Contextual determinants of health behaviours in an aboriginal community in Canada: pilot project

Learning From Our Strengths: Exploring Strategies to Support Heart Health in Indigenous Communities

Indigenous populations have remained resilient in maintaining their unique culture and values, despite facing centuries of colonial oppression. With many discriminatory policies continuing to disempower Indigenous peoples, First Nations communities have been reported to experience a higher level of cardiovascular disease (CVD)-related mortality, compared to that in the general population. Many of the risk factors contributing to the burden of CVD have been attributed to the impact of colonization and the ongoing dismissal of Indigenous knowledge. Despite Indigenous peoples recognizing the value of addressing their mental, physical, spiritual, and emotional well-being in balanced totality, current health services focus predominantly on the promotion of Western biomedicine. To begin to move toward reconciliation, a better understanding of how Indigenous health is defined within different cultural worldviews is needed. The objective of this scoping review was to explore the various Western and/or Indigenous strategies used for the prevention of CVD and the management of heart health and wellness in Indigenous communities in Canada. In this review, a total of 3316 articles were identified, and only 21 articles met the eligibility criteria. Three major themes emerged, as follows: (i) valuing of the emotional domain of health through cultural safety; (ii) community is at the core of empowering health outcomes; and (iii) bridging of cultures through partnership and mutual learning. Most studies recognized the importance of community engagement to develop heart health strategies that integrate traditional languages and cultures. However, to move toward the delivery of culturally safe care, health systems need to rebuild their relationship with Indigenous peoples.

Promoting Slhánay̓ Sḵwálwen (Indigenous Women's Heart Health): Findings From Sharing Circles With Squamish Nation

OBJECTIVE

To gather knowledge and experiences from Squamish Nation citizens to codevelop a model of foraging walks for Indigenous women's heart health.

DESIGN

Qualitative study (sharing circles).

SETTING

Vancouver, Canada (virtual).

PARTICIPANTS

Squamish Nation community members (n = 9), Elders or Knowledge Keepers (n = 5), and researchers (n = 2).

INTERVENTION

Community-led foraging walks as a culturally safe nutrition education strategy.

MAIN OUTCOME MEASURE(S)

Perspectives and experiences.

ANALYSIS

Content analysis and narrative synthesis.

RESULTS

Personal experiences of foraging walks or knowledge of traditional plants were limited for most participants, and all desired to learn more about traditional foods using land-based activities. Participants identified a lack of nutrition education surrounding heart health and common mistreatment and judgment from health professionals. Participants identified important elements of a future Squamish program, including who should be involved, how to implement it, and the most effective temporal and physical setting. All agreed foraging walks help promote 5 dimensions of heart health (physical, emotional, spiritual, mental, and social) through physical activity, purposeful nutrition, and connection to community and culture. Findings from the sharing circles were used in the creation of a template for future foraging sessions and contributed to plant identification cards for the whole community.

CONCLUSIONS AND IMPLICATIONS

Community-based pilot studies to test foraging walks as a culturally safe and environmental approach to nutrition education and cardiovascular health awareness for Indigenous communities are warranted. Research to examine the similarities and differences across Indigenous groups related to understanding heart health and land-based practices for nutrition education and heart health awareness is needed.

Food environment research in Canada: a rapid review of methodologies and measures deployed between 2010 and 2021

