Our Health Counts Governing Council By

Prepared for

De Dwa Da Dehs Ney>s Aboriginal Health Centre,

Ontario Federation of Indian Friendship Centres,

Hamilton Executive Director’s Aboriginal Coalition, and the Our Health Counts Governing Council by:

Janet Smylie, Michelle Firestone, Leslie Cochran,

Conrad Prince, Sylvia Maracle, Marilyn Morley,

Sara Mayo, Trey Spiller and Bella McPherson

April 

4 Acknowledgements

This project was about enhancing community ways of gathering urban Aboriginal health information, and as such, could never have existed without the active participation and vital enthusiasm of hundreds First Nations community members living in the City of Hamilton. It is the intention of this report to honour the generosity of your participation and we therefore dedicate this report to members of the First Nations community in Hamilton.

Special thank-you’s to all the members of the First Nations community in Hamilton who participated, Donna Lyons, Connie Siedule, Lisa Pigeau, Jessica Hill, Betty Kennedy, Dennis Compton, Mandy Berglund, Chester Langille, the Hamilton Executive Directors Aboriginal Coalition, the Social Planning and Research Council of Hamilton, Gordon Gong, Cindy Sue McCormack, Renee Wetselaar, Crystal Burning, Amye Annett, Ashly MacDonald, Trisha McDonald, Diane Therrien, Alisha Hines, Pat O’Campo, Rick Glazier, Kelly McShane, Roseanne Nisenbaum, Dionne Gesink Law, Cyprian Wejnert, and Brandon Zagorski.

This project was funded by the Ontario Federation of Indian Friendship Centres, the Ministry of Health and Long-Term Care Aboriginal Health Transition Fund, and the Centre for Research on Inner City Health (CRICH) at Saint Michael’s Hospital. The Institute for Clinical Evaluative Sciences (ICES) contributed the costs of the in-house ICES data analysis and Dr. Smylie was supported by a Canadian Institutes for Health Research New Investigator in Knowledge Translation award during the course of the project.

This study was supported by the Institute for Clinical Evaluative Sciences ICES( ), which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC). The opinions, results and conclusions reported in this paper are those of the authors and are independent from the funding sources. No endorsement by ICES or the Ontario MOHLTC is intended or should be inferred. Our Health Counts Governing Council

Tungasuvvingat Tungasuvvingat Inuit Inuit Your next appointment is: ______Tungasuvvingat Inuit Your next appointment is: ______Family Family Health Health Team Team Family Health Team Date: ______ᑐᑐᑐᑐᑐᑐᑐ ᑐᖓᓱᕝᕕᖓᑦ ᑐᖓᓱᕝᕕᖓᑦ ᑐᑐᑐᑐ ᐃᓄᐃᑦ ᐃᓄᐃᑦ Date: ______

ᐃᐃᐃᐃᐃ ᐃᓚᒌᓄᑦ ᐃᐃᐃᐃᐃᐃᐃᐃᐃᐋᓐᓂᐊᓯᐅᕐᕕᒃ ᐃᓚᒌᓄᑦ ᐋᓐᓂᐊᓯᐅᕐᕕᒃ Tungasuvvingat Inuit Ann#300, Duggan, 24 Selkirk MD St, FCFP, MPH Tungasuvvingat Inuit Time:Time: ______YourYour next appointmentnext appointment is: is: ______Your next appointment is: #300,Ottawa, 24 ON, Selkirk K1L St. 0A4 Ottawa, ______ON, K1L 0A4 Family Family Health Health Team Team Phone: (613)-740-0999 Colleen Arngna’naaq Comment:Comment: ______Date: ______Phone: (613)-740-0999 Fax: (613) ᑐᑐᑐᑐᑐᑐᑐ- 740 -0991 ᑐᖓᓱᕝᕕᖓᑦ ᑐᖓᓱᕝᕕᖓᑦ ᑐᑐᑐᑐ ᐃᓄᐃᑦ ᐃᓄᐃᑦ Date: ______Community Health Researcher [email protected]: (613)-740-0991 ᐃᐃᐃᐃᐃHepatitus ᐃᐃᐃᐃᐃᐃᐃᐃᐃ C ᐃᓚᒌᓄᑦ ᐃᓚᒌᓄᑦ ᐋᓐᓂᐊᓯᐅᕐᕕᒃ ᐋᓐᓂᐊᓯᐅᕐᕕᒃ

Ann#300, Duggan, 24 Selkirk MD St, FCFP,Tungasuvvingat MPH Inuit Time:Time: ______297 Savard Ave, *Please give 24 hour notice if cancelling an appointment* #300,Ottawa, 24 ON, Selkirk K1L St. 0A4 Ottawa, ON, K1L 0A4 *Please give 24 hour notice if cancelling an appointment* Phone: (613)-740-0999Ottawa, ON K1L 7S1 Comment: ______Phone: (613)-740-0999Tel: (613) Fax: 749-4500 (613)- 740Ext. 21-0991 Colleen Arngna’naaq Comment:Comment: ______Community Health Researcher [email protected]: (613)-740-0991 Fax: (613) 749-8713 Hepatitus C Tungasuvvingat Inuit [email protected] Your next appointment is: ______Tungasuvvingat Inuit www.tungasuvvingatinuit.ca *Please give 24 hour notice if cancelling an appointment* Family Health Team 297 Savard Ave, *Please*Please give 24give hour 24 notice hour noticeif cancelling if cancelling an appointment* an appointment* Ottawa, ON K1L 7S1 ᑐᖓᓱᕝᕕᖓᑦ ᐃᓄᐃᑦ Date: ______Tel: (613) 749-4500 Ext. 21

ᐃᓚᒌᓄᑦ ᐋᓐᓂᐊᓯᐅᕐᕕᒃ Fax: (613) 749-8713 Tungasuvvingat Inuit Time: ______Connie Siedule, Director of Health [email protected] Your next appointment is: ______#300, 24 Selkirk St. Ottawa, ON, K1L 0A4 www.tungasuvvingatinuit.ca Family Health Team Comment: ______Phone: (613)-740-0999 Fax: (613) - 740 -0991 ᑐᖓᓱᕝᕕᖓᑦ ᐃᓄᐃᑦ Date: [email protected] ᐃᓚᒌᓄᑦ ᐋᓐᓂᐊᓯᐅᕐᕕᒃ Connie Siedule, Director of Health Time: ______*Please give 24 hour notice if cancelling an appointment* #300, 24 Selkirk St. Ottawa, ON, K1L 0A4 Phone: (613)-740-0999 Fax: (613)-740-0991 Comment: [email protected] Tungasuvvingat Inuit Your next appointment is: ______*Please give 24 hour notice if cancelling an appointment* Family Health Team 5 Date: ______ᑐᖓᓱᕝᕕᖓᑦ ᐃᓄᐃᑦ ᐃᓚᒌᓄᑦ ᐋᓐᓂᐊᓯᐅᕐᕕᒃ Dr. Indu Gambhir Tungasuvvingat Inuit Time: ______Your next appointment is: ______#300, 24 Selkirk St. Ottawa, ON, K1L 0A4 Family Health Team Comment: ______Phone: (613)-740-0999 Fax: (613) - 740 -0991 ᑐᖓᓱᕝᕕᖓᑦ ᐃᓄᐃᑦ Date: [email protected] ᐃᓚᒌᓄᑦ ᐋᓐᓂᐊᓯᐅᕐᕕᒃ Dr. Indu Gambhir Time: ______*Please give 24 hour notice if cancelling an appointment* #300, 24 Selkirk St. Ottawa, ON, K1L 0A4 Phone: (613)-740-0999 Fax: (613)-740-0991 Comment: [email protected] Tungasuvvingat Inuit Your next appointment is: ______*Please give 24 hour notice if cancelling an appointment* Family Health Team Date: ______ᑐᖓᓱᕝᕕᖓᑦ ᐃᓄᐃᑦ ᐃᓚᒌᓄᑦ ᐋᓐᓂᐊᓯᐅᕐᕕᒃ Heather Burke, Medical Receptionist Tungasuvvingat Inuit Time: ______Your next appointment is: ______#300, 24 Selkirk St. Ottawa, ON, K1L 0A4 Family Health Team Comment: ______Phone: (613)-740-0999 Fax: (613) - 740 -0991 ᑐᖓᓱᕝᕕᖓᑦ ᐃᓄᐃᑦ Date: [email protected] ᐃᓚᒌᓄᑦ ᐋᓐᓂᐊᓯᐅᕐᕕᒃ Heather Burke, Medical Receptionist Time: ______*Please give 24 hour notice if cancelling an appointment* #300, 24 Selkirk St. Ottawa, ON, K1L 0A4 Phone: (613)-740-0999 Fax: (613)-740-0991 Comment: [email protected] Tungasuvvingat Inuit Your next appointment is: ______*Please give 24 hour notice if cancelling an appointment* Family Health Team Date: ______ᑐᖓᓱᕝᕕᖓᑦ ᐃᓄᐃᑦ ᐃᓚᒌᓄᑦ ᐋᓐᓂᐊᓯᐅᕐᕕᒃ Aigah Attagutsiak, Case Manager/ Interpreter Tungasuvvingat Inuit Time: ______Your next appointment is: ______#300, 24 Selkirk St. Ottawa, ON, K1L 0A4 Family Health Team Comment: ______Phone: (613)-740-0999 Fax: (613) - 740 -0991 ᑐᖓᓱᕝᕕᖓᑦ ᐃᓄᐃᑦ Date: [email protected] ᐃᓚᒌᓄᑦ ᐋᓐᓂᐊᓯᐅᕐᕕᒃ Aigah Attagutsiak, Case Manager/ Interpreter Time: ______*Please give 24 hour notice if cancelling an appointment* #300, 24 Selkirk St. Ottawa, ON, K1L 0A4 Phone: (613)-740-0999 Fax: (613)-740-0991 Comment: [email protected]

*Please give 24 hour notice if cancelling an appointment*

We gratefully acknowledge the financial contributions to this project from the Ministry of Health and Long-Term Care, Ontario Federation of Indian Friendship Centres and St. Michael’s Hospital.

We would like to acknowledge the award given to Dr. Janet Smylie by the CIHR New Investigator Award in Knowledge Translation. tABle oF contents

8 eXecutive summArY

16 ProJect overview  Introduction  Objectives  Project Development  Project Governance  Research Team  Hamilton Site

22 metHods  Community Based Participatory Research  Concept Mapping  Respectful Health Survey  Respondent Driven Sampling  ICES Data Linkage  Community Implementation

29 results  Concept Mapping  Respectful Health Survey Data  ICES Data Linkage

77 imPlicAtions For urBAn ABoriginAl HeAltH PolicY And PrActice

 References  APPENDIX A — Community – SMH Research Agreement  APPENDIX b — ICES data sharing agreement  APPENDIX c — First Nations Adult and Child Survey Tool  APPENDIX d — Concept Mapping Statements

7 8 eXecutive summArY COUNTS HEALTH OUR

introduction to tHe our HeAltH counts ProJect – Addressing tHe gAPs in urBAn First nAtions HeAltH dAtA in ontArio:

As a result of these defi cits in urban Aboriginal health information, policy makers in community organizations, small regions, and provincial and federal governments are limited in their abilities to address urban Aboriginal community health challenges and aspirations. Without Aboriginal health information, eﬀ ective health policy, planning, program/service delivery, and performance measurement are limited. Moving toward basic population health measures is essential to improve the health status, access to services, and participation in health planning processes aﬀ ecting Aboriginal people.

For the past three years, the Ontario Federation of Indian Friendship Centres (OFIFC), Métis Nation of Ontario (MNO), Ontario Native Women’s Association (ONWA), and Tungasuvvingat Inuit (TI) have been working with a health research team led by Dr. Janet Smylie based at the Centre for Research on Inner City Health (CRICH), Saint Michael’s Hospital, on the Our Health Counts Urban Aboriginal Health Database project. For the First Nations arm of the project, the community organizational partner OUR

HEALTH 9 COUNTS , and Saint , TI , ONWA , MNO ) Aboriginal Health Transition MOHLTC ) project was to work in partnership was work to ) project with OHC . . Organizational partners OFIFC included and TI innovAtive metHods: innovAtive Concept Mapping andConcept Respectful Mapping Assessment Health Survey: Brainstorming and sorting the surveys for ideas and of using topics was concept done withmapping health and social service stakeholders in Hamilton. and hundred two One Th is wasachieved throughgoverning structure project the including project Governing the Th Council and research and data sharing agreements described as well as above ensuring that capacity building, respect, cultural relevance, representation, and sustainability were core overall ongoing implementation. and day to day features the of project’s Community BasedCommunity Participatory Research Partnerships: wasproject is carried out using community based participatory research methods. Th balance in promoted betweenOur the the relationships approach Aboriginal organizational partners, academic research team Aboriginal members, community participants and collaborating Aboriginal and non-Aboriginal organizations throughout the health information process, adaptation from initiation dissemination. to Th e goal e of OurHealththe ( Counts Th was da Aboriginal De dwa ney>s dehs Health the Access Centre, whichrepresented community theinterests of First Nations in Hamilton behalf on the of broader Hamilton Executive Directors Aboriginal Coalition. Fund, and CRICH Th e OurHealth UrbanAboriginal Counts Health wasDatabase project by OFIFCfunded Th Aboriginal organizational stakeholders to develop a baseline population health database urbanfor Aboriginal living people in Ontario that is immediately useful, accessible, and culturally local, to relevant small and provincial region, policy makers. the Ministry Care ( Health of and Long Term Th ere were were communityFirstNations project Hamilton, threein ere sites: Inuit in Ottawa, and Th report focusesis on FirstNations Hamilton in the communitysite, Métis in Ottawa. Th cant communitywhich was as because project chosen signifi its the site of First Nations reporting persons AboriginalAboriginal ancestry (, population according the to  and infrastructure strong Census) Aboriginal of community health and social services. Michael’s Hospital. CommunityMichael’s partners da Aboriginal De dwa dehs ney>s included behalfHealth the of Hamilton Access Centre (on Executive Directors Aboriginal MNOCoalition), statements were sorted into a concept map of ten domains. Th ese domains and statements were used by the research team and to create questionnaires for both adults and children. Surveys were conducted in person by trained interviewers initially with paper-based questionnaires and later on directly on a computer.

Respondent Driven Sampling and ICES data linkage A respondent driven sampling (RDS) technique was used to recruit individuals to be 10 interviewed for the research. Th is method involved giving tickets to each First Nation participant who completed an interview, and the participants could give these tickets to COUNTS HEALTH OUR other First Nations people they knew, including friends and family. For each participant recruited, the person who made the recruit received . Th e OHC First Nations Hamilton sampling was extremely successful. Over a course of four and a half months a total of  persons were recruited, including  adults and  children. Ninety-two percent of participants gave permission to use their OHIP number to link to their data on health care system usage available through the Institute for Clinical Evaluative Sciences. All the data fi ndings presented in the results section are adjusted for bias using RDS statistics to take into account how spread out diﬀ erent participants are within the social network through which they were recruited.

keY ProJect Findings And imPlicAtions For HeAtH PolicY And PrActice:

Housing, services for low income and marginalized Populations, and Addressing inequities in the social determinants of Health: Th eOHC study identifi ed striking levels of poverty among First Nations residents living in Hamilton. For example, .% of the First Nations persons living in Hamilton earn less than , per year and % of the First Nations population in Hamilton lives in the lowest income quartile neighbourhoods compared to % of the general Hamilton population.

Th is poverty is accompanied by marked challenges in access to housing and food security. For example, % of the First Nations population living in Hamilton had moved at least once in the past  years and over % of the population had moved three or more times in the past  years. Furthermore, % of the First Nations population living in Hamilton reported being homeless, in transition, or living in any other type of dwelling not listed. In addition, .% of First Nations persons in Hamilton reported that they live in crowded conditions, compared to a rate of % general Canadian population. Finally, % of First Nations community members in Hamilton had to give up important things (i.e. buying groceries) in order to meet shelter-related [housing] OUR HEALTH COUNTS 11 study was that First Nations people living study was people that First Nations in Hamilton chronic disease and disability: and disease chronic Th at provincial engage at withgovernments urbanAboriginal communities and Th organizations the purpose for establishing of priorities, and resource funding allocations and action plans address to the critical inequitiesin all and economic ecting Aboriginal health food homelessness, includingsocial poverty, aff conditions healthinsecurity, access, equality employment, education, gender and social safety. Th at all local and provincial agencies that off er services to signifi cant numbers of low of numbers cant er servicessignifi to at alllocal provincial and off agencies that Th income/marginalized urban Aboriginal collaborate populations directly with urban Aboriginal mandatory and organizations agencies and implement and develop Aboriginal cultural diversity training. Th at provincial governments that have responsibility for housingresponsibility provincialsupports at for and have governments that Th (Ministry Care and Health the of Ministry and Long Term Community of and Social Services) with engage urban Aboriginal communities and organizations the for purpose ensuring of that the communities’ priorities and critical needs in the areas of rental housing, supportive and transitionalordable housing, and assisted home aff areownership addressedin accordance with human rights legislation. Addressing Inequities in the Social the Addressing in Inequities Determinants Health: of Services and Marginalized Low for Income Populations: Another key fi nding of OHC the Another key fi are living with disease chronic of burden a disproportionate and example, disability. For more diabetesthe of rate Hamilton the among First adult is Nations population .%, than three times the the among rate general a much Hamilton despite population, Hamilton the of First demographic age Nations population. Furthermore,younger the high in population of the among rate prevalence pressure First adult Nations blood ; the rate prevalence a general to Hamilton .%) of rate (compared Hamilton was .% and the prevalence a general to Hamilton .%); arthritis of of rate (compared was .% an to estimated Ontario .%). of rate prevalence (compared Hepatitis C was of rate .% the of threetotal andIn population % adult over addition, quarters person of (%) or sometimesen experiencing limitations in the kindsor years  reported oft over 3. 2. 1. Housing: Th ese fi resulted have followingndings in the policy inrecommendations theareas of ese Th housing, services and marginalized income low for and populations addressing inequities in the social determinants health: of costs and only % of the First Nations population always the population thecosts enoughof had kinds of First and Nations only % of thatfood they wanted eat. to amount of activity done at home, work or otherwise because of a physical or mental condition or health problem. Finally, % of all adults reported fair or poor mental health and % reported that they had been told by a health care provider that they had a psychological and/or mental health disorder. Th ese fi ndings have led to the following policy recommendation regarding chronic disease and disability:

4. Th at municipal and provincial governments commit to long term resources and 12 funding allocations and engages with urban Aboriginal communities and organizations for the purposes of establishing priorities, preventative action and COUNTS HEALTH OUR promotion plans towards the reduction of the burden of chronic disease and disability in the urban Aboriginal community.

