Indigenous Health Research Monitoring, March 2022

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Just Published

 New scientific publications and articles

Prevention of infectious and chronic diseases

Housing conditions and respiratory morbidity in Indigenous children in remote communities in Northwestern Ontario, Canada

Kovesi, T., Mallach, G., Schreiber, Y., McKay, M., Lawlor, G., Barrowman, N., Tsampalieros, A., Kulka, R., Root, A., Kelly, L., Kirlew, M., & Miller, J. D. (2022). Housing conditions and respiratory morbidity in Indigenous children in remote communities in Northwestern Ontario, Canada. Canadian Medical Association Journal, 194(3), E80–E88.
Open access: PDF

Context

In Canada, young First Nations children present elevated rates of lower respiratory tract infections (LRTIs), including bronchiolitis and pneumonia. For infants younger than one year living in the Sioux Lookout First Nations Health Authority region in Northwestern Ontario, the hospital admission rate is 44 per 1,000 people compared with 25 per 1,000 in the general population. Throughout the world, harmful effects on respiratory health are associated with poor indoor environmental quality (IEQ). The authors point out that the housing crisis is part of the historical context of colonization and assimilation, which led to the inequities and underfunding behind housing issues.

Objective

Quantify the IEQ in isolated First Nations communities and evaluate any associations with respiratory disorders in children.

Methodology

This quantitative study was based on questionnaires administered by a research coordinator, as well as on a medical chart review of 98 First Nations children aged three or less living in four communities in the Sioux Lookout region of Northwestern Ontario.

To quantify the IEQ, data was also collected from the housing units. The presence of mould was quantified and air quality data was collected over a five-day period in each home. In addition, the quantity of toxins (endotoxins) present in dust settled onto floors was measured.

The researchers used univariable and multivariable analyses to analyze the associations between IEQ variables and children’s respiratory conditions.

What was learned? 

The findings confirm the conclusions of previous studies indicating that housing units located in First Nations communities require major repairs. The results describe poor housing conditions observed during the study:

  • The lack of a functioning ventilation system.
  • A high level of mould (average surface area of 0.2 m2) and a high level of contaminants (endotoxins) present in dust.
  • Exposure to second-hand tobacco smoke in 94% of homes.
  • Overcrowded housing (the average occupation is 6.6 people).

The results describe the respiratory problems and show the strength of the associations studied:

  • 21% of children, whose average age at the time of the study was 1.6 years, had been admitted to hospital for a respiratory infection.
  • Multivariable modelling shows an association between LRTIs, log endotoxin (p = 0.07) and age (p = 0.02). An association also exists between upper respiratory tract infections, the presence of mould (p = 0.07) and age (p = 0.03). The presence of wheezing during a cold is associated with log endotoxin (p = 0.03) and age (p = 0.04).

Based on these results, the researchers hypothesize that asthma could be underdiagnosed in First Nations communities. Wheezing is present in more than one third of children (39%), but only 4 of the 98 children (4%) had received a diagnosis of asthma.

Limitations

The authors mentioned several limitations. First, they emphasize that the cross-sectional study design does not make it possible to conclude that the poor IAQ causes the respiratory problems, only that observing such problems is more likely in housing where the air quality is poor. Since the study evaluated several exposures and results, the risks of type I error (erroneously rejecting a hypothesis in a statistical test) may be higher. Finally, the authors point out that the method used to quantify mould has limited precision, since mould may be found outside the living areas, for example in crawl spaces.

Effect of a home-visiting intervention to reduce early childhood obesity among Native American children: A randomized clinical trial

Rosenstock, S., Ingalls, A., Foy Cuddy, R., Neault, N., Littlepage, S., Cohoe, L., Nelson, L., Shephard-Yazzie, K., Yazzie, S., Alikhani, A., Reid, R., Kenney, A., & Barlow, A. (2021). Effect of a home-visiting intervention to reduce early childhood obesity among Native American children: A randomized clinical trial. JAMA Pediatrics, 175(2), 133–142.
Open access: PDF

Context

Early childhood obesity affects Indigenous communities disproportionately. Recent data indicates that 21% of First Nations children between the ages of 2 and 5 suffer from obesity, compared with 14% of non-Indigenous American children. A home-visiting intervention focused on the eating habits of infants and families is a promising strategy for this population.

