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70 Revue canadienne d'ergothérapie avril 2012 79(2)

F irst Nation, Métis, and Inuit ("Aboriginal peoples") in Canada are a?ected by colonial relations of power that result in their marginalization within Cana dian society and, notably for the purposes of this paper, within healthcare settings. Despite a complex colonial legacy that is re?ected by poor health (Adel son, 2005; Newbold, 1998), Aboriginal peoples have nevertheless demonstrated tremendous cultural resilience (Kelm, 1998) and strive for equitable, e?ective, and culturally appropriate healthcare. Like many healthcare professionals, occupational therapists aim to practice in a fair and equitable manner (Canadian Association of

Janet E. G. Jull, Audrey R. Giles

Health equity, Aboriginal peoples and occupational therapy

Key words

Aboriginal peoples

Cultural safety

Culture

Health professions

Mots clés

Culture

Populations autochtones

Professions de la santé

Sécurité culturelle

Abstract

Background

. In Canada, Aboriginal peoples are a?ected by colonial relations of power that result in poor health outcomes. Despite occupational therapists' ef forts to work in a safe and competent manner with people experiencing challenges to participating in daily life, Western healthcare models re?ect values that often undermine Aboriginal peoples' health and well-being. Purpose. Meaningful, ef- fective, and culturally appropriate healthcare practices cannot be fully imple- mented by occupational therapists without an ongoing and critical examination of occupational therapy's foundational belief systems. Only a critical examination of these foundational belief systems will enable occupational therapists to take action towards addressing these inequities, which is an important step in moving towards culturally safe care.

Key Issues

. Canadian health professions, including occupational therapy, have the potential to create positive change at a systems level through the critical exploration of underlying professional assumptions.

Implications

. To advance dialogue about Aboriginal peoples' health, occupation al therapists must engage in exploration of their profession's underlying theoretical concepts or risk participating in the perpetuation of health inequities for already at-risk populations.

Abrégé

Description

. Au Canada, les populations autochtones sont a?ectées par des relations de pouvoir coloniales qui entraînent de faibles résultats en matière de

santé. Malgré les e?orts déployés par les ergothérapeutes pour travailler de manière

sécuritaire et compétente auprès des personnes ayant de la di?culté à participer à la

vie quotidienne, les modèles de soins occidentaux témoignent de valeurs qui nuisent souvent à la santé et au bien-être des populations autochtones. But . Pour mettre en oeuvre des pratiques signi?catives, e?caces et adaptées aux di?érences culturelles, les ergothérapeutes doivent faire un examen continuel et critique des systèmes de croyances fondamentaux en ergothérapie. En e?et, seul un examen critique de ces systèmes de croyances fondamentaux permettra aux ergothérapeutes de prendre des mesures pour aborder ces inégalités, ce qui représente une étape importante vers l'adoption de soins adaptés aux di?érences culturelles.

Questions clés

. Les professions de la santé au Canada, y compris l'ergothérapie, peuvent créer des changements positifs au niveau systémique, en examinant de façon critique leurs hypothèses professionnelles sous-jacentes.

Conséquences

. A?n de faire avancer le dialogue sur la santé des populations autochtones, les ergothérapeutes doivent examiner les concepts théoriques sous-jacents de leur profession, sans quoi ils

risquent de contribuer à la perpétuation des inégalités en matière de santé au sein

des populations déjà vulnérables.

© CAOT PUBLICATIONS ACE

Janet E. G. Jull, MSc, OT Reg. (Ont.),

OT(C), is a PhD candidate in the

Population Health PhD program,

University of Ottawa, Institute of

Population Health, 1 Stewart Street,

Room 302B, University of Ottawa,

Ottawa, ON, Canada, K1N 6N5.

Telephone: 613-562-5691.

E-mail: janetjull@hotmail.com

Audrey R. Giles, PhD.,

Associate

Professor, School of Human Kinetics,

University of Ottawa, 125 University

Private, University of Ottawa, Ottawa,

ON, Canada, K1N 6N5.

Citation

: Jull, J. E. G., & Giles, A. R. (2012).

Health Equity, Aboriginal Peoples and

Occupational Therapy. Canadian Journal of

Occupational Therapy, 79

, 70-76. doi: 10.2182/cjot.2012.79.2.2

Submitted

: 20 May, 2011;

Final acceptance

: 6 February, 2012.