Health care Access: Th eOHC study fi ndings are compelling with respect to the need to urgently address barriers in accessing health care services across the spectrum of preventative, primary, and tertiary care. For example, % of the First Nations population in Hamilton rates their level of access to health care as fair or poor. Identifi ed barriers included long waiting lists (%), lack of transportation (%), not able to aﬀ ord direct costs (%), doctor not available (%), and lack of trust in health care provider (%). Striking diﬀ erences in emergency room admission rates between for First Nations in Hamilton compared to the general Hamilton and Ontario populations for both acute and non-acute illnesses are linked by participant narrative to the barriers listed above to access of timely preventative and primary health care. Fift y two percent of the First Nations population in Hamilton reported at least one visit to the emergency room over the past  years for acute problems compared to % of the Hamilton and % of the Ontario population. Ten point six percent of the First Nations population in Hamilton reported  or more emergency room visits in the previous  years compared to .% and .% of the Hamilton and Ontario populations respectively. Notwithstanding this heavy use of emergency room services, % of the Hamilton First Nations population rated the quality of the emergency care as fair or poor. Th ese fi ndings have led to the following policy recommendation regarding health care access:

5. Th at municipal, provincial and federal governments engage with urban Aboriginal communities and organizations for the purposes of eliminating barriers in access to equitable community health care, emergency department services and inpatient hospital services for acute and non-acute conditions.

Aboriginal specific services, cultural safety, and Aboriginal self-determination of Health care delivery Despite the challenges described above, First Nations people living in Hamilton demonstrate remarkable cultural continuity and resilience. Even though resources and OUR HEALTH COUNTS 13 study measures pre-survey concept mapping study highlighted mapping pre-survey concept thethat idea “Our study found that % of parents and was parents caregivers it very of somewhat that or felt study % found children’s Health: children’s Th at municipal,at provincial recognizefederal governments and validateand the Th Aboriginal cultural the encompasses physical, mental, emotional, (that worldviews spiritual, and social Aboriginal well-being of individuals and that and communities) self-determination is fundamental and thus Aboriginal full have must people in and all choice aspectsinvolvement health of including care governance, delivery, research, planning and development, implementation and evaluation. Th at municipal,at provincial federalhealth governments and and stakeholdersdevelop Th cultural of and initiate the policies towards implementation and/ competency or cultural safety programs that are Aboriginal designed by and delivered that people theincludes recognition and validation Aboriginal of and full worldviews inclusion Aboriginalof healers, medicine midwives, people, community and counselors health orts with western medicine. incare all workers collaborative eff Th at municipal,at provincial adequate of federalensure provision governments and the Th funding the to urban community and organizations directed the towards ective, community based, long-term and expansion culturally of development refl traditional family centres, treatment urban Aboriginal child, and youth mental adult health funded strategies and maternal health, programs and services. Aboriginal Delivery: Self-Determination Care Health of Cultural Safety: Parents and caregiversParents children First Nations of in Hamilton highly value the transmission culture First Nations of and language example, the For to next generation. the OHC important their for child learn to language and parents a First Nations of and % caregivers that traditional felt cultural important very somewhat or in were their events child’s life. 8. 7. 6. Aboriginal Specifi c Services for Family Treatment, Mental Health and Maternal Health Health Mental c Services Treatment, Family for Aboriginal Specifi indicate a strong sense of First Nations identity among the First Nations population living population theidentityamong indicate FirstNations First senseNations a strong of in Hamilton as well as pass desire a strong to culture and language the to next on e OHC generation. Th Health and Dedicated Deserves Care” respectful and Appropriate the subsequent health healthassessment survey Native and care more the documented workers desire for cant andbarriers “lack trust “prejudice” of accessingin and discrimination” as signifi ndingsadvancewe following the policyrecommendations: care. In these to response fi programming Aboriginal for cultural programming in been Hamiltonextremely have cant, OHC limited date and to the been signifi impacts colonization have of Additional key study fi ndings regarding First Nations children’s health included the burden of chronic illness facing First Nations children in Hamilton; concerns regarding child development; and long waiting lists as a barrier to accessing health care. Asthma and allergies were the most commonly reported chronic conditions. Rates of asthma were twice as high for Hamilton First Nations children compared to general Canadian rates for children. Rates of chronic ear infections were also high. Twenty-two percent of parents and caregivers were concerned about their child’s development. While % of participants 14 indicated that their child had seen a family doctor, general practitioner or pediatrician in the past  months (compared to % for the general Canadian population aged - COUNTS HEALTH OUR years), there were a signifi cant number of reported barriers to accessing care. Th e number one barrier to receiving health care reported by child custodians was that the wait list was too long. In response to these fi ndings, we recommend the following policies:

9. Th at municipal and provincial governments, including school boards, recognize the importance of and commit long term funding and resources towards Aboriginal children’s language and cultural programming in collaboration with urban Aboriginal organizations and agencies.

10. Th at municipal and provincial governments work in collaboration with urban Aboriginal agencies and organizations to reduce urban Aboriginal children’s health status inequities by eliminating barriers to urban Aboriginal children accessing regular primary health care, reducing long waiting lists and responding to the increased prevalence of health conditions such as asthma in the urban Aboriginal child population with customized culturally appropriate primary health care programming.

11. Th at municipal and provincial government’s work in partnership with urban Aboriginal agencies and organizations to ensure that urban Aboriginal children are accorded their human rights to live in healthy homes and communities and attend day programs/schools in healthy environments that do not exacerbate chronic health conditions such as asthma and allergies.

research: Urban First Nations organizations and community members in Hamilton successfully partnered with provincial Aboriginal organizations and academic researchers in the collection, governance, management, analysis and documentation of their own urban First Nations health database. Successful research outcomes included:

• Completion of a community concept mapping project that identifi ed First Nations specifi c health domains. OUR HEALTH COUNTS 15 ) allowed for successful) allowed for RDS ) First Nations cohort measures. cohort ) First Nations ICES Th at municipal,at provincial federalsupport interagency governments and Th collaboration urban and amongst cooperation Aboriginal service towards providers of cation funding research and the design and delivery services of and identifi opportunities. municipal,at provincial federal collaborate governments and with urban Th Aboriginal and organizations agencies and gain the of knowledge urban Aboriginal health determinants and health inequities andfurther acknowledge the urban Aboriginal communities right self-determination to planning, in of the control health c services, and delivery culturallyprograms of design, development specifi and policy. system Planning: system Th at municipal,at provincial federal governments and and urban Aboriginal Th organizations recognize the health status inequities and disparities urban of Aboriginal living in the city Hamilton funded of and for advocate urban Aboriginal health applied c servicesresearch. specifi Development and implementation of a customized of and adult child First and Nations implementation Development health needs assessment survey which was administered adults behalf and on  to living community children  in members) the (total city Hamilton. of Successful linkage recruited the to cohort of Institute First Clinical Nations of Evaluative Sciences database. Statistically Driven Sampling ( Respondent rigorous Collaborative production of this project report. derivation of population based population derivation of estimates survey of and Institute Clinical for Evaluative Sciences ( 14. 13. Th e above policy recommendations are prefaced on the need for re-establishmenton for needof prefaced the policy the recommendations e are above Th betweenkey municipal, relationships provincial, and and federal urban governments Aboriginal local and provincial organizations. In particular there ensure is that to a need unresolved jurisdictional perpetuate to accountabilities continue not unnecessary do and cant healthresolvable disparities urban for Aboriginal and pressing signifi Such peoples. Ontario of anduence Canada health inequities are unacceptablegiven aﬄ the relative address these devastating To globally. health and social inequities and disparities nal policyactions required: experiencedare urban by Aboriginal these today fi people 12. • • • • e OurHealth researchdemonstrates project researchCounts that by candone be Th forward result,t. put As a we the Aboriginal Aboriginal for people community benefi following policy recommendation regarding research: 16 ProJect overview COUNTS HEALTH OUR

introduction

Over % of Ontario’s Aboriginal population lives in urban areas.¹ Public health assessment data for this population is almost non-existent, despite its size (, persons). Th is is primarily due to the inability of Ontario’s current health information system to identify urban Aboriginal individuals in its health datasets. Health assessment data that do exist are most oft en program or non-random survey based, not population based. Existing potential sampling frames are either not accessible (ie. Statistic Canada Census) or reﬂ ect biased, non-random subpopulations (ie. program/service clients lists, membership lists, and Métis registry). When urban Aboriginal people have been included in census based national surveys (such as the Canadian Community Health Survey (CCHS) ) these surveys are vastly underpowered and First Nations, Inuit, and Métis data cannot be disaggregated. We do know from the Canadian Census that First Nations, Inuit, and Métis populations experience ongoing disparities in social determinants of health such as income security, employment, education, and adequate housing compared to non-Aboriginal Canadians and that these disparities persist with urban residence.² From a population and public health perspective, this near absence of population based health assessment data is extremely concerning, particularly given the known disparities in social determinants of health. Th is situation is unacceptable in a developed country such as Canada.

For the past three years, the Ontario Federation of Indian Friendship Centres (OFIFC), Métis Nation of Ontario (MNO), Ontario Native Women’s Association (ONWA), and OUR HEALTH COUNTS 17 . , and TI , and the ), Saint Michael’s Saint ), Michael’s and Saint Michael’s TI , CRICH ONWA , ) Aboriginal Fund, Health Transition MNO , ) for this) for through project research ICES MOHLTC ) project was to work in partnership was work to ) project with OHC and a rapid health and a rapid assessment questionnaire. ) has been working with a health research team Dr. Janet by led TI . Organizational partners OFIFC included CRICH agreements and data management/governance protocols. Th is will the include Th protocols. agreements and data management/governance establishment an of Aboriginal Health Data Governance Council the of comprised four core urban Aboriginal provincial organizations. To generate new health data sets reﬂ ective urban of these a sample of priorities for health new generate data sets reﬂ To Inuit,First and Nations, Métis adults and children driven sampling, using respondent secure data linkage with ICES To confi priorityrm health domains domain each for best and indicators through confi To partnerships. these To formalize partnershipsTo between urban the core four Aboriginal provincial organizations, the multidisciplinary academic team, the Ontario MOHLTC Institute Clinical for Evaluative ( Sciences ProJect oBJectives oBJectives ProJect Knowledge Development Data Base Establishment Health through a Population of 3. 2. 1. Formalizing Intersectoral Partnerships and EstablishingFormalizing Intersectoral Priority Measures Tungasuvvingat Inuit ( Smylie based at Centre for Research Inner based City on Centre for Smylie at Health ( Th e goal e of OurHealththe ( Counts Th Hospital, on the on OurHospital, Health Counts Aboriginal Urban Health the Database For project. armFirst the Nations the of project, community organizationalpartner was da De dwa Aboriginaldehs ney>s Health the the interests Access of First Centre, which represented communityNations in Hamilton behalf on Hamilton the of Executive broader Directors Aboriginal Coalition. Th e OurHealth UrbanAboriginal Counts Health was Databaseproject by OFIFCfunded Th Aboriginal organizational stakeholders to develop a baseline population health database urbanfor Aboriginal living people in Ontario that is immediately useful, accessible, and culturally local, to relevant small and provincial region, policy makers. the Ministry Care ( Health of and Long Term and Hospital. Community partners da Aboriginal De dwa dehs ney>s included Health Access behalf the of HamiltonCentre (on Executive Directors Aboriginal MNO Coalition), were communityFirstNations project Hamilton, threein ere sites: Inuit in Ottawa, and Th report is willfocus on FirstNations Hamiltonin the Métis community in Ottawa.site. Th Capacity Building, Training and Mentoring 4. To strengthen capacity and leadership among Ontario’s urban Aboriginal communities and their policy, program and health service collaborators in the area of Aboriginal health information collection, analysis, and application through: a. the involvement of community representatives as active research team members in all aspects of this project; b: a series of community-based health data use workshops.

18 5. To provide a scientifi cally excellent and culturally relevant training and mentorship environment for Aboriginal health researchers at the undergraduate, graduate, post- COUNTS HEALTH OUR doctoral and new investigator level.

Knowledge Dissemination, Application, and Contribution to Future Projects 6. To support community-based, small region, provincial, and federal uptake and application of health data generated through - above to First Nations, Inuit, and Métis health policies, programs, and services. Th is will include the establishment of an Aboriginal health data users group, which will have open membership and allow diverse stakeholders input and access to data generated by the project.

7. To build on the outcomes of this study to design future longitudinal health studies in partnership with First Nations, Inuit, and Métis governing/organizational stakeholders as well as additional strategies to improve the quality of First Nations, Inuit, and Métis health data in Ontario.

8. To share study results and adaptation processes with First Nations, Inuit, and Métis stakeholders in other provinces and territories and thereby contribute to the development of urban Aboriginal health data enhancement strategies.

PreliminArY ProJect develoPment

In the fall of  Sylvia Maracle (OFIFC) approached Dr. Smylie (CRICH) to see if she was interested in collaborating on the improvement of urban Aboriginal health datasets. Over the next few months, TI, MNO and ONWA joined the project team. Of note, Dr. Smylie had a pre-existing research relationship with OFIFC, TI, and MNO. In a previously unfunded project proposal written in partnership with the Tungasuuvingat Inuit Family Resources Centre, Smylie and colleagues had identifi ed respondent driven sampling as a promising method for identifying an urban Inuit cohort for health assessment. A small grant from the Public Health Agency of Canada was used to fund a research planning meeting in March . At this meeting, research principles, partnerships, and methods were further developed. A full research proposal was OUR HEALTH COUNTS 19 , ) – MNO , OFIFC and DHAC . Next, the OHC OFIFC Governing Council monies arriving monies until as voting members and at Saint Hospital at Michael’s , and ONWA TI , and CRICH MNO , as a non-voting governing council participant who was Ontario in June . Ontario in . June ) agreed the following upon research principles: on of behalf of on the of research partners the to Aboriginal Health , and CRICH research is attached agreement in Appendix A. a tri-party Finally, data sharing Aboriginal Leadership Research Protocols and Agreements Data Management/Governance Capacity Building Respect Cultural Relevance Representation Sustainability ProJect governAnce ProJect ONWA , agreement was betweenagreement negotiated the Institute Clinical of and Evaluative Service, the Th e second principle, research principle, agreements governance e second dataand management and Th was operationalizedprotocols, in that a way ensured that the OHC Dr. Janet Smylie from CRICH Smylie Dr. Janet Monthly project. cGoverningfor the Council director ed as scientifi the also identifi throughout themeetings held length were the of project. as well as the Inuit, First and Nations, Métis community partners to project able were their exercise and rights manage data, govern project to including the rights own, to start access and to have possess data. with, project control, To the Governing four Council organizational MOU and signed a project developed members teamproject successfully community and negotiated developed research agreements ( FirstNations e with the each of three community Th sites. project SMH • • • • • • • fi Aboriginal rst principle, operationalizedwas leadership, project by the e Th establishment the of Our Health Governing Counts project Council, which was comprised of representatives from OFIFC were able to identify to start-up funds able project were and was the formally project initiated in January . All organizations the in of core the involved Our Health Counts ( Project TI submitted by OFIFC Transition Fund, MOHLTC team project of e wassuccess informed of tentatively the , application in late their Th federal and provincialhowever funding resulted in delays AHTF no the end of March . Fortunately March both . of theOFIFC end OHC Governing Council (OFIFC, MNO, ONWA and TI) and the CRICH at St Michael’s hospital (Appendix B).

reseArcH teAm

Aboriginal governing council members: 20 Sylvia Maracle (OFIFC), Connie Siedule (TI), Donna Lyons (MNO), Betty Kennedy (ONWA), Janet Smylie (CRICH) COUNTS HEALTH OUR

Academic research team members: Janet Smylie (Scientifi c Director), Pat O’Campo, Rick Glazier, Marcia Anderson, Kelly McShane, Roseanne Nisenbaum, Dionne Gesink Law, Michelle Firestone

Project staff: Cheryl McPherson, Conrad Prince (CRICH); Deborah Tagornak, Colleen Arngna’naaq, Jessica Demeria, Leslie Cochran, Crystal Burning (Community Site Leads); Amye Annett, Ashly MacDonald, Trisha McDonald, Diane Th errien, Alisha Hines (Community Interviewers)

Additional collaborators: Vasanthi Srinivasan (Director, Health System Planning and Research Branch, MOHLTC); Fredrika Scarth (Acting Manager, Research, Health System Planning and Research Branch, MOHLTC); Sue Vanstone (Manager, Aboriginal Health Strategy Unit, MOHLTC); Don Embuldeniya (Manager, Health System Information and Management Branch, MOHLTC); Kelly Murphy (Director of Knowledge Translation, CRICH); Leslie McGregor, Director, Noojamawin Health Authority, Paula Stewart (Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada)

HAmilton site

Th eOFIFC identifi ed the City of Hamilton as a promising First Nations community project site, based on its signifi cant Aboriginal population (, persons reporting Aboriginal ancestry according to the  Census) and strong infrastructure of Aboriginal community health and social services.

