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Indigenous Children's Health Report:
H e a lt h A s s e s s m e n t i n A c t i o n
Edited by:
Janet Smylie MD MPH Canada
Paul Adomako MSc Canada
Indigenous Children's Health Report:
H e a lt h A s s e s s m e n t i n A c t i o n
Edited by:
Janet Smylie MD MPH Canada
Paul Adomako MSc Canada
Contributing Authors:
Sue Crengle MD PhD(c) New Zealand
Jane Freemantle PhD Australia
Gilbert Gallaher PhD Canada
Daniel McAullay PhD(c) Australia
Kelly McShane PhD Canada
Maile Taualii PhD(c) United States
This report was funded by First Nations and Inuit Health Branch, Health Canada.
Opinions expressed in this publication are those of the editors and other
contributors, and do not necessarily express the official policy of Health Canada.
Graphic design: Andrew Scott
Information regarding this publication can be obtained from:
Janet Smylie MD MPH
Research Scientist
Centre for Research on Inner City Health
The Keenan Research Centre in the Li Ka Shing Knowledge Institute
St. Michael’s Hospital
Associate Professor
Dalla Lana School of Public Health
University of Toronto
Email: [email protected]
© 2009 Janet Smylie, Some Rights Reserved.
Creative Commons Attribution - Noncommercial-No Derivs 2.5 Canada
For information on Creative Commons license go to http://creativecommons.org
available to download at: www.crich.ca
c onte n t s
Acknowledgements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Executive Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Chapter One Introduction and Report Overview:
A Global Perspective on Indigenous Child Health in Canada & Beyond
7
Chapter Two Health of First Nations, Inuit, and Métis Children in Canada
11
2.1Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2.2Data Sources and Methods. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2.3Demographics of Aboriginal Children in Canada. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2.4Assessing and Responding to the Health Needs of Aboriginal Children in Canada. . . . . . . . . . 18
2.5Colonization as an Underlying Determinant of Indigenous Children’s Health. . . . . . . . . . . . . . . 19
2.6Additional Social Determinants of First Nations, Inuit, and Métis Children’s Health. . . . . . . . . . 20
2.7Children’s Health Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
I. First Nations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
II. Inuit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
III. Métis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
IV. Information Gaps. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
V. Figures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
2.8Best Practice and Promising Practice Examples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
I. The First Nations Regional Longitudinal Health Survey. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
II. Inuit Health Survey. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
III. Infant Mortality Working Group. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
IV. Kahnawake School Diabetes Prevention Project (KSDPP). . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
V. First Nations Health Plan, British Columbia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
VI. First Nations EpiCentre of Alberta. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
2.9Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
2.10Additional Tables. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
2.11 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Chapter Three Health of Aboriginal and Torres Strait Islander Children in Australia
67
3.1Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
3.2The Colonization of Australian and Torres Strait Islander people. . . . . . . . . . . . . . . . . . . . . . . . . . . 68
3.3Demographics of Aboriginal and Torres Strait Islander Australians . . . . . . . . . . . . . . . . . . . . . . . . 69
3.4Determinants of Aboriginal and Torres Strait Islander child health. . . . . . . . . . . . . . . . . . . . . . . . . 71
3.5Specific Health Issues and risk factors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
3.6Other health conditions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
3.7Access to health care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
3.8 Health Expenditure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
3.9Data limitations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
3.10Examples of positive initiatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
3.11Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
3.12 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Chapter FourHealth of Māori Children in Aotearoa / New Zealand 95
4.1Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
4.2Māori . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
4.3The Māori Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
4.4Social and Economic Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
4.5The Health Sector in Aotearoa / New Zealand. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
4.6Ethnicity Data. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
4.7Child Health Status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
4.8 Use of Ethnicity Data – A Case Study. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
4.9Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
4.10 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Chapter Five Health of Indigenous Children in the United States
107
5.1Introduction
5.2Indigenous Population of the USA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
5.3Social Determinates of Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
5.4 Health of Indigenous children of the USA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
5.5Critical Areas of Focus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
5.6Challenges in Data Collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
5.7Community-Based Strategies and Solutions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
5.8Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
5.9 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Chapter Six Indigenous Child Health Stakeholder’s Meeting:
Discussion and Recommendations
119
6.2 Process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
6.3 Group Activity1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
6.4 Group Activity 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Chapter SevenConcluding Remarks: Finding Strength in Numbers
127
Appendix A: Stakeholder Meeting Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
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Health of Indigenous Children: Health Assessment in Action Acknowledgements
Acknowledgements
This report was funded by First Nations and Inuit
Health Branch, Health Canada. Opinions expressed
in this publication are those of the editors and other
contributors, and do not necessarily express the official
policy of Health Canada.
We would like to acknowledge all of the participant
stakeholders who attended the Indigenous child health
stakeholders meeting in May 2008 for their insights
and contributions. Please see Appendix A for a list
of participants.
Dr. Janet Smylie was supported during the writing
of this report as a Research Scientist at the Centre for
Research on Inner City Health, The Keenan Research
Centre in the Li Ka Shing Knowledge Institute of St.
Michael’s Hospital. Dr. Kelly McShane was supported
by a Social Science and Humanities Research Council
postdoctoral fellowship. Dr. Gilbert Gallaher was
supported by a Canadian Institutes of Health Research
Strategic Fellowship and a Peterborough K.M. Hunter
Fellowship at the Centre for Research on Inner City
Health, St. Michael’s Hospital. Dr. Sue Crengle was
supported by the University of Auckland where she is
Acknowledgements a member of Te Kupenga Hauora Māori (Department
of Māori Health), School of Population Health,
Faculty of Medicine and Health Sciences. Dr. Jane
Freemantle was supported by Onemda VicHealth Koori
Health Unit and by an Australian Research Council
Fellowship. Daniel McAullay was supported by the
Indigenous CBG research program Not Just Scholars
but Leaders, which is funded by the NHMRC and
Curtin University of Technology and conducted by
Curtin University of Technology, the Telethon Institute
for Child Health Research, combined Universities
Centre for Rural Health and the University of Western
Australia. Maile Taualii would like to acknowledge
the Native Hawaiian Epidemiology Center, Papa Ola
Lokahi, and the Urban Indian Health Institute, Seattle
Indian Health Board. Special thanks to Andrew Scott
for the design of this report.
The editors gratefully acknowledge the support of
the Ontario Ministry of Health and Long-Term Care.
The views expressed in this report are the views of the
authors and do not necessarily reflect the views of the
Ontario Ministry of Health and Long-Term Care.
Health of Indigenous Children: Health Assessment in Action
1
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Health of Indigenous Children: Health Assessment in Action Executive Summary
Executive Summary
Introduction: Global Disparities in
Indigenous Children’s Health
This report documents what we know about the health
of Indigenous children (from birth to age twelve) and
evaluates the quality of Indigenous child health data
collection in Canada, Australia, New Zealand, and the
United States.
Striking Indigenous/non-Indigenous health disparities
were identified in all four countries, including:
• Infant Mortality Rates that are 1.7 to 4 times higher
than those of non-Indigenous infants
• higher rates of sudden infant death syndrome
• higher rates of child injury, accidental death,
and suicide
• higher rates of ear infections
• a disproportionate burden of respiratory tract illness
and mortality
• a disproportionate burden of dental caries
• increased exposure to environmental contaminants,
including tobacco smoke
Other common themes identified across the four
countries include:
• a need to improve Indigenous child health
ethnicity data
• the identification of colonization as a shared and
underlying determinant of Indigenous health
• disparate numbers of Indigenous children live
below the poverty line and/or in overcrowded
accommodation and this directly impacts their health
• differential access to healthcare, economic and social
resources for Indigenous children and their families
compared to non-Indigenous populations
Given the diverse genetic heritage of these widely
dispersed Indigenous groups, we must conclude that
Executive Summary similar exclusionary social policies active in all four
countries are at the root of these profound and unjust
differences in child health.
Indigenous Children’s Health Assessment
in Action
This report was funded by Health Canada. It was
conducted by a team of international Indigenous
child health researchers, led by Dr. Janet Smylie at the
Centre for Research on Inner City Health, St. Michael’s
Hospital. The report draws upon on a systematic search
of public health data, including scholarly articles
at the national and provincial/territorial level. The
report first addresses First Nations, Inuit, and Métis
children’s health status and assessment in Canada. In
later chapters, Indigenous children’s health status and
assessment are reported for Australia, New Zealand,
and the United States
Sound measurement and reporting of public
health data are essential steps for overcoming health
disparities but these are obviously only the first steps.
Investment in very strong policies and programming
are required to ensure that Indigenous children
experience the same levels of well-being, prosperity,
environmental support, and access to health care as
non-Indigenous children. This report documents best
practices and describes how health assessment data can
be put to action to inform strong policies and programs
to improve Indigenous child health.
Our report provides a convincing example of the
value that can be added by forming partnerships and
working across jurisdictions – locally, regionally,
nationally, and internationally. In writing this report,
our collective intention has been to equip Indigenous
Health of Indigenous Children: Health Assessment in Action
3
health stakeholders within and across our nations
with rigorous data, and to support them as they work
together to redress Indigenous child health disparities.
The time to take action is long overdue.
Aboriginal Children in Canada:
Key Health Disparities
First Nations, Inuit and Métis children and their
families experience major disparities in the social
determinants of health, compared to other Canadians.
At the root of these disparities are historic and ongoing
impacts of European colonization, which directly and
indirectly impact health. Approximately one-third
of Aboriginal children live in low-income families
and food-security is a serious concern. Substandard
housing conditions, including crowding, need for
repairs and poor water quality, disproportionately affect
Aboriginal peoples.
Given these determinants of health, it is not
surprising that First Nations, Inuit, and Métis
children experience the following significant health
status disparities:
• Infant mortality among First Nations with status
is nearly twice the rate in the general Canadian
population
• Infant Mortality among Inuit is four times higher
than the general Canadian population
• Sudden Infant Death Syndrome rates for First
Nations with status in British Columbia and Inuit in
Nunavik are three to twelve times higher than nonFirst Nations and/or non-Inuit rates respectively.
• Higher incidence of high birthweight babies for
First Nations and Métis compared to general
Canadian rates
4
Health of Indigenous Children: Health Assessment in Action • Higher incidence of preterm babies for Inuit
in Nunavut compared to the general Canadian
population
• Disproportionate burden of respiratory tract
infection among First Nations living on-reserve and
Inuit children, with no data for First Nations without
status, Métis and urban Aboriginal children.
• The obesity rate for First Nations children living
on reserve of 36%, compared to 8% for Canadian
children overall.
• Activity Limitation (ie. physical activity limited by
a health condition) among First Nations, Inuit, and
Métis children between the ages of 6 and 14 years
is more than double the rate among Canadian
children overall.
• Vital registration, health care utilization, and
surveillance data are nearly non-existent for
First Nations without status, Métis, and urban
Aboriginal children.
Aboriginal Children in Canada:
Deficiencies in Current Public Health
Assessment Data
In the 2006 Census, almost 1.2 million persons in
Canada reported Aboriginal identity. At the national
level, Aboriginal people in Canada represented
themselves as belonging to one of several major groups:
First Nations (Status Indians on-reserve, Status Indians
off-reserve, and non-Status Indians), Inuit, and Métis.
Aboriginal children age 14 years and younger account
for 30% of the total Aboriginal population. Aboriginal
children often live in families headed by single parents
and are often raised by young mothers. Many also live in
large families, including multiple-generation households.
Executive Summary
Significant deficiencies in current public health
assessment data for Aboriginal children are evident.
Foremost is the lack of opportunity for individuals to
self-identify as First Nations, Inuit or Métis in most
health data systems, including: vital registries, primary
care and hospital records, and surveillance systems.
Second, we found substandard data collection sources
and methods, which result in inaccurate statistics.
Finally, there is also a lack of organized linkages of First
Nations, Inuit, and Métis health data to First Nations,
Inuit, and Métis health policies, programs and services.
and critiques of ethnicity-based child health data
collection methods.
Throughout the chapters in this report, multiple
examples of Indigenous resistance and resilience are
also provided, including: the successful transmission
of Indigenous languages to children; improvements in
Indigenous educational achievement – often despite
inadequate education systems; the participation of
extended family in parenting; and the participation of
Indigenous communities in specific health assessment
and response activities when opportunities present.
A Global Perspective on Indigenous
Children’s Health
Each international chapter provides a rich introduction
to the history of colonization and its continuing
impacts on Indigenous health and wellbeing for diverse
Indigenous populations including Māori, American
Indian, Alaskan & Hawaiian Natives, Aboriginal
Australians and Torres Straits Islander children. These
chapters provide a comprehensive explanation of local
Indigenous child health disparities across a range of
physical and social health indicators including (but
by no means limited to) exposure to environmental
contaminants, access to health care, accidents/injury
rates, infant mortality rates, Sudden Infant Death
Syndrome, asthma and respiratory infection rates.
Where possible, national level data has been reported
to facilitate comparative perspectives on disparities
between Indigenous and non-Indigenous children’s
health status. These national data sets also shed light on
Indigenous children’s health data collection standards
and practices. We discuss current trends, best practices
Working Together for Policy Action
We held a key stakeholders consultation meeting in
May 2008, to present our preliminary findings and
ask for feedback, comments, and recommendations.
This event brought together 21 key Indigenous
researchers and policy-makers from Canada, United
States, Australia and Aotearoa. This meeting endorsed
a cohesive research, practice and policy approach to
advance our ability to improve the health and mortality
of all Aboriginal children in Canada. Improvements
in the availability of comprehensive and accurate
child health data will assist greatly in concerted
efforts to improve the health of Indigenous children
internationally.
Indigenous health stakeholders in our home
nations have already researched and articulated clear
policy approaches that would address the ongoing
disadvantages experienced by our children and their
families. In Canada, this includes the recommendations
of the Royal Commission of Aboriginal People and the
submissions made at the Kelowna Accord discussions.
Executive Summary Health of Indigenous Children: Health Assessment in Action
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Health of Indigenous Children: Health Assessment in Action Introduction & Report Overview
Introduction and Report Overview
A Global Perspective on Indigenous Child Health in Canada & Beyond
I am extremely pleased to have been able to participate
in the production of “The Health of Indigenous
Children: Health Assessment in Action” report. It
has been an incredible honor to have been supported
in the writing by international Indigenous children’s
health colleagues Jane Freemantle and Daniel McAullay
(AUS), Sue Crengle (NZ) and Maile Taualii (US), as
well as postdoctoral fellows Kelly McShane and Gilbert
Gallaher and research co-ordinator Paul Adomako.
The international contributors have been generous and
astute in their sharing of examples of best practices in
both the collection and the application of Indigenous
child health assessment information.
The focus of the report is First Nations, Inuit, and
Métis children’s health status and assessment in Canada
(from birth to age twelve). There are also chapters on
Indigenous children’s health status and assessment for
Australia, New Zealand, and the United States. Not
only does the report include information describing
what we know about the health of Indigenous children
and how we know this, but it also includes best
practices on how health assessment information can be
applied to improve the health of Indigenous children.
Critical to the resolution of Indigenous child health
disparities is both the generation of health information
and the application of this information to health
policies, programs, and services.
Introduction & Report Overview Report objectives include:
1. To summarize what we know about the health of
Indigenous children living in Canada, Australia,
New Zealand, and the United States.
2. To contribute to the translation of health
information into evidence-based policies, practices,
and services for Aboriginal* children in Canada by
highlighting best practices in the collection and use
of health data.
3. To identify priority areas for Indigenous children’s
health indicator development.
4. To identify key Indigenous children’s health status
inequities in the four countries.
Our hope is that this report will be used as a
reference and advocacy tool by key Indigenous
children’s health stakeholders in Canada and abroad.
With this in mind, we held a key stakeholders
consultation meeting in May 2008, to present our
preliminary findings and ask for feedback, comments,
and recommendations.
While the focus of the report is First Nations, Inuit,
and Métis children’s health status and assessment in
Canada, the chapters on Indigenous children’s health in
Australia, New Zealand and the United States not only
provide insightful country specific overviews, they also
highlight common problems and successful strategies. We
identify cross-cutting issues; locate the roots of Indigenous
Author:
Janet Smylie MD MPH
Research Scientist
Centre for Research on
Inner City Health
The Keenan Research Centre
in the Li Ka Shing Knowledge
Institute
St. Michael’s Hospital
Associate Professor
Dalla Lana School of Public
Health
University of Toronto
We have used the term Aboriginal
to refer collectively to First Nations,
Inuit, and Métis populations in
Canada and the term Indigenous
when we are referring to Indigenous
populations internationally.
Aboriginal is also used in the
Australian chapter to refer to the
group of Indigenous Australians
also known as Aboriginal.
*
Health of Indigenous Children: Health Assessment in Action
7
International Symposium on the
Social Determinants of Indigenous
Health. Social determinants
and Indigenous health: The
International experience and its
policy implications. In: Report
on specially prepared document,
presentations and discussion at the
International Symposium on the
Social Determinants of Indigenous
Health. Adelaide, Australia:
Available at http://www.who.int/
social_determinants/resources/
indigenous_health_adelaide_
report_07.pdf. Accessed
June 6, 2008.
1
8
child health disparities in colonization; document
differential access to healthcare, economic, and social
resources; and share successful strategies for change. There is a need to improve Indigenous child health
ethnicity data. Serious deficiencies in the quality and
coverage of Indigenous ethnicity data are described
in all four country specific chapters. Canada is the
only country that does not have systems in place for
Indigenous self-identity in the majority of hospital,
surveillance, and vital registration (i.e. birth and
death registration) systems. This results in the notable
absence of disease specific mortality and hospitalization
data in the Canadian chapter. All authors were clear
that reliable data describing Indigenous child health
is necessary to inform policy; contribute to the design
and implementation of effective child health programs
and services; and to evaluate policies, programs, and
services. The best practice examples of Indigenous
health measurement in this report are consistently
founded on the central involvement of Indigenous
people in health data collection, analysis, management,
governance, and application.
Indigenous children and their families experience
striking health status disparities compared to nonIndigenous populations regardless of nation. Common
health status disparities between Indigenous and nonIndigenous children found in all four countries include:
Health of Indigenous Children: Health Assessment in Action infant mortality rates that are 1.7 to 4 times higher
than those of non-Indigenous infants; higher rates of
sudden infant death syndrome; higher rates of child
injury, accidental death, and suicide; higher rates of ear
infections; a disproportionate burden of respiratory
tract illness and mortality; a disproportionate burden of
dental caries; and increased exposure to environmental
contaminants, including tobacco smoke.
There is an overwhelming consensus among the
authors and stakeholders that the roots of these
health status inequities are found in social rather than
biologic determinants of health. Colonization has been
identified as a shared and underlying determinant of
Indigenous health by the contributors to this report as
well as participants at the recently held International
Symposium on the Social Determinants of Indigenous
Health.1 Each country author describes historic and
ongoing governmental policies that have contributed
to and perpetuate the dislocation of Indigenous
people from their homelands; the disenfranchisement
of Indigenous peoples from their rights to selfdetermination; the undermining of economic and
social development; and the fragmentation of families,
communities, and nations. Colonial policies are directly
linked to the current day poverty experienced by
many Indigenous children globally. The shared health
status disparities are not surprising when the disparate
Introduction & Report Overview
numbers of Indigenous children living below the
poverty line and/or in overcrowded accommodation in
all four countries are taken into consideration.
The resolution of Indigenous health inequities
requires not only an examination of Indigenous health
status and determinants but also an examination of
the patterns of access to critical societal resources,
such as health care among both Indigenous and nonIndigenous populations. This report identifies that
differential access to health care services is another
cross-cutting factor that appears to be contributing to
disparities in health between Indigenous and nonIndigenous children and their families. In Canada,
Australia, New Zealand and the United States there
were absolute and relative reductions in access to
care for Indigenous children. In New Zealand, these
inequities in access to primary care have been linked to
increased numbers of preventable hospitalizations for
Māori and Pacific Islander children compared to nonIndigenous children.
Although mainstream public health measurement
systems are under developed in the area of strengthbased assessment, and despite the overwhelming
burden of Indigenous child health inequities, a
distinct theme of resilience and resistance emerges.
Throughout the chapters in this report there are
examples of: the successful transmission of Indigenous
Introduction & Report Overview languages to children; improvements in Indigenous
educational achievement – often despite inadequate
education systems; the participation of extended family
in parenting; and the participation of Indigenous
communities in specific health assessment and
response activities when opportunities present.
Indigenous health stakeholders in our home
nations have already researched and articulated clear
policy approaches that would address the ongoing
disadvantages experienced by our children and their
families. In Canada, this includes the recommendations
of the Royal Commission of Aboriginal People2 and the
submissions made at the Kelowna Accord discussions.
The collective intention of the authors in the writing of
this report is that it be used as a reference and advocacy
tool by these same Indigenous health stakeholders as
they work together to support comprehensive policy
actions that will fundamentally address the pressing
issues of Indigenous child health disparities that we
have documented within and across our nations.
Royal Commission on Aboriginal
Peoples. Report of the Royal
Commission on Aboriginal Peoples.
Ottawa: Indian and Northern Affairs
Canada; 1996.
2
Health of Indigenous Children: Health Assessment in Action
9
2
Health of First Nations, Inuit, and Métis Children in Canada
2.1 Introduction. This chapter describes the health and health outcomes of Aboriginal children living in Canada. It includes
an overview of demographics, a discussion of Aboriginal children’s health measurement systems, a description of social
determinants, a detailing of First Nations, Inuit, and Métis child health status and some examples of best or promising practices.
The goal of the chapter is to provide First Nations, Inuit, and Métis child health stakeholders with a comprehensive overview
of First Nations, Inuit, and Métis child health in support of their efforts to address ongoing inequities of health determinants
and health status, therefore ensuring that all children in Canada enjoy their right to health. The authors recognize that
improvements in the assessment of and response to inequities in Aboriginal child health need to be founded on partnerships
between First Nations, Inuit, and Métis health stakeholders and health workers with a background in public health assessment.
2.2 Data Sources and Methods
This chapter focuses on First Nations, Inuit, and
Métis children’s health data at the national and
provincial/territorial level. Where there are gaps in
available national or provincial/territorial data, and/
or the health determinant or indicator was deemed
significant, we opted to cite regional or communityspecific rates.
Information in this report for First Nations living
on-reserve is drawn primarily from the First Nations
Regional Longitudinal Health Survey (RHS)1, the 2006
Census,2, 3, 4 and Indian and Northern Affairs Canada’s
(INAC) Indian Registry.5 Information for First Nations
living off-reserve, Inuit, and Métis are drawn primarily
from the 2006 Census, 2, 3, 4, 6 the 2001,7, 8 and 20069
Aboriginal Peoples Survey (APS), and 2006 Aboriginal
Children’s Survey (ACS).10
In order to identify additional sources of data on
the health of First Nations, Inuit, and Métis children in
Canada, a series of searches were conducted for public
health data, scholarly articles, and published reports.
Public health data available for First Nations, Inuit, and
Métis at populations at the national and provincial/
territorial level had already been systematically
reviewed by our group in an earlier study.11 To
supplement the available public health data, we also
systematically searched the published literature. In
consultation with a medical information specialist, a
set of key words for population and subject headings
was derived, as well as a list of databases to search.
The keywords that were used included the population
keywords: Native, Indian, Aboriginal, Inuit, Métis,
and First Nations. As well, additional population
descriptors were used to focus on children. These
words included: infant and child. For subject headings,
the following terms were used in combination with the
population keywords: health, health status indicators,
health status, health status disparities, health surveys,
Health of First Nations, Inuit, and Métis Children in Canada mental disorders, and suicide. The databases that were
searched were MEDLINE; Bibliography of Native
North Americans; and Health Sciences: A SAGE FullText Collection. From this initial search, a total of 718
articles were identified. This first set of abstracts was
screened by a Masters-level Research Assistant (PA)
using the following criteria: (1) included a population
of children; (2) disease prevalence, incidence presented;
and (3) Aboriginal population in Canada. Using these
criteria, 123 articles were retained. The abstracts were
then independently reviewed by two Aboriginal health
researchers (JS and KM) and were retained if they met
the following criteria: (1) provided statistics specifically
for First Nations, Inuit, or Métis (not ‘Aboriginal’
broadly defined) and (2) national, provincial, or
territorial level statistics. Articles which pertained to
important child health issues, not otherwise covered in
the literature were retained even when neither criterion
was met. The final set of articles reviewed for inclusion
in this report comprised 27 articles.
Based on the two methods detailed above, a
comprehensive set of statistical sources of First Nations,
Inuit, and Métis children’s health was identified and is
listed in Table 1 in the Additional Tables section.
We have attempted to be as inclusive as possible in
providing data for all First Nations, Inuit, and Métis
children. At times this has been challenging, as the data
sources are not always inclusive and/or consistent in
their terminology or indicators. For example, there are
data quality issues and associated limitations of First
Nations census data. There appears to be a significant
undercount of First Nations persons – particularly First
Nations persons living on–reserve. According to the
2006 census the total ‘Registered Indian’ population
was 564,870.2 This is almost 200,000 less than the
763,555 that INAC’s Indian Registry shows for 2006.5
In addition, the 2006 Aboriginal Peoples Survey and
2006 Aboriginal Children’s Survey did not include First
Authors:
Kelly McShane PhD
Assistant Professor
Ryerson University
Associate Researcher
Centre for Research on
Inner City Health
The Keenan Research Centre
in the Li Ka Shing Knowledge
Institute
St. Michael's Hospital
Janet Smylie MD MPH
Research Scientist
Centre for Research on
Inner City Health
The Keenan Research Centre
in the Li Ka Shing Knowledge
Institute
St. Michael's Hospital
Associate Professor
Dalla Lana School of
Public Health
University of Toronto
Paul Adomako MSc
Research Coordinator III
Centre for Research on
Inner City Health
The Keenan Research Centre
in the Li Ka Shing Knowledge
Institute
St. Michael's Hospital
Health of Indigenous Children: Health Assessment in Action
11
600,000
564,870
500,000
400,000
389,785
300,000
200,000
133,155
100,000
Figure 1
Aboriginal Population
Composition
Source: Census 2006
Currently in
Canada, Aboriginal
people represent
themselves politically
as belonging to one
of several major
groups: First Nations
(Status Indians
on-reserve, Status
Indians off-reserve,
and non-Status
Indians), Inuit,
and Métis.
a
This is the census term used to
identify persons of First Nations
ancestry. It is in quotation marks,
because the word Indian is recognized
as a misnomer for Aboriginal people
of First Nations ancestry.
12
50,485
0
First Nations
with status or treaty
(on/off-reserve)
First Nations
without status or treaty
(on/off-reserve)
Nations peoples living on-reserve. Fortunately we are
able to draw on the First Nations Regional Longitudinal
Health Survey to address this deficiency and ensure
that First Nations on-reserve information is included.
The existing reports for the 2006 Aboriginal Peoples
Survey and the 2006 Aboriginal Children’s Survey also
uniquely combine those who are ‘Status or Registered
Indians’ living off-reserve with those who are ‘Treaty
Indians’ living off-reserve. For this reason, when we
are citing the 2006 Aboriginal Peoples Survey and the
2006 Aboriginal Children’s Survey data we use the terms
‘First Nations with status or treaty living off-reserve’ and
‘First Nations without status or treaty living off-reserve’.
In all other cases when referring to First Nations data,
if the term First Nations is used without qualifiers, it
means that the data is inclusive of the total First Nations
population (i.e., status and non-status as well as onreserve and off-reserve). Data from the First Nations
Regional Longitudinal Health Survey is always for First
Nations persons living on-reserve who participated in
the survey. In all other cases we clarify the First Nations
population being described by identifying if it is ‘status’
or ‘non-status’ and/or ‘on-reserve’ or ‘off/reserve’. Further
challenges were found with locating information for
First Nations persons without status, Métis people,
and Aboriginal people living in urban areas. With the
exception of the Aboriginal Peoples Survey and the
Health of Indigenous Children: Health Assessment in Action Métis
Inuit
Aboriginal Children’s Survey, health information for
these groups is close to non-existent.
2.3 Demographics of Aboriginal Children
in Canada
Currently in Canada, Aboriginal people represent
themselves politically as belonging to one of several
major groups: First Nations (Status Indians on-reserve,
Status Indians off-reserve, and non-Status Indians), Inuit,
and Métis. These groupings reflect Section 35 of Canada’s
Constitution Act as well as the federal Indian Act,
which defines the term ‘Status Indian’. From a cultural
perspective, Aboriginal people in Canada comprise
over 50 distinct and diverse groups, each with its own
distinct language and traditional land base.12 Further,
each of these larger groups represents a complex network
of communities and kinship systems, often with their
own distinct language dialects.ibid According to the 2006
census,2 just under 1.2 million persons in Canada report
Aboriginal identity: approximately 60% identified as
‘North American Indian’,a 33% identified as Métis, 4%
identified as Inuit, and the remaining 3% identified with
more than one Aboriginal group and/or self-reported as
‘registered Indians’ or members of First Nations bands
but didn’t identify as Aboriginal.2 (See Figure 1) These
numbers underestimate the actual Aboriginal population,
as there was significant non-participation in the census
Health of First Nations, Inuit, and Métis Children in Canada
350,000
300,000
284,794
273,626
250,000
200,000
150,000
100,000
50,000
Figure 2
First Nations with Status by
Place of Residence
0
On-Reserve
Off-Reserve
Source: Census 2006
Figure 3
Proportion of Total
Population Identifying
as Aboriginal
100%
First Nations
Inuit
Métis
80%
Source: Census 2006
60%
40%
20%
0%
N.L.
P.E.I.
N.S.
N.B.
Que.
Ont.
Man.
Sask.
Alta.
B.C.
Y.T.
N.W.T.
Nvt.
1.6%
0.9%
1.7%
1.7%
0.9%
1.3%
8.9%
9.6%
3.0%
3.2%
20.8%
30.8%
0.3%
0.2%
0.9%
0.0%
0.0%
0.1%
0.0%
0.0%
0.0%
0.0%
0.0%
0.8%
10.1%
84.0%
1.3%
0.3%
0.9%
0.6%
0.4%
0.6%
6.3%
5.0%
2.6%
1.5%
2.6%
8.7%
0.4%
by a number of First Nations living on-reserveb and
possibly other Aboriginal groups. Additionally, it is likely
that a significant number of individuals chose not to selfidentify as Aboriginal to government workers. Currently,
81% of the First Nations population is considered ‘Status
Indian’. Approximately half of First Nations (51%) live
off-reserve, with 76% of those living off-reserve living in
urban areas.2 (See Figure 2.) The majority of Métis live in
urban areas (69%) and a growing number of Inuit (22%)
live outside of Inuit Nunaatc (See Figure 3 for the portion
of the population by region that identified as First
Nations, Inuit, and Métis.)
b
As discussed earlier INAC figures
indicate that the census undercount
of First Nations persons with status
is approximately 200,000 individuals
Inuit Nunaat comprises four Inuit
regions: Nunatsiavut, Nunavik,
Nunavut, and Inuvialuit.
c
Health of First Nations, Inuit, and Métis Children in Canada Health of Indigenous Children: Health Assessment in Action
13
40%
35%
34%
35%
32%
31%
30%
25%
25%
20%
17%
15%
10%
5%
Figure 4
Aboriginal Population
Under 14 Years of Age
0%
First Nations
total (on/off-reserve)
Source: Census 2006
Figure 5
Proportion of Aboriginal
Population that are Children
aged 14 & under
Source: Census 2006
First Nations
(on reserve)
First Nations
(off-reserve)
Métis
Inuit
non-Aboriginal
population
50%
38%
40%
36%
35%
33%
31%
30%
26%
25%
25%
N.B.
Que.
30%
28%
27%
27%
23%
20%
10%
0%
N.L.
P.E.I.
N.S.
Ont.
Man.
Sask.
Alta.
B.C.
Y.T.
N.W.T.
Nvt.
The population of Aboriginal children in Canada
represents a sizeable portion of the total Aboriginal
population (See Figure 4). In Figure 5, there are
some regional differences in the proportion of
Aboriginal children (in relation to the total Aboriginal
population), with higher proportions observed in
Nunavut, Saskatchewan and Prince Edward Island.
The large and growing populations of First Nations,
Inuit, and Métis infants, children, and youth is linked
to a birth rate that is 1.5 times higher than the nonAboriginal birth rate.2 Specifically, the fertility rate
14
Health of Indigenous Children: Health Assessment in Action Health of First Nations, Inuit, and Métis Children in Canada
between 1996 and 2001 for First Nations women was
2.9 children, 2.2 for Métis women, and 3.4 for Inuit
women, compared to a rate of 1.5 among all Canadian
women.13 As evidenced in Figure 6, in comparison
to the non-Aboriginal population, the First Nations,
Inuit, and Métis populations have a larger segment
of young adults (15-24 years) and smaller segment of
older adults (65 and over). This young and growing
population impacts health and education systems, and
the future labour market, particularly in provinces and
territories such as Manitoba, Saskatchewan, Alberta,
and Nunavut where there are high concentrations of
Aboriginal people.
The First Nations, Inuit, and Métis populations
are all much younger than the rest of the Canadian
population, with a collective median age of 27
years, compared to 40 years in the non-Aboriginal
population. Specifically, the median age of the First
Nations population was 25 years, 22 years for the Inuit
population and 30 years for the Métis population.2
13%
5%
65 yrs +
Métis
Figure 6
Proportion of Population by
Age Category
Inuit
Source: Census 2006
non-Aboriginal
4%
5%
First Nations
12%
8%
55-64 yrs
5%
6%
16%
14%
45-54 yrs
8%
11%
15%
15%
35-44 yrs
13%
14%
13%
14%
25-34 yrs
14%
14%
13%
18%
15-24 yrs
21%
18%
17%
25%
0-14 yrs
35%
32%
0%
5%
10%
15%
Health of First Nations, Inuit, and Métis Children in Canada 20%
25%
30%
35%
40%
Health of Indigenous Children: Health Assessment in Action
15
Aboriginal children often live in families headed by
single parents (See Figures 7 and 8). According to the
2006 Aboriginal Children’s Survey, 2006 Census, and
the First Nations Regional Longitudinal Health Survey,
considerably more First Nations, Inuit, and Métis
children live in single parent families, as compared
to non-Aboriginal Children (See Figure 7).1,2,10 Note
that First Nations children living on-reserve were not
included in the APS and are therefore not included in
the chart for children aged five and under. They are
included in Figure 8 which draws on the 2006 Census,
Figure 7
Percentage of Young
Children (aged 5 & under)
Living in Lone
Parent Families
Source: ACS 2006, Census 2006
as well as the First Nations Regional Longitudinal
Health Survey for older children.1,2
The majority of lone-parent families are led by
mothers and many of these mothers are younger when
compared to non-Aboriginal families. According to
the 2006 Aboriginal Children’s Survey, 27% of young
(aged five and under) First Nations children living
off-reserve, 22% of young Métis children, and 26% of
young Inuit children, had mothers between the ages
of 15 and 24.10 The rate of young mothers between the
ages of 15 and 24 for non-Aboriginal families was 8%.
50%
45%
42%
40%
35%
31%
28%
30%
23%
25%
20%
13%
15%
10%
5%
0%
First Nations
with status or treaty
(off-reserve)
Figure 8
Percentage of Children
Living in Lone
Parent Families
Source: APS 2006, RHS 2002/3,
Census 2006
First Nations
without status or treaty
(off-reserve)
Inuit
Métis
non-Aboriginal
population
50%
Census 2006 (aged 14 & under)
45%
40%
40%
37%
RHS 2002/3 (aged 11 & under)
41%
33%
35%
31%
30%
26%
25%
18%
20%
15%
10%
5%
0%
First Nations total
(on/off reserve)
16
Health of Indigenous Children: Health Assessment in Action First Nations
(on-reserve)
First Nations
(off-reserve)
Inuit
Métis
non-Aboriginal
population
Health of First Nations, Inuit, and Métis Children in Canada
50%
ACS 2006 (aged 14 & under)
45%
RHS 2002/3 (aged 11 & under)
42%
40%
35%
31%
28%
30%
23%
25%
17%
20%
13%
15%
10%
5%
0%
First Nations
with status or treaty
(off-reserve)
First Nations
without status or treaty
(off-reserve)
First Nations
(on-reserve)
Aboriginal families are more likely to be large
families. According to the First Nations Regional
Longitudinal Health Survey, 63% of First Nations
children living on reserve aged 11 and under lived in
families with three or more children.1 According to the
2006 Aboriginal Children’s Survey, 17% of young First
Nations children living off-reserve and 28% of young
Inuit children, lived in families with four or more
children, compared to 8% of young non-Aboriginal
children. For Métis families, 32% of young Métis
children lived in families with three or more children,
compared to 25% of non-Aboriginal children.10
Health of First Nations, Inuit, and Métis Children in Canada Inuit
Métis
non-Aboriginal
population
Figure 9
Percentage of Children
Living in Multiple
Generation Households
Source: ACS 2006, Census 2006
Results from the Aboriginal Children’s Survey 2006
and the First Nations Regional Longitudinal Health
Survey (see Figure 9) showed that Aboriginal children
are also twice as likely as non-Aboriginal children
to live in multiple-generation households (children,
parents, grandparents).1,10 Additionally, a number of
children lived with their grandparents: 9% of First
Nations children living off-reserve, 8% of Métis, and
16% for Inuit children lived with grandparents (either
as part of a multiple generation household or living
with grandparents alone). The comparable rate for
non-Aboriginal children aged five and under living
in the same household with their grandparents is 5%.
Note that these ACS results again exclude First Nations
families living on-reserve.
Health of Indigenous Children: Health Assessment in Action
17
2.4 Assessing and Responding to the
Health Needs of Aboriginal Children
in Canada
Health workers are trained to identify their client’s
illness and its cause or source. Public health assessment
similarly measures health and its determinants among
populations. The assessment of Aboriginal children’s
health challenges public health stakeholders to take
into account not only illness, but also wellness, using
methods that build on these children’s rich and diverse
cultural, linguistic and geographic heritage.
Public health assessment data typically relies on five
main sources: (1) Census data; (2) Vital registration;
(3) Acute and chronic disease surveillance; (4) Primary
and tertiary health services utilization records; and (5)
Surveys. In Canada, health data exists at the national,
provincial/territorial, regional, and community levels.
For First Nations, Inuit and Métis peoples, there is
limited health assessment data due to problems with
data coverage and quality. Smylie and Anderson14 have
detailed the significant issues with each of the five
health data sources (see Text Box 1 in Additional Tables
Section). Broadly speaking, in the health care and
vital statistics system, there are few opportunities for
individuals to self-identify themselves or their children
as First Nations, Inuit or Métis. When opportunities to
self-identify do exist, Métis and First Nations persons
without status are almost always excluded. This results
18
Health of Indigenous Children: Health Assessment in Action in the lack of accurate and inclusive First Nations,
Inuit, and Métis identifiers or flags in vital registration,
acute and chronic disease surveillance, and health
service utilization data sets. There is an urgent need to
remedy this situation and provide more opportunities
for First Nations, Inuit, and Métis to self-identify in
health information systems. In addition, there are
instances of substandard data collection sources and
methods, which have resulted in inaccurate statistics.
For example, under reporting of First Nations infant
mortality has recently been identified at national and
provincial levels.14,15
Also essential to public health data systems is their
connection to and integration with health policies,
programs, and services. The various sources of health
data need to be planned and organized so together
they form a comprehensive set of health system
performance measures. These performance measures
should give an integrated picture of the vitality
and wellbeing of Aboriginal children as well as the
environments in which they live and grow. Data on its
own, without an organized interface to health policies,
programs and services, has little meaning or utility.
The organized linkage of First Nations, Inuit, and Métis
health data to First Nations, Inuit, and Métis health
policies, programs and services is another area where
there are significant challenges in Canada. This may
be related to the use of health survey data to address
Health of First Nations, Inuit, and Métis Children in Canada
gaps in vital registration, acute and chronic disease
surveillance and health service utilization data sets.
While we were able to locate a significant amount of
First Nations, Inuit, and Métis data using the methods
described below, it was much more difficult to put these
data sets together to provide a comprehensive overview
of First Nations, Inuit, and Métis children’s health and
an assessment of the strengths and limitations of First
Nations, Inuit and Métis children’s health policies,
programs, and services.
