Health in Context - Diabetes in Indigenous Populations

Introduction

In this post I aim to analyze and integrate what I have learned from Athabasca University’s MHST-601 course in the context of type 2 diabetes mellitus (T2MD) in Indigenous populations. I will discuss the Indigenous health care system, the definition of health, determinants of health, an ecological model of health, and strategies to improve T2DM prevention and management in Indigenous populations.

T2DM is a chronic condition in which your body cannot produce enough insulin or does not properly use the insulin it produces (Diabetes Canada, n.d.). Risk factors include high blood pressure, high cholesterol, obesity, psychiatric disorders, obstructive sleep apnea, and acanthosis nigricans (Diabetes Canada, n.d.). Untreated T2DM can cause devastating complications including kidney disease, eye damage, heart disease, stroke, high blood pressure, mental health issues, nerve damage, and amputation (Diabetes Canada, n.d.).

Vulnerable populations are defined as groups who are at increased risk of receiving a disparity in medical care on the basis of social, economic, or environmental factors (“Care of Vulnerable Populations,” 2006; Health Equity Institute, 2014). Indigenous populations are some of the most vulnerable in Canada (Public Health Agency of Canada, 2018). The health inequities experienced by Indigenous populations are a result of forced relocation, loss of lands, creation of the reserve system, banning of Indigenous lands and cultural practices, and the creation of the residential school system (Public Health Agency of Canada, 2018; Rahim et al., 2018). Vulnerable populations in Canada are discussed further in this blog post. Indigenous populations are among the highest-risk for T2DM in Canada, with age-standardized prevalence rates of 17.2% among First Nations living on-reserve, 10.3% among First Nations living off-reserve, and 7.3% among Métis, compared to 5.0% in the general population (Public Health Agency of Canada, 2011). Indigenous people tend to develop T2DM at younger ages, have complications sooner, and have poorer treatment outcomes (Jacklin et al., 2017).

The health care system

The Canadian health system is a complex a patchwork of federal, provincial/territorial, and municipal policies, legislation, and relationships (National Collaborating Centre for Aboriginal Health, 2011). Indigenous populations face barriers to health services as they are subject to an inadequate federal system of health care delivery, compared to Non-Indigenous Canadians who fall under provincial systems (Reading & Wein, 2009). Various Indigenous authorities and self-government agreements further complicate Indigenous health care (National Collaborating Centre for Aboriginal Health, 2011). This ill-defined patchwork of programs and policies results in limited accountability, fragmented delivery, and jurisdictional ambiguity (Reading & Wein, 2009). The danger of this fragmented system is demonstrated by Jordan River Anderson’s story. Jordan was a member of Manitoba’s Norway House Cree Nation. He was born with a rare disorder and spent his short life in a hospital because of a dispute between provincial and federal governments over who should pay for his home care. ‘Jordan’s Principle’ was passed in the House of Commons in 2007, stating “that in the event of jurisdictional dispute over funding for a First Nation child, the government of first contact will pay for services and seek cost-sharing later” (Kallil, 2019; National Collaborating Centre for Aboriginal Health, 2011). Sadly, there has been little progress in implementing Jordan’s Principle, and the health of Indigenous children across Canada is still widely overlooked (Kallil, 2019; National Collaborating Centre for Aboriginal Health, 2011).

The definition of health and chronic disease

The World Health Organization’s (WHO) definition of health has not been updated since 1948, and states that health is “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” (World Health Organization, 1995). I explore the limitations and importance of the definition of health in more detail in this blog post. The definition is especially problematic in the context of chronic disease (Huber et al., 2011). Improved public health measures have allowed populations to manage chronic disease and live longer, increasing the prevalence of chronic disease around the world (Huber et al., 2011). The WHO definition calls for “complete” well-being, declaring people with chronic disease definitively ill (Huber et al., 2011). The definition does not include a measure of one’s ability to adapt and cope with their health conditions (Huber et al., 2011).

There are several treatment options that allow individuals to manage and cope with T2DM, including weight loss, physical activity, following nutrition guidelines, oral hypoglycemic agents, and insulin (Nyenwe et al., 2011). Studies have shown that both intensive weight management (Lean et al., 2018) and bariatric surgery (Dixon et al., 2008) can be effective at putting T2DM patients into remission (described as a non-diabetic state and off antidiabetic drugs). The vast amount of treatment options make living with T2DM a manageable disease for many people. However, anyone with the diagnosis is definitively ill according to the WHO definition of health, highlighting its outdatedness. As previously discussed, Indigenous populations are among the highest-risk populations for T2DM in Canada, and are therefore more apt to suffer from the current definition of health, which has vast implications in all health fiends, including practice, policy, services, and promotion (Leonardi, 2018).

Determinants of health

The Public Health Agency of Canada describes determinants of health as the broad range of personal, social, economic, and environmental factors that determine individual and population health (Public Health Agency of Canada, 2020). The 12 determinants of health are illustrated in Figure 1.

Figure 1. Public Health Agency of Canada’s determinants of health (Public Health Agency of Canada, 2020).

