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The Role of Cultural, Societal and Historical Issues Dr. Veronica McKinney, Director, Northern Medical Services.

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Presentation on theme: "The Role of Cultural, Societal and Historical Issues Dr. Veronica McKinney, Director, Northern Medical Services."— Presentation transcript:

1 The Role of Cultural, Societal and Historical Issues Dr. Veronica McKinney, Director, Northern Medical Services

2 To highlight various issues that impact health care delivery in Saskatchewans Indigenous population. To review factors that can contribute to inadequate treatment or non-adherence to treatment To provide some potential strategies to better engage the Indigenous population.

3 Indigenous peoples worldwide suffer a disproportionate burden of illness due to TB Canada, 2008: Indigenous rate of TB28.2/100,000 (FN/I/M) Canadian born Non-AB0.8 cases/100,000 Poor adherence to TB therapy is the most common cause of initial treatment failure and disease relapse, which in turn contributes to patient morbidity, mortality, the transmission of the disease to others and the development of drug resistance

4 Aboriginal communities and peoples are not the same. (The landscape is extremely varied). Heritage language & culture Political designation Social integration Religion Community Socio-Economic Stratification

5 In Canada, how many groups are recognized as Indigenous? A. 2 B. 4 C. 1 D. 3

6 The Constitution Act, 1982, refers to the Indigenous people of Canada as aboriginal peoples which it defines as including Indian, Inuit and Métis peoples. Although Indian is a legal term, it is more common now to use First Nations.

7 Athapaskan Dene: Chipweyan Algonquian Nehiowuk: Plains, Woods or Swampy Cree Anishnabe: Saulteaux, Ojibwa Siouan Nakota: Assiniboine, Stony Dakota & Lakota: Sioux

8 Receive health services through a unique combination of federal, provincial and Aboriginal-run programs and services Have created gaps and inadequacies Need: improved access, greater Aboriginal control and involvement, and improved working relationships with the health system

9 Remote, Rural or Urban Suburban or inner city On or Off Reserve Non-Status Community Metis Settlement

10 Increasing dramatically Education Economic Development Employment opportunities


12 On September 13 th, 2007, the United Nations General Assembly adopted the declaration on the Rights of Indigenous Peoples. Which country or countries voted against the declaration? A. United States B. Canada C. Australia D. New Zealand E. None of the above F. All of the above

13 The US, Canada, Australia and New Zealand were the only four votes against the UN declaration. The declaration outlaws discrimination against Indigenous peoples and promotes their full and effective participation in all matters that concern them. It also ensures their right to remain distinct and to pursue their own priorities in economic, social and cultural development.

14 Most of the rights included in the declaration are enshrined in other human rights treaties already adopted by Canada including the rights to cultural development, health and freedom from discrimination. Source:

15 Fur & whiskey trade Epidemics Missionaries Extermination of the Buffalo

16 Nation to nation contracts Partially fulfilled Poorly administered Reserves: Inadequate size and resources Served to isolate and impoverish

17 Doctrine of Assimilation and Domination Aboriginals are inferior Unable to govern themselves Treaties meaningless European ideas correct, imposable on others Protectionism lead to wide holes in Aboriginal cultures, autonomy, and feelings of low self- worth

18 Restrictive Controlled membership & all economic & political activity Oppressive Outlawed ceremonies Pass laws

19 In what year was the Indian Act officially legislated in Canada? A. 1867 B. 1900 C. 1891 D. 1876 E. 1922

20 The first Indian Act was passed by Parliament in 1875. Since then, numerous amendments have been made to the act. The present act was passed in 1971, but its provisions are still rooted in colonial ordinances and royal proclamations. forms the basis for federal jurisdiction on reserves One complicating issue is how provincial public health acts are applied on reserves.

21 In what year was the Indian Act amended to make residential school attendance compulsory for all First Nations children ages 7 – 15 years? A. 1886 B. 1900 C. 1920 D. 1934

22 The written federal policy was to assimilate First Nations children by educating children away from family and community. The last residential school closed in SK in 1996. In the prime ministers statement of apology regarding residential schools, in one statement he refers to an infamous quote that describes the intended effect of the schools: to be to kill the Indian in the child.

