Exploring Why First Nations' Children Rank First in ... · Children Rank First in Canadian...
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viha.ca Exploring Why First Nations' Children Rank First in Canadian Pediatric Unintentional Injuries Richard Stanwick MD, FRCPC, F.A.A.P. Chief Medical Health Officer Island Health, Vancouver Island Chair, Injury Prevention Committee Canadian Paediatric Society Denver, Colorado April 1, 2017
Exploring Why First Nations' Children Rank First in ... · Children Rank First in Canadian Pediatric Unintentional Injuries Richard Stanwick MD, FRCPC, F.A.A.P. Chief Medical Health
Exploring Why First Nations' Children Rank First in Canadian Pediatric Unintentional Injuries
Richard Stanwick MD, FRCPC, F.A.A.P. Chief Medical Health Officer Island Health, Vancouver Island Chair, Injury Prevention Committee Canadian Paediatric Society
Denver, Colorado April 1, 2017
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Disclosures
• I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services referenced in this public presentation.
• I will not discuss an unapproved or investigative use of a commercial product or device in this presentation.
Presenter
Presentation Notes
This slide must be visually presented to the audience AND verbalized by the speaker.
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Learning Objectives
Describe the extent and pattern of injuries of First Nation’s children relative the rest of the Canadian population. Speak to the role of the determinants of health in contributing to these trends including colonialism and reconciliation. Be culturally sensitive in the development of preventive strategies with this vulnerable population to reduce the burden of illness. Appreciate the importance of autonomy in effective interventions.
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ABORIGINAL PEOPLES IN CANADA – SOME TERMINOLOGY
Aboriginal is a collective name for all of the original peoples of Canada and their descendants. Most Aboriginal peoples in Canada identify themselves politically as belonging to one of three major groups: First Nations, Métis and Inuit.
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ABORIGINAL PEOPLES IN CANADA – SOME TERMINOLOGY
The term First Nations came into common use in the 1970s to replace ‘Indian’, which some people found offensive. Despite its widespread use, there is no legal definition for this term. A Métis is a person who self-identifies as Métis, is of historic Métis Nation ancestry, is distinct from other Aboriginal peoples and is accepted by the Métis Nation. Inuit are a distinct group of Aboriginal people living in northern Canada, generally in Nunavut, the Northwest Territories, northern Quebec and northern Labrador.
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Presentation Notes
Adapted from ‘Assembly of First Nations terminology fact sheet’, www.afn.ca/article.asp?id=437. Métis National Council, www.metisnation.ca/who/definition.html. Indian and Northern Affairs Canada terminology list’, www.ainc-inac.gc.ca/ap/tln-eng.asp.
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Source: the Innocenti Report Card, Issue released in February 2001
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Source: Statistics Canada tabulated data, provided by the Public Health Agency of Canada’s Injury and Child Maltreatment Section. While tremendous progress has been made in other areas of childhood disease prevention and treatment – injuries have persisted.
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The Numbers
• There have been surveys that have collected some injury data such as the First Nations Regional Longitudinal Health Survey capturing at the individual and community level.
• No systematic gathering of comprehensive injury information currently takes place across the country for First Nations children and youth in Canada.
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The Numbers
• Canadian indigenous First Nations and Inuit communities have more than 50% of their populations under 25 years of age.
• Injury is by far the greatest source of potential years of life lost (PYLL) among First Nations populations.
• Rate almost 3.5 times the national average, injury accounts for 26% of deaths among First Nations, compared with 6% of deaths overall in Canada.
Presenter
Presentation Notes
Health Canada. A statistical profile on the health of First Nations in Canada: Health services utilization in Western Canada, 2000 [Internet]. Ottawa (ON): Health Canada; 2009 [cited 2012 Apr 15]. Available from: http://www.hc-sc.gc.ca /fniah-spnia/pubs/aborig-autoch/2009-stats -profil-vol2/index-eng.php. Banerji A; Canadian Paediatric Society; First Nations, Inuit and Metis Health Committee. Preventing unintentional injuries in Children and Youth in Canada. Paediatr Child Health. 2012;17(7):393-4.
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The Numbers • Injury rates among indigenous teens are almost 4
times greater than those of non-indigenous Canadians.
• Hospitalization rates due to injury are also significantly higher (twice the rate) for children and youth living in areas with a high percentage of indigenous residents.
