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UrbanAboriginalhealth: Examininginequalities
betweenAboriginaland non-Aboriginalpopulations inCanada
KathiWilson
DepartmentofGeography, UniversityofToronto Mississauga
NicoletteCardwell
DepartmentofGeography, UniversityofToronto Mississauga Thisarticlecontributes tothenascent literatureonthe healthofurban Aboriginalpeopleby comparingthe healthstatus anddeterminantsofhealthof theurbanAboriginal andurbannon-Aboriginal populationin Canada.Datafor theresearchwere takenfromthe 2001AboriginalPeoples Survey(APS) andthe2000-2001 CanadianCommunityHealth Survey(CCHS) Cycle1.1.Framed withinapopulation healthapproach,we explore theextentto whichhealths tatusanddeterminants ofhealthdi ff erbetweenAboriginal andnon-Aboriginal
populationslivingin urbanareas.Health statusismeasured bythreevariables - self-assessed healthstatus,
chronicconditions,and activitylimitations.While disparitiesinhealth existbetweenthe urbanAboriginal and
non-Aboriginalpopulation, theyarenot aslargeas thosebetweenthe Aboriginalpopulationliving onareserve andnon-Aboriginalpeople. Thesocial determinantsofhealth arequitesimilar betweenthetwopopulationsbut theresults alsorevealthe significanceofcultural factorsinshaping healthamongthe urbanAboriginal
population.Theresearch demonstratesaneed forfuturer esearchto focusonculturally specificdeterminantsof
healthas onepotentialexplanation fordisparitiesin healthbetweenurban Aboriginalandnon-Aboriginal people. Keywords:Aboriginal,urban, socialdeterminantsof health,culturaldeterminants Lasant´edesAutochtones enmilieuurbain :uneexploration desin´egalit´esentreles Canadiens autochtonesetnon autochtones
Cetarticlea pourbut decontribuer`alalitt ´eratureen´emergenceportantsur lasant ´edesAutochtones enmilieu
urbain,encomparant l'´etatdesant ´eetles d´eterminantsdela sant´edela populationautochtoneet
non-autochtoneen milieuurbainau Canada.L'´etudes'appuiesur desdonn´eestir´eesdel'Enqu ˆeteaupr`esdes
peuplesautochtones (EPA)de2001 etdel'Enqu ˆetesurla sant´edansles communaut´escanadiennes(ESCC), cycle
1.1.Pr´econisantuneapproche ax´eesurla sant´edela population,nousexplorons lesdiff´erencesdel' ´etatde
sant´eetdes d´eterminantsde lasant ´eentreles populationsautochtoneset non-autochtonesenmilieu urbain.
Troisvariablessont utilis´eespourd ´ecrirel'´etatdesant ´e:l' auto-´evaluationdel' ´etatdesant ´e,lesmaladies
chroniquesetla limitationd'activit´es.Sil'existence dedisparit´esenmati `eredes ant´eentrela population
autochtoneetnon-autochtone enmilieuurbain estd´emontr´ee,celles-cine sontpas aussiimportantesque les
disparit´esquicaract ´erisentlapopulation non-autochtoneetautochtone vivantdansune r´eserve.Les
d´eterminantssociaux delasant´esont comparablespourlesdeuxpopulations,mais lesr´esultatsillustrent`a
quelpointdes facteursculturels peuvent´egalementinterveniren faveurouau d´etrimentde lasant´eparmila
populationautochtoneen milieuurbain.Cette ´etudeexploratoire faitressortirla n´ecessit´ede tenircomptedes
facteursculturelspropres auxd´eterminantsdela sant ´edansles recherchesult´erieuresafind'identifier des
Correspondenceto/Adresse decorrespondance:Kathi Wilson,Departmentof Geography,Universityof TorontoMississauga,3359
MississaugaRd.N., Mississauga,ON L5L1C6.Email/Courriel: kathi.wilson@utoronto.ca TheCanadianGeographer /LeG ´eographecanadien2012,56(1):98-116
DOI:10.1111/j.1541-0064.2011.00397.x
C?CanadianAssociation ofGeographers/ L'Associationcanadiennedes g´eographes
UrbanAboriginalhealth 99
pistesd'explicationdes disparit´esenmati `eredes ant´eentreles individusautochtoneset non-autochtonesen
milieuurbain. Motscl´es:Autochtones, urbain,d´eterminantssociauxde lasant´e,d´eterminantsculturels
Introduction
Thenumberof peopleinCanada whoidentify
asAboriginalnow exceedsonemillion (Canada
2008a).