23 Residential School Experience Developed to expedite assimilation Segregated Aboriginal children from their families created an environment where infectious diseases thrived, made worse by "overwork, underfeeding, and various forms of abuse In place for more than a century The effects on peoples lives have not ended.

24 Loss of identity & language Self & cultural shame Abuse: physical, sexual & emotional Family disintegration Substandard education Accumulated generational impact

25 Lost cultural identity, self-respect, and connections to their family, suffered sexual abuse, and had difficulties readjusting after going back home Show symptoms similar to PTSD High levels of suicide, alcoholism, and family violence Cultural genocide

26 Which of the following were conditions in the residential schools? A. Students were separated from their siblings B. Students were punished from speaking Aboriginal languages C. Students were at risk for malnutrition and infectious diseases D. A high proportion suffered various forms of abuse E. All of the above

27 These aspects (among others) contiributed to what have been described as the four fundamental harms of residential schools: 1. physical and consequent emotional harm; 2. educational harm; 3. loss of culture and language; and 4. harm to family structures

28 60s Scoop Indian Hospitals – to fufill burden to care, to further assimilate, to prevent interracial contagion numerous accounts from Indian hospital survivors of multiple abuses, including sterilization and medical experimentation TB Sanitoriums: Presented as positive forces in the treatment of TB amongst Indigenous Peoples Demonstrates the paternalistic white mans approach to caring for indigenous people.

29 This care was enforced by law. The Notifiable Disease Act includes provision for detention of people with active TB until they are no longer infectious (NB Notifiable Disease Act; Campion, 1999). From the perspective of many aboriginal people who became ill with TB, even though they were cared for and provided with good food, adequate rest and medications in the sanatoria, this treatment was not their choice and, indeed, the perception of many was that they were incarcerated in a sanatorium for several years at a time.

30 Economic Social Political Profound personal and cultural loss – Intergenerational Trauma Reinforcing a culture of victimization.


32 Long wait times for care Health care facilities or mechanisms that actively or passively promote feelings of physical insecurity or rejection Lack of trust, respect and/or dignity in relationships between patients and HCWs, as well as between HCWs.

33 Clients describe feeling patronized, not respected, controlled, not informed, and not listened to or taken seriously.

34 Failure on the part of HCWs and the health system to provide continuity of care and consistent care. Care that is apparently available but in reality is not accessible due to an operational culture that does not accord with patient needs (e.g., hours of operation, lack of home care, inaccessibility to the disabled, transportation barriers, etc..

35 Care, particularly within in-patient settings, that engenders or fails to address feelings of isolation, stigmatization and fear (with ensuing depression, anger or anxiety). Staff that are insufficiently knowledgeable or skilled in the diagnosis, investigation and management of TB, particularly the potential side effects and toxicity of therapy. Such defects in quality of care fuel patient concerns about TB (e.g., medication side effects, fear of venipuncture, etc.). These factors have been commonly and consistently found to be negatively associated with TB adherence in many studies.

36 TB programs that lose migratory patients due to watershed areas of jurisdiction and/or poor patient follow-up and tracking sessions. Care that focuses on TB but obstructs, or fails to acknowledge and assist, the patient with regards to other perceived health or social priority needs or adherence barrier (e.g., co-morbidities including addiction, employment, securing concerns, homelessness, etc.). In particular, TB programs that compete with addictions will most likely fail.


38 Knowledge, attitudes and beliefs. Recent studies in both rural and urban Canadian Aboriginal populations have revealed widespread misunderstanding of the causes, symptoms and risks associated with TB. Many make meaning of TB based on their own and/or familial experiences with the disease and many connect TB to the transgression of social norms.

39 Many people do not feel information that is written, broadcasted or delivered orally by health professionals is relevant, or they simply do not notice it.

