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Module 8: Cancer and The Risk Factors Among FNIM People.

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1 Module 8: Cancer and The Risk Factors Among FNIM People

2 Welcome to Cancer and Risk Factors Among FNIM People. This course takes 45 minutes to complete. There is a quiz at the end of each chapter and a link to handouts and resources at the end of the learning module. Select the arrow keys at the bottom of your screen to move forward and move back, or to stop and start the module. There is a quiz at the end of each chapter and a link to handouts and resources at the end of the learning module.

3 Course Learnings Understand Aboriginal Cancer Statistics Cancer and The Risk Factors Among FNIM People Identify Risk Factors By the time you complete this learning module, you will be able to:

4 Acronyms Used in This Learning Module  CCO: Cancer Care Ontario  FNIM: First Nations, Inuit, Métis This list can be printed if you want to refer to it throughout the module.

5 Insert Pre-Test Quiz Slide Q: Name the Top (most common) Cancer for FNIM People A:____________________________________ Move forward to begin Chapter 1

6 Part I: Aboriginal Cancer Statistics Part I of the learning module provides an overview of cancer statistics in FNIM communities. You will learn about: Risks and circumstance Statistics broken down

7 Chapter 1: Risks and Circumstances

8 Risks A shift in disease patterns is evident for First Nations, Inuit and Métis (FNIM) populations over the past several decades, away from infectious diseases and toward chronic conditions such as cancer and diabetes. Studies invariably show that cancer incidence has risen dramatically in each of the FNIM populations over the past few decades. From being nearly unknown a few generations ago, cancer is now among the top three causes of death among FNIM people.

9 Limited data exists on national cancer incidence and mortality rates for FNIM communities due to lack of research. Limited Data Information on ethnicity is not captured by most health information databases, making it difficult to know the impact of cancer on different populations. Ethnicity Data not Captured Within the data that does exist, it has shown that cancer incidence has risen dramatically in each of the FNIM populations over the past few decades. Certain Factors Exists

10 From being nearly unknown a few generations ago: Cancer is one of the top three causes of death among FNIM people (circulatory diseases and external factors, such as accidents or suicide, are the other two*). Breast and colorectal cancer in First Nations people and lung cancer in the Inuit population are on the rise. * Source: Mortality of Métis and Registered Indian adults in Canada: An 11-year follow-up studyby Michael Tjepkema, Russell Wilkins, Sacha Senécal, Éric Guimond and Christopher Penney, December, 2009

11 About 50% of all cancer deaths are related to commercial tobacco use, diet and physical inactivity. Smoking rates among FNIM people are much higher than in the remaining Canadian population. Lack of consumption of fruits and vegetables, and physical inactivity are also reported to be higher among FNIM people. About 50% of all cancer deaths are related to commercial tobacco use, diet and physical inactivity. Smoking rates among FNIM people are much higher than in the remaining Canadian population. Lack of consumption of fruits and vegetables, and physical inactivity are also reported to be higher among FNIM people.

12 Cancer survival is worse for FNIM than for other Ontarians. Some reasons include: FNIM people are diagnosed with later stage cancers. Access to screening and treatment is difficult for many FNIM people living in rural and remote communities.

13 Lack of awareness and understanding of cultural elements that can reduce the effectiveness of treatment. Awareness Challenges A lack of health-care resources in communities. Resource Challenges Poor co-ordination of care across the continuum of care, which can undermine follow up and palliative care. Co- ordination Challenges Challenges within the health system in Ontario:

14 Circumstance: Shift from Traditional Diet and Lifestyle

15 Shift from Traditional Diet and Lifestyle FNIM people in Canada traditionally consumed a wide variety of foods harvested and gathered from the land and water.

16 Foods harvested from the local environment, such as fish and marine mammals, game meat, plants, and berries are highly nutritious and sustained FNIM people for many generations.

17 Traditional foods are significant to FNIM people not only because of their health benefits, but also because the act of harvesting, collecting, preparing, and sharing food. plays an important role in maintaining a lifestyle with strong connections with the land and cultural identities.

18 In post-contact era, the types of food consumed by FNIM people changed significantly. Traditional food use diminished as a result of: Relocation into settlements Decreased access to land Depletion of game Concern about environmental contaminants

19 In post-contact era, the types of food consumed by FNIM people changed significantly. Traditional food use diminished as a result of: Less time and energy Fewer harvesting skills Costs of hunting Restrictions on hunting

20 Many FNIM communities transitioned from traditional foods to store-bought and processed foods. As a result of: declining availability and access to traditional foods increased convenience and availability of store-bought foods declining availability and access to traditional foods increased convenience and availability of store-bought foods Many FNIM communities transitioned from traditional foods to store-bought and processed foods. As a result of:

21 Processed foods are the only foods that many families can afford. For example, packaged foods such as Kraft dinner. Weather also impacts access to food. If planes can’t land and there is no road access for a period of time – food does not reach communities. Making the situation more difficult: the food mail subsidy program that provided food to people in need ended.