Numerous research methodologies have been used to examine food environments. Existing reviews synthesizing food environment measures have examined a limited number of domains or settings and none have specifically targeted Canada. This rapid review aimed to 1) map research methodologies and measures that have been used to assess food environments; 2) examine what food environment dimensions and equity related-factors have been assessed; and 3) identify research gaps and priorities to guide future research. A systematic search of primary articles evaluating the Canadian food environment in a real-world setting was conducted. Publications in English or French published in peer-reviewed journals between January 1 2010 and June 17 2021 and indexed in Web of Science, CAB Abstracts and Ovid MEDLINE were considered. The search strategy adapted an internationally-adopted food environment monitoring framework covering 7 domains (Food Marketing; Labelling; Prices; Provision; Composition; Retail; and Trade and Investment). The final sample included 220 articles. Overall, Trade and Investment (1%, n = 2), Labelling (7%, n = 15) and, to a lesser extent, Prices (14%, n = 30) were the least studied domains in Canada. Among Provision articles, healthcare (2%, n = 1) settings were underrepresented compared to school (67%, n = 28) and recreation and sport (24%, n = 10) settings, as was the food service industry (14%, n = 6) compared to grocery stores (86%, n = 36) in the Composition domain. The study identified a vast selection of measures employed in Canada overall and within single domains. Equity-related factors were only examined in half of articles (n = 108), mostly related to Retail (n = 81). A number of gaps remain that prevent a holistic and systems-level analysis of food environments in Canada. As Canada continues to implement policies to improve the quality of food environments in order to improve dietary patterns, targeted research to address identified gaps and harmonize methods across studies will help evaluate policy impact over time.

The hidden imbalance in neighbourhood nutrition environment: a perspective from lower-middle-income country setting

Neighbourhood environment plays a pivotal role in determining the individual's nutrition through availability and accessibility of healthy food options. This community-based cross-sectional descriptive study examined neighbourhood spatial attributes using Geographical Information System (GIS) and describe perceived nutrition environment among adult residents in urban Puducherry, India. The density of grocery shops, fruits and vegetable shops, food outlets and restaurants were 64.4, 74.8 and 88.7 per km2, respectively. Out of 200 participants, 191 (95.5%) and 190 (95%) reported easy accessibility to fruits and vegetables shops and restaurants, respectively, while 192 (96%) agreed on availability of unhealthy food options in shops. Current study provides framework for assessment of objective and perceived neighbourhood nutrition environment in lower-middle-income countries with a user-friendly and easily administrable tool.

Exploring the environmental determinants of food choice among Haudenosaunee female youth

Background

Research on Indigenous food literacy within Canada has been focused on northern and remote communities despite the fact there are considerable and unique barriers to food access, availability, and utilization in southern Indigenous communities. Food insecurity is also a prevalent issue among Indigenous Peoples living in these more populous regions. Study objectives included investigating the determinants of food choice among youth, along with perceived opportunities that would improve food environments individually and at the community level.

Methods

This community-based study used Photovoice to explore the perceptions and experiences of traditional foods and the determinants of food choice among youth in the community of Six Nations of the Grand River. Participants took photos of their local food environments, including where foods were acquired, consumed, prepared, or shared, and participated in semi-structured interviews to share the stories behind these images. Thematic analysis was used to identify patterns in participants’ photos and interview content.

Results

Environmental factors were found to influence participants’ traditional and everyday food choices. Built, social, economic and ecological environments were described by the youth as distinct yet inter-related determinants that converge to influence individual food choice. Built environments had a notable impact on food choice, most notably at home and in school settings. Home and family were found to be facilitators of meal consistency and healthy food choices across participants. The social environment including participants’ relationships with their peers and community friends was often a barrier to healthy food choices. Eating at fast food outlets was a common social activity. The economic environment included cost deterrents associated with food choices and regular meals. The ecological environment was less of an influence and impacted the seasonal consumption of traditional and other locally harvested foods.

Conclusions

Overall, the study findings have generated important knowledge regarding food environments and literacy and serves as a unique example of how to explore the traditional and everyday food experiences of Indigenous youth. Recommendations will inform the development of new as well as existing initiatives and resources to enhance the holistic wellbeing of youth and the broader community.