• Consistent with non-indigenous populations, male gender was associated with higher morbidity and mortality rates in Aboriginal communities.
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Presentation Notes
Oliver LN, Kohen DE. Unintentional injury hospitalizations among children and youth in areas with a high percentage of Aboriginal identity residents: 2001/2002 to 2005/2006. Health Rep. 2012;23(3):7-15. [Statistics Canada, Catalogue No.: 82-003- XPE]. Allard YE, Wilkins R, Jean-Marie Berthelot J-M. Premature mortality in health regions with high Aboriginal populations. Health Reports 2004; 15(1): 51-60.
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The Numbers
• Seatbelt use in First Nations communities is reported at 50% compared to the Canadian usage average of over 80%.
• Motorized transportation related injuries are associated with the use of snowmobiles and all terrain vehicles (ATVs).
• The remoteness of many Aboriginal communities often means that people need to travel greater distances on poor-quality/ice roads or cross-country on off-road vehicles.
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Presentation Notes
Health Canada. (2005). Unintentional and intentional injury profile for Aboriginal people in Canada. Ottawa: Minister of Public Works and Government Services Canada. http://www.hcsc. gc.ca/fniahspnia/pubs/promotion/_injury-bless/2001_trauma/index-eng.php. Accessed March 2107
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The Numbers • Drowning is the second most common cause of injury-
related death in Aboriginal communities, particularly as associated with snowmobile, boating/transportation, and recreational water use. Aboriginal people access bodies of water for recreation, transportation and food all serve to increase the risk of drowning. (Aboriginal children drown at a rate that is 15 times the national average.)
• Geographic remoteness and distance from emergency rescue and medical assistance also heighten the risk.
• Health Canada data in 1996 indicate that among drowning victims, only 6% of Aboriginals wore a flotation device.
Presenter
Presentation Notes
Health Canada. (2005). Unintentional and intentional injury profile for Aboriginal people in Canada. Ottawa: Minister of Public Works and Government Services Canada. http://www.hcsc. gc.ca/fniahspnia/pubs/promotion/_injury-bless/2001_trauma/index-eng.php. Accessed March 2107 Demographic factors, such as having more children in the community, increase the likelihood of drowning incidents that are most common among children, including falls into water.
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The Numbers
• Aboriginal children are also at higher risk of injury and death by fire.
• Higher rates of smoking, reliance on wood heat, poor housing conditions, and a lack of smoke detectors increase this risk.
• Unlike other forms of injury, rates of poisoning in First Nations communities actually increased in the 1990s for children.
Presenter
Presentation Notes
Health Canada. (2005). Unintentional and intentional injury profile for Aboriginal people in Canada. Ottawa: Minister of Public Works and Government Services Canada. http://www.hcsc. gc.ca/fniahspnia/pubs/promotion/_injury-bless/2001_trauma/index-eng.php. Accessed March 2107
Age Specific Injury Mortality Rates per 10,000 population, British Columbia, 1992-2002
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Age Specific Injury Hospitalization Rates per 10,000 population, British Columbia, 1992-2003
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The Numbers
• All major types of injury and causes of injury showed decreases in rates over time for both populations, which is contrary with US studies which show levelling of rates or even increases.
Presenter
Presentation Notes
George A, Jin A, Brussoni M, Lalonde C, McCormick. Injury risk in British Columbia, Canada, 1986 to 2009: are Aboriginal children and youth over-represented? Injury Epidemiology (2015) 2:7 U.S. Department of Health and Human Services. Centers for Disease Control and Prevention. National Center for Health Statistics. Health, United States, 2013: With Special Feature on Prescription Drugs. Hyattsville, MD. 2014. http://www.cdc.gov/nchs/data/hus/hus13.pdf Accessed March 2017
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Community Well Being Index
Indian and Northern Affairs Canada has created a Community Well-Being index which results in a composite score for a community based on the characteristics of its residents – specifically their income, education, housing quantity and quality, and labour force characteristics (participation and employment rates).
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Presentation Notes
http://www.nccah-ccnsa.ca/docs/social%20determinates/nccah-loppie-wien_report.pdf. Accessed March 2017
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Housing Stock
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Presentation Notes
http://www.nccah-ccnsa.ca/docs/social%20determinates/nccah-loppie-wien_report.pdf. Accessed March 2017 Reserve refers to lands owned by the Crown and held in trust for the use and benefit of First Nations, for which they were set apart. The legal title to reserve land is vested in the federal government. Source: ‘Assembly of First Nations terminology fact sheet’, www.afn.ca/article.asp?id=437.