1
AstheAboriginal populationinCanada
continuestogrow muchfasterthan thenon-
Aboriginalpopulation,so dodisparitiesin health.
Researchdemonstratesa disproportionategap
inhealthstatus betweenAboriginaland non-
Aboriginalpopulations(Waldram etal.2006;
Esteyetal. 2007;Wilsonet al.2010).While there
ismuchdocumented informationaboutinequali- tiesinmortality andmorbiditybetween Aborig- inalandnon-Aboriginal populationsinCanada, whatweknow aboutthehealth statusofthe
Aboriginalpopulationis mainlylimitedto Reg-
isteredIndiansliving onreserves(see, forex- ample,Bartonet al.2005;Martens etal.2005). 2
Thus,littleis knownabout thehealthof other
segmentsofthe Aboriginalpopulationsuch as thosewholive inurbanareas (whichcaninclude RegisteredIndians,non-status Indians,M´etis,and
Inuit).
Sincethe1960s, Canadahaswitnessed un-
precedentedgrowthin theurbanAboriginal pop- ulation.Inthe early1950s,less than7percent oftheAboriginal populationlivedin urbanar- eas.Bythe early1960s,approximately 13per- centofthe totalAboriginalpopulation livedin 1 Theterm"Aboriginal" isusedin thisarticleto refertothe descendantsofthe originalinhabitants ofCanada.The Con- stitutionActof Canada(1982)recognizes threebroadAborig- inalidentityg roups:NorthAmerican Indians,M´etis,andInuit (Canada1982).M any"Indians"prefer thephrase"FirstNa- tions"whenreferring tothemselvesas acollective group.The InuitareAboriginals whomainlylive inCanada'smost north- ernregions.Traditionally theterm M´etiswasused todescribe thechildrenof Creewomenand Frenchfurtraders livingin theprairieregion ofCanada. Howevertodaythe termisused quitebroadly torefertoindividualsofmixed FirstNations andEuropeanancestry (Canada2004b). Theterm"Registered" or"Status"Indians referstothose individualswhoare regis- teredunderthe IndianActof Canada.Thisterm isonlyused inthisarticle whenquoting directlyfromother studies. 2 Areserveis atractof landsetaside fortheuse andbenefit ofaFirst Nationcommunity (Canada2004b).The majorityof Aboriginalpeopleliving onreservesare RegisteredorStatus
Indians.
urbanareas(see Kalbach1987).Data fromthe
2006Censusof Canadarevealthat thisfig-
urehasincreased toover50 percentwhilethe populationresidingon IndianReservesaccounts forlessthan 30percentof theAboriginalpop- ulation(Canada2008a). 3
Onthesurface, the
increasingurbanizationof theAboriginalpopula- tionsuggestsa massivemigrationfrom reserves andadepopulation ofreserveand ruralareas (Norrisetal. 2001,2003a;Peters 2005).How- ever,asPeters (2005)andothers havedemon- strated,Aboriginalurbanization isquitecomplex.
Thegrowthof theurbanAboriginal population
isnotnecessarily reflectiveofmass movement fromreservesto citiesbutrather acombina- tionofmovement, highratesof naturalincrease, changingpatternsof self-identification(i.e.,eth- nicmobility),and legislatedchangesto theIn- dianActin 1985(BillC-31) (Guimond2003a;
Norrisetal. 2003b).