The Retail Food Sector and Indigenous Peoples in High-Income Countries: A Systematic Scoping Review

Indigenous Peoples in high-income countries experience higher burdens of food insecurity, obesity, and diet-related health conditions compared to national averages. The objective of this systematic scoping review is to synthesize information from the published literature on the methods/approaches, findings, and scope for research and interventions on the retail food sector servicing Indigenous Peoples in high-income countries. A structured literature search in two major international databases yielded 139 relevant peer-reviewed articles from nine countries. Most research was conducted in Oceania and North America, and in rural and remote regions. Several convergent issues were identified across global regions including limited grocery store availability/access, heightened exposure to unhealthy food environments, inadequate market food supplies (i.e., high prices, limited availability, and poor quality), and common underlying structural factors including socio-economic inequality and colonialism. A list of actions that can modify the nature and structure of retailing systems to enhance the availability, accessibility, and quality of healthful foods is identified. While continuing to (re)align research with community priorities, international collaboration may foster enhanced opportunities to strengthen the evidence base for policy and practice and contribute to the amelioration of diet quality and health at the population level.

The Retail Food Environment, Store Foods, and Diet and Health among Indigenous Populations: a Scoping Review

PURPOSE OF THE REVIEW

Describe the state of knowledge on how the retail food environment contributes to diet-related health and obesity among Indigenous populations, and assess how the literature incorporates Indigenous perspectives, methodologies and engagement throughout the research process. Outcomes included dietary behaviour (purchasing, intakes and diet quality) and diet-related health outcomes (weight-related outcomes, non-communicable diseases and holistic health or definitions of health as defined by Indigenous populations involved in the study).

RECENT FINDINGS

Of fifty included articles (1996-2019), the largest proportions described Indigenous communities in Canada (20 studies, 40%), the USA (16, 32%) and Australia (9, 18%). Among articles that specified the Indigenous population of focus (42 studies, 84%), the largest proportion (11 studies, 26%) took place in Inuit communities, followed by Aboriginal and Torres Strait Islander communities (8 studies, 19%). The included literature encompassed four main study designs: type A, dietary intakes of store foods (14 studies, 28%), and type B, store food environments (16, 32%), comprised the greatest proportion of articles; the remainder were type C, store food environments and diet (7, 14%), and type D, store food environment interventions (13, 26%). Of the studies that assessed diet or health outcomes (36, 72%), 22 (61%) assessed dietary intakes; 16 (44%) sales/purchasing; and 8 (22%) weight-related outcomes. Store foods tended to contribute the greatest amount of dietary energy to the diets of Indigenous peoples and increased non-communicable disease risk as compared to traditional foods. Multi-pronged interventions appeared to have positive impacts on dietary behaviours, food purchasing and nutrition knowledge; promotion and nutrition education alone had more mixed effects. Of the nine studies which were found to have strong engagement with Indigenous populations, eight had moderate or high methodological quality. Eighteen studies (36%) did not mention any engagement with Indigenous populations. The literature confirmed the importance of store foods to the total energy intake of the contemporary diets of Indigenous people, the gaps in accessing both retail food environments and traditional foods and the potential for both new dietary assessment research and retail food environment intervention strategies to better align with and privilege Indigenous Ways of Knowing.

Strategies for Promoting Healthy Nutrition and Physical Activity Among Young Children: Priorities of Two Indigenous Communities in Canada

BACKGROUND

Indigenous people in Canada carry a disproportionate burden of obesity and obesity-related diseases compared with non-Indigenous Canadians, which could be related to intergenerational trauma exposures. Implementing effective health promotion strategies to improve nutrition and physical activity behaviors during early childhood could be a strategy to mitigate the burden of intergenerational trauma exposures that have the potential to impact the trajectory to obesity and related complications throughout the lifecycle.

OBJECTIVES

The aim of this study was to support 2 Indigenous communities in identifying priorities and strategies for promoting healthy nutrition and physical activity for young children.

METHODS

Using a formative approach, we conducted a 2-phase study that started with 2 community engagement workshops (n = 37 participants), followed by a qualitative descriptive study. In this latter study, in-depth interviews were conducted with a purposeful sample of 23 community parents, health care providers, and traditional knowledge holders. Data from both study phases were analyzed and synthesized using conventional content analysis.

