Ongoing evidence-based reporting throughout the COVID-19 pandemic has uncovered health disparities arising from social determinants of health (SDOH) among Indigenous communities across Canada (Government of Canada, 2020). These SDOH-related disparities in health status are closely related to health inequities. For clarity, health disparity refers to differences in health across population groups, while health inequity refers to the causes of these health disparities (Reutter & Kushner, 2010). Through intersectoral collaboration, community health leaders can work with Indigenous communities to address these SDOH-related health disparities and inequities.
It is well documented that Indigenous communities are at a much greater risk of poor health outcomes than non-Indigenous Canadians (Reutter & Kushner, 2010). Death rates, hospitalizations, and infectious transmission rates in both the 2009 H1N1 and the 1918 influenza pandemics were higher among Indigenous peoples than the national average (Saint-Girons et al., 2020). Similarly, emerging data from the current COVID-19 pandemic is revealing higher infection rates, which points to pre-existing health disparities and inequities among this population. Here, we identify current determinants of health of particular importance to poor Indigenous health outcomes during the COVID-19 pandemic in Canada, and some crucial ways in which community health leaders can address these determinants.
Indigenous communities are highly predisposed to COVID-19-related hospitalizations due, in part, to high rates of chronic health conditions, including hypertension, diabetes, and cardiovascular disease (Statistics Canada, 2020a). Throughout this pandemic, Indigenous peoples with chronic conditions have consistently had increasingly compromised physical, mental, and social health compared with non-Indigenous Canadians (Hahmann, 2020; Jenkins et al., 2021). Additionally, Indigenous peoples with physical and/or mental health disabilities face decreased access to social and cultural support due to a combination of diminished personal and community resources, including digital service accessibility (Hahmann, 2020). It is also becoming apparent that the mental health effects of COVID-19 will be the longest-lasting wave of the pandemic, where consequences can be expected for years post-lockdown (Jenkins et al., 2021). Low income, food insecurity, disrupted family dynamics, lack of immediate and ongoing social support, and increased substance use are among the most significant factors contributing to deteriorated mental wellness among Indigenous persons and communities throughout this pandemic (Jenkins et al., 2021). As a result, compromised physical and mental health are contributing to health disparities that are as far-reaching and devastating as the virus itself.
According to the National Occupation Standard Housing Suitability Measure, 23.1% of Indigenous individuals currently live in unsuitable housing conditions, with crowded quarters, lack of proper infrastructure, and geographical isolation being major factors (Statistics Canada, 2020a). These living conditions existed long before the pandemic, but their detrimental health effects are exacerbated by the COVID-19 pandemic. Community spread may be disproportionately increased among and between Indigenous households as a result. Comparatively, unsuitable housing conditions averaged 8.5% for non-Indigenous households (Statistics Canada, 2020a). Furthermore, 57 long-term drinking water advisories currently exist for 39 First Nations communities (Statistics Canada, 2021). Water insecurity greatly impacts the living conditions, sanitation, and overall health of community members. There are also implications with crowded multi-generational homes, where a combination of age, comorbidities, and inadequate infrastructure will contribute to long-term negative health outcomes even after the COVID-19 pandemic is overcome.
In terms of income, 24% of Indigenous communities live at or below the national poverty line versus 13% of non-Indigenous people (Arriagada et al., 2020). These households are further impacted by public health measures aimed at flattening the pandemic curve, including business closures, staffing reductions, and stay-at-home mandates. While a similar employment decline between Indigenous and non-Indigenous individuals was found in 2020, the economic recovery through employment income is much slower among Indigenous communities (Statistics Canada, 2020b). National data further highlights this issue: 39% of off-reserve First Nations households last year could not cover unexpected expenses of $500 or more (Arriagada et al., 2020). The Government of Canada consequently designed Indigenous support funds to prepare and assist communities where needed, but barriers to funding access persist (Government of Canada, 2021). These barriers include differences in eligibility depending on treaty status and residing off-reserve, lack of internet accessibility, and at times confusing and vague website information.