22 Effects of History on Perception and Health The effects of colonization have been compared to being similar to post-traumatic stress disorder.

23 Generations of FNIM children were born into communities where hopelessness and discrimination were common, and there were many barriers to building healthy communities.

24 Insert pop up exercise box This is a non-scoring exercise [Add in a pop-up: Write down two barriers to building healthy communities and a short strategy to help break down each barrier (no more than two sentences).

25 In the last few decades in particular, governments have been trying to rebuild the relationships with FNIM communities but there are still activities that occur that have left FNIM people wary.

26 Promises for more autonomy over health care, but no funding for the identified needs (i.e. traditional healing) – ongoing since the 1990s Broken Promises Under the act First Nations communities can lease designated reserve lands if a majority attending a meeting called for that purpose vote to do so, regardless of how many people show up. Bill C-45 implemented in 2012: Previously, approval required the support of a majority of eligible voters. Bill C-45 implemented in 2012: Some examples include:

27 Increased isolation has occurred over generations based on a variety of reasons. Some of which include: Stereotyping and discrimination Remote living areas Feeling of persecution from some non-Aboriginal Canadians Cross-cultural communication who have misconceptions about how history has shaped FNIM perspectives. Source: Aboriginal Cultural Safety Initiative, Anishnawbe Health Toronto, 2008

28 These events and circumstances shape FNIM people’s level of trust and ability and desire to seek out health care from non- Aboriginal providers.

29 . Personal Views of Cancer In some FNIM communities, cancer is a taboo subject surrounded in secrecy and fear. Traditional spirituality, (important to a majority of FNIM people): For example, the Dene Nation in the Northwest Territories believes that: These and other views have implications on receptiveness to, and participation in: Cancer education, prevention and treatment programs. FNIM people ‘s views of cancer are heterogeneous, like many Canadians: For some, there is a belief that cancer is an unavoidable death sentence. May contribute to beliefs about cancer. Speaking explicitly about terminal illness and death may hasten death.

30 FNIM people’s cultural conceptions of cancer may help in part to explain lower rates of participation in prevention, early diagnosis, and treatment programs. Therefore FNIM people may be unaware of the existence or benefits of these programs. Those in rural and remote communities may also have difficulty accessing the relevant resources to inform themselves. Cancer information resources generally do not address the uniqueness of FNIM cultures.

31 Placeholder for: interview segment from Alethea re: what providers can do to help support FNIM patients (approx. 1 minute) – replacing text: one First Nations leader said:. ”We need community-based education and culturally responsive resources related to cancer and screening, the role of nutrition and physical activity, and how to develop support groups or talking circles in communities. Resources need to describe that cancer treatments would not hinder or affect First Nations spirituality.”

32 Many health care providers may be unaware of the historical and cultural factors that contribute to FNIM people’s views of cancer, and views of general health care. Cultural differences may create barriers to effective cancer care, as caregivers’ may not understand and are unable to address perceptions of cancer. Many health care providers may be unaware of the historical and cultural factors that contribute to FNIM people’s views of cancer, and views of general health care. Cultural differences may create barriers to effective cancer care, as caregivers’ may not understand and are unable to address perceptions of cancer. Move forward to begin the quiz for this chapter

33 Insert Quiz slide: Test for Part I, Chapter 1 This chapter has one question. Q: Name two of the reasons cancer survival is worse for FNIM people than for other Ontarians, as outlined in this chapter. A: __________________________

34 Chapter 2: Statistics Broken Down Overall FNIM Cancer Stats and How They Compare To Non- Aboriginal Cancer Stats

35 Placeholder for: interview segment(s) from Ontario Regional Chief Stan Beardy and/or Greg Peters

36 Overall Statistics New Cases (Counts)New Cases (Rates) TotalMaleFemaleTotalMaleFemale All Cancers63,49232,87630, Prostate9, Breast8,271708, Lung7,8724,1803, Colon & Rectum 7,6594,1213, Non-Hodgkin Lymphoma 2,8681,6101, Not Applicable Report date: Sept. 11, Data source, Cancer Care Ontario (Ontario Cancer Registry, 2010 for SEER*Release 8 Feb, 2011). New Cases for Cancers by Sex, Ontario, 2007

37 First Nations Male and Female Cancer Statistics First Nations Female Cancer TypeIncident Rate Breast.54 Lung.92 Colorectal.57 Kidney1.28 Cervix1.73 Oral.98 Stomach.66 First Nations Males Cancer typeIncident Rate Prostate.57 Lung.68 Colorectal.58 Kidney1.18 Oral.65 Stomach.66 Sources: Assembly of First Nations, 2009 from Marret, 2003 and Wiggins, 2008

38 Select Mortality Rates: First Nations On- Reserve vs. Non-Aboriginal Canada Source: Public Health Agency of Canada (2011), using data from Canadian Community Health Survey; First Nations Information Governance Centre (2011); Social and Aboriginal Statistics Division, Aboriginal Peoples Survey, 2006; Inuit Health and Social Conditions: Ottawa, ON: Statics Canada, Percent (%)

39 Lung cancer rates for Canadian Inuit males and females are the highest in the world and rising in Inuit men and women at 3.2 and 5.3 times the Canadian averages, respectively. Inuit have had higher rates of nasopharyngeal, salivary gland and esophageal cancers, but rates are decreasing. Rates of lung, breast, colorectal and cervical cancers have increased sharply across all regions.