When assessing the determinants of health in Indigenous populations, it is important to consider the historical, political, social, and economic conditions that have influenced Indigenous health (Public Health Agency of Canada, 2018). Colonialism of Indigenous populations into Euro-Canadian culture has been largely responsible for destabilizing the determinants of Indigenous health (Public Health Agency of Canada, 2018). The destabilization of determinants of health in Indigenous populations has led to higher rates of infectious and chronic diseases, including the epidemic of T2DM in First Nations adults (Mikkonen & Raphael, 2010; Reading & Wein, 2009). To demonstrate the significance of the disparity between Indigenous and Non-Indigenous populations in Canada, Table 1 provides specific data for several determinants.

Table 1. Determinants of health comparison between Indigenous and Non-Indigenous populations in Canada.

The determinants of health are interrelated and often compounding. Income has a direct effect on health outcomes and access to health services, with lower socioeconomic status being associated with higher rates of T2DM (Public Health Agency of Canada, 2019). Individuals with low-income may be faced with challenges such as transportation to appointments, inability to pay for prescription or over-the-counter medication, inability to miss work for appointments, and inability to afford healthy foods (Center for Health Progress, 2013). I discuss the determinants of health in more detail in this blog post.

Multilevel approach to understanding health

Understanding health-related behavior requires a comprehensive assessment and multi-level perspective. Ecological models provide a framework for understanding the factors that affect specific health behaviours, including the determinants of health (Bolton, n.d.). It consists of five tiers: individual, interpersonal, community, organizational, and policy (Figure 2). In this blog post I introduce the ecological model of health in the context of physical activity.

Figure 2. Ecological model of health framework (Bolton, n.d.).

Ecological models should be used by public health agencies and organizations to identify effective strategies for health promotion (Shefner­‐Rogers, 2013). Public health interventions that consider multiple levels of influence and target upstream levels are more successful, but less prevalent, than interventions that focus on individual and interpersonal factors (Stellefson, 2019). Health promotion and interventions can be used to prevent and manage T2DM, by targeting health behaviours such as diet and physical activity.

Health promotion initiatives have been assessed using the ecological model in Australian Indigenous communities. It is recognized that health education and health promotion initiatives are most often generated from a Western culture perspective that reflects particular values that are potentially distinct to those of some Indigenous people and communities (Nelson et al., 2010). Therefore, in order to be successful, interventions must function in a complex social environment, respect Indigenous knowledge, culture, and social systems (Reilly et al., 2011).

A study by Nelson et al. (2010) used a social-ecological model as an organizational framework to synthesize the current literature on Indigenous Australians and their engagement in physical activity. The authors found that engagement in physical activity was linked to a many influences such as social relationships, underlying environmental, occupational, nutritional, residential, and experiential conditions (Nelson et al., 2010). They concluded that health educators and health promotion initiatives must acknowledge that there are different approaches and meanings attached to physical activity for all people and require a complex consideration of this diversity in order to be successful (Nelson et al., 2010). An ecological approach allows evaluation of a holistic model of health service delivery and provided useful information for planning subsequent interventions (Reilly et al., 2011).

Into the future: T2DM screening, prevention, and management strategies

The Truth and Reconciliation Committee of Canada’s Calls to Action (2012) identifies areas for improvement in the health sector for Indigenous peoples. These calls to action include accepting responsibility for current disparities in health, providing sustainable funding, addressing distinct health needs, increasing the number of Indigenous professionals in the health field, and providing cultural competency training for all health care professionals (Truth and Reconciliation Commission of Canada, 2012).

The causes and origins of the health disparities faced by Indigenous peoples in Canada are historic and complex. T2DM screening, prevention, and management strategies must be tailored to the complex social environment to be successful. Jacklin et al. (2017) conducted focus groups with 32 participants diagnosed with T2DM in 5 Indigenous communities. The authors found that experiences were improved when patients have a positive and equitable relationship with their health care provider and organization (Jacklin et al., 2017). Opportunities to improve training in medical education were identified, including enhanced patient-centered care approaches and cultural safety training (Jacklin et al., 2017).

The 2018 clinical practice guidelines for T2DM and Indigenous peoples identify several areas for improvement, with a focus on screening and prevention strategies (Crowshoe et al., 2018). Effective strategies for prevention will incorporate specific social, cultural, and health service contexts of the community, and effective management will require continuous self-reflection on the part of the health care worker to integrate Indigenous-specific contexts to the clinical approach (Crowshoe et al., 2018).

Conclusion

T2DM is a prevalent issue for Indigenous populations in Canada. Fragmented delivery and limited accountability within the Indigenous health care system is enabling disparities in health care. Colonial policies and practices have caused the adverse determinants of health faced by Indigenous populations. Health promotion and interventions must focus on upstream levels of influence in the ecological model and account for complex social structures. Strategies for improvement should consider the unique circumstances, beliefs, and culture of Indigenous populations. It is important to take a comprehensive approach to better understanding and address health issues and disparities, specifically in vulnerable populations.

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