4
Infact,Guimond (2003b)
hasarguedthat intragenerationalethnicmobility, whichoccurswhen apersonchanges theirethnic a ffi liationovertime, isresponsible forthelarge increasein theurbanAboriginal populationfrom themid-1980s to2001.Despite themovementof individualsfromreserve tourbansettings and theincreasein thenumberof individualsliving inurbanareas whoidentifythemselves asAbo- riginal,theresearch onAboriginalhealth contin- uestoconcentrate onRegisteredIndians living onreserves(Hotson etal.2004; Kauretal. 2004;
Muttittetal. 2004;Dobbelsteyn2006). Twore-
centreviewsof Aboriginalhealthresearch con- ductedinmedical/health sciences(Young2003) andthesocial sciences(Wilsonand Young2008) concludethatresearch failstoreflect thegeo- graphicprofileof AboriginalPeoplesin Canada withasevere under-representationofurban 3 Itisimportant tonotethat thewayin whichtheAboriginal populationhadb eenidentified andcountedintheCensusof Canadahaschanged overtime.Thus, thesesources arelikely usingdi ff erentpopulationdefinitions andmaynot bedirectly comparable. 4 Thismainly referstoBill C-31reinstatements,the majorityof whichlivein urbanareas(Norris etal.2003a). TheCanadianGeographer /LeG ´eographecanadien2012,56(1):98-116
100KathiWilson andNicoletteCardwell
AboriginalPeoples.This canbe explained,in
part,bythe lackofhealth dataavailablefor ur- banAboriginalpeople sincemuchof theannual healthinformationcollected isonlyavailable for theon-reservepopulation andthisis severely limitedinterms ofcoverageand scope(Waldram etal.2006). Beyondissuesof dataavailabil- ity,theRoyal CommissiononAboriginal Peoples arguedthatnon-Aboriginal researchersoverlook theurbanpopulation duetopervasive andper- sistentideasabout whereAboriginalPeoples be- long(i.e.,on reservesandin remotelocations) (Canada1996b).
Thisstudybegins tofillthe gapinthe existing
knowledgebaseon Aboriginalhealthby examin- ingthehealth oftheurban Aboriginalpopulation inCanada.More specifically,usingdata fromthe
2001AboriginalPeoples Survey(APS)(Canada
2001a)andthe 2000/2001CanadianCommunity
HealthSurvey(CCHS) (Canada2001b),this article
presentstheresults ofstatisticalanalysis aimed atcomparingthe healthstatusand determinants ofhealthbetween urbanAboriginalPeoples and non-AboriginalsinCanada. Thisisan important avenueofinvestigation becauseitsheds lighton theextentto whichAboriginalhealth disparities continuetopersist inurbanlocations.
Background
Aboriginalpeoplein Canadasu
ff erfrommuch higherratesof mortalityandmorbidity than thenon-Aboriginalpopulation (seeFrolichet al.
2005).Forexample, thegapin lifeexpectancybe-
tweenRegisteredIndians andthegeneral Cana- dianpopulationis almostsevenyears (Canada
2004a).Infantmortality ratesare40 percent
higheramongthe RegisteredIndianpopulation andsuiciderates aretwiceas highascompared withthegeneral Canadianpopulation(Canada
2004a;Kirmayeret al.2007).Morbidity isalso
moreprevalentwithin theAboriginalpopulation.
Whileinfectiousdiseases areonthe decline,as
Waldrametal. (2006)note,they havebeeno
ff set bychronic conditionsandinjuries astheleading causesofdeath andhealthproblems withinthe
Aboriginalpopulation.While cancerratesremain
lowerwithinthe Aboriginalpopulationcompared tothenon-Aboriginal population,diabetes,hy- pertension,cardiovasculardisease, andobesity aremuchmore prevalentamong Aboriginalpeo- ple(Waldramet al.2006; Canada2008b,2009a).
Researchshowslarge disparitiesinhealth be-
tweenAboriginaland non-Aboriginalpopulations butmuchof whatweknow abouttheAboriginal healthisbased ondatacollected foronreserve
FirstNationspopulations (Waldrametal. 2006).
Savefora handfulofstudies, relativelylittleis
knownaboutthe healthofurban Aboriginalpeo- ple.Interestingly,much ofwhathealth research existsabouturban Aboriginalpopulationsmainly focusesonissues relatedtohealth careuse.In oneofthe earliesthealthstudies ontheurban
Aboriginalpopulation,Waldram (1990a,1990b)
conductedextensivesurveys onthehealth care utilizationbehavioursof urbanAboriginalpeo- plelivingin thecityof Saskatoon,Saskatchewan.