40 Inuit Male and Female Cancer Statistics RankMale Population %Female Population % 1Lung28.3Cervix17.6 2Colon8.1Lung13.7 3Stomach7Breast11.4 4Nasopharynx6.5Colon9.6 Source: Public Health Agency of Canada (2011), using data from Canadian Community Health Survey; First Nations Information Governance Centre (2011); Social and Aboriginal Statistics Division, Aboriginal Peoples Survey, 2006; Inuit Health and Social Conditions: Ottawa, ON: Statics Canada, 2008.

41 Métis: Cancer Profile The most common cancers among the Métis: prostate lung breast colorectal This is the same as for other Ontarians. Ontario Métis have a 20% lower incidence of cancer compared to the general population. Except for lung cancer in females: The rate may be as much as 40% higher. Source: The Burden of Cancer Risk in Canada’s Indigenous Population: a Comparative Study of Known Risks in a Canadian Region, Brenda Elias,Erich V Kliewer, Madelyn Hall, Alain A Demers, Donna Turner, Patricia Martens,Say P Hong, Lyna Hart, Caroline Chartrand, and Garry Munro, Oct. 19, 2011

42 Métis Male and Female Cancer Statistics Cancer TypeMaleGeneral Population Cancer TypeFemaleGeneral Population Colorectal0.57 (0.30, 1.00) 0.74 (0.73, 0.76) Breast1.05 (0.63, 1.64) 1.48 (1.46, 1.50) Lung0.62 (0.32, 1.06) 0.74 (0.73, 0.76) Colorectal0.59 (0.58, 0.60) Non- Hodgkin Lymphoma 0.24 (0.08, 0.55) 0.28 (0.27, 029) Lung0.88 (0.50, 1.43) 0.62 (0.61, 0.63) Prostate1.10 (0.70, 1.65) 1.82 (1.80, 1.84) Non-Hodgkin Lymphoma 0.06 (0.00, 0.31) 0.22 (0.21, 0.23) Source: Public Health Agency of Canada (2011), using data from Canadian Community Health Survey; First Nations Information Governance Centre (2011); Social and Aboriginal Statistics Division, Aboriginal Peoples Survey, 2006; Inuit Health and Social Conditions: Ottawa, ON: Statics Canada, 2008.

43 Métis Risk Modifiers and Common Cancers Cancer Type Risk FactorsProstateLungBreastColorectal Tobacco Smoke  Alcohol  Obesity  Inactivity  Diet  Move forward to begin the quiz for this chapter

44 Insert Quiz slide: Test for Part I, Chapter 2 This chapter has one question. Q: Name the top two cancers for First Nations men in Ontario. A: __________________________

45 Part II: Risk Factors Part II of the learning module provides an overview of the cancer risk factors in FNIM communities. You will learn about: First Nations’ risk factors Inuit risk factors Métis risk factors

46 Chapter 1: Overview In this chapter, we will review some of the overall factors that adversely impact FNIM health and can increase probabilities for diseases such as cancer and diabetes. At the end of this learning module, there will be links to additional resources and some information specific to culturally appropriate nutrition guides, tobacco and screening initiatives.

47 Food Security and Nutrition Food security exists when all people, at all times, have the physical and economic access to food that is: Sufficient Safe Nutritious It has to meet dietary needs and food preferences for an active and healthy life. Two key factors are: 1) Income 2) Accessibility of food

48 Given the geographic location of many FNIM communities, lack of access to food results in poorer quality and fewer nutritious options.

49 The link between food security and health is so clear that Health Canada has recognized that “income-related food insecurity is an important public health issue in Canada and is a key social determinant of health” in the Office of Nutrition Policy and Promotion 2007 report.

