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  Urban Absrcinal health: Examining inequalitiesbetween Absrcinal and non-Absrcinal populationsin Canada Kathi Wilson Department of Geography, University of Toronto Mississauga Nicolette Cardwell Department of Geography, University of Toronto Mississauga This article contributes to the nascent literature on the health of urban Absrcinal people by comparing thehealth status and determinants of health of the urban Absrcinal and urban non-Absrcinal population inCanada. Data for the research were taken from the 2001 Absrcinal Peoples Survey (APS) and the 2000–2001Canadian Community Health Survey (CCHS) Cycle 1.1. Framed within a population health approach, we explorethe extent to which health status and determinants of health differ between Absrcinal and non-Absrcinal populations living in urban areas. Health status is measured by three variables—self-assessed health status,chronic conditions, and activity limitations. While disparities in health exist between the urban Absrcinal and non-Absrcinal population, they are not as large as those between the Absrcinal population living on a reserveand non-Absrcinal people. The social determinants of health are quite similar between the two populations but the results also reveal the significance of cultural factors in shaping health among the urban Absrcinal population. The research demonstrates a need for future research to focus on culturally specific determinants of health as one potential explanation for disparities in health between urban Absrcinal and non-Absrcinal people. Keywords: Absrcinal, urban, social determinants of health, cultural determinants La sant´e des Autochtones en milieu urbain : une exploration des in´egalit´es entre les Canadiens autochtones et non autochtones Cet article a pour but de contribuer `a la litt´erature en ´emergence portant sur la sant´e des Autochtones en milieu urbain, en comparant l’ ´ etat de sant ´ e et les d ´ eterminants de la sant ´ e de la population autochtone et non-autochtone en milieu urbain au Canada. L’´etude s’appuie sur des donn´ees tir´ees de l’Enquˆete aupr`es des peuples autochtones (EPA) de 2001 et de l’Enqu ˆ ete sur la sant ´ e dans les communaut ´ es canadiennes (ESCC), cycle1.1. Pr´econisant une approche ax´ee sur la sant´e de la population, nous explorons les diff´erences de l’´etat desant ´ e et des d ´ eterminants de la sant ´ e entre les populations autochtones et non-autochtones en milieu urbain.Trois variables sont utilis´ees pour d´ecrire l’´etat de sant´e : l’auto-´evaluation de l’´etat de sant´e, les maladies chroniques et la limitation d’activit ´ es. Si l’existence de disparit ´ es en mati `ere de sant ´ e entre la populationautochtone et non-autochtone en milieu urbain est d´emontr´ee, celles-ci ne sont pas aussi importantes que les disparit ´ es qui caract ´ erisent la population non-autochtone et autochtone vivant dans une r ´ eserve. Les d´eterminants sociaux de la sant´e sont comparables pour les deux populations, mais les r´esultats illustrent `a quel point des facteurs culturels peuvent  ´ egalement intervenir en faveur ou au d ´ etriment de la sant ´ e parmi la population autochtone en milieu urbain. Cette ´etude exploratoire fait ressortir la n´ecessit´e de tenir compte des facteurs culturels propres aux d ´ eterminants de la sant ´ e dans les recherches ult ´ erieures afin d’identifier des  Correspondence to/Adresse de correspondance: Kathi Wilson, Department of Geography, University of Toronto Mississauga, 3359Mississauga Rd. N., Mississauga, ON L5L 1C6. Email/Courriel: The Canadian Geographer / Le G ´ eographe canadien  2012, 56(1): 98–116DOI: 10.1111/j.1541-0064.2011.00397.x C   Canadian Association of Geographers / L’Association canadienne des g´eographes  Urban Aboriginal health 99 pistes d’explication des disparit´es en mati`ere de sant´e entre les individus autochtones et non-autochtones enmilieu urbain. Mots cl´es : Autochtones, urbain, d´eterminants sociaux de la sant´e, d´eterminants culturels Introduction The number of people in Canada who identifyas Aboriginal now exceeds one million (Canada2008a). 1 As the Absrcinal population in Canadacontinues to grow much faster than the non-Absrcinal population, so do disparities in health.Research demonstrates a disproportionate gapin health status between Aboriginal and non-Aboriginal populations (Waldram et al. 2006;Estey et al. 2007; Wilson et al. 2010). While thereis much documented information about inequali-ties in mortality and morbidity between Aborig-inal and non-Aboriginal populations in Canada,what we know about the health status of theAboriginal population is mainly limited to Reg-istered Indians living on reserves (see, for ex-ample, Barton et al. 2005; Martens et al. 2005). 