In the spring of , OFIFC Executive Director Sylvia Maracle travelled to Hamilton with Dr. Smylie to meet with the Hamilton Executive Directors Aboriginal Coalition (HEDAC) to tell them about the project. Th e HEDAC agreed to move forward with the project and OUR HEALTH COUNTS 21 ) as the DAHC is centrally for and located a touchstone provides primary provides care, traditional healing programs and health to promotion DAHC many Aboriginal living people in both Hamilton and the Brantford, Our Health Counts study only collected health were information who population from the First Nations the to City Hamilton. of resident Th e Aboriginalnearly  living people in both Hamilton and Ontario. Brantford, Its ismission “improving the wellness Aboriginal of individuals and the community by providing services that as respect individuals people with a distinctive cultural identity and distinctive While values and DAHC beliefs”. Th e City of Hamilton is located in southern Ontario,  minutes west of Toronto and . . and Toronto CityHamilton e of located is of westin  southern Ontario, minutes Th Located was what east traditionally hours on London. of (Iroquoian) Haudenosaunee Hamilton isterritory, situated near reserves: two the First of Nations Grand Six Nations e  Census statistics totalthat show the River and Mississaugas the Credit. Th of New Aboriginal ancestry by the of overall in population Hamilton .% comprising is , under- cant e  Censussignifi is to have known Th ). the of citypopulation (, representation of the First Nations population in the Hamilton area, including but not participate to limited not choose in who persons political the personal to: Census and/or for participatereasons; who persons identify to in the not choose or as census but First Nations identify not do because their the match ethnicity self-identify; and persons don’t questions ree thousand,hundred sixty two and without a permanent or address. are Th who homeless livingpeople in the City Hamilton of declared they are registered Indians, according the to ed as RegisteredIndians is alikely gross identifi number who of persons is Indian Act. Th underestimate political as for and cultural living persons reasons many First Nations in federal on cation that draws IndianAct self-identifi of rejected a notion Hamilton have may legislation though even technically they are recognized this by legislation as Registered Indians.  reserves of was Six Of one that note, participate Nations did not in the  census and given the geographic and family ties in that persons many First Nations Hamilton with have an had this Six impact the have Nations would on census. boycott organizational project lead. identifi ed dwa Aboriginalney>s De dehs da the Health Access ( Centre identifi 22 reseArcH metHods COUNTS HEALTH OUR

metHods summArY

• Th is project was carried out using community based participatory research methods. • Our approach promoted balance in the relationships between the Aboriginal organizational partners, academic research team members, Aboriginal community participants and collaborating Aboriginal and non-Aboriginal organizations throughout the health information adaptation process, from initiation to dissemination. • Th is was achieved through the project governing structure including the project Governing Council and research and data sharing agreements described above as well as ensuring that capacity building, respect, cultural relevance, representation, and sustainability were core features of the project’s ongoing overall and day to day implementation. • Brainstorming and sorting of ideas and topics for the surveys was done using concept mapping with health and social service stakeholders in Hamilton. One hundred and two statements were sorted into a concept map of ten domains. • Th ese domains and statements were used by the research team and to create. Questionnaires for both adults and children. Surveys were shortened aft er pilot testing in the community. • Surveys were conducted in person by trained interviewers initially with paper-based questionnaires and later on directly on a computer. • A respondent driven sampling (RDS) technique was used to recruit individuals to be interviewed for the research. Th is method involved giving tickets to each First Nation participant who completed an interview, and the participants could give these tickets to other First Nations people they knew, including friends and family. For each participant recruited, the person who made the recruit received . • Th eOHC First Nations Hamilton sampling was extremely successful. Over a course of four and a half months a total of  persons were recruited, including  adults and  children. OUR HEALTH COUNTS 23 number to link to number their to data on research team employed concept concept research team employed approach drew on the drew on existing approach ) was deemed the most appropriate ) was the deemed appropriate most ⁹ Th e OHC CBPR Our approach promoted balance in promoted ³ ⁴ ⁵ ⁶ ⁷ ⁸ Our the approach project’s CBPR project’s project because uniquely emphasizes project it shared decision concePt mAPPing communitY BAsed PArticiPAtorY reseArcH PArticiPAtorY communitY BAsed % of participants of permission use to % their gave OHIP health care system usage available throughthe Institute Clinical for Evaluative Sciences. ndingsin presented resultsbias the usingsectionfor RDS adjusted are All the data fi participantserent are within the diﬀ statistics out spread taketo how account into social through network which recruited. they were mapping in order to create three site specifi c culturallyand community appropriate three create to specifi in site mapping order According to Trochim and Kane, concept mapping is “considered a structured and is “considered Kane, mapping Trochim to According concept organizingmethodology for organization, or the a group bring ideas to of together framework them that a common form stakeholders rapidly and of help diverse groups can planning, be used for evaluation, both”. or Community-based, participatory research ( Community-based research takes in place community settings community and involves research and of Its projects. documentation inmembers the design, implementation, and methodsprinciples ensure that processes are and have relevant that the outcomes It has for beencommunities ts the used widely adapted involved. and in tangible benefi research with Aboriginal communities. • • research the methodology OHC for making study among partners and Aboriginal because the of supported it principles data e OHC and Th management. governance research experiences of the participant core organizations and the project scientifi c direc- research experiences the of participant organizations core and scientifi the project and successfultor regarding and recommendations of community-based models participatory Indigenous health research. relationships between the Aboriginal organizational partners, academic research team Aboriginalmembers, community participantsand collaborating Aboriginal and non- Aboriginal organizations throughout the health information adaptation process, from is wasachieved throughgoverning structure project the initiation dissemination. to Th including Governing the project Council and research and data sharing agreements described as well as above ensuring that capacity building, respect, cultural relevance, overall and sustainability ongoing and representation, features the of project’s core were day to day implementation. health survey questionnaires (First Nations, Inuit, and Métis). Th e method was identifi ed as promising given the long history of using maps as a tool to document traditional land use and knowledge in Indigenous communities.

Th eOHC concept mapping method involved three main community participatory steps: () Group Brainstorming, () Group and/or Online Sorting and Rating and () Group Map Interpretation. 24 Key health and social service stakeholders were identifi ed in partnership with DHAC and COUNTS HEALTH OUR invited to attend a group brainstorming session. Participants were purposely selected to ensure a diversity of representation according to organization represented, gender, age, and organizational role (ie. both staﬀ and clients) were included. Sixteen persons participated in two brainstorming sessions and responded to the following question:

Health and health related issues and topics in the Hamilton First Nations community that are prevalent, serious, have the fewest solutions, or otherwise important include.…

Th e result was  statements. In a subsequent sorting and rating session, participants sorted these statements into piles that made sense to them and rated each statement according to service availability, need for health information and overall health concern. Concept systems soft ware was used to create preliminary point and cluster maps reﬂ ecting the overall group sort and rate. Community stakeholders were then engaged in two further group sessions to refi ne these preliminary maps. Concept mapping fi ndings are presented in the results section.

resPectFul HeAltH surveY

It was determined very early in the research process that the needs assessment survey should be renamed and reconceptualized as “respectful” rather than “rapid” as this would be more fi tting with community processes and values.

In March , Governing Council representatives identifi ed priority health and social issues that they wanted to be included in the needs assessment surveys. Drawing on this preliminary list of priority areas and existing survey tools the academic research team developed a bank of questions.

Once the concept mapping processes were complete, the health statements and health domains identifi ed in the First Nations concept mapping were used to develop a community specifi c adult and child health survey for First Nations in Hamilton. Survey OUR HEALTH COUNTS 25 ); however, this however, ); ) soft ware. ) soft ) to generate generate ) to It combines a combines It ¹² ¹¹ ¹⁰ CAPI SPSS RDS electronic survey in March research team to input over   research over team input to Data Collection Interviewer package was used to ¹³ has emerged as a technique for sampling as has a technique emerged for hard identify to Data Collection Author Professional was and Data Collection Professional used develop to Author and contributed, in an on-going manner, to identify to and in manner, issues contributed, an arising on-going with the CAPI resPondent driven sAmPling  on a go forward with a go basis on and worked the CRICH In an the of and absence accessible accurate based population sampling frame urban for Inuit,First and Nations, Métis communities, the academic team and key Aboriginal stakeholders selected driven a sampling respondent technique ( electronic survey. Th e Hamilton e team started using SPSSthe Th electronic survey. administer the survey. Th is presented a signifi technicalcant challengefor researchthe signifi a presented is administer the Th survey. team the of as well as in delays launching completion the electronic Upon survey. program, localcomputer survey administrators in the involved piloting were process of the SPSS fi scal yearend. to prior les fi paper program the survey and the tool SPSS consultant failed to deliver. Th e Research Team therefore programmed Teamownits CAPItherefore Research e consultant Th failed deliver. to Statisticalusing implemented the Packages Social for ( Sciences cally, SPSSthe Specifi representative samples. RDS andpopulations has been used in urban across centres the world. snowballed or chain referral technique sample with a mathematical for system modifi not it weighing for the social data based compensate sample self-reported to on nework having been drawn as Each sample. a random participant is asked regarding questions them the to their referred the study to who and person the relationship size their of which allowsnetwork, the bias in the sampling be process estimated to and unbiased and behaviors birthplace), age, gender, (e.g., composition estimates a population’s of disease be obtained. to prevalence Th e survey e was surveys using paper launched while academic research the team worked Th Th Teamworkedwith consultant a on e Research nalizing based version. a computer fi on Assisted a Computer of Personal Interviewingthe development ( tools were piloted with piloted otherwise community were were tools First who Nations members ineligible of rounds Two the of city the Hamilton). was their survey of for outside residence (i.e. occurred. informed included verbalEach provided consent) piloting session (which language adjust to become the how to survey, improve to valuable suggestions how on surveys e were the to questions. Th ow respectful, a logicalmore ﬂ promote to and how also shortened. research Academic subsequently team then incorporated members the to local product the nished survey changes the to survey and returned tool a fi fi nal survey is tool attachedAppendix in C. e administration team. Th Sample sizes were calculated using the formula provided by Salgunik¹¹ for RDS, who recommends sample sizes that are twice as large as those that would be needed under simple random sampling. Based on this formulate we originally aimed to recruit  First Nations adults and  children in Hamilton. Th is was modifi ed to  adults and  children as the study progressed as it became apparent that the child sample recruitment was reﬂ ecting the age make-up of the Hamilton First Nations population, and that children would make up one-third of the total sample as opposed to one half. 26 In RDS, the sampling is done by study participants who are given tickets and asked to COUNTS HEALTH OUR recruit other study participant by giving out the tickets. In the OHC First Nations Hamilton RDS each participant was given  –  tickets for recruitment. For each participant recruited, the person who made the recruit received . An RDS sample is initiated by providing a limited number of persons (ie. -), who then become known as “seeds” with tickets for recruitment. It is noteworthy that in the past First Nations were at times coerced into participating in harmful colonial processes by the use of incentives, such as cheese or money, which would be dispensed by the Indian agent in return for participation in colonial activites, which at times included health treatments and data collection. Ethically this means that extra caution may be required when considering incentives for participation in a research study, even when the research study is being run by First Nations community members. In this case, even though the use of incentives may have negative historical connotations, the study design is carefully structured to ensure that study results will empower rather than harm community members.

In the OHC First Nations Hamilton RDS the DHAC outreach worker as well as members of the research team identifi ed potential seeds who represented a diverse demographic of First Nations people living in Hamilton. Gender, age, family size, occupation, and where in the city a person lived were all factors which were considered seed selection.

Inclusion criteria for participation in the study included adults who were resident within the geographic boundaries of the City of Hamilton and self-identifi ed First Nations/ Native/Indian identity. Adults were defi ned as persons  years of age and older or persons younger than the age of  years who were parents. Th e child survey was completed by parents or custodial relatives/guardians for all children who resided with the adult and were under the age of  years. In order not to exclude First Nations children who were living with a non-First Nation biologic or adoptive parent/relative/ guardian we additionally allowed coupons to be given to non-First Nations persons who were the custodial parent/relative/guardian of one or more First Nations children.

Approximately  people identifi ed as potential seeds attended a lunch and learn session at DHAC where the community research team explained the study and its potential to OUR HEALTH COUNTS 27 . research . In February , enabled the OHC enabled ) is an independent, not for profi t profi for ) is an not independent, ICES s t a ff . , by ICES, by First Nations survey were able to opt in or out of the of ICES in out opt or to survey able First Nations were -adjusted estimates. First Nations Hamilton surveys. All the data fi ndings presented ndingsin presented Hamilton First Nations surveys. All the data fi stat program used we social the self-reported and referral network dAtA linkAge dAtA First Nations Hamilton First Nations sampling was extremely successful. Over four a course of OHC ices Adult participantsAdult in the OHC ed in larger ICESthe and adult childFirst Nations participants identifi in were our sample database using a deterministic linkage based their on Ontario health date card number, dentiality of studyparticipants, this birth, of the and protect confi to name. In order linkage internally was done ICES at team to produce, for the fi rst time, urbanAboriginal based population emergency of rates the fi for team produce, to use,room hospital admission and participation screening in programs, preventative testing, and colorectal cancer (Pap) Papanicolaou screening.including mammography, data linkage themselves and their for children their forms. on consent organization whose core business is to contribute to the eff ectiveness, and quality, equity, the to organization eff business contribute is to core whose healthciency of care and health services link anonymously to is in able Ontario. It effi healthpopulation sources using from of a number a participant’s information compiled opportunity e to connect with ICES health Th card number. Th e ClinicalInstitutefor Evaluative ( and Sciences Th the results section are RDS Th e and a half recruited, children. were persons a total adults including and months    of willWe further detail recruitment in chains long the results how resulted section in below departure from the original in sampling “equilibrium” a state of of and bias the achievement ects the the demographics of which the probability recruitment the of into study refl ed thissuccessful departure the at health original verifi centre from the population. Staff sampling observing bias by study participants DHAC at they seen who before never had based population estimatesinformation generate to the of health and social indicators inincluded the OHC in order to increase the number of completed child increase to surveys,in the completed of order number two additional seeds were cally targeting families specifi added with children. the RDSUsing improve First Nations health First Nations statusimprove and access services. to Of this six people group, agreed the seeds survey become to and completed within their of a week stated friend, a commitment. Each seed three acquaintance, refer to received coupons family the of six referrals seeds Five stranger or produced within the into study. member, the two DAHC weeks at leading closure the to December holiday up  A total of  First Nations study participants (% of all study participants) opted into the baseline ICES data linkage and were successfully identifi ed in the ICES database. Th is included  adults (% of adult participants) and  children (% of children participants).

Tables describing income quintile by census postal code, emergency room admissions, hospital admissions, and participation in preventative care screening by mammography, 28 Papanicolaou (Pap) testing testing and colorectal screening by occult blood were produced for the First Nations cohort, the City of Hamilton and the province of Ontario. COUNTS HEALTH OUR Th e estimates for the First Nations income quintile and health care utilization were adjusted using the RDS stat soft ware program, which was described in the preceding section. RDS uses the self-reported social network and referral information of the OHC First Nations Hamilton cohort to generate population based estimates. Th ese tables are presented in the results section.

communitY imPlementAtion

Th e local survey administration team in Hamilton consisted of two site coordinators and fi ve survey administrators. A community research oﬃ ce was established in the DHAC Hamilton facility. A customized training was conducted for all survey staﬀ drawing on a customized project training manual, which was prepared by the CRICH research team. Th e local team was further supported by monthly larger group research team meetings and weekly RDS work group meetings which included an RDS data analyst. Further details regarding the specifi cs of community implementation are available upon request. OUR HEALTH COUNTS 29 concePt mAPPing Figure First 1: nations Hamilton concept map results Th e initial brainstorming session generated  statements, which are attached in Appendix D. Th e concept mapping process revealed the ten interconnected domains that provided the framework for the First Nations health survey.

At the fi nal concept map interpretation meeting the map was placed inside a circle and two perpendicular arrows were drawn across the circle. Th e fi rst arrow connected the “disconnection from who we are” cluster to the “reclaiming who we are cluster” and the 30 second arrow connected the “impacts of colonization” cluster to the “our health deserves appropriate and dedicated care” cluster. Th e resulting fi gure resonated with medicine wheel COUNTS HEALTH OUR and Haudenosaunee lodge teachings, fi gures, and directions. Th ese views reﬂ ected traditional ways of interpreting and contextualizing information in a local manner. One key stakeholder gave the research team a teaching of the traditional ways of the Haudenosaunee people and how this map interpretation was in fact reﬂ ective of that teaching.

For the purposes of the survey the housing and issues linked to poverty were combined in the fi rst section of the survey, which was titled socio-demographics. Survey domains are as follows:

Socio-demographics: Th is section addressed housing and mobility, socio-economic status, food security, water quality, and links to poverty.

What happens when we are out of balance: Th is section addressed physical, mental, and emotional health problems. Questions explored chronic disease, mental health, fetal alcohol spectrum disorder, injury and acute illness, sexual and reproductive health.

Reclaiming who we are: Th is section addressed aspects of First Nations identity. A series of identity statements were read to survey respondents that spoke to issues of belonging, participation in cultural practices, self-esteem, and understanding.

Disconnection from who we are: Th is section addressed substance use, including cigarettes, alcohol, illicit and prescription drugs. Perceptions on the level of access and availability of health services were also surveyed, which included traditional medicines and experiences with non-insured health benefi ts. Th is section also addressed barriers to health care and use of any Aboriginal specifi c services in the community.