50 Inuit go hungry more than any other indigenous group: report A Nunavut family's annual groceries cost $19,760, but half of Inuit adults earn less than $20,000 CBC NewsCBC News Posted: Mar 27, :54 AM CT Last Updated: Mar 27, :02 AM CT A new study released Thursday highlights the fact that people in Nunavut have the highest food insecurity rate for any indigenous population in a developed country at 68%. Source:

51 54.2% of all households are food insecure. Of those food- insecure FNIM households: one-quarter (14%) have been found to be severely food- insecure. This compares to only a third of non-Aboriginal households. Source: Regional Health Survey

52 Percentage of on-reserve First Nations adults cut the size of their meals or skipped meals because there was not enough money for food: Percentage that did so almost every month in the year prior. Source: Regional Health Survey 20% 36.5%

53 Proportion of FNIM adults who reported “always” or “almost always” eating a healthy diet was higher among food-secure households. Understanding patterns of food security for FNIM people will be critical in developing and evaluating national public health policies and programs. Source: Regional Health Survey

54 The consumption of traditional foods was higher for remote and isolated communities than for urban and rural communities. This included: protein, berries, and other wild vegetation. The consumption of traditional foods was higher for remote and isolated communities than for urban and rural communities. This included: protein, berries, and other wild vegetation.

55 Insert pop up exercise box This is a non-scoring exercise [Add in a pop-up: Write down some ways you can support a FNIM patient with nutritional advice, based on your location.]

56 Some of the FNIM people that live in poverty live in Fourth world conditions. Some of the FNIM people that live in poverty live in Fourth world conditions. FNIM people are at the bottom of almost every available index of socioeconomic wellbeing, whether measuring: educational levels employment opportunities housing conditions per capita incomes FNIM people are at the bottom of almost every available index of socioeconomic wellbeing, whether measuring: educational levels employment opportunities housing conditions per capita incomes Or any of the other conditions that give non-Aboriginal Canadians one of the highest standards of living in the world.

57 While there are overall health and economic differences among FNIM populations, there are significant disparities between Canada’s FNIM and non-Aboriginal Canadian populations. The United Nations’ Human Development Index ranks 174 countries on the social and economic well-being of their people. While there are overall health and economic differences among FNIM populations, there are significant disparities between Canada’s FNIM and non-Aboriginal Canadian populations. The United Nations’ Human Development Index ranks 174 countries on the social and economic well-being of their people.

58 In 2010: Canada came in 8th place when considering the entire population. When judged solely on the social and economic well-being of our FNIM people, the ranking dropped to In 2010: Canada came in 8th place when considering the entire population. When judged solely on the social and economic well-being of our FNIM people, the ranking dropped to 48 th Place More astonishing was that two short years later: That ranking fell to almost 100 th Place That ranking fell to almost 100 th Place While the overall population ranking slipped to 11th place.

59 Economic self-sufficiency and economic equality predict community health and well- being. Inadequate: Impact social capital and, in turn, community cohesion. Housing Food Medicine Water Employment

60 . Poor Living Conditions Nearly one in four First Nations and Inuit adults live in crowded homes. 23% of FNIM people live in houses in need of major repairs. First Nations people and Inuit suffer from ‘third world’ diseases such as tuberculosis at: FNIM people in Canada were found to be four times more likely to: Experience hunger as a direct result of poverty. More than 100 First Nations communities are currently under boil water advisories. And have little or no access to clean water for drinking and sanitation. Eight to ten times the rate of Canadians in general.

61 Poverty Prevalence Prevalence (%) (95% confidence interval) SourceAgeCrudeAge Standardized Non-Aboriginal CCHS ( )5.0 ( ) First Nations (on reserve) CCHS ( ) 17.2 ( ) First Nations (off reserve) CCHS ( ) 10.3 ( ) Inuit2006 APS15+4 ( )N/A Métis CCHS ( )7.3 ( ) Source: Public Health Agency of Canada (2011), using data from Canadian Community Health Survey; First Nations Information Governance Centre (2011); Social and Aboriginal Statistics Division, Aboriginal Peoples Survey, 2006; Inuit Health and Social Conditions: Ottawa, ON: Statics Canada, 2008.

62 The impact of poverty on health is well documented, and has been mentioned throughout this learning module. To name a few, it adversely impacts: Nutrition Lifestyle choices Ability to travel for health care Ability to afford some health care options

63 Insert pop up exercise box This is a non-scoring exercise [Add in a pop-up: Write down 2-5 resources you can offer a FNIM patient that may not be able to afford to travel for cancer prevention services or treatment options.]

64 Behavioural/ Lifestyle Risk Factors

65 Overweight and Obesity 79.4% First Nations on-reserve 57.5% First Nations off-reserve 70.6% of Inuit 55.6% of Métis Percentage of Ontario population overweight or obese based on self- reported height and weight (aged 18+) 48.6% non-Aboriginal population Compared to: Source: Canadian Community Health Survey, (Data for First Nations off-reserve, Inuit and Métis) First Nations Regional Health Survey (Ontario Region) 2008/10 (Data for First Nations on-reserve)

66 Tobacco Misuse Tobacco has been used traditionally in ceremonies, rituals, and prayers for thousands of years. With the exception of the Arctic, where tobacco did not grow and was not commonly used, tobacco traditionally had spiritual significance and was considered by many to be a sacred gift from the Creator. Tobacco Misuse Tobacco has been used traditionally in ceremonies, rituals, and prayers for thousands of years. With the exception of the Arctic, where tobacco did not grow and was not commonly used, tobacco traditionally had spiritual significance and was considered by many to be a sacred gift from the Creator.