2 Thus, little is known about the health of othersegments of the Aboriginal population such asthose who live in urban areas (which can includeRegistered Indians, non-status Indians, M´etis, andInuit).Since the 1960s, Canada has witnessed un-precedented growth in the urban Absrcinal pop-ulation. In the early 1950s, less than 7 percentof the Aboriginal population lived in urban ar-eas. By the early 1960s, approximately 13 per-cent of the total Aboriginal population lived in 1 The term “Aboriginal” is used in this article to refer to thedescendants of the original inhabitants of Canada. The Con-stitution Act of Canada (1982) recognizes three broad Absrc-inal identity groups: North American Indians, M´etis, and Inuit(Canada 1982). Many “Indians” prefer the phrase “First Na-tions” when referring to themselves as a collective group. TheInuit are Absrcinals who mainly live in Canada’s most north-ern regions. Traditionally the term M´etis was used to describethe children of Cree women and French fur traders living inthe prairie region of Canada. However today the term is usedquite broadly to refer to individuals of mixed First Nationsand European ancestry (Canada 2004b). The term “Registered”or “Status” Indians refers to those individuals who are regis-tered under the Indian Act of Canada. This term is only usedin this article when quoting directly from other studies. 2 A reserve is a tract of land set aside for the use and benefitof a First Nation community (Canada 2004b). The majority of Absrcinal people living on reserves are Registered or StatusIndians. urban areas (see Kalbach 1987). Data from the2006 Census of Canada reveal that this fig-ure has increased to over 50 percent while thepopulation residing on Indian Reserves accountsfor less than 30 percent of the Aboriginal pop-ulation (Canada 2008a). 3 On the surface, theincreasing urbanization of the Absrcinal popula-tion suggests a massive migration from reservesand a depopulation of reserve and rural areas(Norris et al. 2001, 2003a; Peters 2005). How-ever, as Peters (2005) and others have demon-strated, Absrcinal urbanization is quite complex.The growth of the urban Aboriginal populationis not necessarily reflective of mass movementfrom reserves to cities but rather a combina-tion of movement, high rates of natural increase,changing patterns of self-identification (i.e., eth-nic mobility), and legislated changes to the In-dian Act in 1985 (Bill C-31) (Guimond 2003a;Norris et al. 2003b). 4 In fact, Guimond (2003b)has argued that intragenerational ethnic mobility,which occurs when a person changes their ethnicaffiliation over time, is responsible for the largeincrease in the urban Absrcinal population fromthe mid-1980s to 2001. Despite the movement of individuals from reserve to urban settings andthe increase in the number of individuals livingin urban areas who identify themselves as Abo-riginal, the research on Aboriginal health contin-ues to concentrate on Registered Indians livingon reserves (Hotson et al. 2004; Kaur et al. 2004;Muttitt et al. 2004; Dobbelsteyn 2006). Two re-cent reviews of Aboriginal health research con-ducted in medical/health sciences (Young 2003)and the social sciences (Wilson and Young 2008)conclude that research fails to reflect the geo-graphic profile of Aboriginal Peoples in Canadawith a severe under-representation of urban 3 It is important to note that the way in which the Aboriginalpopulation had been identified and counted in the Census of Canada has changed over time. Thus, these sources are likelyusing different population definitions and may not be directlycomparable. 