SOCIAL DETERMINANTS OF HEALTH AND

INDIGENOUS PEOPLE
INHS 100 ONLINE
Social Determinants of Health
■ A determinant of health is simply something that can impact an
individual’s, a family’s or a community’s health.
■ Social determinants of health:
 Determinants resulting from social constructions and situations. 
• Social determinants of health provide us with a framework for
understanding health and what influences it.
The WHO states:
• Social Determinants of Health are the conditions in which
people are born, grow, live, work, and age, including the health
system.
• The WHO, as well as the Public Health Agency of Canada, have
adopted this framework.
– Social Determinants of Health are mostly responsible for health
inequities – the unfair and avoidable differences in health status
seen within and between countries.
– Lalonde Report (1974) and the Ottawa Charter of Health
Promotion (1986) acknowledged the need for an approach to
holistically explore what factors influence health and wellbeing.
Social Determinants of Health can include:

Gender, early life, education, employment and working conditions, food

security, health care services, housing, income and income distribution,
social safety net, social exclusion/inclusion, minority status, Indigenous
status, unemployment and employment security (Raphael, 2004).
■ Concepts of social determinants of health do not deny that there are
biological and genetic influences on health. However, in medical models
of health, these determinants have been the primary focus, and other
influences of health have been largely neglected.
(Canadian Medical Association, 2013)
Determinants of Health - What Makes Canadians Healthy or Unhealthy?
This deceptively simple story speaks to the complex set of factors or conditions that determine the level of health of
every Canadian.
■ "Why is Jason in the hospital? 
■ Because he has a bad infection in his leg.
■ But why does he have an infection? 
■ Because he has a cut on his leg and it got infected. 
■ But why does he have a cut on his leg? 
■ Because he was playing in the junk yard next to his apartment building and there was some sharp, jagged steel
there that he fell on.
■ But why was he playing in a junk yard? 
■ Because his neighborhood is kind of run down. A lot of kids play there and there is no one to supervise them. 
■ But why does he live in that neighborhood? 
■ Because his parents can't afford a nicer place to live. 
■ But why can't his parents afford a nicer place to live? 
■ Because his Dad is unemployed and his Mom is sick. 
■ But why is his Dad unemployed? 
■ Because he doesn't have much education and he can't find a job. 
■ But why ...?
Public Health Agency of Canada
The Public Health Agency of Canada outlines the
following as twelve key determinants of health:

1. Income and Social Status: 7. Personal Health Practices

and Coping Skills 
2. Social Support Networks
8. Healthy Child Development
3. Education and Literacy
9. Biology and Genetic
4. Employment/Working Endowment
Conditions
10. Health Services
5. Social Environments
11. Gender
6. Physical Environments
12. Culture
■ Through research on what impacts health, we have discovered that trends of ill
health are complicated and connected to large-scale social situations such as
poverty and colonization.
■ On a population level, ill health is not simply consequences to individuals’
choices.
– There are factors that limit ‘choice’ and opportunities to live healthy, and
these factors are connected to social values and systems that privilege
various populations differently.
■ Determinants of health do not act independently
■ “Such determinants interact with one another and are interrelated in a complex
causal web”
Source: Waldram, Herring, & Young, 2006
■ Health researchers, educators, practitioners, provincial, and federal governments
are now faced with the challenge of addressing and overcoming the complex
interaction of factors that are leading to such health disparity
Sources: Reading, 2009.
 The Canadian Institute for Health Information notes that social and
economic conditions have “had a profound impact on the health of
Aboriginal Peoples in Canada … The contemporary health and well-being of
Canada’s Aboriginal Peoples must be viewed in this broad historical and
social context” (CIHI, 2004).
 Health Disparities, Inequalities, and
Inequities

■ The terms disparity and inequality are often used interchangeably to

signify that something is not equal
– Inequities also signify that something is not equal, however it implies
that things are unequal as a result of a social injustice
Naomi Adelson states: 
"Health disparities are those indicators that show a
disproportionate burden of disease on a particular population.
 Health inequities point to the underlying causes of the
disparities".
■ The WHO, as well as the Public Health Agency of Canada have adopted
this framework.
■ Lalonde Report (1974) and the Ottawa Charter of Health Promotion
(1986) acknowledged the need for an approach to holistically explore
what factors influence health and wellbeing.
Human Rights

■ Why study human rights as applied to health?