67 Tobacco misuse is defined as the non-traditional, recreational and/or habitual use of commercial tobacco products, including: CigarettesCigars and pipes Chewing tobacco Spit tobacco Smoking cigarettes is the most common form of tobacco misuse. Source: Public Health Agency of Canada 2011 data

68 Tobacco misuse became prevalent post-contact for a number of reasons, e.g. the industrialization of tobacco as a cash crop and a shift in values towards consumption. Today, despite declining rates of smoking across Canada, FNIM people still have among the highest rates of smoking at double that of the general population. Source: Public Health Agency of Canada 2011 data

69 Alcohol Use Heavy drinking is classified as having 5 or more drinks in one occasion, at least once a month over the course of a year. According to data from Statistics Canada 2006 less FNIM people drink than the general population, but have slightly higher rates of heavy drinking than the general population. (First Nations people with the highest rates). Alcohol Use Heavy drinking is classified as having 5 or more drinks in one occasion, at least once a month over the course of a year. According to data from Statistics Canada 2006 less FNIM people drink than the general population, but have slightly higher rates of heavy drinking than the general population. (First Nations people with the highest rates).

70 35% of FNIM are heavy drinkers. Compared to 17% of the general population. Alcohol can be used as a coping mechanism to escape the harsh realities of poverty, historical and present-day abuse. Source: Statistics Canada 2006

71 Drug Use Drug use is a persistent problem among First Nations youth and adults living in Canada. The 1996 Northwest Territories Alcohol and Drug Survey revealed that First Nations people 15 years and older were almost: 3 to 3.5 times more likely to have used cannabis, LSD, speed, cocaine, crack or heroin and 11 times more likely to have sniffed solvents or aerosols than their non-First Nations counterparts. Drug Use Drug use is a persistent problem among First Nations youth and adults living in Canada. The 1996 Northwest Territories Alcohol and Drug Survey revealed that First Nations people 15 years and older were almost: 3 to 3.5 times more likely to have used cannabis, LSD, speed, cocaine, crack or heroin and 11 times more likely to have sniffed solvents or aerosols than their non-First Nations counterparts. Source: Statistics Canada : 27% of First Nations adults reported using cannabis at least once in the past year.

72 Insert Quiz slide: Test for Part II, Chapter 1 This chapter has one question. True or False Q: First Nations people and Inuit suffer from ‘third world’ diseases such as tuberculosis at four times the rate of the general population in Canada. A:  True  False

73 Chapter 2: Statistics Broken Down First Nations Cancer is the third leading cause of death for First Nations people.

74 Overweight and Obesity: First Nations Sources: Gionet and Roshanafshar, 2013: Canadian Community Health Survey, (First Nations off-reserve and non-Aboriginal data; aged 18+), First Nations Regional Health Survey (National Report; Ontario Region), 2008/10 (First Nations on-reserve data; aged 18+)

75 Tobacco Smoking: First Nations Sources: Gionet and Roshanafshar, 2013: Canadian Community Health Survey, (First Nations off- reserve and non-Aboriginal data, aged 12+), First Nations Regional Health Survey (National Report; Ontario Region), 2008/10 (First Nations on-reserve data, aged 18+) % of population who are current (daily or occasional) smokers.

76 Alcohol Consumption: First Nations % that consume 5+ drinks on one occasion, at least once a month in the past year (excluding non-drinkers in the past year). Sources: Canadian Community Health Survey (unpublished data), 2007/08 (aged 19+), First Nations Regional Health Survey (National Report; Ontario Region), 2008/10 (aged 18+)

77 Alcohol Consumption: First Nations % exceeding cancer prevention recommendations for alcohol consumption (> 1 drink/day for women; > 2 drinks/day for men) Sources: Cancer Care Ontario. Aboriginal Cancer Strategy II – Annual Report: Staying on the path. Toronto, Canada, 2013: Canadian Community Health Survey, (aged 19+).

78 Physical inactivity: First Nations Source: Gionet and Roshanafshar, 2013: Canadian Community Health Survey, (First Nations off-reserve and non-Aboriginal data, aged 12+) First Nations Regional Health Survey (National Report; Ontario Region), 2008/10 (First Nations on-reserve data, aged 18+)

79 Nutrition Rates of individual and household food insecurity are much higher for the First Nations populations than for the general Canadian population. Nutrition Rates of individual and household food insecurity are much higher for the First Nations populations than for the general Canadian population. Source: The Canadian Community Health Survey One- in-five adults cut meal sizes or skipped meals because they had no money for food. First Nations adults who reported always or almost always eating a nutritious balanced diet increased with age (21.9% for those aged 18 to 29, up to 45.9% for those aged 65 or over). Nearly one-in-ten adults reported that they never or hardly ever consumed milk or milk products. More than one-third reported drinking soft drinks one or more times a day.