Objective

Evaluate the impact of a home-visiting strategy (Family Spirit Nurture or FSN) on the consumption of sugar-sweetened beverages (SSBs), the parent’s responsiveness to the infant’s eating habits and the infant’s body mass index (BMI) up to 12 months following birth.

Methodology and data

This clinical trial using 1:1 randomization included 134 Navajo mothers aged 13 or older and their infants less than 14 weeks of age recruited in the Navajo Nation community in Shiprock, U.S.A. The intervention group of 68 mother-infant dyads was exposed to six FSN sessions, whereas the control group attended three educational sessions on preventing injury. The intervention took place in the home between three and six months post-partum, and the effects of the intervention were evaluated at 4, 6, 7, 8, 9 and 12 months. To achieve the objective, multivariable analyses were conducted using Stata, version 14.

What was learned?

The infants of mothers exposed to FSN consumed significantly fewer SSBs than the control group right up to 12 months post-partum. The parents’ responsiveness to the infant’s eating habits improved significantly up to 9 months post-partum. Children of mothers exposed to FSN were introduced to solid food at an earlier age and presented a lower BMI at six and nine months compared with the control group.

Limitations

The authors report several methodological limitations. First, the study was conducted in a single community, which limits the generalizability of the results. Next, monitoring of the participants ended at 12 months post-partum, thereby limiting observation of the durability of the intervention effects. In addition, a toddler responsive feeding scale would have been more appropriate than the infant responsive feeding scale for infants aged 12 months, given that infants at this age have more independent eating habits. Finally, the intervention could have started during the first weeks of pregnancy and continued following the delivery in order to promote good eating habits among infants from birth.

Promotion of wellbeing and mental health

Adaptation and implementation of the Housing Outreach Program Collaborative (HOP-C) North for Indigenous youth

Toombs, E., Mushquash, C. J., Lund, J., Pitura, V. A., Toneguzzi, K., Leon, S., Bobinski, T., Vitopoulos, N., Frederick, T., & Kidd, S. (2021). Adaption and implementation of the Housing Outreach Program Collaborative (HOP-C) North for Indigenous youth. American Journal of Orthopsychiatry, 91(1), 96–108. DOI: 10.1037/ort0000520
Not available through open access.

Context

A large number of Indigenous youths in Northwestern Ontario are living in precarious housing or are homeless. Since the pathways to homelessness are different for Indigenous youth than for non-Indigenous young people, interventions targeting homelessness should be adapted to meet their needs.

The Housing Outreach Program Collaborative (HOP-C) North has been culturally adapted in collaboration with local Indigenous organizations. It is based on a tertiary prevention intervention program in Toronto offering housing and mental health support for young people in transitional situations to help them get off the streets. Nevertheless, little is known about the program’s relevance in the Northwestern Ontario Indigenous context.

Objectives

There were two objectives in evaluating the program:

  1. Describe the participation of Indigenous young people transitioning from adolescence into adulthood who registered for the program to find a way out of homelessness.
  2. Evaluate the relevance of this adaptation of the Toronto-based program to Thunder Bay in Northern Ontario.

Methodology

The authors used a mixed-methods approach. To describe the participation of young people in the program, quantitative (questionnaire) and qualitative (interviews) measures were taken before (n = 15) and after (n = 8) the program. The participants’ health and wellbeing, housing stability and social support were measured. To assess the relevance of the adaptation of the program, personal interviews were conducted with employees (managers, mentors, case managers and counsellors) who took part in implementing the program in Thunder Bay (n = 8). Finally, a discussion group was held with six other employees working on the frontline with the young people.