Hefoundfew di
ff erencesinphysician usebe- tweenthenon-Aboriginal andAboriginal popula- tionandshowed (contraryto assumptionsthat existedat thetime)that urbanAboriginalpeople donotavoid conventionalhealthcare (Waldram
1990a).Waldram(1990b) alsofoundthat urban
Aboriginalpeoplecontinue toutilizetraditional
healingpracticeswhile livinginthe city,partic- ularlyasa complementtocontemporary health care(i.e.,physicians). Inanotherstudy, Benoit etal.(2003) interviewedAboriginalwomen living inVancouver's"Downtown Eastside"tounder- standtheirperceptions ofhowhealth careser- vicesmeettheir specifichealthcare needs.They foundthaturban Aboriginalwomencontend with racismanddiscrimination withinthecontem- poraryhealthcare systemandhave astrong desireforculturally appropriateandtraditional approachestohealing (seealsoTang andBrowne
2008).Workby LevinandHerbert (2004)also
pointstoproblems ofracialbias andcultural insensitivitywhenurban Aboriginalpeopleac- cesshealthcare (seealsoBrowne etal.2011) whileastudy byMundeland Chapman(2010) oftheUrban AboriginalCommunityKitchen
GardenProjectin Vancouveridentifiesthe
importanceofa decolonizingapproachto health promotionthathas thepotentialto addressthe healthneedsand causesofurban Aboriginal healthdisparities.Research byWaljiet al.(2010) pointstothe potentialimportanceof naturo- pathicmedicinefor providingholisticand cultur- allysensitivehealth caretoAboriginal patients inanAboriginal healthcentrein Toronto.Other TheCanadianGeographer /LeG ´eographecanadien2012,56(1):98-116
UrbanAboriginalhealth 101
studiesfocusmore closelyonspecific healthis- sues,riskyhealth behaviours,andproblems in particularcities.For example,Iwasakiand col- leagues(Iwasakiet al.2004,2005) studiedthe copingmechanismsof Aboriginalwomenand menwithdiabetes livinginWinnipeg, Manitoba, andMacdonaldet al.(2010)explored Aboriginal understandingsoftuberculosis inMontreal.In otherresearch, Heathetal. (1999)andMehrabadi etal.(2008) haveexaminedrisk factorsasso- ciatedwithHIV (seealsoMill etal.2008) and
Milleretal. (2011)hasstudied thedeterminants
ofinjectiondrug useamongurban Aboriginal youthinPrince GeorgeandVancouver, BC.
Thecurrentbody ofliteratureon urbanAbo-
riginalhealtho ff ersinsightinto healthcareuse andaccessibilityproblems butvery littleinterms ofhealthstatus. Muchofthe researchconducted focusesononly asmallnumber ofCanadian citiesleavingus withlittleor nopictureof ur- banAboriginalhealth atthenational scaleof analysis.However,a studybasedon datafrom the2001Canadian CommunityHealthSurvey (CCHS)revealedthat thehealthof theo ff -reserve
Aboriginalpopulation(i.e., thoseliving incities,
towns,rural areas)isworse thanthehealth oftheirnon-Aboriginal counterparts(Tjepkema
2002).In particular,theresearch showsthata
higherpercentageof theurbanAboriginal popu- lationratestheir healthasfair/poor andhasat leastonechronic conditionincomparison tothe non-Aboriginalpopulation.While thestudyrep- resentsanimportant firstglimpseof thehealth ofurbanAboriginal Peoples,importantgaps re- main.First,the CCHSisa nationalsurveyof thegeneralCanadian population.Assuch, it doesnottarget Aboriginalpeople.The CCHS onlycaptured3500 individualsreportingAborig- inalancestry.Since theCCHSdid notsetout to sampleAboriginalpopulations bydesign,those capturedinthe CCHSmaynot berepresentative oftheoverall o ff -reservepopulationand maynot identifythemselves asAboriginal.Second, while theresearchdoes revealimportant disparitiesin health,we stillknowlittle abouttheextent of thedi ff erencesinthe determinantsof health.
Thisknowledgeis crucialforan in-depthun-
derstandingofthe mostimportantfactors that shapethehealth statusofCanada's urbanAbo- riginalpopulation.Such informationisnecessary toensurethat thehealthand socialservicessys- teminurban settingsmeetsthe needsofthe
Aboriginalpopulation.It isthesetwo gapsin
knowledgethatthis researchseeksto fill.