80 Nutrition: First Nations % of people that reported food insecurity (moderate or severe food insecurity) Sources: Gionet and Roshanafshar, 2013: Canadian Community Health Survey, (First Nations off- reserve and non-Aboriginal data, aged 12+), First Nations Regional Health Survey (National Report; Ontario Region), 2008/10 (First Nations on-reserve data, aged 18+)

81 Nutrition: First Nations % who consume vegetables or fruit ≥ 5 times per day (recommended) Source: Gionet and Roshanafshar, 2013: Canadian Community Health Survey, (aged 12+)

82 Insert Quiz slide: Test for Part II, Chapter 2 This chapter has one question. Fill in the blank Q: A recent Canadian Community Health Survey estimates that 33.3% off- reserve First Nations households experience ___________, compared to 10.2% of non-Aboriginal households. A: ______________________________-

83 Chapter 3: Inuit Statistics Broken Down Cancer is the second leading cause of death for Inuit.

84 Overweight and Obesity: Inuit Source: Gionet and Roshanafshar, 2013: Canadian Community Health Survey, (aged 18+) *Estimate should be interpreted with caution, due to high variation (Coefficient of variation is between 16.6% and 33%)

85 Tobacco Smoking: Inuit Lung cancer rates among the Inuit are now the highest in the world. % of population who are current (daily or occasional) smokers. Source: Gionet and Roshanafshar, 2013: Canadian Community Health Survey, (aged 12+)

86 Alcohol Consumption: Inuit % that consume 5+ drinks in one occasion, at least once a month in the past year (including non-drinkers in the past year). Source: Gionet and Roshanafshar, 2013: Canadian Community Health Survey, (aged 12+)

87 Physical Inactivity: Inuit Source: Gionet and Roshanafshar, 2013: Canadian Community Health Survey, (aged 12+) *Estimate should be interpreted with caution, due to high variation (Coefficient of variation is between 16.6% and 33%)

88 Nutrition: Inuit % of people that reported food insecurity (moderate or severe food insecurity) Source: Gionet and Roshanafshar, 2013: Canadian Community Health Survey, (aged 12+)

89 Nutrition: Inuit Source: Gionet and Roshanafshar, 2013: Canadian Community Health Survey, (aged 12+) * Estimate should be interpreted with caution, due to high variation (Coefficient of variation is between 16.6% and 33%) % who consume vegetables or fruit ≥ 5 times per day (recommended)

90 Nutrition Inuit’s food security issues contribute to their poor nutritional status. Food security has been identified by Inuit as a policy priority and an area of ongoing concern. Food sold in stores across the Arctic is 3-5 times more expensive than food sold in urban centres. Nutrition Inuit’s food security issues contribute to their poor nutritional status. Food security has been identified by Inuit as a policy priority and an area of ongoing concern. Food sold in stores across the Arctic is 3-5 times more expensive than food sold in urban centres. Source: Inuit Tapiriit Kanatami. Inuit & Cancer: Fact Sheets. February 2009

91 Insert Quiz slide: Test for Part II, Chapter 3 This chapter has one question. True or False Q: Inuit males have a higher rate of obesity than First Nations males. A:  True  False

92 Chapter 4: Métis Statistics Broken Down Cancer is the second leading cause of death for Métis.

93 Overweight and Obesity: Métis Source: Gionet and Roshanafshar, 2013: Canadian Community Health Survey,

94 Tobacco Smoking: Métis % of population who are current (daily or occasional) smokers. Source: Gionet and Roshanafshar, 2013: Canadian Community Health Survey,

95 Alcohol Consumption: Métis % that consume 5+ drinks in one occasion, at least once a month in the past year (including non-drinkers in the past year). Source: Gionet and Roshanafshar, 2013: Canadian Community Health Survey,

96 Alcohol Consumption: Métis % exceeding cancer prevention recommendations for alcohol consumption (> 1 drink/day for women; > 2 drinks/day for men) Source: Cancer Care Ontario. Aboriginal Cancer Strategy II – Annual Report: Staying on the path. Toronto, Canada, 2013: Canadian Community Health Survey,

97 Physically inactive: Métis Source: Gionet and Roshanafshar, 2013: Canadian Community Health Survey,

98 Nutrition: Métis % of people that reported food insecurity (moderate or severe food insecurity) Source: Gionet and Roshanafshar, 2013: Canadian Community Health Survey,

99 Nutrition: Métis Source: Gionet and Roshanafshar, 2013: Canadian Community Health Survey, (aged 12+) % who consume vegetables or fruit ≥ 5 times per day (recommended)

100 Chapter 3: Strategies to Reduce Mortality In this chapter, we will review some strategies that can help reduce the mortality rates in FNIM people. At the end of this learning module, there will be links to additional resources and some information targeted to First Nations, Inuit and/or Métis people.