An additional challenge facing First Nations, Inuit,
and Métis health information stakeholders is the issue
of jurisdictional complexity. Multiple jurisdictions can
be involved in collecting, analyzing, disseminating
and responding to health information, and the levels
of interface vary. For example, in one province, First
Nations infant mortality rates were being calculated
by both the provincial health department as well as
the regional office of Health Canada, First Nations
and Inuit Health Branch (FNIHB). Two slightly
different rates were produced. The regional First
Nations governing authority felt that they should share
responsibility for the governance of this information,
but were not yet actively included in data collection,
analysis, or dissemination activities.
At a national level, the need for data that relates to,
and can be applied to specific ethnic and geographic
contexts is not always understood. For example,
the recent Maternal Experiences Survey, which was
conducted by Statistics Canada at the request of
Canadian Perinatal Surveillance System, Public Health
Agency of Canada, was not adequately powered to
provide First Nations, Inuit, and Métis specific data.
Hence, the experiences of an Inuit women living in
Nunavut may be compiled with those of a First Nations
women living in downtown Toronto. Such data will
be of little use to regional policy makers and service
providers anxious for data that would help them
improve their local services, which clearly are very
different. Ideally, such national level surveys need to
be powered to provide data that is specific to First
Nations (status and non-status), Inuit and Métis with
further ability to stratify for geography (ie. urban/
rural/settlement for Métis; on-reserve/off-reserve for
First Nations with status; urban/rural for First Nations
without status; and territorial land claim area/urban for
Inuit). These are the ethnic and geographic groupings
upon which current health services are structured.
Health of First Nations, Inuit, and Métis Children in Canada 2.5 Colonization as an Underlying
Determinant of Indigenous
Children’s Health
‘Everyone agrees that there is one critical social
determinant of health, the effect of colonization.’16
The colonization of Indigenous peoples globally
has been increasingly recognized as a fundamental
underlying determinant of health. Participants at
the first International Symposium on the Social
Determinants of Indigenous Health documented the
links between colonial policies and the following:
dislocation from traditional lands, cultural suppression,
political marginalization, forced assimilation, and the
excess burden of health disparities experienced by
Indigenous peoples.16
First Nations, Inuit and Métis peoples in Canada
continue to endure the effects of European colonization
with direct impacts on health. Government policies
have supported the disruption of family networks, the
forced dislocation of communities from traditional
lands, and increased environmental degradation
of natural resources due to industrial processes.
Historically, First Nations, Inuit, and Métis knowledge
regarding infant, child and family health was shared
verbally and experientially among family and extended
kin. The overt suppression of Aboriginal cultures
and languages has caused severe repercussions to
the intergenerational transmission of knowledge and
traditional teachings.
Colonial processes in Canada varied according to
Aboriginal group, time, and geographic location.12 First
Nations, Inuit, and Métis peoples have all experienced
dislocation from and appropriation of their traditional
territories.ibid For example, the Indian Acts imposed
a system for the management of First Nations lands
which legalized removal of First Nations communities
(who had signed treaties) from their homelands to
‘reserve lands’ controlled by the Government of Canada
on behalf of ‘Indians’ As a result, the livelihoods of
these communities were undermined as their local
economies were strongly tied to traditional lands.
After Métis homelands were sold by the Hudson Bay
Company to the Government of Canada, the Manitoba
Act of 1870 reserved 1.4 million acres of Crown land
for the unmarried children of Métis.17 However,
incoming settlers showed disregard for Métis land
claims and the implementation of the land provisions
for the Métis in the Manitoba Act was plagued by
Health of Indigenous Children: Health Assessment in Action
19
d
The unemployment rate particular
group (age, sex, marital status,
geographic area, etc.) is the number
of persons unemployed, expressed
as a percentage of the total
population in that particular group
(adults aged 15 and over).
The employment rate for a
particular group (age, sex, marital
status, geographic area, etc.) is
the number of persons employed
in the week (Sunday to Saturday)
prior to Census Day (May 16, 2006),
expressed as a percentage of the
total population in that particular
group (adults aged 15 and over).
e
20
delays, speculation, and theft. Consequently, the
majority of land set aside for Métis children in the
Manitoba Act ended up being acquired by speculators
for only a fraction of its value and in the end Métis
occupied less than a quarter of the land.ibid
Between 1936 and 1963, federal relocation policies
‘encouraged’ Inuit to relocate into permanent villages
in areas selected by the government17 and required
children to attend schools in these villages in order to
receive family allowance. The hunting conditions of the
new sites were suboptimal, leading to food insecurity,
unemployment, and housing issues. Furthermore, the
move to permanent settlements was accompanied by
outbreaks of tuberculosis. By 1964, more than 70%
of Keewatin Inuit had been in tuberculosis sanatoria.
In some cases, children sent to sanatoria were later
adopted by southern families without their parents
being informed.17
Federal policies also supported the abduction of
Aboriginal children to residential schools, where
language and culture were actively suppressed and
child neglect and abuse were commonplace. Indian Act
legislation in 1920 made school attendance compulsory
for all First Nations children between the ages of 7 to
15 years. Between 1849 and 1983, approximately 100
residential schools operated in Canada and included
First Nations, Métis and Inuit students.17 According to
the Aboriginal Peoples Survey in 20069, 16% of Inuit
children aged 6 to 14 years had a parent who attended
a residential school and 49% of Inuit children aged 6 to
14 years had parents with at least one relative (mother,
grandfather, etc.) or spouse who attended a residential
school. According to the RHS 2002–3, 16.5% of First
Nations children (aged 11 and under) living onreserves had at least one parent and 58.6% had at least
one grandparent who attended residential schools.1
The residential school experience is described in the
following excerpt from the 1999 First Nations and Inuit
Regional Health Survey Report:
In some areas as many as five separate generations
of children were removed from their homes, families,
culture, and language…many of the children endured
long years of isolation and loneliness…Scores of children
died from disease; others were emotionally and spiritually
destroyed by the harsh discipline and living conditions.18
Inuit children also endured the residential
school experience. Mary Carpenter, an Inuk woman
summarizes her experience of residential school:
After a lifetime of beating, going hungry, standing in
a corridor on one leg, and walking in the snow with no
Health of Indigenous Children: Health Assessment in Action shoes for speaking Inuvialuktun, and having a heavy
stinging paste rubbed on my face, which they did to
stop us from expressing our Eskimo custom of raising
our eyebrows for ‘yes’ and wrinkling our nose for ‘no,’ I
soon lost the ability to speak my mother tongue. When a
language dies, the world it was generated from is broken
down too.19
Métis children and youth in some parts of the country
also attended residential schools, and were commonly
excluded and/or barred from attending community
schools set up for the children of European colonists.
The impact of residential schools goes far beyond
the impact on individual survivors; the trauma is
evident across generations of families. Dr. Cornelia
Wieman highlights the enduring aftermath of the
residential schools, asserting that:
In addition to the damage caused to the individual
survivors who endured emotional, physical, and sexual
abuse, we must consider the long-term, cumulative
intergenerational effects on First Nations Communities…
including dislocation from one’s community, loss of pride
and self-respect, loss of identity, language, spirituality,
culture, and ability to parent.20
The evidence suggests that health status, health
service, and/or economic considerations themselves
are not sufficient to describe the excess burden
of health disparities experienced by Indigenous
children and their families, nor are they adequate
to identify appropriate strategies for remediation.
Historic and ongoing colonial policies need to be
addressed. Key to the reversal of colonization is
the restitution of the right of Indigenous peoples to
self-determination, including the implementation of
the standards in the UN declaration on the Rights of
Indigenous Peoples.21
2.6 Additional Social Determinants
of First Nations, Inuit, and Métis
Children’s Health
Employment
Overall, rates of unemployment are higher for
Aboriginal peoples compared to non-Aboriginal
Canadians. Results from the 2006 Aboriginal Peoples
Survey found that unemployment ratesd for the adult
population (15 years and over) were four to five times
higher for the Aboriginal population compared to the
non-Aboriginal population7 (See Figure 10). Rates
for employmente were generally comparable across
the First Nations, Inuit, Métis, and Non-Aboriginal
Health of First Nations, Inuit, and Métis Children in Canada
Unemployment
Employment
80%
67%
70%
63%
62%
58%
57%
60%
49%
50%
49% 49%
40%
40%
34%
33%
31%
30%
20%
7%
10%
0%
First Nations
(on-reserve
18+ years)
First Nations with First Nations without
status or treaty
status or treaty
(off-reserve
(off-reserve
15+ years)
15+ years)
Fished
Hunted
Trapped
Hunted or Trapped
Inuit
(inside Nunaat
15+ years)
Canadian
population
15+ years
Métis
15+ years
Inuit
(outside Nunaat
15+ years)
Figure 10
Rates of Unemployment
& Employment
Source: APS 2006, RHS 2002/3,
Census 2006
Figure 11
Harvesting of Country
Foods for Consumption
(in past 12 months)
Berry picking or Food gathering
100%
Source: APS 2006, RHS 2002/3
78%
80%
72%
60%
55%
47%
46%
43%
37%
40%
43%
38%
36%
32%
32%
32%
27%
20%
15%
13%
13%
0%
First Nations
with status or treaty
(off-reserve)
First Nations
without status or treaty
(off-reserve)
Inuit
(inside Nunaat)
population. According to the 2006 Census, the rate
of employment for the First Nations on-reserve adult
population (over 18 years of age) was 49%.3
The harvesting of country food was included as a
labor activity on the 2006 Aboriginal Peoples Survey
and the 2002/2003 First Nations Regional Longitudinal
Health of First Nations, Inuit, and Métis Children in Canada Inuit
(outside Nunaat)
Métis
First Nations
(on-reserve)
Health Survey. Gathering or harvesting country food
for personal consumption was an important labour
activity across all groups. Inuit respondents, living
inside Inuit Nunaat, had significantly higher rates of
hunting, fishing and trapping, compared to off-reserve
First Nations and Métis groups (See Figure 11).1,9
Health of Indigenous Children: Health Assessment in Action
21
Total
First Nations First Nations
Aboriginal (on and off (on reserve
reserve)
only)
Table 2
Median Employment
Income for Aboriginal and
non-Aboriginal Population
in Canada (based on
2005 earnings)
Métis
Inuit
Non
Aboriginal
Women
(all age groups)
16,079
15,489
13,800
17,002
15,387
21,765
Men
(all age groups)
22,386
19,061
13,607
27,881
19,229
33,214
Total (Men and
Women)
18,962
17,007
13,705
21,498
17,268
27,097
Source: 2006 Census.
A CMA is an urban area with
a population of more than
100,000 people
f
g
The CCHS excludes on-reserve
First Nations populations and Inuit
populations living in the territories.
22
Income
Median income for the Aboriginal and non-Aboriginal
population is presented in Table 2.4 Significant
disparities exist for First Nations, Inuit, and Métis,
in comparison to the non-Aboriginal population. The
most marked disparities are for First Nations living
on reserve.
Further, according to the Aboriginal Children’s
Survey 2006, 41% of young First Nations children
(aged five and under) living off-reserve and 32% of
young Métis children were from low-income families,
compared to 18% of non-Aboriginal young children.10
Differences in frequency of low-income families were
also noted between urban and rural residences. For
First Nations families living off-reserve with young
children (aged five and under), a higher percentage
of urban families were in the low-income category as
compared to families living in rural areas (54% and
27% respectively). A similar trend was found for Métis;
36% of families with young Métis children in urban
areas were in the low-income category, compared to
20% of rural families. Rates for Inuit families with
young children (aged five and under) were calculated
differently based on geography. For young Inuit
children living outside of Inuit Nunaat and living in a
Census Metropolitan Area (CMA),f 45% were living
in low-income families, compared to 21% of young
non-Aboriginal children living in CMAs. There were
no rates available for First Nations children living
on-reserve or for Inuit children living inside Inuit
Health of Indigenous Children: Health Assessment in Action Nunaat.10 For the total Canadian population, 14.5% of
young children under 6 years old and 13% of children
aged six to 14 years old lived in a low income family.
Overall, this suggests that young Aboriginal children
and their families are more often living in poverty, as
compared to non-Aboriginal families.
In the Aboriginal Peoples Survey, 17% of status or
treaty First Nations living off-reserve and 11% of nonstatus or non-treaty First Nations living off-reserve,
utilized social assistance or welfare as an income
source. For Inuit living within Inuit Nunaat, rates were
24% compared to rates of 13% for Inuit living outside
Inuit Nunaat. The rate for Métis respondents was 7%.9
The APS excluded First Nations living on-reserve.
These income disparities are all the more alarming
given the household and demographic characteristics
of Aboriginal families. As mentioned previously,
many Aboriginal children live in lone parent
households. Additionally, children and youth account
for just under half of the Aboriginal population.
Therefore, the reduced annual incomes of Aboriginal
adults described above will often be providing for
a larger group of dependents, compared to nonAboriginal households.
Education
Only the First Nations Regional Longitudinal Health
Survey has data on parental education. According to
RHS 2002/3, 54% of mothers and 43% of fathers were
high school graduates.1
Health of First Nations, Inuit, and Métis Children in Canada
100%
85%
80%
78%
75%
76%
69%
60%
52%
40%
20%
0%
First Nations
with status or treaty
(off-reserve)
First Nations
without status or treaty
(off-reserve)
Inuit
(inside Nunaat)
Inuit
(outside Nunaat)
Métis
non-Aboriginal
population
Figure 12
High School Completion
Source: APS 2006, Census 2006
Figure 13
Exposure to Aboriginal
Teachers or Teacher Aides
(elementary or
secondary school)
80%
70%
58%
60%
Source: APS 2006
50%
40%
30%
23%
20%
20%
14%
11%
10%
0%
First Nations
with status or treaty
(off-reserve)
First Nations
without status or treaty
(off-reserve)
Inuit
(inside Nunaat)
As there are currently no specific data on parental
education for First Nations off-reserve, Inuit,
and Metis, we report figures for the general adult
population. According to the 2006 Census, rates for
high school completion are generally somewhat lower
for Aboriginal populations, as compared to the nonAboriginal population. In particular, Inuit living inside
Inuit Nunaat have considerably lower rates of high
school completion (See Figure 12).6
Other data in the 2006 Census examined student
exposure to Aboriginal teachers at the elementary or
Health of First Nations, Inuit, and Métis Children in Canada Inuit
(outside Nunaat)
Métis
high school level. Evidenced from Figure 13, there were
significant differences in these rates for First Nations,
Inuit, and Métis.6 These trends could suggest that
having treaty or status, and living within Inuit Nunaat
may provide increased opportunities for exposure to
Aboriginal teachers and possibly Aboriginal-based
teachings and philosophies.
Food Security
There is only sparse and inconsistent information
regarding the rates of food security and insecurity
Health of Indigenous Children: Health Assessment in Action
23
Moderate and Severe
Severe only
40%
35%
33%
30%
25%
20%
14%
15%
9%
10%
5%
Figure 14
Food Insecurity
Source: CCHS 2004
3%
0%
Aboriginal
Note: The CCHS excludes on-reserve First Nations populations and Inuit populations living in the territories.
among First Nations, Inuit, and Métis populations.
Data collection and quality is further complicated by
the use of different measurement instruments, most of
which have not been validated in First Nations, Inuit,
and Métis contexts. Given the strong links between
food security, income, and employment,22 the paucity
of information regarding food security is particularly
concerning. As we know from the income and
employment statistics detailed above, some Aboriginal
people will be at risk of food insecurity, possibly
leading to negative health outcomes.
Results from the 2004 Canadian Community Health
Survey (CCHS)g indicated disproportionately high rates
of food insecurity for the Aboriginal population, when
compared to the non-Aboriginal population22 (See
24
non-Aboriginal
Health of Indigenous Children: Health Assessment in Action Figure 14). Rates of food insecurity for First Nations
populations living on-reserve vary from 21% to 83%23
According to the 2006 APS, 30% of Inuit children in
Canada had at some point experienced hunger as a
result of their family having run out of food or money
to buy food. Of those who experienced hunger, 24%
experienced it regularly at the end of the month and
21% had experienced it more than once a month.9 It
is also important to recognize that the frequency of
food insecurity may in fact be higher than observed
as a community organizations may be ‘filling the gaps’
through community food banks and meal vouchers.
Remote and/or northern Aboriginal communities
can face additional food security challenges, as
nutritious food can be difficult and costly to find. For
Health of First Nations, Inuit, and Métis Children in Canada
80%
75%
70%
66%
59%
60%
57%
47%
50%
40%
30%
25%
20%
10%
0%
First Nations
with status or treaty
(off-reserve)
First Nations
without status or treaty
(off-reserve)
Inuit
(inside Nunaat)
Inuit
(outside Nunaat)
Métis
non-Aboriginal
population
Source: APS 2006, Census 2006
Figure 16
Housing Conditions
50%
Crowded conditions
Figure 15
Home Ownership
Homes in need of major repairs
43%
Source: ACS 2006, RHS 2002/3,
Census 2006
40%
40%
34%
32%
29%
30%
26%
22%
20%
18%
16%
14%
8%
10%
7%
6%
6%
7%
0%
First Nations
(off-reserve)
Inuit
nonAboriginal
First Nations
(off-reserve)
Children 5 and under
example, a healthy food basket to feed a family of four
for a week costs between $350-450 in Inuit Nunaat,
compared to $200 in the south.24
Housing
According to the 2006 APS, rates of home ownership
were lower for Aboriginal populations, compared
to non-Aboriginal population.9 Furthermore, there
was significant variability among First Nations, Inuit
Health of First Nations, Inuit, and Métis Children in Canada Inuit
Métis
Children aged 14 and under
nonAboriginal
First Nations
(on-reserve)
Adult
and Métis populations (See Figure 15). Data was not
available for First Nations living on-reserve.
Results from the 2006 Census and ACS 2006 show
overall higher rates of crowdingh and homes in need
of repairs for families with Aboriginal children, as
compared with non-Aboriginal families (See Figure
16).2,6,10 More specifically, Inuit participants reported
significantly higher rates of problems with housing,
as well as lower rates of home ownership. This
h
Crowded conditions is defined as
more than one person per room.
Health of Indigenous Children: Health Assessment in Action
25
30%
Water contamination
Unsafe water
25%
21%
20%
18%
17%
15%
13%
17%
16%
13%
11%
10%
5%
Figure 17
Water Quality Issues
0%
First Nations
without status or treaty
(off-reserve)
First Nations
with status or treaty
(off-reserve)
Source: APS 2006
Figure 18
Kinship Networks
Inuit
First Nations
Inuit
Métis
Métis
Source: ACS 2006
100%
93%
92%
94%
77%
80%
78%
72%
60%
44%
47%
46%
41%
40%
28%
21%
20%
0%
Raised by mother
Since 99% of the adults
participating in the RHS had
children living with them, the RHS
figures are comparable to the 2006
Census/ACS figures and are included
in Figure 16.
i
26
Raised by father
could suggest that landlords are not maintaining an
acceptable level of safety in their rental units. Data
for First Nations living on-reserve was not included
in this 2006 Census/ACS analysis. According to the
RHS 2002/3, 32% of adults reported their homes were
crowded and 34% reported of adults reported their
homes were in need of major repairs.1i
In addition, between 10% and 20% of Aboriginal
people participating in the 2006APS report water
quality issues in their homes (See Figure 17).9 The
water quality situation is even more alarming for First
Nations people living on reserve, with only 68% of
Health of Indigenous Children: Health Assessment in Action Raised by grandparents
Raised by other
(aunts, uncles, cousins, siblings)
participants in the RHS 2002/3 reporting that water in
their home was safe to drink.1 No comparable statistics
from the 2006 census have been released for the general
Canadian population.
Kinship and Support Networks
Many First Nations, Inuit, and Métis parents and
extended family are involved in raising young children
(under six years old). The majority of Aboriginal children
were raised by their mother and father, and approximately
half were raised by grandparents. (See Figure 18). No
statistics from the 2006 census have been released for
Health of First Nations, Inuit, and Métis Children in Canada
the general Canadian population or for the First Nations
population living on-reserve. The only comparable
statistics for the Canadian population are from the
NLSCY 2006/07 for children aged five and under.25 When
asked who the child lived with, 86% of children lived
with biological parents, 11% lived with biological mother
and did not live with their father, and 0.6% lived with
biological father and did not live with biological mother
(although this last statistic was flagged to indicate that
caution should be used in its interpretation).
Communication Technology
The 2006 Aboriginal Peoples Survey and Statistics
Canada indicated that most Aboriginal adults had
used a computer and the internet in the past year
(See Figure 19).7,26 Slightly lower rates were found for
Computer use (past 12 months)
Inuit specifically living inside Inuit Nunaat, which
might reflect the limited number of internet services
providers, the high costs of computer and internet
access, or computer illiteracy. According to the RHS
2002/3, 41% of participant First Nations adults living
on-reserve reported having a home computer and
29% reported having access to the internet in their
home.1
Language
Results from the 2006 Aboriginal Peoples Survey
showed considerable variability in language fluency
among First Nations, Inuit, and Métis adults (See
Figure 20).7 Rates of Aboriginal language retention
among First Nations, Inuit, and Métis children are
included in the health status sections below. Rates for
Internet use (past 12 months)
Personal non-business internet use (past 12 months)
100%
82%
80%
79%
74%
78%
Source: APS 2006, Canadian Internet
Use Survey 2005
84%
81%
77%
Figure 19
Communication
Technology Use
80%
68%
67%
61%
60%
40%
20%
0%
First Nations
with status or treaty
(off-reserve)
First Nations
without status or treaty
(off-reserve)
Inuit
(inside Nunaat)
Health of First Nations, Inuit, and Métis Children in Canada Inuit
(outside Nunaat)
Métis
Canadian
population
Health of Indigenous Children: Health Assessment in Action
27
accessing care in an Aboriginal language were around
20% (See Figure 20). It is unclear if these rates include
use of an interpreter or simply accessing a health-care
provider who speaks an Aboriginal language. First
Nations living on-reserve were not included in these
analyses. Increasing the amount of health services
available in an Aboriginal language could significantly
contribute to access and utilization of health services
for diverse Aboriginal populations. The discrepancy
between the language capacities of those surveyed
and available health services in a primary Aboriginal
language highlights a critical opportunity for growth
and improvement in the delivery of appropriate and
inclusive health programs and initiatives.
Figure 20
Aboriginal Language Use &
Access to Health Services in
Aboriginal Language
Source: APS 2006
Speak or understand Aboriginal language
100%
2.7 Children’s Health Status
Refer to the end of this section (v. Figures) for
children's health status figures. Comparisons in this
section are made to the National Longitudinal Survey
of Children and Youth (NLSCY).25,27 Ideally, we would
have presented comparisons to the non Aboriginal
participants in the NLSCY however, due to the very
small sample size of the Aboriginal participants
included in the NLSCY, data for the Aboriginal and
non-Aboriginal subsamples has been suppressed to
protect confidentiality. Instead, we therefore make
comparisons with data from the general Canadian
sample, which includes a small proportion of
Aboriginal children.
Access to health care in primary Aboriginal language
96%
90%
80%
70%
60%
68%
53%
50%
37%
40%
30%
30%
27%
22%
29%
19%
20%
13%
10%
0%
First Nations
with status or treaty
(off-reserve)
28
Health of Indigenous Children: Health Assessment in Action First Nations
without status or treaty
(off-reserve)
Inuit
(inside Nunaat)
Inuit
(outside Nunaat)
Métis
Health of First Nations, Inuit, and Métis Children in Canada
First Nations Section Highlights
• Infant mortality rates for status First Nations appear to be decreasing but remain approximately
twice as high as Canadian infant mortality rates. There are no infant mortality rates for non-status
First Nations.
• In 2002/3, rates of high birth weight (>4.0kg) were significantly higher for First Nations children
living on reserve (21%) compared to the non-Aboriginal population (13.1%).
• In 2006, rates for breastfeeding initiation, sustained breastfeeding at four months, and sustained
breastfeeding at six months for status or treaty First Nations living off-reserve were 69%, 56%, and
48% respectively. In 2002/3 rates for initiation and sustained breastfeeding at six months for First
Nations on-reserve were 63% and 43% respectively.
• According to the RHS, 3.6% of First Nations children living on reserve had bronchitis; more than
double the rate for the Canadian population (1.4%).
• In 2006, 42% of status or treaty First Nations children aged six to 14 years living off-reserve and 45%
of non-status or non-treaty First Nations children aged six to 14 years living off-reserve had one ore
more severe chronic health conditions.
• In 2006, 15% of status or treaty First Nations children aged five years or less living off-reserve had
asthma or used an inhaler/puffer. In 2002/3 14% of First Nations children aged 11 or younger living
on reserve had asthma.
• In 2006, 18% of status or treaty First Nations children aged six to 14 years living off reserve and 22%
of non-status or non-treaty First Nations children aged six to 14 living off-reserve suffered from one
or more activity limitations; according to the RHS 8.1% of First Nations children(11 and under) living
off-reserve suffer from an activity limitation.
• According to the RHS, 55% of First Nations children (aged 11 and under) living on-reserve reported
always or almost always eating a nutritious and balanced diet.
• In 2006, 25% of status or treaty First Nations children aged five years or less living off-reserve and 9%
of status or treaty First Nations children aged five years or less living off-reserve were able to speak
or understand an Aboriginal language. In 2002/3, 25% of First Nations children aged 11 or younger
living on reserve were able to speak or understand an Aboriginal language.
• 96% of First Nations children (aged 11 and under) living on-reserve had at least one person helped
them understand their culture.
• In 2006, 12% of status or treaty First Nations children aged five years or less living off-reserve and 8%
of non-status or non-treaty First Nations children aged five years or living off-reserve were unable to
obtain health care or medication when needed in the past 12 months.
• 15.4% of First Nations children (aged 11 and under) living on reserve were reported to have an
emotional or behavioural problem.
• 29.5% of First Nations children between 12 and 14 years old living on reserve smoked tobacco in 2002/3.
I. FIRST NATIONS
Self-rated health
The measure of ‘self-rated’ health has yet to be
validated in Aboriginal communities, and in general
is considered problematic in the field of population
health.28 For example, individuals may rate their health
in comparison to others. Thus, their perception of their
own health is a relative comparison, and if the absolute
level of health of a group is low, the perception will not
accurately reflect a true measure of health. Results from
the Aboriginal Children’s Survey (2006) found that
Health of First Nations, Inuit, and Métis Children in Canada nearly all children are described in ‘good,’ ‘very good,’ or
‘excellent’ health (See Figure 21), which is comparable to
the rate for the Canadian population.10,25,27
Infant mortality and perinatal health outcomes
This section covers infant mortality, birth weight, preterm
birth, breastfeeding, sudden infant death syndrome (SIDS),
and fetal alcohol spectrum disorder (FASD).
Infant mortality
The Joint Working Group of Infant Mortality has
identified that high quality infant mortality rates are
Health of Indigenous Children: Health Assessment in Action
29
The Joint Working Group of Infant
First Nations and Inuit population
Mortality has identified that high quality
in Canada and exclude the Métis
infant mortality rates are currently only
population. Moreover, these rates
available for regional subgroups of the
do not exist at a national level.
currently only available for regional subgroups of the
First Nations and Inuit population in Canada and
exclude the Métis population. Moreover, these rates do
not exist at a national level.29
The averaged infant mortality rate for First Nations
families with status, living both on and off reserve
for 1976-1980 was 29 deaths per 1,000 live births.30
This was over two times the infant mortality rate
for Canada during the same time period.ibid More
recently, First Nations infant mortality rates appear to
be decreasing with respect to absolute numbers but
remain approximately twice as high as Canadian infant
mortality rates (which have also been decreasing).
In British Columbia, using vital statistics data from
1981 to 2000, the overall infant death rates were 2.27
times higher for status First Nations compared to
non-First Nations living in rural areas, and 2.08 times
higher for status First Nations compared to non-First
Nations living in urban areas.31 In Manitoba, using vital
statistics data from 1991 to 2000, the infant mortality
rate for First Nations persons self-identifying on birth
and/or infant death registrations as First Nations with
status was 10.2 deaths per 1,000 births compared to
a non-First Nations rate of 5.4. The rate disparity was
most marked for post-neonatal death (death between
29 days to 364 days of age), for which the First Nations
rate was more than three times the non-First Nations
rate (6.1 per 1,000 compared to 1.7 per 1,000).32
It is important to note that no reliable infant
mortality rates exist for First Nations persons living in
other parts of the country and for First Nations persons
without status. Additional regional rates are produced
by First Nations and Inuit Health Branch and/or the
provinces for the four Western provinces, however
due to variations in the calculation methods, as well as
quality, they have not been included.16
population (see Figure 22a). Rates for high birth
weight (>4.0kg) showed some variation, with higher
rates observed for First Nations living on-reserve
and First Nations with status or treaty living offreserve.1,10,27 (See Figure 22b).
In a study examining all births of First Nations infants
with status in British Columbia between 1981 and
2000, First Nations infants with status had heavier birth
weights, as compared to non-First Nations infants.31
The reasons for the elevated proportions of high
birth weight First Nations babies are unclear and this
issue requires further investigation.
Birth weight
Rates of low birth weight for First Nations living on
and off-reserve with status were similar to those of
the Canadian population. Rates of low birthweight
for First Nations without treaty or status living
off-reserve were higher than those of the Canadian
30
Health of Indigenous Children: Health Assessment in Action Preterm birth
There is no consistent provincial or territorial tracking
of preterm birth rates among First Nations. A provincial
research study of preterm birth among First Nations
with status in British Columbia revealed preterm
birth rates that were consistently over 40% to 70%
higher than those of non-First Nations.31 In Manitoba,
published rates of preterm birth for First Nations with
status are only slightly elevated compared to those of
non-First Nations,33,34 with higher rates for First Nations
persons living off-reserve compared to on-reserve.
Elevated rates of preterm birth have been linked
to increases in multiple births, increased frequency
of obstetrical interventions, early complications
during pregnancy (e.g., vaginal bleeding, gestational
hypertension), inadequate prenatal care and high levels
of perceived stress.34 Accordingly, the high rates of
preterm birth may be related to health service delivery
and maternal well-being.
Breastfeeding
Rates of breastfeeding initiation for First Nations
were slightly lower than the rate for the Canadian
population (in particular for the on-reserve
population).1,27 However, rates of sustained
breastfeeding (at six months in particular) were
higher than the rate for the Canadian population
(See Figures 23, 24, and 25). This suggests that
mothers who decide to breastfeed are adequately
supported to continue breastfeeding, but that fewer
Health of First Nations, Inuit, and Métis Children in Canada
mothers are deciding to breastfeed. This might be
related to an increased rate of preterm labour that can
interfere with the early interactions and opportunities
for breastfeeding. It might also be indicative of the
limited success of breastfeeding promotion efforts.
Mothers may be receiving ongoing support from
within their family (as evidenced by the strong
kinship networks), which would explain the higher
rates of sustained breastfeeding.
Sudden infant death syndrome (SIDS)
In a population-based study in the province of British
Columbia, which included all First Nations with
status births between 1981 and 2000, the incidence of
postneonatal SIDS was higher for both rural and urban
First Nations with status, as compared to both rural
and urban non-First Nations.31
In a study of all infants born in Quebec (Nunavik
region) from 1985 to 1997, the incidence of SIDS for
Indian (North American Native language base) was
2.6 per 1,000, which was higher than among infants of
French language background (0.5 per 1,000), English
background (0.4 per 1,000), and other language
background infants (0.5 per 1,000).35 Infant’s ethnicity
was identified using mother’s language. SIDS has been
linked to certain risk factors including infant sleep
position, poverty and environmental smoke exposure.
Fetal alcohol spectrum disorder (FASD)
Much controversy surrounds the diagnosis of fetal
alcohol spectrum disorder (FASD), particularly for
Aboriginal communities. The diagnostic category
is relatively new and diagnostic instruments are
only now being standardized. For the Aboriginal
population, the struggle for accurate diagnosis is
greater and complex as access to trained physicians
is often limited. Furthermore, the physical diagnostic
features of FASD (e.g., typical facial features,
height, head size) were established for Caucasian
children and their use in Aboriginal settings can
lead to misdiagnosis or over-diagnosis of FASD.36
Additionally, standardized testing instruments for
cognitive and behavioural features of FASD have yet to
be validated with Aboriginal populations.37
Presently, no population-based estimates for FASD
exist for First Nations, Inuit or Métis children in
Canada. Furthermore, most studies that are conducted
at a provincial or territorial level are criticized for a
failure to use blind examiners for maternal alcohol
use.38 According to parental self-report in the RHS
2002/3, 1.8% of participant First Nations children
(aged 11 and under) suffer from Fetal Alcohol Effects
(considered a broader diagnostic category)1.
Health of First Nations, Inuit, and Métis Children in Canada One comprehensive community level study has
been conducted to determine prevalence rates of
FASD; between January 1998 and June 1999, the
prevalence of FASD was 193 per 1,000 (or 19.25%)
for children in grades one to eight in one Atlantic
First Nations community.39
According to Health Canada, among the general
Canadian population the incidence of FASD is 1 out of
every 500 to 3,000 live births per year, and the incidence
of FAE is five to 10 times the incidence of FASD.38
Nutrition
There is relatively little data regarding the nutrition
of First Nations children, despite the evidence
indicating high rates of food insecurity discussed
earlier. According to the RHS 2002/3, 55% of First
Nations children (aged 11 and under) living on-reserve
reported always or almost always eating a nutritious
and balanced diet.1 According to the APS 2001, 90% of
First Nations children (aged six to 14) living off-reserve
and 84% of First Nations children living on selected
reserves had breakfast five to seven days a week.7 In a
study conducted with six of nine Cree villages in the
James Bay region, between January 1995 and October
1998, 31.9% of infants had anemia.40 No national,
provincial or territorial rates of anemia in First Nations
children were identified.
Infectious diseases
Immunization and immunizationpreventable diseases
No national, provincial or territorial rates were
identified for immunization against preventable
childhood infections (measles, mumps, rubella,
haemophilus influenza, diphtheria, polio, tetanus,
pertussus, pneumococcus, and varicella zoster).
Otitis media
Rates for ear infections or problems are presented in
Figure 26. Rates were comparable for status or treaty First
Nations living off-reserve, non-status or non-treaty First
Nations living off-reserve, and First Nations children living
on-reserve.1,10 At present, we do not have a comparison for
the Canadian or non-Aboriginal population.
Respiratory tract infection
Respiratory tract infections constitute a major cause of
childhood morbidity and mortality. According to the
RHS 2002/3, 3.6% of First Nations children living on
reserve had bronchitis, which was more than double
the rate for the Canadian population (1.4%).1 It should
be noted that the statistic for First Nations children
Health of Indigenous Children: Health Assessment in Action
31
living on reserve is flagged and must be interpreted
with caution due to high sampling variability.
Inadequate housing conditions, including poor
ventilation and crowding, directly contribute to the
elevated rates of respiratory tract infections.41
With the exception of TB (below) national,
provincial and territorial hospitalization and mortality
rates for childhood respiratory tract infection are
noticeably absent.
Tuberculosis (TB)
According to the RHS 2002/3, 0.5% of First Nations
children living on reserve (aged 11 and under) had
tuberculosis (although this number should be interpreted
with caution because of high sampling variability.1
Yip et al. (2007) examined cases of pediatric
tuberculosis in the province of Alberta, including a
sample of First Nations with status.42 It should be noted
that the Canadian ‘other’ category included: nonStatus First Nations, Métis, Inuit, and Canadian-born
non-Aboriginal children of foreign-born or Canadianborn parents. Thus, this statistic on tuberculosis is not
representative of the entire population of First Nations
children in Alberta. The overall rate of pediatric
tuberculosis in Alberta between 1990 and 2004 was 1.1
per 100,000 person-years. The rate for First Nations
with status was higher in comparison to the Canadianborn ‘other’ (First Nations with status rate ratio of
29.69) after controlling for gender.
Tuberculosis has been linked to health determinants
including crowded housing43 and living in remote areas
where access to medical professionals is more difficult.44
j
The RHS used the internationally
accepted definition for childhood
obesity, which is based on
calculation of the child’s body mass
index and the internationally
accepted cut-off points to define
obesity for that child’s particular
age group.1
32
Hepatitis
Jin and Martin (2003) counted all viral hepatitis A
cases (children and adults) on First Nations reserves
in British Columbia that were reported to the First
Nations and Inuit Health Branch between January 1991
and September 1996.45 The incidence rate was 31 per
100,000 persons per year, which was double the rate
for the general population of British Columbia (15.1
per 100,000).
Health of Indigenous Children: Health Assessment in Action Viral hepatitis has been linked to housing conditions
and other determinants of health; higher incidence
rates were associated with crowded housing and water
quality problems.45
HIV
No national, provincial or territorial rates identified.
Chronic disease
Rates of chronic disease for First Nations children
are between 28% and 45% (See Figures 27 and 28).10
Such elevated rates suggest that efforts in preventive
treatment are falling short. As well, it indicates that
frequent medical care and access to specialists is
required. Unfortunately, there is very limited data on
such health care access
Obesity
Childhood obesity has been recognized by policymakers
as a significant problem facing Canadian children. Data
regarding obesity prevalence rates are limited for First
Nations children. The only available data is for First
Nations children living on-reserve.j In comparison to
the Canadian population, rates of obesity are over four
times higher (See Figure 29).1
Obesity has been linked to a number of
determinants of health. In particular, obesity in First
Nations children has been linked to family income,
parental education, and physical activity.1 For First
Nations children, the significant disparities in obesity
rates are clear evidence of the impact of determinants
of health. This disparity suggests that prevention
measures are ineffective. For example, access to
preventative healthcare would be able to identify
nutritional issues before a weight problem
is pronounced.
Diabetes
The epidemic of diabetes among First Nations adults
continues to grow.46 Elevated rates of diabetes47,48,49
have also been reported among subpopulations of
First Nations youth, although nothing has been
Health of First Nations, Inuit, and Métis Children in Canada
reported for children under the age of 12. However,
the presence of childhood obesity may be a precursor
to diabetes later in life. There is at least one report
of a First Nations youth in Manitoba who died from
diabetes. Efforts to combat obesity, increase physical
activity, and improve access to medical care are key
to preventing diabetes.
Physical activity
According to the Aboriginal Children’s Survey 2006,
63% of status or treaty First Nations children (aged six
to 14 years) living off-reserve and 69% of non-status
or non-treaty First Nations children (aged six to 14
years) living off-reserve played sports one or more
times a week.10 The RHS 2002/3, asked 20 questions
about various types of physical activity, including
multiple sports; thus, an appropriate comparison was
not possible.1 No comparable rate was identified for the
Canadian or non-Aboriginal population.
Asthma
Rates of asthma for First Nations children were between
12% and 16% (See Figure 30), and comparable to the
rate for Canadian children.1,10,27
Allergies
Rates of allergies were generally similar for First Nations
children, as compared to the rate for Canadian children
(see Figure 31).1,10,27
Cancer
No national, provincial or territorial rates identified.
Heart Condition
Rates of heart conditions for First Nations children
were comparable across First Nations groups (See
Figure 32).1,10
Child development and disability
Disabilities
The rate of activity limitations for First Nations children
living off-reserve was higher than the rate for Canadian
children. The rate for First Nations children living
on-reserve was comparable to the rate for Canadian
children (See Figure 33).1,10,27
With respect to specific hearing and visual
impairments, rates of hearing impairments were much
lower than rates of visual impairments (See Figures 34a
& 34b).1,10 It is unclear how many First Nations children
have access to proper eye care, which is concerning
given the high rates of visual impairments. Furthermore,
the impact of visual impairments on children’s learning
Health of First Nations, Inuit, and Métis Children in Canada and development remains unclear. Perhaps this is linked
to the higher rates of learning problems.
Attention deficit hyperactivity disorder (ADHD)
Based on the RHS 2002/3, 2.6% of First Nations
children living on reserve had ADHD, which is
consistent with the rate for Canadian children.1 No rates
are available for First Nations children living off-reserve.
Learning disorders
Based on the RHS 2002/3, 2.9% of First Nations
children (aged 11 and under) living on reserve had
a learning disorder, which was reportedly consistent
with the rate for the Canadian population.1 According
to the APS 2001, it is estimated that 3% of First Nations
children living on selected reserves and 9% of First
Nations children living off-reserve, suffered from a
learning disorder.7 Note that the statistic for First
Nations children on selected reserves is flagged to be
interpreted with caution.
Language and Cultural Engagement
Rates of language comprehension and ability to speak
an Aboriginal language did show some differences;
First Nations children without status or treaty had
lower rates when compared to Inuit or Métis children
(See Figure 35).10 Language retention is fundamental to
identity and results suggest that colonization has had
a substantial impact on the transmission of language
and culture. Additionally, the relative infrequency of
Aboriginal teachers providing instruction suggests that
the school system is not an effective environment for
fostering language development.
