304** 3.684 1.716 7.908

40–64 1.801*** 6.059 4.271 8.595 2.158*** 8.654 3.609 20.755

65+ 2.218*** 9.187 6.141 13.745 1.923** 6.838 1.864 25.081


Divorced/Sepa-

rated/widowed

�0.087 0.917 0.685 1.227 �0822* 0.439 0.221 0.874

Married �0.178 0.837 0.656 1.068 �0.886* 0.412 0.202 0.840


10,000–19,999 �0.013 0.987 0.796 1.225 0.355 1.426 0.837 2.430

20,000–39,999 �0.151 0.859 0.612 1.207 �0.487 0.615 0.240 1.576

40,000+ �0.574 0.563 0.245 1.296 �1.788 0.167 0.008 3.440


High school 0.532*** 1.702 1.334 2.173 �0.688* 0.502 0.256 0.984

Post-secondary 0.152 1.164 0.867 1.562 �1.140** 0.320 0.154 0.666


Unemployed 0.001 1.001 0.691 1.450 0.158 1.171 0.476 2.879

Not in labour

Force

0.753*** 2.123 1.621 2.781 1.265*** 3.543 1.776 7.067

Physician use (Ref:

Yes)

�0.753*** 0.471 0.321 0.690 �0.867 0.420 0.062 2.849

Land (Ref: No) �0.096 0.908 0.735 1.121 �0.875 0.417 0.149 1.170

Hunt (Ref: Yes) �0.079 0.924 0.727 1.174 0.176 1.192 0.723 1.968

Traditional activities

(Ref: Yes)

0.234* 1.263 1.049 1.522 �0.412 0.663 0.404 1.087

Constant �3.238*** �2.659***

Model chi-square 630.778*** 116.557*** *po0:05 **po0:01 ***po0:001Percentage of correct predictions 79.7% 88.0%

Sensitivity 24.5% 12.4%

Specificity 94.4% 98.1%

N 3732 812

Rho 0.16 0.20


married and divorced respondents are less likely to be in

poor health.

When exploring the variables that act as measures

for traditional activities, the results show that only

one variable is significantly associated with health

status. For individuals living on reserves, those who

have not participated in traditional activities are 1.3

times more likely to report being unhealthy, as compared

to individuals who have participated in traditional

activities providing additional support for the importance

that traditional ways play in the lives of First Nations

peoples.

Both models had higher rho-squared values (0.16

(reserves) and 0.20 (CMAs)) and good specificity,

94.4% for reserves and 98.1% for CMAs. Sensitivity

was much higher for the reserves (24.5%), as compared

to CMAs (12.4%), suggesting that the determinants of

health are better predictors of ‘unhealthy’ health

status on reserves than in CMAs. Overall, the models

correctly classified 88% (CMAs) and 79.7% (reserves) of

respondents.

From traditional activities to cultural attachment

The purpose of this study was to examine if the

inclusion of variables measuring traditional activities in

a social determinants of health framework could further

our understanding of First Nations peoples’ health. The

results from this analysis raise a number of issues. First,

the majority of the variables that were statistically

significantly related to health (i.e., age, income, educa-

tion, employment, utilization of health care and place of

residence) are similar to variables that are commonly

shown to be determinants of health for the general

Canadian population (see Badgley, 1993; Canada,

1995b, 1996c; Canada, 1998; Grayson, 1993, Wilson,

Jerrett, & Eyles, 2001). This implies that the health of

First Nations peoples is dependant on similar determi-

nants of health as those found for the Canadian

population in general and all other things being equal

it follows that the same policies and programs used to

improve the health of Canadians in general should be

sufficient to improve the health of First Nations peoples.

Indeed, there is superficial evidence to support this

viewpoint when one examines the convergence in

morbidity and mortality rates between First Nations

peoples and the Canadian population during the

twentieth century (see Waldram, Herring, & Young,

1995).

Second, the findings of this study revealed only a

limited number of significant relationships between

traditional activities and health even when the data

were disaggregated to examine only those individuals

living on reserves compared to those living in CMAs. As

noted earlier, First Nations peoples suffer from higher

levels of morbidity and mortality as compared to the

general Canadian population even though convergence

is taking place over time. The same research (i.e.,

Waldram et al., 1995), does, however, also show that

there remains a gap in the morbidity and mortality rates

between First Nations peoples and the general Canadian

population and gaps between First Nations peoples

living on isolated reserves mainly in the northern parts

of most provinces and First Nations peoples living on

reserves in southern Canada and near to major urban

places. Without taking these trends into account, the

findings in this paper might lead one to conclude: (i) that

traditional activities are not important determinants of

health; and/or (ii) First Nations peoples’ culture, in

general, cannot be conceptualized within a determinants

of health framework. Each of these ‘conclusions’ needs

to be considered.

First, utilization and access to health care services are

important determinants of health. Within the APS, the

utilization of conventional health care services (e.g.,

physician, nurse, eye specialist) is emphasized. Incorpor-

ating a conventional measure of health care, such as

physician utilization, into this analysis is problematic

since there are no regular physician services and access is

highly circumscribed for those First Nations peoples

living on isolated reserves. In addition, the survey under-

emphasizes the importance of traditional health prac-

tices. While the APS measures the utilization of

traditional healers, it does not take into account other

traditional healing practices, such as the use of sweat

lodges (see Adair, Deuschle, & Barnett, 1988; Kunitz,

1989; Waldram, 1997, 1993; Waldram et al., 1995;

Wilbush, 1988). Unfortunately, only 8% of respondents

in the APS indicated that they had used a traditional

healer, but there is no way to determine how many

reserves actually have a traditional healer and whether

respondents from isolated reserves are under-repre-

sented where they might be most likely to use traditional

healers and other traditional health practices (see

below).