What was learned?

The program enabled the young people to improve their:

  • Mental health through the effectiveness of the services provided
  • Sense of independence and self-sufficiency
  • Trust in the employees
  • Ability to achieve longer-term goals (for example, travel, get an education or obtain a mortgage).

The employees noticed an improvement in the young peoples’ personal hygiene and the cleanliness of their living space. Employees also reported that getting to know other young people in the context of the program helped some participants to overcome their social anxiety and become more open to others. However, staff indicated that not all participants improved as a result of the program.

Several program characteristics contributed to its success:

  • Accessibility. Among the strategies implemented, services were offered to young people right where they live.
  • Voluntary participation and program flexibility.
  • Active participation. Emphasis was placed on gradually building individual (participant-to-professional) and organizational relationships of trust.
  • Relevant cultural programming.

The study suggests that this program, which is adapted both culturally and to the Northern Ontario context, can be helpful to Indigenous young people who are homeless or living in precarious housing.

Limitations

Several limitations were identified by the authors:

  • The small sample size limits the statistical power.
  • Participation bias for the post-test interviews may have influenced the results.
  • The recruited participants were being followed by a mental health services organization, which may affect the sample representativeness and external validity.
  • Several services were provided, making it difficult to identify the specific component that influenced participant change over time.
  • Study attrition is common among individuals experiencing homelessness, who strive to meet many demands associated with exiting homelessness

Ngarratja Kulpaana : Talking together about the impacts of lateral violence on Aboriginal social and emotional well-being and identity

Whyman, T., Murrup-Stewart, C., Carter, A., Young, U. M., & Jobson, L. (2022). Ngarratja Kulpaana: Talking together about the impacts of lateral violence on Aboriginal social and emotional well-being and identity. Cultural Diversity & Ethnic Minority Psychology, 28(2): 290–298. DOI: 10.1037/cdp0000518.
Not available through open access.

Context

Lateral violence occurs when, in response to experiences of oppression, members of the oppressed group take out their anger on members of their own group. This phenomenon is common among Indigenous peoples where colonial practices, such as the forced removal of children from their family, led to the propagation of pejorative beliefs and values regarding Indigenous peoples. Indigenous peoples may internalize negative beliefs and values, which then drive them to commit lateral violence. While lateral violence may include physical acts, it generally takes the form of bullying, gossiping, family quarrels and social isolation. The most common form involves attacking the Indigenous identity of others using colonialist stereotypes about what constitutes a “real” Indigenous person. Despite the foregoing, few studies have explored the impacts of lateral violence on the wellbeing of Aboriginal Australians.

Objectives

This study aimed to examine the impacts of lateral violence on the social and emotional wellbeing and the identity of Aboriginal Australians. The study was guided by two research questions:

  • What impacts does lateral violence have on the social and emotional wellbeing of Aboriginal peoples?
  • How does lateral violence affect Aboriginal identity?

Methodology and data

The article presents data collected during yarning circles attended by 17 Aboriginal Australians (9 men and 8 women) aged 18 to 65. The authors refer to participants as “knowledge-holders.” As a form of traditional conversation among Aboriginal peoples of Australia, yarning circles are described as informal discussion through which information and stories are shared in an atmosphere of respect and listening. Recruitment, which took place among staff and students at a university, was terminated when the data saturation point was reached. The yarning circles were analyzed using content summaries and thematic analyses.

What was learned?

The results brought to the fore three themes concerning the impacts of lateral violence on the wellbeing and identity of Aboriginal Australians.