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Aboriginal children’s health: Leaving no child behind. Canadian UNICEF Committee, 2009. http://www.nccah-ccnsa.ca/docs/nccah%20partner%20documents/UNICEF%20Report,%20English.pdf. Accessed March 2017
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One half of the duplex was totally destroyed by the fire, police said. Fire investigators and RCMP are working to determine the cause of the blaze. - See more at: http://www.timescolonist.com/news/local/nine-escape-fire-that-destroyed-duplex-on-pauquachin-first-nation-1.10438406#sthash.f4JbfLBd.dpuf
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Four generations of a family are homeless and separated after fire ravaged their house on the Pauquachin First Nation in North Saanich. Homeowners Russell and Nora Henry, who are in their 70s, were among the 16 people who fled the house at 8709 West Saanich Rd. when fire broke out at 2:48 a.m. on Feb. 6. - See more at: http://www.timescolonist.com/a-family-struggles-to-rebuild-after-narrow-escape-from-fire-1.848366#sthash.4vOjNdmw.lY4xUmal.dpuf
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What has transpired in Canada
Birken, C., Parkin, P., To, T., MacArthur, C. (2006). Trends in rates of death from unintentional injury among Canadian children in urban areas: Influence of socioeconomic status. Canadian Medical Association Journal175(8):867–8.
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Presentation Notes
The difference in rates of death from unintentional injury between low- and high income quintiles did not widen over time. Targeted prevention should be implemented for injuries with the largest SES rate differences, such as those from fires, drowning and falls. Birken, C., Parkin, P., To, T., MacArthur, C. (2006). Trends in rates of death from unintentional injury among Canadian children in urban areas: Influence of socioeconomic status. Canadian Medical Association Journal 175(8):867–8.
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Determinants of Health
• Improving daily living conditions (Social Determinants of Injury), will reduce the incidence and severity of injury and make individuals more receptive to injury prevention initiatives.
• World Health Organization’s investigation into health determinants now recognizes European colonization as a common and fundamental underlying determinant of Indigenous health.
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Presentation Notes
The Social Determinants of Injury. ACIPCAPB. http://www.parachutecanada.org/downloads/research/reports/ACIP_Report_SDOI.pdf. Accessed March 2017 Social determinants and Indigenous health: the international experience and its policy implications. Presented at the International Symposium on the Social Determinants of Indigenous Health. Adelaide, Australia. April 29-30, 2007. Available at: http://www.who.int/ social_determinants/resources/indigenous_health_adelaide_ report_07.pdf. Accessed March, 2017.
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Determinants of Health • Injury prevention, like the broader area of
health promotion, must take into account the immediate realities of individuals’ day-to-day lives that include their home and work environments, their communities, and the economic, educational, and social resources each setting makes available – in conjunction with individuals’ own personal resources - Dennis Raphael PhD, Professor of Health Policy and Management, York University, Toronto, Ontario
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Presentation Notes
The Social Determinants of Injury. ACIPCAPB. http://www.parachutecanada.org/downloads/research/reports/ACIP_Report_SDOI.pdf. Accessed March 2017 Social determinants and Indigenous health: the international experience and its policy implications. Presented at the International Symposium on the Social Determinants of Indigenous Health. Adelaide, Australia. April 29-30, 2007. Available at: http://www.who.int/ social_determinants/resources/indigenous_health_adelaide_ report_07.pdf. Accessed March, 2017.
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Determinants of Health • The social determinants of health are linked to
injury through a variety of pathways including risks and hazards in community and home environments, stress caused by poverty and social exclusion, hazards, and access to safety equipment, services, and education.
• The connection between socioeconomic status (SES) and injury is mediated by conditions in housing, education, family, and neighbourhood contexts as well as type of injury.
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Presentation Notes
The Social Determinants of Injury. ACIPCAPB. http://www.parachutecanada.org/downloads/research/reports/ACIP_Report_SDOI.pdf. Accessed March 2017
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Determinants of Health • Observed decreases in SES are associated with
increases in fatal and serious injuries in a variety of studies. Conversely, as SES increases, rates of injury decline.