No funding was received to support this

work. at PENNSYLVANIA STATE UNIV on September 18, 2016cjo.sagepub.comDownloaded from

Jull & Giles

Canadian Journal of Occupational Therapy April 2012 79(2) 71 eral health promotion programs (Health Canada, 2005). Fol lowing many years of e?ort on the part of First Nations and Inuit, in 1989 the treasury board approved support for the transfer of Indian Health Services from Medical Services, Health and Welfare Canada (now Health Canada) to First Nations and Inuit communities wanting to direct their own healthcare services, although transfers to communities identi ?ed as eligible have been limited (Health Canada, 2005). ?us, as a result of the federally mandated categorization of Aborigi nal peoples, many people who self-identify as Aboriginal have limited access to or are excluded from health and social pro grams (Smylie, 2010; UNICEF Canada, 2009). ?e complexity of the federal categorization of Aboriginal peoples is compounded by the fact that provincial and territo- rial jurisdictions have each responded di?erently to Aboriginal peoples' health programming needs. Health and social services delivered to Aboriginal peoples are fragmented, with di?ering policies within government and across programs within federal and provincial/territorial ministries. ?e result is inconsistent access to opportunities and resources within communities for people living in Canada and identifying as First Nations, Inuit, or Métis. Existing jurisdictional tensions have had disastrous consequences for Aboriginal peoples, as illustrated by the case of Jordan River Anderson, a child living in the First Nations community of Norway House Cree Nation. Jordan was hos pitalized for over two years and was unable to return home while provincial and federal governments disputed responsi bility for homecare costs. He passed away without being able to return to his family home (First Nations Child and Fam ily Caring Society of Canada, 2011). Jordan River Anderson's experience demonstrated how healthcare services available to non-Aboriginal children could be denied to those of Aborigi nal descent because of payment and jurisdictional disputes within and between the federal and provincial or territorial governments. For occupational therapists, understanding the ways in which the colonial categorization and jurisdictional tensions a?ect Aboriginal peoples' eligibility for healthcare is important to ensure that their clients receive the best possible care. For example, occupational therapists may work with First Nations clients: on reserve, through federally funded programs; o? reserve, through the noninsured health bene?ts program; or through provincial or territorial healthcare service programs. Or, occupational therapy services may not be available to those of Aboriginal descent at all. For instance, school-aged Aborigi nal children with disabilities have been identi?ed as more likely to have unmet needs relating to their disabilities due to the jurisdictional issues a?ecting services for Aboriginal peo ples (Canadian Council on Social Development, 2007). Such ?ndings re?ect the inequity experienced by Aboriginal peoples within the Canadian healthcare system, when they are unable to access a healthcare provider such as an occupational thera pist for assistance. In addition, non-status members of First Nations, status members of First Nations who live o?-reserve, and Métis peoples may rely on their healthcare providers such as occupational therapists to help them negotiate healthcare programs. It is therefore imperative that we understand colo

nial categorizations and their impacts so we can provide our Occupational ?erapists [CAOT], 2007). Indeed, in part due to Aboriginal peoples' self-identi?ed healthcare needs, con-cepts such as cultural safety are being introduced into main-stream healthcare practices in Canada (National Aboriginal Health Organization [NAHO], 2008). Despite the existence of policy and frameworks for the delivery of health services to Aboriginal peoples, the health of First Nations, Métis, and Inuit peoples in Canada has been de?ned as poor, with shorter life expectancies, and higher rates of illness, injury, and suicide when compared to non-Aboriginal Canadians (Aboriginal A?airs and Northern Development Canada [AANDC], 2010; Health Disparities Task Group of the Federal/Provincial/Ter-

ritorial Advisory Committee on Population Health and Health Security, 2004). In this paper, we argue that occupational ther- apists can play a meaningful and e?ective role in improving Aboriginal peoples' health through the application of cultur- ally safe healthcare. However, we assert that this goal cannot be realized within occupational therapy without ?rst examining, critiquing, and then changing the ways in which the profes sion's foundational beliefs, such as those pertaining to occupa tion (see Iwana, 2005), re?ect Eurocentric values. We situate our arguments within Canada's colonial history, culturally safe healthcare, and the social determinants of health.