According to the RHS 2002/3, 96% of First Nations
children (aged 11 and under) living on-reserve had
at least one person helped them understand their
culture. A variety of different people helped them; 67%
reported help from their parents and 62% reported help
from their grandparents.1
According to the Aboriginal Children’s Survey
(2006), 45% of First Nations children (aged five and
under) living off-reserve had someone who helped
them understand Aboriginal history and culture. Most
were helped by their parents (60%) and grandparents
(50%). Differences were noted for First Nations
children with status (54% had someone who helped
them) and First Nations children without status (32%
had someone who helped them).10
Injuries
This section deals with injuries, accidents and
accidental deaths. It should be noted that some suicides
are classified as accidental deaths.
Health of Indigenous Children: Health Assessment in Action
33
Rates for injuries were higher for First Nations
children living on reserve, as compared to rates for the
Canadian population (See Figure 36).1,27
Some injuries may have occurred at home and
perhaps could be linked to substandard and/or
crowded housing. Other injuries may have been the
result of a lack of safety equipment (e.g., car seats,
helmets), failed prevention efforts, lack of availability of
safety equipment and/or financial constraints.
Harrop et al (2007) examined injury mortality rates
for First Nations children (aged 19 years and under) in
Alberta.50 Over a 10-year period (1985 to 1994), annual
injury mortality rate decreased from 129 per 100,000
to 68 per 100,000, representing a 47% decline. This
decline was comparable to the rate decrease for nonFirst Nations children. However, injury mortality rates
were consistently higher for non-First Nations children.
It is unclear how access to quality medical care
factors into the increased rates of injury mortality.
Remote and isolated areas present challenges for
travelling to tertiary care centres.
Smoking, alcohol, and drug use
There is very little information on alcohol and drug use
for children less than 14 years old. According to the RHS
34
Health of Indigenous Children: Health Assessment in Action 2002/3, the rate for smoking tobacco was 29.5% for First
Nations children between 12 and 14 years old living on
reserve.1 The average age of smoking initiation was 12.7
years old and some respondents started as young as four
years old. For First Nations children between 12 and
14 years old living on reserve, 22.3% reported having
had alcohol in the past 12 months and 14.9% reported
having used marijuana in the past 12 months.1
Mental health
This section covers socioemotional problems,
depression, and suicide. There is no data on
access to medical care for mental health concerns
specifically, and similarly no data on access to mental
health professionals, such as psychiatrists, clinical
psychologists, or social workers.
Socioemotional problems
According to the RHS 2002/3, 15.4% of First Nations
children (aged 11 and under) living on reserve were
reported to have an emotional or behavioural problem.1
This rate was considered comparable to the rate for
the Canadian population according to the NLSCY,
however it should be noted that items from the NLSCY
2000/2001 were worded differently.27
Health of First Nations, Inuit, and Métis Children in Canada
Depression
According to the RHS 2002/3, 28% of First Nations
girls aged 11 to 14 years living on reserve, reported
feeling sad or depressed. This rate was two-times higher
than the rate for First Nations boys aged 11 to 14 years
also living on reserve (13.3%).1
Suicide
Suicide data sets that did not include children under
the age of 12 were excluded. According to the RHS
2002/3, among First Nations girls aged 12 to 14 years
living on reserve, 6.7% reported suicidal thoughts
and 2.6% reported a suicide attempt.1 In comparison,
among First Nations boys aged 12 to 14 years old living
on reserve, 1.8% reported suicidal thoughts and none
reported a suicide attempt.1
In a population based study of First Nations
children with status living in Alberta (from 1985-1994),
suicide ranked second as the leading cause of injury
for children aged 10 to 14 years.50 The suicide rate for
First Nations children was 12.8 per 100,000 per year,
considerable higher than the rate for non-Aboriginal
children (at 2.4 per 100,000 per year).
Suicide is the result of a variety of pre-existing
factors, including hopelessness, depression, and
substance misuse. Links have been established between
the experience of trauma during residential schooling
and mental health, substance abuse problems, and
suicide for adult survivors of residential schooling. As
well, there is emerging evidence and recognition of
the intergenerational effects of residential schooling.
It is likely that the effects of residential schooling and
subsequent family disruption are evidenced in the
mental health of children.
Dental health
Rates of dental problems varied for First Nations
children, with fewer problems noted for non-status or
non-treaty children (See Figure 37).10 However, young
children without status or treaty also had low rates of
accessing dental services, making it possible that dental
problems were not diagnosed (See Figure 38).1,10,25,27
Rates of access to dental care were comparable to those
of the Canadian population. Rates for access to dental
care were lower for older First Nations children living
on-reserve, compared to those living off-reserve.
Health of First Nations, Inuit, and Métis Children in Canada Environmental exposures
The rate of prenatal environmental tobacco exposure
(smoking in the home of a pregnant First Nations
mother) reported by participants in the RHS 2002/3,
was about one out of every two families living on
reserve (48.2%).1 No national, provincial or territorial
rates were identified for environmental exposures
such as mold in houses, crowding in homes, and
environmental contaminants (e.g., PCBs). Also, recall
that the housing condition and water quality of some
First Nations children and their families is substandard
(see Additional social determinants section).
Access to health care
Rates for accessing a family doctor, general practitioner
or pediatrician were comparable for young First
Nations children, although status or treaty First
Nations children off-reserve were more likely to have
been unable to obtain health care or medication. The
reasons for this are unclear. Rates of access to care for
the Canadian population were comparable (See Figure
39)10,25 Perceptions of health care facilities were equal
for both status or treaty and non-status or non-treaty
First Nations children living off-reserve (See Figure
40).10 Rates of access to medical care for older children
showed a similar pattern (See Figure 41).10
The RHS 2002/3 asked different questions regarding
access to health care. The focus was on barriers for
adults in accessing health services. The following
barriers were identified by participants: Doctor or nurse
not available (18.5% of adult participants); service not
available (14.7% of adult participants); not being able to
afford childcare costs (7.1% of adult participants).1
Additional data on interactions, proximity to health
care facilities, and quality of health care are necessary
to understand the health care experience of First
Nations children and their families.
Health of Indigenous Children: Health Assessment in Action
35
Inuit Section Highlights
• Over a three year period from 1999 to 2001, the infant mortality rate for Canada was 4.4 per 1,000
births compared to a rate 13.9 per 1,000 births for Nunavut.
• In Quebec (Nunavik region) from 1985 to 1997, the incidence of SIDS for Inuit was 6.0 per 1,000,
which was higher than rates among infants of French language background (0.5/1,000) or Indian
(North American Native language base) background (2.6/1,000).
• 33% of Inuit children aged six to 14 years were diagnosed with one or more severe chronic health
conditions in 2006
• Between 1998 and 2000 18.2% of births in the Baffin Island region were preterm.
• In 2006, 66% of Inuit women initiated breastfeeding and 54% maintained breastfeeding after
six months.
• In 2006, 15% of Inuit children aged six to 14 years old had an ear infection or ear problem.
• According to a 2006 follow up study in Nunavik, 97% of children had one or more episodes of upper
respiratory tract infection and 83% had one or more episodes of lower respiratory tract infection
before the age of five.
• In 2006, 48% of Inuit children aged five years or less could speak or understand an Aboriginal
language compared to 72% of Inuit children aged six to 14 years.
• In 2001, 56% of smokers in Nunavut were children and youth aged 12 to 19 years.
• In 2006, 53% of Inuit children aged five years or less and 35% of Inuit children aged six to 14 years
had seen a family doctor, general practitioner or pediatrician in the past 12 months.
II. Inuit
Refer to the end of this section (v. Figures) for
children's health status figures.
Self-rated health
The measure of ‘self-rated’ health has yet to be
validated in Aboriginal communities, and in general
is considered problematic in the field of population
health.28 For example, individuals may rate their health
in comparison to others. Thus, their perception of their
own health is a relative comparison, and if the absolute
level of health of a group is low, the perception will
not accurately reflect a true measure of health. Results
from the Aboriginal Children’s Survey (2006) found
that nearly all Inuit children described being in ‘good,’
‘very good,’ or ‘excellent’ health (See Figure 21),
which is comparable to the rates for the Canadian
population.10,25,27
Infant mortality and perinatal health outcomes
This section covers infant mortality, birth weight, preterm
birth, breastfeeding, sudden infant death syndrome (SIDS),
and fetal alcohol spectrum disorder (FASD).
Infant mortality
At present, IMR for Inuit are inferred using population
based statistics in territories. This is due to the lack of
Aboriginal identifiers on death registrations. Authors
36
Health of Indigenous Children: Health Assessment in Action of a recent study generated abridged life tables using
census and vital statistics data for residents of census
subdivisions in which 33% or more of the population
was Inuit – this included all communities in the four
Inuit land claim settlement territories. The infant
mortality rate for Inuit inhabited areas decreased from
25.6 deaths per 1,000 births for 1989-1993 to 21.9
deaths per 1,000 births for 1994-1998 to 18.5 deaths per
1,000 live births for 1999-2003. These rates persisted to
be four times the general Canadian rate, which also fell
during the period of the study.51
The rate for infant mortality in 2001 in Nunavut was
15.6 per 1,000 births, which is almost four times greater
than the rate for Canada (4.4 per 1,000 births). Over
a three year period, from 1999 to 2001, the rate for
Canada was 4.4 and the rate for Nunavut was 13.9 per
1,000 births.52
Birth weight
The rate of low birthweight for Inuit was slightly higher
compared to the Canadian population. The rate of
high birthweight was slightly lower than that of the
Canadian population (see Figure 22).10
For Nunavut, high birth weight was 8.7% and 9.2%
and for Canada it was 5.2% and 5.8%, for males and
females, respectively. Over a three year period from
1999 to 2001, the rate for low birth weight was 7.6% for
Nunavut and 5.5 for Canada.52
Health of First Nations, Inuit, and Métis Children in Canada
Preterm birth
There is no consistent provincial or territorial tracking
of preterm birth rates among Inuit. Muggah et al (2003)
collected information on all live births in the Baffin
Region between 1998 and 2000.53 A sample of 835 Inuit
births and 45 non-Inuit births was identified. Among
Inuit women, 18.2% of births were preterm (before
37 weeks) and 2.4% of births were extremely preterm
(before 32 weeks). These rates are much higher than
reported rates of preterm births in other regions of
Canada for the same time period.54
Elevated rates of preterm birth have been linked
to increases in multiple births, increased frequency
of obstetrical interventions, early complications
during pregnancy (e.g., vaginal bleeding, gestational
hypertension), inadequate prenatal care and high levels
of perceived stress.33 In a study of risk factors for Inuit
preterm birth in Baffin Region,53 preterm birth was
associated with fewer prenatal visits, previous preterm
delivery, and previous births.
Breastfeeding
Rates of breastfeeding initiation for Inuit were
lower than the rates for the Canadian population.1,27
However, rates of sustained breastfeeding (at six
months in particular) were higher than the rate for
the Canadian population (See Figures 23, 24, and
25).10,27 Additionally, according to the APS 2001,
the average duration for breastfeeding for Inuit
children was 15 months.7 The relatively high rates
of sustained breastfeeding may reflect a supportive
family environment and/or cultural norms. The
overall lower rates of breastfeeding initiation for Inuit
may be attributable to concern about environmental
toxins contained in breastmilk (see discussion in
Environmental Exposures). Furthermore, rates of
breastfeeding for Inuit might also be lower because
adoption is common, which might preclude the
possibility of breastfeeding.
Sudden Infant Death Syndrome (SIDS)
In a study of all infants born in Quebec (Nunavik
region) from 1985 to 1997, the incidence of SIDS
for Inuit was 6.0 per 1,000, which was higher than
among infants of French language background (0.5
per 1,000), Indian (North American Native language
base; 2.6 per 1,000), English background (0.4 per
1,000), and other language background infants (0.5
per 1,000)35. Infants’ ethnicity was identified using
mother’s language. SIDS has been linked to certain
risk factors including infant sleep position, poverty
and environmental smoke exposure.
Health of First Nations, Inuit, and Métis Children in Canada Fetal alcohol spectrum disorder (FASD)
No national, provincial or territorial rates were
identified for Inuit.
Nutrition and traditional foods
According to the APS 2001, 49% of Inuit children (aged
six to 14) ate wild meat at least three times a week.8
Infectious diseases
Immunization and immunization
preventable Illness
No national, provincial or territorial rates were
identified for immunization against preventable
childhood infections (measles, mumps, rubella,
haemophilus influenza, diphtheria, polio, tetanus,
pertussus, pneumococcus, and varicella zoster).
According to the Nunavut Comparable Health
Indicators Report (2004), there were no reported cases
of measles in 2002.52 There was one new case of invasive
meningococcal disease and two cases of invasive
Haemophilus influenzae B reported in 2002, which
resulted in rates of 7.6 per 100,000 and 57.8 per 100,000
respectively.ibid However, these rates are for the general
population, not children specifically.
Otitis media
Rates for ear infections or problems are elevated for
Inuit10 (See Figure 26).
Dallaire et al. (2004) recruited a sample of Inuit
infants in Nunavik to participate in a prospective
cohort study.55 All Inuit infants born in Nunavik
between November 1995 and March 2001 were eligible
to participate. The researchers reported that there were
417 pregnancies in the identified communities during
the study period. They reported that 96% of infants had
at least one episode of otitis media.
In a follow-up study completed by Dallaire et al.
(2006), they reported on the sample group of infants
who were now preschoolers.56 The recruited sample
represented 75% of infants born in Nunavik during
the study period. Medical charts were reviewed for
diagnoses of infection over the first 5 years of the
infants’ lives. The cumulative incidence, which is the
percentage of children with one or more episodes
before age five, was 95% for acute otitis media.
Environmental contaminants remain a significant
health risk for Inuit living in the north (see below).
Researchers have also identified an association between
otitis media in infants and exposure to Polychlorinated
Biphenyls (PCB). In one study, infants who had
experienced one or more acute otitis media infections
Health of Indigenous Children: Health Assessment in Action
37
had higher prenatal exposures to PCBs (based on cord
blood) than healthy infants.55
The impact of ear infections on hearing, learning
and language ability remains poorly understood among
Inuit infants and children.
Bronchitis and respiratory tract infection
In one study, all Inuit infants born in Nunavik between
November 1995 and March 2001 were recruited
to participate in a prospective cohort study.55 The
researchers reported that there were 417 pregnancies
in the identified communities during the study period.
They found that 90% had at least one episode of upper
respiratory tract infection and 73.4% had at least one
episode of lower respiratory tract infection.
In a follow-up study, they reported on the sample
group of infants who were now preschoolers.56 The
recruited sample represented 75% of infants born
in Nunavik during the study period. Medical charts
were reviewed for diagnoses of infection over the
first five years of the infants’ lives. The cumulative
incidence, which is the percentage of children with one
or more episodes before five years of age was 97% for
upper respiratory tract infections and 83% for lower
respiratory tract infections.
A prospective case study found a hospital admission
rate for bronchiolitis of 484 per 1,000 infants of less
than six months of age at the Baffin Regional Hospital,
which services Iqaluit and ten smaller communities
in Nunavut. This is the highest reported rate of
hospitalization for respiratory tract infections in
the world.57
Inadequate housing conditions, including poor
ventilation and crowding, directly contribute to the
elevated rates of respiratory tract infections.42
With the exception of TB (below) national,
provincial and territorial hospitalization and mortality
rates for childhood respiratory tract infection are
noticeably absent.
Tuberculosis
Nguyen et al. (2003) analyzed data on tuberculosis
cases in 14 Inuit communities in Nunavik, representing
90% of the total Inuit population in Nunavik.58 Between
1990 and 2000, the incidence rate decreased to a low
of 3.7 per 100,000 in 2000. According to the Public
Health Agency of Canada, the rate for 2002 was 93.4
per 100,000 for Nunavut.59 It should be noted that
these rates are not specific for children. The incidence
rate for new and relapsed cases in 2000 for the general
Canadian population was 5.2 per 100,000.59
Tuberculosis has been linked to health determinants
including crowded housing and living in remote areas
38
Health of Indigenous Children: Health Assessment in Action where access to medical professionals is more difficult,
which are significant factors for Inuit.43
HIV
There are no sources of data for children specifically,
and sources for the population in general are not
comprehensively reported. For example, statistics
reported for Nunavut do not include positive tests for
anonymous individuals. According to the Nunavut
Comparable Health Indicators Report of 2004, no new
cases were reported between 1995 and 2001 and up to
five cases were reported in 2002 and 2003 combined.52
Again, these reports are not specific to Inuit children.
Chronic disease
Chronic disease affects approximately one in three Inuit
children (See Figures 27 and 28).7
Obesity
The standard measures used to calculate obesity in
Inuit have been called into question. One study found
that Inuit have shorter legs, yet relatively higher sitting
heights when compared to all other populations.60
Thus, their BMI would be disproportionately higher,
solely as a result of their shorter legs. Consequently, the
incidence of obesity would be overestimated as a result
of the invalid BMI measurement. It has been suggested
that for Inuit, high BMI may not be indicative of
obesity and that calculating BMI using sitting height
would provide a more valid estimate of obesity.
At present, national, provincial or territorial rates
were not identified for obesity or overweight.
Diabetes
No national, provincial or territorial rates identified.
Physical activity
According to the Aboriginal Children’s Survey 2006,
70% of Inuit children (aged six to 14 years) played
sports one or more times a week.10 No comparable rate
was identified for the Canadian population.
Asthma
Rates of asthma for Inuit children are lower than the
rate for Canadian children (See Figure 30).10,27
Allergies
Rates of allergies were slightly lower for Inuit children,
as compared to the rate for Canadian children (see
Figure 31).10,27
Cancer
No national, provincial or territorial rates identified.
Health of First Nations, Inuit, and Métis Children in Canada
Environmental contaminants remain
a significant health risk for Inuit
living in the north
Heart condition
The rate of heart conditions for Inuit children was
higher than the rates for First Nations and Métis
children (See Figure 32).10
Child development and disability.
Disabilities
Rates for activity limitations for Inuit children were higher
than rates for the Canadian population (see Figure 33).10,27
Rates of hearing impairment are higher for Inuit, as
compared to other Aboriginal children (See Figure 34).10
As mentioned previously, this might be the consequence
of elevated rates of chronic otitis media or ear infections
amongst Inuit children. As noted for First Nations
children, the impact of visual and hearing impairments
on learning for Inuit children remains unclear.
Attention deficit hyperactivity disorder (ADHD)
No national, provincial or territorial rates identified.
Learning disorders
According to the APS 2001, it is estimated that 4% of Inuit
children have a learning disability. Note that this statistic
is flagged and should be interpreted with caution.8
Language and Cultural Engagement
Rates of Aboriginal language comprehension and ability
to speak were generally high for Inuit (See Figure 35).10
This is likely linked to high fluency rates among Inuit
adults, as well as high rates of student exposure to
Aboriginal teachers.
According to the Aboriginal Children’s Survey
(2006), 65% Inuit children (aged five and under) had
someone help them understand Aboriginal culture
and history.10 No rates were reported on who helped
them understand.
Injuries
Rates of injury for Inuit were comparable to those of
Canadian children (See Figure 36).10
Health of First Nations, Inuit, and Métis Children in Canada Smoking, alcohol, and drug use
There is very little information on alcohol and drug use
for children less than 14 years old. According to the
Nunavut Comparable Health Indicators Report (2004),
in 2001, 56% of current smokers were children and youth
aged 12 to 19 years.52 This is substantially higher than the
rate for the general Canadian population (14.8%).
Mental health
No national, provincial or territorial rates for
socioemotional problems, depression, and suicide were
identified for Inuit children. Suicide data sets, that did
not include children under the age of 12, were excluded.
Dental health
Rates of dental problems were elevated for Inuit
compared to other Aboriginal children. The rates of
dental treatment were somewhat lower (for older Inuit)
compared to other Aboriginal children and the Canadian
population (See Figures 37 and 38).10,25,27 This suggests
deficiencies in the delivery of dental care services.
Environmental exposures
Multiple small studies have been conducted that
examine prenatal exposures to environmental
contaminants such as lead, environmental
contaminants such as organochlorines including DDT,
HCB, and PCBs, DDE. These studies have examined
cord blood measures among Inuit living in Nunavik
and Nunavut.55,61,62 Elevated levels of mercury were
found in the cord blood of infants from Nunavik
and Nunavut. Elevated levels of lead were found in
Nunavik and Nunavut. Elevated levels of cadmium
were found in cord blood in all regions. Infants
exposed to the highest levels of PCBs and DDE in
Nunavik had the most infections, as compared to
infants exposed to the lowest levels of PCBs and DDE.
Elevated levels of organochlorines were associated with
higher rate of infections during the first six months of
infants’ lives. Studies in the 1980s and 1990s conducted
in villages in northern Quebec found that Inuit
Health of Indigenous Children: Health Assessment in Action
39
mothers’ breast milk had five to six times the amount
of PCBs, PCDDs, and PCDFs, when compared to
breast milk of mothers living in southern Quebec.63,64
The authors suggested that the increased levels of PCBs
were the result of high consumption of fish and sea
mammals among Inuit women.
In a small community-based study in Nunavut,
Kovesi et al. (2006) found that exposure to second hand
smoke and reduced air exchange, as a result of the small
size of the dwellings, were linked to lower respiratory
tract infection.65 They found that 90% of households
had smokers present.
Also, recall that housing conditions and water quality
for some Inuit children and their families is substandard
(see Additional social determinants section).
40
Health of Indigenous Children: Health Assessment in Action Access to health care
Rates for accessing a family doctor, general practitioner
or pediatrician were considerably lower for Inuit, as
compared to other Aboriginal children (See Figure 39 and
41).10 Rates of access to care for the Canadian population
were considerably higher. Despite this fact, perceptions
of health care facilities among Inuit were consistent with
other Aboriginal populations (See Figure 40).10
The reasons for this are unclear. Additional data
on interactions, proximity to health care facilities, and
quality of health care are necessary to understand the
health care experience of Inuit children and their families.
The discrepancy between access to health care
providers and perceptions of health care facilities is
interesting. It may be related to the fact that nurses
are providing care to Inuit children at local nursing
stations, where there are no resident doctors.
Health of First Nations, Inuit, and Métis Children in Canada
Métis Section Highlights
• Despite accounting for 33% of the Aboriginal population there is currently no information available
on infant mortality rates for Métis populations.
• In 2006, rates for breastfeeding initiation and sustained breastfeeding at six months were 74% and
51% respectively for Métis children aged five years or less.
• 42% of Métis children aged six to 14 years had one or more severed chronic health conditions in 2006.
• 28% of Métis children aged five years or less had a long-term health condition diagnosed by a health
professional in 2006.
• In 2006, 9% of Métis children aged six to 14 years were diagnosed with an ear infection or ear problem.
• In 2006,13% of Métis children aged five years or less were diagnosed with asthma or used a
puffer/inhaler.
• In 2006, 19% of Métis children aged six to 14 years were diagnosed with allergies.
• In 2006, 10% of Métis children aged five years or less could speak or understand an Aboriginal
language; the rate was 7% for Métis children aged six to 14 years.
• In 2006, 18% of Métis children aged six to 14 years suffered from one or more activity limitations.
• In 2006, 12% of Métis children aged six to 14 years experienced an injury in the past 12 months.
• 81% of Métis children aged five years or less and 54% of children aged six to 14 years had seen a
family doctor, general practitioner or pediatrician in 2006.
III. Métis
Refer to the end of this section (v. Figures) for
children's health status figures.
Self-rated health
The measure of ‘self-rated’ health has yet to be
validated in Aboriginal communities, and in general
is considered problematic in the field of population
health.28 For example, individuals may rate their
health in comparison to others. Thus, their perception
of their own health is a relative comparison, and
if the absolute level of health of a group is low, the
perception will not accurately reflect a true measure
of health. Results from the Aboriginal Children’s
Survey (2006) found that nearly all Métis children are
described as having ‘good,’ ‘very good,’ or ‘excellent’
health (See Figure 21), which is comparable to the rate
for the Canadian population.10,25,27
Infant mortality and perinatal health outcomes
This section covers infant mortality, birth weight,
preterm birth, breastfeeding, sudden infant death
syndrome (SIDS), and fetal alcohol spectrum
disorder (FASD).
Infant mortality rate
There is currently no information on infant mortality
rates for Métis populations in Canada. Métis currently
account for 33% of the total Aboriginal population in
Health of First Nations, Inuit, and Métis Children in Canada Canada and number just under 400,000 persons.2 The
census socio-demographic profile of this population
indicates that this is a population that would be at risk
for a disproportionate burden of infant mortality and
morbidity.4,6,9
Birth weight
The rate of low birth weight was slightly higher for
Métis infants compared to the Canadian population,
as was the rate of high birthweight (see Figure 22).10,27
Preterm birth
No national, provincial or territorial rates identified
for Métis.
Breastfeeding
Rates of breastfeeding initiation for Métis were
comparable to the rate for the Canadian population.
However, rates of sustained breastfeeding (at six
months in particular) were higher than the rate for
the Canadian population (See Figures 23, 24, and
25).10,27 As mentioned in both the First Nations and
Inuit sections, this suggests that mothers may be
receiving ongoing support from within their family
which explains higher rates of sustained breastfeeding.
Sudden infant death syndrome (SIDS)
No national, provincial or territorial rates identified
for Métis.
Health of Indigenous Children: Health Assessment in Action
41
Fetal alcohol spectrum disorder (FASD)
No national, provincial or territorial rates identified
for Métis.
Nutrition
According to the APS 2001, 87% of Métis children
(aged six to 14) had breakfast five to seven days a week.7
Heart condition
The rate of heart conditions for Métis children was
similar to that of First Nations children and lower than
that of Inuit children (See Figure 32).10
Other chronic conditions
No national, provincial or territorial rates were
identified for obesity, diabetes, or cancer.
Infectious diseases
Child development and disability
Immunization and immunization
preventable diseases
No national, provincial or territorial rates were
identified for immunization against preventable
childhood infections (measles, mumps, rubella,
haemophilus influenza, diphtheria, polio, tetanus,
pertussus, pneumococcus, varicella zoster).
Otitis media
Rates for ear infections were comparable to other
Aboriginal populations (See Figure 26).10,27 At present,
we do not have a comparison for the Canadian or nonAboriginal population.
Other infectious diseases
No national, provincial or territorial rates for
bronchitis, respiratory tract infection, tuberculosis or
HIV were identified for Métis children.
Chronic disease
Rates for chronic disease for Métis children are
comparable to those of First Nations and Inuit (See
Figures 27 and 28).10
Physical activity
According to the Aboriginal Children’s Survey 2006,
70% of Métis children (aged six to 14 years) played
sports one or more times a week.10 No comparable
rate was identified for the Canadian or nonAboriginal population.
42
Disabilities
Rates of activity limitations for Métis children were
higher than the rate for the Canadian children (see
Figure 33).10
Rates for hearing impairments were much lower than
rates for visual impairments (See Figure 32).8 As noted
in the First Nations section, it is unclear how many
Métis children have access to proper eye care, which is
concerning given the high rates of visual impairments.
Additionally, the impact of visual impairments on
children’s learning and development remains unclear.
Attention deficit hyperactivity disorder
No national, provincial or territorial rates identified.
Learning disorders
According to the APS 2001, it is estimated that 8% of
Métis children have a learning disability. Note that this
statistic is to be interpreted with caution.7
Language and Cultural Engagement
Rates of Aboriginal language comprehension and
ability to speak were low for Métis children (see Figure
35).10 This may reflect the distinct multilingual (Michif,
French, English) language heritage of the Métis.
According to the Aboriginal Children’s Survey
(2006), 31% of Métis children (aged five and under)
had someone who helped them understand Aboriginal
culture and history. Most were helped by their parents
(56%) and their grandparents (46%).10
Asthma
Rates of asthma for Métis children were comparable to
other Aboriginal populations (See Figure 30),10,27 and
comparable to the rate for Canadian children.
Injuries
Rates of injuries were similar for Métis as compared to
the Canadian population (See Figure 36).10
Allergies
Rates of allergies were generally comparable for Métis
children, as compared to the rate for Canadian children
(see Figure 31).10,27
Smoking, alcohol, and drug use
In general, there is very little information on smoking,
alcohol, and drug use for children less than 14 years old.
No national, provincial or territorial rates were identified.
Health of Indigenous Children: Health Assessment in Action Health of First Nations, Inuit, and Métis Children in Canada
Mental health
No national, provincial or territorial rates of socioemotional
problems, depression, and suicide were identified.
Dental health
Rates of dental problems were lower for young Métis
children and comparable for older Métis children,
as compared to other Aboriginal populations and
the Canadian population (See Figure 37).10 Access to
dental care was also comparable to other Aboriginal
populations (See Figure 38).10
Environmental exposures
In a comprehensive review of environmental
contaminants, van Oostdam et al. (2005) found
that Métis in the north had elevated levels of lead in
maternal cord blood.61
Also, recall that housing conditions and water
quality for some Métis children and their families is
substandard (see Additional social determinants section).
Access to health care
Rates for accessing a family doctor, general
practitioner or pediatrician were similar for Métis
children, as compared to other Aboriginal children
(See Figures 39 and 41).10 Rates of access to care for
the Canadian population were comparable. Rates for
accessing a traditional Aboriginal healer were low
for Métis (See Figure 41).10 Ratings of health care
facilities as excellent or very good were comparable
to those of other Aboriginal children (See Figure
40).10 As mentioned in the First Nations section,
additional data on interactions, proximity to health
care facilities, and quality of health care are necessary
to understand the heath care experience of Métis
children and their famlies.
IV. Information Gaps
There are large gaps in the health information available
for First Nations, Inuit, and Métis children living
in Canada. Most notably, there is very little vital
registration (infant mortality and disease specific
mortality) and health care utilization data (including
hospitalization data) at all levels of aggregation. There
is very little data for Métis and non-status First Nations
children, as well as Aboriginal children living in urban
areas. There is almost no data regarding the prevalence
of immunization preventable childhood diseases,
immunization rates, obesity, diabetes, cancer, and most
mental health indices. Progress continues to be made
Health of First Nations, Inuit, and Métis Children in Canada in the collection of survey data. For example, the First
Nations Regional Longitudinal Health Survey 08–09
is collecting immunization data. However, survey
data is a complement to, not a replacement of, vital
registration and health care utilization data.
Health care access data is limited to medical
and dental health care professionals, little is known
about accessing specialists for eye sight and hearing,
particularly important given the high rates of
vision and hearing impairment. In addition, little
information exists on accessing mental health
professionals, including clinical psychologists,
psychiatrists, and social workers. Furthermore, no
information exists on the quality of interactions with
health care professionals, and experiences with the
healthcare system.
Other challenges include existing data sets that
focus on disease and illness outcomes rather than
preventative and wellness measures; a paucity of
culturally relevant Indigenous specific measures; and
the need for validation of many existing measures and
scales (such as self-rated health and developmental/
psychological indices) in Aboriginal cultural contexts.
Again, the First Nations Regional Longitudinal
Health Survey is exemplary and unique in it focus on
preventative and wellness measure and application of a
cultural framework.
Canada’s child health measurement gaps are
particularly evident when Canada’s Aboriginal child
health surveillance is compared to the systems in
Australia, New Zealand and the United States. All three
of these countries have superior systems, particularly
with respect to core measures such as mortality and
health care utilization. These deficiencies in Canada’s
Aboriginal child health assessment system represent
a missed opportunity to address the health status
inequities experienced by Aboriginal children in
Canada, compared to the rest of Canadian children.
Over the past several years the First Nations Regional
Longitudinal Health Survey has been the only
comprehensive source of First Nations on-reserve
children’s health survey data. Recent federal initiatives
to improve the availability of Aboriginal children’s
health information include the initiation of the
Aboriginal Children’s Survey, which released its first
dataset in December 2008.
Health of Indigenous Children: Health Assessment in Action
43
V. Figures
100%
Children <6yrs old (ACS 2006)
Children <6yrs old (NLSCY 2006/7)
Children 6-14yrs old (ACS 2006)
Children 6-14yrs old (NLSCY 2001/2)
96%
96%
97%
97%
96%
97%
95%
97%
99%
98%
80%
60%
40%
Figure 21
Children's Self-Rated Health
(good, very good
or excellent)
20%
0%
First Nations
with status or treaty
(off-reserve)
Source: ACS 2006, NLSCY 2001/2,
NLSCY 2006/7
Figure 22a
Low Birthweight
First Nations
without status or treaty
(off-reserve)
Children 6-14yrs old (ACS 2006)
Inuit
Métis
Canadian
population
Children 6-14yrs old (NLSCY 2000/1)
Children <12yrs old (RHS 2002/3)
10%
Source: ACS 2006, RHS 2002/3,
NLSCY 2000/1
8.0%
7.0%
7.0%
6.0%
6.0%
5.5%
5%
0%
First Nations
with status or treaty
(off-reserve)
44
Health of Indigenous Children: Health Assessment in Action First Nations
without status or treaty
(off-reserve)
First Nations
(on-reserve)
Inuit
Métis
Canadian
population
Health of First Nations, Inuit, and Métis Children in Canada
Children <6yrs old (ACS 2006)
Children (NLSCY 2000/1)
Children <12yrs old (RHS 2002/3)
25%
21%
20%
18%
15%
15%
15%
13%
11%
10%
5%
0%
First Nations
with status or treaty
(off-reserve)
First Nations
without status or treaty
(off-reserve)
Children <6yrs old (ACS 2006)
First Nations
(on-reserve)
Inuit
Métis
Canadian
population
90%
80%
80%
70%
74%
74%
69%
63%
Source: ACS 2006, RHS 2002/3,
NLSCY 2000/1
Figure 23
Breastfeeding Initiation
Children (NLSCY 2000/1)
Children <12yrs old (RHS 2002/3)
Figure 22b
High Birthweight
Source: ACS 2006, RHS 2002/3,
NLSCY 2000/1
66%
60%
50%
40%
30%
20%
10%
0%
First Nations
with status or treaty
(off-reserve)
First Nations
without status or treaty
(off-reserve)
First Nations
(on-reserve)
Health of First Nations, Inuit, and Métis Children in Canada Inuit
Métis
Canadian
population
Health of Indigenous Children: Health Assessment in Action
45
70%
63%
61%
60%
60%
56%
50%
40%
30%
20%
10%
Figure 24
Sustained Breastfeeding
(at 4 months)
0%
Source: ACS 2006
Figure 25
Sustained Breastfeeding
(at 6 months)
Source: ACS 2006, RHS 2002/3,
NLSCY 2000/1
First Nations
without status or treaty
(off-reserve)
First Nations
with status or treaty
(off-reserve)
Children <6yrs old (ACS 2006)
Inuit
Métis
Children (NLSCY 2000/1)
Children <12yrs old (RHS 2002/3)
60%
54%
52%
50%
51%
48%
43%
40%
34%
30%
20%
10%
0%
First Nations
with status or treaty
(off-reserve)
46
Health of Indigenous Children: Health Assessment in Action First Nations
without status or treaty
(off-reserve)
First Nations
(on-reserve)
Inuit
Métis
Canadian
population
Health of First Nations, Inuit, and Métis Children in Canada
Children 6-14yrs old (ACS 2006)
Children <12yrs old (RHS 2002/3)
16%
15%
14%
12%
10%
9%
9%
9%
8%
8%
6%
4%
2%
0%
First Nations
with status or treaty
(off-reserve)
First Nations
without status or treaty
(off-reserve)
First Nations
(on-reserve)
Inuit
Métis
Note: The ACS asked about ear infection or problem diagnosed by a health professional, whereas the RHS asked about otitis media.
Source: ACS 2006, RHS 2002/3
35%
30%
30%
28%
28%
Figure 26
Ear Problems / Infections
28%
Figure 27
Any Chronic Disease for
Young Children
(aged 5 & under)
Source: ACS 2006
25%
20%
15%
10%
5%
0%
First Nations
with status or treaty
(on/off-reserve)
First Nations
without status or treaty
(on/off-reserve)
Inuit
Métis
Note: The ACS asked about long-term health condition diagnosed by a health professional.
Health of First Nations, Inuit, and Métis Children in Canada Health of Indigenous Children: Health Assessment in Action
47
50%
45%
42%
42%
40%
33%
30%
20%
10%
Figure 28
Any Chronic Disease for
Children (aged 6 to 14)
Source: ACS 2006
Figure 29
Overweight & Obesity
0%
First Nations
without status or treaty
(off-reserve)
First Nations
with status or treaty
(off-reserve)
Inuit
Métis
Note: The ACS asked about one more severe chronic conditions diagnosed by a health professional.
First Nations children <12yrs old (RHS 2002/3)
Canadian children (CCHS)
40%
36%
Source: RHS 2002/3, CCHS 2004
35%
30%
26%
25%
22%
20%
15%
10%
8%
5%
0%
Overweight
Obesity
Note: The CCHS excludes on-reserve First Nations populations and Inuit populations living in the territories. The RHS included children aged 11 and under,
whereas the CCHS included children age 2 to 17 years.
48
Health of Indigenous Children: Health Assessment in Action Health of First Nations, Inuit, and Métis Children in Canada
Children <6yrs old (ACS 2006)
Children (NLSCY 2000/1)
Children 6-14yrs old (ACS 2006)
Children <12yrs old (RHS 2002/3)
20%
16%
16%
15%
15%
15%
14%
14%
13%
12%
11%
10%
7%
5%
0%
First Nations
with status or treaty
(off-reserve)
First Nations
without status or treaty
(off-reserve)
First Nations
(on-reserve)
Inuit
Métis
Canadian
population
Note: Note. The ACS (younger children) asked about asthma or inhaler/puffer use; the ACS (older children) and the NLSCY asked about asthma.
Children 6-14yrs old (ACS 2006)
Source: ACS 2006, RHS 2002/3,
NLSCY 2000/1
Figure 31
Allergies
Children 6-14yrs old (NLSCY 2000/1)
Children <12yrs old (RHS 2002/3)
Figure 30
Asthma
25%
Source: ACS 2006, RHS 2002/3
22%
20%
19%
18%
15%
15%
12%
10%
10%
5%
0%
First Nations
with status or treaty
(off-reserve)
First Nations
without status or treaty
(off-reserve)
First Nations
(on-reserve)
Health of First Nations, Inuit, and Métis Children in Canada Inuit
Métis
Canadian
population
Health of Indigenous Children: Health Assessment in Action
49
Children 6-14yrs old (ACS 2006)
Children <12yrs old (RHS 2002/3)
3.5%
3.0%
3.0%
2.5%
2.1%
2.0%
2.0%
First Nations
with status or treaty
(off-reserve)
First Nations
without status or treaty
(off-reserve)
2.0%
2.0%
1.5%
1.0%
0.5%
0.0%
Figure 32
Heart Condition
Source: ACS 2006, RHS 2002/3
Figure 33
Activity Limitation
First Nations
(on-reserve)
Inuit
Métis
Note: Inuit statistic is flagged (interpret with caution).
Children 6-14yrs old (ACS 2006)
Children 6-14yrs old (NLSCY 2000/1)
Children <12yrs old (RHS 2002/3)
25%
Source: ACS 2006, RHS 2002/3,
NLSCY 2000/1
22.0%
20%
18.0%
18.0%
17.0%
15%
10%
8.6%
8.1%
5%
0%
First Nations
with status or treaty
(off-reserve)
First Nations
without status or treaty
(off-reserve)
First Nations
(on-reserve)
Inuit
Métis
Canadian
population
Note: The RHS asked 'presence of a physical, mental condition or health problem which reduces the amount or the kind of activity'. The ACS and the NLSCY
asked about in general if physical activity was limited.
50
Health of Indigenous Children: Health Assessment in Action Health of First Nations, Inuit, and Métis Children in Canada
Children 6-14yrs old (ACS 2006)
Children <12yrs old (RHS 2002/3)
8%
6.0%
6%
4%
3.0%
3.0%
3.0%
2%
1.6%
0%
First Nations
with status or treaty
(off-reserve)
First Nations
without status or treaty
(off-reserve)
First Nations
(on-reserve)
Inuit
Métis
Figure 34a
Hearing Impairments
Note: The ACS asked about vision impairments and the RHS asked about blindness or vision problems.