• The Canadian Institute for Health Information states that the poorest Canadians experience injury at a rate 1.3 times higher than the wealthiest.
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Presentation Notes
Laflamme, L., Burrows, S., Hasselberg, M. (2009). Socioeconomic differences in injury risks: A review of findings and a discussion of potential countermeasures. World Health Organization Europe. Canadian Institute for Health Information. (2010). Injury hospitalizations and socioeconomic status. Ottawa: Canadian Institute for Health Information. The Social Determinants of Injury. ACIPCAPB. http://www.parachutecanada.org/downloads/research/reports/ACIP_Report_SDOI.pdf. Accessed March 2017
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Determinants of Health • Higher injury rates are also correlated with living
in areas of concentrated poverty and/or concentrated minority group status. It is partially explained by housing conditions, for children who live in older or rented homes experience higher rates of injury from falls and burns.
• These communities also experience more fatal and non-fatal injuries from causes such as motor vehicle collisions and fire.
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Presentation Notes
Shenassa, E., Stubbendick, A., Brown, M. (2004). Social disparities in housing and related pediatric injury: A multilevel study. American Journal of Public Health 94(4):633–9. Cubbin, C., Smith, G. (2002). Socioeconomic inequalities in injury: Critical issues in design and analysis. Annual Review of Public Health 23:349–75.
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Indigenous Determinants of Health
• These additional determinants incorporate the historical experiences and culture of Aboriginal people in Canada and include the effects of colonization, globalization, and migration, as well as the need for cultural continuity, access, territory, and self-determination.
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Presentation Notes
National Aboriginal Health Organization. (2007). Broader Determinants of Health in an Aboriginal Context. Ottawa: National Aboriginal Health Organization.
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Interaction of the Determinants of Health
• Early childhood experiences of material or social deprivation can affect learning ability, relationships, and mental well-being. In the absence of safe and supportive environments, youth may be more likely to take excessive risk that place them at high risk for injury.
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Presentation Notes
The Social Determinants of Injury. ACIPCAPB. http://www.parachutecanada.org/downloads/research/reports/ACIP_Report_SDOI.pdf. Accessed March 2017
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The Challenges • Low SES individuals are less likely to believe
that injuries are preventable and are less likely to practice effective injury prevention measures. injury prevention
• Campaigns should be accessible and clear to individuals with low literacy rates and basic levels of comprehension, to ensure adequate outreach to people most likely at risk. (Failure to do so could increase disparity by only benefiting those at lower risk for injury.)
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Presentation Notes
The Social Determinants of Injury. ACIPCAPB. http://www.parachutecanada.org/downloads/research/reports/ACIP_Report_SDOI.pdf. Accessed March 2017 Cubbin, C., Smith, G. (2002). Socioeconomic inequalities in injury: Critical issues in design and analysis. Annual Review of Public Health 23:349–75. Batty, D., Gale, C., Tynelius, P., Deary, I., Rasmussen, F. (2008). IQ in early adulthood, socioeconomic position, and unintentional injury mortality by middle age: A cohort study of more than 1 million Swedish men. American Journal of Epidemiology 169(5):606–15.
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The Challenges • There have been extensive public safety
campaigns and training programs that have been used in attempts to enhance water based injury prevention and reduce risk in the NWT and Nunavut over the past 40 years (e.g. Canadian Red Cross swimming lessons, Lifesaving Society lifesaving/lifeguarding programs, Department of Transportation boating safety programs).
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Giles AR, Castleden H, Baker AC. ‘‘We listen to our Elders. You live longer that way’’: Examining aquatic risk communication and water safety practices in Canada’s North. Health & Place 16 (2010) 1–9
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The Legend of Qallupilluit the Female Sea Monsters
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Qallupilluit, female sea monsters Kigatilik (Inuit) – Once normal children they now serve their Qalupiluk “mothers” at the bottom of the sea. Drowning prevention story to keep young children away from the water’s edge.