Colonial In?uences on Healthcare:

Jurisdictional Issues

For Canadian occupational therapists, issues that in?uence Aboriginal peoples' health and well-being, such as the legisla tion of their cultural identities, can seem overwhelming and complex. As such, we begin by situating Aboriginal peoples' current health status within its colonial context. Canadians' healthcare is the responsibility of the province or territory in which each Canadian lives-the exception to this rule, however, is healthcare for First Nations and Inuit peoples. ?e feder- ally legislated Indian Act of 1876 (Department of Justice, 2011) identi?ed "Indians and lands reserved for Indians" as federal responsibilities (?e Constitution Act, 1982). ?ough it has undergone revisions since ?rst developed in 1876, this legisla tion, which was developed to determine the eligibility of First Nations peoples for federal recognition as "registered Indians," is still used by the federal department of Aboriginal A?airs and Northern Development Canada (formerly Indian and North ern A?airs Canada) (AANDC, 2011). Registered First Nations peoples listed with AANDC and who live on reserve are eligible for federally funded health and social bene?ts through the federal First Nations and Inuit Health Branch, as are Inuit living in their traditional territories (Health Canada, 2010). In contrast, registered First Nations peoples on the AANDC list and living o? reserve and Inuit people living outside traditional territories are only eligible for some services through Health Canada's federal noninsured health bene?ts program (Health Canada, 2009). Inuit peoples are excluded from registration under the Indian Act, but are eligible for some federal health and social service programs (Health Canada, 2011). Métis peoples are not usually able to register under the Indian Act, do not receive comprehensive federal healthcare services, and are only eligible for some fed at PENNSYLVANIA STATE UNIV on September 18, 2016cjo.sagepub.comDownloaded from

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72 Revue canadienne d'ergothérapie avril 2012 79(2)

of occupational therapy stands to gain a better understand ing of the ways in which potential changes could be made to the profession to enhance the likelihood of the development of culturally safe healthcare with Aboriginal clients. Such an understanding and ensuing action, however, is not possible without self-re?ection. Without self-re?ection, occupational therapy could risk being an inadvertent contributor to the issues that undermine Aboriginal health. Health researchers have argued that Western-trained healthcare professionals have an inadequate understanding of Aboriginal cultures (Browne, 2005; Browne & Fiske, 2001), which has had and continues to have deleterious impacts on Aboriginal peoples' health (NAHO, 2003). Additionally, the negative experiences with Western-trained healthcare pro fessionals have been described as constituting interpersonal and institutional racism (NAHO, 2003; Papps, 2005) that is grounded in the con?icting cultural beliefs between Aborigi nal peoples who seek healthcare and the typically non-Aborig inal healthcare professionals who provide it. Western models of healthcare delivery are alone insu?cient for understanding and addressing Aboriginal populations' needs for health and well-being (Browne, Smye, Varcoe, 2005; RCAP, 1996; Smith, Varcoe, & Edwards, 2005). Certainly, healthcare practices based solely on culturally insensitive approaches have led to Aboriginal peoples' health being jeopardized and Aboriginal peoples choosing not to use healthcare services or seeking care as a last resort (Smith, Edwards, Varcoe, Martens, & Davies,

2006). To promote the possibility of o?ering culturally safe ser-

vices, occupational therapists must re-examine the profession's core assumptions to re?ect and con?rm more universal (i.e., not Eurocentric) perspectives and values. Moreover, this re- examination must occur from within the context of relation ships with Aboriginal partners. A re-examination of Canadian occupational therapy's core assumptions in collaboration with Aboriginal partners will inform the development and delivery of better healthcare services for Aboriginal clients. By engaging in such processes, the profession of occupational therapy can build partnerships and gain experiences to enhance relation ships with others identi?ed as vulnerable within our society.

Aspiring for a Just Society

Vulnerable peoples' marginalization within healthcare chal lenges occupational therapy's professional commitment towards creating a just society (Hammel, 2008; Kronenberg & Pollard, 2005; Molke & Rudman, 2009). Like many other healthcare professionals committed to promoting an equitable Canadian society, occupational therapists are directed by their governing bodies to be inclusive of people from diverse back grounds and practice in ways that are "accessible, welcom ing, meaningful and e?ective" (ACOTRO, ACOTUP, CAOT, COTF, & PAC, 2007, para.1). Unfortunately, there is o?en dis sonance between policy and practice. ?e awareness of other worldviews and perspectives cre ates an opportunity to promote more equitable therapeutic environments in which Aboriginal peoples' health needs can be better addressed. First, however, we must recognize the existence of theoretical imperialism within guiding occupa

tional therapy documents. Hammel (2008) has argued that clients with access to the healthcare services to which they are entitled. Healthcare service availability is, however, just one aspect of healthcare provision for Aboriginal peoples; indeed, healthcare must also be culturally safe to be e?ective.