Impacts of colonization: Th is section addressed the health impacts of residential schools, child protection agency involvement, and dislocation from traditional lands in the lives of urban First Nations people. Questions about racism, discrimination, violence, and abuse were also included. OUR HEALTH COUNTS 31 . prevention, sample of First Nations in Hamilton, .% of participants of recruited in were Hamilton, First Nations of sample .% resPectFul HeAltH surveY dAtA surveY HeAltH resPectFul dynamics recruitment Figure 2. recruitment tree of First nations in Hamilton, our Health counts via referral trees originating from two seeds (see fi gure ). Th is is quite typical of RDS ). gure via referral trees originating fi from two seeds (see Among theAmong RDS We developed a child specifi c survey, survey, c a child developed specifi s of our children and youth: We Importance of the gi the results which will of be summarized report. in a subsequent pandemic planning). Th is section included open ended questions for respondents to list respondents for questions ended open is section included pandemic planning). Th any areas which community particularly for resources were lacking. length e of bothof recruitmentthese chainsenough long bothis that chains were Th of waves or  er  is usually happens aft the original overcome to samplingable bias. Th ese recruitmentrecruitment of two chains  each.  waves and had recruitment. Th The between wasrelationship recruiter recruit) “friend” to and recruit (according in “boyfriend/girlfriend”% or recruitments, of “relative” recruitments, of in .% average e recruitments, of recruitments.“acquaintance” and of “stranger” in in % Th .% sizenetwork varied participants, among a median with and , a range of a mean ., of meane recruited the others into Th respondents sample. of A total % of ]. [, of the recruitments all mean recruitments of number of number for is .; members sample thoseamong recruited who is .. Th is section surveyaskedto list Lackrespondents main the of government responsibility: Th challenges and strengths Community the of community. services also were assessed for Spirit Lesbian Gay particularadequacy for single Two youth, men, (i.e. populations Bisexual and services Queer legal, Questioning HIV Trans Identities) (i.e. methodological note regarding the interpretation of self-report data It is important to recognize that the cycle of poverty experienced by this population (i.e. reporting of high mobility, overcrowding and very low income) is likely associated with an under-reporting of socio-economic stressors and ill health. Th is needs to be taken into consideration when interpreting the results of self-report questions such as: having to give up important things to meet shelter related costs; self-reported balanced diet; self-rated health) for a number of reasons. Firstly, there may be some stigma around 32 self-reporting of not having the fi nancial stability to pay rent and meet other needs. Secondly, individuals in a population that has experienced longstanding adverse COUNTS HEALTH OUR conditions may have internalized notions of “not being good enough” and therefore accept what others might perceive as hardship. Th irdly, lowering expectations is a strategy for survival when one faces chronic and recurrent hardship. Finally, multi- generational experiences of adversity may result in the normalization of what outsiders living in more prosperous circumstances might consider unmet needs or ill health.

Th e following results are presented according to the domains of the First Nations health assessment survey tool. As outlined in the Concept Mapping section of this report, the content of each domain and its title reﬂ ect the health priorities of First Nation community stakeholders. Th e results below are for adults. Child survey results are presented in a later section of this report.

domAin 1: sociodemogrAPHics

Highlights from domain 1 • Ninety percent of the First Nations population living in Hamilton had moved at least once in the past  years and over % of the population had moved three or more times in the past  years. • Th irteen percent of the First Nations population living in Hamilton reported being homeless, in transition, or “living in any other type of dwelling. • Using the Statistics Canada defi nition of crowded housing as more than one person per room, .% of First Nations persons in Hamilton live in crowded conditions. • Sixty-three percent of First Nations community members in Hamilton had to give up important things (i.e. buying groceries) in order to meet shelter-related [housing] costs. • Twenty-two percent of the First Nations population sometimes or oft en did not have enough food to eat. OUR HEALTH COUNTS 33 2.4% Language French Only or French English and Another Only 2.7% ) First Nations adult population in population adult Hamilton) First Nations was comprised Aboriginal Language OHC 94.9% English Only demographics 0.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% Figure 3. language spoken at home for First nations Adults, our Health counts Th e OurHealth ( Counts Th the had of children, the population no had of sample children, % of number % As for children. more  or had  children, had  children,either  or and % % When asked what language was spoken most oft en at home, % spoke English only, % spoke Englishspoke % only, home, at en When asked language what oft was most spoken an Aboriginal English only language or and French another spoke only language and % (see Th ect the decline ofIroquoian longstandinglanguages to due clearly reﬂ ese numbers ). gure fi withcontact colonizers, the impact residential and schools otherof challenges. such Despite high the English importance of numbers home, at spoken children of learning a First Nations language was very rated home high at this among population. of a total  participants: % men and % women. For men, about a third about the men, of For participants:women. a total and % of men  % (.%) - fellpopulation in years the each of (.%), following - categories: age with years. Overall, was younger, the however female population years (.%) and + Among the . of age over and % between - between the .% -, ages of .% this First Nations population, indicated .% that they were Status (RegisteredIndian gure is likely an is important that It according this the note to to Indian fi Act). underestimate participants the of of proportion are who Registered Indians as for political and cultural self- of participants rejected reasons some a notion have may federal cation on that draws IndianActlegislation even thoughtechnically they identifi are recognized this by legislation as Registered Indians. example, community For Mohawk, Haudenosaunee, value their from may Six identity (i.e. members Nations nation than more they Cayuga,Oneida, Onondaga, value ‘being Seneca and Tuscarora) Indian’. 100.0% Overall, the OHC First Nations population reported low levels of formal education. When asked the highest level of education completed, the OHC RDS adjusted estimates for First Nations adults over the age of  years were: % had completed some high school or less and % completed high school, % had completed some or all of college and only % had completed some or all of university. As a comparison, according to the  census, % of residents of the city of Hamilton aged  and older had some high school or less, % had completed a high school diploma, % had completed college and % 34 had completed university.¹⁴ In the OHC First Nations population, there is evidence to suggest a trend towards more women completing higher levels of education compared to COUNTS HEALTH OUR men. For example, % of women completed some or all of college compared to % of men (see fi gure ).

70.0%

59.8% Male 60.0% 52.6% Female

50.0%

40.0%

30.0% 23.0% 20.6% 20.0% 17.4% 15.6%

10.0% 7.0% 4.0%

0.0% Some High Completed High Some or Some or School or less School Completed Completed College University

Figure 4. level of education by gender for First nations Adults, our Health counts

When asked to indicate the source(s) of the total income for all household members in the past  months, the following results emerged: wages and salaries (.%), income from self-employment (.%), employment insurance (.%), Child Tax Benefi ts (%), Provincial or municipal social assistance or welfare (e.g. ODSP, Ontario Works) (.%), child support (%), any other income source (.%). Clearly, this population is relying heavily on social assistance. While more women than men reported child benefi ts and child support as income sources, more men reported income from self-employment (% vs. %) (see fi gure ). OUR HEALTH COUNTS 35 ¹⁵ survey income 90% 75.4% 80% Male Female 64.7% 70% 60% 50% income quintile income in the data (reported cohort into the lowest income quartile income the into cohort lowest 40% 29.3% 28.4% 26.3% 30% Hamilton was population also asked indicate to statistics, and the Census is known have to 11.0% 20% 13.3% 13.4% adjusted ICES 10.9% 8.3% 7.5% 7.4% 10% 3.0% RDS 0.0% 0 ¹⁵ Child Support Child Tax Benefit Child Tax First Nations population than population First Nations within the general in population Hamilton. First Nations population was stratifi ed by gender, we observedwe more that gender, by ed was population stratifi First Nations Wages and Salaries Wages Employment Insurance Employment Any other Income Source Income from Self-Employment Income from Provincial or Municipal Social Assistance or Municipal Social Provincial Ontario Works) (e.g. ODSP, or Welfare their the year personal for ending Based December st, income the on . on answers thisto determined we question the following estimates .% population income: for earned between .% earnedearned and ,, between less than , .% ,, earned and .% over and , earned .% between and ,, , , the of city of residents As of a comparison, according the to census,  % ,. earned andHamilton older earned less than aged %  and between , ,, and , earned % between and ,, , earned between % , ,, and % earned ,. over When the OHC with all bracket reported of income who earning .% the fell women into lower women less all of reported men In men. terms higher of .% of income, .% than to compared , was not erence this diﬀ however women, of earning .% to than compared more , diﬀwomen erences menare and between Th incomee fi). gure (see cant statistically signifi larger in the OHC In addition to sources of income, the income, In OHC sources of to addition Figure 5. sources of income by gender for First nations Adults, ourHealth counts Th is income data may be considered a more rigorous representation of actual the representation rigorous more a income be considered data may is income Th of population FirstHamiltonNations in le the than  Censusthe data it wasas profi validated bias using RDS for and adjusted communityFirstNations by members,particularly cant under-participation in signifi ties close the to nearby Six have Nations residents Hamilton many First Nations where e Census is communityFirst Nations participate which did not in the census.  Th low have transient who are or who homeless, persons also known under-represent to literacy skills, all higher issues populations, in prevalence which and have First Nations all issues that are the associated Finally, levels. OHC income with lower data is also validated the by OHC next section), which places over % of the of OHC % which places over next section), compared to % of the of general Hamilton the % to of and Ontario population compared % population. Clearly, this population is facing high levels of poverty. Poverty is so prevalent in fact that the breakdown of study fi ndings by income categories was not possible due to such high numbers in the lower income brackets and little variation in total earnings.

40.0% Male Female 31.2% 30.0% 26.1% 24.8% 25.3% 36 19.4% 20.0% 17.5%

COUNTS HEALTH OUR 16.9% 14.5% 14.9%

10.0% 9.3%

0.0% $ $ $ $ $ 0 5 1 1 2 - .0 0 5 0 4 0 ,0 ,0 ,0 ,9 0 0 0 0 9 - 0 0 0 9 9 - - ,9 1 1 + 9 4 9 9 ,9 ,9 9 9 9 9

Figure 6. income categories by gender for First nations Adults, our Health counts

Housing and mobility With respect to current dwelling type, around % of the population lived in each of the following: a single house (not attached to any other dwelling), a semi-detached, duplex house, row house, or townhouse or a self-contained apartment within a single detached house. Most of the population (%) lived in an apartment or condominium. Th e distribution of dwelling type across genders was fairly consistent, with the exception that among women, % reported living in a semi-detached home or duplex compared to .% of men and these diﬀ erences were statistically signifi cant. Within the overall dwelling types in the city of Hamilton, % of dwellings are apartments,¹⁵ which indicates that the OHC First Nations population is much more likely to be living in apartment buildings than average Hamiltonians.

In addition, % of the OHC First Nations population described themselves as homeless, in transition, or living in any other type of dwelling. Th ere is also a trend to suggest that more men in this population are homeless or experience transitional housing compared to women (see fi gure ).

Th ere was a strikingly high mobility reported among the study population. Only % of the population had no moves over the past  years. Over % of the population had moved  times in the past fi ve years, while % had moved between  and  times in the past  years and % had moved  to  times in the past  years (see fi gure ). Th ese numbers are very high compared to total urban populations in Canada. For example, according to the  Census, among all people living in the city of Hamilton, % had OUR HEALTH COUNTS 37 ¹⁴ 8.9% Male Female Other 2.7% Homeless. 11+ Moves Transistion or Transistion 15.8% 6-10 37.4% Moves 10.4% Apartment or Condominium 42.6% 41.1% 3-5 Moves 15.2% Apartment 17.5% Self contained within a single detached house 20.2% 2 Moves 24.0% ¹⁶ House or Townhouse Duplex,Row 8.6% 15.5% 1 Move Semi-detached, 14.6% 10.2% No Moves 15.5% dwelling) any other Single House (Not attached to 0.0% 0.0% 50.0% 10.0% 20.0% 30.0% 40.0% 50.0% 10.0% 20.0% 30.0% 40.0% Figure 8. number of moves in the Past 5 Years for First nations Adults, our Health counts Figure dwelling 7. type by gender for counts First Health our Adults, nations thelived at same address  years and ago the % lived had at same address  year ago. Th is high mobility pattern refl ects of poverty the facingcycle thisFrequent population. is highmobility pattern refl Th cult in engage regular to employment stress puts the on familymoves unit; makes diffi it and educational programs; and is associated with availability food poor and unstable, inadequate shelter. overcrowded, With respect the to total urban Aboriginal in populations Canada, the Census  therevealed of total that % urban Aboriginal in least the at once has population moved theyear census. before Following Statistics Canada standards, we calculated overcrowding in this population by dividing the number of rooms in each household (excluding bathroom) by the number of people residing in the home. Using the Statistics Canada defi nition of crowded housing as more than one person per room, .% of First Nations persons in Hamilton live in crowded conditions. Specifi cally, .% of the population were living with less than or equal to  person per room, % were living with more than - persons per room and .% were living with more than  persons per room. Th e rate of housing crowding for 38 the general Canadian population according to the  Census was %.¹⁷ COUNTS HEALTH OUR Over two thirds (.%) of the population felt that their dwelling was not in need of repairs, but only regular maintenance was needed (painting, furnace cleaning, etc.). Over one quarter (.%) of the population felt that their dwelling needed minor repairs (missing or loose fl oor tiles, bricks or shingles, defective steps, railing or siding, etc.) and .% of the population felt that major repairs were needed (defective plumbing or electrical wiring, structural repairs to walls, fl oors or ceilings etc.). Th ese fi ndings are very close to results from the  census for the overall city of Hamilton population (% of Hamilton occupants reported that their dwelling only needed regular maintenance, % reported dwellings needed minor repairs, and % reported dwellings needed major repairs).¹⁵ Th e similarities may be due to the question being very subjective. As one Hamilton Aboriginal community member stated “housing in Hamilton is great compared to reserve housing”. Th e high proportion of people living in unstable housing in the OHC First Nations population may mean that for many “good housing” is just a roof over their head and a lease in their name. As well, the higher proportion of OHC First Nations population who are tenants of apartment buildings, and lower proportion living in smaller housing types, may be a factor. A recent Social Planning Network of Ontario report noted that tenants of larger buildings may be unaware of the repair needs of their dwellings (e.g. roof, sewage, electricity, etc.) unless these repair issues are immediately obvious to the individual tenant. As such, the extent of apartment buildings dwellings in need of major repair may be undercounted.¹⁸

With respect to how oft en First Nations community members in Hamilton had to give up important things (i.e. buying groceries) in order to meet shelter-related [housing] costs, .% had to give up things several things several times a month, about half the population had to give up things between once a month and a few times a year and % reported never having to give up important things. While women were pretty evenly distributed across each category, among men, fewer reported having to give up important things with % saying they were never faced with this situation. Th ere was also a strong trend of more men who reported never having given up important things to meet shelter- related costs as compared to women (see fi gure ). As discussed at the beginning of this section, it is important to recognize that the cycle of poverty experienced by this OUR HEALTH COUNTS 39 27.5% Never 45.0% 28.4% Year A few times a 16.1% 24.4% Once a Month 23.9% 19.7% Male Female Month 15.0% Several times a nutrition and Food security Food and nutrition 0.0% 50.0% 10.0% 20.0% 30.0% 40.0% For self-reported nutritious balanced self-reported For that diet, they felt overall, always almost or % always a balanced ate they diet, sometimes felt a balanced % ate they diet felt and % men observed more we towards a trend a balanced ate never rarely or diet. gender, Across ). gure fi (see eating reportedwho never rarely women or a nutritious diet to compared “When I was streets the on or social assistance, health the workers would tell need me I that I eat as what watch to I am diabetic, is it expensive eat to healthy.” “On a fi xed income, food money gets short. I fi nd myself binge eating the fi rst two weeks, fi the eating binge nd myself xed income, food money gets short. I fi a fi “On in andhigh (expired) fito t eat food foodbank e isn’t otherthe two weeks I am starving. Th sodium…it is depressing.” “I need “I access a doctor to sign special to my diet form so I can lower cholesterol” my “I live entirely off food banks, of nutrition the where comes that’s in, choice no over food.” off entirely live “I Figure 9. giving up important things to meet shelter-related costs by gender counts Health our Adults, nations First for population (i.e. reporting of high mobility, overcrowding and very low income) is likely income) and veryreporting low high overcrowding (i.e. of population mobility, associated with an stressors socio-economic under-reporting of and ill health reasons for detailedthat were earlier. 60.0%

Male Female 48.9% 50.0%

39.3% 40.0%

33.2% 31.9% 40 30.0% 27.4% COUNTS HEALTH OUR 19.1% 20.0%

10.0%

0.0% Always or Almost Sometimes Rarely or Never Always

Figure 10. self-reported Balanced diet by gender for First nations Adults, our Health counts

Regarding food security, a fairly even distribution across the age groups revealed that over % of the population, both young and old felt that they and others in their household had enough to eat, but not always the kinds of food they wanted. A similar distribution was revealed for both men and women, again with over % of males and females reporting that they and others in their household had enough to eat, but not always the kinds of food they wanted. Twenty-two percent of the population sometimes or oft en did not have enough to eat (see fi gure ). Having enough to eat, but not always the desired type of food may be linked to a higher intake of carbohydrates and sugars, which can lead to feeling full, but not represent a nutritious balanced diet. Th is higher intake of carbohydrates and sugar in turn is linked to blood sugar problems, including diabetes.

domAin 2: “wHAt HAPPens wHen we Are out oF BAlAnce” PHYsicAl, mentAl, And emotionAl HeAltH ProBlems

Highlights from domain 2 • Only one quarter of the First Nations population living in Hamilton reported excellent or very good health. Th is self-reported health status is much lower than for the general Hamilton population. OUR HEALTH COUNTS 41 t Male Female 24.8% 19.9% not have enough to ea Sometimes or often did 51.1% food you wanted 52.0% Had enough to eat, but not always the kinds of 24.1% wanted to eat 28.1% the kinds of food you Always had enough of general Health status and exercise and status Health general High physical activity of levels reported, were with the of First Nations % in population moderate Hamilton of reporting more minutes or  having completed physical vigorous activityor  days a week. more than of three .%, e diabetesrate times is adult population among the the Th age younger the among rate general a much Hamilton despite population, demographic of the FirstNations Hamilton population. of pressurepopulation First high Nations e in blood rate adult among the Th Hamilton was .%. of e arthritisrate was.%. Th hepatitisof .%. C was e rate Th of total the over adult population threequarters y-two percent and of (%) Fift or sometimesen experiencing limitations in the years  reported oft over person otherwisekinds or activity amount of work or home, because at a physical or of done mental condition or health problem. irty-sixof alladultsreported fairmentalhealth or poor reported Th % and that a healththey by been had told care that they provider a psychological had and/or mental health disorder. 0.0% 60.0% 10.0% 20.0% 30.0% 40.0% 50.0% One quarterOne living population the of First Nations in Hamilton reported or excellent very reported health. good health. good A slightly Twenty-seven higher (%) number fi much show ndings ese reported fair and % and health Th poor percent respectively. Figure Food Availability 11. by gender for First nations Adults, our Health counts • • • • • • • lower self-reported health status than has been reported for the overall Hamilton population in the Canadian Community Health Survey.¹⁵ Th e  CCHS reported that % of Hamiltonians over age  perceived their health to be excellent or very good.ibid Th ese fi ndings also show the First Nations population in Hamilton has a lower self-rated health than First-Nations living on-reserve. Th e First Nations Regional Longitudinal Health Survey (-) reported that .% rated their health as excellent or very good¹⁹ (compared to % for the OHC First Nations Population). 42 Self-rated health status varied across age categories and gender. Overall, there was a trend COUNTS HEALTH OUR towards persons over  years reporting poorer self-rated health status than their younger counterparts with % of those above  who felt that their physical health was poor compared to % of those between  and  years (fi gure ). Th e diﬀ erences between the OHC First Nations population and the overall Hamilton population are most striking in the oldest age groups. While .% of the Hamilton population aged  years or older considered themselves to be in excellent or very good health,¹⁵ only .% of the OHC First Nations population in Hamilton aged  years and older reported themselves in this same category.