4 This mainly refers to Bill C-31 reinstatements, the majority of which live in urban areas (Norris et al. 2003a). The Canadian Geographer / Le G ´ eographe canadien  2012, 56(1): 98–116  100 Kathi Wilson and Nicolette Cardwell Aboriginal Peoples. This can be explained, inpart, by the lack of health data available for ur- ban Absrcinal people since much of the annualhealth information collected is only available forthe on-reserve population and this is severelylimited in terms of coverage and scope (Waldramet al. 2006). Beyond issues of data availabil-ity, the Royal Commission on Aboriginal Peoplesargued that non-Aboriginal researchers overlookthe urban population due to pervasive and per-sistent ideas about where Absrcinal Peoples be-long (i.e., on reserves and in remote locations)(Canada 1996b).This study begins to fill the gap in the existingknowledge base on Aboriginal health by examin-ing the health of the urban Absrcinal populationin Canada. More specifically, using data from the2001 Aboriginal Peoples Survey (APS) (Canada2001a) and the 2000/2001 Canadian CommunityHealth Survey (CCHS) (Canada 2001b), this articlepresents the results of statistical analysis aimedat comparing the health status and determinantsof health between urban Aboriginal Peoples andnon-Aboriginals in Canada. This is an importantavenue of investigation because it sheds light onthe extent to which Absrcinal health disparitiescontinue to persist in urban locations. Background Aboriginal people in Canada suffer from muchhigher rates of mortality and morbidity thanthe non-Aboriginal population (see Frolich et al.2005). For example, the gap in life expectancy be-tween Registered Indians and the general Cana-dian population is almost seven years (Canada2004a). Infant mortality rates are 40 percenthigher among the Registered Indian populationand suicide rates are twice as high as comparedwith the general Canadian population (Canada2004a; Kirmayer et al. 2007). Morbidity is alsomore prevalent within the Aboriginal population.While infectious diseases are on the decline, asWaldram et al. (2006) note, they have been offset by chronic conditions and injuries as the leadingcauses of death and health problems within theAboriginal population. While cancer rates remainlower within the Absrcinal population comparedto the non-Aboriginal population, diabetes, hy-pertension, cardiovascular disease, and obesityare much more prevalent among Aboriginal peo-ple (Waldram et al. 2006; Canada 2008b, 2009a).Research shows large disparities in health be-tween Aboriginal and non-Absrcinal populations but much of what we know about the Absrcinalhealth is based on data collected for on reserveFirst Nations populations (Waldram et al. 2006).Save for a handful of studies, relatively little isknown about the health of urban Absrcinal peo-ple. Interestingly, much of what health researchexists about urban Absrcinal populations mainlyfocuses on issues related to health care use. Inone of the earliest health studies on the urbanAboriginal population, Waldram (1990a, 1990b)conducted extensive surveys on the health careutilization behaviours of urban Aboriginal peo-ple living in the city of Saskatoon, Saskatchewan.He found few differences in physician use be-tween the non-Absrcinal and Absrcinal popula-tion and showed (contrary to assumptions thatexisted at the time) that urban Absrcinal peopledo not avoid conventional health care (Waldram1990a). Waldram (1990b) also found that urbanAboriginal people continue to utilize traditionalhealing practices while living in the city, partic-ularly as a complement to contemporary healthcare (i.e., physicians). In another study, Benoitet al. (2003) interviewed Absrcinal women livingin Vancouver’s “Downtown Eastside” to under-stand their perceptions of how health care ser-vices meet their specific health care needs. Theyfound that urban Absrcinal women contend withracism and discrimination within the contem-porary health care system and have a strongdesire for culturally appropriate and traditionalapproaches to healing (see also Tang and Browne2008). Work by Levin and Herbert (2004) alsopoints to problems of racial bias and culturalinsensitivity when urban Aboriginal people ac-cess health care (see also Browne et al. 2011)while a study by Mundel and Chapman (2010)of the Urban Aboriginal Community KitchenGarden Project in Vancouver identifies theimportance of a decolonizing approach to healthpromotion that has the potential to address thehealth needs and causes of urban Aboriginalhealth disparities. Research by Walji et al. (2010)points to the potential importance of naturo-pathic medicine for providing holistic and cultur-ally sensitive health care to Aboriginal patientsin an Aboriginal health centre in Toronto. Other The Canadian Geographer / Le G ´ eographe canadien  2012, 56(1): 98–116  Urban Aboriginal health 101 studies focus more closely on specific health is-sues, risky health behaviours, and problems inparticular cities. For example, Iwasaki and col-leagues (Iwasaki et al. 2004, 2005) studied