Culturally Safe Healthcare

In its guiding documents, the profession of occupational ther- apy in Canada has acknowledged the importance of collabo ration and building relationships with vulnerable groups and has articulated the need to "strongly support initiatives within the profession to examine the impact and potential impact of diversity" (ACOTRO, ACOTUP, CAOT, COTF, & PAC, 2007, para. 2). Such a statement implies that occupational therapists advocate for fair and inclusive practices in their delivery of healthcare services; however, despite the intent behind such statements, Aboriginal healthcare recipients in Canada o?en experience a di?erent reality. As a consequence, they are docu mented as being more likely to experience poorer health and have shorter lifespans than non-Aboriginal peoples (Tjepkema, Wilkins, Pennock, & Goedhuis, 2011; Tjepkema, Wilkins, Sen ecal, Guimond, & Penney, 2011). Furthermore, the systems that structure Canadian healthcare programs and approaches, which include occupational therapy amongst other healthcare professions, are based on Western knowledge and models of service delivery. During its review of Canadian healthcare sys tems, the Royal Commission on Aboriginal Peoples (RCAP,

1996) identi?ed healthcare models as re?ecting oppressive val

ues because they fail to recognize Aboriginal peoples' cultures. ?e RCAP further found mainstream healthcare approaches to be unable to understand or fully meet Aboriginal peoples' health needs. As a result, the extent to which occupational therapists are able to provide culturally safe care must be called into question. Concepts of safe and competent healthcare have been enacted in the healthcare arena through models of culturally safe care, which has been de?ned as healthcare delivery that shows an awareness of both the client's cultural background as well as the healthcare providers' personal and professional culture (Brascoupé & Waters, 2009). Cultural safety was devel oped and formalized in 1988 in New Zealand by Maori nurses in response to the colonial experiences and subsequent poor health of the Indigenous peoples of New Zealand. ?e aims of concepts related to cultural safety were to change the way in which healthcare was delivered and incorporated into nurs ing curricula (Papps & Ramsden, 1996). Cultural safety refers to what is felt or experienced by a client when a healthcare provider communicates with the client in a respectful, inclu sive way, empowers the client in decision making, and builds a healthcare relationship in which the client and provider work together as a team to ensure maximum e?ectiveness of care (NAHO, 2008). Cultural safety requires that healthcare pro viders treat clients with the understanding that not all individ uals in a group act the same way or have the same assumptions and beliefs (NAHO, 2003). ?is can only begin when health care providers become aware of the personal and professional assumptions and beliefs that they bring into every healthcare relationship. By collaboratively examining the meaning of client-centred care with Aboriginal partners, the profession at PENNSYLVANIA STATE UNIV on September 18, 2016cjo.sagepub.comDownloaded from

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Canadian Journal of Occupational Therapy April 2012 79(2) 73 live and work, such as increasing income or making health services more accessible. In fact, research has suggested that with such an approach health inequities can change within societies and between nations. Indeed, Marmot (2006) argued, "Rapid health improvements in some countries and the lack of improvement in others suggest that changes in social and envi ronmental conditions, and in public health and basic medi cal care, could do much to change things for the better" (p.

2085). For instance, it has been shown that the hierarchical,

graded relationships between socioeconomic status and health mean that individuals who experience higher socioeconomic conditions have better health ("the social gradient") (Marmot,

2004). An individual's status within the social gradient has

been shown to have a signi?cant impact on health and in?u ence health outcomes such as life expectancy, rates of illness and injury, and infant mortality (Marmot, 2004; Wilkinson & Pickett, 2010). It is encouraging that Marmot (2006) also found that "hierarchies might be inevitable but the health gra dient linked to hierarchies is less so" (p. 2085). Occupational therapists have an opportunity to partici pate in partnerships with Aboriginal peoples and to address issues of health equity. Other professions have shown us that such partnerships can be achieved. For example, in Western Canada, an educational strategy was developed with the aim of in?uencing the broader systems to a?ect the social deter- minants of Aboriginal peoples' health. Educational attainment is linked with health. People with higher attainment in formal education have better access to environments that promote health, better socioeconomic status, more life satisfaction, bet ter self-actualization, and dependent care (CSDH, 2008). Evi dence shows that in comparison to other students, Aboriginal learners have lower graduation rates and are less likely to be in age appropriate grades (Battiste, 2005). In response to requests from Aboriginal organizations concerned with school perfor- mance within their populations, the British Columbia Min istry of Education developed a program aimed at achieving equity in schooling experiences between Aboriginal and non-quotesdbs_dbs26.pdfusesText_32

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