Children 6-14yrs old (ACS 2006)
Source: ACS 2006, RHS 2002/3
Figure 34b
Vision Impairments
Children <12yrs old (RHS 2002/3)
12%
11.0%
11.0%
11.0%
Source: ACS 2006, RHS 2002/3
10%
8%
6%
5.0%
4%
2%
1.1%
0%
First Nations
with status or treaty
(off-reserve)
First Nations
without status or treaty
(off-reserve)
First Nations
(on-reserve)
Inuit
Métis
Note: The ACS asked about vision impairments and the RHS asked about blindness or vision problems.
Health of First Nations, Inuit, and Métis Children in Canada Health of Indigenous Children: Health Assessment in Action
51
Children <6yrs old (ACS 2006)
Children 6-14yrs old (ACS 2006)
Children <12yrs old (RHS 2002/3)
80%
72%
70%
60%
48%
50%
40%
30%
25%
25%
25%
20%
9%
10%
10%
7%
6%
0%
Figure 35
Fluency in
Aboriginal Language
Source: ACS 2006, RHS 2002/3
Figure 36
Injuries
First Nations
with status or treaty
(off-reserve)
First Nations
without status or treaty
(off-reserve)
First Nations
(on-reserve)
Inuit
Métis
Note: The ACS asked about ability to understand or speak, whereas the RHS asked separate questions for ability to understand (25%) and ability to speak
(19%) relatively well.
Children 6-14yrs old (ACS 2006)
Children (NLSCY 2000/1)
Children <12yrs old (RHS 2002/3)
20%
18%
Source: ACS 2006, RHS 2002/3,
NLSCY 2000/1
15%
12%
11%
11%
10%
10%
9%
5%
0%
First Nations
with status or treaty
(off-reserve)
52
Health of Indigenous Children: Health Assessment in Action First Nations
without status or treaty
(off-reserve)
First Nations
(on-reserve)
Inuit
Métis
Canadian
population
Health of First Nations, Inuit, and Métis Children in Canada
35%
Preschool Children (RHS 2002/3)
Children <6yrs old (ACS 2006)
31%
29%
30%
24%
25%
20%
15%
15%
13%
10%
5%
0%
First Nations
with status or treaty
(off-reserve)
First Nations
without status or treaty
(off-reserve)
First Nations
(on-reserve)
Inuit
Métis
Figure 37
Dental Problems
Note: The ACS asked about dental problems, whereas the RHS asked about dental caries in children 3-5 years).
Source: ACS 2006, RHS 2002/3
Children <6yrs old (ACS 2006)
Preschool Children on-reserve (RHS 2002/3)
Children <6yrs old (NLSCY 2006/7)
Children 6-14yrs old (ACS 2006)
Children <12yrs old (RHS 2002/3)
Children 6-14yrs old (NLSCY 2000/1)
100%
Figure 38
Access to Dental Care
Source: ACS 2006, RHS 2002/3,
NLSCY 2000/1, NLSCY 2006/7
88%
83%
81%
82%
80%
67%
69%
63%
60%
44%
41%
40%
36%
40%
35%
20%
0%
First Nations
with status or treaty
(off-reserve)
First Nations
without status or treaty
(off-reserve)
First Nations
(on-reserve)
Inuit
Métis
Canadian
population
Note: The ACS asked about access to dentist, dental therapise, or orthodontist; whereas the RHS asked about treatment for dental caries in preschool
children and dental care for all children.
Health of First Nations, Inuit, and Métis Children in Canada Health of Indigenous Children: Health Assessment in Action
53
100%
Unable to obtain health care or mediation
Seen family doctor, general practitioner, or pediatrician
83%
80%
88%
81%
80%
60%
53%
40%
20%
12%
8%
Figure 39
Access to Medical Care for
Children Under 6 years old
Source: ACS 2006
7%
0%
First Nations
without status or treaty
(off-reserve)
First Nations
with status or treaty
(off-reserve)
Source: ACS 2006, NLSCY 2006/7
Figure 40
Perceptions of
Health Care Facilities
8%
60%
50%
Excellent or Very Good
Good
Inuit
Canadian population
(NLSCY 2006/7)
Fair or Poor
48%
47%
45%
Métis
45%
40%
32%
32%
30%
30%
20%
20%
19%
20%
10%
0%
First Nations
with status or treaty
(off-reserve)
First Nations
without status or treaty
(off-reserve)
Inuit
Métis
Note: The ACS Métis section is pending, thus there is missing data.
54
Health of Indigenous Children: Health Assessment in Action Health of First Nations, Inuit, and Métis Children in Canada
70%
Seen family doctor, general practitioner, or pediatrician
60%
Seen traditional Aboriginal healer
59%
55%
54%
50%
40%
35%
30%
20%
10%
8%
4%
2%
1%
0%
First Nations
with status or treaty
(off-reserve)
First Nations
without status or treaty
(off-reserve)
Inuit
Note: Statistics for traditional Aboriginal healer for Inuit is flagged (should be interpreted with caution).
Health of First Nations, Inuit, and Métis Children in Canada Métis
Figure 41
Access to Medical Care for
Children 6 to 14 years old
(ACS 2006)
Source: ACS 2006
Health of Indigenous Children: Health Assessment in Action
55
2.8 Best Practice and Promising
Practice Examples
I. The First Nations Regional Longitudinal
Health Survey
The First Nations Regional Longitudinal Health Survey
is the only First Nations governed national health
survey in Canada.66 It is also the only national survey
data for the First Nation on-reserve populations.
The report of the First Nations Regional
Longitudinal Health Survey (RHS) 2002/2003 was
released in Fall 2005 and contains information from
over 30 topic areas, including demographics, language,
housing, health status, culture, and community
development. It builds on the 1997 First Nations and
Inuit Regional Health Survey, which included five
Labrador Inuit communities and 181 First Nations
communities. The RHS 2002/3 collected 22,602 surveys
from 238 First Nations communities across the country.
Data collection is currently underway for RHS Phase 2
(2008/2009).
The purpose of the RHS is to obtain longitudinal,
comparable data that is centered around First
Nations conceptualizations of health, is controlled by
First Nations, reflects the priorities of First Nations
communities, and respects the principles of OCAP (the
56
Health of Indigenous Children: Health Assessment in Action right of Indigenous people to Own, Control, Access
and Possess Indigenous health information). The
RHS collects information based on both Western and
traditional understandings of health and wellbeing. The
RHS survey fills a gap left by large national population
based surveys which exclude sampling from reserves.
Furthermore, in contrast to the RHS, the majority
of national population based surveys do not provide
respondents an opportunity to self-identify their
Aboriginal ethnicity, thereby failing to generate any
Indigenous-specific health information.
In addition to its progressive First Nations
controlled governance structure, and its broad scope
of both Western and traditional health measures, the
RHS is an excellent example of health measurement
with respect to community engagement and capacity
building. See the RHS website for more info:
http://www.rhs-ers.ca/english/
II. Inuit Health Survey
‘Qanuippitali?’ <How about us? How are we?>
represents the first comprehensive examination
of the health of Inuit residing in Nunavut, the
Inuvialuit settlement region, and Nuntsiavut. This
Inuit Health Survey is based on a collaboration of
partners from the north and the south, including
Health of First Nations, Inuit, and Métis Children in Canada
academic researchers, communities and health
departments. The survey has been developed through
a participatory partnership and is co-owned, with the
ultimate plan for the survey to be owned in the longterm by Inuit and community representatives. The
mission is to improve health care planning, personal
health, and community wellness for Inuit. The project
is funded by the Government of Canada, Federal
Program for International Polar Year, Canadian
Institutes of Health Research, Health Canada, Indian
and Northern Affairs, the Government of Nunavut
and ArcticNet.
The Inuit Health Survey for children ages three to
five relies on interviews, questionnaires, and a clinical
appointment with health care professionals. Children and
their caregivers will be seen in their home communities.
The child health survey data collection started in 2007
and concluded in fall 2008 (after 15 months of data
collection). Health data will be collected on:
• Nutritional health: levels of vitamin D and iron;
exposure to mercury and bacteria (H. pylon which
causes iron deficiency); traditional food use and
general eating habits (including early infant feeding)
• Healthy growth and bones: heel ultrasound for bone
density, height, weight, vitamin and supplements,
medication usage
• Vision testing
• Medical History
In total, approximately 12% of Inuit from
communities in the three regions will be randomly
selected to participate. Following data collection, all
child participants will receive their personal results in
the mail. Communities will receive information on the
health of their residents, as well as the areas of focus for
health promotion.
III. Infant Mortality Working Group
The Canadian Perinatal Surveillance System, Health
Information Analysis Division – First Nations and
Inuit Health Branch, Inuit Tapiriit Kanatami, and
Métis National Council Joint Working Group on
First Nations, Inuit, and Métis Infant Mortality Data
(also known as the Joint Working Group on Infant
Mortality) was formed in 2005 in response to problems
in the accuracy of publically released First Nations
infant mortality data, as well as major deficits in
the coverage and quality of infant mortality data for
Aboriginal populations in Canada. Infant mortality
rates are only available for subgroups of the First
Nations and Inuit population in Canada. No rates are
available for Métis. The infant mortality data that is
available is often of substandard quality. For example,
problems with the accuracy of several publicly released
Health of First Nations, Inuit, and Métis Children in Canada infant mortality rates for First Nations populations
have been identified by members of our group. These
deficits of coverage and quality interfere with the efforts
of public health workers to identify and respond to
conditions leading to infant death and are unacceptable
in a developed country such as Canada. As a working
group, the primary goal is to improve the accuracy,
reliability, coverage, and appropriateness of First
Nations, Inuit, and Métis infant mortality data.
The Joint Working Group approach is premised on
the understanding that improvement to First Nations,
Inuit, and Métis infant mortality data can only be
done through partnerships with First Nations, Inuit
and Métis governing and representative organizations.
Members include representatives from national
Aboriginal governance groups, including the Congress
of Aboriginal Peoples, Inuit Tapiriit Kanatami, Métis
National Council, and the Native Women’s Association
of Canada, as well as representatives from the Canadian
Perinatal Surveillance System - Public Health Agency
of Canada, First Nations and Inuit Health Branch
– Health Canada, Statistics Canada, and the Vital
Statistics Council of Canada. The Joint Working
Group also maintains regular communication with the
Assembly of First Nations.
This initiative has a multi-pronged approach to the
improvement of First Nations, Inuit, and Métis infant
mortality data. This includes: supporting the liaison
between provincial and territorial vital registrars and
First Nations, Inuit, and Métis stakeholders groups
in their region, to develop joint data governance and
management agreements, if these do not already exist;
support for the First Nations client registry pilots;
and discussion of an improved and formulation
of a standardized question regarding Aboriginal
ethnicity that would accurately identify First Nations,
Inuit, and Métis infants and their parents on vital
registration forms.
Key achievements to data include: annual
presentations to the provincial and territorial vital
registrars; a review of First Nations, Inuit, and Métis
infant mortality data practices in all provinces and
territories; agreement on a draft Aboriginal ethnicity
question that could be used by provincial/territorial
registrars on the birth registration; funding of two
regional pilot projects to support regional planning,
consultation, and liaison process and to improve
regional First Nations, Inuit and/or Métis infant
mortality rates; briefings regarding IMR data to
regional and national level First Nations, Inuit, and
Métis stakeholders; and the preparation of a national
statement on First Nations, Inuit, and Métis Infant
Mortality Rates.
Health of Indigenous Children: Health Assessment in Action
57
IV. Kahnawake School Diabetes
Prevention Project (KSDPP)
Kahnawake is a Mohawk territory near Montreal,
Quebec, with a population of 7000. In the 1980s,
physicians documented high rates of Type 2 diabetes
and the community responded by requesting help to
prevent future generations from developing diabetes.
The community took action in partnership with
academic researchers and developed a prevention
program focused on elementary school children,
their families, and the community. KSDPP began in
1994 and continues to date. The goal is to decrease
the onset of Type 2 diabetes in Kahnawake, through
the promotion of health eating, physical activity and a
positive attitude.
Most recently, community workers were
disheartened to see that obesity rates were elevated
in children starting nursery school and kindergarten.
Discussions at the Community Advisory Board
meetings lead to focus activities geared towards
young mothers. This resulted in the refinement of a
yearly calendar of eating habits according to the foods
on a seasonal level and cooking workshops which
focus on young mothers making meals for the family,
as well as foods which can be put into a blender to
be made into baby food, put in ice cube trays, and
frozen for future use. Parents are also provided with
information about how the intestines function to
break down the foods.
KSDPP has developed a traditional approach to
combating diabetes through programs such as ‘Healthy
Mind in a Healthy Body’ workshops which link the
relationship between Mind, Body and Spirit and
Haudenosaunee Foods Cooking Workshops geared to
teach young mothers how to cook economical healthy
meals using native cultural and seasonal foods to
enhance cultural pride.
V. First Nations Health Plan, British Columbia
In 2007, a Tripartite First Nations Health Plan was
signed by the First Nations Leadership Council
(representing the BC Assembly of First Nations), the
First Nations Summit and the Union of BC Indian
Chiefs; and the Government of Canada; and the
Government of British Columbia. The goals of the
First Nations Health Plan is to improve the health and
well-being of First Nations in British Columbia, close
the gaps in health between First Nations people and
other British Columbians, and ensure First Nations are
fully involved in decision-making regarding the health
of their peoples. In this 10-year trilateral agreement,
all three parties have committed to action in four
priority areas:
58
Health of Indigenous Children: Health Assessment in Action •
•
•
•
Governance, relationships and accountability
Health promotion and disease and injury prevention
Health services
Performance tracking
A new First Nations Health Council was established
to provide leadership in the implementation of the First
Nations Health Plan.
In the area of performance tracking the parties
agreed to work together to develop the data and
information necessary to improve health services,
and to monitor and report on health status and health
care information for First Nations in B.C. Specifically,
the parties committed to tracking progress for the
following indicators: life expectancy at birth; mortality
rates (deaths due to all causes); infant mortality rates;
diabetes rates; status Indian youth suicide rates;
childhood obesity; and practising, certified First Nation
health care professionals. A Tripartitie Data Quality
and Sharing Agreement between the Government
of British Columbia, Health Canada’s First Nations
and Inuit Health Branch and the First Nations Health
Council is being developed and will facilitate data
linkages and define how federally and provincially held
information on First Nations is to be used and shared.
Through this agreement, OCAP principals will govern
the collection, analysis and sharing of BC First Nations
health information.
VI. First Nations EpiCentre of Alberta
The name ‘EpiCentre’ comes from the Epidemiology
Centers established by the US Indian Health Services
in 1996. These US Tribal Epicentres are described in
the US chapter of this report. The recently established
First Nations EpiCentre of Alberta is the first such
organization in Canada. The EpiCentre brings together
specialists in public health, epidemiology and other
disciplines to develop the intelligence needed to
improve public health programs for First Nations in
Alberta and beyond. The EpiCentre was established
in partnership with First Nations communities and
federal/provincial governments in Alberta. The
mission of the First Nations EpiCentre of Alberta is to
improve the quality and use of information required
to take action on health, health programs and health
determinants while respecting the Treaty rights to
health and the cultural diversity of First Nations.
Core business of the EpiCentre includes:
• improving the quality of information available to
communities
• developing the capacity of communities to collect,
manage, and use health data
• fostering strategic health information partnerships
and policies to support public health programs
Health of First Nations, Inuit, and Métis Children in Canada
First Nations, Inuit and Métis children
face striking disparities in the social
determinants of health, including family
income, parental employment, parental
education, food security, and housing,
compared to non-Aboriginal children.
The EpiCentre has programs in environmental
health, diabetes, prescription drugs, community
health, planning, and homecare. Staff includes four
epidemiologists, a medical geographer, a health
economist, a pharmacist, a statistician, and a data
analyst. More information can be found on the
Epicentre’s website:
http://www.fnepicentre.org/
2.9 Conclusion
The human right to health is internationally
recognized. For example, Article 12.1 of the United
Nations’ International Covenant on Economic, Social
and Cultural Rights identifies the ‘the right of everyone
to the enjoyment of the highest attainable standard
of physical and mental health’.67 The next article of
the covenant highlights the importance of child and
reproductive health, with a provision ‘for the reduction
of the stillbirth rate and of infant mortality and for
the healthy development of the child’ (art. 12.2 -a).67
Despite international agreement that substandard
health is unacceptable, First Nations, Inuit, and Métis
children in Canada continue to experience inequities
in health status and health determinants compared
to non-Aboriginal Canadians. The persistence of
these inequities and substandard health outcomes is
particularly bothersome in Canada, one of the world’s
richest nations.
First Nations, Inuit and Métis children face striking
disparities in the social determinants of health,
including family income, parental employment,
parental education, food security, and housing,
compared to non-Aboriginal children. For example, the
Canadian Community Health Survey revealed rates of
severe food insecurity that were over five times higher
for Aboriginal households compared to non-Aboriginal
households and the Aboriginal Peoples Survey 2006
Health of First Nations, Inuit, and Métis Children in Canada revealed that 30% of Inuit children experience hunger
as a result of their family having run out of food
or money to buy food. The First Nations Regional
Longitudinal Health Survey reveals that only 68% of
First Nations participants living on-reserve considered
their water safe to drink.
Underlying these classic health determinants is the
experience of colonization, which disrupted family
networks, dislocated communities from traditional
lands, and interfered with the intergenerational
transmission of knowledge and culture. Colonial
processes continue to have direct and indirect impacts
on the health of First Nations, Inuit, and Métis children
and their families. The reversal of colonial policies
and the restitution of the rights of Indigenous peoples,
including the implementation of the standards in the
UN declaration on the Rights of Indigenous Peoples, is
a necessary prerequisite to fundamental improvements
in the health determinants and health status of
Aboriginal children.
Despite the knowledge that Aboriginal children in
Canada are at risk of adverse health outcomes, given
these disparities in social determinants of health,
there are large gaps in available health information.
When it comes to health surveillance in Canada,
many First Nations, Inuit, and Métis children remain
invisible or uncounted. For example, currently there
is no information regarding the infant mortality of
Métis in Canada, despite the fact that Métis account
for approximately one third of Canada’s Aboriginal
population. There is are similar gaps in information for
First Nations children without status and Aboriginal
children living in urban areas. One of the major health
information challenges is the lack of standardized
First Nations, Inuit, and Métis identifiers in vital
registration, surveillance, and health care utilization
databases. Another major challenge is the lack of
Health of Indigenous Children: Health Assessment in Action
59
The long term goal with respect to
Aboriginal children’s health assessment
and health performance measurement
information is clearly better evidence
for decision making, resulting in better
health outcomes and a reduction
in health disparities
integration of First Nations, Inuit, and Métis health
information with health care programs and services.
In the end, this review was able to identify quite a
bit of health determinant and health status data for
Aboriginal children living in Canada, however, very
little of this data was already linked to the ongoing
evaluation the health services and programs that are
serving Aboriginal children.
This is not the first time that an Indigenous group
has faced a challenge in exercising the ‘right to be
counted’. It wasn’t until 1967 that Aboriginal Australians
were recognized as having the right to be counted in
the national census and 40% of infants born worldwide
still do not have reliable access to birth registration.68,69
Being recognized in a census and/or through birth
registration are essential steps in ensuring that other
human rights, including the right to health are achieved.
Public health programs designed to safeguard the health
of children are founded on health information systems
that count or survey health determinants and outcomes
drawing on the census, birth and death registrations,
health care utilization records, disease reporting,
and health surveys. As stated earlier, these shortfalls
in Aboriginal child health assessment and health
system performance measurement represent a missed
opportunity to address the health status inequities
experienced by Aboriginal children in Canada,
compared to the rest of Canadian children.
The best practice examples at the end of this
chapter demonstrate the way forward with respect
to the enhancement of Aboriginal children’s health
information systems in Canada. Notably, all six
examples are founded on partnerships between
Aboriginal stakeholders and health workers with a
background in public health assessment. These models
allow for a balance between the desires of First Nations,
Inuit, and Métis health stakeholders to play a role
in the governance and management of their health
information and the pressing need to better health
60
Health of Indigenous Children: Health Assessment in Action information to address and prevent unnecessary child
illness and death.
At a policy level, the long term goal with respect
to Aboriginal children’s health assessment and health
performance measurement information is clearly
better evidence for decision making, resulting in better
health outcomes and a reduction in health disparities.
The current gaps in health information, while
undesirable, do not provide an excuse for inaction.
This chapter has clearly detailed pressing inequities in
health determinants and health status outcomes for
First Nations, Inuit, and Métis children compared to
non-Aboriginal children in Canada. These disparities
are not new and are not just. Over a decade ago, the
Royal Commission on Aboriginal Peoples (RCAP)
examined the health of Aboriginal people, including
infant, child and maternal health. While some gains
were identified, clear disadvantages persisted. In
addition, the roots of the disproportionate burden
of ill health were linked ‘outside the boundaries of
ordinary medicine’ to ‘social, emotional and economic
conditions that in turn lead back to the complex,
destabilizing and demoralizing legacy of colonialism’.
Recommendations of the RCAP were aimed at
addressing these underlying causes of health status
disparities and included: a significant restructuring
of relationships between the federal government and
Aboriginal nations; a substantial federal investment
in Aboriginal institutions and communities; and a
redistribution of lands. Unfortunately, to date very few
of these (and other RCAP) recommendations have
been implemented. There appears to be an ongoing
disconnect between the undeniable evidence regarding
the unacceptable disparities in Aboriginal children’s
health in Canada and the implementation of federal
policies that would rectify these disparities. It is our
hope that the information in this chapter can be used
as an advocacy tool and resource for those working to
bridge this disconnect.
Health of First Nations, Inuit, and Métis Children in Canada
2.10 Additional Tables
Census data
Data produced when participants identify themselves as First Nations (registered and nonregistered),
Métis or Inuit
• Nonparticipation is common
• On many reserves, enumeration is incomplete
• Mobility and overrepresentation of homeless people contributes to undercounting of Aboriginal groups
• The ethnicity question appears on only about 20% of forms
• Aboriginal people may choose not to self-identify to government employees
• Ethnic mobility contributes to inaccuracy of data
Vital registration data
INAC’s Indian Register: First Nations–specific rates generated from cross-linkage of data from four provinces
• Lack of prospectively collected data on ethnicity by voluntary self-identification excludes generation
of rates for nonregistered First Nations, Métis and Inuit people
Questions about Aboriginal ethnicity on the registration forms of some provinces and territories
• Privacy concerns about transfer of the INAC registry
• Lack of standardization of ethnicity questions on forms
Data from health surveys
National health surveys (none to very limited)
• Most national surveys done by Statistics Canada exclude sampling from reserves, don’t ask about
Aboriginal ethnicity, or use a sample too small to generate anything other than national panAboriginal data
Aboriginal Peoples Survey: nonregistered First Nations, Métis and Inuit people
• Sampling frames are derived from the census data from self-identified Aboriginal people, so
coverage issues are the same as for the census
• Done only every 10 years
First Nations Regional Longitudinal Health Survey: First Nations
people living on-reserve
• Comprehensive coverage of First Nations reserve communities in most regions of the country
• In some regions not all First Nations reserve communities participate
• Questions reflect health issues and measures that are important to participant First Nations
communities
• Content is not entirely comparable to other national surveys
Health services utilization data
Compiled by Canadian Institute of Health Information (CIHI)*
• Compiled by geographic region: no ethnic-specific data
• In some regions where the proportion of Aboriginal people is very high (e.g., Northern
Saskatchewan and Nunavut), geography can serve as proxy measure
Data from surveillance systems
• Registered First Nations people only, by data linkage in National Diabetes Surveillance System and
some surveillance systems for notifiable diseases
• Lack of standardized, inclusive means to permit self identification of Aboriginal ethnicity
Note: INAC = Indian and Northern Affairs Canada.
*Reports have been published in which provincial health systems linked their databases with the Indian
Register or Band Membership lists to generate health-service utilization data specific to Aboriginal people.
Text Box 1
Concern with statistical
sources for First Nation,
Inuit and Métis health
adapted from Smylie &
Anderson, 2006
Health of First Nations, Inuit, and Métis Children in Canada Health of Indigenous Children: Health Assessment in Action
61
Aboriginal Children’s Survey, 2006
Canadian Census 2006
First Nations Longitudinal Regional
Health Survey 2002/3 (RHS)
Source
Includes Inuit, Métis and off-reserve First
Nations living in urban, rural and northern
locations in Canada
Children aged 0 to 14 years
Includes Inuit, Métis, and off-reserve First
Nations living in urban, rural and northern
locations in Canada
Children aged 0 to 14 years
First Nations children (0-11 years) living on
reserve in Canada
Population
First Canadian survey devoted to
pregnancy, labour, birth and postpartum
Aboriginal report pending
Includes only those respondents who
completed 2006 census and indicated some
form of First Nations, Inuit or Métis identity
Includes only those respondents who
completed 2006 census and indicated some
form of First Nations, Inuit or Métis identity
See Table 3 for concerns
Not all First Nations reserves participated
http://www.statcan.gc.ca/cgi-bin/imdb/
p2SV.pl?Function=getSurvey&SDDS=5019&
lang=en&db=imdb&adm=8&dis=2
http://www.statcan.gc.ca/cgi-bin/imdb/
p2SV.pl?Function=getSurvey&SDDS=3250&
lang=en&db=imdb&adm=8&dis=2
http://www.statcan.gc.ca/aboriginal/
acs/5801793-eng.htm
http://www12.statcan.ca/english/census06/
analysis/aboriginal/index.cfm
http://www.rhs-ers.ca/english/
Major Statistical Sources for First Nations, Inuit & Métis Children's Health
Aboriginal Peoples Survey, 2006
Census based sampling frame, 6000 +
total respondents
411 self-identified First Nations, Inuit,
and Métis mothers
Reserves excluded
http://www.hc-sc.gc.ca/fnih-spni/pubs/gen/
stats_profil_e.html
Table 1
Maternal Experiences Survey
First Nations with status
Some figures are for First Nations
on-reserve only
Uses a variety of data sources
Technical issues with vital registration rates,
as coverage (on/off-reserve) and source of
data (death certificate vs. nursing station
report) is not consistent across provinces
and territories
http://www.inuithealthsurvey.
ca/?nav=childrens
Access/Location
First Nations Comparable
Health Indicators
No results at time of publication.
Comments
Inuit Health Survey
Inuit children age 3-5 years living in
Nunavut, the Inuvialuit Settlement Region
and Nunatsiavut.
Data collection 2007-2008.
Inconsistencies in ethnic identifiers and
rate calculation methods result in data of
variable quality for western provinces.
Métis and Inuit specific rates are not
available. Comprehensiveness of data
release varies.
Mother tongue identifier in Quebec
sensitive and specific for Inuit but much less
sensitive for other Aboriginal groups.
Capacity issues in Nunavut prohibit regular
and comprehensive health data release.
http://www.gov.nu.ca/health/
PIRCenglishlow.pdf
Nunavut Report on Comparable Health
Indicators 2004
http://www.gov.nu.ca/health/hir.shtml
http://www.fnepicentre.org/
http://www.health.gov.bc.ca/aboriginal/
pho.html
Provincial/
territorial ministries of health
Four western provinces produce vital
registration and some health care utilization
data for First Nations persons with status
and/or living on reserve, using birth
registration identifier, linkage to INAC
registration lists, and/or on-reserve postal
codes
Quebec has a ‘mother tongue’ birth
registration identifier
Nunavut vital registration, utilization,
and surveillance data includes very small
proportion of non-Inuit
Health of First Nations, Inuit, and Métis Children in Canada
Health of Indigenous Children: Health Assessment in Action 62
2.11 References
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The International experience and its policy implications. In: Report
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the Rights of Indigenous Peoples. Geneva: United Nations. Available
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en.pdf. Accessed September 9, 2008.
22. Health Canada. Canadian Community Health Survey Cycle 2.2
(2004). Nutrition: Income-Related Household Food Security in
Canada. Ottawa: Office of Nutrition Policy and Promotion; 2007.
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Health Canada; 2007.
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24. Northern Food Security, Strategic Policy and Devolution Branch,
Indian and Northern Affairs Canada. The Revised Northern Food
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25. Statistics Canada. National Longitudinal Survey of Children and
Youth (NLSCY) cycle 7, 2006-2007. Ottawa: Statistics Canada; 2009.
36. Tait CL. (2003). Fetal Alcohol Syndrome among Aboriginal people
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26. Underhill C, McKeown L. Getting a Second Opinion: Health
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article/10515-eng.pdf. Accessed February 15, 2009.
37. Burd L, Moffat ME. Epidemiology of fetal alcohol syndrome in
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27. Statistics Canada. National Longitudinal Survey of Children and
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38. Health Canada. Fetal Alcohol Syndrome/Fetal Alcohol Effects –
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php. Accessed February 10, 2009.
28. Kawachi L, Kennedy B, Glass R. Social capital and self-rated health:
A contextual analysis. American Journal of Public Health. 1999; 89:
1187-1193.
29. Smylie J, Fell D, Pennock J, and the Joint Working Group on
First Nations, Inuit, and MétisInfant Mortality. Statement on First
Nations, Inuit, and Métis infant mortality rates in Canada. Under
review.
39. Cox LV, Dickenson M. The prevalence of Fetal Alcohol Spectrum
Disorder in a Maritime First Nation Community. Int JFAS. (In press).
40. Willows ND, Morel J, Gray-Donal K (2000). Prevalence of anemia
among James Bay Cree infants of northern Quebec. CMAJ. 2000;
162(3): 323–6.
30. Health and Welfare Canada, Indian and Northern Health Services,
Medical Services Branch. Health Status of Canadian Indians and
Inuit, update 1987. Ottawa: Health and Welfare Canada; 1988.
41. Kovesi T, N Gilbert, C Stocco, D Fugler, R Dales, M Guay, JD Miller.
Indoor air quality and the risk of lower respiratory tract infections
in young Canadian Inuit children. Canadian Medical Association
Journal 2007; 177 (2).
31. Luo ZC, Kierans WJ, Wilkins R, Liston RM, Uh S, Kramer M. Infant
mortality among First Nations versus non-First Nations in British
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42. Yip D, Bhargava R, Yao Y, Sutherland K, Manfreda J, Long R.
Pediatric tuberculosis in Alberta: epidemiology and case
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2007; 98(4): 276–80.
32. Zhong-Cheng Luo and Manitoba Assembly of First Nations.
Community Report: Community Characteristics and Birth Outcomes
among First Nations and non-First Nations in Manitoba, 1991–2000.
Available by contacting the author or Manitoba Assembly of First
Nations.
43. Clark M, Riben P, Nowgesic, E. The association of housing density,
isolation and tuberculosis in Canadian First Nations communities.
Int J Epidemiol. 2002; 31:940–43.
33. Heaman MI, Blanchard JF, Gupton AL, Moffatt MK, Currie RF.
Original articles: Risk factors for spontaneous preterm birth
among Aboriginal and non-Aboriginal women in Manitoba.
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34. Luo ZC, Heaman M, Wilkins R, Smylie J, Martens P, Fraser WD,
for the CIHR Community and Aboriginal Birth Outcomes study
group. Community Report: Community characteristics and birth
outcomes among First Nations and non-First Nations in Manitoba,
1991-2000. Released 2007. Available by contacting the first
author or Assembly of Manitoba Chiefs – Health Information and
Research Governance Committee.
64
35. Luo ZC, Wilkins R, Platt R, Kramer S. Risk of adverse pregnancy
outcomes among Inuit and North American Indian women in
Quebec, 1985–97. Paediatric & Perinatal Epidemiology. 2004; 18(1):
40–50.
Health of Indigenous Children: Health Assessment in Action 44. Health Canada. Tuberculosis-First Nations, Inuit and Aboriginal
Health. Health Canada website http://www.hc-sc.gc.ca/fniahspnia/diseases-maladies/tuberculos/index-eng.php. Accessed
February 10, 2009.
45. Jin A, Martin D. Hepatitis A among residents of First Nations
Reserves in British Columbia, 1991-1996. Canadian journal of public
health. 2003; 94(3):176-9.
46. Kue Young T, Reading J, Elias B, O’Neil J. Type 2 diabetes mellitus
in Canada's First Nations: status of an epidemic in progress. CMAJ.
2000; 163 (5):561-6.
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47. Dean HJ, Mundy RL, Moffatt M. Non-insulin-dependent diabetes
mellitus in Indian children in Manitoba. CMAJ. 1992;147(1):52-7.
48. Harris SB, Perkins BA, Whalen-Brough E. Non-insulin-dependent
diabetes mellitus among First Nations children. A new entity
among First Nations people of north western Ontario. Can Fam
Physician. 1996; 42:869-76.
49. Dean HJ. NIDDM-Y in First Nations children in Canada. Clin Pediat.r
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50. Harrop AR, Brant RF, Ghali WA, Macarthur C. Injury mortality rates
in Native and non-Native children: A population-based study.
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expectancy in the Inuit-inhabited areas of Canada, 1989 to 2003.
Ottawa: Statistics Canada. Available at http://www.statcan.ca/
english/freepub/82-003-XIE/2008001/article/10463-en.htm
Accessed June 18, 2008.
52. Government of Nunavut. Nunavut Report on Comparable Health
Indicators. Nunavt: Government of Nunavut-Department of Health
and Social Services; 2004.
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among Inuit women in the Baffin Region of the Canadian Arctic.
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60. Charbonneau-Roberts G, Saudny-Unterberger H, Kuhnlein HV,
Egeland GM. Body mass index may overestimate the prevalence of
overweight and obesity among the Inuit. International Journal of
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61. Van Oostdam J, Donaldson SG, Feeley M, Arnold D, Ayotte P, Bondy
G, Chan L, Dewaily E, Furgal CM, Kuhnlein H, Loring E, Muckle
G, Myles E, Receveur O, Tracy B, Gill U, Kalhok S. Human health
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in breast milk of Inuit women from Arctic. Bull. Environ. Contam,
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Randhawa N, Miller JD. Indoor air quality risk factors for severe
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55. Dallaire F, Dewailly E, Muckle G, Vezina C, Jacobson SW, Jacobson
JL, Ayotte P. Acute Infections and Environmental Exposure to
Organochlorines in Inuit Infants from Nunavik. Environ. Health
Perspect. 2004; 112(14): 1359-1364.
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website http://rhs-ers.ca/english/background-governance.asp..
Accessed Oct 1, 2008.
56. Dallaire F, Dewailly E, Vezina C, Bruneau S, Ayotte P. Portrait of
outpatient visits and hospitalizations for acute infections in
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highest attainable standard of health.11/08/2000. (General
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E.C.12.2000.4.En. Accessed November 15, 2008.
57. Banerji A, Bell A, Mills EL, et al. Lower respiratory tract infections in
Inuit infants on Baffin Island. CMAJ 2001; 164:1847-50.
58. Nguyen D, Proulx JF, Westley J, Thibert L, Dery S, Behr MA.
Tuberculosis in the Inuit community of Quebec, Canada. American
Journal of Respiratory and Critical Care Medicine. 2003; 168(11):
1353-1357.
59. Public Health Agency of Canada. Tuberculosis in Canada-2002.
Ottawa: Public Health Agency of Canada. Cat. H39-1/6-2002E.
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dl.screenaustralia.gov.au/module/1354/. Accessed on Oct 1, 2008.
69. Todres J. Birth Registration: An Essential First Step toward Ensuring
the Rights of All Children. Human Rights Brief. 2003; 10(3): 32-35.
70. Royal Commission on Aboriginal Peoples. People to People, nation
to nation: Highlights from the Report of the Royal Commission
on Aboriginal Peoples. Ottawa: Ministry of Supply and Services
Canada; 1996.
Health of Indigenous Children: Health Assessment in Action
65
3
66
Health of Indigenous Children: Health Assessment in Action Health of Aboriginal and Torres Strait Islander Children in Australia
Health of Aboriginal and Torres Strait Islander Children in Australia
“Ampe Akelyernemane Meke Mekarle – Little Children are Sacred – In our Law children are very sacred because they carry the
two spring wells of water from our country within them” (traditional Aboriginal law of the Yolngu people of Arnhem Land in
the Northern Territory).1
‘Compared with their non-Aboriginal and Torres Strait Islander Australian counterparts, Aboriginal and
Torres Strait Islander children are:
• more likely to be stillborn, to be born pre-term, to have low birth weight, or to die in the first month
of life;
• 2 to 3 times more likely to die in the first twelve months of life, and 11 times more likely to die from
respiratory causes;
• at a much higher risk of suffering from infectious and parasitic diseases, diseases of the respiratory
and circulatory system, hearing loss, rheumatic fever, dental caries, injuries, and clinically significant
emotional and behavioural difficulties;
• nearly 30 times more likely to suffer from nutritional anaemia and malnutrition up to 4 years of age;
• cared for by significantly fewer adults, who are also at higher risk of premature death, serious illness,
substance abuse, imprisonment, major social and emotional stress, lower household income, lower
educational attainment, lower employment, and lower access to appropriate sanitary and household
conditions, than other Australian adults.’ Australian Medical Association Report Card, 2008
Source: Australian Medical
Association6
3.1 Introduction
The United Nations International Children’s
Emergency Fund (UNICEF), better known as the
United Nations Children’s Fund, suggests that:
the true measure of a nation’s standing is how well it
attends to its children – their health and safety, their
material security, their education and socialization, and
their sense of being loved, valued, and included in the
families and societies into which they are born. 7
Indeed, Aboriginal and Torres Strait Islanders view
health from a holistic perspective. They believe that:
Aboriginal health is not just the physical wellbeing of
an individual but is the social, emotional and cultural
wellbeing of the whole community in which each
individual is able to achieve their full potential thereby
bringing the total well being of their community. It is a
whole-of-life view and includes the cyclical concept of lifedeath-life. National Aboriginal Health Strategy Working
Party8 available: http://www.health.gov.au/oatsih/pubs/
An analysis of national health information gives a
powerful insight into the ongoing legacy of colonization
on the Indigenous people of Australia, New Zealand,
Health of Aboriginal and Torres Strait Islander Children in Australia Canada and the United States of America. While these
first-world nations boast first class health systems, the
key health indicators clearly show that the traditional
custodians of the land do not share equally in the
benefits of these systems. There is a pressing social
justice issue in the wide disparity in outcomes that
results in Indigenous people suffering a far greater
health burden than non-Indigenous people. Of great
concern is that despite widespread acknowledgment
of the gap and actions to address it, progress in its
reduction appears to be minimal for many indicators.
Indigenous populations in Australia, New Zealand,
Canada and the United States of America share many
commonalities of cultures that extend for thousands
of years: deeply held spiritual beliefs and practices;
prolonged experiences of exploitation, prejudice
and discrimination; attempts at forced segregation
followed by forced assimilation; large-scale neglect
of human rights; inequalities in health status; and
an increasing, if at times ignored, effort to achieve
international recognition and protection for their
peoples and cultures.
It is a human right to be counted in population
statistics and Indigenous people should not be
invisible in national health statistics. Currently, the
measurement of the health of Indigenous people
Authors:
Dr. Jane Freemantle PhD
Associate Professor
Centre for Health and Society
Melbourne School of
Population Health
The University of Melbourne
Principal Research Fellow
Onemda VicHealth Koori
Health Unit
Daniel McAullay PhD(c)
Senior Research Officer
PhD Candidate
Telethon Institute for
Child Health Research
Health of Indigenous Children: Health Assessment in Action
67
Pictured:
Hiarnz & Darheio
world-wide is complicated by deficiencies in the data
describing Indigenous people. These deficiencies
are in part due to inconsistencies in the collection,
the sources, completeness, classifications, analysis
interpretation and ownership of the data in each
jurisdiction. This chapter, while providing an insight
into the state of the health of Aboriginal and Torres
Strait Islander children, and at times linking their
health outcomes to the health outcomes of Indigenous
children in other countries, does not attempt to directly
compare outcomes between the contributing countries5.
3.2 The colonization of Australian and
Torres Strait Islander people
The colonization of Australia by Great Britain
began in 1788 with the arrival of the First Fleet.
The original ‘protectorate’ system of the 19th
and early 20th Century resulted in wide-spread
displacement of Aboriginal and Torres Strait Islander
people. ‘Protectionism’ was replaced by a policy
of ‘assimilation’ after a 1937 national conference,
at which the assimilation policy was adopted.
From this date all States began adopting policies
designed to ‘assimilate’ Indigenous people of mixed
descent. Assimilation was ‘a highly intensive process
necessitating constant surveillance of people’s lives’.
New legislation was introduced almost everywhere
by 1940. The policy of assimilation was replaced by a
policy of ‘self-determination’ in the 1970s.