■ What is the major cause of despair in
– Canada
– North America
– Globally
■ How does politics affect health?
 Human Rights Canada

■ Universal Declaration of Human Rights (UDHR):

– United Nations 1948
■ Canadian Charter of Rights and Freedoms
– Constitution Act 1982
Charter of Rights and Freedom

1. Fundamental Freedoms
2. Democratic rights
3. Mobility rights
4. Legal rights
5. Equity rights
6. Language Rights
7. Other
– Aboriginal rights, including treaty rights, receive more direct
constitutional protection under section 35 of the Constitution
Act
Fundamental Freedoms

■ Freedom of
– Consciousness
– Religion
– Thought
– Belief
– Expression
– Press
– Peaceful Assembly
– Association
Mobility Rights
– Right to enter, leave and remain in Canada
Legal Rights
– Life, liberty and security, detention, unusual punishment….
Equity Rights
– Protection and benefits
Language Rights
– English and French
Other

■  Aboriginal rights, including treaty rights, receive more direct

constitutional protection under section 35 of the Constitution Act,
■ Equally to men and women
■ Multicultural
■ Does not extend to hate and obscenity (vs Keegstra, 1990)
■ Definition of marriage (2004-Saskatchewan; 2005-Canada)
Indigenous people
(compared to non-Indigenous people)

■ Have lower median after-tax income;

■ Are more likely to experience unemployment;
■ Are more likely to collect employment insurance and social assistance;
■ Are more likely to live in housing in need of major repairs;
■ Are more likely to experience physical, emotional or sexual abuse;
■ Are more likely to be victims of violent crimes; and
■ Are more likely to be incarcerated and less likely to be granted parole.
Human rights for Indigenous people

■ Prior to 2008, the Human Rights Act did NOT apply to people living on
reserve land.
– This was because the Canadian Human Rights Act specifically
excluded anything that had to do with the Indian Act. 
– http://www.chrc-ccdp.ca/sites/default/files/report_a_matter_of_rig
hts_en.pdf
United Nations Declaration on the Rights
of Indigenous Peoples (UNDRIP)
■ In November 2010, after careful consideration, Canada formally endorsed
this Declaration. 
– the right to the full enjoyment of all human rights and fundamental
freedoms;
– the right to be free from any kind of discrimination;
– the right to self-determination, autonomy or self-government; and 
– the right to life, physical and mental integrity, liberty and security of
the person.
– http://www.un.org/esa/socdev/unpfii/documents/DRIPS_en.pdf
Health Services
■ Provincial systems provide most acute and intensive services for ALL
Aboriginal populations (ie/ hospital services)
■ The Federal government provides some health services for on-reserve
status First Nations and Inuit communities as well as Non-Insured Health
Benefits (NIHB)
– This funding is not provided for non-status or Métis populations
“Federal system of health care delivery for status First Nations people
resembles a collage of public health programs with limited accountability,
fragmented delivery and jurisdictional ambiguity”

Loppie Reading & Wein, 2009

Self-Determination and Self-Government
■ Self-Government introduces a third approach for First Nations and Inuit
Communities to increase their control over health programs and
services.
■ Under this policy, First Nations may be entitled to make certain laws
governing their community with respect to health.

Why is this important?

Health Transfer
■ Health Transfer is a complex process, with opportunities and limits,
that shifts varying levels of control from FNIHB to First Nations
communities in regards to the administration of health services
■ Throughout the country, communities are at varying levels of
health transfer
■ Health Transfer allows for some administrative flexibilities and
control over funding, however, it still exists within a larger system
that has significant restraints.
■ Movement towards self-government that builds upon the ideas of
health transfer, and would allow for greater self-determination
Self-Determination and Health Services

■ However, provinces and territories must be involved in negotiations

where matters affecting their jurisdiction are being discussed – therefore
in terms of the health within Indigenous communities, collaboration
amongst federal, provincial, territorial and Aboriginal governments are
required to effectively work within the current system
Self-Determination and Health Outcomes

■ At first glance, it makes sense that if the community understands its

needs the best, then the community is the best-suited to have control
over the services that are provided.
■ But, are there additional connections to health outcomes?
– What did the Loppie Reading & Wein article (2013) discuss in terms
of self-determination?

Can increasing self-determination significantly impact health outcomes?