50.0% 18-34 Years Old 35-49 Years Old 40.8% 50 Years and Older 40.0% 36.0%

30.0% 30.0% 28.0% 27.6% 27.3% 26.1% 23.8% 21.5% 20.0% 16.7%

12.6% 9.7% 10.0%

0.0% Excellent or Very Good Good Fair Poor

Figure 12. self-rated Health by Age for First nations Adults, our Health counts

Th e gender distribution revealed more men who felt their health was excellent or very good compared to women and fewer men felt their health was poor compared to women (see fi gure ). Th ese gender diff erences were statistically signifi cant. Th e comparison with the City of Hamilton CCHS data shows that there is a much larger gap for women than for men between the overall Hamilton population and the OHC First Nations OUR HEALTH COUNTS 43 First Nations women ¹⁵ 18.1% Male Female Poor 12.4% 27.6% Fair 26.9% 36.4% Good 31.3% 17.9% Good 29.4% Excellent or Very 0.0% 10.0% 20.0% 30.0% 40.0% Overall, this reported population high physical activity of levels with reporting % physical vigorous activity or moderate of more minutes  days or a  having completed individuals older physical asked activity, surprisingly, when about week. more Not (age activity days of reported one zero or during younger the to as+) week compared wastowards a there trend gender, Across ). gure fi years (see community (- members For many First Nations individuals many First Nations For and communities, than health more is considered physical wellness,simply rather a balance but the of physical, mental, emotional, and spiritual aspects self. the of of Regarding First Nations members not whether or community in Hamilton in feel balance in they the aspects of four were felt life, of % balance all the of in time, they most balance or were the felt % of time some and % .% to compared women three of point eight percent a the of little time. none Twenty or indicated men thatof their life was in balance the only a little of time and none this or erences in lifebalance self-reported not are cant. Diff is statisticallyerence signifi diff fi ). gure (see cantacross age categories statistically signifi Figure 13. self-rated Health by gender for First nations Adults, our Health counts in themselves be Hamilton in to this considered same category. population in Hamilton. While .% of Hamilton’s women over age  considered  age considered over women Hamilton’s of inpopulation Hamilton. While .% OHC of themselves very be in to or health, good excellent only .% 55.0%

50.0% 18-34 Years Old 48.0% 35-49 Years Old 45.3% 50 Years and Olde 45.0% r

40.0% 39.1% 36.6% 36.6% 35.0% 34.1%

30.0% 26.9% 25.0% 20.6% 44 20.0% 15.0%

COUNTS HEALTH OUR 12.9% 10.0%

5.0%

0.0% All or Most of the Time Some of the Time A little or None of the Time

Figure 14. in Balance of 4 Aspects of life by Age for First nations Adults, our Health counts

60.0% 18-34 Years Old 35-49 Years Old 50.0% 50.0% 50 Years and Older

40.0% 38.1%

33.0% 30.1% 30.1% 30.0% 25.5% 22.6% 20.0% 20.0% 16.9% 13.3% 11.2% 10.0% 9.2%

0.0% 0 - 1 Day 2 - 3 Days 4 - 6 Days 7 Days

Figure 15. Physical Activity by Age for First nations Adults, our Health counts

more physical activity among men compared to women, with more women than men reporting zero or one days of activity during the week and more men reporting , , or  days of activity during the week (see fi gure ). Likely, given the socio-economic conditions reported among this population, the high levels of physical activity refl ect a lack of access to transportation and life-based activities that must be conducted by walking. OUR HEALTH COUNTS 45 ¹⁵ Within ¹⁵ 40.9% 7 Days 41.5% ¹⁵ 21.2% 4 - 6 Days First Nations population are high (see table ). ). table are population high First Nations (see 33.5% 18.5% 2 - 3 Days 17.3% 19.3% Male Female 0 - 1 Day Hamilton population, % reported having a health Hamilton by being % population, told care 7.6% First Nations population, % of men reported a health men having by of % population, been told care First Nations chronic Health conditions 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% Th ere was a trend towards higher rates of heart wastowards vs. ere of a higher rates trend (.% disease men thanamong women Th healthyearsreportedby a  men of older being told % and care . cally, specifi More .%). that years they  andprofessional men younger. heart had of disease .% to compared In total, arthritis of rate the self-reported with similar was .% rates reported men by Hamiltoniansof is is beinghigher self-reported who than.% the Th and women. diagnosed with arthritis in the Canadian  Community Health Survey. reported inHigh were this pressure blood rates of with population, a self-reported of overall the Hamilton .% population self- that to is compares Th .%. of prevalence reported high in pressure the blood Canadian  Community Health Survey. the OHC erence is diff Th women. of that .% high to theyprovider compared pressure have blood Th ofhighrate eself-reported cant. statistically was not between and women men signifi years  was those higher over for thanpressure blood those that between for the of age to compared reported pressure who blood and   years those of with over .%  to years.  age persons % of Rates of manyRates diseases chronic of in the OHC Among OHC is is that asthma, theyprovider have with similar Th and rates women. reported men by the by overall than self-reported Hamiltonmore population twice the asthma (.%) rate in the Canadian  Community Health Survey. Figure 16. Physical Activity by gender for First nations Adults, our Health counts In total, the self-reported rate of stroke was .% with no signifi cant diff erence between men and women. Th ere is no comparable general Canadian rate but the American prevalence of stroke for non-institutionalized adults was .% in .²⁰

A total of .% of the adult study population reported having diabetes as diagnosed by a health care provider. Th is is approximately three times the rate among the general Hamilton population, which was .% in  according to the Canadian Community 46 Health Survey.¹⁵ Th is isdespite a much younger age demographic of the First Nations Hamilton population. For First Nations in Hamilton, over % of person who were over COUNTS HEALTH OUR  years reported having received a diabetes diagnosis compared to % of persons  to  years. Th is pattern was strongly observed among women, among whom % over the age of  reported diabetes compared to % of women aged  to . Among those who reported a diabetes diagnosis, .% had been tested for haemoglobin “A-one-C” in the past  months, .% reported that a health care professional had checked their feet for any sores or irritations in the past  months and .% reported that a health care professional had tested their urine for protein in the past  months.

Hepatitis B was not prevalent in the study population (.%), however Hepatitis C was highly prevalent with .% of the total population having been told by a health care professional that they had Hepatitis C. Th is prevalence rate of Hepatitis C is over ten times the estimated Hepatitis C prevalence rate for the province of Ontario (.%) and almost three times the estimated Hepatitis C prevalence rate for the total Aboriginal population in Canada (.%).²¹

Th e adjusted rate of chronic bronchitis, emphysema, or COPD (Chronic Obstructive Pulmonary Disease) was .%. Th e rates for women and men did not diﬀ er signifi cantly.

At the time this survey was conducted, % of the study population reported having received the HN vaccine. Th e rate of vaccination appears consistent across income brackets. While this rate of immunization is similar to the immunization rate for the general Hamilton population,¹⁵ it is strikingly low given that First Nations populations were identifi ed as extremely vulnerable to HN infection very early on in the epidemic and experienced much higher morbidity and mortality from HN compared to the general Canadian population. OUR HEALTH COUNTS 47 ¹⁹ 25% 0.7% 8.7% 8.4% 8.4% 9.3% rAte 25.8% 56.3% 68-100% of Children 23.8% 34-67% of Children 19.8% 0-33% of Children Breastfeeding Stroke 5.9% Stroke Diabetes15.6% Hepatitis B Hepatitis C vaccination H1N1 Allergies Arthritis30.7% pressure blood High Heart disease Chronic bronchitis, emphysema, or COPD (Chronic Obstructive Pulmonary Disease) 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% Figure Percent 17. of children Breastfed for First nations women, our Health counts A total of % of women in the Our women of HealthA total % Counts of study reported having breastfed any theirof children. many children % When breastfed, how these asked over for women Th e ). gure reported than breastfeeding more two for thirds their of fi children (see lengthaverage time of breastfed their each these of children women % was as follows: less breastfed than for breastfed for  months, %  to breastfed three for months, % Th ehigh of rates ). gure fi than more (see breastfed  months  for and %  months to breastfeeding observed in this with are population very consistent those observed among other Aboriginal datasets, Regional example the First Nations Health for Survey. table 1. rates of chronic disease For First nations Adults in Hamilton, oHc Hamilton, in Adults nations First For disease chronic of rates 1. table Improvements in programming accessible Improvements greatly and care to pre-natal have contributed an increase in breastfeeding prevalence. 40.0%

33.2%

30.0% 24.9% 25.6%

20.0% 16.3%

10.0% 48 0.0% COUNTS HEALTH OUR 1 Month to less 3 Months to 6 Months to 9 Months or than 3 Months less than 6 less than 9 longer Months Months

Figure 18. Average length of time Breastfed for First nations women, our Health counts

Preventative care Papanicolaou (Pap) Among First Nations women in the study population, .% reported ever having a Papanicolaou (Pap) test. Of these women, .% reported having received a Pap test in the last  years. Th is rate is about % higher than the rate found by the ICES data linkage, which will follow. One reason for the diff erence in the survey and ICES Pap screening rates is that the questions asked were slightly diff erent. Th e survey question only reported the three year rate of Pap screening for women who had ever had a Pap test and the ICES linkage allowed examination of participation in Pap screen for the past  years for all women, whether or not they had ever had a Pap test. Th is however would only account for approximately % of the diff erence in the survey and ICES rates since this is the self- reported rate of never having had a Pap test for First Nations women in Hamilton, so further exploration of this diff erence is needed. In the lead researcher’s clinical experience as a women’s health care provider who has worked in Aboriginal communities for two decades it is common that women assume that every pelvic examination includes a Pap test, when oft en only swabs for STDs are taken and no Pap test is done. Th e ICES database does reliably capture all Pap smears that were submitted to community laboratories for analysis, but does not include Pap smears collected and analysed in hospital. However, Pap smears are rarely collected in the emergency department and rates of hospitalization are similar for the Hamilton First Nations and general Hamilton and Ontario population. So unless a large proportion of First Nations women in Hamilton are attending a hospital based outpatient clinic that uses a hospital laboratory for its Pap smear analysis, then the most likely explanation for the diff erence in the self-report and ICES estimate rates for Pap smear testing for the Hamilton First Nations population is that women are assuming that their health care provider is doing Pap testing during pelvic exams that do not include Pap testing and/or their health care provider is not providing adequate information regarding the actual tests that are being done. OUR HEALTH COUNTS 49 for linkage linkage the reported ICES rate by ¹⁵ data linkage section). linkage data question regarding activity limitation test, compared to .% of men. Off ering Off men. of .% test, to compared test was %. Further test was %. this of interpretation First Nations population may explain may population First Nations in part the test than men. Sixty nine point fi ve percent of Firstof ve percent test than Sixty men. nine fi point testing given the overall risk in this population. Th ere was a trend of was ere a trend testing given the overall risk in this population. Th testing in rate the female population. survey data indicates decreasing towards a trend participation in screening Pap OHC Ability tests is oft en part en prenatalpregnantand women largeroutine of the for care tests is oft testing HIV proportion of mothers in the OHC higher HIV Th e adjusted rate for ever receiving ever for rate adjusted e an HIV Th HIV women in the City of Hamilton is in .% (see ICES in the (see City Hamiltonwomen of is in .% Th e substantiatedis is by withintrend ICESthe the past  years with advancing age. Th data. highlights It a particular better to need cervical understand and promote cancer years between age. Again and of  thescreening  women ages of First among Nations in the clinical childbearing researcher, lead experience this First Nations of project’s in urbanwomen access areas good and to participationhave in cervical screening as is it integrated their into prenatal care during participation their years, reproductive however nish having rates in cervical these once Aboriginal screening fi lower are much women orts access and regarding to participation improve in cervicaltheir children. Further eff have not do who women screening focus First want Nations to on might therefore havingnished their children. children are who fi or statistic is required, as appears high be it quite to indicate an may and it inappropriately high HIV of level receiving women an HIVmore in Hamilton an women received HIVNations was slightly diff thanerent that the of Canadian Communitywas slightly Health making Survey, diff cult. direct comparison diffi Th e adjusted rate of limitation rate adjusted e in or the activityof work kindsor home, amount at done Th otherwise Not was health %. or because mental a physical condition or problem of surprisingly, ability the of rate limitation to compared persons was older higher for en persons, with yearsyounger three  reporting over quarters over person of oft (%) OHC e sometimesor experiencing limitations. Th A similaris seen trend in general Hamilton data. population Hamilton of While .% reported having smearwomen in a Pap the lastthree years, mental and emotional Health

“Depression is more common than people are willing to admit. More prevalent in lower income families/households.”

“Doctors need to get oﬀ their high horse, not just give you the drugs and say, “see you later”. Th e ones [doctors] I am with now actually care about people. Th ey follow up and try and 50 help you solve your disorders.” COUNTS HEALTH OUR When asked to rate their mental health compared to other people they knew, % reported excellent mental health, % reported good mental health and % reported fair or poor mental health. Th ere were no signifi cant diﬀ erences in these rates across gender. Forty-two percent reported that they had been told by a health care provider that they had a psychological and/or mental health disorder. Further analysis into substance use, particularly prescription opioid misuse may reveal a relationship between self-medication and self-reporting of better mental health.

domAin 3: “reclAiming wHo we Are”

Highlights from domain 3 • Multi-Group Ethnic Identity Measure scores indicate a strong sense of First Nations identity among the First Nations population living in Hamilton.

In order to explore First Nations identity in our health assessment we used the Th e Multigroup Ethnic Identity Measure (MEIM) that was originally published by Dr. Jean S. Phinney, at California State University.²² Th e measure is comprised of two factors: ethnic identity search (a developmental and cognitive component) and affi rmation, belonging, and commitment (an aff ective component). Th e measure includes  items, which are listed below. Participants were asked how strongly they agreed with the statements on a scale from  to  with  being “strongly agree” and  being “strongly disagree”. Th e fi rst factor, ethnic identity search, contains items , , , , and , while the second factor, affi rmation, belonging, and commitment, contains items , , , , , , . Th e preferred scoring is to use the mean of the item scores; that is, the mean of the  items for an overall score, and, if desired, the mean of the  items for search and the  items for affi rmation. Th us the range of scores is from  to .

1. I have spent time trying to fi nd out more about First Nations, such as our history, traditions, and customs. 2. I am active in organizations or social groups that include mostly First Nations people. OUR HEALTH COUNTS 51 4.000 3.625- 15.4% 3.625 3.250- 24.9% 3.249 2.875- 30.3% 2.874 2.500- 20.6% 2.499 5.8% 2.125- 2.124 1.0% 1.750- score for First nations Adults, our Health counts Health our Adults, nations First for score 1.749 1.0% 1.375- 1.374 1.0% 1.000- I participate in cultural practices, Aboriginal wows, as such pow events, day feasts,ceremonies, drumming, singing etc. attachment First a strong Nations. towards I feel background. First Nations my about good I feel I have a strong sense of belonging to First Nations community. belonging sense First a strong Nations to of I have I understand pretty means being wellwhat me. First to Nations en talked otherto people oft being I have First about learn Nations, to In more order about First Nations. in pride First Nations. of a lot I have I have a clear cultural my senseI have of background and person what as First a Nations that me. means for ected because I am First Nations. lifeI think my will how about a lot be aff I am that I am happy First Nations. 0.0% 10.0% 20.0% 30.0% 40.0% For the total identity score (range from  to ) for each of the each observed of  we items, for that ) from  to the totalFor (range identity score ). gure fi almost  (see of three out quarters . above the scored population of sample calculated the we  items, ethnic of For comprised three that identity search over factor, identityfor Finally, the gure ). fi  (see of out . quarters above scored population of the of population observed % we  items, that of comprised over rmation factor, affi we calculated When gure mean). for the all scores fi  (see of out . above scored the generated we rmation factor,  theitems, identity search and factor identity affi Clearly these gurethree ). fi (see following three . ., mean ., scores: adultsect can as identity First sense among we a strong Nations of see that the graphs refl ratings a scaleaverage on  is from around  to . Figure total 19. meim 11. 12. 9. 10. 7. 8. 4. 5. 6. 3. 40.0%

32.7%

30.0%

22.1%

20.0% 16.8% 14.8%

10.0% 52 6.9% 2.2% 2.2% 2.2% COUNTS HEALTH OUR 0.0% 1.000- 1.375- 1.750- 2.125- 2.500- 2.875- 3.250- 3.625- 1.374 1.749 2.124 2.499 2.874 3.249 3.625 4.000 Figure 20. meim search subscale for First nations Adults, our Health counts

40.0%

31.5% 30.0%

22.5% 21.0% 20.0% 17.8%

10.0% 7.2%

2.4% 2.4% 2.4% 0.0% 1.000- 1.375- 1.750- 2.125- 2.500- 2.875- 3.250- 3.625- 1.374 1.749 2.124 2.499 2.874 3.249 3.625 4.000