68
Health of Indigenous Children: Health Assessment in Action Health of Aboriginal and Torres Strait Islander Children in Australia
The 1967 Referendum afforded the Commonwealth
Government legislative authority for Aboriginal and
Torres Strait Islander people (formally the power
rested with the States).5 Prior to the referendum,
Aboriginal and Torres Strait Islander Australians were
included in Census data under the section ‘flora and
fauna’. Following the referendum, people were able
to self identify as an Aboriginal and or Torres Strait
Islander. Since the inclusion of Aboriginal and Torres
Strait Islander Australians in the Census, Australia has
sought only information about ‘general ancestry’ as
defined by the Census question. The Census definition
of an Aboriginal and Torres Strait Islander is “a person
of Aboriginal or Torres Strait Islander descent who
identifies as an Aboriginal or Torres Strait Islander
and is accepted as such by the community in which he
or she lives”. 15 The 1986 Census did include a question
to identify Aboriginal and Torres Strait Islander
origin and a question to determine the ancestry or
forebears of all people including Indigenous people.
However, these questions were cross-edited 9 and thus
no distinction can be drawn between the historical
ancestry and the current identity of the population.
In Australia, since 1981, all Censuses have used the
same question to identify Aboriginal and Torres Strait
Islander people.9-10
Following the Referendum, the Office of
Aboriginal Affairs was set up to establish Aboriginal
health units.11 The Aboriginal and Torres Strait
Islander Commission was established in 1990 and
disbanded in 2005. A number of regional Indigenous
Coordination Centres were then convened to advise
the Federal Government on funding priorities and
process. However, with the change in the Federal
Government in 2007, these Centres are being
reviewed and the current Aboriginal and Torres Strait
Islander Social Justice Commissioner Tom Calma
has been appointed to oversee the establishment of a
new body that will advise the Federal Government on
Indigenous affairs. Historically and currently, there
are no Treaties between the Australian Government
and the Aboriginal and Torres Strait Islander people.
By the late 1800s there were systematic
removal practices being implemented through a
range of assimilation and ‘protection policies’. A
seminal report, the Bringing Them Home report,
acknowledged that ‘Indigenous children had
indeed been forcibly separated from their families
and communities since the very first days of the
European occupation of Australia’ by governments
and missionaries. These children who were removed
came to be known as the Stolen Generations. The
public and political debate about the removal of
Health of Aboriginal and Torres Strait Islander Children in Australia children was marked by intense political activity
from the mid-to-late 1980s.12 In 1992 Prime
Minister Keating acknowledged that ‘we took the
children from their mothers’, at a speech in Redfern.
In 1994, legal action was commenced in the
Supreme Court of New South Wales by members of
the Stolen Generation.13
On the 13th of February 2008, more than ten
years after the Bringing Them Home report was
accepted, the Prime Minister, Kevin Rudd, tabled
a motion in parliament apologizing to Australia’s
Indigenous peoples, particularly the Stolen
Generations and their families and communities, for
laws and policies which had ‘inflicted profound grief,
suffering and loss on these our fellow Australians’ .
This motion was passed with acclamation.
The apology included a proposal for a policy
commission to be convened and to be responsible
for advising the government on how to ‘close the gap’
between Indigenous and non-Indigenous Australians
in ‘life expectancy, educational achievement and
economic opportunity’.14
3.3 Demographics of Aboriginal and
Torres Strait Islander Australians
Aboriginal and Torres Strait Islander people have
a wide range of lifestyles and social, cultural,
educational and family backgrounds. What is true
of one Indigenous person or group is not necessarily
true of another’s values and life style.16 Currently,
there are at least 250 documented Aboriginal and
Torres Strait Islander language groups.
In June 2006, the estimated Aboriginal and Torres
Strait Islander population was 517, 200 or 2.5% of
the total Australian population.17 The Indigenous
population is estimated to have increased by 58,700
(13%) between 2001 and 2006. People identifying
as Aboriginal made up 90% of the Aboriginal and
Torres Strait Islander population, 6% identified as
Torres Strait Islander and 4% as Aboriginal and Torres
Strait Islanders.18
Torres Strait Islanders are the Indigenous people
of the Torres Strait Islands, part of the State of
Queensland, and are culturally akin to the coastal
peoples of Papua New Guinea. They are regarded
as being distinct from other Aboriginal peoples in
Australia, and are generally referred to separately. The
Indigenous people of the Torres Strait have a distinct
culture, with slight variants between the different
islands. They are a seafaring people and engaged in
trade with people of Papua New Guinea.19 In 2006,
there were 6,958 Torres Strait Islander people living
in the Torres Strait Indigenous Region (15% of the
Health of Indigenous Children: Health Assessment in Action
69
Size of green circles is indicative of
relative size of the Aboriginal and Torres
Strait Islander population for example :
Large green circles:29,000 persons
Medium green circles: 14,500 persons
Small green circles: 2,900 persons
Figure 1
Distribution and relative
size of Australian
Indigenous population in
Indigenous locations, rural
towns and urban centres.
Source: Department of the
Environment and Heritage22
The continuing
disparities in health
outcomes among
Indigenous people
in Australia, New
Zealand, Canada
and the United States
of America is in great
part the legacy of
the colonization of
their lands
total count of Torres Strait Islander people), and
around 42,000 others living outside this area, mostly
in the north of Queensland, particularly in Townsville
and Cairns.20
Geographical distribution
In 2006, the largest population of Aboriginal and
Torres Strait Islander people in Australia lived in major
cities (31%). The remaining population was evenly
distributed across areas categorised by the Australian
Bureau of Statistics as Inner Regional (22%), Outer
Regional (23%) and Remote/Very Remote Australia
(24%) (See Figure 1).
States with relatively high proportions of Aboriginal
and Torres Strait Islander people living in major
cities included South Australia (48%), Victoria (48%)
and New South Wales (42%). In contrast, 81% of the
Aboriginal and Torres Strait Islander population in the
Northern Territory lived in Remote/Very Remote areas.
Similarly, in Western Australia 41% of the Aboriginal
and Torres Strait Islander population lived in Remote/
Very Remote areas.23
Age structure
The Aboriginal and Torres Strait Islander population
at 30 June 2006 had a younger age structure than the
70
Health of Indigenous Children: Health Assessment in Action non-Aboriginal and Torres Strait Islander population,
with large proportions of young people and small
proportions of older people (See Figure 2). The median
age of the Aboriginal and Torres Strait Islander
population at 30 June 2006 was 21.0 years, compared
to 37.0 years for the non-Aboriginal and Torres Strait
Islander population.
Based on estimates for 2003, there were 179,128
Aboriginal and Torres Strait Islander children living
in Australia. All Australian children aged from zero
to fourteen years accounted for 20% of the total
population. Aboriginal and Torres Strait Islander
children aged from zero to fourteen years accounted
for 39% of the total Aboriginal and Torres Strait
Islander Australian population. Australia is a vast
country and the numbers of Aboriginal and Torres
Strait Islander children living in the various states
and territories of Australia vary significantly. In the
Northern Territory, 40% of the child population aged
less than fourteen years is Aboriginal and Torres
Strait Islander which compares with Victoria, where
this percentage is 1%. Further, 30% of Australia’s
Aboriginal and Torres Strait Islander children aged
less than fourteen years live in New South Wales, 28%
live in Queensland, 14% in Western Australia, 11%
in the Northern Territory, 6% in Victoria and South
Health of Aboriginal and Torres Strait Islander Children in Australia
Australia, 4% in Tasmania and 0.8% in the Australian
Capital Territory.17
Indigenous families
The 2006 national Census reported that Aboriginal
and Torres Strait Islander families are more likely to
be larger, with an average of 3.4 people compared with
other Australian households (2.6 people). Aboriginal
and Torres Strait Islander families are three times
more likely than other single family households to
be one-parent families with dependent children or
students (30% compared with 10%) but are less likely to
be families without dependents. (33% compared with
54%). 17 The characteristics of Aboriginal and Torres
Strait Islander families differ from the majority of other
Australian families. They tend to be larger, non-nuclear
and more fluid in composition. Aboriginal and Torres
Strait Islander families have overlapping and extensive
kinship, with both adults and children moving between
different households.24 These extensive and fluid family
structures are more common in remote communities,
but are also found in more settled areas of Australia.25
3.4 Determinants of Aboriginal and
Torres Strait Islander child health
Employment
Being employed leads to improved income for families
and communities, which in turn has a positive
influence on the health and education of children. It
also enhances self-esteem, increases opportunities for
self-development, influences interaction at the family
and community level, and decreases social alienation.26
In 2004–2005, after adjusting for the age difference, the
unemployment rate for Aboriginal and Torres Strait
Islander people (12.9%) was about three times higher
than for non-Aboriginal and Torres Strait Islander
people (4.4%) 26. Aboriginal and Torres Strait Islander
children were also less likely to have a parent in paid
employment and, in 2006, 42% of Aboriginal and Torres
Strait Islander children lived in families where there was
no parent working, which was three times higher than
non-Aboriginal and Torres Strait Islander children.17
Income
The incomes of Aboriginal and Torres Strait Islander
people are generally below those of non-Aboriginal
and Torres Strait Islander people, and there tends to
be a relatively higher proportion of Aboriginal and
Torres Strait Islander people with lower incomes and
a lower proportion with higher incomes.26 People who
have lower incomes or are socially disadvantaged in
other ways tend to live shorter lives and suffer more
illnesses than those who are well off. It is widely
acknowledged that health status is affected by the
availability of material resources and the income to
buy them. Higher incomes can enable the purchase
of health-related goods and services, such as better
food, housing, recreation and health care, and may
provide psychological benefits such as a greater sense
of security and control.27
Adverse health outcomes and higher mortality
rates are important examples of the effect that low
income has on people, and the link between reduced
family income and associated poor child health
outcomes is compelling. For the period 2002 and
2004–05, after adjusting for inflation, median gross
weekly equivilised household income for Aboriginal
and Torres Strait Islander people rose by 10% from
$AU 308 to$AU 340. This compare to $AU 618 for
Age group (years)
85+
80-84
75-79
70-74
65-69
60-64
55-59
50-54
45-49
40-44
35-39
30-34
25-29
20-24
15-19
10-14
5-9
0-4
Male
7
6
Percent
5
4
3
Figure 2
Aboriginal and Torres Strait
Islander and non-Aboriginal
and Torres Strait Islander
population at
30 June 2006
Age group (years)
85+
80-84
75-79
70-74
65-69
60-64
55-59
50-54
45-49
40-44
35-39
30-34
25-29
20-24
15-19
10-14
5-9
0-4
Female
2
1
0
1
2
3
4
5
6
INDIGENOUS
Health of Aboriginal and Torres Strait Islander Children in Australia 7
Male
Female
Source: Australian Bureau of
Statistics23
7
6
Percent
5
4
3
2
1
0
1
2
3
4
5
6
7
non-INDIGENOUS
Health of Indigenous Children: Health Assessment in Action
71
Percent
100
Figure 3
Proportion of students
who achieve the numeracy
benchmark
Year 3 students
100
90
90
80
80
70
70
60
60
50
50
40
40
30
30
20
10
0
Indigenous students
2001
2002
20
All Students
2003
10
2004
2005
non-Aboriginal and Torres Strait Islander households
in 2004–05.26
Housing
A poor living environment, with for example, low or
no access to clean water, functional sewerage systems
or appropriate housing conditions, has been associated
with tuberculosis, rheumatic heart disease, respiratory
diseases, urinary tract diseases, intestinal worms,
trachoma and intestinal infections.28 Many rural and
remote Indigenous communities still do not have access
to the basic level of environmental health experienced
by the rest of the population. Overcrowded housing,
in particular, still remains a significant problem. In
2006, an estimated 25% of Aboriginal and Torres Strait
Islander people lived in overcrowded accommodation.17
Education
International research has clearly established that
higher levels of educational attainment are associated
with improved health outcomes.29 There is also
persistent evidence regarding the importance of
completing Year 12 at school.30 Positive relationships
have been observed between levels of educational
attainment and positive health outcomes.31 Young
people who do not complete Year 12 are less likely
to be fully engaged in study or work compared with
those who do complete Year 12, and the fewer years of
schooling competed, the less likelihood of engagement
in study or work.32 Aboriginal and Torres Strait Islander
children are more likely to have parents who left school
early (57% of children in Aboriginal and Torres Strait
Islander households are living with parents who had
not completed Year 10, compared with 25% of children
in other households).
Between 2001 and 2005, 78% of Year 3 Aboriginal
and Torres Strait Islander students met the reading
benchmark and 80% met the numeracy benchmark.
72
Health of Indigenous Children: Health Assessment in Action Year 7 students
0
2001
2002
2003
2004
2005
However, at Year 7 in the same period, 65% of
Aboriginal and Torres Strait Islander students met
the reading benchmark and 50% met the numeracy
benchmark. Between Year 3 in 2001 and Year 7 in 2005,
the rate of attainment of the numeracy benchmark
almost halved among Aboriginal and Torres Strait
Islander students, from 80.2% to 48.8% (See Figure 3).
Rates of attainment of the reading benchmark dropped
from 72% to 65% among these students.26
Food security
The hunter–gatherer lifestyle of Aboriginal and Torres
Strait Islander people changed after the arrival of
Europeans.33 Many Aboriginal and Torres Strait Islander
people became dependent on Europeans for food, as
well as for many other resources. Indigenous population
numbers decreased after initial contact with Europeans
due to violence, introduced diseases and malnutrition.
A rapid change in the diet of many Indigenous people
from a fibre-rich, high-protein, low-fat traditional diet
to one high in refined carbohydrates and saturated fats
increased the risk of diet-related disease. Vulnerability
to obesity and non-insulin-dependent diabetes mellitus
has been common among other groups that have
been subjected to similar rapid lifestyle changes—for
example, Pima Indians and Native Americans.34
Food security has been largely unreported and
could be a major factor contributing to poor childhood
growth and nutrition. Good nutrition is necessary for
growth and physical and mental health. The effects of
diet and nutrition in pregnancy and during a child’s
early life may have lifelong consequences.35 Poor
fetal growth (or stunting in the first two years of life )
leads to irreversible damage, including shorter adult
stature, lower attained schooling and reduced adult
income. Healthy nutrition in pregnancy is crucial for
the mother, as it influences both her health and that
of her baby. Low dietary-energy intake, malnutrition,
Health of Aboriginal and Torres Strait Islander Children in Australia
Aboriginal and Torres Strait Islander
people have a wide range of diverse lifestyles
and social, cultural, educational and
family backgrounds. What is true of one
Indigenous person or group is not necessarily
true of another person’s values and life style.
inadequate weight gain during pregnancy and low
pre-pregnancy weight can lead to intra-uterine growth
retardation, which in turn can reduce birth weight. For
many Aboriginal and Torres Strait Islander Australians,
whether living in urban, rural or remote settings, the
availability and cost of healthy nutritious food is a basic
public health issue. In 2004–05, among Indigenous
children aged twelve to fourteen years in non-remote
areas, only 24% met the recommended daily fruit intake
of three or more serves, and 59% met the recommended
daily vegetable intake of three or more serves. Among
teenagers fifteen to seventeen years of age, 20% met the
daily fruit consumption guidelines and 61% met the
daily vegetable consumption guidelines.17
3.5 Specific Health Issues and risk factors
Tobacco smoking
Smoking during pregnancy is associated with poor
perinatal outcomes such as low birth weight, preterm
birth and perinatal death. For the period 2001–04,
51% of all Aboriginal and Torres Strait Islander women
reported smoking during pregnancy. Aboriginal and
Torres Strait Islander mothers were about three times
more likely to smoke in pregnancy compared with
non-Aboriginal and Torres Strait Islander mothers.29 In
contrast, only about 20% of all other Australian women
were reported to smoke during pregnancy and this
figure appears to be declining.20
Aboriginal and Torres Strait Islander children were
exposed to nearly twice the amount of environmental
tobacco smoke compared with non-Aboriginal and
Torres Strait Islander children and were significantly
more likely to live in a household with smokers (68.4%
compared with 36.3% of non-Aboriginal and Torres
Strait Islander children). Between 2004–05, 30.5% of
Aboriginal and Torres Strait Islander children were
exposed to regular indoor smokers compared with 10%
of non-Aboriginal and Torres Strait Islander children
(See Table 1).
Alcohol use
Alcohol use in pregnancy is associated with an
increased risk of fetal alcohol syndrome and perinatal
Indigenous children
Non-Indigenous children
aged 0–18
aged 0–18
%
%
Does the regular smoker in your household smoke at home indoors?
(a)
No
37.6
26.1
Yes
30.5
10.2
Regular smoker in household
68.4
36.3
No regular smoker
31.6
63.7
100.0
100.0
217,815
4,802,303
Total
Total number of children
(a)
Table 1
Children aged zero to
eighteen years: smoking
status in households,
2004–05
Source: Adapted from ABS and
AIHW Analysis of 2004–05 NATSIHS
and 2004–05 National Health
Survey.
Excludes not applicable, not asked (single-person household), not stated and not known.
Health of Aboriginal and Torres Strait Islander Children in Australia Health of Indigenous Children: Health Assessment in Action
73
Proportion
Table 2
Self-assessed health status
of people aged fifteen to
eighteen years 2004–05
Source: AIHW analyses of 2004-05
National Aboriginal and Torres Strait
Islander Health Survey
Indigenous
Non-Indigenous
Excellent
30.0
40.3
Very good
34.4
38.3
Excellent/very good
64.5
78.6
Good
26.8
16.6
Fair
7.6
4.0
Poor
1.1
0.8
Fair/poor
8.7
4.8
100.0
100.0
Total
Note: Excludes persons for whom self-assessed health status was not stated.
death. The Western Australian Aboriginal Child Health
Survey reported that the mothers of an estimated 23%
of Aboriginal children reported that they drank alcohol
during their pregnancies.36 Risky alcohol consumption
has not abated for men and has increased for women.
Excessive alcohol consumption also accounted for the
greatest proportion of the burden of disease and injury
for young Aboriginal and Torres Strait Islander males
(fifteen to thirty-four years) and the second highest
proportion for young Aboriginal and Torres Strait
Islander females (after intimate partner violence).36
Self-rated health
Self-rated health status provides an overall measure of
a population’s health based on an individual’s personal
perception of his or her own health. Health is recognised
as having physical, mental, social and spiritual
components, and measures of them go beyond more
objective measures such as morbidity and mortality.
Aboriginal and Torres Strait Islander teenagers aged
between fifteen and eighteen years rated their health
as consistently poorer than their non-Aboriginal and
Torres Strait Islander counterparts (See Table 2).
Perinatal health outcomes
Births
The recording of Indigenous births is likely to be an
underestimate because the Aboriginal and Torres Strait
Islander status of the parent is not always recorded or
correctly recorded. In 2006, there were about 12,300
live births registered in Australia for which at least one
parent was of Aboriginal and Torres Strait Islander
origin; these accounted for about 5% of total births.37
About one-third of these babies had both an Aboriginal
and/or Torres Strait Islander mother and father, 41% had
an Aboriginal and/orTorres Strait Islander mother and
74
Health of Indigenous Children: Health Assessment in Action non-Indigenous father, and 29% had a non-Indigenous
mother and Indigenous father.17 These percentages
varied by state/territory (also reflecting ascertainment)
between 39% of all babies in the Northern Territory, and
0.7% of all babies in Victoria. In 2006, the total fertility
rate for Aboriginal and Torres Strait Islander mothers
was 2.1 babies compared with 1.8 babies for nonAboriginal and Torres Strait Islander mothers.17
In the period 2001–04, approximately 23% of
Aboriginal and Torres Strait Islander females who
gave birth were aged less than 20 years compared
with about 4% of non-Aboriginal and Torres Strait
Islander females.
The life expectancy at birth for Aboriginal and
Torres Strait Islander babies born in the period
1996–2001 was estimated to be 59.4 years for males and
64.8 years for females compared with 76.6 years for all
males and 82.0 years for all females. This represents an
estimated difference of approximately seventeen years
for both males and females.17
Preterm births
A baby born at a gestational age or length of pregnancy
less than thirty-seven completed weeks is preterm.
Preterm birth is associated with early health problems
that cause considerable illness and a higher risk of
death in newborn babies. In the period 2001–04,
14% of all babies born to Aboriginal and Torres Strait
Islander women were born preterm, compared with
8% of babies born to non-Aboriginal and Torres Strait
Islander women.37
Birth weight
Babies born with a birth weight of less than 2500 grams
are classified as low birth weight. Low birth weight
may result from being born preterm or from poor fetal
Health of Aboriginal and Torres Strait Islander Children in Australia
Since the most powerful
determinants of infant mortality are
social and economic, death in infancy is
a good indicator of the social progress of
a society, country or group of people
growth during pregnancy. Being born low birth weight
increases an infant’s chances of dying in the first year of
life and of poor health outcomes throughout life.
During 2003–05, there were 3,601 low birth weight
babies born to Aboriginal and Torres Strait Islander
mothers, which represented 13% of all Aboriginal and
Torres Strait Islander births. This was more than double
the proportion of low birth weight babies born to nonAboriginal and Torres Strait Islander mothers (6.1%).17
Data from 1991–2004 show a significant increase in the
rate of low birth weight babies born to Aboriginal and
Torres Strait Islander mothers, from 11.2 to 12.1 per 100
live births (See Figure 4).
Breast feeding
Breast feeding has many positive effects on survival,
growth, development and the health of infants. There
is strong evidence to support the protective effect of
Source: CRCAH-Cooperative
Research Centre for Aboriginal
Health, Darwin
Figure 4
Rate of low birth weight
babies by Indigenous status
of mother 1991-2004
14
Indigenous
Other
11
Source: AIHW National Perinatal
Data Collection
Percent
8
6
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
0
1991
3
Year
(a) Excludes data for Tasmania and the Australian Capital Territory
(b) Rates have been directly age standardized using all Australian mothers who gave birth in 2001 as the standard population.
(c) Comprises non-Indigenous mothers and mothers for whom Indigenous status was not stated.
Health of Aboriginal and Torres Strait Islander Children in Australia Health of Indigenous Children: Health Assessment in Action
75
Source: CRCAH-Cooperative
Research Centre for Aboriginal
Health, Darwin
breast feeding against conditions such as diarrhoea
and respiratory infections. Breast feeding has also
been shown to benefit children’s growth, cognitive
development and immunological functioning,38 and
also to offer a protective effect against Sudden Infant
Death Syndrome (SIDS), asthma and other allergic
diseases.39 The National Aboriginal and Torres Strait
Islander Health Survey in 2004–05 reported that
approximately 79% of Aboriginal and Torres Strait
Islander children living in non-remote areas had been
breastfed compared with 88% of non-Aboriginal and
Torres Strait Islander children. A higher proportion
of non-Aboriginal and Torres Strait Islander than
Table 3
Breastfeeding status,
Indigenous infants aged 0
to less than 6 months and
6 months to less than 12
months 2004–05
Breastfeeding status
Aboriginal and Torres Strait Islander children (aged
zero to three years) had been fed for longer than twelve
months (14% compared with 11%).27 85% of Aboriginal
and Torres Strait Islander children aged between zero
and three years living in remote areas and 75% living
in non-remote areas were currently being or had been
breastfed in 2004–05. The proportion of Aboriginal
and Torres Strait Islander infants less than twelve
months old living in remote areas who were being
breastfed in 2004–05 was particularly high (85% of
babies less than six months and 82% aged between
six and twelve months).27
Age 0–<6 months
Currently breastfeeding
61.2
Previously breastfed but not currently
Never breastfed
Total (b)
Source: ABS and AIHW analysis of
2004–05 NATSIHS
46.5
26.2
(a)
42.17
12.6
(a)
11.3 (a)
100.0
Total no. of infants
Age 6–<12 months
5,124
100.0
5,247
(a)
Estimate has a relative standard error of between 25% and 50% and should be used with caution.
(b)
Includes previously breastfed but current status not known, not stated and not known if breastfed.
Table 4
Rates of fetal, neonatal and
perinatal deaths by selected
characteristics, 2006
Characteristic
Fetal deaths
Maternal status
Neonatal deaths (a) (b)
Perinatal deaths (a) (b)
Rate per 1000 births (c)
Indigenous
11.4
7.1
20.7
Non-Indigenous
7.2
2.8
10.1
Numerators exclude neonatal deaths in NT. Denominators exclude live births in NT.
Except in WA, these may exclude neonatal deaths within 28 days of birth for babies transferred to another
hospital or readmitted to hospital, and those dying at home.
(c)
Fetal and perinatal death rates were calculated using all births (live births and fetal deaths). Neonatal
death rates were calculated using all live births.
(a)
(b)
76
Health of Indigenous Children: Health Assessment in Action Health of Aboriginal and Torres Strait Islander Children in Australia
2004
2003
2002
2001
2000
1999
1998
Infant deaths
Infant deaths are deaths of live-born children before
they reach their first birthday. For the period 2001–05,
Aboriginal and Torres Strait Islander infants in
Queensland, Western Australia, South Australia and
Annual
change (b)
% change over
period (c)
-0.5*
-24.9*
4.2
-0.1*
-17.8*
2.7
0.0
-8.4
7.4
-0.4*
-28.5*
2006
Perinatal deaths
Neonatal deaths are deaths of live-born babies in
the first 28 days of life. Perinatal death includes
stillbirths and neonatal deaths. These deaths typically
result from factors arising during pregnancy and
childbirth. In 2006, Aboriginal and Torres Strait
Islander babies were over two and a half times more
likely to die in the neonatal period and nearly twice
as likely to die in the perinatal period compared with
non-Aboriginal and Torres Strait Islander babies
(See Table 4).
the Northern Territory were two to three times more
likely to die in infancy than non-Aboriginal and
Torres Strait Islander infants.17 However, between
1998 (15.2 per 1000 live births) and 2006 (11.6 per
1000 live births), there have been significant decreases
in the rates of Aboriginal and Torres Strait Islander
infant deaths in Queensland, Western Australia, South
Australia and the Northern Territory. These rates
compared with rates of 5.1 per 1000 live births in 1998
and 4.2 per 1000 live births in 2006 for non-Aboriginal
and Torres Strait Islander infants. The disparity
between these two populations has also decreased
over these years from a rate ration of 3.0 to 2.7, which
represents a 30% decrease (See Table 5) (source AIHW
analysis of the National Mortality Database, 2008).
Postneonatal death occurs after 28 days and
before the first birthday. Data from Western Australia
indicates that the post-neonatal death rate is higher
than the neonatal death rate for Aboriginal and Torres
Strait Islander infants, and the disparity between
Aboriginal and Torres Strait Islander and nonAboriginal and Torres Strait Islander post-neonatal
mortality rates is increasing. This is a pattern found in
less-developed countries.2
Between 1998–2006, an Aboriginal and Torres Strait
Islander boy was 2½ times more likely to die in the
2005
Perinatal and infant mortality
Since the most powerful determinants of infant
mortality are social and economic, death in infancy
is a good indicator of the social progress of a society,
country or group of people. Many of the causes
of infant death, such as infections, are potentially
preventable; others, such as low birthweight or preterm
birth can be treated with good health care and services.
Indigenous deaths per 1,000 live births
15.2
14.7
14.9
13.0
14.0
11.6
11.8
12.6
11.6
Non-Indigenous deaths per 1,000 live births
5.1
4.7
4.7
4.8
4.8
3.8
4.0
Rate ratio
3.0
3.2
3.1
2.7
3.0
3.1
3.0
4.4
10.1
10.1
8.2
9.3
7.8
7.8
Source: AIHW analysis of National
Mortality Database
(d)
2.9
Rate difference
10.2
Table 5
Infant mortality rates, rate
ratios and rate differences,
Qld, WA, SA and NT,
1998–2006(a)
(e)
8.2
* Represents results with statistically significant increases or decreases at the p < 0.05 level over the period
1998–2006.
Data exclude 90 registered infant deaths where Indigenous status was not stated over the period
1998–2006 in Queensland, Western Australia, South Australia and the Northern Territory combined.
(a)
Average annual change in rates, rate ratios and rate differences determined using linear regression
analysis.
(b)
(c)
% change between 1998 and 2006 based on the average annual change over the period.
(d)
Mortality rate for Indigenous infants divided by the mortality rate for non-Indigenous infants.
(e)
Mortality rate for Indigenous infants minus the mortality rate for non-Indigenous infants.
Health of Aboriginal and Torres Strait Islander Children in Australia Health of Indigenous Children: Health Assessment in Action
77
first year of his life than a non-Aboriginal and Torres
Strait Islander boy, and an Aboriginal and Torres Strait
Islander girl was 3½ times more likely to die than a
non-Aboriginal and Torres Strait Islander girl.17
Cause of Death
Between 2002–2006, the major causes of death for
Aboriginal and Torres Strait Islander infants were
conditions originating in the perinatal period (44%),
SIDS (22%), congenital malformations (12%),
respiratory diseases (8%), external causes (mainly
accidents) (4%), and infectious and parasitic diseases
(such as septicaemia, meningococcal infection and
congenital syphilis) (4%) (See Table 6). The rate of
deaths due to respiratory diseases and infectious and
parasitic diseases was particularly high for Aboriginal
and Torres Strait Islander infants, and was between five
times higher (for infectious and parasitic diseases) and
eleven times higher (for respiratory diseases) than nonAboriginal and Torres Strait Islander infants.
Table 6
Causes of infant death by
Aboriginal and Torres Strait
Islander status, Queensland,
Western Australia, South
Australia and the Northern
Territory, 2002–06
Source: AIHW analysis of National
Mortality Database
Cause of death
Indigenous
Non-Indigenous
Rate ratio
Deaths per 1,000 live births
Certain conditions originating in the perinatal
period (P00–P96)
5.7
2.1
2.7*
Symptoms, signs, and abnormal clinical findings
n.e.c. (R00-R99)
2.7
0.5
5.7*
SIDS (R95)
1.1
0.2
5.4*
Congenital malformations, deformations and
chromosomal abnormalities (Q00–Q99)
1.5
1.0
1.5*
Diseases of the respiratory system (J00–J99)
0.9
0.1
8.6*
External causes (injury & poisoning) (V01–Y99)
0.5
0.1
3.8*
Certain infectious and parasitic diseases (A00–B99)
0.3
0.1
4.2*
Diseases of the circulatory system (I00–I99)
0.2
0.1
3.1*
Other conditions(a)
0.5
0.3
1.8*
12.3
4.2
2.9*
Total
* Represents results with statistically significant differences in the Indigenous/non-Indigenous
comparisons at the p < 0.05 level.
Other conditions include: neoplasms (C00–D48); diseases of blood and blood-forming organs (D50–D89);
endocrine, nutritional and metabolic diseases (E00–E89); mental and behavioural disorders (F00–F99);
diseases of the nervous system (G00–G99); diseases of the eye and adnexa (H00–H59); diseases of
the ear and mastoid process (H60–H95); diseases of the digestive system (K00–K93); diseases of the
musculoskeletal system and connective tissues M00–M99); diseases of the genitourinary system N00–
N99); and diseases of the skin and subcutaneous tissue (L00–L99).
Note: Data are reported for Queensland, Western Australia, South Australia and the Northern Territory
only. These four states and territories are considered to have adequate levels of Indigenous identification
in mortality data. They do not represent a quasi-Australian figure.
78
Health of Indigenous Children: Health Assessment in Action Health of Aboriginal and Torres Strait Islander Children in Australia
Sudden Infant Death Syndrome (SIDS)
The rate of SIDS among the total Australian infant
population has decreased significantly over the past two
decades from 17.9 per 10,000 live births in the period
1980–90 to 11.5 per 10,000 live births in the period
1997–2002. However, these decreases have not been
observed among the Indigenous population. Given
the inaccuracies and lack of inclusion of Indigenousspecific information in statutory and administrative
data-sets, there is no available national information
describing the rates of Indigenous SIDS. However, a
total population study that included all deaths that had
occurred in Western Australia between 1980 and 2002,
reported that the rate of SIDS among non-Aboriginal
and Torres Strait Islander infants had decreased
significantly over this period, from 1.3/1000 live births
to 0.6/1000 live births. However, a similar decrease
was not observed among Aboriginal and Torres Strait
Islander infants: 4.9/1000 live births to 4.7/1000 live
births over the same time period. This slower decrease
among Aboriginal and Torres Strait Islander infants
relative to non-Aboriginal and Torres Strait Islander
infants resulted in an increase relative risk (RR= 7.9).3
There are a number of factors that are associated
with an increased risk of SIDS, including sharing
sleep surfaces, maternal smoking, infant exposure
to environmental smoke, overcrowding in homes,
prematurity and lack of breast feeding. These factors are
proportionately more prevalent among the Indigenous
population. It is therefore critical that well-resourced
education campaigns led by Indigenous people are
instigated in order to reduce these unexpectedly high
rates of SIDS.
Childhood deaths
Child mortality rates should be interpreted with
caution due to the small number of deaths each year
of Aboriginal and Torres Strait Islander and other
Australian children. The quality of death data is only
acceptable in Western Australia, South Australia, the
Northern Territory and Queensland (after 1998) (See
Table 7). Available data report that Aboriginal and
Torres Strait Islander children are three times more
likely to die in the first eighteen years of life compared
with non-Aboriginal and Torres Strait Islander
children. The disparities varied according to the age
group: one to four years, rate ratio 2.8; five to twelve
years, rate ratio 2.3; thirteen to eighteen years, rate
ratio 2.8.
Deaths among children aged 1–4 years
For the period 2002–06, an Aboriginal and Torres Strait
Islander boy aged one to four years was 2.6 times more
likely to die than a non-Aboriginal and Torres Strait
Islander boy. An Aboriginal and Torres Strait Islander
girl was 2.9 times more likely to die than
a non-Aboriginal and Torres Strait Islander girl.17
There has been a statistically significant reduction in
all-cause mortality rates, particularly in children aged
less than five years in the Northern Territory and
Western Australia2, 40.
Deaths among children aged 5–12 years
For the period 2002-06, an Aboriginal and Torres Strait
Islander boy was 2.2 times more likely to die than a
non-Aboriginal and Torres Strait Islander boy. For the
same period an Aboriginal and Torres Strait Islander
girl was 2.1 times more likely to die than a nonAboriginal and Torres Strait Islander girl.
Deaths among children aged 13–18 years
For the period 2002–06, an Aboriginal and Torres Strait
Islander boy was 2.7 times more likely to die than a
non-Aboriginal and Torres Strait Islander boy. For the
same period an Aboriginal and Torres Strait Islander
girl was three times more likely to die than a nonAboriginal and Torres Strait Islander girl.
Causes of deaths among children
For the period 2002–06, the death rate from external
causes (such as transport accidents, accidental
drowning, assault and intentional self-harm) was
Indigenous
Males
Females
Non-Indigenous
All
Males
Females
All
Deaths per 100,000
0
1,452.8
1,028.9
1,246.3
447.7
390.4
419.9
1–4
70.9
62.2
66.6
26.9
21.3
24.2
5–12
27.5
19.1
23.4
11.4
9.0
10.2
13–18
44.8
26.6
35.9
16.5
8.6
12.7
Total
97.1
67.9
82.8
31.2
23.5
27.5
Health of Aboriginal and Torres Strait Islander Children in Australia Table 7
Deaths of children, age
group and Indigenous
status, Queensland, Western
Australia, South Australia
and the Northern Territory,
2002–06
Source: AIHW analyses of AIHW
National Mortality Database
Health of Indigenous Children: Health Assessment in Action
79
Source: CRCAH-Cooperative
Research Centre for Aboriginal
Health, Darwin
around three times higher for Aboriginal and Torres
Strait Islander children (between six and eleven per
10,000 population) than for non-Aboriginal and Torres
Strait Islander children (between one and three per
10,000 population) in Queensland, Western Australia,
South Australia and the Northern Territory. Deaths
due to accidental drowning continued to be prevalent
among Aboriginal and Torres Strait Islander children.
Aboriginal and Torres Strait Islander children also died
from infectious and parasitic diseases and diseases
Table 8
Deaths of children aged
0-4 years, by main cause
of death and Indigenous
status, Queensland, Western
Australia, South Australia
and the Northern Territory,
2002–06
Source: AIHW analyses of AIHW
National Mortality Database
of the respiratory and circulatory system at three to
six times the rate of non-Aboriginal and Torres Strait
Islander children. Tables 8 and 9 show the main causes
of death according to the International Classification of
Diseases version 10 for children aged between zero and
four (See Table 8) and for children aged between five
and eighteen (See Table 9), highlighting the differences
between the rates of death for Aboriginal and Torres
Strait Islander children compared with non-Aboriginal
and Torres Strait Islander children.
Indigenous
Males
Females
Non-Indigenous
All
Males
Females
All
Deaths per 100,000
Certain conditions originating in the
Perinatal period (P00–P99)
134.7
96.1
115.8
43.5
39.4
41.5
Symptoms, signs and abnormal findings
n.e.c. (R00–R99)
71.7
48.6
60.4
12.6
9.2
11.0
Congenital malformations, deformations
and chromosomal abnormalities (Q00–Q99)
35.8
31.6
33.8
22.5
19.3
20.9
External causes (injury & poisoning)
(V01–Y98)
40.2
24.9
32.7
12.0
10.0
11.0
Diseases of the respiratory system (J00–J99)
26.1
17.0
21.6
3.1
2.9
3.0
Diseases of the nervous system (G00–G99)
10.9
11.3
11.1
3.9
3.5
3.7
Certain infectious and parasitic diseases
(A00–B99)
8.7
10.2
9.4
2.5
2.0
2.2
Diseases of the circulatory system (I00–I99)
8.7
5.7
7.2
2.3
1.5
1.9
15.2
11.3
13.3
7.8
6.3
7.1
351.9
256.5
305.2
110.1
94.1
102.3
Other causes
(a)
Total
Other causes includes: neoplasms (COO–D48); diseases of the blood and blood-forming organs and
certain disorders involving the immune mechanism (D50–D89); endocrine, nutritional and metabolic
diseases (E00–E89); mental and behavioural disorders (F00–F99); diseases of the eye and adnexa (H00–
H59); diseases of the ear and mastoid process (H60–H95); diseases of the digestive system (K00–K93);
diseases of the skin and subcutaneous tissue (L00–L99); diseases of the musculoskeletal system and
connective tissue (M00–M99); and diseases of the genitourinary system (N00–N99).
(a)
80
Health of Indigenous Children: Health Assessment in Action Health of Aboriginal and Torres Strait Islander Children in Australia
There is evidence that improved access to
primary healthcare can impede increasing
preventable mortality rates. Such programs
must be supported by well-constructed and
well-resourced secondary prevention and
health promotion programs
Injuries
Rates of injury mortality and hospital admission
due to injury are substantially higher for Aboriginal
and Torres Strait Islander Australians than for the
Australian population as a whole.11 Children aged
zero to fourteen years are known to be particularly
vulnerable to injury, but very little is known about the
nature and extent of injury to Indigenous children.
Injury issues that confront children in Aboriginal and
Torres Strait Islander communities are more complex
Indigenous
Males
Females
Non-Indigenous
All
Males
Females
All
Deaths per 100,000
External causes (injury and poisoning)
(V01–Y98)
42.4
23.6
33.3
14.7
6.7
10.8
Symptoms, signs and abnormal findings
n.e.c. (R00–R99)
4.8
1.7.
3.3
0.6
0.6
0.6
Diseases of the circulatory system (I00–I99)
3.6
2.5
3.1
0.8
0.4
0.6
Neoplasms (C00–D48)
3.2
2.5
2.9
2.8
2.8
2.8
Diseases of the nervous system (G00–G99)
2.4
2.1
2.3
1.5
0.9
1.2
Other causes
4.8
5.5
5.1
2.6
2.2
2.4
61.2
38.0
49.9
22.9
13.7
18.4
Total
(a)
Table 9
Deaths of children aged
5–18 years, by main cause
of death and Indigenous
status, Queensland, Western
Australia, South Australia
and the Northern Territory,
2002–06
Source: AIHW analyses of AIHW
National Mortality Database
Other causes includes: infectious and parasitic diseases (A00–B99); diseases of the blood and bloodforming organs and certain disorders involving the immune mechanism (D50–D89); endocrine,
nutritional and metabolic diseases (E00–E89); mental and behavioural disorders (F00–F99); diseases
of the eye and adnexa (H00–H59); diseases of the ear and mastoid process (H60–H95); diseases of the
respiratory system; diseases of the digestive system (K00–K93); diseases of the skin and subcutaneous
tissue (L00–L99); diseases of the musculoskeletal system and connective tissue (M00–M99); diseases
of the genitourinary system (N00–N99); pregnancy, childbirth and the puerperium (O00–O99); certain
conditions originating in the perinatal period (P00–P96); and congenital malformations, deformations
ad chromosomal abnormalities (Q00–Q99).