■ :
Chandler and Lalonde

Chandler & Lalonde, 2008

Chandler and Lalonde study found:

■ Aboriginal people account for 3% of the total population in BC

■ Aboriginal people account for 9% of all suicides in BC
■ Aboriginal youth account for 23% of all youth suicides in BC

BUT….. Lets look at the information a little closer

Case Study

Chandler & Lalonde, 2008

Suicide Rate by First Nations Community

Chandler & Lalonde, 2008

Suicide Rate by Tribal Council

Chandler & Lalonde, 2008

So what does Chandler and Lalonde’s
study tell us?
■ The province-wide rate of Aboriginal youth suicide (which was 5x the national average)
was not capturing the reality of the province’s communities
■ There were no recorded suicides in 1 out of every 5 tribal councils
■ In the period covered by the study, 90% of suicides were in less then 10% of the bands
■ Youth suicide is not an ‘Aboriginal’ issue – it is an issue in some Aboriginal communities
■ Why do rates vary between communities?
– Differing histories of cultural assault?
– Different successes in resistance and cultural restoration?
■ What factors are contributing to resilience in some communities?

Chandler & Lalonde, 2008/2009

Study suggests suicide rates are associated with 6
factors
The six factors associated with cultural continuity include
1. Land claims;
2. Self-government;
3. Education services;
4. Police and fire services;
5. Health services;
6. Cultural facilities.
• While these controls are present in any Canadian community, the
difference is the opportunity to make these institutions more culturally
sensitive and appropriate, as the community sees fit.
Let’s discuss the importance of Cultural Continuity

■ Culture as something that is potentially enduring or continuously linked

through processes of historical transformation with an identifiable past
of tradition (Kirmayer)
■ The contemporary preservation of traditional culture (Chandler and
Lalonde)
■ Cultural continuity, identity or “being who we are,” is foundational to
health in successful First Nations.
Self Determination
■ determine their political status and freely pursue their economic, social,
and cultural development; and

■ dispose of and benefit from their wealth and natural resources. Under
international treaty law, Canada is obligated to respect the First Nations’
right of self-determination.

Source: Assembly of First Nations,

http://www.afn.ca/Fact%20Sheets/first_nations_self.htm
Discussion of Chandler and Lalonde study:

■ In communities where all cultural continuity factors were in place NO

suicides were present (first wave was 1987-1992 and then 1993-2000),
compared with up to 800x the national average, for communities
without these factors.
 Chandler and Lalonde

■ (Chandler, M., Lalonde, C. (2008). Cultural Continuity as a Hedge Against Suicide.

Retrieved from: http://web.uvic.ca/~lalonde/manuscripts/1998TransCultural.pdf)

(Chandler, M., Lalonde, C. (2008). Cultural Continuity as a Hedge Against Suicide.

Retrieved from: http://web.uvic.ca/~lalonde/manuscripts/1998TransCultural.pdf)
Therefore:

“First Nations communities that succeeded in taking steps to preserve their

heritage, culture and that work to control their own destinies, are
dramatically more successful in insulating their youth against the risks of
suicide.”

Chandler, M. & Lalonde, C. (2008) “Cultural Continuity as a Protective Factor Against Suicide
in First Nations Youth” in Horizons – A Special Issue on Aboriginal Youth, Hope or
Heartbreak: Aboriginal Youth and Canada’s Future. 10(1), 68-72.
Health Governance

■ The rationale for Indigenous control of Indigenous health services is

clearly laid out in the RCAP findings and recommendations.
■ Implementing those recommendations in practice is much more
complicated, with diverse results in diverse Indigenous territories.
(Note RCAP will be covered in next class)
Some things to think about….

■ How might a person’s identity as a non-Status First Nations person

impact their access to services?
■ What happens to people who move off First Nations territory? Or
move back and forth?
■ How might self-determination affect the kinds of services offered in
First Nations territories?
Access to Healthcare

■ Within Canada, access to health care is ‘universal’ as outlined in the

Canada Health Act
■ This universal access is premised by “the strong social value of equality,
defined as the distribution of services to those in need for the common
good and health of all residents”
Access to Healthcare

■ Equitable access to service therefore does not mean that everyone

receives the exact same services (or number of services)
■ It is “the fair and just distribution of resources where the service is based
on need”
Reflect

What prevents access to care?