101 Improve Education FNIM people’s cultural concepts of cancer may help to explain lower rates of participation in: prevention, early diagnosis, and treatment programs. Cancer information resources generally do not address the uniqueness of FNIM cultures.

102 FNIM people may be unaware of the existence or benefits of programs that can help them Lack of Awareness May experience difficulty in accessing the relevant resources to inform themselves Difficulties Finding Resources Deep held beliefs about cancer cannot be overcome to improve earlier diagnosis Cancer Beliefs are Maintained What a Lack of Culturally Relevant Information Looks Like

103 Improve Education FNIM people have identified that adequate information can help to enhance their sense of control throughout the cancer journey, as well as diminish their fears. Cancer Care Ontario (CCO) interviews with FNIM leaders, health workers and cancer survivors unanimously emphasized the importance of education and cancer awareness.

104 . Knowledge and awareness improves mortality rates It is a small step from that insight to knowledge of how cancer affects the body and how to prevent it. Enhance FNIM peoples’ knowledge and awareness of cancer and cancer success stories. Focus on improving knowledge about prevention and screening. This includes ensuring FNIM people understand the importance of timely access to: Accurate diagnosis and safe, high- quality care. Traditional values emphasize the connection of spiritual, physical and mental wellness.

105 Thunder Bay Regional Health Sciences Cancer Centre Word Book as an Example of Culturally Appropriate Education The Cancer Word Book aims to improve cross- cultural communication between health care providers, patients and family members. The Regional Cancer Care’s Aboriginal Cancer Committee at Thunder Bay Regional Health Sciences Cancer Centre developed this tool for translators and those who assist health care providers to communicate with FNIM people. The Cancer Word Book aims to improve cross- cultural communication between health care providers, patients and family members. The Regional Cancer Care’s Aboriginal Cancer Committee at Thunder Bay Regional Health Sciences Cancer Centre developed this tool for translators and those who assist health care providers to communicate with FNIM people.

106 The Cancer Word Book is a concise dictionary of over 150 cancer terms. It is translated from English to Ojibwe, designed to assist: patient navigators cultural interpreters, and translators who support First Nations patients and their families who are diagnosed with cancer.

107 The Cancer World Book includes a guide to reading, writing and speaking the Ojibwe language, to assist health care providers in communicating with First Nations patients and families when translation is not available.

108 Source: pauktuutit.ca/kaggutiq/tim

109 Kaggutiq Inuit Cancer Glossary Pauktuutit’s newest cancer resource for Inuit. It is intended to provide Inuit patients and caregivers, as well as health care professionals, plain language information in English and five major dialects of Inuktitut. Kaggutiq Inuit Cancer Glossary Pauktuutit’s newest cancer resource for Inuit. It is intended to provide Inuit patients and caregivers, as well as health care professionals, plain language information in English and five major dialects of Inuktitut.

110 Create a Culturally Safe Environment. Culturally safe practice involves building health care providers’ communication skills so they are: Aware of what needs or issues a patient might have. Inclusive and consider the cultural needs of patients. Able to recognize and not negatively judge verbal /non- verbal information patients provide. Able to ask questions to get information to best serve their patient. Trusting relationships and culturally safe environments can work to encourage FNIM people to participate in screening and other prevention programs and contribute to more positive experiences.

111 Improve Research and Surveillance “You can’t manage what you don’t measure” is as true for cancer prevention as for anything else. There is very limited recent data on the cancer journey and outcomes of Ontario’s FNIM people. The cancer system requires accurate FNIM baseline measures and regular updates to evaluate progress. Improve Research and Surveillance “You can’t manage what you don’t measure” is as true for cancer prevention as for anything else. There is very limited recent data on the cancer journey and outcomes of Ontario’s FNIM people. The cancer system requires accurate FNIM baseline measures and regular updates to evaluate progress. Initiatives are underway to improve FNIM screening and surveillance, including CCO’s work to:

112 CCO Initiatives Work directly with FNIM communities and health care providers to establish a community screening activity report. Identify large datasets of FNIM identifiers that can be linked with CCO data holdings to improve screening and surveillance. Undertake pilot initiatives to inform future initiatives. Partner with key stakeholders such as Chiefs of Ontario and the Institute of Clinical Evaluation Studies on cancer statistics.

113 Insert pop up exercise box This is a non-scoring exercise [Add in a pop-up: Write down 1way you can work with one of CCO’s initiatives to help better support your FNIM patient(s).]

114 Additional Strategies for Women FNIM females tends to present with later-stage cancers. and have higher mortality rates from preventable cancers Breast Cancer Example: 66 % of First Nations women were diagnosed at a later stage than non-Aboriginal Ontarians. Sources: Marrett, L., and Chaudry, M. Cancer incidence and mortality in Ontario First Nations, (Canada), Alvi, R.A. Breast, Cervical and Colorectal Cancer Survival Rates for Northern Saskatchewan Residents and First Nations. Thesis (M.Sc.), Sheppard, A., et al. Detection of Later Stage Breast Cancer in First Nations Women in Ontario. 2010

115 These findings suggest issues related to: Access to cancer programs and services, and A general lack of awareness about cancer and its causative factors. These findings suggest issues related to: Access to cancer programs and services, and A general lack of awareness about cancer and its causative factors.