RESULTS

To promote healthy nutrition and physical activity among young children living in Indigenous communities, it was identified that the primary pathway to health and well-being must prioritize the integration of knowledge about Indigenous ways of life including traditional Indigenous foods and physical activities. Participants also identified individual/family and community/contextual factors that ultimately influence the nutrition and physical activity of children in their communities.

CONCLUSIONS

Informed by this formative study conducted to better understand community members' strategies for healthy eating and physical activity for young children, we argue for the continued recognition of the unique Indigenous context, incorporating the history of inequity and injustice and looking toward Indigenous-led interventions that incorporate this history and ways of life as solutions in the future.

Association between built environment and the incidence of disability in basic and instrumental activities of daily living in the older adults: Results of a cohort study in southern Brazil

The aim of this study was to evaluate the association between subjective and objective characteristics of the built environment and the incidence of disability in the activities of daily living in the older adults. A cohort study was conducted with 1196 older adults from Florianopolis, Santa Catarina, Brazil. Incidences were evaluated after four years by the difficulty or inability to perform six basic and nine instrumental activities. The subjective built environment was evaluated by the adapted Neighborhood Environment Walkability Scale and the objective for variables related to the characteristics of streets, sidewalks and land uses in the census tracts. Multilevel Logistic Regression analyzes were performed, where significant positive associations were observed between the presence of hills, and negative associations between safety for walking at night, a high proportion of commercial area, intermediate mixed land use and the incidence of disability in basic activities. The built environment characteristics associated with disability point to the need for improvements in urban infrastructure to promote functional independence in the older adults.

Reducing the prevalence of obesity in Canada: a call to action

With rates of obesity among adults and youth rising in Canada, it is clear that the current approaches currently used to reduce the prevalence of obesity, with an emphasis on individual weight management interventions focused on restrictive dieting, are not proving successful at a population level. Given that obesity is associated with poor physical and mental health outcomes, is placing a multi-billion-dollar economic burden on Canada and disproportionately affects disadvantaged groups, such as Aboriginal Canadians and women of low socioeconomic status, it is a health and social issue that must be addressed immediately by social workers and policy makers. This article discusses the benefits of implementing a multifaceted population-level intervention that is health centered, evidence based, antistigmatizing to obese individuals, and accessible to all Canadians. The proposed intervention includes increased education for primary care physicians, the development of walkable neighborhoods, taxation of junk food, financial incentives, clear nutrition labelling, public awareness campaigns, regulation of food advertising (especially targeted to children), and school-based health promotion initiatives. This article also discusses the unique role that social workers must play in leading the charge against the stigmatization of obese individuals, while also championing policies to effectively reduce the prevalence of obesity in Canada.

Environments favorable to healthy lifestyles: A systematic review of initiatives in Canada

BACKGROUND

In recent years, a number of initiatives aimed at promoting healthy lifestyles in health-friendly environments have been implemented. The purpose of this review is to synthesize initiatives conducted in Canada and documented in publications for the period 1995-2015 in order to gain a better understanding of their objectives and impacts.

METHODS

A systematic review of Canadian initiatives published over the past 20 years was conducted from multiple databases (i.e., Scopus, SPORTDiscus, PubMed, Academic search complete, Reseausante.com, Cairn, and Erudit). In total, 264 publications were identified and retained for the final analysis based on 5 criteria: (1) publication between 1995 and 2015, (2) online availability, (3) research conducted in Canada, (4) main topic related to environments favorable to healthy lifestyles (EFHL), and (5) publication in French or English.

RESULTS

A sharp increase in the number of studies on EFHL was observed between 2010 and 2015 (57%). Two major lifestyle components-physical activity and nutrition-and 2 environmental aspects-neighborhood and built environment-were the elements most frequently examined regarding adults (48%), young people (34%), and seniors (9%), using quantitative (60%) and qualitative (18%) methods. Furthermore, the analysis reveals a greater focus on the municipal (53%) than the national or provincial levels (31%).

CONCLUSION

This work is a first map of Canadian studies related to EFHL. It clarifies the definition of EFHL and classifies its components. As well, it documents the issues raised, the research methods employed, and the role of stakeholders, while outlining a new research agenda that includes dimensions of EFHL formerly neglected by researchers, namely, political and sociocultural spheres of action.