(a)
Health of Aboriginal and Torres Strait Islander Children in Australia Health of Indigenous Children: Health Assessment in Action
81
Pictured: Darheio
than those commonly experienced within the general
population, and are related to Aboriginal and Torres
Strait Islander social disadvantage, poverty and general
ill health. Aboriginal and Torres Strait Islander children
may be put at risk through living in an overcrowded
home environment, economic deprivation, high stress
levels and recurring domestic violence.26
Between 2001 and 2003, Aboriginal and Torres
Strait Islander children aged zero to fourteen years
experienced a 2.5 times higher average injury mortality
rate compared with non-Aboriginal and Torres Strait
Islander children.41 In 2004–05, Aboriginal and Torres
Strait Islander children under four years were nearly
1.5 times more likely to be hospitalised as a result of
injuries, poisoning and other external causes than
non-Aboriginal and Torres Strait Islander children
82
Health of Indigenous Children: Health Assessment in Action (See Figure 6).26 Aboriginal and Torres Strait Islander
children had a higher hospitalization rate for injuries
from burns and scalds (approximately 2.3 times higher),
assault and traffic-related pedestrian injury (two times
higher) compared with other Australian children.41
Suicide and self-harm
Suicide is influenced by a complex set of factors as
indicated by the significant differences that exist
in suicidal behaviour not only between Aboriginal
and Torres Strait Islander and non-Aboriginal and
Torres Strait Islander populations, but also between
different Indigenous communities.42 These factors
include the history of disposition, removal from
family, discrimination, resilience, social capital and
socioeconomic factors.26 Evidence suggests that
Health of Aboriginal and Torres Strait Islander Children in Australia
Aboriginal and Torres Strait Islander suicide is most
common among young men, while suicide attempts are
reported to be more common among women.43,44
Mental and behavioural disorders are often
associated with an increased risk of self-harm, as is
alcohol and substance abuse.45 Environmental risk
factors have also been associated with a higher rate of
suicide. Relevant family factors have included parents
who are substance dependent, have been imprisoned
or have violent tendencies, particularly if this translates
into family violence.26
In the period 2001 to 2005, after taking into account
the different age structures in the Aboriginal and Torres
Strait Islander and non-Aboriginal and Torres Strait
Islander populations, data from Queensland, Western
Australia, South Australia and the Northern Territory
reported that suicide rates among all Aboriginal
and Torres Strait Islander males were significantly
higher (between 32.3 and 84.9/100,000) than for
non-Aboriginal and Torres Strait Islander males
(between 17.0 and 25.8/100,000) and also higher for all
Aboriginal and Torres Strait Islander females (between
6.2 and 21.0/100,000) compared with non-Aboriginal
and Torres Strait Islander females (between 4.3 and
5.1/100,000).26
For Indigenous males aged 0–24 years, the agespecific rates were three times the corresponding agespecific rates for non-Indigenous males. The suicide
rate for Indigenous females aged 0–24 years was five
times the corresponding age-specific rates for nonIndigenous females.17
In 2005, suicide was the second leading cause of
death (after transport accidents) for people aged
15–24 years, accounting for 22.2% of deaths in this
age group.26
Hospital admissions
In 2005-06, Aboriginal and Torres Strait Islander
infants were 1.4 times more likely to be admitted
to hospital compared with non-Aboriginal and
Torres Strait Islander infants. For skin diseases,
respiratory conditions, and infectious and parasitic
diseases Aboriginal and Torres Strait Islander infants
were around three to four times more likely to be
admitted to hospital than other infants. In 2005-06,
Aboriginal and Torres Strait Islander children aged
one to fourteen years were 1.3 times more likely
to be admitted to hospital than other Australian
children. Diseases of the respiratory system were the
major cause of hospitalization for these Aboriginal
and Torres Strait Islander children.17 Most of the
conditions resulting in Aboriginal and Torres Strait
Islander infants and young children being admitted
to hospital are related to poverty, housing and
environmental conditions.26
3.6 Other health conditions
Long term health conditions in childhood
Similar proportions of Aboriginal and Torres Strait
Islander and non-Aboriginal and Torres Strait Islander
children had long-term health conditions, the main
being diseases of the respiratory, ear and mastoid,
eye and adnexa, skin and subcutaneous tissue and
the nervous systems. There were similar percentages
of respiratory morbidity in both populations in the
years 2004-05. However, Aboriginal and Torres Strait
Islander children were more likely to suffer from
asthma (14% compared with 11%) and/or bronchitis
(2% compared with 1%) and more likely to have ear/
hearing problems especially partial deafness (5%
Indigenous
Other
Figure 6
Rates of children
hospitalized for injuries,
2004-05
Source: SCRGSP 2007
0
50
100
150
200
250
300
Children Aged < 4 years
Rate / 1000
Health of Aboriginal and Torres Strait Islander Children in Australia Health of Indigenous Children: Health Assessment in Action
83
compared with 1%) and /or otitis media (4% compared
with 2%).
Asthma
Asthma is the second most common self-reported
illness among Aboriginal and Torres Strait Islander
Australians. According to the report Asthma in
Australia 2008 46 when compared to the non-Aboriginal
and Torres Strait Islander population Aboriginal people:
• have a higher prevalence of asthma, particularly
among older people, children and those living in
non-remote localities
• have a higher rate of mortality due to asthma
• have higher rates of hospitalization for asthma
• are less likely to use inhaled corticosteroids for
asthma, at least among children.
In the years 2004–05, the age-standardised
prevalence of asthma for those who have ever been
diagnosed was 24% (95% CI: 21.5–26.6) for Aboriginal
and Torres Strait Islander children aged zero to
seventeen years compared to 21.3 (95% CI: 19.9–22.7)
for non-Aboriginal and Torres Strait Islander children.
The age-standardised prevalence of current asthma
in the same period was 13.5% (95% CI: 11.9–15.1)
for Aboriginal and Torres Strait Islander children
aged zero to seventeen years compared to 11.2% (95%
CI: 10.1–12.3) for non-Aboriginal and Torres Strait
Islander children.46
Asthma in Australia 2008, also shows that
Aboriginal and Torres Strait Islander infants aged
up to one year have a higher prevalence of asthma
when compared to non-Aboriginal and Torres Strait
Islander infants. However, as diagnosis in this age
group is uncertain, it is possible that these figures
are inflated because it is not uncommon in this age
group for other respiratory conditions, especially,
bronchiolitis to be diagnosed as asthma. It is also
well known that the Aboriginal and Torres Strait
Islander population suffers significantly higher
rates of bronchiolitis.46
Rheumatic fever
Acute rheumatic fever and rheumatic heart disease are
now rare in populations with good living conditions
– optimal living conditions and minimal household
overcrowding – and easy access to quality medical
care (things that many Aboriginal and Torres Strait
Islander people often lack). With this in mind, it is
disturbing to note that in remote communities in
the Northern Territory, 1–3% of the population has
established rheumatic heart disease generally as a
result of cumulative damage from repeated episodes of
acute rheumatic fever. Rheumatic fever was commonly
84
Health of Indigenous Children: Health Assessment in Action seen in the non-Aboriginal and Torres Strait Islander
child population in all Australian urban centres in
the first half of the twentieth century. Today there are
continuing high rates of acute rheumatic fever among
Aboriginal and Torres Strait Islander children, largely
as a result of overcrowding and poor living conditions
and a very high level of exposure to group
A streptococci infections.47
In a retrospective review from the Northern
Territory there were 555 episodes of acute rheumatic
fever in 367 people, of which 543 were episodes in 355
Aboriginal and Torres Strait Islander patients, nearly
all from remote Aboriginal and Torres Strait Islander
communities. None of the twelve non-Aboriginal
and Torres Strait Islander patients had a recurrence,
whereas 39.2% of the episodes in Aboriginal and Torres
Strait Islander children were recurrent among 107
individuals with previously diagnosed rheumatic fever
or rheumatic heart disease.48
Oral health
The Australian Institute of Health and Welfare (AIHW)
reports that a higher percentage of Aboriginal and
Torres Strait Islander children had experienced
dental caries than other Australian children at all
ages between four and fourteen years, with the most
affected being in socially disadvantaged groups and
those living in rural / remote areas. Aboriginal and
Torres Strait Islander children under five had almost
one-and-a-half times the hospitalization rate for dental
care as other Australian children, and the rate of these
admissions increased with increasing remoteness. They
also had consistently higher levels of dental caries in
the deciduous or ‘baby teeth’ (extensive in many remote
communities) and permanent dentition than their
non-Aboriginal and Torres Strait Islander counterparts
and the prevalence of caries is rising particularly in the
deciduous dentition.49
Ear health
Aboriginal and Torres Strait Islander children
are reported as having ear and hearing problems
approximately twice as often as non-Indigenous
children. This is due in part to high rates of otitis
media (middle ear infection) among children in many
Aboriginal and Torres Strait Islander communities.50
Results of the 2004–05 National Aboriginal and Torres
Strait Islander Health Survey (NATSIHS) show that
the prevalence of hearing loss / diseases of the ear was
10% for Aboriginal and Torres Strait Islander children
aged zero to fourteen years, compared with only 3%
of non-Indigenous children.27 A recent study identified
an association between a child’s exposure to tobacco
Health of Aboriginal and Torres Strait Islander Children in Australia
30
Prevalence of current asthma (%)
Indigenous
Males
Non-indigenous
25
20
15
10
5
0
30
0-14
15-34
35-54
55 & over
Prevalence of current asthma (%)
Indigenous
Females
Non-indigenous
25
20
15
10
5
0
0-14
15-34
35-54
55 & over
Note: Age-standardized to the Australian population as at June 2001.
Source: Australian Centre for Asthma Monitoring (ACAM) analysis of the Australian Bureau of Statistics (ABS) National Aboriginal and Torres Strait
Islander Health Survey (NATSIHS) and National Health Survey (NHS) 2004-05, expanded confidentialised unit record files, Remote Access Data
Laboratory.
Figure 8
Prevalence of current
asthma by age, sex and
Indigenous status, 2004–05
Source: Asthma in Australia46
smoke in the home (and not attending organised
childcare) and an increased risk of otitis media.51
Eye health
Trachoma is a disease of early childhood and if
untreated leads to significant vision impairment and
blindness. Trachoma is the most common cause of
infectious blindness, with Australia being the only
developed country to still have blinding endemic
trachoma. A review of the National Aboriginal and
Torres Strait Islander Eye Health Program in northern
and western Australia in 2003 found prevalence of
active trachoma (>20%) similar to those of thirty
years ago.52 Studies have identified a maximum
age-specific infection in pre-school Aboriginal and
Torres Strait Islander children, but there are also
considerable rates of active trachoma into the teenage
years. Studies have also identified that between 20%
Health of Aboriginal and Torres Strait Islander Children in Australia and 30% of Indigenous children in rural and remote
Australia have active trachoma. Trachoma can be
treated by antibiotics and can be prevented through
health promotion and education that highlights the
importance of face washing and facial cleanliness and
improved environments and health hardware.53
Immunization
There are varying estimates of the level of
immunization coverage among Aboriginal and Torres
Strait Islander children. Coverage varies from being
much lower to being the same as non-Aboriginal and
Torres Strait Islander children. In general, vaccination
coverage tends to be higher among Aboriginal and
Torres Strait Islander children living in remote areas
compared with those living in non-remote areas.
However, there are concerns as to the adequacies in
data collection because estimates are drawn from a
Health of Indigenous Children: Health Assessment in Action
85
Pictured:
Hiarnz & Darheio
number of sources and different methods can be used
to ascertain the level of coverage among Aboriginal
and Torres Strait Islander children. Data suggests that
Aboriginal and Torres Strait Islander at twelve months
of age had lower vaccine coverage compared with
non-Aboriginal and Torres Strait Islander children at
the same age (82% compared with 91%), whereas at
twenty-four months of age they had the same level of
coverage as other Australian children (90.9% compared
with 91.3%).54
Mental health
There is a paucity of data to describe the mental health
and wellbeing of Aboriginal and Torres Strait Islander
children. The Western Australian Aboriginal Child
Health Survey (WAACHS), conducted in 2001 and
2002, found that:
• 24% of Aboriginal and Torres Strait Islander children
were at high risk of clinically significant emotional or
behavioural difficulties compared with 15% of nonAboriginal and Torres Strait Islander children.36
• more than one in five (22%) Aboriginal and Torres
Strait Islander children aged zero to seventeen years
were living in families where between seven and
fourteen major life stress events had occurred in the
twelve months prior to the survey.55
• the proportion of children at high risk of clinically
significant emotional or behavioural problems was
lowest in areas of extreme isolation.55
86
Health of Indigenous Children: Health Assessment in Action • stronger adherence to traditional culture and ways
of life in extremely isolated areas may be a protective
factor.55
• of the Aboriginal and Torres Strait Islander young
people aged twelve to seventeen years who were
surveyed, 9.0% of females and 4.1% of males had
attempted suicide in the past twelve months.56
• the children of Aboriginal and Torres Strait Islander
carers who had been forcibly separated from their
natural families by a mission, the government or
welfare were more than twice as likely to be at high
risk of clinically significant emotional or behavioural
difficulties.55
Child abuse and neglect
The relationship between child abuse and neglect and
child health and wellbeing is complex and related to
the type, severity and duration of the abuse and neglect
and to the context in which it occurs. As in nonAboriginal and Torres Strait Islander communities,
it is commonly believed that child abuse and neglect
in Aboriginal and Torres Strait Islander communities
are caused by a multitude of factors However, the
Indigenous perspective usually places considerably
more emphasis on the impact of the wider community
and societal causal factors.57 Memmot suggests these
factors include: precipitating causes (one or more
events triggering a violent episode); underlying factors
(historical circumstances); and situational factors (such
Health of Aboriginal and Torres Strait Islander Children in Australia
as the combination of alcohol abuse, unemployment,
and welfare dependency).
A number of prominent Indigenous spokespersons
believe that present dysfunctional behaviour in some
Indigenous communities, including the abuse and
neglect of children, is grounded in unresolved grief
associated with multiple layers of trauma that has
spanned many generations.58-60
The report, Bringing Them Home drew attention
to the fact that violence may also be transmitted by
omission. The past forced separation of Indigenous
children from their families and communities has
resulted in a loss of parenting skills and abilities12, thus
increasing the likelihood of the involvement of child
protection services in Aboriginal families.61
It is clear that Aboriginal and Torres Strait
Islander children are significantly over-represented
in most statutory child protection systems. Based
on notifications (or reports) to child protection
departments in Australia in 2001–02, 3,254 Aboriginal
and Torres Strait Islander children under seventeen
years had some form of abuse substantiated—that is,
the statutory protection authority believed that abuse
or neglect had occurred.62 This rate of substantiation
was on average 4.3 times higher (for all types of abuse)
in the Aboriginal and Torres Strait Islander population
than in the non-Aboriginal and Torres Strait Islander
population. The rate varied widely between states, with
Victoria and Western Australia having a substantiation
rate nearly eight times higher for Aboriginal and Torres
Strait Islander children than non-Aboriginal and Torres
Strait Islander children.
Aboriginal and Torres Strait Islander children are
six times more likely to be removed from their families
than other Australian children63, a situation that has
changed little since this problem was identified in
1979 at the First Aboriginal Child Survival Seminar.64
Aboriginal and Torres Strait Islander children comprise
2.7% of children in Australia, yet constitute 20% of
those placed in out-of-home care.61
3.7 Access to health care
There is very little information detailing issues of
Aboriginal and Torres Strait Islander children’s
access to health care at a national level. The most
comprehensive information available is at the Western
Australian state level from the WAACHS.
The WAACHS survey found that Aboriginal
children had fewer contacts with doctors when
compared with non-Aboriginal and Torres Strait
Islander children. This difference becomes greater the
more isolated children are. The more isolated children
were, the less likely they were to see a doctor and more
Health of Aboriginal and Torres Strait Islander Children in Australia likely to see a nurse or Aboriginal Health Worker.65 The
survey also found that:
• Aboriginal and Torres Strait Islander children have a
very low attendance for dental care
• Aboriginal and Torres Strait Islander children
attended accident and emergency health care at
similar rates to non-Aboriginal and Torres Strait
Islander children, regardless of location
• Aboriginal and Torres Strait Islander children had
a higher overall hospitalization rate compared to
non-Aboriginal and Torres Strait Islander children.
However, the reasons for admission were similar,
with the most common causes of hospitalization
for all children being respiratory illnesses, other
infections and injuries
• the hospitalization rate for people who live in very
remote areas of Australia is almost 50% higher than
that for people living in major cities.65
3.8 Health Expenditure
Over one-quarter of Aboriginal and Torres Strait
Islander peoples live in remote and very remote areas
in Australia.66 As such, and in order to experience the
same level and quality of care as their Aboriginal and
Torres Strait Islander and non-Aboriginal and Torres
Strait Islander urban counterparts, an increase in health
care expenditure per capita must occur.
In 2004–05, $1.17 per person was spent on
Aboriginal and Torres Strait Islander healthcare for
every $1.00 spent on the health of non-Aboriginal
and Torres Strait Islander health. Average total health
expenditure per Aboriginal and Torres Strait Islander
person was $4,718 compared with $4,019 per person
estimated for non-Aboriginal and Torres Strait Islander
people. It was also estimated that $2,304 million was
expended on health care in 2004–05 for Aboriginal
and Torres Strait Islander people. This was 2.8% of the
total national expenditure on health services. Further,
when compared to non-Aboriginal and Torres Strait
Islander people, Aboriginal and Torres Strait Islander
people used public hospital and community health
services more, and used less medical, pharmaceutical,
dental and other health services. However, accurate
and consistent Aboriginal and Torres Strait Islander
identification continues to be a major barrier to precise
estimates of Aboriginal and Torres Strait Islander use of
health care.66
3.9 Data limitations
Currently, Indigenous people are relatively invisible in
global health statistics due to major deficiencies in the
health data describing them. Such deficiencies have
been acknowledged in New Zealand,67-69 Canada and
Health of Indigenous Children: Health Assessment in Action
87
Statutory data are data that are
regulated or imposed by or in
conformity with laws passed. They
include vital statistics data.
(1)
Administrative data are
data collected as part of the
administrative process generally
for audit purposes.
(2)
the United States and in a number of Australian states
and territories. These deficiencies are in part due to
misclassification of Indigenous people; inconsistencies in
the collection, sources, completeness and classifications
in statutory(1) and administrative(2) data collections; and
inconsistencies in analysis, interpretation and ownership
of the data in each jurisdiction.
Prior to 1976, no Australian jurisdiction separately
identified Aboriginal and Torres Strait Islander people
in vital statistics or hospital-based collections. In 1984,
the Australian Government initiated moves to identify
all Aboriginal and Torres Strait Islander Australians in
births and deaths data collections. By the end of 1997
all major vital statistics and hospital-based collections
included the Aboriginal and Torres Strait Islander
status of people who are born, die or are admitted to
hospital in every state and territory. However, there is
an acknowledged under-identification of Aboriginal
and Torres Strait Islander people in statutory and
administrative data collections due to a general lack of
recognition of the importance of collecting accurate
data, ineffective processes for the collection of data
and the absence of mandates to ensure that accurate
data are collected. Thus, the complete ascertainment
of Aboriginal and Torres Strait Islander people is
questionable. Those states where the ascertainment is of
concern are Victoria, New South Wales, the Australian
Capital Territory, Tasmania and Queensland (before
1998), which makes it impossible to provide a complete
and accurate profile of the mortality of Australia’s
Aboriginal and Torres Strait Islander people.5
Mortality statistics are important indicators of a
population’s health, as they provide vital information
on the prevalence of serious diseases and injuries.
Studies of the trends in mortality and related statistics
also demonstrate how the health status of a population
is changing, and enable the effect of health policies,
services and interventions to be monitored and
evaluated. The lack of ascertainment and accuracy in
these collections is of great concern because mortality
data is one of the most important ways of measuring
community health. Important information about
the patterns of illness and deaths for the community
as a whole become available when details about the
deaths in the community are disaggregated. The excess
burden of mortality borne by young Aboriginal and
Torres Strait Islander Australians, and the disparity in
the rates of infant and childhood mortality that exists
between Aboriginal and Torres Strait Islander and nonAboriginal and Torres Strait Islander Australians, has
been reported in the Northern Territory and in the two
states (South Australia and Western Australia) that have
accurate mortality data.
Notwithstanding these limitations, the magnitude of
health disparities in Aboriginal and Torres Strait Islander
child populations is concerning. Perhaps equally
worrying is that these disparities have not reduced in
recent years and, in many cases, are increasing.
3.10 Examples of positive initiatives
The health status of Aboriginal and Torres Strait
Islander people is significantly poorer than for
Australians as a whole. However, there have been
some improvements. Data indicates that the
increase in death rates for many chronic diseases is
slowing and that deaths due to infectious diseases
have significantly declined. Improvements have
been identified across all age groups, but are most
dramatic in the under-five age group. These results
show evidence of health gain and that interventions
can make a difference. They demonstrate clearly
that improved access to primary healthcare can
impede increasing preventable mortality rates. Such
programs must be supported by well-constructed
An Aboriginal and Torres Strait Islander
boy was two-and-a-half times more likely to
die in the first year of his life than a nonAboriginal and Torres Strait Islander boy,
and an Aboriginal and Torres Strait Islander
girl was three-and-a-half times more likely
to die than a non-Aboriginal and Torres
Strait Islander girl.
88
Health of Indigenous Children: Health Assessment in Action Health of Aboriginal and Torres Strait Islander Children in Australia
Healthy for Life is an Australian Government initiative that commenced during the 2005–06
budget cycle.
The four year program, with an allocated budget of A$102.4 million, aims to improve the health of
Aboriginal and Torres Strait Islander mothers, babies and children, improve the quality of life for people
with a chronic condition, and over time, reduce the incidence of adult chronic disease .
The program is based strongly around the use of quality improvement principles, processes and tools
to deliver primary maternal, infant and child health care. The first phase of the program has seen
participating services analyze collected information about the child and maternal health and chronic
disease service activity with the purpose of establishing baseline information.
This baseline information has been used to monitor progress in achieving objectives for improvement
in maternal, infant and child health.
The objectives of Healthy for Life are to improve the:
• availability of child and maternal health care
• prevention, early detection and management of chronic disease
• long term health outcomes for Aboriginal and Torres Strait Islander Australians
• Aboriginal and Torres Strait Islander health workforce.
The expected short, medium and long term outcomes include:
Short to medium term outcomes (1–4 years)
• increase in first attendance for antenatal care in first trimester
• 10% increase per year of adult and child health checks, with associated plans for follow-up
• 30% improvement in best practice service delivery for people with chronic conditions.
Longer term outcomes (5–10 years)
• increase in mean birth weight to within 200g of the non-Indigenous population
• decrease in incidence of low birth weight by 10%
• reduction in selected behavioural risk factors (eg smoking, harmful alcohol intake among others)
in pregnancy by 10%
• 30% reduction in hospital admissions for chronic disease complications
• 30% improvement in numbers of patients with intermediate health outcomes within acceptable range.
and well-resourced secondary prevention and health
promotion programs.
Reliable total population data in some Australian
states and territories provide an excellent resource
in determining the patterns and trends of morbidity
and mortality among Aboriginal and Torres Strait
Islander people.
The authors of this paper have identified a couple of
initiatives that have demonstrated that well-resourced,
community-controlled and culturally appropriate
and accessible programs can, and do, have a positive
impact, and result in significant and sustained
improvement in the health outcomes of Aboriginal
Health of Aboriginal and Torres Strait Islander Children in Australia Text Box 1
Healthy for Life program
people. An important component of any health
improvement program will be the ability to measure
accurately the disparities and to track the impact that
policies, strategies and interventions have on health
outcomes and the reduction of health disparities.
Collection of data
Text Box 1 provides a description of the program
Healthy for Life. Importantly, this program will
contribute not only to an improvement in Aboriginal
and Torres Strait Islander health in the perinatal period
and the early years, but also to the more accurate and
complete collection of vital statistics data describing
Health of Indigenous Children: Health Assessment in Action
89
Text Box 2
The Western Australian
Mortality Database, Infants,
Children and Young People
• The primary source of data was the WA Maternal and Child Health Research Database which is a
comprehensive linked total population data base including comprehensible information describing
birth, death, hospitalizations and the health status for every child born in Western Australia.
• The other data sources include: The Registry of Births, Deaths and Marriages; autopsy case reports;
reports of Coronial enquiries; forensic pathology reports; the Birth Defects Registry.
• The forensic and coronial documents for every death are reviewed and the information informs the
classification of the death and coding of the cause of death.
• A rigorous validation process is undertaken to ensure objectivity and every classification and code is
reviewed by three independent experts to ensure internal validity of the classifications.
• The databases is managed at the Telethon Institute for Child health research, Centre for Child Health
Research, the University of Western Australia.
• The continuing collection, review and analysis of these data has been funded by the Western
Australia government – initially the Department for Community Development and more recently the
Department of Child Protection.
Pictured: Hiarnz
Aboriginal and Torres Strait Islander, maternal, infant
and child health.
The Western Australian Mortality Database,
Infants, Children and Young People
This database includes comprehensive information
describing the death and the context in which the death
has occurred for every child born in Western Australia
between 1980 and 2006. The data from this database
have been rigorously analyzed, and the patterns and
trends of mortality among Western Australian born
infants, children and young people that have occurred
in the last quarter of a century have been widely
reported. The following information describes the
structure and content of this database.
Particular focus has been on describing the change in
the disparities existing among the Indigenous population
when compared with the non-Indigenous population.
These data have informed evidence-based policy, practice
and health information and education initiatives,
particularly the prevention of SIDS and the change in
legislation to allow the fortification of flour with folate
to assist in the prevention of Neural Tube Defects.
‘Closing the Gap on Aboriginal and Torres Strait
Islander disadvantage’
In 2007, the new Federal Government made a
commitment to Close the Gap in Aboriginal and Torres
Strait Islander disadvantage including disparities
90
Health of Indigenous Children: Health Assessment in Action Health of Aboriginal and Torres Strait Islander Children in Australia
• To close the life-expectancy gap between Aboriginal and Torres Strait Islander people and other
Australians within a generation;
• To halve the mortality gap between Aboriginal and Torres Strait Islander children and other children
under age five within a decade;
• To halve the gap in literacy and numeracy achievement between Aboriginal and Torres Strait
Islander students and other students within a decade;
• To halve the gap in employment outcomes for Aboriginal and Torres Strait Islander people within a
decade;
• To at least halve the gap in attainment at Year 12 schooling (or equivalent level) by 2020; and
• To provide all Aboriginal and Torres Strait Islander four year olds in remote communities with access
to a quality preschool program within five years.
• Commonwealth of Australia, 2008 Statement by the honourable Jenny Macklin MP Minister for
Families, Housing, Community Services and Indigenous Affairs. Closing the gap between Indigenous
and non-Indigenous Australians.
that exist between the Aboriginal and Torres Strait
Islander populations and other Australians in all
the social determinants of health. The Close the Gap
campaign, launched in 2007 was centred on two goals.
The first being to drive existing Australian, state and
territory government commitments targeted at ending
Aboriginal and Torres Strait Islander health inequality
with added accountable timeframes. The second being
the development of a set of ‘Close the Gap Indigenous
Health Equality Targets’. In 2008, the Australian
Government allocated $AU 425.3 million in new funds
in the 2008-09 Budget specifically addressing the Closing
the Gap targets. The Australian Government has also
agreed to an annual regimen of reporting the progress
on reducing the gap of inequality. The threat to being
able to measure the success or failure of the campaign
lies with the ability to accurately measure progress to the
targets set. Text Box 3 identifies the specific targets.
3.11 Conclusion
‘[T]he time is right for a global response to improve the
health and well-being of Indigenous peoples’ (Assembly
of First Nations, Discussion Paper, p.40)70
Significant efforts and resources have been devoted
to improving the health of Indigenous infants, children
and young people in Australia, Canada, New Zealand
and the United States of America over the past decade.
There have been improvements in some educational
and health outcomes for Indigenous children. However,
Health of Aboriginal and Torres Strait Islander Children in Australia even in the face of these improvements, Indigenous
children continue to fare worse than their nonIndigenous counterparts and disparities continue to
exist among Indigenous populations. Many of these
disparities reflect the historic, economic and social
circumstances of Indigenous communities. These
continuing and in some cases widening disparities,
should challenge us all to do whatever is necessary
and to commit whatever resources at whatever cost, to
remedy the causes of Indigenous disadvantage.
Too often Indigenous people and their social
conditions are invisible. Much better data and quality
research on Indigenous health needs to be generated, but
this must be with the specific agreement of Indigenous
communities. This includes the need to take account of
the Indigenous communities’ holistic approaches to, and
understandings of, health and well-being. Indigenous
communities must be been actively involved in deciding
how or what should be studied about them, and for what
purpose. This is particularly important, considering that
many political decisions are made on the basis of this
research and often simplistic interpretations of data.70
Good health, education and social connectedness
in childhood are fundamental to the development
of human potential and to full participation in a
democratic society. Improving the health and well
being across all social determinants and reducing the
disparities that currently exist for Indigenous children
in our society is not an option, it is an imperative.
Text Box 3
Closing the Gap on
Aboriginal and Torres Strait
Islander Disadvantage
Improvements have
been identified across
all age groups among
Aboriginal and
Torres Strait Islander
children, but are
most dramatic in the
under-five age group.
Health of Indigenous Children: Health Assessment in Action
91
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Health of Indigenous Children: Health Assessment in Action
93
4
94
Health of Indigenous Children: Health Assessment in Action Health of Māori Children in Aotearoa / New Zealand
Health of Māori Children in Aotearoa / New Zealand
4.1 Introduction. This report is a background document that outlines Māori child health outcomes in Aotearoa / New Zealand.
It contains an overview of the Māori population, a brief description of the health system in Aotearoa / New Zealand, a
description of the collection and use of ethnicity data, an account of Māori children’s health status, and an outline of the use
of ethnicity data using sudden infant death syndrome as an example.
4.2 MĀori
Māori are the Indigenous peoples of Aotearoa / New
Zealand. Prior to colonization Māori society was
structured around kinship groups – whānau (families),
hapū (sub-tribes) and iwi (tribes). The colonization
of Aotearoa / New Zealand commenced in the late
1700’s and progressed at a more rapid rate after the
signing of the Treaty of Waitangi (the Treaty). The
Treaty formalized the relationship between Māori and
the British monarch and is sometimes referred to as
the ‘founding document’ of New Zealand. It forms the
basis of the relationship between Māori (the collective
group) and the government of New Zealand (as the
representative of the Monarch). There has been, and
continues to be, considerable debate about the Treaty,
its implementation, and its relevance to contemporary
Aotearoa / New Zealand. Historical and contemporary
claims regarding breaches of the Treaty are heard by
the Waitangi Tribunal, which is able to make findings
about alleged breaches and, where claims are upheld,
recommend actions to address the breaches. The
recommendations it makes to government are nonbinding, and the government and the group who made
the claim then enter into negotiations in order to settle
the grievance. Further detailed information about the
colonization of Aotearoa / New Zealand, the Treaty,
and the Waitangi Tribunal may be found in Orange1
and Walker².
Each tribe occupies specific regions in Aotearoa.
Post-colonial settlements (rural, towns, and cities) are
contained within traditional tribal areas. For example,
the greater Auckland region, which includes Auckland
City and contains about one-third of the population
of Aotearoa / New Zealand, is located within the tribal
areas of the Ngāti Whātua and Tainui tribes. There are
no reserves or reservations of the type found in Canada
and the USA.
4.3 The Māori population
In the 2006 census 15% of the population reported
Māori ethnicity – a total of 565,329 people. Just over
half (52.8%) only identified Māori as their ethnic
group, with the remainder identifying Māori and at
least one other ethnic group.³
The Māori population is younger than the nonMāori population with a median age of 23 years for
Māori and 36 years for the total population in 2006. In
2006, 35% of the Māori population were under 5 years
of age, and 53% were less than 25 years of age.⁴ Figure 1
presents the population pyramids for Māori and nonMāori, illustrating the younger age structure of Māori
compared to the non-Māori population.
Age group (years)
85+
80-84
75-79
70-74
65-69
60-64
55-59
50-54
45-49
40-44
35-39
30-34
25-29
20-24
15-19
10-14
5-9
0-4
15
Percent
10
Figure 1
Age distributions of the
Māori and non-Māori
populations 2006
Age group (years)
Male
85+
80-84
75-79
70-74
65-69
60-64
55-59
50-54
45-49
40-44
35-39
30-34
25-29
20-24
15-19
10-14
5-9
0-4
Female
5
0
5
Māori
Health of Māori Children in Aotearoa / New Zealand 10
15
Author
Sue Crengle PhD(c)
Senior Lecturer
Te Kupenga Hauora Māori
Director
Tōmaiora Māori Health
Research Centre
Faculty of Medical &
Health Sciences
University of Auckland
Male
Female
Source: Hauora: Māori Standards
of Health IV
10
8
Percent
6
4
2
0
2
4
6
8
10
non-Māori
Health of Indigenous Children: Health Assessment in Action
95
30
Percentage
25
Māori
non-Māori
20
15
10
5
Figure 2
Distribution of deprivation
by ethnicity 2006
Source: Ministry of Health
Māori women
experience both
the ethnic and the
gender income gaps.5
This is particularly
important in relation
to Māori children,
as a substantial
proportion of Māori
children are living
in households
headed by a sole
female adult.
0
1
2
3
4
The Māori population continues to grow and is
predicted to account for 17% of the total population
by 2021. The number of Māori children is expected to
continue to increase, but will do so at a slower rate than
seen in previous years. Predictions suggest that by 2021
the proportion of children in the Māori population will
be smaller than it is currently.⁴
Māori are highly urbanized, and many live outside
their tribal areas. In 2006, 84% of Māori lived in urban
areas. The majority of Māori live in the North Island
(87%) and about 25% of the Māori population live in
the greater Auckland region.³
Just over 23% of Māori reported speaking more
than one language in the 2006 population census. This
percentage is consistent with the proportion of Māori
adults who reported speaking Māori with some degree
of proficiency in the 2006 Māori language survey.
An estimated 9,500 children attended Kohanga
reo (Māori language immersion pre-schools) and
over 26,000 Māori children attended Māori language
medium schools in 2006.
4.4 Social and economic indicators
This section provides a brief overview of Māori
socio-economic status, experience of the wider
determinants of health, and an overview of the living
standards experienced by Māori. These factors are
vitally important in determining the health status
of individuals and families, and are also important
determinants of access to care and health outcomes.
Māori are over-represented in indictors of deprivation
and have poorer access to the social and economic
factors that are important determinants of health.
96
5
6
7
8
9
10
NZ Index of Deprivation decile 2001
Decile 1 = least deprived; decile 10 = most deprived
Health of Indigenous Children: Health Assessment in Action Income
There is a persistent disparity between the incomes
of Māori and non-Māori. The median annual income
for Māori 15 years of age and over was $NZ 20,900 in
2006 while that of non-Māori was $NZ 24,400. The
ethnic income gap is greater than the gender income
gap. Māori women experience both the ethnic and the
gender income gaps.⁵ This is particularly important in
relation to Māori children, as a substantial proportion
of Māori children are living in households headed by a
sole female adult.
27% of Māori children live in poverty (defined
as a household income below 60% of the median
household income), as compared to 16% of NZ
European children.⁵
Deprivation
The New Zealand Index of Deprivation is a small
area (neighbourhood) measure of deprivation.
Small area deprivation is associated with both
mortality and morbidity in Aotearoa / New Zealand.
Using nine variables from the population census,
the index assigns each census mesh block to a
deprivation decile.
The least deprived decile is decile 1, and the most
deprived is decile 10. Theoretically, ten percent of
the population should reside in areas associated
with each decile. However deprivation is not equally
distributed across the population. In 2001 over half
the Māori population lived in areas associated with
the three most deprived deciles. However, less than
one third of non-Māori lived in areas associated with
those deciles. (See Figure 2)
Health of Māori Children in Aotearoa / New Zealand
Education
Evidence suggests that the education system continues
to provide Māori students with lower quality education
than that provided to non-Māori students. Māori
children are more likely to leave school without a
National Certificate of Educational Achievement
(NCEA) qualification. Half (49%) of Māori students
left school without this qualification in 2005, compared
with 22% of non-Māori students. In tertiary education
settings Māori are more likely to be studying for
certificate level qualifications than for degrees.⁵
Employment
A higher proportion of the Māori population is
unemployed with 7.6% of Māori and 2.6% of NZ
European people aged 15 years of age or over
unemployed in June 2007.
Māori who are employed are more likely to work
in service industries and as machine operators and
assemblers. Furthermore, there is evidence that Māori
experience discrimination in getting a job, the type of
jobs they are able to obtain, and the wages paid for a
specific job.⁵
Housing
Quality of housing is an important determinant of
health. Māori are more likely to live in temporary or
rental accommodation and to live in crowded houses.⁵
Living Standards
The living standards experienced by children are
significant determinants of a child’s opportunities for
healthy development. The Economic Living Standard
Index (ELSI) incorporates data from a range of
indicators and measures the living standards of family
units across Aotearoa / New Zealand. In 2000 and 2004
the living standards for Māori were significantly lower
than those of the total population. In 2004, 40% of
Māori families were living in hardship, compared with
19% of European families.
Discrimination
The 2002/03 New Zealand Health Survey asked
participants about their experience of ethnically
motivated discrimination. Māori reported the highest
prevalence of having ‘ever’ experienced discrimination
in the health sector, work environment or when
buying or renting housing. Overall, one third of Māori
reported experiencing discrimination in any one of
these settings. Furthermore, Māori were nearly ten
times as likely to report experiencing discrimination
in all three setting (4.5% compared with 0.5% of
European participants). The reported experience
of discrimination was significantly associated with
adverse health outcomes in relation to self-rated health,
physical functioning, mental health, being a current
smoker, and reporting cardiovascular disease. 6,7
4.5 The health sector in Aotearoa /
New Zealand
The NZ Public Health and Disability Act (2000)
provides for the public funding and provision of
personal health services, public health services,
and disability support services. The first two stated
objectives of the Act are:
(a) to achieve for New Zealanders –
(i) the improvement, promotion, and protection
of their health:
(ii) the promotion of the inclusion and
participation in society and independence of
people with disabilities:
(iii) the best care or support for those in need of
services.
(b)to reduce health disparities by improving the health
outcomes of Māori and other population groups.
The majority of health services in Aotearoa / New
Zealand are publically funded, with private insurance
accounting for a small part of health sector activity.
Services in secondary and tertiary care are free.
Primary care funding includes a contribution from
the government but patients also contribute towards
Māori – the indigenous people of Aotearoa / New Zealand
• In 2006 about 15% of the population were Māori
• The Māori population is younger than the non-Māori population
• In 2006 35% of the Māori population was under 5 years of age and 53% were under 25 years of age
• The Māori population is growing and is predicted to account for 17% of the population by 2021
Health of Māori Children in Aotearoa / New Zealand Health of Indigenous Children: Health Assessment in Action
97
Social and environmental determinants of health
• Māori children are more likely to experience adverse social and environmental determinants of health
• 40% of Māori families live in hardship compared with 19% of European (White)
• 27% of Māori children live in poverty compared to 16% of European children
• Māori are more likely to live in crowded homes
• The education system fails to provide Māori children with the same quality of education as non-Māori
• Māori are more likely to report experiencing discrimination that other population groups in
New Zealand
the cost of seeing a primary care doctor (user partcharges). Following the implementation of primary
health care reforms in 2001 the level of government
subsidy for primary care has increased, and the user
part-charges have been reduced for a substantial
proportion of the population. Health care to children
under six years of age is typically free if the child
attends the General Practitioner who usually provides
their care. Routine childhood immunizations are
free. Prescriptions attract a small charge – ranging
from three to fifteen dollars per item if the drug is
fully subsidized by the government. Prescriptions
for medications that are not fully subsidized by the
government have higher charges.
Māori health service providers (Māori providers)
deliver primary health care and community health
programmes to Māori who choose to access these
services. The number of Māori providers increased
substantially after the implementation of health sector
reforms in 1991 – 1992, and there are now over 200
Māori providers. However, the majority of these
services do not deliver primary medical care services.