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The Challenges
A Gathering of Elders
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Transport Canada (the federal department responsible for transportation) mandates that individuals using motorized boats carry with them items such as lifejackets, flares, lights, and extra gasoline; nowhere on these lists do items such as caribou skin clothing and boots, knives, harpoons, sled dogs, or even rifles appear. Instead, it has been assumed that expensive, and sometimes impractical, safety items (e.g., lights for boats are mandatory despite the fact that boats are typically operated during the summer when the Arctic has 24 hours of daylight) that have been developed by non-Aboriginal ‘‘experts’’ for warm southern Canadian climates will work more effectively in Arctic aquatic conditions than will clothes, equipment, and their associated practices developed in Arctic conditions for and by Arctic residents. The communication of this information draws on an assumption that knowledge from the South is unsurpassed and can be universally applied. This assumption results in the marginalization of local Aboriginal knowledge in favour of hegemonic perspectives concerning water, boat, and ice safe. There has not been a single drowning at a swimming pool in the NWT or Nunavut. By contrast, drownings in rivers, lakes, and oceans in the NWT and Nunavut occur at the highest rates in Canada (Canadian Red Cross, 2006. Drownings and Other Water-Related Injuries in Canada: 10 Years of Research. Author, Ottawa. ). Giles AR, Castleden H, Baker AC. ‘‘We listen to our Elders. You live longer that way’’: Examining aquatic risk communication and water safety practices in Canada’s North. Health & Place 16 (2010) 1–9
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The Challenges
• No amount of information will make a difference if one is unable to afford the safety devices, such as car seats, helmets and safety gates, that make a difference to injury rates and severity.
• Active involvement of members of the target population in program development is needed to increase the effectiveness of community-specific strategies.
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Presentation Notes
The Social Determinants of Injury. ACIPCAPB. http://www.parachutecanada.org/downloads/research/reports/ACIP_Report_SDOI.pdf. Accessed March 2017 Alberta Centre for Injury Control and Research. (2006). Socioeconomic status and injury. Injury Examiner. http://acicr.ca/Upload/news-events/communications-education/injuryexaminer/ socioeconomic-status/SES.pdf Accessed March 2017
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The Approach Excessive focus on either micro- or macro-level influences is likely to result in ineffective strategies.
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The Social Determinants of Injury. ACIPCAPB. http://www.parachutecanada.org/downloads/research/reports/ACIP_Report_SDOI.pdf. Accessed March 2017
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The Approach
• To address these injury disparities, respectful approaches that are collaborative, sustainable and culturally sensitive and that reflect the unique identities of First Nations and Inuit peoples are recommended.
• The OCAPTM principles underlying the collection of indigenous peoples’ data and information in Canada.
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Presentation Notes
Banerji A; Canadian Paediatric Society; First Nations, Inuit and Metis Health Committee. Preventing unintentional injuries in Children and Youth in Canada. Paediatr Child Health. 2012;17(7):393-4.
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OCAPTM Principles
• The data are Owned, Controlled, Accessed and Possessed by the indigenous community.
• Development of Canadian indicators by coalition - the First Nations and Inuit Child and Youth Injury Indicators Project Working Group.
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Presentation Notes
First Nations Information Governance Centre. The First Nations principles of OCAPTM [Internet]. Akwesasne (ON): FNIGC; 2013 [cited 2013 Aug 19]. Available from: www.fnigc.ca/ocap.html
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British Columbia is home to 198 First Nations, about one third of all First Nations in Canada. The First Nations of BC have rich and varied cultures, histories and traditions. BC has the greatest diversity of Aboriginal cultures in Canada. For example, seven of Canada's 11 unique language families are located exclusively in BC - more than 60% of the country's First Nations languages.
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http://www.nccah-ccnsa.ca/docs/social%20determinates/FirstNationsHealthImplementationPlan_Combo_LowRes.pdf. Accessed March 2017
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2005 Action Plan • Governance, Relationships and Accountability - 2015 • 1. Establish a new First Nations Health Council. • 2. The Provincial Health Officer will appoint an Aboriginal
physician to advise on Aboriginal health issues. • 3. Each health authority and the First Nations in their service
delivery area will develop Aboriginal Health Plans that are consistent with the priorities in this Plan, and that emphasize actions on issues unique or specific to each region.
• 4. Establish a First Nations Health Advisory Committee. • 5. Establish a province-wide Health Partners Group. • 6. Develop a reciprocal accountability framework to address
gaps in health services for First Nations in B.C.