Retail food environments research in Canada: A scoping review

OBJECTIVES

The field of retail food environments research is relatively new in Canada. The objective of this scoping review is to provide an overview of retail food environments research conducted before July 2015 in Canada. Specifically, this review describes research foci and key findings, identifies knowledge gaps and suggests future directions for research.

METHODS

A search of published literature concerning Canadian investigations of retail food environment settings (food stores, restaurants) was conducted in July 2015 using PubMed, Web of Science, Scopus, PsychInfo and ERIC. Studies published in English that reported qualitative or quantitative data on any aspect of the retail food environment were included, as were conceptual papers and commentaries.

SYNTHESIS

Eighty-eight studies were included in this review and suggest that the field of retail food environments research is rapidly expanding in Canada. While only 1 paper was published before 2005, 66 papers were published between 2010 and 2015. Canadian food environments research typically assessed either the socio-economic patterning of food environments (n = 28) or associations between retail food environments and diet, anthropometric or health outcomes (n = 33). Other papers profiled methodological research, qualitative studies, intervention research and critical commentaries (n = 27). Key gaps in the current literature include measurement inconsistency among studies and a lack of longitudinal and intervention studies.

CONCLUSION

Retail food environments are a growing topic of research, policy and program development in Canada. Consistent methods (where appropriate), longitudinal and intervention research, and close partnerships between researchers and key stakeholders would greatly advance the field of retail food environments research in Canada.

Best Practices for the Prevention and Management of Diabetes and Obesity-Related Chronic Disease among Indigenous Peoples in Canada: A Review

OBJECTIVES

To carry out a systematic review of interventions that have aimed at improving screening, treatment, prevention and management of type 2 diabetes and obesity-related chronic disease in Indigenous communities in Canada from 2008 to 2014, with the aim of identifying current best practices.

METHODS

A comprehensive literature review was carried out through an electronic database search using Medline, EMBASE, PubMED and Google scholar.

RESULTS

We identified 17 publications, comprising 13 evaluated interventions. Of them, 7 were school-based programs focused on children, 5 focused on adults, and 1 included both adults and children. Most interventions aimed at encouraging behaviour change, especially dietary change, but did little to address the underlying context of systemic marginalization and colonialism experienced in many Indigenous communities. Interventions focused on improving fitness were more effective than those aimed at dietary change. Overall, we found a range of successes among these interventions. Those that met with limited success reported that complex social issues and poverty presented challenges to effective intervention work in these communities. Participatory action research methods and community ownership of the intervention were found to be essential for project success.

CONCLUSIONS

Diabetes-focused intervention research in Indigenous communities appears to be a low priority for Canadian funders and policymakers. More intervention research is urgently needed in these communities. To be effective, this work must take an approach that is historically deep and sufficiently broad as to enable the ideologic, policy and institutional changes necessary in order to achieve true equity. This will involve addressing colonialism, racism and social exclusion as broader determinants of health.

Implications of Risk Factors for Alzheimer's Disease in Canada's Indigenous Population

Background

Indigenous peoples in Canada have higher prevalence of modifiable risk factors for Alzheimer’s disease (AD). The relative importance of these risk factors on AD risk management is poorly understood.

Methods

Relative risks from literature and prevalence of risk factors from Statistics Canada or the First Nations Regional Health Survey were used to determine projected population attributable risk (PAR) associated with modifiable risk factors for AD (low education and vascular risk factors) among on- and off-reserve Indigenous and non-Indigenous people in Canada using the Levin formula.

Results

Physical inactivity had the highest PAR for AD among Indigenous and non-Indigenous peoples in Canada (32.5% [10.1%–51.1%] and 30.5% [9.2%–48.8%] respectively). The PAR for most modifiable risk factors was higher among Indigenous peoples in Canada, particularly among on-reserve groups. The greatest differences in PAR were for low educational attainment and smoking, which were approximately 10% higher among Indigenous peoples in Canada. The combined PAR for AD for all six modifiable risk factors was 79.6% among on-reserve Indigenous, 74.9% among off-reserve Indigenous, and 67.1% among non-Indigenous peoples in Canada. (All differences significant to p < .001.)