Figure 21. meim Afﬁ rmation Subscale for First Nations Adults, Our Health Counts

4.0

3.27 3.09 3.0 2.83

MEAN 2.0

1.0

0.0 Overall Identity Search Subscale Affirmation Subscale

Figure 22. Mean Scores for Overall Identity, Search Subscale and Affi rmation Subscale scores First nations Adults, our Health counts OUR HEALTH COUNTS 53 Male Female 9.9% Occasionally 14.6% 71.1% Daily 66.2% 19.0% 4: “disconnection From wHo we Are” Not at all 19.2% substance use substance domAin 4 domain Highlights from Sixty-eight the reported of population daily percent smoking. substances of chewing inUse the tobacco; past .%  was months as follows: marijuana; % ecstasy; cocaine; % prescription sedatives; % and % % , Fentanyl, use, Codeine, which included Morphine,Tylenol opioid Percodan, Talwin etc. Sixty-six that their the access felt of of population was level the percent same as the general Canadian they they while population, less had access felt felt % and % hadbetter access. in population the HamiltonForty of First Nations their rated access percent of level lack of healthto care Barriers waiting as fair long poor. included lists or (%), available (%), not doctor directord costs (%), aff to able not transportation (%), and trust lack of in health care (%). provider 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% Figure 23. Frequency of smoking cigarettes by gender for First nations Adults, our Health counts When asked if they cigarettes time, the smoked reported of population the at present % daily observed higher towards smoking a trend rates of under the smoking. of age We were smokingof e rates betweenwomen men and Th  bothyears and women. men for total, In fi). gure (see erences cant diff fairly with consistent, statistically no signifi in population the Hamiltonof First Nations reported that they daily.% smoked or than whichoccasionally, is more three times the the general for Hamilton rate population reported in the Canadian  Community(.%) Health Survey. • • • • Participants were asked how oft en they had  or more drinks on one occasion in the past  months. Th e adjusted population distribution was as follows: % answered never, .% answered less than once per month, % answered once per month, .% answered – times per month, % answered once per week and % answered more than once per week or everyday. Diff erences in the rates between men and women were not statistically signifi cant, however the data suggests a trend towards more men consuming more than  drinks on one occasion more than once per week compared to women (% vs. %) and 54 more women never consuming over  drinks in one occasion compared to their male counterparts (% vs. %). Still, a high number of women reported consumption of  or COUNTS HEALTH OUR more drinks on one occasion - times a week (see fi gure ). In total, .% of the First Nations population in Hamilton reported that they had  or more drinks on one occasion at least once per month, which is more than twice the rate for the general Hamilton population (.%) reported in the  Canadian Community Health Survey.¹⁵

40.0%

Male Female 30.0% 29.6%

24.2%

20.8% 20.5% 20.0% 19.4% 16.6% 16.6% 15.5%

11.3% 12.3% 10.0% 7.8% 5.5%

0.0% Never Less thanOnce Once 2-3 times Once per More than Once per Month per Month per Month Week per Week

Figure 24. consumption of 5 or more drinks on one occasion by gender for First nations Adults, our Health counts

Th e First Nations Our Health Counts participants were asked to report on substance abuse in the last  months, including abuse of illicit and prescription drugs. Adjusted self-reported rates were: .% for chewing tobacco; % for marijuana use; % for ecstasy; % for sedatives; % for cocaine; and % for prescription opioid use, which included Codeine, Morphine, Percodan, Tylenol , Fentanyl, Talwin etc. For all of these substances there were no statistically signifi cant diﬀ erences in rates of use between men and women.

As mentioned above, higher rates of marijuana and prescription opioid misuse may reﬂ ect mechanisms by which people are managing their poverty and stress/mental emotional health issues. Th is is preliminary, descriptive data, however a more in-depth analysis in the future will help to build a more in-depth understanding. OUR HEALTH COUNTS 55 /Angel dust, /Angel 14.3% Better Access 19.8% Less Access 65.9% Access Same level of /Amphetamines, Inhalants/Amphetamines, and Ritalin, small too the were numbers but to LSD Health services 0.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% When asked the rate to availability health of services in felt their % community, availability availability felt was excellent, % was felt in good their % community, Figure 25. level of Access to Health services for First nations Adults, our Health counts less access and % felt they had better access (see fi ). gure theyless access better had fi felt and access % (see Study participants access asked of the health rate to to level were services available to thatthem their Canadians to as felt compared % Our rates were: adjusted generally. access of waslevel the same as the general Canadian they while population, had felt % “I wish“I I had husband someone talk when my to died. to been I need trying closure. I’ve to cult.” withget appointment a psychiatrist an has and it been diﬃ “Life just gets harder“Life and harder and government the is helping, not they seem to backwards, dealing with mental health issues…they gets done, dictate and nothing you service.” get lip get counselling or prevention. You don’t “We need more Aboriginal need more people health care, in education, places“We looking people where are models.” role other native up to people. More Acid/ report. For thereport. drugs, majority of For the use vary of prevalence did not substantially across the case for except groups, age ecstasy of observed higher persons we use much for where years age. of under  Inthe to addition drugsalso listed we above, asked participants PCP about availability was fair and % felt availability of services was poor (see fi gure ). Th e fact that % of the population felt their level of access to health care was fair or poor, despite the geographic proximity to extensive health and social services that the City of Hamilton provides, substantiates the idea that just because the services are geographically proximate, does not mean that they are accessible to First Nations people.

56 50.0% 43.3% COUNTS HEALTH OUR 40.0%

28.9% 30.0%

20.0% 16.7%

11.1% 10.0%

0.0% Excellent Good Fair Poor

Figure 26. Availability of Health services for First nations Adults, our Health counts

Participants were asked to indicate any barriers they may have experienced to receiving health care in the past  months. Th e list of barriers included the following: Doctor not available in my area, Nurse not available, Lack of trust in health care provider, Waiting list too long, Unable to arrange transportation, Diffi culty getting traditional care, Not covered by NIHB, Prior approval for services under NIHB was denied, Could not aff ord direct cost of care, Could not aff ord transportation costs, Could not aff ord childcare costs, Felt health care provided was inadequate, Felt health care provided was not culturally appropriate, chose not to see health professional, service was not available in my area and other. Th e distribution of percentages reported for each of these barriers is displayed in the graph below (see fi gure ). OUR HEALTH COUNTS 57 70% linkage included included linkage 61.4% 60.0% 47.9% 50.0% 40.0% 35.2% 32.0% 28.6% 27.9% 26.8% 30.0% 25.4% 25.0% 23.9% 21.0% 20.9% 19.8% 19.0% 20.0% 16.5% 6.7% 10.0% 0.0% Other Barriers Care Provider Care Childcare costs Childcare Could not afford Nurse not available Waiting list too long list too Waiting Felt Service was not Culturally appropiate Lack of trust in Health in my area in my area Service was not available Doctor not available in my area Difficulty getting Traditional Care getting Traditional Difficulty Prior approval for Services under Prior approval Unable to arrange Transportation Unable to arrange NIHB Health Benefits was denied (e.g. Healer, Medicine Person, Elder) Medicine (e.g. Healer, Chose not to see Health Professional Could not afford Transportation costs Transportation Could not afford (e.g. Service, Medication, Equipment) other Barriers to receiving Health care included: care Health receiving to Barriers other Felt Health Care provided was Inadequate provided Felt Health Care Could not afford direct cost of Care/Service cost of direct Could not afford Not covered by Non-Insured Health Benefits by Non-Insured Not covered Our population-based self-report estimate is that % of First Nations adults inOur estimate First Nations Hamilton of self-report population-based is that % cant no statistically were ere signifi accessed carehave emergency in the past  Th months. result is withis consistent ICESthe categories. Th and age income across gender, erences diff datacally, ICES linkagethe results reported in the next section. Specifi “Lack of specialists [including psychiatrist]” [including specialists of “Lack “Not a fan of doctors or hospitals. I feel judged before being treated.” being before judged I feel hospitals. or doctors of a fan “Not “Lack of trust and cultural understanding” cultural and trust of “Lack “Prejudice” “No sweats in the city [Hamilton].” city the in sweats “No Figure Barriers 27. to receiving Health care in Past months 12 for First nations Adults, our Health counts emergency room admissions over the past two years, rather than past year, and found that approximately .% of the study participants had accessed the ER over the past  years.

When asked to rate the quality of emergency care accessed in the past  months, % felt it was excellent or good, while % felt it was fair or poor. Little variation was observed between men and women.

58 Study participants were asked if they had ever been treated unfairly by health professionals because of being First Nations. Our adjusted rate was % yes with similar COUNTS HEALTH OUR rates reported by men and women. Reporting of unfair treatment also appeared to increase with age as % of persons over  reported unfair treatment as compared to % of persons between the age of  and  years, however these diﬀ erences were not statistically signifi cant. Questions regarding discrimination as a result of being First Nations more generally as well as experiences of ethnically or racially motivated attack were asked in a later section of the survey. Th e results for these questions are reporting in the following section on Impacts of Colonization. Further interpretation of the OHC discrimination data is required, as the interpretation of self-report data regarding experiences of racism is complex. Under-reporting is common and the need for validated, multiple measures has been identifi ed in working class African and Latino American populations.²³ Th ere is a paucity of validated tools to measure discrimination in Aboriginal groups.

Access to traditional medicine Use of traditional medicine was quite common among the study population with one third of the First Nations study population reported use of traditional medicine. It should be noted, however, that the survey itself did not provide a defi nition of traditional medicine in this context, so there may have been some inconsistency with reporting. Specifi cally, those who answered, ‘Can’t aﬀ ord it’ may have been thinking of other non- Western services such as visiting a naturopath or chiropractor as traditional medicine. Of those who had diﬃ culty accessing traditional medicine, we observed the following breakdown of specifi c barriers (see fi gure ).

Participants who had Non-Insured Health Benefi ts NIHB( ) were asked if they had experienced any diﬃ culty accessing any of the health services provided through the Non-Insured Health Benefi ts Program NIHB( ) provided to status First Nations and Inuit persons through Health Canada. Our population based estimate is that % report no diﬃ culties accessing the NIHB program.

Of those who had diffi culty accessing services provided through NIHB, we observed the following breakdown of specifi c barriers (see fi gure ). OUR HEALTH COUNTS 59 70.0% ” 30.0% 60.6% 60.0% 20.6% by this by experience. 50.0% 20.0% 16.1% 40.0% coloniZAtion 30.0% 9.7% 9.2% oF 10.0% 6.9% 20.0% For First nations Adults, our Health counts Health our Adults, nations First For 4.1% 10.5% 8.0% 7.4% 2.9% 2.3% 5.5% 5.4% 10.0% 4.5% 3.6% 1.2% 0.1% 0.0% imPActs 0.0% Other Other 5: “ Medication Don’t Know Don’t Dental Care Don't Know Hearing Aid Can't afford it Can't afford No Difficulties Too far to travel far to Too Vision Care (glasses) Care Vision Health Benefits (NIHB) Other Medical Supplies Concerned About Effects Not covered by Non Insured Not covered domAin Highlights from domain 5 domain Highlights from Six point one percent of the of study reported population that percent they Six at one been had a student point a federal a federal or residential industrial school, that Of school. their those, felt % ected health aff and well-being been had negatively participantsForty of percent reported that a child in agency was protection involved their own personal care as a child. adults in First Nations Hamilton of reported thatA total their .% of home land claim. more community or one had Do not know enough about them Do not know enough about Transportation Services or Costs Transportation Do not know where to get the them Do not know where Not available through Health Center Health Not available through • • • Figure 29. Diffi cultyFigure Accessing 29. Diffi niHB Figure 28. Diffi Figurecult Accessing 28. Diffi Traditional Medicine for First Nations Adults, Our Health Counts • Half of the study population reported ever receiving unfair treatment because they are First Nations. • High rates of community and family violence were also reported.

residential school Six point one percent of the study population reported that they had been a student at a federal residential school, or a federal industrial school. Of those, when asked if their 60 overall health and well-being had been aﬀ ected by their attendance at a residential school, % felt that their health had been negatively aﬀ ected. Clearly, these numbers indicate COUNTS HEALTH OUR that the legacy of residential school continues persists in urban areas and is not something observed only on reserve or in Northern communities.

Forty percent of First Nations in Hamilton reported that a family member had been a student at a federal residential school or a federal industrial school. Of these, % had a grandparent who attended, % had a parent who attended, .% had a sibling who attended, % had an aunt or uncle who attended and % had another family member who attended. Of those who had a family member who attended residential school, % felt it had a negative impact and % felt it had no impact on their overall health.

child Protection Agency involvement Study participants were asked if a child protection agency was involved in their own personal care as a child. Our adjusted rates indicated that in total, % answered yes. Th e rate for men was % and the rate for women was %. Such a high number of men reporting their own experience with child protection agencies speaks to the need for services targeting men in this community. We observed that more younger persons reported child protection agency involvement in their care compared to older persons. When asked if a child protection agency had ever been involved in the care of one of their children, .% reported yes, of whom % were women. While there was not much variation across age, we did observe higher rates of child protection involvement in participants’ children among those individuals who were more economically marginalized. Over % of the population who earn less than , a year reported child protection agency involvement in the care of their children. Finally, of those who reported the involvement of a child protection agency in their family (either as a child or for the care of one of their children), % felt that childcare protection agency involvement had a negative aﬀ ect on their overall health and well-being.

dislocation from traditional lands A total of .% of First Nations in Hamilton reported that their home community had one or more land claim. Th e rate for men was % and the rate for women was %. When asked if their overall health and wellbeing was aff ected by dislocation from traditional lands, % felt there was no impact and % felt there was a negative impact. OUR HEALTH COUNTS 61 self-reported discrimination rate data to study were asked if study treated were ever unfairly they were because they are discrimination better understand the links between reported experiences discrimination of and health status outcomes is ongoing. Further examination OHC the of First Nations A total of % of the of study believed population thatA total their % of overall health and wellbeing was wasis similarrate women. men and for ected racism. by Th aff Participants the of OHC When asked if they been ever the had victim an of ethnically racially or verbal motivated physical attack,or observed we the reported following: experience a verbal no % of or been had a victimphysical attack, within .% a verbal of attack (% the past  months) been had the victimand a physical .% attack of been had the (% victim a physical of in ethnicallyerences rates of racially or motivated attack within Diff the past  months). Th figure following e cant. statistically not attack were between and women men signifi illustrates the physical and breakdown of verbal attack in less than  and more months ). gure fi than (see gender  by months “…less opportunities and because of not having, you can’t provide the way you would like to to like would you way the provide can’t you having, not of because and opportunities “…less survival.” about always Its family. your for reported that they HalfFirst Nations. had the including population, (%) slightly men more experienced unfair in the data suggest treatment. that Trends discrimination was reported the  years and of age higher and over persons was both among among prevalent lower more and highest reported the groups unfair of lowest income treatment). brackets (% income “…distrust of people. Programs aren’t functional for Natives because we are never asked for input.” for asked never are we because Natives for functional aren’t Programs people. of “…distrust “people get racist against me and it just makes me stronger. I get stronger when I come on to to on I come when stronger I get stronger. me makes just it and me against racist get “people that.” like people “…in high school, being off the reserve and fi nding out how white people treat native people. people. native treat people white how out nding fi and reserve the off being school, high “…in here. belong don’t we that and teepees our in live go us to telling burners, us wagon Calling day.” this to on going is still it And When asked how their overall health and well-being have been aff of some racism, ected by been aff have well-being health and their overall how asked When included: the responses “Th e only discrimination that I have received was from First Nations people. Being urban and urban Being people. Nations First was from received have I that discrimination only e “Th culture.” Ojibway my of respectful being Not area. this from being not reserve, on being not 70.0% Male 61.2% 60.0% Female 59.4%

50.0%

40.0%

30.0% 22.9% 19.8% 20.0% 15.0% 13.1% 9.9% 10.3% 10.0% 62 6.2% 2.9% 1.3% 1.0% 0.0%

COUNTS HEALTH OUR Yes to Verbal Yes to Verbal Yes to Physical Yes to Physical No Don’t Know attack attack more attack attack more within the past than within the past than 12 Months 12 Months ago 12 Months 12 Months ago

Figure 30. victim of Physical and verbal Attack by gender for First nations Adults, our Health counts

violence and Abuse Th e following data presents descriptive RDS-adjusted frequencies on violence and neglect in the community. More analysis of this data set and additional focussed data collection in the future will further our understanding of these issues and their impact. When asked if any types of violence occur in the community, % answered yes. In terms of specifi c kinds of violence, % of those reporting violence, reported family violence in the community, % reported violence related to crime and criminal behaviour in the community, % reported violence related to racism and discrimination, and % reported lateral violence in the community. Among those who reported family violence specifi cally, % felt that family violence included mental or emotional abuse, % felt that family violence included physical abuse and % felt that family violence included sexual abuse. Th e breakdown of types of family violence reported by those who reported family violence in the community by gender is illustrated in the following fi gure. Th e diﬀ erences between men and women were not statistically signifi cant (see fi gure ).

One gap in the current study is it doesn’t ask about the incidence of and types of abuse that are perpetrated by persons outside of the family.