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FEATURED CONTENT Inuit Qaujimajatuqangit - Rhoda's Dream: Burying the BabyNew Video Inuit Qaujimajatuqangit - Rhoda's Dream: Burying the Baby NEWS HEADLINES EVENTS CALENDAR WELCOME TO THE NCCAH The National Collaborating Centre for Aboriginal Health (NCCAH) is a national Aboriginal organization established in 2005 by the Government of Canada and funded through the Public Health Agency of Canada to support First Nations, Inuit, and Métis public health renewal and health equity through knowledge translation and exchange. The NCCAH is hosted by the University of Northern BC (UNBC) in Prince George, BC.
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RECOMMENDATIONS FOR ACTION • Collect more high-quality data on all areas of
Aboriginal health and well-being by and for Aboriginal peoples to meet their specific and various needs for evidence-based policy, practice and service. Allocate greater resources and funding for research, policy development and service provision.
• Increase capacity-building initiatives for Aboriginal peoples to actively and effectively govern their own social, health and education initiatives.
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Aboriginal children’s health: Leaving no child behind. Canadian UNICEF Committee, 2009. http://www.nccah-ccnsa.ca/docs/nccah%20partner%20documents/UNICEF%20Report,%20English.pdf. Accessed March 2017
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RECOMMENDATIONS FOR ACTION
• Inherent inequality in Canadian governance structures is a fundamental contributing factor to health disparities. Remove jurisdictional boundaries blocking effective health care delivery.
• Increase capacity-building initiatives for Aboriginal peoples to actively and effectively govern their own social, health and education initiatives.
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Presentation Notes
Aboriginal children’s health: Leaving no child behind. Canadian UNICEF Committee, 2009. http://www.nccah-ccnsa.ca/docs/nccah%20partner%20documents/UNICEF%20Report,%20English.pdf. Accessed March 2017
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Joe Gallagher J, Mendez JK, Kehoe T. The First Nations Health Authority: A transformation in healthcare for BC First Nations. Healthcare Management Forum 2015, Vol. 28(6) 255-261
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First Nations Health Authority
• The FHHA occupies a completely unique place in the health system in BC, holding strategic policy functions, service delivery functions, and population health functions at all levels.
• The FNHA offers a full spectrum of health services and support depending on the needs of the 203 First Nations communities in BC.
• The FNHA community-based services are largely focused on health promotion, disease prevention, and primary care.
• services.
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The FNHA does not replace or duplicate health services provided by the Ministry of Health and regional health authorities. Regional health authorities in BC oversee and coordinate the delivery of core primary care and specialist health services for First Nations citizens in urban areas across the province. Joe Gallagher J, Mendez JK, Kehoe T. The First Nations Health Authority: A transformation in healthcare for BC First Nations. Healthcare Management Forum 2015, Vol. 28(6) 255-261
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First Nations Health Authority
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Joe Gallagher J, Mendez JK, Kehoe T. The First Nations Health Authority: A transformation in healthcare for BC First Nations. Healthcare Management Forum 2015, Vol. 28(6) 255-261
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Wellness is a philosophy of the FNHA. It is holistic and includes living well through a balanced lifestyle and a harmonious relationship with one’s environment. The First Nations Perspective on Wellness image aims to create a shared understanding of FNHA’s holistic vision of wellness. Wellness for First Nations encompasses the mental, physical, emotional, environmental, social, economic, cultural, and spiritual aspects of an individual, family, and community. Joe Gallagher J, Mendez JK, Kehoe T. The First Nations Health Authority: A transformation in healthcare for BC First Nations. Healthcare Management Forum 2015, Vol. 28(6) 255-261 First Nations Health Authority. First Nations Perspective on Wellness. Available at: http://www.fnha.ca/wellness/wellnessand-the-first-nations-health-authority/first-nations-perspectiveon- wellness. Accessed March, 2017.
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A Holistic Perspective of Health
• It has become widely accepted in mainstream health literature and, to some extent, practice that a “silo” approach to prevention and treatment of ill-health fails to address the complexity of most health issues. This is particularly true for Aboriginal peoples, who have historically been collectivist in their social institutions and processes, specifically the ways in which health is perceived and addressed.
• Indigenous ideologies embrace a holistic concept of health that reflects physical, spiritual, emotional and mental dimensions. However, it is the interrelatedness of these dimensions that is perhaps most noteworthy.
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http://www.nccah-ccnsa.ca/docs/social%20determinates/nccah-loppie-wien_report.pdf. Accessed March 2017
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Available at: http://www.trc.ca/websites/trcinstitution/index.php?p=890. Accessed March 2017.