Health Care Interactions

■ Typically, studies of health-care interactions have focused on

doctor–patient relationships. Many focus:
• On the social, economic, political, and historical determinants
of health care;
• Power differentials and social conflict in health care;
• The capacity of people to navigate health-care systems;
• Professional control of health services.

Browne, 2007
Health Care Interactions

– The factors that influence health-care interactions are understood as

occurring within a set of wider social relations that, though often not
visible, profoundly influence patient–provider relations.
– Recent research suggests that the power relations within the doctor–
patient relationship also influence nurse–patient relations, and these
power differentials are magnified when gender, ethnocultural
background, and class are considered

Browne, 2007
“It is well documented that many underlying factors negatively affect the
health of Aboriginal people in Canada, including poverty and the
intergenerational effects of colonization and residential school. BUT one
barrier to good health lies squarely in the lap of the health care system itself.

Many Aboriginal people don’t trust – and therefore don’t use – mainstream
health care services because they don’t feel safe from stereotyping and
racism, and because the Western approach to health care can feel alienating
and intimidating.”

Health Council of Canada, 2012

 Access to Health Care
■ Aboriginal People are less likely to
seek help when symptoms are present
■ Aboriginal People are more likely to
be diagnosed at a later stage of disease
than non-Aboriginal people
Delays in diagnosis can make treatment
more difficult, less effective, or no longer
possible
“If the health system is not safe for
Aboriginal people, they miss the benefits
of preventative care such as
immunizations and screening tests”
Health Council of Canada, 2012
Access to Health Care

Many Aboriginal people do not like to use the mainstream health

care system because, in the words of one session participant, “they
have had experiences like being treated with contempt, judged,
ignored, stereotyped, racialized, and minimized.”

Health Council of Canada, 2012

Examples of experiences within Mainstream
Healthcare:
Health Council of Canada Report:
■ Doctors who would not prescribe painkillers to Aboriginal people
(even when they were in severe pain)
■ Emergency room patients who were assumed to be under the
influence of drugs or alcohol and not given proper assessments as a
result.
Examples of experiences within Mainstream
Healthcare:
Health Council of Canada Report:
■ Code words to signal dismissively to colleagues that the next patient
is an Aboriginal person
■ Keeping mothers and newborn babies longer than necessary to
‘assess’ whether she will be a good parent
■ An Aboriginal woman who was told that she would not be included
in the planning process for her family member’s care because she
“wouldn’t understand.”
■ A new study suggests racism against Indigenous people in the health-care
system is "pervasive" and a major factor in substandard health
among native people in Canada.

– The doctor wrote her a prescription, and told her she was good to
go. When she got home, she discovered all the doctor had scribbled on
the prescription form was a crude drawing of a beer bottle, circled with
a slash through it.

– http://www.cbc.ca/news/aboriginal/racism-against-aboriginal-people-in-health-care-
system-pervasive-study-1.2942644
First Nations Women’s Encounters with Mainstream
Health Care Services
■ A study conducted by Browne and Fiske examined mainstream health care
encounters from the viewpoint of First Nations women from a reserve
community in Northwestern Canada.
 Dismissal by Health Care Providers
 Transforming oneself to gain credibility
 Negative stereotypes about First Nation women
 Marginalization from the Mainstream
 Situations of vulnerability
 Disregard for personal circumstances
Access to Treatment

■ Approximately 25% of Indigenous persons living with HIV/AIDS respondents

report being denied services because they were believed to have been drinking
whether they were or not.

CAAN, 2011
Alcohol Use and Access to Treatment

■ Twenty one percent of (people living with AIDS) reported having

been denied community based care/in-patient care at least once
in their lives for having drank alcohol when in fact they were
sober.
■ Twenty eight percent reported to not seek in-patient care out of
fear of being denied services for having drank alcohol — whether
they were sober or not.

CAAN, 2011
Clinical encounters between nurses and First
Nations women in a Western Canadian Hospital

• Relating across presumed “cultural differences”

• Constructing the “Other”
• Assumptions influencing clinical practice
• Responding to routine patient requests
Canadian Health Care System

■ Higher value placed on Western educational credentials

■ A lack of respect for traditional Indigenous approaches to healing
■ Power differentials and different communication styles between provider and
patients
■ Use of complicated medical terminology instead of conversational language
■ The rapid pace that health care professionals work within
■ Western focus on disease rather than on the whole person and life
circumstances
■ Lack of ‘space’ for ceremonies

Health Council of Canada, 2012