Dataandmethods
Tounderstanddi
ff erencesinhealth statusand determinantsofhealth betweenurban Abo- riginalandnon-Aboriginal peopleinCanada, apopulationhealth approachisemployed. A populationhealthapproach seekstoimprove the healthofpopulations byidentifyinginequalities inhealthand focusingonwhy somepopulations arehealthyand othersarenot (EvansandStod- dart1994;Canada 2003b;Richmondand Ross
2009).Theapproach placesemphasison abroad
rangeoffactors suchasage, gender,income, andeducationthat shapethehealth ofpopula- tions(Canada2008c). Whilesocialand economic factorsinfluencethe healthofboth Aboriginal andnon-Aboriginalpopulations, evidencealsoin- dicatesthatAboriginal cultureisalso animpor- tantdeterminantof health(Canada1996a; Smylie andAboriginalHealth IssuesCommittee2001;
Adelson2005;Waldram etal.2006). Giventhe
healthbeliefsof AboriginalPeoplesin Canada,it isessentialin thisresearchto considernotonly characteristicsrelatedto sociodemographicand socioeconomicstatus,health behaviours,geogra- phy,andhealth careuse butalsocultural fac- tors.Indoing so,weexamine theextentto which disparitiesanddi ff erencesinthe determinantsof healthexist betweenurbanAboriginal andnon-
Aboriginalpopulations andalsothe relativerole
ofcultural factorsinshaping healthamongur- banAboriginalpeople.
Dataforthe analysiscamefrom twonational
cross-sectionalsurveys - the2001 AboriginalPeo- plesSurvey(APS) andthe2000-2001 CCHSCycle
1.1.TheAPS isanational surveyofindivid-
ualslivingon reservesando ff reservewho self-reporttheir Aboriginalidentityand/or re- portAboriginalancestry (Canada2003a). Data forthe2001 APSwere collectedbetweenSeptem- ber2001and June2002from approximately
98649respondentswitha responserateof 84
percent(Canada2003a). TheAPSincluded four questionnaires:i)adult coresurvey,ii) Inuitsup- plement,iii)M ´etissupplement,and iv)childsur- vey.The adultcoresurvey isadministeredto all TheCanadian Geographer/Le G´eographecanadien2012,56(1):98-116
102KathiWilson andNicoletteCardwell
individualsaged15 yearsand olderandcontains ninethematicsections (language,mobility, edu- cation,technology, health,employment,income, justice/policing,and housing)thatinclude astan- dardsetof questionsthat supportourcom- parativeanalysis (furtherdetailsbelow). Forthe purposesofthis analysisweinclude onlythe
Aboriginalidentitypopulation livinginurban
settings. 5
TheCCHSwas selectedtorepresent thenon-
Aboriginalpopulationin Canada.Itis across-
sectionalsurveyconducted throughoutCanada everytwoyears byStatisticsCanada beginning in2000/2001.Data werecollectedfrom approx- imately130827 respondentsbetweenSeptember
2000andOctober 2001excludingthose livingin
remoteregions,on IndianReservesand Crown
Lands,andthose livingininstitutions. Thesur-
veycontainsquestions relatedtohealth, health careuse,and healthbehaviours.The CCHSis designedtoproduce informationatthe provin- cial,territorial,and healthregionlevels (Beland
2002).Datafrom the2000/2001(Cycle 1.1)CCHS
areusedin thisresearchto analyzehealthsta- tusanddeterminants ofhealthfor thegeneral
Canadianpopulation.The publicusemicrodata
file(PUMF)of theCCHSthat wasusedfor this articledoesnot containdetailedinformation on ethnicitysowe couldnotexclude thoseindivid- ualswhomay havereportedAboriginal ancestry.
Thus,theremay besomeindividuals intheCCHS
whoarein factAboriginalPeoples. However, giventhatthe CCHSdoesnot targettheAbo- riginalpopulation,the potentialproportionof
Aboriginalrespondentswould beextremelysmall
relativetonon-Aboriginal respondents,makingit themost suitableandcomprehensive dataset forrepresentingthe non-Aboriginalpopulation.
CCHSCycle1.1 waschosen overmorerecent cy-
clesofCCHS becausethedata collectionperiod matchesmoreclosely withthe2001 APS.
The2001APS andthe2000/2001 CCHSare
bothadministeredby StatisticsCanadaand pro- videtheideal datasetsfor conductingthis analysis.Bothsurveys wereconductedduring a 5quotesdbs_dbs11.pdfusesText_17
Strong and Smart: Reinforcing Aboriginal perceptions of being