40 Negative beliefs, attitudes and interpretations regarding tuberculosis are generated through internal and external (social) mechanisms and may lead to fear, hopelessness, anger and a sense of loss that is directed inwards (depression) or outwards (anger and aggression). Co-morbidities and life stressors

41 Life stressors such as lack of resources (financial, shelter, time, available transportation), unemployment, instability in relationships, insecurity and fear are associated with decreased adherence to medical therapy. Such stressors compromise healthy coping mechanisms (e.g., adherence to medication) and promote

42 Patients who do not feel in control of their treatment, or who feel left out of their treatment, are more likely to be non-adherent


44 Poverty creates barriers to adherence to TB therapy. Poverty is characterized by disadvantage both in a material sense (money, shelter, food, physical security, material goods, etc.) as well as in less tangible but critical spheres of power, voice and esteem Social Stigma

45 Self and community efficacy Approaches to the diagnosis and care of tuberculosis that carry messages of victimization or helplessness to patients, families and communities result in ambivalent states of dependency on, and anger with, ostensible helpers. There is a prevalent negative stigma attached to TB in Canadian Aboriginal communities

46 The experience of colonization and institutionalization, alienation and marginalization has promoted the dissolution of traditional internal social control and norms of behaviour in some Aboriginal communities


48 How does a Health Care Professional Respond?

49 Establishment of a knowledgeable, skilled and well-resourced multidisciplinary team with clear lines of authority and responsibility. The team members are accountable to the patient, to each other and to the program. Case manager is central to the team.

50 Provision of dedicated TB physician support and oversight Health services that require minimal negotiations or power to use, which encourage patients to feel that they are valued, respected and the focus of care, and engender cultural safety.

51 Bringing care closer to the patient Provision of holistic care that attends to, rather than competes with, other patient priorities. Efficient care through the development of reminder and follow-up mechanisms, database linkages, simplification and harmonization of protocols, reduction of referral times, etc..

52 Assistance and counselling, use of cultural advocates and creative educational programs for patients, families, communities and HCWs Use of incentives Use of enablers The existence of clear public health legislation that balances the rights of individuals and society, and promotion of the understanding of this legislation among patients, families and communities.

53 Role of the HCW Knowledgeable and skilled must use understandable language, show genuine warmth and concern, solicit the beliefs, concerns and suggestions of the patient and foster a sense of control on the part of the patient with regard to their health and therapy. must have clear and accessible consultative and referral mechanisms when problems arise that are beyond their skill level.

54 Evaluate the health system factors that act as barriers to adherence for their patients

55 Interventions to improve adherence to TB therapy must focus on both the individual patient and on his or her self-defined community or people. This is true for Aboriginal and non-Aboriginal people. The motivation to be healthy requires an appreciation of identity – of who I am. For many Aboriginal people, identity begins with an understanding of who are my people?

56 Educational interventions must start with listening to the patient tell the story of his or her illness and its meaning in their life Explore the patients belief about his or her current health, desire and motivation to change and belief in the power to achieve change. Provision of educational programs that embrace a non-didactic, patient-centred and culturally appropriate approach

57 Indigenous beliefs about causation and cure need to be incorporated into a program which has meaning for the patient. Research is required regarding the causation, transmission and meaning of TB in the lives of patients and their communities. Efforts must be made to develop a shared knowledge and understanding of TB which includes Indigenous and Western scientific health beliefs and practices.

58 Aboriginal communities and people are not all the same, so development of Health education strategies must reflect this. Language is also critical. We should engage patients and communities in a discussion regarding how words like sleeping TB, and germ are translated and whether they are appropriate.

59 The use of key language concepts developed within the culture, along with visual aids, is encouraged. Self-efficacy-based interventions in relation to TB should be developed, implemented and studied in partnership with patients, families and communities similar to those for HIV care and diabetes.

60 Adherence to TB care does not require abstention from alcohol and/or illicit drugs. For some individuals, the use of traditional healing practices including smudging, talking and drumming circles and sweat lodges contribute to self-efficacy, empowerment and self-determinations.

61 TB programs may wish to utilize techniques used in other health models, including those for addictions, in which patients identify a sponsor, companion or mentor who accompanies them on their journey to health. Significant positive effect for patients receiving practical social support such as assistance with childcare, transportation and shelter.

62 TB programs should not attempt to compete with other priorities, such as economic security, in the lives of patients and families. Local governments and band councils have an important role to play through the provision and/or promotion of social support, education, leadership and mentoring.

63 If patients are expected to adhere to therapy, they will also have a reasonable expectation that their health workers, leaders, governments and societal institutions will advocate for, and work towards, reduction and correction of the social determinants of TB, including poverty, racism and stigma, crowded and poor quality housing and ineffective health systems.

64 Tuberculosis programs must build on the existing resilience and strengths of individuals, families and communities in order to promote self-efficacy – the confident belief in ones own ability to make choices that will result in cure and good health


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