To address these Indigenous SDOH-related health disparities, it is imperative to adopt Indigenous frameworks as a starting point. Significantly, the First Nations Information Governance Centre (FNIGC) and Métis National Council (MNC) highlight the importance of holistic health through collectively incorporating physical, emotional, mental, and spiritual aspects of health (Public Health Agency of Canada [PHAC], 2018). This holism is the basis for the medicine wheel. Furthermore, the Canadian Council on Social Determinants of Health highlights an Indigenous framework entitled the First Nations Holistic Policy and Planning Model (FNHPPM) to conceptualize and address Indigenous health inequities (Canadian Council on Social Determinants of Health [CCSDOH], 2015). Key areas of this model include the medicine wheel at its core, followed by the role of community members, Indigenous self-governance, health determinants, and social capital. This framework champions holistic and intersectoral approaches as they relate to the complex relationships between individuals and communities. Using this framework will therefore facilitate a unified approach rooted in Indigenous culture, with guidance from evidence-informed health practices. It is therefore anticipated that the framework will be beneficial for Indigenous communities and community health leaders working together towards pandemic recovery.
Community collaboration addresses all areas of the FNHPPM (CCSDOH, 2015). Moreover, related frameworks, such as the client-centred McGill nursing theory (Gottlieb & Rowat, 1987) or a recently validated COVID-19 Equity Matrix (Ismail et al., 2021), can also be integrated with the community health aspects of this holistic Indigenous model. Commonalities between these various paradigms enable the foundation of a unified strengths-based approach. During this pandemic, the positive effects of collaborative decision-making between community health and Indigenous leaders have already been shown for the Nisichawayasihk Cree Nation (Kyoon-Achan & Wright, 2020). In this case, joint decision-making was associated with decreased community transmission, where community healthcare leaders used a strengths-based approach to disseminate best practice recommendations while preserving community sovereignty and Indigenous cultural practices. Such collaborative approaches may also foster long-lasting local relationships between Indigenous community members, health leaders, and community health institutions.
Cultural safety is another critically important consideration which pervades all areas of the FNHPPM (CCSDOH, 2015). It is crucial to contextualize Indigenous individuals in their unique historical, economic, political, and social histories, as these continue to significantly influence Indigenous health outcomes (PHAC, 2018). In doing so, community health leaders can better understand the complex cultural undertones permeating the current health deficiencies in Indigenous communities as a result of COVID-19. In the case of the Nisichawayasihk Cree nation, traditional healing practices were incorporated with community care planning throughout the pandemic, resulting in positive health outcomes for all sectors of the medicine wheel (Kyoon-Achan & Wright, 2020). However, ongoing tension remains between Indigenous community leaders and healthcare institutions. As an example of reconciliation attempts, the Canadian Nurses Association (CNA) appointed an Indigenous member to its Board of Directors as part of its cultural competence framework (Villeneuve & Betker, 2020). Although this inclusion is a step in the right direction, community health leaders must continue to proactively include culturally safe collaboration in their own practices.
In addition to community collaboration and cultural safety, political competence is necessary for health policy creation and implementation rooted in Indigenous culture. In light of COVID-19, the community health leader is increasingly integral to facilitating improved care organization, allocating resources, ensuring frontline workforce safety, delivering virtual care, and enabling public engagement, all of which involve some level of political competence (McMahon et al., 2020). Political acumen is also required as varied and ever-changing pandemic responses among provinces, coupled with complex bureaucratic structures, render intersectoral policy-related projects difficult to plan and initiate. However, community health leaders must strongly advocate for Indigenous communities, especially during crises such as the COVID-19 pandemic. Widespread positive community outcomes can only be accomplished through cross-jurisdictional approaches, informed by political competence and grounded in community and culture.
Emerging research is revealing the impacts of COVID-19 on key Indigenous SDOH-related health disparities. These disparities are pre-existing but are exacerbated by the ongoing COVID-19 pandemic. Compromised physical and mental health, poor living conditions, and low income are some of the key determinants of health that are impacting Indigenous peoples and their health outcomes currently. Here, we highlight the role of community health leaders in addressing these SDOH, namely through adopting the FNHPPM, community collaboration, cultural safety, and political competence. By no means is this list exhaustive, but it may serve as a starting point for further discussion surrounding the interplay between community health leadership, Indigenous health, community care institutions, and appropriate pandemic responses. As the road to pandemic recovery begins, future research should continue to examine the immediate and long-term implications of COVID-19 on Indigenous SDOH-related health outcomes, so that community health leaders can better understand how to address health needs. A collaborative approach can be solidified, where community health is addressed while preserving deep cultural identities and sovereignty.
The authors have no conflicts of interest to declare.
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Faculty of Nursing, University of Alberta, Edmonton, AB, Canada.
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Journal of CSWB, VOLUME 6, NUMBER 3, September 2021