The majority of Māori receive care from ‘mainstream’
health services (i.e. not from Māori providers). About
14% of Māori participants in the 2002/03 New Zealand
Health Survey reported using a Māori health provider
in the twelve months prior to their interview⁸. More
detailed accounts of Māori providers may be found
in Crengle⁹; Crengle, Crampton & Woodward10 and
Crengle, Lay-Yee & Davis11.
Specific strategies have been developed and
implemented to assist the health sector to achieve
the objectives of the NZ Public Health and Disability
Act. He Korowai Oranga: Māori Health Strategy was
published by the Ministry of Health in 2002. The
strategy contains four pathways:
• Pathway 1 – development of whānau, hapu, iwi and
Māori communities
• Pathway 2 – Māori participation in the health and
disability sector
98
Health of Indigenous Children: Health Assessment in Action • Pathway 3 – effective health and disability services
• Pathway 4 – working across sectors.
Increasing Māori provider capacity and capability
and developing the Māori health and disability
workforces are included within Pathway 2. Pathway
3 includes addressing health inequalities for Māori;
improving the effectiveness of ‘mainstream’ services
in relation to Māori health; providing highest quality
services; and improving Māori health information.
4.6 Ethnicity data
Improving Māori health status and reducing
inequalities in health outcomes between Māori and
non-Māori are key objectives for the New Zealand
health sector.12, 13 In order to achieve these objectives
we must able to describe and monitor Māori health
outcomes. This requires complete, accurate, reliable,
and valid ethnicity data.
Prior to the 1986 census, for statistical purposes
membership of the Māori population was based on
a biological definition (‘persons greater than half
Māori blood’, ‘persons of half or more Māori blood’).
In 1986 the biological definition of ethnicity used in
the national census was replaced by a definition that
was based on a social construct of ethnicity. However,
ethnicity data relating to births and deaths continued
to use the biological definition until 1995 when this
was also replaced by the social definition.
The definition of ethnic group developed in 1988 by
the Department of Statistics is still in use. According
to this definition (Ministry of Health, 2004 pg.5) an
ethnic group is:
A social group whose members:
• share a sense of common origin
• claim a common and distinctive history and destiny
• possess one or more dimensions of collective
cultural individuality
• feel a sense of unique collective solidarity.
Each individual is able to nominate their ethnic
affiliation(s) – the ethnic group or groups which
Health of Māori Children in Aotearoa / New Zealand
they (or their child) belong to. That is, an individual’s
ethnic affiliation is self-identified, and is not limited
to one ethnic group. Furthermore, an individual’s
ethnic affiliation may vary according to the situation,
circumstances, or manner in which they are being
asked their ethnicity, and may vary over time.
Although the definition of ethnicity has not been
changed for twenty years there have been significant
variations in the manner in which ethnicity data
have been collected and used over those twenty years.
These variations have adversely affected the accuracy,
completeness, reliability and validity of (particularly
Māori) ethnicity data. The utility of the data for
comparison and time series analyses has also been
compromised by regular changes to the ethnicity
question and changes to methods used for classifying
and using ethnicity data.15-23
In recent years strategies such as workforce training
and the development of ethnicity data protocols have
been implemented in order to improve the collection
and use of ethnicity data across the health sector.
Recent evidence suggests that for the period 2001–04
differences in ethnicity counts between the census and
mortality datasets are minimal but hospitalization and
Age group
< 1 year
1 – 4 years
5 – 14 years
cancer registration datasets continue to undercount
the Māori ethnic group.24 The completeness and
accuracy of ethnicity data in primary care is poor and
the differential misclassification of ethnicity in these
databases results in under-enumeration of Māori and
Pacific people.25-27
4.7 Child health status
This section contains a brief overview of Māori
child health outcomes. With few exceptions the data
demonstrates significant disparities in health outcomes
with Māori children experiencing worse outcomes
than non-Māori children.
There are significant ethnic (and gender)
differences in life expectancy at birth. A Māori male
born in 2006 has a life expectancy of 71.2 years (78.8
years for non-Māori males) and Māori females can
expect to live for 75.8 years (82.8 years for non-Māori
females).28
Table 1 presents all-cause mortality rates by age
group for children and young people aged 0–14 years.
In each age group Māori experience higher mortality
rates with the greatest disparity occurring in infants
(under one year).
Māori rate
Non-Māori rate
Rate ratio
95% CI
95% CI
95% CI
840.2
501.3
1.68
777.7 – 907.6
471.4 – 533.1
1.52 – 1.85
40.9
30.1
1.36
34.2 – 48.8
26.6 – 34.1
1.09 – 1.69
22.7
15.4
1.47
19.4 – 26.4
13.9 – 17.1
1.22 – 1.77
Māori children face significant challenges
in health and social outcomes that are
to their opportunities to develop and realise
experienced by Māori children are breaches
their potential. Many of these challenges,
of the rights and protections afforded them
such as socioeconomic disadvantage, poverty,
by the United Nations Declaration of the
and poorer outcomes from health services,
Rights of the Child, Declaration on the
are located within the structures, institutions,
Rights of Indigenous Peoples, Universal
services, and the power relationships inherent
Declaration of Human Rights and the
in New Zealand society. The disparities
Treaty of Waitangi.
Health of Māori Children in Aotearoa / New Zealand Table 1
All-cause mortality rates
per 100,000, by age group
2000 – 2004
Source Hauora: Māori Standards
of Health IV
Health of Indigenous Children: Health Assessment in Action
99
Cause of death
Māori
Rate
Non-Māori
Rank
Rate
Rate ratio
Rank
Infants under 1 year (rate per 1,000 live births)
Total: all causes
8.1
Perinatal conditions
2.8
– Premature birth
1.3
Unknown causes
2.4
– Sudden infant death syndrome
2.0
Congenital anomalies
1.2
3
4
Accidents
0.7
– Accidental suffocation in bed
0.5
Respiratory diseases
0.3
5.0
1
2.5
1.64*
1
0.7
2
0.4
1.76*
3
0.4
1.4
2
0.2
4
0.1
5.91*
5.66*
0.1
5
1.1
0.86
4.10*
4.27*
7
4.11*
Children ages 1 – 4 years (rate per 100,000)
Total: all causes
40.9
30.1
Accidents
18.1
Drowning
6.4
2.8
2.29*
Pedestrian
4.4
2.4
1.80
Motor vehicle (land)
3.7
1.4
2.54*
1
9.8
1.36*
1
0.7
1.88*
Fires
2.3
Congenital anomalies
5.0
2
5.1
2
3.23*
0.99
Infectious diseases
3.7
3
2.5
5
1.45
Meningococcal infection
3.0
Nervous system diseases
2.7
4
3.3
4
0.82
Cancer
2.0
5=
3.6
3
0.55
Homicide
2.0
5=
0.6
11
3.33*
1.2
2.49*
Children ages 5 – 14 years (rate per 100,000)
Table 2
Major causes of death by
age group 2000-04
Source Hauora: Māori Standards of
Health IV
Total: all causes
22.7
Accidents
9.8
1
5.9
1.47*
1
1.66*
Motor vehicle (land)
3.4
2.0
1.67*
Pedestrian
1.8
1.0
1.81
Drowning
1.7
0.7
2.40*
Cancer
3.9
2
3.5
2
1.12
Nervous system diseases
2.1
3
1.4
4
1.55
Suicide
1.4
4
0.4
8
4.00*
Congenital anomalies
1.3
5
1.8
3
0.69
* indicates rate ratios are statistically significant at the 5% level
The leading causes of death vary by age and by
ethnicity. Table 2 presents leading causes of death by
ethnicity for the age groups less than one year, one to
four years, and five to fourteen years. Among infants the
leading cause of death was ‘perinatal conditions’, and
within this category premature birth was the commonest
100
15.4
Health of Indigenous Children: Health Assessment in Action cause of death for both Māori and non-Māori infants.
Among Māori infants the second to fifth leading causes
of death were: ‘unknown causes’ (primarily sudden
infant death syndrome; SIDS); congenital anomalies,
accidents (particularly accidental suffocation in bed);
and respiratory diseases. Māori infant mortality rates
Health of Māori Children in Aotearoa / New Zealand
were significantly higher than non-Māori for premature
birth, unknown causes, SIDS, accidents, accidental
suffocation in bed, and respiratory diseases.
In the two older age groups accidents are the
commonest cause of death for both Māori and nonMāori although Māori rates are significantly higher
than non-Māori. In the one to four year age groups
Māori also have significantly higher mortality rates
from meningococcal disease and homicide. Mortality
rates from accidents (especially motor vehicle accidents
and drowning) and suicide are significantly higher
among Māori children aged five to fourteen years
compared with their non-Māori peers.
Table 3 presents the leading causes of hospitalization
for infants under one year, and children aged one to
Cause of Hospitalization
four years, and five to fourteen years. The all-cause
hospitalization rate for Māori infants was significantly
lower than that of non-Māori infants, while the allcause rates were significantly higher for Māori children
aged one to four and five to fifteen years compared with
their non-Māori peers.
The leading causes of hospitalization were the same
in the two ethnic groups. In both ethnic groups live
births was the most common reason for admission
of infants under one year. However, Māori infant
hospitalization rates for perinatal conditions (including
premature birth) and congenital anomalies were
significantly lower than those of non-Māori, while
the hospitalization rate for respiratory disease was
significantly higher for Māori infants.
Māori
Rate
Non-Māori
Rank
Rate
Rate ratio
Rank
Infants under 1 year (rate per 100,000)
Total: all causes
130764.6
161434.5
0.81*
Liveborn infants **
58338.0
1
71092.7
1
2
36003.6
2
Source Hauora: Māori Standards of
Health IV
0.82*
Perinatal conditions
21958.5
– Premature birth
6393.9
Respiratory diseases
18853.6
3
9213.8
3
2.05*
Congenital anomalies
5203.2
4
7010.0
4
0.74*
Infectious diseases
4956.0
5
4778.7
5
1.04
7892.3
Table 3
Leading causes of public
hospitalizations by age
group 2000-04
0.61*
0.81*
Children ages 1 – 4 years
Total: all causes
17634.5
16793.2
1.05*
Respiratory diseases
5094.3
1
4266.7
1
1.19*
Injury and poisoning
2227.6
2
2022.3
3
1.10*
Digestive system diseases
2003.1
3
1478.4
5
1.35*
Ear disease
1874.5
4
1748.7
4
1.07*
Infectious diseases
1666.9
5
2096.6
2
0.80*
Children ages 5 – 14 years
Total: all causes
8189.8
7587.4
1.08*
Injury and poisoning
1850.3
1
1687.6
1
1.10*
Digestive system diseases
1079.8
2
959.3
2
1.13*
Respiratory diseases
1022.0
3
944.8
3
1.08*
Ear disease
950.5
4
523.7
5
1.81*
Symptoms and signs (unknown
cause)
466.2
5
593.6
4
0.79*
* Rate ratios are statistically significant at the 5% level
** Liveborn infants do not include all live births. They are discharges with live birth recorded as the
principle diagnosis. These rates use babies born in hospital as the numerator and intercensual estimates
of the number of Māori and non-Māori babies as the denominator. They do not reflect the higher birth
rates among Māori, where the rate is based on numbers of women giving birth.
Health of Māori Children in Aotearoa / New Zealand Health of Indigenous Children: Health Assessment in Action
101
The leading cause of hospitalizations for children
aged one to four years, and for those aged five to
fourteen were the same for the Māori and non-Māori
ethnic groups, although the ranking varied.
Among children aged one to four years
hospitalization rates for respiratory diseases, injury and
poisoning, digestive system diseases, and ear diseases
were all significantly higher for Māori than for nonMāori. However the Māori hospitalization rate for
infectious diseases was significantly lower than that
of non-Māori.
Among children aged five to fifteen years
hospitalization rates for injury and poisoning,
digestive system diseases, respiratory diseases, and ear
diseases were all significantly higher for Māori than
for non-Māori. However the Māori hospitalization
rate for ‘symptoms and signs (unknown cause)’ was
significantly lower than that of non-Māori.
Māori children are less likely to experience the
benefits of preventive strategies such as routine
childhood immunization. National data indicate that, in
the 12 months to September 2008, fewer Māori children
(68% of 24 month olds) had received their routine
immunizations compared with 82% of NZ European
children.29 Disparities in access to immunization have
Figure 3
Māori and non-Māori SIDS
mortality rates by NZ Index
of Deprivation decile
2000-2004
10
been documented for many years and reflect barriers to
accessing these services. It is possible for health services
to deliver effective immunization services to their
communities and achieve near complete immunization
coverage (Rachel Thomson personal communication).
However, effective delivery such as this is the exception
rather than the rule.
Other data suggests that Māori children are not
served as well by primary care services. ‘The Top 10
Report’ on the health and wellbeing of children and
young people aged 0 to 24 years in the Auckland and
Waikato regions found that regional rates of potentially
avoidable hospitalizations in 1999 were higher for the
Māori and Pacific ethnic groups30.
Disparities in mortality and hospitalization rates are
not simply due to differences in socioeconomic status
between the Māori and non-Māori populations. Within
each decile of the New Zealand Index of Deprivation
age-standardized all-cause mortality rates are higher in
the Māori than in the non-Māori population.
This pattern is evident in SIDS mortality. As seen in
Figure 3 Māori mortality rates from SIDS in deciles two
through ten exceed that of non-Māori indicating that
the differences in mortality are not due to differences
in socioeconomic status alone.
Age-sex-standardized rate per 100,000
8
Source Hauora: Māori Standards
of Health IV
Māori
non-Māori
6
4
2
0
1
2
3
4
5
6
7
8
9
10
NZ Index of Deprivation decile 2000 – 2004
Decile 1 = least deprived; decile 10 = most deprived
102
Health of Indigenous Children: Health Assessment in Action Health of Māori Children in Aotearoa / New Zealand
12
10
Māori
Pacific
Other
Rate
8
6
4
2004
2002
2000
1998
1996
1994
1992
1990
1988
1986
1984
1982
1980
1978
1976
1974
1972
1970
0
1968
2
Source: New Zealand Health
Information Service, 2008
Year
4.8 Use of ethnicity data – a case study
This section briefly describes the use of ethnicity data
for the monitoring of Māori SIDS.
Figure 4 presents SIDS mortality rates by ethnicity
for the years 1968 – 2005. Pacific ethnic group data is
only available from 1998 onwards. Direct comparisons
between the years before 1995 and those after 1995 are
difficult as the method for classifying ethnicity changed
from the biological definition to the social definition
in 1995. The effects of this change are most evident in
the Māori ethnic group, which substantially increased
in size. That is, there was a marked increase in the
denominator for Māori and the apparent reduction
in Māori SIDS rates between 1994 and 1996 is largely
due to the increase in denominator rather than a ‘true’
reduction. Nevertheless, some general observations
can be made. Māori SIDS rates have exceeded those of
the ‘Other’ and Pacific ethnic groups in all years. From
1968 both the Māori and Other ethnic groups SIDS
rates increased. The rate for Other ethnic group infants
peaked at about 4 per 1000 live births in the years 1980
– 1988. The Māori SIDS rate peaked at 8 – 10 per 1000
live births in 1983 – 1993. As the SIDS rates increased,
the Māori rate increased more rapidly resulting in a
marked widening of the disparities between Māori and
non-Māori infants.
The initial results of a major national study
to identify the factors associated with SIDS were
published in 199131. The study identified four
modifiable risk factors: prone sleeping position
of baby, maternal smoking, absence of breastfeeding, and bed sharing. A major health promotion
programme to reduce these risk factors was designed
and implemented in 1991 – 1992. Although Māori
Health of Māori Children in Aotearoa / New Zealand Figure 4 SIDS rates per 1000
live births, by ethnicity
1968-2005
mortality was greater than non-Māori, the intervention
was universally targeted and did not include Māori
specific messages or mechanisms for implementing the
programme in Māori communities. The Other ethnic
group SIDS rate fell steadily over the years 1990 – 1994,
while the Māori rate fluctuated between about 7 and
8 per 1000 live births, suggesting that the programme
was more effective for the non-Māori community.
Furthermore, as the non-Māori SIDS rate fell much
faster than the Māori rate, the disparity between
Māori and non-Māori increased markedly. Specific
critique of the universal programme included that: the
programme did not include appropriate and effective
messages for Māori, did not consider appropriate
mechanisms for disseminating the messages among
the Māori community, and did not provide culturally
acceptable alternatives for bed sharing – a common
practice in the Māori community.
In 1994 a Māori SIDS prevention team was
established and subsequently implemented a specific
Māori SIDS prevention programme across the country.
Māori SIDS rates have steadily fallen since 1995. It
should be noted that while the data suggests that the
Māori SIDS programme was more effective than the
universal programme, we are unable to draw absolute
conclusions that this was the case as the mortality
data is ecologically derived rather than obtained from
a specific outcome evaluation of the programme. It
should also be noted that there is a yet to be answered
question about whether the reduction in Māori SIDS
is a ‘real’ reduction or is an apparent one arising from
changes in the classification of the cause of death. The
use of ‘accidental suffocation in bed’ as the cause of
death has increased in recent years and is significantly
Health of Indigenous Children: Health Assessment in Action
103
Improving Māori health status and reducing
to achieve these objectives we must able to
inequalities in health outcomes between
describe and monitor Māori health outcomes.
Māori and non-Māori are key objectives
This requires complete, accurate, reliable,
for the New Zealand health sector. In order
and valid ethnicity data.
Māori children’s health
• The delivery of childhood immunizations is less effective for Māori children who have lower levels of
immunisation coverage than European children
• Data about potentially avoidable hospitalizations suggest that provision of primary care services to
Māori children could be improved
• All-cause mortality rates for Māori children under 1 year of age, aged 1-4 years and aged 5-14 years
are significantly higher than those of non-Māori children
• For many conditions Māori hospitalization rates exceed those of non-Māori children
more common for Māori infants (see Table 2). Whether
the use of ‘accidental suffocation’ instead of ‘SIDS’
accounts for all the apparent reduction in the Māori
SIDS rate is yet to be determined. The final point to
note is that although SIDS mortality rates for Māori
and non-Māori have dropped, the disparity between
Māori and non-Māori persists, and in the years 20002004 Māori were more than five times likely to die from
SIDS than non-Māori32.
4.9 Conclusion
This paper has provided a brief overview of indigenous
(Māori) child health in Aotearoa / New Zealand.
Māori children face significant challenges to their
opportunities to develop and realize their potential.
Many of these challenges, such as socioeconomic
disadvantage, poverty, and poorer outcomes from
health services, are located within the structures,
institutions, services, and the power relationships
inherent in New Zealand society. The disparities
in health and social outcomes that are experienced
by Māori children are breaches of the rights and
protections afforded them by the United Nations
Declaration of the Rights of the Child, Declaration on
the Rights of Indigenous Peoples, Universal Declaration
of Human Rights and the Treaty of Waitangi.
Improving health and social outcomes for Māori
children requires us to collect accurate, complete,
reliable, and valid ethnicity data. In addition to
reporting these outcomes for Māori children, we must
also compare them with the most advantaged children
in our society.
104
Health of Indigenous Children: Health Assessment in Action Health of Māori Children in Aotearoa / New Zealand
4.10 References
1. Orange C. The Treaty of Waitangi. First ed. Wellington, New
Zealand: Allen and Unwin in association with Port Nicholson Press;
1987.
2. Walker R. Ka Whawhai Tonu Matou: Struggle Without End: Penguin
Books; 1990.
3. Statistics New Zealand. QuickStats About Māori. Census 2006.
Wellington: Statistics New Zealand; 2007.
4. Cormack D. The Māori Population In: Robson B, Harris R, eds.
Hauora: Māori Standards of Health IV. Wellington: Te Rōpū
Rangahau Hauora a Eru Pōmare; 2007.
5. Robson B, Cormack D, Cram F. Social and Economic Indicators.
Hauora: Māori Standards of Health IV. Wellington: Te Rōpū
Rangahau Hauora a Eru Pōmare; 2007.
6. Harris R, Tobias M, Jeffreys M, Waldegrave K, Karlsen S, Nazroo
J. Racism and health: the relationship between experience of
racial discrimination and health in New Zealand. Social Science &
Medicine. Sep 2006;63(6):1428-1441.
7. Harris R, Tobias M, Jeffreys M, Waldegrave K, Karlsen S, Nazroo J.
Effects of self-reported racial discrimination and deprivation on
Maori health and inequalities in New Zealand: cross-sectional
study. Lancet. Jun 17 2006;367(9527):2005-2009.
8. Ministry of Health. Tatau Kahukura: Māori Health Chart Book.
Wellington: Ministry of Health; 2006.
9. Crengle S. Māori Primary Care Services: A report prepared for
the National Health Committee. Wellington: National Health
Committee/National Advisory Committee on Health and
Disability; 1999.
10. Crengle S, Crampton P, Woodward A. Māori in Aotearoa /
New Zealand. In: Healy J, McKee M, eds. Accessing health care:
responding to diversity. Oxford: Oxford University Press; 2004.
11. Crengle S, Lay-Yee R, Davis P. Māori Providers: Primary health care
delivered by doctors and nurses:The National Primary Medical Care
Survey (NatMedCa): 2001/02 Report 3. Wellington: Ministry of
Health; 2004.
12. New Zealand Public Health and Disability Act 2000; 2000.
13. Ministry of Health. He Korowai Oranga: Māori Health Strategy.
Wellington: Ministry of Health; 2002.
14. Ministry of Health. Ethnicity Data Protocols for the Health and
Disability Sector. Wellington: Ministry of Health; 2004.
15. Robson B, Harris R. Hauora: Māori Standards of Health IV. A study of
the years 2000-2005. Wellington: Te Rōpū Rangahau a Eru Pōmare;
2007.
16. Ajwani S, Blakely T, Robson B, Atkinson J, Kiro C. Unlocking the
numerator-denominator bias III: adjustment ratios by ethnicity
for 1981-1999 mortality data. The New Zealand Census-Mortality
Study. New Zealand Medical Journal. Jun 6 2003;116(1175):U456.
17. Blakely T, Kiro C, Woodward A. Unlocking the numeratordenominator bias. II: Adjustments to mortality rates by
ethnicity and deprivation during 1991-94. The New Zealand
Census-Mortality Study.[erratum appears in N Z Med J 2002
Feb 22;115(1148):87]. New Zealand Medical Journal. Feb 8
2002;115(1147):43-48.
18. Blakely T, Robson B, Atkinson J, Sporle A, Kiro C. Unlocking the
numerator-denominator bias. I: Adjustments ratios by ethnicity for
1991-94 mortality data. The New Zealand Census-Mortality Study.
New Zealand Medical Journal. Feb 8 2002;115(1147):39-43.
19. Pōmare E, Keefe-Ormsby V, Ormsby C, et al. Hauora: Maori
Standards of Health III; 1995.
20. Robson B, Reid P. Ethnicity Matters: Māori Perspectives. Wellington:
Statistics New Zealand; Sept 2001 2001.
21. Smartt P, Marshall RJ, Kjellstrom T, Dyall L. Reporting comparisons
between Maori and non-Maori populations.[see comment]. New
Zealand Medical Journal. Apr 12 2002;115(1151):167-169.
22. Te Rōpū Rangahau a Eru Pōmare. Counting for Nothing:
Understanding the issues in monitoring disparities in health.
Social Policy Journal of New Zealand. July 2000 2000(14):1-16.
23. Thomas DR. Assessing ethnicity in New Zealand health research.
New Zealand Medical Journal. Mar 9 2001;114(1127):86-88.
24. Harris R, Purdie G, Robson B, Wright C, Zhang J, Baker M. Appendix
3: Estimating Māori Hospitalizations and Cancer Registrations.
Wellington: Te Rōpū Rangahau Hauora a Eru Pōmare; 2007.
25. Bramley D, Latimer S. The accuracy of ethnicity data in primary
care. New Zealand Medical Journal. 2007;120(1264):U2779.
26. Health Utilisation Research A. Ethnicity data and primary care in
New Zealand: lessons from the Health Utilisation Research Alliance
(HURA) study. New Zealand Medical Journal. 2006;119(1231):U1917.
27. Marshall RJ, Zhang Z, Broad JB, Wells S. Agreement between
ethnicity recorded in two New Zealand health databases: effects
of discordance on cardiovascular outcome measures (PREDICT
CVD3). Australian & New Zealand Journal of Public Health. Jun
2007;31(3):211-216.
28. Ministry of Health, Minister of Health. Health and Independence
Report 2008. Wellington: Ministry of Health; 2008.
29. Ministry of Health. Immunisation Coverage National and DHB
Data. http://www.moh.govt.nz/moh.nsf/indexmh/immunisationcoverage-data. Accessed 21 November 2008.
30. Graham D, Leversha A, Vogel A. The Top 10 Report: Top 10 issues
affecting the health and wellbeing of children and young people in
Auckland and Waikato. Hamilton: Waikato District Health Board;
December 2001 2001.
31. Mitchell EA, Scragg R, Stewart AW, et al. Results from the first year
of the New Zealand cot death study. New Zealand Medical Journal.
Feb 27 1991;104(906):71-76.
32. Robson B, Purdie G. Mortality. In: Robson B, Harris R, eds. Hauora:
Māori Standards of Health IV. Wellington: Te Rōpū Rangahau
Hauora a Eru Pōmare; 2007.
Health of Māori Children in Aotearoa / New Zealand Health of Indigenous Children: Health Assessment in Action
105
5
106
Health of Indigenous Children: Health Assessment in Action Health of Indigenous Children in the United States
Health of Indigenous Children in the United States
5.1 Introduction. The United States population spends more on health care than any other country in the world.1-3 And yet, as
a whole, the health status of the United States’ population lags behind citizens of other industrial nations who spend less on
health care. As of 2006, the US was 30th in life expectancy of 30 developed counties.4 Research shows that not all Americans
have equivalent life expectancy. Some studies report that the gap between the highest and lowest life expectancies for a race
and geographic combination in the United States is over 35 years.5, 6
Indigenous people in the United States are among those in the US with the lowest life expectancy.7 One contributor to the
poor health status of Indigenous people in the US is infant mortality. Infant mortality is regarded as an important indicator of
a nation’s health and social well-being. Some Indigenous groups in the US experience the highest infant mortality rates
in the country.
This chapter discusses briefly a number of key issues, including infant mortality, which affects the health of Indigenous
children in the United States. In addition, this chapter provides a brief overview of the Indigenous people of the United States
and their health status, highlights some lesser known social determinates of health, presents available data on the health of
Indigenous children, and describes some major difficulties with the data collected on and for Indigenous people in the country.
Finally, this chapter presents a successful strategy to address a number of key challenges; Indigenous epidemiology centers.
5.2 Indigenous Population of the USA
In this publication, the Indigenous people of the United
States are defined as populations who:
• Have Pre-Invasion/Pre-Colonial Historical
Continuity on Territory
• Are Considered Distinct from those Now Prevailing
in Territories
• Are in Their Present Form, Non-Dominant Sectors
of Society
• Are Determined to Preserve, Develop and Transmit
Ancestral Territories and Ethnic Identity to Future
Generations
Although many members of these Indigenous
communities refer to themselves using traditional
names, the United States refers to members of these
groups as American Indians, Alaska Natives and Native
Hawaiians (AIANNH). There are over 562 federally
recognized American Indian and Alaska Native Tribes
and many more petitioning and working towards for
Federal Recognition or Sovereignty, including Native
Hawaiians. The Indigenous peoples of the United States
have diverse histories and rich cultures.
According to the most recent US Census in 2000,
4.3 million people, or 1.5% of the total US population,
reported that they were American Indian or Alaska
Native.8 Native Hawaiians makes up approximately
0.1% of the US population, and currently numbers
401,000 people. Residing on traditional home lands or
Health of Indigenous Children in the United States on reservations/homesteads is an important measure
for Indigenous communities in the US because many of
the resources and services provided to these populations
are available only in these areas. While having access to
such lands may be equated with greater access to targeted
services, for various reasons, both by force and by choice,
many Indigenous people have relocated to urban areas
or relocated completely off island. An example of such a
Diaspora is revealed in the fact that over 67% of American
Indians/Alaska Natives (AIAN) and 43% of Native
Hawaiians (NH) reside off reservation or off island.8
Similar to other nations, the Indigenous people of
the USA suffer grave health concerns.
• AI/AN/NH have lower educational levels and higher
unemployment rates AI/AN/NH population is a
younger population. Median age AIAN 28.0 years,
NH 32 years, compared to 35.3 years for the US All
Races.
• Life expectancy for AI/AN 74.5 years (compared to
US Population 77.8)
• Diseases of the heart, malignant neoplasm,
unintentional injuries, diabetes mellitus, and
cerebrovascular disease are the five leading causes of
Indian deaths (2002–04).
• Native Hawaiians also have a higher rate of death
and disability due to stroke and cerebrovascular
conditions than other populations (mortality rate
of 58 per 100,000).
Author:
Maile Taualii MPH PhD(c)
Director
Native Hawaiian
Epidemiology Center
Papa Ola Lokahi
Health of Indigenous Children: Health Assessment in Action
107
Table1
Socioeconomic
Characteristics Among
American Indians/Alaska
Natives/Native Hawaiians,
2000
Source: 2000 US Census
Nationwide Populations
AIAN
NH
General
%
%
%
22.0
14.6
12.4
7.5
5.3
3.7
Older than 25 years with a high school diploma or GED
70.9
84.0
80.4
Older than 25 years with 4 year college degree
11.5
10.0
24.4
2.0
1.6
1.0
23.5
15.4
18.3
Socioeconomic Characteristics
Income in 1999 below poverty level
Children (age<15) below poverty level
Reported Disability (5 to 15 years)
Reported Disability (16+ years)
AIAN=American Indian/Alaska Native; NH= Native Hawaiian
Accurate health
information is
essential to
effectively address
and eliminate
current health
disparities
108
• Between age 36 and 64, Native Hawaiians have
a rate of diabetes that is over twice that of other
populations (79 vs. 34 per 1000).
• Native Hawaiian females have the highest mortality
rate from lung, liver, pancreatic, breast, cervical,
uterine, stomach, and rectal cancer.
5.3 Social Determinates of Health
Table 1 presents a number of socioeconomic
characteristics of the AIANNH population which
play a central role influencing health outcomes of
Indigenous people in the US These social determinates
of health have an effect on the US Indigenous
population similar to what is seen in the other
countries outlined in this report. Poverty, limited
educational attainment, and unemployment are all
factors that influence health. AIANNH children are
exposed to these determinates and the results are seen
in the resultant health disparities.
Health of Indigenous Children: Health Assessment in Action Previous country sections of this report, as well
as numerous studies, have outlined and described
the effects of poverty, unemployment, and limited
education on health. Therefore, to build on that
knowledge and discussion, this section of the report
will highlight two social determinates of health
mentioned less frequently, but have a grave impact
Indigenous communities.
Historical Trauma
The psychosocial and anthropologic concepts of
‘intergenerational trauma’ and ‘historical trauma’
began evolving in the 1960s and 1970s as descriptive
research terms after having studied the residual
effects experienced by the offspring of World War II
Holocaust victims.9 Historical trauma has since been
defined as a cumulative emotional and psychological
wounding over the lifespan and across generations,
emanating from massive group trauma.10 Scholars have
Health of Indigenous Children in the United States
examined and applied the effects of historical trauma
on Indigenous people. Contemporary symptoms of
depression, posttraumatic stress disorder (PTSD) and
grief have been attributed to historical trauma.
Loss of Traditional Diet
One of the most crucial, yet still insufficiently
emphasized social determinate of health is the loss
of traditional foods. In many cultures food is held
sacred. Often times, there are many direct links to food
and the creation beliefs. An example of this spiritual
relationship can be seen in the Hawaiian creation story:
The taro, or kalo plant originated when the son of
Wakea (Sky Father) and his daughter Ho’ohokukalani
was born lifeless and deformed like the gnarled root
of a plant. The grieving parents buried the baby, but the
next day a taro plant sprouted from the grave, which
Wakea named Haloa-naka. When the second son of
Wakea and Ho’ohokukalani was born, they named him
Haloa, because he was the younger brother of taro,
from whom all Hawaiians descended. Haloa, first-born
man, was to respect and to look after his older brother
forever more. In return, the elder Haloa-naka, would
always sustain and nourish him and his descendants.
The spiritual connection between food and man
in many societies is not a coincidence. For survival
purposes, societies were completely dependent on the
food they were able to grow and harvest. They chose
food products that would ensure their ability to survive
and thrive. In the example of the Hawaiian diet, the
taro plant, mentioned above, was the major staple of
the diet. They considered the plant akin to a god, and
believed they ingested his power when they consumed
the plant. In addition to strong cultural and spiritual
ties to the food source, taro is a nutritional food source.
American Indian/
Alaska Native
1.91%
It is rich in calcium, riboflavin, iron and thiamine, has
no cholesterol and almost no fat, and is also used as a
medicinal preparation for many ailments.
The social costs resulting from a loss of traditional
diet present themselves at both the individual and
societal level. Initial costs to the individual begin
with the shift from consumption of healthier,
traditional foods to the consumption of foods of
lower nutritional value. It has been observed globally
that when changes in dietary consumption such as
these occur, there is a profound increase in dietrelated chronic diseases such as obesity, coronary
heart disease, diabetes, high blood cholesterol levels,
stroke, etc. These poor health outcomes have the
potential of limiting employment opportunities for
those individuals where the disease state results
in a reduced capacity for work or left the person
with physical limitations at performing work.
Consequently, reduced employability has an obvious
negative consequence on income and social status.
In addition to these individual impacts, there are
also a number of societal consequences whenever there
is a loss of access to a traditional diet. For example,
nutrition transition, especially among Indigenous
peoples, has been noted to result in a grave loss of
cultural and spiritual connection to traditional food.
The very food that has for centuries served as the
spiritual, cultural, and physical lifeblood of Indigenous
people the world around has suddenly become
unavailable or ‘unsafe’ to consume. This, in turn, lends
to the potential demise of those customs and traditions
associated with traditional foods. Other challenges
to society include rising health care costs due to
diet-related diseases. This is especially pronounced
when the abandoning of native diets with its inherent
Figure 1
US Children – Ages 0–14
Native Hawaiian
0.21%
Source: 2000 US Census
Non-Indigenous
97.89%
Health of Indigenous Children in the United States Health of Indigenous Children: Health Assessment in Action
109
protective benefits is substituted for foods with highfat and high-sugar content which can lead to those
predictable poor health outcomes. While this is a global
phenomenon, government agencies of many countries
are ill-equipped and poorly educated to effectively
address the resultant increase in costs in health care.
In addition, national productivity (i.e. industrial)
decreases when work days and school days are missed
due to diet-related chronic diseases.
5.4 Health of Indigenous children of
the USA
In the United States there are approximately 1,274,000
American Indian/Alaska Native/Native Hawaiian
children between the ages of 0–14. These Indigenous
children comprise roughly 2.1% of the total 0–14 age
group and more than 25% of the Indigenous population.
The health status of these children mirrors that of
their preceding generations, in that there are grave
Table 2
Mortality rate per 1,000 live
births
Source: CDC, National Center for
Health Statistics (NCHS).
110
Race of mother
health disparities. A number of key areas of disparities
are highlighted within this report.
Infant Mortality
Infant mortality is one of the most reliable indicators
of a nation’s health and social well-being. The United
States ranked 26th among thirty developed countries
in terms of infant mortality rate in 2000 and recent
data suggest that the rate of decline in the national
infant mortality rate has stabilized.11 However, for some
Indigenous communities in the US, disparities in infant
mortality persist and in some instances have even
worsened. All of this while proportional risk factors
to infant mortality (e.g., rates of low-birth weight)
continued to increase.12-15
Among Indigenous populations in the US,
Native Hawaiians experience the highest infant and
neonatal mortality rates.15, 16 American Indians/Alaska
Natives also experience high infant mortality rates.14
Infant
Neonatal
Postneonatal
All races
7.0
4.7
2.3
White
5.8
3.9
1.9
American Indian/Alaska Native
8.6
4.6
4.0
Native Hawaiian
9.6
5.6
4.0
Health of Indigenous Children: Health Assessment in Action Health of Indigenous Children in the United States
Disease patterns and health disparities among this
heterogeneous population have been associated with
poverty, limited access to health care services, and
cultural dislocation. Much of the research on infant
mortality among American Indians/Alaska Natives has
focused on Sudden Infant Death Syndrome (SIDS).14
Although little is known and documented related to
the direct causes of infant mortality, one surveillance
project, the Pregnancy Risk Assessment Monitoring
System (PRAMS), conducted by the US Centers for
Disease Control and Prevention (CDC) as well as state
health departments, aim to collect population-based
data on maternal attitudes and experiences before,
during, and shortly after pregnancy. Table 3 shows
a number of key factors associated with poor health
and infant mortality for American Indians and Alaska
Natives. Comparable data on Native Hawaiians is not
available at this time.
Table 4 shows the mortality rate for AIAN children
by age group. Data for Native Hawaiian children is not
yet available.
Hospitalization
Hospitalization data specific to AIANNH populations
is very limited. Many of the complexities related to data
interpretation results from the non-uniformity of health
service delivery in the US The US is the only western
industrialized nation that relies on for-profit private
insurance agencies to fund the cost of health care for a
majority of the US population.17 This has lead to a crisislevel lack of adequate access to health care in the United
States for some 45 million people.18
Although limited, some hospitalization data
is available for American Indians/Alaska Natives.
Hospitalization rates for injury among AI/ANs have
been published for the Indian Health Service (IHS)
service population, but these analyses have not
specifically focused on children (IHS). Furthermore,
these analyses have used IHS hospital discharge data
and may miss AI/AN patients who receive hospital
care outside of the IHS system, especially if the
payer is other than the IHS. State hospital discharge
registries represent another potential source of data
for surveillance of hospitalizations, but many do not
contain racial or ethnic identification data. If they do,
the potential also exists for racial misclassification.13
The most widely used source of information on
hospitalization is National Hospital Discharge Survey
(NHDS). Conducted annually by the National Center
for Health Statistics, NHDS collects medical and
Nationwide Populations
AIAN
%
General
95% CI
%
95% CI
Poor Birth Outcomes/Risk Factors (1991-2000)
Low birth weight (<2,500 grams)
6.6
(6.5-6.7)
7.4
(7.4-7.4)
12.1*
(12.0-12.3)
11.1
(11.0-11.1)
Mother’s age <18
8.2*
(8.2-8.3)
4.8
(4.8-4.9)
Mother unmarried
57.4*
(57.2-57.7)
31.9
(31.9-31.9)
7.3*
(7.2-7.4)
3.0
(3.0-3.0)
21.1*
(21.0-21.3)
14.3
(14.3-14.3)
0.3
(0.3-0.4)
0.3
(0.3-0.3)
Premature birth
Received late or no prenatal care
Smoked during pregnancy
Alcohol use during pregnancy
Table 3
Poor Birth Outcomes/
Risk Factors and Factors
Associated with Infant
Death Among American
Indians/Alaska Natives
Factors Associated with Infant Deaths (1995-2000)
Mother unmarried
65.6
(62.1-69.1)
47.2
(46.9-47.5)
Low birth weight (<2,500 grams)
49.7
(46.7-52.8)
65.2
(64.8-65.6)
Premature birth
50.1
(46.9-53.6)
64.5
(64.1-64.9)
Smoked during pregnancy
29.8
(27.3-32.5)
19.5
(19.3-19.7)
Mother’s age <18
10.2
(8.9-11.6)
7.6
(7.4-7.7)
Alcohol use during pregnancy
7.4
(6.2-8.9)
2.3
(2.2-2.4)
Received late or no prenatal care
7.1
(5.9-8.4)
2.7
(2.6-2.7)
CI=confidence interval
*Significantly higher for AIAN compared to the general population
Health of Indigenous Children in the United States Health of Indigenous Children: Health Assessment in Action
111
AIAN
All Races Combined
Rate per 100,000
95% CI
Rate per 100,000
95% CI
Less than 1 Year
All Causes
Congen malfrm/defrm/chrm abn
782.17
147.72
(753.49, 811.7)
(135.41, 160.87)
715.11
140.85
(712.15,718.08)
(139.54, 142.17)
Accidents and external causes
41.24
(34.87, 48.46)
22.84
(22.31, 23.37)
Influenza and pneumonia
22.95
(18.27, 28.47)
7.57
(7.26, 7.88)
Diseases of heart
19.46
(15.17, 24.59)
13
(12.6, 13.4)
Assault (homicide)
16.2
(12.31, 20.92)
8.3
(7.98, 8.62)
Age 1-4
All Causes
Accidents and external causes
47.53
19.25
(44.19, 51.07)
(17.15, 21.55)
32.79
11.62
(32.47, 33.11)
(11.43, 11.81)
Assault (homicide)
4.07
(3.14, 5.2)
2.49
(2.40, 2.58)
Congen malfrm/defrm/chrm abn
3.96
(3.04, 5.07)
3.4
(3.30, 3.50)
(44.19, 51.07)
(17.15, 21.55)
32.79
11.62
(32.47, 33.11)
(11.43, 11.81)
Age 5-9
All Causes
Malignant neoplasm (MNP)
47.53
19.25
Assault (homicide)
4.07
(3.14, 5.2)
2.49
(2.4, 2.58)
Accidents and external causes
3.96
(3.04, 5.07)
3.4
(3.3, 3.5)
Age 10-14
All Causes
Accidents and external causes
Table 4
American Indians/Alaska
Natives Children Mortality
112
24.11
12.44
(22.16, 26.19)
(11.05, 13.95)
20.11
7.9
(19.89, 20.32)
(7.76, 8.04)
Intent self-harm (suicide)
2.4
(1.82, 3.12)
1.35
(1.29, 1.41)
Assault (homicide)
1.2
(0.8, 1.74)
1.13
(1.08, 1.18)
CI=confidence interval
demographic information from a sample of inpatient
discharge records selected from a national probability
sample of non-Federal, short-stay hospitals. The data
serve as a basis for calculating statistics on hospital
inpatient utilization in the United States.