When asked to rate the impact of violence and neglect in their community, .% felt it had an extremely high impact, % felt it had a high impact, % felt it had a moderate impact, % felt it had little impact, and % felt it had no impact. Diff erences between men and women and their rating of the impact of violence in their community can be observed in the following fi gure (see fi gure ). Overall women rated the impact of violence in the community as having a higher impact than men, with a signifi cantly higher number of women rating the impact as “high” compared to men and a signifi cantly higher number of men rating the impact as “little” compared to women. OUR HEALTH COUNTS 63 13.3% Male Female 61.0% No Impact Male Female 14.0% Sexual 42.2% 13.1% Little Impact 25.2% 89.0% 32.9% Physical 34.8% 91.6% Moderate Impact 31.6% 19.4% High Impact 94.7% Mental 9.1% 96.1% Impact 6.5% Extremely High Extremely 0.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 100.0% 10.0% 20.0% 30.0% 40.0% “Younger children are not receiving adequate food, supervision and examples of family values.” family of examples and supervision food, adequate receiving not are children “Younger “…unattended children, young children smoking cigarettes and doing drugs…” doing and cigarettes smoking children young children, “…unattended “Th e young people (teenagers), I see them on the street being violent to each other. You can’t can’t You other. each to violent being street the on them I see (teenagers), people young e “Th something.” say and in step When asked list to neglect the in impacts and/or many the violence community, of cally neglect youth of and children: and participants described specifi violence youth Figure 32. Perceived impact of community violence and neglect by gender for First nations Adults, our Health counts Figure Types 31. of Family Violence ed as Occurring Identifi in the Hamilton First Nations Community counts Health our Adults, nations First for gender by Among those who felt comfortable sharing their experiences about confl ict in their own household, .% reported that someone in their household had physically hurt them, % reported being insulted or talked down to, % reported being threatened with harm, % reported being screamed or cursed at, % reported having their actions restricted by someone in the household and fi nally, % reported having sex when they didn’t feel like it. Th e breakdown by gender for each type of household confl ict are presented in the fi gure below. Overall there is a trend towards women reporting all types 64 of violence more frequently than men. Th is diff erence between women and men is statistically signifi cant for physical harm (see fi gure ). COUNTS HEALTH OUR

80.0% Male 70.0% 68.1% Female

60.0% 52.8% 56.0% 50.0% 40.3% 40.0% 39.0% 30.8% 30.0% 29.3% 23.4% 25.6% 20.0% 18.5% 13.9% 10.0% 7.1%

0.0% Physically Hurt Insulted or Threatened You Screamed or Restricted Had sex when You talked with harm cursed at You Your You didn't feel down to You actions like it

Figure 33. Types of Household Conﬂ ict by Gender for First Nations Adults, Our Health Counts

domAin 6: “lAck oF government resPonsiBilitY”

“Th ere are more services available to women then men (gender based.…i.e. belly dancing, sewing, quilt making) Would like more social activities geared toward men (cards, exercise)”

When asked what the main challenges were facing their community, % felt that alcohol and drug abuse were a main challenge, % felt that housing was a main challenge, .% felt that crime was a main challenge, % felt poverty was an issue, and % also felt that employment and number of jobs was an issue.

In terms of strengths of the community, .% felt family values were a strength, % felt that Elders were a strength of the community, % felt awareness of First Nations culture was a strength, % felt that community health programs and traditional ceremonial activities were a strength and % felt social connections were a strength in their community.

When asked if they felt there were adequate resources for community services, the following results were revealed: % felt there were adequate resources for family violence, .% felt there were enough services for HIV prevention, % felt there were adequate OUR HEALTH COUNTS 65 ²⁴ cohort were in this were cohort highest income linkage, the of % which places over . -adjusted estimates. linkage First Nations Hamilton years the  First was of age Nations sample over ) sample was much younger than younger was) sample much the general Hamilton and Ontario services, % felt there were enough services for youth, .% felt there felt enough services services, there were .% youth, felt for % OHC dAtA linkAge dAtA cohort into the lowest income quartile income the the of general into cohort Hamilton lowest % to compared survey data is income validated the by ICES record), Pap smear in Pap the the admissions previous  years, room over emergency record), First Nations sample appears to be somewhat under-represented in the over  age age in  the over under-represented appears sample be somewhat to First Nations sociodemographics ices ices Highlights from OHC population and % of the Ontario population. fell of Ontarioresidents into the Hamiltonof % and residents een percent Fift highest quartile income the while of OHC only % quartile. population of FirstHamiltonNations in reportedthe least to one at y percent visit Fift the of % to compared the problems past acute  years over for room the emergency Hamilton the of and Ontario % population. in population the Hamilton of First Nations six point reported more percent  or Ten the of visits and room .% inemergency the .% previous  years to compared Hamilton and Ontario populations respectively OHC compared to .% of the of Aboriginal Métis, First Nations, (includes identity population .% to compared in years the  Hamilton of according age and the to Inuit) over Census.  populations. Overall, this with the pattern know demography about is consistent we what theof Aboriginal in population Hamilton from the Census, with the that exception the OHC the % of OHC . category. Th e study wasvery population similar to of total that the Hamilton population and the Th Ontario with population breakdown. respect In the terms to age, the gender of Our Health Counts ( • • • • Using healthUsing Our card by Health provided numbers Counts study participants, a e successful link data the to at Institute Clinical for Th Evaluative was Sciences completed. data estimates through generated this linkage the of following: consist neighbourhood quintilesincome (based the Census on  and participant postal codes listed in their OHIP for here e presented data previous  years and hospitalization the past  years. over Th and healthincome care utilization the Our compare Health Counts estimates population with the the total of Ontario Hamilton provincial % and population subset a random of thatpopulation. Again, be the noted should Our it Health Hamilton Counts First Nations ect RDS and healthincome care use reﬂ numbers services for pregnant women, % felt there enough legal services, .% felt there were there were felt there enough legal services, felt services % pregnant women, .% for enough LGBTTQQI were enough services for single men, % felt there were enough suicide prevention prevention enough suicide enough services there were were felt single % men, for pandemics asservices such resources HN. for there adequate felt and % In terms of income quartiles, we observed that over % of the OHC population fell into the lowest quartile compared to % of the general Hamilton population and % of the Ontario population. While % of Hamilton residents and % of Ontario residents fell into the highest income quartile, only % of the First Nations adults sampled for OHC were in the highest income quartile. Clearly, these data highlight the poverty experienced by this community.

66 oHc oHc rds-AdJusted HAmilton ontArio-10% n col% col % 95% c.i. n col% n col%

COUNTS HEALTH OUR Adults Age on 18-34 196 37.4 41.9 [34.4, 49.9] 125,189 28.18 307,751 28.15 2010-04-01 35-49 197 37.6 36.6 [29.9, 43.1] 124,857 28.11 322,730 29.52 50-64 120 22.9 20.7 [14.7, 26.9] 110,332 24.84 271,028 24.79 65+ 11 2.1 0.8 [0.3, 1.6] 83,829 18.87 191,904 17.55 Sex F 259 49.43 37.6 [29.6, 43.6] 226,269 50.94 560,690 51.28 M 265 50.57 62.4 [56.4, 70.4] 217,938 49.06 532,723 48.72 Income 1-Low 376 71.76 73 [66.5, 79.2] 111,468 25.09 213,212 19.5 Quintile 2 85 16.22 11.8 [7.7, 16] 101,200 22.78 216,461 19.8 3 33 6.3 7.4 [3.6, 10.5] 90,069 20.28 216,614 19.81 4 13 2.48 4.9 [2.5, 9.8] 75,704 17.04 223,113 20.41 5-High 7 1.34 3 [1.1, 5.4] 65,375 14.72 220,665 20.18 Missing 10 1.91 na na 391 0.09 3,348 0.31 total 524 100 100 na 444,207 100 1,093,413 100 cHildren Age on 0-5 89 45.88 48.74 [ 42.5, 55] 34,662 37.66 88,182 38.2 2010-04-01 6-14 105 54.12 51.27 [ 45, 57.5] 57,384 62.34 142,646 61.8 Sex F 88 45.36 45.42 [ 39.2, 51.6] 44,575 48.43 112,435 48.71 M 106 54.64 54.58 [ 48.4, 60.8] 47,471 51.57 118,393 51.29 Income 1-Low 144 74.23 75.25 [ 69.9, 80.6] 23,741 25.79 46,102 19.97 Quintile 2 30 15.46 15.58 [ 11.1, 20.1] 18,857 20.49 42,636 18.47 3 9 4.64 5.4 [ 2.6, 8.2] 19,030 20.67 46,192 20.01 4 < /=5 1.03 1.26 [ 0.01, 2.7] 16,363 17.78 49,563 21.47 5-High 8 4.12 2.52 [ 0.6, 4.5] 13,975 15.18 45,675 19.79 Missing < /=5 0.52 na na 80 0.09 660 0.29 total 194 100 100 na 92,046 100 230,828 100

table 2. gender, Age and income Quartiles for Hamilton and our Health counts Adults

Preventative screening Pap Smear Overall, First Nations women in Hamilton had similar levels of having received a Pap smear in the previous  years, compared to women in Hamilton and Ontario. With OUR HEALTH COUNTS 67 ] CI ADJUSTED [ RDS N ROW% YES ] CI ADJUSTED [ linked estimates smear testing. Pap of RDS N ROW% NO PAP smeAr in Previous 3 YeArs 93 38.3 46 46.7 [31.7,67.1] 47 53.3 [32.9, 68.3] 44 18.1 25 56.8[46.9,88.9] 19 [11.1,53.1] 31.6 estimates. Th is is partly due to subtle diﬀ erences in how how the erences in is partlyis subtleto due diﬀ estimates. Th 243 243 100 98 [30.6, 51.2] 40.1 145 59.9 [48.8, 69.1] 106 106 43.6 27 40.0] [15.7, 28.1 79 [60.0, 84.3] 71.9 N COL%

overAll database all gathers reliably tests Pap that are submitted to

estimates will estimates rigorous this the at more be considered time. s, and that there is no known diﬀ between hospital based testing rateserence of Pap s, and that known there is no diﬀ AGE

35-49 All 18-34 50-69

table 3. Pap smear in Previous 3 Years by Age for Adult women, our Health counts As noted earlierAs noted in the survey rates of self-reported data section this of ), report (Page smear testingPap % in population the among Hamilton about First Nations were higher than these ICES increasing age, however, the smear reported tests rates of Pap the among First Nations increasing age, however, cantlyto both compared Hamilton the Ontarioand study signifi dropped population receiving were cervicaladequate women FirstNations of e majority populations. Th and women, older among years,cancer the  screening however of age before In the particularly lower. participation much rates of were group, age in  the over clinical childbearing good have experience the researcher, of lead women First Nations access and to participation in cervical screening as is integrated it their into prenatal care, childbearingnished less are likelyparticipateto in cervical are who fi women however reason one participation be that is may rates drop withadvancing age. screening. Th Screening are indicated. programs women Also First Nations that focus older further on regardinginvestigation participation in cervical who women screening First Nations for children have is also not do required. survey wasquestion asked data (the  year participation was question the only asked for this only would However participants of % subset test). of that a Pap had had ever Furthererence. required better to is investigation therefore the of diﬀ % for account and in ICES self-report erent understand this diﬀ Given that theGiven ICES analysis;community for laboratories in that is common the it clinical experience the of Aboriginal for understand to investigator lead test that a Pap had women they have during a pelvic exam rather test, just swabs in for a Pap but had when fact not they have STD living women in First Nations Hamiltonfor and the general Hamilton the population, ICES overAll PAP smeAr in Previous 3 YeArs NO YES

AGE N COL% N ROW% N ROW%

All 179,134 100 66,963 37.4 112,171 62.6 18-34 61,857 34.5 23,505 38 38,352 62 35-49 58,710 32.8 18,865 32.1 39,845 67.9 50-69 58,567 32.7 24,593 42 33,974 58 68 table 4. Pap smear in Previous 3 Years by Age for Adult women in Hamilton COUNTS HEALTH OUR overAll PAP smeAr in Previous 3 YeArs NO YES

AGE N COL% N ROW% N ROW%

All 456,729 100 171,998 37.7 284,731 62.3 18-34 154,208 33.8 62,425 40.5 91,783 59.5 35-49 155,030 33.9 51,042 32.9 103,988 67.1 50-69 147,491 32.3 58,531 39.7 88,960 60.3

table 5. Pap smear in Previous 3 Years by Age for Adult women in ontario (10%)

emergency room visits Emergency room visits were much more frequent among the First Nations population in Hamilton as compared to the general Hamilton and Ontario populations, overall and for both acute and non-acute illnesses. Th ese diﬀ erences are statistically signifi cant and striking, particularly with respect to the relative percentages of multiple ER visits for the First Nations OHC, Hamilton, and Ontario populations. Ten point six of the First Nations adult population in Hamilton reported  or more emergency room visits in the previous  years compared to .% and .% of the Hamilton and Ontario adult populations respectively. Fift y percent of the First Nations adult population in Hamilton had at least one recorded visit to the emergency room for acute problems compared to % of the Hamilton and % of the Ontario adult populations.

Rates of emergency room use were similar for men and women in the OHC First Nations population with no signifi cant diﬀ erences in access rates detected. Th is similarity across gender in ER use was also found in the Hamilton and Ontario populations. Th e OHC First Nations sample wasn’t adequately powered to detect diﬀ erences in ER access across adult age strata.

Rates of emergency room use were also signifi cantly higher for First Nations children between the ages of  and  years of age compared to Hamilton and Ontario children from the same age group. For example, % of First Nations children aged - years had one or more recorded visits to the emergency room over the past two years, compared to % of Hamilton and % of Ontario children in the same age groups. OUR HEALTH COUNTS 69 .6 .6 6+ 6+ 6+ 1.9 2.9 [1,5.6] 2.9 4 [1.6,6.9] First nations nations First 6.0 6.3 2-5 2-5 2-5 12.3 12.3 First nations cohort First nations cohort 1 1 1 13.1 13.1 12.2 12.2 16.8 16.8 adjusted rates and the adjusted general Hamilton adult and Ontario 69.1 69.1 80.1 80.1 81.2 81.2 none none none emergencY room visits (non-Acute) visits room emergencY emergencY room visits (All) emergencY room visits (Acute) 54.3 [47.6,61.2] 54.3 [47.6,61.2] 22.4 [17.3,28.5] 20.4 [14.5,25.4] 31.5 [25.8,37.5] [25.8,37.5] 31.5 26.2 [20.7,32.8] [25.9,37.8] 31.7 [6.2,14.5] 10.6 50.2 [43.9, 57.5] 50.2 [43.9, 57.5] [18.7,30.1] 24.7 [15.3,26.1] 20.7 visits in the Previous64 years, 2 Years for adults oHc aged – 18 adjusted with conﬁ adjusteddence intervals), with conﬁ Hamilton and Ontario rds

adjusted with confi adjusteddence intervals), with confi Hamilton and Ontario adjusted with confi adjusteddence intervals), with confi Hamilton and Ontario Hospitalizations OHC Hamilton 14.0 79.4 10% 6.3 Ontario – .4 OHC

OHC Hamilton 66.3 18.7 13.4 1.6 10% Ontario – Hamilton 78.4 14.2 10% 6.8 Ontario – .6 visits in the Previous64 years, 2 Years for adults oHc aged – 18 rds rds table 8. non-Acute emergencyPercentage room visits of Population – with 0,1,2-5 or 6+ non-Acute er cohort ( Rates of hospitalizationRates of appear be similar to between in population adult the First Nations Hamilton based the on OHC populations, with a slightly higher frequency hospitalization of the among First Nations of .) the to Hamilton compared population (., and Ontario populations. Overall, % between population the and years the First  Nations  ages in of Hamilton been not had Th ese high rates of emergency room usage by First Nations persons persons FirstNations living by eseroom usage highemergency of Hamiltonrates in may Th healthbe linked in care accessing the that to problems non-emergent are revealed the by survey data and described in the preceding sectionthis of the of example, report. % For their rated population First access Nations health to care fair as or poor and indicated% that “waiting lists was barrier a long” too in accessing health care. In in addition, least at cases,some primary usage, increase room since rostered emergency have care may reform primary their by primary be told care may patients the to emergency go care to providers department rather than a walk-in clinic their when primary care team available. is not table 6. All emergencyPercentage room visits of Population – with 0,1,2-5 or 6+ total er visits in the Previous64 years, 2 Years for adults oHc aged – 18 ( table 7. Acutetable 7. emergencyPercentage room visits of Population – with 0,1,2-5 or 6+ Acute er ( hospitalized at all over the past fi ve years compared to .% of the general Hamilton population and % of the Ontario population in the same age group. Th is is partly explained by the higher birth rate among the First Nations population in Hamilton which is reﬂ ected by slightly higher rates of obstetrics hospitalization for this group compared to the general Hamilton and Ontario population. Eighty-nine point one percent (., .) of the First Nations population between the ages of  and  years in Hamilton had not been hospitalized for obstetrical reasons compared to . of the general Hamilton and . of the Ontario 70 population in the same age group. However, given the high rates of chronic diseases such as diabetes and stroke and the much higher rates of emergency room use among the OHC First COUNTS HEALTH OUR Nations population compared to the Hamilton and Ontario populations an even higher rate diﬀ erence of hospital admissions between the OHC First Nations population and Hamilton and Ontario population could be anticipated.

With respect to the hospitalization of children ages  to , rates of hospitalization for First Nations children living in Hamilton are signifi cantly lower than rates of hospitalization for the general population of children living in Hamilton and Ontario. Two point four percent (., .) of First Nations children had been hospitalized one or more times over the past fi ve years compared to .% and .% of all children living in Hamilton and Ontario respectively.

Further examination of this data and additional study is therefore required to better understand whether or not there is a systematic bias in hospital admission practices which prioritizes the admission of non-First Nations community members over First Nations community members.

Because hospitalization is less frequent event than emergency room use, the study was not adequately powered to detect diﬀ erences in other types of hospitalizations (i.e. mental health, surgical, and medical hospitalizations) between the First Nations Hamilton population and the general Hamilton and Ontario populations.

resPectFul HeAltH cHild surveY dAtA

Highlights from the child Health survey • Ninety-three percent of parents and caregivers felt it was very or somewhat important for their child to learn a First Nations language • Ninety-four percent of parents and caregivers felt that traditional cultural events were very or somewhat important in their child’s life • Asthma and allergies were the most commonly reported chronic conditions. Rates of asthma were twice as high for Hamilton First Nations children compared to general Canadian rates for children. OUR HEALTH COUNTS 71 2.0% Not Important 4.6% Not very Important 44.3% Important Somewhat 49.0% Very Important Very language Rates of chronic ear chronic Rates of infections high were their and about parents caregivers child’s concerned of were percent Twenty-two development participants of Eighty-three percent indicatedthat their child seen had a family general pediatrician practitioner or % to doctor, in the past  (compared months the generalfor Canadian aged - population years) barrier numberone receiving e to health carereported by child custodians was Th that the wait list was long too 0.0% 60.0% 10.0% 20.0% 30.0% 40.0% 50.0% Figure 34. importance of the child learning a First nations language for counts Health our children, nations First When participants important the asked child is for how it learn were to a First Nations language, said was it very % important, said important, was % it somewhat while the gure ). remaining very wasfi it important not important % not felt or (see Among the total child surveys that were completed (N=), % were male children were and the % Among totalchild surveys (N=), completed that were the of children  years female children. and percent younger, were were Forty-four % while  years A fairly old. the distribution over even remaining were across genders % was observed in both the of categories. age • • • • As explained the child above, custodial survey or parents by was relatives/ completed guardians all for children with resided who under the  the of age and years. adult were living children First were Nations who Nation exclude with to not In a non-First order additionally we parent/relative/guardian be given to adoptive allowed or coupons biologic the custodial were who persons or Nations one of parent/relative/guardian non-First to more First Nations children. When asked how important traditional cultural events were in the child’s life, % felt they were very important, % felt they were somewhat important and the remaining % felt that they were not very important or not important.