Second, with respect to measures of traditional

activities and health status, there is a certain level of

ambiguity in how one interprets the direction of the

relationships. For example, the odds ratio for the

hunting variable revealed that individuals who reported

that they had not obtained any of their food through

hunting, fishing or trapping were less likely to be

unhealthy compared to those who had reported that

they had. This finding may indicate that hunting, fishing

and trapping supplement diets and therefore the

relationship represents a positive covariate for health.

Conversely, it may be a proxy measure for poverty and

therefore can be interpreted as a negative covariate for

health. This level of ambiguity indicates a need for more

measures of traditional activities that do not conflate

traditional activities in one aggregated variable. For


example, the APS defines traditional activities as a

wide range of activities: ‘‘hunting, fishing, trapping,

storytelling, traditional dancing, fiddle playing, jigging,

arts and crafts, pow-wows, etc.’’ (Canada, 1991, p. 6).

As such, there is no way to tease out which of these

traditional activities may be a significant determinant of

health.

Third, the analysis is also constrained by the

limitations inherent in using a public use microdata

file and more general data collections encountered by

Statistics Canada in developing the APS. Due to reasons

of confidentiality and anonymity the data cannot be

divided into northern and non-northern regions nor

can specific bands or communities be identified.

Consequently, it is not possible to explore how the

relationship between traditional activities and health

varies by location. For example, it is reasonable to

believe that the health experiences of a First Nations

person living on an isolated reserve far from any

urban place, an urban First Nations person living in a

northern Ontario town such as Kenora, and an

urban First Nations person living in Toronto would all

differ.

A final limitation of the survey is its categorization of

Aboriginal peoples into three groups; North American

Indian, M!etis and Inuit. Contemporary feminist litera-

ture has explored the impact of essentialized categoriza-

tion on gender, race and sexuality (Kobayashi & Peake,

1994; McDowell, 1991; McDowell, 1992; Nicholson,

1995; Penrose et al, 1992; Pile, 1994; Rose, 1993). The

very basis of these categories is difference, with

categories set up in opposition to one another (Kobaya-

shi & Peake, 1994). This structure has at least two

inherent problems. First, naturalized and essentialized

categories limit differences to polarized opposites.

Second, as Rose (1993) argues, such categories often

deny and do not allow for radical difference within

oppositions.

At first glance, the analysis shows that, in general,

traditional activities are not conclusively linked to health

status. Due to the essentialized categorization of

Aboriginal identity, it is not possible to explore this

relationship for different First Nations groups, such as

the Ojibwa, Mohawk and Dene. The categories North

American Indian, M!etis, and Inuit are not sufficient for

acknowledging the distinct identities within each group.

As such, the survey denies the existence of multiple

Aboriginal identities. Thus, this categorization is a crude

measure of ethnicity that creates three homogeneous

categories of Aboriginal peoples, which do not actually

exist.

If the analysis of First Nations peoples’ health is to

move from a focus on traditional activities to cultural

attachment, future population health surveys like the

APS will need to take into account other potentially

important cultural determinants of health. First Nations

cultures are deeply rooted in spirituality. Many First

Nations peoples participate in activities or ceremonies

such as sweat lodges, the use of sacred medicines,

and the offering of tobacco, as part of their spiritual

way of life (Akiwenzie-Damm, 1996; Canada, 1996a,

1996b, 1996d, 1996e). Taking into account the other

limitations of this analysis as discussed above would

also help to breakdown the dichotomy between

the medical literature, which is characterized by

quantitative and epidemiologic research surrounding

the prevalence of illness and disease and on the other

side a qualitative body of research that is concerned with

the specificity of First Nations peoples, their culture and

their health.

Conclusions

This paper explored the importance of traditional

activities for First Nations peoples’ health based on a

determinants of health framework and employing

sample data from the APS. The research shows the

significance of income, education and employment for

health similar to other analyses of the Canadian

population in general where a determinants of health

framework has been employed. While the inclusion of a

subset of variables measuring traditional activities

resulted in an attenuated set of meaningful results,

taking into account the limitations of the APS in future

surveys has the potential to move research beyond the

division which now exists between epidemiological and

cultural studies.

In 2001, Statistics Canada began collecting data

for the second Aboriginal Peoples Survey. This will be

an important data set as it will allow us to explore

whether the relationships identified in this paper are

consistent over time. In addition, the new survey holds

out the potential to move from the analysis of

traditional activities to a more nuanced analysis of

cultural attachment. In the 2001 APS, there is disag-

gregation of traditional activities. For example, indivi-

duals are asked if they participate in four categories of

activities (hunting, fishing, gathering wild plants and

trapping) and the reasons for participation in those

activities (e.g., food, pleasure, commercial, and medic-

inal/ceremonial) (Canada, 2001). In this way, one

can distinguish between activities performed for

primarily economic reasons from those aimed primarily

at improving health. In terms of health care, the

survey also explores the availability of traditional

medicines, healing and wellness practices. Given these

improvements, future research using data from the

2001 APS may be better able to enhance our under-

standings of the role of traditional activities in shaping

health.


Acknowledgements

Funding for this project was provided by the Social

Science and Humanities Research Council of Canada.

Special thanks to Bob Earickson and three anonymous

reviewers for their thoughtful comments.

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Documents

Exploring the determinants of health for First Nations peoples in Canada: can existing frameworks accommodate traditional activities?