  1. Impacts of lateral violence on social and emotional wellbeing: Lateral violence can damage and even sever family relationships. On the community level, lateral violence discourages participation in social and cultural activities and events. Difficulty in attending cultural events, or those related to the traditional territory, were also mentioned as widespread impacts of lateral violence.
  2. Lateral violence and identity: Lateral violence is primarily described as attacks by one community member on the Indigenous identity of another community member. For example, if the physical appearance of someone does not correspond exactly with the typical Indigenous phenotype, it may become the object of lateral violence. This may lead individuals targeted by such attacks to call into question their own Indigenous identity and so disengage completely from their cultural heritage.
  3. The interconnected impacts of lateral violence on identity and social and emotional wellbeing: The impact of lateral violence on identity is described as being directly related to social and emotional wellbeing. Mental health issues (such as depression and anxiety) may appear following attacks on someone’s Indigenous identity. Certain colonial practices have resulted in some Aboriginal Australians being less familiar with their culture and traditional territory, making them a possible target of lateral violence.

In a context in which Aboriginal Australians already suffer the negative consequences of oppression, lateral violence is yet another obstacle to their wellbeing. The authors recommend developing strategies and interventions aimed at preventing and reducing lateral violence and its impacts on Aboriginal health.

Limitations

The authors mention that data collection took place in only one city, using a small sample of participants, which may limit the generalizability of the results. Most of the knowledge-holders had received higher education, which may have influenced the manner in which lateral violence was discussed and articulated. Finally, the study did not look at the participants’ personal experience of lateral violence or their ideas for addressing lateral violence.

Social inequalities and determinants of health

Bonding social capital and health within Four first Nations communities in Canada: A cross-sectional study

Yeung, S., Rosenberg, M., Banach, D., Mayotte, L., Anand, S. S., Lac La Ronge Indian Band, Fort McKay First Nation, & Castleden, H. (2021). Bonding social capital and health within four First Nations communities in Canada: A cross-sectional study. SSM - Population Health, 16, Article 100962.
Open access: PDF.

Context

The concept of social capital is increasingly used in the field of health research since it acts as a determinant of health. Research shows that a positive association exists between social capital and physical, mental and emotional health, as well as with the adoption of health-promoting behaviours. That said, only one social capital and health model has been created to explain the specifics of Indigenous social capital. The model lays out three social capital scales: bonding (relationships within the community), bridging (relationships with other communities) and linking (relationships with formal institutions). A component of the three scales is community ethos, described as an individual’s habits within their community. In order to advance knowledge about Indigenous social capital and better understand its interaction with health, this study undertook to test the model in Indigenous communities.

Objectives

Within a strengths-based framework, the study aimed to 1) quantitatively describe the ethos dimension of bonding social capital in Canadian First Nations communities, and 2) examine the associations between bonding social capital and individual self-rated health.

Methodology and data

A total of 591 individuals from four First Nations communities volunteered to participate. Cross‑sectional data was obtained from the baseline evaluation of the Canadian Alliance for Healthy Hearts and Minds (CAHHM), which took place from 2013 to 2018. Using the CAHHM study, contextual factors, health and lifestyle, and health services were analyzed. Social capital was measured through: civic involvement (e.g., involvement in a social or religious group), political engagement (voting frequency in local, provincial and federal elections) and social contact (frequency of contact with friends). Feelings of safety, trust and reciprocity, as well as collective action were also documented as representing the community ethos.

What was learned?

The results of bivariable analyses show that participants in the four communities reported high levels of social capital. Specifically, they reported frequent socialization with a circle of friends and the extended family, as well as a feeling of reciprocity towards their community. Nevertheless, significant differences were observed between the communities, for example, with respect to values, attitudes, trust and standards, as well as to political engagement on the local, provincial and federal levels and civic involvement.

The results of the multivariable analyses indicate that education and gender are associated with individual self-rated health, which is also associated with civic involvement and political engagement on the provincial and federal levels. Significant differences were observed between the four communities in the area of individual self-rated health. Moreover, the community of residence was a significant indicator of self-rated health in all the analyses.