thecoping mechanisms of Aboriginal women andmen with diabetes living in Winnipeg, Manitoba,and Macdonald et al. (2010) explored Absrcinalunderstandings of tuberculosis in Montreal. Inother research, Heath et al. (1999) and Mehrabadiet al. (2008) have examined risk factors asso-ciated with HIV (see also Mill et al. 2008) andMiller et al. (2011) has studied the determinantsof injection drug use among urban Aboriginalyouth in Prince George and Vancouver, BC.The current body of literature on urban Abo-riginal health offers insight into health care useand accessibility problems but very little in termsof health status. Much of the research conductedfocuses on only a small number of Canadiancities leaving us with little or no picture of ur- ban Absrcinal health at the national scale of analysis. However, a study based on data fromthe 2001 Canadian Community Health Survey(CCHS) revealed that the health of the off-reserveAboriginal population (i.e., those living in cities,towns, rural areas) is worse than the healthof their non-Absrcinal counterparts (Tjepkema2002). In particular, the research shows that ahigher percentage of the urban Absrcinal popu-lation rates their health as fair/poor and has atleast one chronic condition in comparison to thenon-Aboriginal population. While the study rep-resents an important first glimpse of the healthof urban Aboriginal Peoples, important gaps re-main. First, the CCHS is a national survey of the general Canadian population. As such, itdoes not target Aboriginal people. The CCHSonly captured 3500 individuals reporting Absrc-inal ancestry. Since the CCHS did not set out tosample Aboriginal populations by design, thosecaptured in the CCHS may not be representativeof the overall off-reserve population and may notidentify themselves as Aboriginal. Second, whilethe research does reveal important disparities inhealth, we still know little about the extent of the differences in the determinants of health.This knowledge is crucial for an in-depth un-derstanding of the most important factors thatshape the health status of Canada’s urban Abo-riginal population. Such information is necessaryto ensure that the health and social services sys-tem in urban settings meets the needs of theAboriginal population. It is these two gaps inknowledge that this research seeks to fill. Data and methods To understand differences in health status anddeterminants of health between urban Abo-riginal and non-Aboriginal people in Canada,a population health approach is employed. Apopulation health approach seeks to improve thehealth of populations by identifying inequalitiesin health and focusing on why some populationsare healthy and others are not (Evans and Stod-dart 1994; Canada 2003b; Richmond and Ross2009). The approach places emphasis on a broadrange of factors such as age, gender, income,and education that shape the health of popula-tions (Canada 2008c). While social and economicfactors influence the health of both Aboriginaland non-Absrcinal populations, evidence also in-dicates that Aboriginal culture is also an impor-tant determinant of health (Canada 1996a; Smylieand Aboriginal Health Issues Committee 2001;Adelson 2005; Waldram et al. 2006). Given thehealth beliefs of Absrcinal Peoples in Canada, itis essential in this research to consider not onlycharacteristics related to sociodemographic andsocioeconomic status, health behaviours, geogra-phy, and health care use but also cultural fac-tors. In doing so, we examine the extent to whichdisparities and differences in the determinants of health exist between urban Aboriginal and non-Aboriginal populations and also the relative roleof cultural factors in shaping health among ur- ban Absrcinal people.Data for the analysis came from two nationalcross-sectional surveys—the 2001 Absrcinal Peo-ples Survey (APS) and the 2000–2001 CCHS Cycle1.1. The APS is a national survey of individ-uals living on reserves and off reserve whoself-report their Aboriginal identity and/or re-port Aboriginal ancestry (Canada 2003a). Datafor the 2001 APS were collected between Septem- ber 2001 and June 2002 from approximately98649 respondents with a response rate of 84percent (Canada 2003a). The APS included fourquestionnaires: i) adult core survey, ii) Inuit sup-plement, iii) M´etis supplement, and iv) child sur-vey. The adult core survey is administered to all The Canadian Geographer / Le G ´ eographe canadien  2012, 56(1): 98–116

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