116 Sensitive women’s health issues are not properly addressed, and screening environments generally do not foster confidentiality and cultural safety. Privacy Modesty or embarrassment about exposing their bodies may prevent them from pursuing screening examinations that they may perceive as intrusive. Modesty Discomfort with male physicians is a significant barrier for many FNIM women. An Example FNIM women have communicated that in many cases:

117 Health Care Providers can Create a culturally sensitive environment that: includes female health care workers; and options to increase her participation in screening or programs that may improve her mortality rates.

118 Enhance knowledge and awareness of cancer with a focus on prevention, early detection and screening. Enhance Knowledge Educational resources/tools need to reach FNIM women. Disseminated in ways that are understandable and culturally aware. Cultural Aware Tools This includes gearing information specific to women and using visuals appropriate to women. Use Visual Aids Improve Awareness through Education

119 Discussion and explanations should be in plain language. The language of care may not be the patient’s first language. Plain Language Try not to not use technical or academic terms. Explain things simply and ask the patient to explain back in his/her own words. Be Clear Use visual, culturally appropriate resources to educate, inform and increase understanding. Use Visual Aids Improve Awareness through Education

120 Placeholder for: Survivor Video Stories

121 Additional Strategies for Men Past experiences with the health system have a lasting effect on the decision to participate in programs. Poor experiences with cancer in many communities may manifest the belief that a cancer diagnosis represents a death sentence. For some, rather than motivating them to seek help earlier, the fear of cancer acts as a deterrent to pursuing preventative procedures.

122 Improve Awareness through Education Resources need to be disseminated in ways that are understandable and culturally aware. Discussion and explanations should be in plain language. Try not to not use technical or academic terms, and explain things simply and clearly. Discussions should make the patient feel like his opinions and thoughts are respected and valued. FNIM people are very visual, so visual aids work better than words can in some cases. Enhance FNIM males’ knowledge and awareness of cancer. Focus on prevention, early detection and screening. The language of care may not be the patient‘s first language.

123 Screening Many FNIM people have expressed that existing screening facilities and programs are not culturally safe environments. For some FNIM men, this can manifest in different ways. For example: Screening Many FNIM people have expressed that existing screening facilities and programs are not culturally safe environments. For some FNIM men, this can manifest in different ways. For example: It may contribute to their tendency to access health and screening services less often than women. Adds to discomfort with routine screening exams, such as rectal exams. Or

124 Due to the lack of available cancer education: Misperceptions about the purpose of screening programs exist with some males in some FNIM communities Some believe cancer screening to be a diagnostic test for cancer when it is present, rather than a system of early detection.

125 Ask questions to understand what issues he may have Engage with Questions Pay close attention to his verbal and non-verbal cues Look for Cues Ask questions that make him feel like his opinion is valued. Show his Opinion is Valued Create a Culturally Safe Environment

126 Placeholder for: Survivor Video Stories Move forward to begin the quiz for this chapter

127 Insert Quiz slide: Test for Part I, Chapter 4 This chapter has one short answer question. Q: Is tobacco a greater or smaller risk factor for FNIM people than non-Aboriginal people? A: __________________________

128 Sources 1.Access to Cancer Screening and First Nations, Assembly of First Nations, Cancer Care Ontario, cancercare.on.ca 3.Cancer In The Métis Nation Of Ontario Clinical Significance report, Diana Withrow, Alethea Kewayosh and Loraine Marrett, March Cancer Risk Factors in Ontario Aboriginal Peoples (off-reserve), Cancer Care Ontario, The Crisis of Chronic Disease among Aboriginal Peoples: A Challenge for Public Health, Population Health and Social Policy, J. Reading Ph.D., Director, Centre for Aboriginal Health Research, Diabetes in Canada: Facts and figures from a public health perspective, Public Health Agency of Canada, Improving the Nutritional Status of Aboriginal People in Canada, Noreen D. Willows PhD, Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, Alberta, Canada, Pauktuutit Website, 9.Select Health Indicators Of First Nations People Living Off Reserve, Métis and Inuit, Statistics Canada, January The Burden of Cancer Risk in Canada’s Indigenous Population: A Comparative Study of Known Risks in a Canadian Region, Faculty of Medicine, Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada, Tobacco Fact Sheet, National Collaboration Centre for Aboriginal Health, Women in Canada: A Gender-based Statistical Report, Statistics Canada, 2011

129 Thank you for your participation in this course. Please click this link to download and save, or print your course handouts. If you have any questions not addressed in this course or comments, please contact we will respond within three business days.


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