Limitations

The small sample size does not allow for generalization to other Indigenous communities. The measurement instruments used, which were not specifically designed to measure social capital and not specific to Indigenous social capital, were an obstacle to the in-depth exploration of certain subtleties of Indigenous social capital, as well as to making a contribution to the advancement of knowledge on the subject. Variations observed between the four communities underscore the importance of contacting communities one by one in order to explore their unique attributes and generate significant data.

Food safety and traditional diets

Development of an optimal grocery list based on actual intake from a cross-sectional study of First Nations adults in Ontario, Canada

Batal, M., Kenny, T.-A., Johnson-Down, L., Ing, A., Fediuk, K., Sadik, T., Chan, H. M., and Willows, N. (2021). Development of an optimal grocery list based on actual intake from a cross‑sectional study of First Nations adults in Ontario, Canada. Applied Physiology, Nutrition, and Metabolism. Online ahead of print. DOI: 10.1139/apnm-2020-0950.
Open access: PDF

Context

In Canadian Indigenous communities, nearly half of households experience food insecurity, and many Indigenous people face nutrition-related disease. Among First Nations, for example, type 2 diabetes is three to fives more prevalent than in the general population. The geographic isolation of Indigenous communities results in higher food costs and reduces the variety and quality of what is available. Moreover, environmental degradation and colonial policies have disrupted access to traditional foods, which were generally nutritionally complete. In order to reduce the burden of chronic diseases, practical, culturally adapted recommendations to improve the contemporary diet of Indigenous peoples are needed.

Objectives

Develop a nutritious food basket and a weekly grocery list of market food frequently consumed by members of the target First Nations that met the nutritional constraints proposed by the Institute of Medicine (IOM) and was less than or equal to existing diet costs.

Methodology and data

In fall 2011 and 2012, 24-hour diet recall questionnaires were completed as part of the First Nations Food, Nutrition & Environment Study (FNFNES). In 18 Indigenous communities in Ontario, 1,387 participants reported 1,705 food items, including traditional foods. Grouped by nutritional profile, the food items were categorized into 570 food groups. Average quantities for the 100 most reported food groups in the recall questionnaires represent the eating habits of study participants. Costs were calculated using Health Canada’s 2008 national nutritious food basket, adjusted to the 2020 cost of living and for geographical remoteness and confirmed directly from retailers.

A mathematical modelling tool (linear programming) was used to determine the optimal food model. This model is a combination of foods that meet nutritional and cost constraints. The grocery list derived from the model is designed for a family of four (two adults and two children).

What was learned?

First, the eating habits observed among participants do not fully meet the recommended nutritional intake.

Three food models were created using linear programming. The authors deemed the “all foods” model to be optimal, since it includes all 100 market food groups as well as the most popular traditional foods in the sampled communities, which makes it easier to adopt than Health Canada’s national nutritious food basket.

The three models respect the nutritional constraints for men, but not women, regarding the intake of dietary fibre, linoleic acid, phosphorus and potassium. That said, the intake of those nutrients in the “all food” model is superior to the intake associated with eating habits observed among participants.

The researchers reiterate that contemporary First Nations eating habits diverge from their healthier traditional eating habits. A culturally appropriate diet would therefore contain more traditional foods and fewer market foods.

Finally, although the grocery list proposed by the researchers underestimates the actual weekly cost, since the cost of traditional foods has not been included (e.g., the cost of hunting and fishing equipment), the list is representative of First Nations eating habits in Ontario. From a public health perspective, therefore, the grocery list is a culturally adapted alternative to Health Canada’s national nutritious food basket.

Limitations

The authors did not take into consideration constraints associated with the possible contamination of some traditional foods. Seasonality can have an effect on the traditional foods reported in data collected in the summer or fall. Finally, alcohol consumption was not considered, which may impact the energy intake and cost calculations.

The inclusion of articles presented in this monitoring newsletter does not represent their endorsement by the Institut. Professional judgment remains essential in assessing the value of these articles for your work. You can also consult the Methodology for Indigenous Health Research Monitoring.