Race is not reported in about 18% of NHDS
records since data on race are not reported by many
hospitals due to the omission of a race field on
hospital discharge reporting forms.19 More hospitals
have automated their discharge systems in recent years
and are currently using a form which does not require
race reporting.
Because population based, hospitalization data for
US Indigenous children is not available at this time, a
special focus highlighting areas of concern is included
for this report.
Injury
Injuries are a leading cause of childhood morbidity
and mortality throughout the world. Although there
have been substantial declines in the rates of death
from injuries among children in developed nations,
it still remains the principal threat to the health and
welfare of children and adolescents. American Indians
and Alaska Natives (AI/ANs) have higher rates of
injury morbidity and mortality than all other races.20
In addition, AI/AN children experience higher rates of
morbidity and mortality from unintentional injuries
than do other US children. The 881 injury deaths to AI
children between 1992 and 1994 translate to an overall
rate of 52.3 deaths per 100,000 children per year. This
rate is nearly twice the US rate of 28.3 per 100,000
children for all races (1993).21, 22
Limitations in the health population data
to advocate for resources to create
make it nearly impossible for communities
culturally appropriate care
Health of Indigenous Children: Health Assessment in Action Health of Indigenous Children in the United States
A particularly revealing study which examined
hospitalizations for AIAN youth provides an analysis
highlighting one area of health disparities existing in
the US23 In this analysis, a total of 694 hospitalizations
for injury were identified for AI/AN youth and
29,048 were identified for all races. Table 5 presents
findings from this study. In summary, AI/AN children
experience a disproportional rate of hospitalizations
due to injury and therefore more efforts to reduce
injury are critical for this population.
Diarrhea
For 2000–04, diarrhea-associated hospitalization rates
were similar for AI/AN children versus US children <5
years of age (65.9 and 79.3 of 10,000, respectively).24,
25
However, the rate among AI/AN infants was nearly
twice the rate among US infants (262.6 and 154.7 of
10,000, respectively). The rate of diarrhea-associated
outpatient visits among AI/AN children was higher
than for US children (2,255.4 versus 1,647.9 of 10,000,
respectively), as a result of the high rate among AI/AN
infants compared with US infants (6,103.5 and 2,956.3
of 10,000, respectively).26 Understanding the causes of
these disparities among AIAN infants is an important
endeavour to undertake.
Otitis Media
Otitis media (OM) is one of the most common and
costly health problems that affect children younger
than five years in the United States.27, 28 Approximately
half of US children have an episode of OM before their
first birthday, and nine out of ten children have an
episode by five years of age.29 Studies report the rates
of OM-associated hospitalization were significantly
higher for AI/AN children than for all US children
1,542 vs. 1,021 per 100,000 children/y. 30 As with
OM-associated outpatient visits, much of the disparity
in OM hospitalization rates was attributed to the
difference among infants (1994–1996 rates: 5,643 vs.
2,440 per 100,000 infants/y, 823 vs. 665 per 100,000 1to 4-year-olds/y).
Hospitalization for Injuries – Discharges
Motor Vehicle
Falls
Poisonings
Fire
5.5 Critical Areas of Focus
Type 2 Diabetes Mellitus
Type 2 diabetes mellitus is a new morbidity trend
amongst children and adolescents.31-34 For pediatric
patients, it is an ominous risk indicator for the
earlier onset of cardiovascular disease, retinopathy,
nephropathy, and neuropathy, along with its increased
morbidity/mortality risks of impaired quality of life and
premature death.31 The emergence of type 2 diabetes
mellitus in young people is believed to be associated
with overall decreased physical activity and poorer
nutrition; negative factors which are ubiquitous in
modern society. However, not all populations are
equally affected. American Indian/Alaska Native (AI/
AN) children in the United States have a higher rate
of this disease than do children of other ethnicities.35
Rates and disease patterns in the population provide
evidence that this is also a growing concern for Native
Hawaiian children. In US children, the prevalence
of type 2 diabetes mellitus is expected to exceed that
of type 1 diabetes mellitus within 10 years. There is
an undeniable need for additional research, primary
and secondary prevention efforts, and evidence-based
treatment for youth at risk for type 2 diabetes mellitus,
paying special attention to AIANNH children.
Sudden Infant Death Syndrome (SIDS)
The Back to Sleep campaign, lead by the National
Institute for Child Health and Human Development
(NICHD) has resulted in an overall decline in SIDS
rates of about 50%. While the decline has occurred
in all segments of the population, it has been less
in American Indian and Alaska Native (AI/AN)
communities. A recent report showed that AI/AN
infants were still almost three times more likely to
die from SIDS as white infants, and the rates are
particularly high in Alaska and the Northwest and
Northern Plains of the continental United States.21, 36
Studies have been conducted to investigate causes
for regional differences. One study conducted in the
Rate
507/100, 000
Incidence Rate
1.30
1.73
0.95
1.20
2.35
95% CI
1.20, 1.40
1.49, 1.40
0.79, 1.15
0.80, 1.78
1.42, 3.87
Table 5
Youth Hospitalizations
Resulting from Injury
Among American Indians/
Alaska Natives
CI=confidence interval
Health of Indigenous Children in the United States Health of Indigenous Children: Health Assessment in Action
113
Aberdeen area found that binge drinking (five or more
drinks at a time) during the mother’s first trimester
of pregnancy made it eight times more likely that her
infant would die of SIDS.36 Any maternal alcohol use
during the periconceptional period (three months
before pregnancy or during the first trimester) was
associated with a six-fold increased risk of SIDS. The
study also found that infants were more likely to die of
SIDS if they wore two or more layers of clothing while
they slept.36
5.6 Challenges in Data Collection
Local, state and federal public health institutions
routinely develop, coordinate, and maintain
surveillance systems for the US populations; however,
major gaps exist for Indigenous communities.
Although various departments of health collect data
which might include Indigenous populations, it is
atypical for the surveillance data to be disaggregated or
separately analyzed for the population. The occurrence
of sub-analysis and/or the availability of this data vary
114
Health of Indigenous Children: Health Assessment in Action between the different health departments. Federal
public health institutions may conduct national surveys
(through state agencies) which provide national and
state data for monitoring various health indices.
However, small population numbers, low response
rates, and the lack of dis-aggregation for analyses are
some examples of why such analyses have failed to be
forthcoming. This continues to be one of the ongoing
challenges faced.
One solution to this data survey discrepancy is to
perform sub-population oversampling. Unfortunately,
this requires additional financing and consequently
may not be frequently considered or incorporated.
Until recently, no national data was available on the
health of Native Hawaiians. Data was only collected for
the aggregate population group, Asian/Pacific Islanders
(Asian/PI). Asian/PI encompasses many distinct
cultures and as a consequence, the disparities affecting
NH become invisible under this system. Current
efforts to describe the health of NH are challenged
due to sample size limitations and under counting. As
Health of Indigenous Children in the United States
An example of successful strategies employed
in the U.S. Indigenous communities are the
creation and establishment of the Tribal
Epidemiology Centers.
more government agencies adopt and implement the
new Federal data collection guidelines on race which
specifically identifies NH separately from the larger
Asian category, more data will be available and the
health status of the now identifiable sub-population can
be measured and monitored with greater accuracy.
Recent literature provides strong evidence of how
essential accurate health information is in effectively
identifying and eliminating current health disparities.
Limited or inaccurate population health data is a
core problem for Indigenous communities. Data
is needed to create culturally appropriate health
programs, identify areas of need, and for advocating
on behalf of the community. Such efforts could redress
the health disparities and would result in improved
access and affordability of health care. Inaccuracies
and deficiencies in the health population data due
to misclassification and aggregation make it nearly
impossible for subpopulation groups to advocate for
resources to create culturally appropriate care essential
to address health needs.
5.7 Community-Based Strategies
and Solutions
In recent years, the Indigenous communities of
the US have expressed interest in increasing their
understanding, capacity in effective use, and control
over health data for the purposes of developing
programs and in forming policy. Indigenous
communities express a clear understanding of the value
of data, and especially of high quality data, as a tool
for making better program and funding decisions that
will have demonstrated benefits for their community
members. This insight and strategy is tremendously
important for any program wishing to strengthen and
expand its use of health data.
An example of successful strategies employed by
Indigenous communities within the US is seen in the
creation and establishment of the Tribal Epidemiology
Centers. Funded by the Indian Health Service, Tribal
Epidemiology Centers are community or Tribal-based
organizations that plan, coordinate, and perform
essential public health services necessary to address
Health of Indigenous Children in the United States the health deficiencies specific to AIAN. In 2009, the
Native Hawaiian health organization, Papa Ola Lokahi,
announced the establishment of its own Indigenous
epidemiology center.
Effectively addressing the health and wellness of
the US Indigenous populations demands a greater
accountability with sound planning and development.
Central to this effort is consistent, specific, and
standardized data collection and the utilization of
that information which addresses all factors affecting
Indigenous health. Indigenous epidemiology centers
manage public health information systems, investigate
diseases of concern, manage disease prevention
programs, and coordinate activities with other public
health authorities. The Indigenous epidemiology
centers focus on collaboration with existing public
health entities and filling gaps in the public health
system where Indigenous populations’ needs might
otherwise go unnoticed.
5.8 Conclusion
In reviewing data for this chapter, a number of
challenges were raised, particularly since no prior
report has detailed health issues facing American
Indians, Alaska Natives, and Native Hawaiian children
collectively. A key challenge was the availability of
quality data for all Indigenous children in the United
States. Thus, data which highlighted or reported the
health of the United States Indigenous people was
limited; only subsections of the people were highlighted,
data was regional, or the data excluded a substantial
proportion of the population (e.g. off-reserve
populations and non-federally recognized people).
Unfortunately, the special and unique relationship
formalized between the US government and the nation’s
first and original people does not ensure systematic,
standardized, and comprehensive monitoring of health.
This negligence, whether intended or unintended, has
serious deleterious effects on the Indigenous children
in the US, as many health issues may go unmonitored
and unmeasured. Without careful attention and
prioritization of Indigenous children in the US, many
will continue to suffer grave disparities.
Health of Indigenous Children: Health Assessment in Action
115
Indigenous epidemiology centers
manage public health information systems,
investigate diseases of concern, manage
disease prevention programs, and coordinate
activities with other public health authorities
Despite the limitations of low quality data, findings
show that Indigenous children of the US carry a
disproportionate weight of the burden of poor health
in the country and efforts must be made to improve
their health status. In a nation as wealthy as the United
States, children should always have access to health
care. Timely access to culturally sensitive and high
quality health care is central to improving the health of
Indigenous children.
In addition to the health challenges which could
be resolved by access to quality health care, a number
of health issues faced by Indigenous children could be
addressed through support services to families. Social
determinants of health such as poverty, employment,
116
Health of Indigenous Children: Health Assessment in Action and education can have a greater impact on health then
access to health care.
Most importantly, efforts must be made to support
the resurgence of Indigenous culture, language, and
traditions. Resiliency of traditional practices, access
to traditional foods, and the resurgence of Native
languages help to address the effects of colonization.
Local community based solutions which support
traditional practises, coupled with community based
solutions to monitor progress towards improving
health (i.e. Indigenous epidemiology centers) will
enrich the lives of Indigenous people in the United
States, resulting in improved quality of life for
Indigenous children.
Health of Indigenous Children in the United States
5.9 References
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3. Anderson GF, Hussey PS, Frogner BK, Waters HR. Health spending
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24. Holman RC, Curns AT, Cheek JE, Singleton RJ, Anderson
LJ, Pinner RW. Infectious disease hospitalizations among
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Wiley & Sons; 1973.
10. Brave Heart MY, DeBruyn LM. The American Indian Holocaust:
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Health Res. 1998;8(2):56–78.
11. Arias E, MacDorman MF, Strobino DM, Guyer B. Annual summary
of vital statistics–2002. Pediatrics. Dec 2003;112(6 Pt 1):1215–1230.
12. Baldwin LM, Grossman DC, Casey S, et al. Perinatal and infant
health among rural and urban American Indians/Alaska Natives.
Am J Public Health. Sep 2002;92(9):1491–1497.
13. Castor ML, Smyser MS, Taualii MM, Park AN, Lawson SA, Forquera
RA. A nationwide population-based study identifying health
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general populations living in select urban counties. Am J Public
Health. Aug 2006;96(8):1478–1484.
14. Tomashek KM, Qin C, Hsia J, Iyasu S, Barfield WD, Flowers LM.
Infant mortality trends and differences between American
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15. Wong E. Health of Native Hawaiians and Other Pacific Islanders in
King County. Public Health Data Watch. In: County. PH-SK, ed10.
August 2008.
16. CDC NCfHSN. Health United States 2007. Table 19 Infant, neonatal,
and postneonatal.
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29. Paradise JL, Rockette HE, Colborn DK, et al. Otitis media
in 2,253 Pittsburgh-area infants: prevalence and risk
factors during the first two years of life. Pediatrics. Mar
1997;99(3):318–333.
30. Curns AT, Holman RC, Shay DK, et al. Outpatient and hospital
visits associated with otitis media among American Indian
and Alaska native children younger than 5 years. Pediatrics.
Mar 2002;109(3):E41–41.
31. Type 2 diabetes in children and adolescents. American
Diabetes Association. Diabetes Care. Mar 2000;23(3):381–389.
32. Acton KJ, Burrows NR, Moore K, Querec L, Geiss LS, Engelgau
MM. Trends in diabetes prevalence among American Indian
and Alaska native children, adolescents, and young adults.
Am J Public Health. Sep 2002;92(9):1485–1490.
33. Ludwig DS, Ebbeling CB. Type 2 diabetes mellitus in children:
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34. Rosenbloom AL, Joe JR, Young RS, Winter WE. Emerging
epidemic of type 2 diabetes in youth. Diabetes Care. Feb
1999;22(2):345–354.
35. Gahagan S, Silverstein J. Prevention and treatment of type
2 diabetes mellitus in children, with special emphasis on
American Indian and Alaska Native children. American
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36. Iyasu S, Randall LL, Welty TK, et al. Risk factors for sudden
infant death syndrome among northern plains Indians. JAMA.
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18. Bodenheimer T, Grumbach K. Understanding Health Policy: A
Clinical Approach. The McGraw-Hill Companies, Inc.; 2005.
19. Kozak LJ. Underreporting of race in the National Hospital
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Health of Indigenous Children in the United States Health of Indigenous Children: Health Assessment in Action
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6
118
Health of Indigenous Children: Health Assessment in Action Indigenous Child Health Stakeholder’s Meeting – Discussion & Recommendations
Indigenous Child Health Stakeholder’s Meeting –
Discussion and Recommendations
6.1 Introduction.. The chapter presents a summary of findings from discussion groups held with key First Nations, Inuit,
and Métis child health stakeholders in Canada and the international authors. The summary is derived from The Health of
Indigenous Children: Health Assessment in Action Meeting held at St. Michael’s Hospital, Toronto, Canada, on May 30th, 2008.
This important meeting brought together a diverse mix of twenty-one health professionals, policy makers, community
representatives, analysts and researchers working in the field of Indigenous children’s health from Canada, New Zealand,
Australia, and the United States. (Participants are listed in Appendix A). Discussion topics included: identification of key
health issues; best practice ideas; and policy approaches. This summary is a reflection of the stakeholders enthusiasm and
passion for improving Indigenous children’s health in both a Canadian and international context.
6.2 PROCESS
Presentations
At the meeting, Canadian and international authors
shared their knowledge with stakeholders on current
Indigenous child health assessment information and
best practices from each presenter’s home country.
Presentations focused on commonly used children’s
health measures as well as Indigenous-specific
measures where available. Please refer to previous
chapters for more in-depth accounts of Indigenous
children’s health assessment in individual countries.
(a) key health status inequities and / or issues facing
Indigenous children (First Nations, Inuit and
Métis respectively)
(b)priority areas for Indigenous children’s health
assessment and response
Group Activities and Feedback
Following the presentations, those at the meeting
participated in two discussion group activities. The first
activity involved small group discussions. The second
activity was a large group discussion involving everyone
in attendance. Following the meeting, all the priorities
and recommendations identified and discussed were
summarized and provided to participants via email
for review and clarification. This final report summary
incorporates that additional feedback.
Group Activity 2
Following the first group activity, a larger group
discussion took place to identify:
Group Activity 1
Participants were organized into three groups: First
Nations, Inuit, and Métis. Each group brainstormed
ideas, provided insights and developed a list of:
The groups then presented the lists they had
generated to the larger group. These lists were later
arranged by the chapter authors into the following
broad theme groups: Social Concerns; Health
Concerns; and Health Service Delivery Concerns.
(a) Indigenous child health assessment and response
issues that cut across First Nations, Inuit, and
Métis groups
(b)best practice ideas for Indigenous children’s health
assessment and response
(c) policy approaches to Indigenous children’s health
assessment and response (i.e. balancing the right
to be counted, OCAP (ownership, control, access
and possession of information), Indigenous right
to participate in governance and management of
health data, and the rights of children)
Authors:
Dr Gilbert Gallaher PhD
Research Fellow
Centre for Research on
Inner City Health
The Keenan Research Centre
in the Li Ka Shing Knowledge
Institute
St Michael’s Hospital
Paul Adomako MSc
Research Coordinator III
Centre for Research on
Inner City Health
The Keenan Research Centre
in the Li Ka Shing Knowledge
Institute
St Michael’s Hospital
Janet Smylie MD MPH
Research Scientist
Centre for Research on
Inner City Health
The Keenan Research Centre
in the Li Ka Shing Knowledge
Institute
St Michael’s Hospital
Associate Professor
Dalla Lana School of
Public Health
University of Toronto
Community autonomy and selfdetermination do not necessarily need to
be incompatible with using other western
tools for accurate data collection
Indigenous Child Health Stakeholder’s Meeting – Discussion & Recommendations Health of Indigenous Children: Health Assessment in Action
119
6.3 GROUP ACTIVITY 1
Table 1
Small Group One – First Nations
Additional comments from flipcharts /
mini-group presentations
Inequities / Priorities
Social Concerns
1. Poverty
2. Housing
−− Lack of access to quality on-reserve education
−− Difficulty accessing off-reserve education
−− Post and secondary retention rates
−− Sustainable costs
3. Education
4. Food security
5. Child welfare
−− Family violence; foster care; abuse
6. Environmentally related impacts
−− Environmental contamination and some cancers
linked to child health
7. Experiences of racism
−− Interpersonal & institutional (systemic) racism
affecting accessibility to services
Health Concerns
1. Oral health
−− Access to fluoridation in water; access to receive
treatment (anesthetic waiting lists)
2. Obesity
−− Links to other chronic conditions including
diabetes / hypertension
3. Cervical Cancer Screening* (see below)
−− Implications of HPV vaccinations
4. Special needs:
• Autism
• Fetal Alcohol Syndrome
−− Stereotypes and stigma associated with labeling
and the potential for this to impact service
accessibility
5. Hearing (Otitis Media)
Health Service Delivery Concerns
1. Lack of coordinated care
• Multiple visits with different care providers /
specialists
−− Need for a harmonization of services
Other
1. * Scope of the proposed Report
120
Health of Indigenous Children: Health Assessment in Action −− * Clarification required re: ‘just’ Child health –
or Child and Maternal Health?
Need to note linkages between these.
Indigenous Child Health Stakeholder’s Meeting – Discussion & Recommendations
Small Group Two – Inuit
Additional comments from flipcharts /
mini-group presentations
Inequities / Priorities
Social Concerns
−− Workforce/Human Resources (across sectors;
1. Schooling
Inuit capacity; retention)
• Quality of education/curriculum
• Workforce
−− Increase Aboriginal Head Start programs.
• Historical family experiences
Making the system work better for Inuit children –
• Pre-school and Day Care needs (especially with
improving retention in Education
economic development drive)
−− Second languages and bilingualism
−− Balancing women in the workforce and the needs
of their children
2. Housing
• Quality of housing
• Overcrowded housing
• Health impacts of poor housing
−− Respiratory illnesses and infectious diseases
−− Reduced schooling
−− Social impacts
−− How do Inuit access quality housing?
3. Food Security
• Multifaceted
−− Traditional economy: hunter / gathering / fishing
and how to preserve this
−− Implications of foods and their links to oral health
−− Links between workforce and being able to access
oral health
4. Exposure to violence
Health Concerns
1. Mental Health
2. Suicide
−− Suicide awareness
Health Service Delivery Concerns
1. Lack of child-centered care
Limited access to healthcare/doctors
2. Lack of data
• ‘Next to nothing’
• Limited mortality information
• Data use and accessibility
−− Establish data protocols with researcher
accountability; researchers need to return
information back to the community
−− Include statistics on resilience outcomes from
‘on the land’ programs etc.
−− Data to reflect regions and communities as well as
‘national’ (total Inuit) population
Other
Nurturing intra-cultural resilience and wellbeing
−− Inuit traditional values:
On the Land & ‘Country Food’
Table 2
Indigenous Child Health Stakeholder’s Meeting – Discussion & Recommendations Health of Indigenous Children: Health Assessment in Action
121
Small Group Three – Métis
Additional comments from flipcharts /
mini-group presentations
Inequities / Priorities
1. Health Status Inequities are unclear because of:
• lack of ability to measure
• lack of consistent terminology
• Data is required to provide reasons as to why
these events occur
−− Currently no baseline data records / measurements
for infant health exist – so difficult to paint an
accurate & ongoing picture of Métis health or to
plan more appropriate health service delivery
−− Cross-jurisdictional challenges
−− Communities to identify the health and wellbeing
indicators that are relevant to them:
• interpreted in context (community norms &
mores could be reflected within these indicators)
• Community to be involved as a Data Working
Group & provide input on a ‘Data Dictionary’
Social Concerns
1. Racial discrimination
−− Lateral violence is an issue that is often articulated
by Métis and can be more common and destructive
than within First Nation Communities
−− Discrimination exists within families, between
communities as well as from other Aboriginal
communities
2. Kinship / Family
−− Acceptance of heritage or lack of recognition,
generational effects of abuse may be present due
to a number of factors not excluding residential
school experience
−− Domestic violence, ‘parenting’ knowledge
& strategies
3. Food security
4. Housing security
Health Concerns
1. Infant mortality – reproductive health
−− Pre-conception and pre-natal
2. Mental wellbeing
3. Mobility
−− Highly mobile population intra and
intergenerational mobility thus difficult to identify
actual numbers, and deliver programs when
population is often in flux
Health Service Delivery Concerns
1. Pre-natal care
Table 3
122
Health of Indigenous Children: Health Assessment in Action Indigenous Child Health Stakeholder’s Meeting – Discussion & Recommendations
6.4 Group Activity 2
A) Cross-Cutting Indigenous Children’s Health and
Health Assessment Issues and Priorities
As evident from Group Activity 1, many of the
issues affecting the health of Indigenous children
are cross-cutting for First Nations, Inuit and Métis
populations. Some similarities / commonalities
were also identified and shared with the Canadian
stakeholders by international guest speakers from
New Zealand, Australia and the USA. Although the
following cross-cutting areas of concern were identified
as priority areas, they are not listed in any hierarchy. It
is also acknowledged that these issues are not seen as
occurring in isolation from one another, but rather are
undoubtedly inter-related.
Social Concerns
• Poverty
• Housing
• Education / Schooling
• Food Security
• Child Welfare / Exposure to Violence
• Racial discrimination as a determinant of health
affecting access to services and quality of care
in services
Health Concerns
• Oral health
• Hearing health
• Diabetes, Obesity & other chronic diseases
• Respiratory & other infectious diseases
• Mental health
Health Service Delivery Concerns
• Lack of child-centered care
• Lack of coordinated care
Health Status Inequities and IMR
• Health status inequities for Indigenous children
are currently unclear because of the inability to
accurately measure them
• Need for the development and/or improvement of
both data collection and data sharing protocols in a
manner that is respectful and ensures cultural safety
for Aboriginal groups
B) Best practice ideas
Best practice ideas generated from discussions at the
meeting reflected the concept of ‘Practice Partnerships’.
This included more consultation, engagement and
involvement amongst researchers, public health
practitioners and Aboriginal communities. This would
provide communities with the time and space to
identify, utilize and then apply health data products
to benefit their children. Most importantly, practice
partnerships would foster increased opportunities
for engaging with and drawing on the expertise of
Aboriginal community leaders. This was seen as a
fundamental and necessary for establishing trust
and negotiating ownership of data for Aboriginal
communities.
In the spirit of best practice partnerships and in
light of Canada’s colonial history, it was identified that
community autonomy and self-determination do not
necessarily need to be incompatible with using other
‘western’ tools for accurate data collection. Participants
recognized that attempts to achieve a balance in this
sense must account for the differences in historical
perspectives and experiences of First Nations, Inuit and
Métis. Understanding these differences when informing
best practice and policy initiatives is important, for
it avoids the mentality of ‘a one size fits all’ approach
to Aboriginal issues. As such, it reduces the social
fallacy of Aboriginal essentialism and promotes a space
for recognizing and celebrating the diversity of First
Nations, Inuit, and Métis in Canada.
Participants highlighted that action was required
to strengthen and increase the capacity for Indigenous
communities to identify issues and address inequities
in relation to data collection (or lack thereof) which
continue to have huge impacts on the health of
Aboriginal children. This action is important because
current data sets are skewing (underestimating /
misrepresenting) infant and child morbidity and
mortality rates for our children. Again, the notion of
best practice and sustainable partnerships was raised
as one way for reducing the chance of data misuse
or misinterpretation. This would be seen in practice
as advocating for community representatives, public
health data practitioners, and other stakeholders
to work together. One example of this discussed
at the meeting came from the SOGC (Society of
Obstetricians and Gynecologists of Canada). The
SOGC stated their strong interest in collaborating
with Aboriginal groups, noting that addressing
Indigenous maternal and child health data problems
and discrepancies could greatly contribute to the
improvement of Indigenous children’s health.
Some Aboriginal community representatives also
identified that there was a mismatch between what
academic institutions recognized as ‘research’ and
what Aboriginal communities ‘need’ as ‘action’ and
‘deliverables’. As a result, best practice would need to
take account of research and data collection approaches
that incorporate the timely needs and desires of the
Indigenous Child Health Stakeholder’s Meeting – Discussion & Recommendations Health of Indigenous Children: Health Assessment in Action
123
There is currently a mismatch between what
academic institutions recognize as research
and what Aboriginal communities need as
action and deliverables
community, so that research and data collection
translates into tangible outcomes and benefits for
Aboriginal communities. Part of this best practice
process would involve increasing the capacity for
Aboriginal communities and researchers to have their
community based health research approaches (as CIHR
guidelines for research involving Aboriginal peoples
advocate) recognized and funded accordingly for
ongoing sustainability.
C) Policy Approaches
A central theme to the meeting discussions was
the development of balanced policy and practice
approaches to the collection of Indigenous child
infant mortality and morbidity data in Canada. These
approaches call for the need to balance the right to be
counted, with OCAP Indigenous right to participate in
governance and management of health data, and the
overarching rights of children.
Policy and practice considerations discussed at the
meeting reflected the complexities associated with
orchestrating and implementing initiatives aimed at
improving Indigenous children’s health. Having no
standardized data collection methods, little statistical
data readily available to accurately identify health status
inequalities (or even where they stem from in relation
124
Health of Indigenous Children: Health Assessment in Action to Indigenous infant and child morbidity and mortality
rates), is in itself a major public health issue; arguably
one that speaks to colonization and many of its ongoing
guises. As Aboriginal people we can not, nor should we,
ignore the power dynamics inherent at a functioning
social systems level between non-Aboriginal and
Aboriginal Canada - for it is these power relationships
that shape and determine what is socially ‘significant’
and worth ‘measuring’ in terms of health status
inequities. One thing we can say with certainty is
that our meeting and the discussions generated
demonstrated the shared commitment to improving
the health of Aboriginal children in Canada – for they
are our future. Having established our dedication to
improving the health of Aboriginal children, the next
obstacle to overcome is how we work together with
diverse Aboriginal communities to achieve improved
health outcomes for our children.
As any good healer knows, before you can begin to
treat it helps if you can first identify the poisons. One
major concern at the moment is that we do not have an
accurate picture of Indigenous child health status. Thus,
we are unaware of the specific ‘poisons’ we are dealing
with. Any policy or best practice designed to change
this lack of knowledge will therefore need to be well
informed and be able to engage community support.
Indigenous Child Health Stakeholder’s Meeting – Discussion & Recommendations
Any policy and practice initiatives formulated that
consider the rights of children, the right to be counted,
and the rights of Aboriginal communities to participate
in the governance and management of their health
data will have a host of complex questions that must be
addressed. Due to the social, political, economic, and
health ramifications we should ask ourselves: ‘What are
the costs associated with opting out of census in terms
of political repercussions and funding? What will be
the repercussions of this on smaller Aboriginal groups
being able to run their own data systems independently?
How does this sit with vital statistical information?’
To help navigate our way through some of these
complex questions in relation to our approaches to
policy and practice in the area of Indigenous child
health data collection, participants at our meeting
shared their ideas in relation to both policy concepts /
ideas, as well as actual policy strategies.
Policy Concepts / Ideas
Policy concepts that emerged from our meeting
were heavily focused on establishing policies and
practices that support the preservation and protection
of Indigenous OCAP (Ownership, Control, Access,
Possession) principles. This would include reserving
the right for Aboriginal groups to collect data for
themselves and operationalize this for themselves
– without necessarily having to share this data with
other Aboriginal groups. This reflects that some
Aboriginal groups may prefer not to share data
with other Aboriginal groups in an ‘overarching’
macro-Aboriginal health agenda and this should
be respected. This raises an important implication
for policy formulation in terms of avoiding a ‘one
size fits all’ approach. Flexibility and scope for
maneuverability in relation to tailoring policy
approaches that are applicable to specific Aboriginal
groups will therefore be necessary. This does not
mean that individual Aboriginal communities and
groups are not interested in the collection of data for
improving child and maternal health. It also doesn’t
mean that all Aboriginal groups/communities agree
with OCAP principles.
Flexibility in policy and practice approaches is also
necessary in light of some Aboriginal groups’ strong
belief that if an issue within their community needs
to be ‘studied’ then they themselves should be the
ones initiating this study first. Help would be sought
from outside the community only if it is required.
This stands in stark contrast to historical policy and
practice initiatives that view Aboriginal community
health issues through a western frame, dictating from
the ‘outside’, ‘What is needed’. In this instance, these
Aboriginal groups follow the concept of initiating,
controlling, and having ownership over research data
and research practice.
Different experiences for different Aboriginal
groups however, may not necessarily mean that
different truths and perspectives are incompatible.
For instance, Métis people have been completely
ignored in the collection of health status data, and
this in itself is a major health status inequity. Some
communities, including Métis, have not been funded
for infrastructure around health or other socially
related data collection. In a practical sense, the notion
of integrating Indigenous and Western knowledge
when developing policies aimed at working with
Aboriginal communities would need to involve
Aboriginal communities taking a pro-active approach
in the research/data collection process. This will help
to identify the health and wellbeing indicators that
are relevant to each communities needs. In so doing,
community norms and mores would be reflected
in those indicators. Our strength and creativity as
Aboriginal people affords us the ability to identify the
scope and potential opportunities for us to explore
avenues for improving our children’s health, whilst
at the same time respecting diversity between and
within Aboriginal groups and our sovereign right to
participate in the implementation and sharing of our
children’s health data.
Policy Strategies
One key policy strategy that emerged through our
discussions included being respectful of the ownership
and use of data. Developing partnerships and protocols
for the sharing of information between Aboriginal
groups and data collection agencies is therefore a
major priority. So too is respecting that data from
multiple sources may be conflicting or contradictory.
Again, this is where knowledge sharing between
Aboriginal groups and researchers can help to clarify
data and what data means.
Additionally, the meeting discussions addressed the
need for communities and researchers to work together
in lobbying as advocates for improvements in children’s
health and to use community lobbying platforms to
drive and inform policy on the issue of data collection,
ownership and sharing agreements. Appropriate policy
was identified as a critical and crucial step in the
development of data collection. The use of culturally
meaningful marketing strategies was identified as an
important policy strategy to give communities a better
understanding of how data collection initiatives can
help us to provide better services and improve the
health of children in Aboriginal communities.
Indigenous Child Health Stakeholder’s Meeting – Discussion & Recommendations Health of Indigenous Children: Health Assessment in Action
125
126
Health of Indigenous Children: Health Assessment in Action Concluding Remarks – Finding Strength in Numbers
Concluding Remarks
Finding Strength in Numbers
Eighteen months ago Health Canada approached me to
write this report. Although enthusiastic about the task
at the time, I did not anticipate the broad scope and
new depths of knowledge about Indigenous children’s
health that this project has generated. The quality and
comprehensiveness of this final product is rooted in
a fundamental commitment by all of the writers and
participant stakeholders to the health and wellbeing
of Indigenous children not only in this generation,
but for many generations to come. Action to ensure
that Indigenous children begin to experience the
same levels of prosperity, environmental nurturance,
access to health services and wellbeing that most nonIndigenous children take for granted in our relatively
affluent countries is long overdue.
In Canada, jurisdictional complexities are often
used as an excuse for double standards in Indigenous/
non-Indigenous health assessment and response.
Commonly, the argument is between the provinces/
territories and the federal government as to who holds
the responsibility for Indigenous health and public
health assessment and service. Unfortunately, more
often than not, the argument is not clearly resolved and
there is a resultant lack of action. It is First Nations,
Inuit, and Métis children who end up experiencing
avoidable suffering as a result of these stalemates. It is
one of the causes of the deficiencies in Indigenous child
health assessment data in Canada, and also results in
significant challenges in access to care. For example,
in 2005 a chronically ill and disabled First Nations
child by the name of Jordan River Anderson died in
a Winnipeg hospital, far away from his family and
Concluding Remarks – Finding Strength in Numbers home community in northern Manitoba, because the
federal and provincial government argued for over two
years over which government would be responsible for
the cost of his home health care. In response to this
situation, Jordan’s Principle, a child first approach to
resolving jurisdictional disputes within and between
the federal and provincial/territorial governments1 was
developed as a private members bill and unanimously
approved by federal parliament. Jordan’s Principle
requires that the government of first contact pays for
the service to the child without delay or disruption.
Although it is now legislated, Jordan’s Principle has yet
to be implemented.
This report provides a convincing example of
the value that can be added by forming partnerships
and working across jurisdictions – locally, regionally,
nationally, and internationally. Collaborating
internationally in the production of this report has
provided an opportunity for the authors to highlight
the Indigenous child health disparities that exist in each
of our countries and also identify a number of crosscutting issues. The report is crafted as a reference and
advocacy tool for Indigenous child health stakeholders
committed to ensuring the prosperity, environmental
nurturance and well being of Indigenous children
around the world. Hopefully these stakeholders will
similarly find “strength in numbers” both through
mutual collaboration and the figures shared in the
preceding chapters and with this renewed energy
continue to press for the policy actions required to
address Indigenous children’s health disparities at home
and abroad.
Author:
Janet Smylie MD MPH
Research Scientist
Centre for Research on
Inner City Health
The Keenan Research Centre
in the Li Ka Shing Knowledge
Institute
St. Michael’s Hospital
Associate Professor
Dalla Lana School of Public
Health
University of Toronto
1
http://www.fncfcs.com/docs/
JordansPrincipleFactSheet.pdf
Health of Indigenous Children: Health Assessment in Action
127
128
Health of Indigenous Children: Health Assessment in Action Appendix A – Stakeholder Meeting Participants
Appendix A
Stakeholder Meeting Participants
Indigenous Children’s Health Report
Stakeholder Meeting
Friday May 30th , 2008
St. Michael’s Hospital
Please note that attendants’ participation at
the stakeholder meeting does not indicate an
endorsement from their respective organizations
for the information contained in this report.
We acknowledge with thanks their time and
contributions to the engaging discussions that
took place.
Heather McCormack
Children and Youth Division
Community Programs Directorate
First Nations and Inuit Health Branch
Health Canada
Jennifer Pennock MSc
Manager, Surveillance and Data Collection
Health Information Analysis and Research Division
First Nations and Inuit Health Branch
Health Canada
Janet Smylie MD MPH
Research Scientist
Centre for Research on Inner City Health
The Keenan Research Centre in the
Li Ka Shing Knowledge Institute
St. Michael’s Hospital
Associate Professor
Dalla Lana School of Public Health
University of Toronto
Appendix A – Stakeholder Meeting Participants Kelly McShane PhD
Assistant Professor
Ryerson University
Associate Researcher
Centre for Research on Inner City Health
The Keenan Research Centre in the
Li Ka Shing Knowledge Institute
St. Michael’s Hospital
Gilbert Gallaher PhD
Research Fellow
Centre for Research on Inner City Health
The Keenan Research Centre in the
Li Ka Shing Knowledge Institute
St. Michael’s Hospital
Paul Adomako MSc
Research Coordinator III
Centre for Research on Inner City Health
The Keenan Research Centre in the
Li Ka Shing Knowledge Institute
St. Michael’s Hospital
Jane Freemantle PhD
Associate Professor
Centre for Health and Society
Melbourne School of Population Health
The University of Melbourne
Principal Research Fellow
Onemda VicHealth Koori Health Unit
Daniel McAullay PhD(c)
Senior Research Officer
PhD Candidate
Telethon Institute for Child Health Research
Health of Indigenous Children: Health Assessment in Action
129
Sue Crengle PhD(c)
Senior Lecturer
Te Kupenga Hauora Māori
Director
Tōmaiora Māori Health Research Centre
Faculty of Medical & Health Sciences
University of Auckland
Alastair MacPhee
Congress of Aboriginal Peoples
Melanie Morningstar
Senior Policy Analyst
Assembly of First Nations
Maile Taualii MPH PhD(c)
Director
Native Hawaiian Epidemiology Center
Papa Ola Lokahi
Margo Greenwood
Scientific Director
National Collaborating Centre for Aboriginal Health
Assistant Professor
University of Northern British Columbia
Jessica Demeria
Research Officer
Metis Centre
National Aboriginal Health Organization
Kent Saylor MD
Consultant Pediatrician
Montreal Children’s Hospital
Canadian Paediatric Society
Winona Polson-Lahache
Research Officer
First Nations Centre
National Aboriginal Health Organization
Lisa Sterling
Special Advisor/Director of Aboriginal Affairs
Office of the Vice-President, Academic
And Assistant Professor
Simon Fraser University
Katherine Minich
Chair, Governing Committee
Inuit Tuttarvingat (formerly Ajunnginiq Centre)
National Aboriginal Health Organization
Mishael Gordon
Early Childhood Development Coordinator
Dept. of Socio-Economic Development
Inuit Tapiriit Kanatam
Dr. Suzanne Tough
Scientific Director
Alberta Centre for Child, Family and Community
Research
Vyta Senikas BSc MDCM FRCSC FSOGC CSPQ
Associate Executive Vice-President
The Society of Obstetricians and Gynaecologists
of Canada (SOGC)
Heather Tait
Data Coordinator
Inuit Tapiriit Kanatam
130
Health of Indigenous Children: Health Assessment in Action Appendix A – Stakeholder Meeting Participants
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