Conclusions

Modifiable risk factors are responsible for the most AD cases among Indigenous peoples in Canada. Further research is necessary to determine the prevalence of AD and the impact of risk factor modification among Indigenous peoples in Canada.

Emergency Health Care Use among Sociodemographic Groups of Children Presenting to Emergency Departments for Self-Harm in Alberta

OBJECTIVE

To examine sociodemographic variations among children <18 years in (1) rates of self-harm visits to emergency departments (EDs) and (2) physician follow-up after the self-harm visit in Alberta.

METHODS

A retrospective, population-based cohort (2002-2011) of ED visits for self-harm by individuals <18 years was conducted using administrative databases from Alberta, Canada. Individuals were grouped by First Nations status or type of health care premium subsidy (family receipt of government subsidy, human services program subsidy, no subsidy received). Visits from 104 EDs were summarized by crude and directly standardized visit rates (DSVRs) per 100,000 individuals. Kaplan-Meier estimates for median estimated time to physician follow-up were calculated with 95% confidence intervals (CIs).

RESULTS

During the study period, visit rates decreased with the exception of children from families receiving government-sponsored program subsidy (DSVRs 163/100,000 to 250/100,000; p=0.032). First Nations children had disproportionately fewer follow-up visits compared to other children. The median time to follow-up for First Nations children was 39 days (95% CI: 32, 48) compared to 16 days for children from families receiving no subsidy (95% CI: 14, 19), who had the shortest follow-up time after an ED visit.

CONCLUSIONS

Sociodemographic differences were evident in ED visit rates as well as the number of and time to physician follow-up visit. The disparities experienced by First Nations children in the follow-up period highlight an opportunity for culturally-grounded risk and needs assessment in the ED to determine and facilitate timely and appropriate follow-up care.

The ethnoepidemiology of obesity

The prevalence of overweight and obesity varies significantly across ethnic groups and among aboriginal people in Canada and appears to be increasing overall in children and youth, which will have significant health consequences in the future. Individual health behaviours, genetic predisposition, and community-level factors all contribute to the high burden of overweight and obesity across communities in Canada. Preliminary studies indicate that individuals who live in neighbourhoods in Canada with increased walkability, fewer fast food outlets, and higher socioeconomic status have lower rates of overweight/obesity when compared with other neighbourhoods. However, more research is required to understand the impact of community level factors on overweight/obesity trends in Canadian ethnic groups, including children and youth, and aboriginal people.

Aboriginal birth cohort (ABC): a prospective cohort study of early life determinants of adiposity and associated risk factors among Aboriginal people in Canada

BACKGROUND

Aboriginal people living in Canada have a high prevalence of obesity, type 2 diabetes, and cardiovascular disease (CVD). To better understand the pre and postnatal influences on the development of adiposity and related cardio-metabolic factors in adult Aboriginal people, we will recruit and follow prospectively Aboriginal pregnant mothers and their children - the Aboriginal Birth Cohort (ABC) study.

METHODS/DESIGN

We aim to recruit 300 Aboriginal pregnant mothers and their newborns from the Six Nations Reserve, and follow them prospectively to age 3 years. Key details of environment and health including maternal nutrition, glucose tolerance, physical activity, and weight gain will be collected. At birth, cord blood and placenta samples will be collected, as well as newborn anthropometric measurements. Mothers and offspring will be followed annually with serial measurements of diet and physical activity, growth trajectory, and adiposity.

DISCUSSION

There is an urgent need to understand maternal and child factors that underlie the early development of adiposity and type 2 diabetes in Aboriginal people. The information generated from this cohort will assist the Six Nations community in developing interventions to prevent early adiposity in Aboriginal children.