Parents (%) and grandparents (%) were reported most oft en as the family members responsible for helping the child to understand Firs Nations culture, followed by aunts and uncles (%), other relatives (%) and friends (%). 72 general Health COUNTS HEALTH OUR Child custodians were asked to rate their child’s health on a -point scale from excellent to poor. Overall, children’s health in this population was rated quite high, with % who reported that their child’s health was excellent and over % who reported that their child’s health was either very good or good. Th ese rates are very similar to the self-rated health fi ndings of the Aboriginal Children’s Survey and the National Longitudinal Survey of Children and Youth.²⁵ Variation across gender was not substantial, however there does appear to be a trend with more guardians of male children reporting very good health as compared to guardians of female children (see fi gure ). Similarly, across age groups, the data was fairly consistent, although we did observe a trend towards guardians of younger children (- years) reporting better overall health of their children as compared to guardians of children over  years (see fi gure ).

50.0%

44.1% Male 41.3% Female 40.0%

29.6% 30.0% 27.8% 25.9%

20.0% 18.3%

10.0% 8.0% 4.3% 0.6% 0.0% 0.0% Excellent Very Good Good Fair Poor

Figure 35. overall Health by gender for First nations children, our Health counts

Participants who completed the child survey were asked about a number of commonly reported chronic conditions. Th e following table displays the most prevalent conditions and the percentages across gender and age. Conditions that were also included in the survey, but are not presented here due to very small numbers included: OUR HEALTH COUNTS 73 1.3% 1.3% 6.1% 4.2% 3.8% YeArs And older Among Among Among 0.0% Poor ²⁶ 0.7% 0-5 Years Old 0-5 Years and Over 6 Years

2.4% 2.4% 3.6% 3.6% FemAle FemAle cHildren cHildren 7.4% Fair ²⁵ 4.6%

4.3% 4.3% 5.6% 5.6% 31.1% , autism, blindness or serious vision problems, blindness, autism, serious vision problems, or Good 25.7% ADHD / 20.2%

rAte cHildren cHildren Aged 0-5 6 YeArs Very Good Very 24.4% overAll overAll Among Among rePorted rePorted mAle 41.3% Excellent 44.6% Allergies Asthma 10.3% 11.7% Heart Condition 9.1% 18.1% 22.6% 15.7% 3.5% 13.7% 20.5% 14.9% 4.0% Diabetes Anemia 0.7% 0.0% Dermatitis 1.3% 1.7% 0.0% 1.5% 1.6% 6.1% Hearing Impairment 11.3% 1.8% 1.0% 1.4% 2.1% 5.2% 7.2% 4.0%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% Th e rate of allergies reported among the First Nations population in Hamilton (.%) is is of e rate allergiesreported(.%) population FirstHamiltonNations in among the Th very similar reported in the National the to overall in rate Canadian children (.%) Longitudinal (/). Survey Children of and Youth cancer, chronic bronchitis, cognitive or mental disability, fetal alcohol disorder, cognitive bronchitis, mental chronic disability, or fetalcancer, disorder, alcohol hearing impairment, hepatitis, kidney disease, learning disability, speech/language culties, physical disability than visual (other hearing and and/or impairment) diﬃ tuberculosis. table 9. commonly reported chronic conditions by gender and Age for counts Health our Hamilton, in children nations First child of custodiansEighteen percent is is rate reported that their child asthma. had Th Canadian reportedhigher National rate for than .% children of rate (/ Longitudinal Survey Children of and Youth). anxiety and depression, ADD Figure 36. overall Health by Age for First nations children, our Health counts Rates of chronic ear infections were high in this population. A total % of child custodians reported that their child had had an ear infection since birth, and of those % reported one ear infection in the past  months (% reported  or more in the past  months). Finally, when specifi cally asked if they had been told by a health care professional that their child had chronic ear infections or ear problems, % reported yes.

74 injury When asked if the child required medical attention for a serious injury in the last COUNTS HEALTH OUR  months, % responded yes. When asked to describe the type of injury, % reported broken or fractured bones, % reported a dental injury and % reported minor cuts, scrapes or bruises.

Access Eighty-three percent of participants indicated that their child had seen a family doctor, general practitioner or pediatrician in the past  months and % reported that their child had seen a dentist, dental therapist, or orthodontist in the past  months. Th is compares to a rate of % for the general Canadian population aged - years.²⁷

Participants were asked if they had experienced any barriers to receiving health care for the child in the past  months (see fi gure ). Th e number one barrier reported by child custodians was that the wait list was too long (%). Next, participants reported being unable to arrange transportation (.%), that they could not aﬀ ord transportation (%), that a doctor was not available (.%), that a nurse was not available (.%) and that they could not aﬀ ord direct cost of care/services (.%). Th e full list of barriers to receiving health care for children are displayed in the fi gure below.

When asked if their child had participated in any Aboriginal community programs, % said they had been to an Ontario Early Years Centre, % reported that their child had participated in the Niwasa Aboriginal Head Start Program and % reported that their child had participated in Aboriginal Health Babies or Health Children Program. For each of the other programs listed, the numbers were very small. A total of % reported that their child had not participated in any of the community programs listed (see fi gure ).

child development When adults were asked if they had any concern about the progress of their child’s physical, mental, emotional, spiritual and/or social development, % answered yes. Among those who indicated they had concern, when asked to specify the area of development they were concerned about, the following results emerged: % reported OUR HEALTH COUNTS 75 40.0% 60.0% 54.6% 31.7% 30.0% 50.0% 22.5% 40.0% 18.3% 20.0% 15.3% 26.6% 15.1% 15.1% 30.0% 13.8% 8.7% 8.5% 8.3% 8.1% 20.0% 13.9% 5.8% 10.0% 7.0% 5.8% 10.0% 4.0% 2.5% 2.0% 1.4% 1.4% 0.4% 0.0% 0.0% Other None of the Above None of the Nurse not available Waiting list too long Waiting Doctor not available Not covered by NIHB Not covered Ontario Early Years Centre Years Ontario Early at Hamilton Regional Indian Centre at Hamilton Regional Indian Centre Difficulty getting Traditional Care getting Traditional Difficulty Could not afford Childcare costs Childcare Could not afford Unable to arrange Transportation Unable to arrange Action Program for Children Program at Ontario Native Women' Association at Ontario Native Women' atOntario Native Women's Association atOntario Native Women's Prior approval of NIHB was denied Prior approval Niwasa Aboriginal Head Start Program Aboriginal Head Niwasa Felt Health Provider was inadequate Felt Health Provider Could not afford Transportation costs Transportation Could not afford Chose not to see Health Care Provider Chose not to see Health Care Hamilton's Regional Indian Centre's Canada Aboriginal FASD and Child Nutrition Institute Aboriginal FASD and Child Nutrition Institute Aboriginal FASD Niwasa Toy Lending and Resource Program Toy Niwasa Could not afford direct costs of Care/Services direct Could not afford Aboriginal Healthy Babies, Healthy Children Program Aboriginal Healthy Babies, Healthy Children Program Figure 38. Participation of child Aboriginal community Programs for First nations children, children, nations First for Programs community Aboriginal child of 38. Participation Figure our Health counts Hamilton Regional Indian Centre's AKWE:GO Program Hamilton Regional Indian Centre's Figure Barriers 37. to receiving Health care for child in Past months 12 for First nations children, our Health counts that this was a concern about their child’s physical health, % were concerned about emotional development, % were concerned about the child’s speech/language, % were concerned about the child’s mental/intellectual development, and % were concerned about social development (see fi gure ).

70.0%

76 60.0% 56.2% 54.0%

COUNTS HEALTH OUR 50.0% 41.3% 40.0% 38.2%

30.0% 25.1%

20.0%

10.0%

0.0% Physical Mental / Speech / Emotional Social Intellectual Language

Figure 39. Area of concern for child’s development for First nations children, our Health counts OUR HEALTH COUNTS 77 PolicY urBAn For HeAltH PrActice is now able to to Database Aboriginal able Health project isUrban now Counts – Health introduction Th e rst health time,FirstNations data clearlydemonstrates that alarming the fi for provide O u r inequities in areas as such services and housing, income, marginalized income low for disease,chronic health carepopulations, access, culture-based programmes and services, health and self-determination, empowerment research and system planning, fi ndings alsoindicate Nations thatthe First project’s e and child and family health. Th Hamilton community maintain remarkable cultural resilience and hope, continuity, alarmingsuch of inlight inequities. the With this urban new Aboriginal health data and health measures, all health in together stakeholders will work to be able now intersectoral partnerships the health improve to status, access services, to and ectingparticipation urban in Aboriginal health planning in Ontario. people processes aﬀ the drive to of health systemicIn order policy and changes the towards improvement Th rough the development of a sustainableof a roughinfrastructure development the partnerships,of data Th urban between core four protocols/agreements of and management governance Aboriginal provincial organizations, Research the Inner City on Centre for Health – Care, Institute theSaint Hospital, Ministry for Michael’s Health of and Long-Term Clinical and Evaluative Services and the Counts – Hamilton Our the Health community, Database Aboriginal Health project hasUrban successfully established a First Nations HealthUrban Database. With limited urban health public data Ontario’s available for populations, theFirst Nations increasing disparities in social determinants health of for urban Aboriginal and peoples, jurisdictional policy complexities, makers in small regions, and provincial and and federal urban governments Aboriginal stakeholders were restricted in their abilities address to inequitable healthsuch challenges. imPlicAtions ABoriginAl And social status of urban Aboriginal people living in Ontario, the development of an urban Aboriginal specifi c, cultural based community driven strategy is essential. Such a strategy would incorporate the urban Aboriginal community’s leadership and governance structures in all health planning, programme and service development and resource allocation at a local, provincial and federal level.

Immediate action is required by local, provincial and federal governments to re-establish 78 key relationships with urban Aboriginal local and provincial organizations to address the policy actions required to address the devastating health and social inequities and COUNTS HEALTH OUR disparities experienced by urban Aboriginal people today. Unresolved jurisdictional accountabilities and systemic disparities in access to care for Aboriginal people are far too oft en illustrated by the fate of Aboriginal children. Such cases should not exist, as in the example of Jordan River Anderson of Norway House Cree Nation, a chronically ill and disabled First Nations child, who died far away from his family, because of jurisdictional conﬂ icts between the federal and provincial government, over the cost of his home health care. In honour of Jordan River Anderson, the Jordan’s Principle was established with the goal of ensuring equitable access to government services for First Nations children. Jordan’s Principle is consistent with government obligations set out in the United Nations Convention on the Rights of the Child, the Charter of Rights and Freedoms and many federal, provincial and territorial child focused statutes. While Jordan’s Principle arose from a jurisdictional conﬂ ict over on-reserve health care costs, the principle is relevant and required with respect to ensuring timely and equitable access to health care for all Aboriginal children, including Aboriginal children living in urban areas in Ontario who are oft en also left behind due to debates between municipal, provincial and federal stakeholders regarding accountability. To date, no provincial/ territorial government has fully implemented Jordan’s Principle.²⁸

Th e Royal Commission on Aboriginal Peoples identifi ed the need to negotiate and reconcile Aboriginal governments within Canada as one key step towards resolving the concerns of Aboriginal peoples and building a new relationship between Aboriginal and non-Aboriginal peoples based on mutual respect, recognition and sharing.²⁹ Th e establishment of a commitment, by all levels of governments to establish collaborative policies and planned principled approaches, to work across local, regional and national jurisdictions with urban Aboriginal health stakeholders will ensure that all governments meets their judicial obligations and Aboriginal people in Canada are aﬀ orded their full human rights as set out in the United Nations Declaration on the Rights of Indigenous People³⁰ and the  Constitution Act of Canada³¹ and international law.

Th e First Nations Hamilton community project participants have demonstrated their resilience in the light of extreme adversity in many areas of the social determinants of OUR HEALTH COUNTS 79 : recommendAtions study identifi ed striking livingof residents poverty levels FirstNations in among study identifi OHC Housing, services for low income and marginalized Populations, and and Populations, marginalized and income low services for Housing, Health: of determinants social the in inequities Addressing Th at provincial governments that have responsibility for housingresponsibility provincialsupports at for and have governments that Th (Ministry Care and Health the of Ministry and Long Term Community of and Social Services) with engage urban Aboriginal communities and organizations the for purpose ensuring of that the communities priorities and critical needs in the areas of rental housing, supportive and transitionalordable housing, and assisted home aﬀ areownership addressed in accordance with human rights legislation. PolicY 1. Housing: Th ese fi resulted have ndingsfollowing in the policy recommendations intheareas of ese Th housing, services and marginalized income low for and populations addressing inequities in the social determinants health: of Th is povertyby marked accompaniedis challenges accessin housingfood to and Th living population the of First Nations example, % security. For in Hamilton moved had three in the more moved least had of or population theat once past %  years and over times in the living population past the  years. of First Nations Furthermore, in % Hamilton reported in being transition, homeless, living or in any other type dwelling of in persons Hamilton listed. First Nations of not reported that In .% addition, they live general Canadian % of a rate to compared conditions, population. Finally, in crowded community First in Nations of members Hamilton important give up to had % things the costs meet housing of First to and Nations buying only in % order groceries) (i.e. always thepopulation enough of had kinds that food they of wanted eat. to Th e living persons the of First Nations Hamilton. example, in .% Hamilton For earn less in population the Hamiltonthan of First per year Nations and lives in % , the quartile income the of generallowest Hamilton % to neighbourhoods compared population. Counts – Urban AboriginalUrban health through and now their participation in the Health Counts – Database canHealth illustrate, project we now through established a newly First healthNations database, cleardata and measures making towards strategic directions the of health and social thetowards improvement status urban of Aboriginal people in Ontario. Services for Low Income and Marginalized Populations: 2. Th at all local and provincial agencies that oﬀ er services to signifi cant numbers of low income/marginalized urban Aboriginal populations collaborate directly with urban Aboriginal agencies and organizations and develop and implement mandatory Aboriginal cultural diversity training.

Addressing Inequities in the Social Determinants of Health: 80 3. Th at provincial governments engage with urban Aboriginal communities and organizations for the purpose of establishing priorities, resource and funding COUNTS HEALTH OUR allocations and action plans to address the critical inequities in all economic and social conditions aﬀ ecting Aboriginal health including poverty, homelessness, food insecurity, education, employment, health access, gender equality and social safety.

chronic disease and disability: Another key fi nding of the OHC study was that First Nations people living in Hamilton are living with a disproportionate burden of chronic disease and disability. For example, the rate of diabetes among the adult First Nations Hamilton population is .%, more than three times the rate among the general Hamilton population, despite a much younger age demographic of the First Nations Hamilton population. Furthermore, the prevalence rate of high blood pressure among the adult First Nations population in Hamilton was .% (compared to a general Hamilton rate of .%) ; the prevalence rate of arthritis was .% (compared to a general Hamilton rate of .%); and the prevalence rate of Hepatitis C was .% (compared to an estimated Ontario prevalence rate of .%). In addition, % of the total adult population and over three quarters (%) of person over  years reported oft en or sometimes experiencing limitations in the kinds or amount of activity done at home, work or otherwise because of a physical or mental condition or health problem. Finally, % of all adults reported fair or poor mental health and % reported that they had been told by a health care provider that they had a psychological and/or mental health disorder. Th ese fi ndings have led to the following policy recommendation regarding chronic disease and disability:

4. Th at municipal and provincial governments commit to long term resources and funding allocations and engages with urban Aboriginal communities and organizations for the purposes of establishing priorities, preventative action and promotion plans towards the reduction of the burden of chronic disease and disability in the urban Aboriginal community.

Health care Access: Th eOHC study fi ndings are compelling with respect to the need to urgently address barriers in accessing health care services across the spectrum of preventative, primary, OUR HEALTH COUNTS 81 study measures pre-survey concept mapping study highlighted mapping pre-survey concept the that idea “Our Th at municipal,at provincial adequate of federalensure provision governments and the Th funding the to urban community and organizations directed the towards ective, community based, long-term and expansion culturally of development refl Aboriginal specific services, cultural safety, and Aboriginal self- delivery Health care determination of Th at municipal,at provincial federalengage withgovernments and urbanAboriginal Th communities and organizations the purposes for eliminating of barriers in access to communityequitable health care, department emergency services and inpatient hospital services conditions. and acute non-acute for 6. Aboriginal Specifi c Services for Family Treatment, Mental Health and Maternal Health Health Mental c Services Treatment, Family for Aboriginal Specifi indicate a strong sense of First Nations identity among the First Nations population living population theidentity among indicate FirstNations First sense a strong Nations of in Hamilton as well as pass desire a strong to culture and language the to next on e OHC generation. Th Health and Dedicated Deserves Care” respectful and Appropriate the subsequent health assessment survey Aboriginal more the documented desire for health and care workers andcantbarriers “lack trust “prejudice” of accessingin and discrimination” as signifi ndingsadvancewe following the policyrecommendations: care. In these to response fi Despite the challengesDespite living described people First Nations in above, Hamilton remarkable culturaldemonstrate continuity though and resilience. resources and Even programming Aboriginal for cultural programming in Hamilton been extremely have cant, OHC limited date and to the been signifi impacts colonization have of 5. and tertiaryin population the Hamilton of care. First example,Nations % rates For barriersed long included their access of health to level care Identifi as fair poor. or directord costs (%), aff to able not transportation lack of (%), waiting lists (%), Striking and trust lack of in health care (%). provider available (%), not doctor in admission Hamilton First in room rates between Nations erences emergency for diff the to generalcompared Hamilton and both Ontario and acute for populations non- illnessesacute are linked participant by narrative the to barriers access listed to above of FirstNations the y percent and primary timelyof preventative health care. Fift the inpopulation past Hamilton over visit room reported the least to at one emergency the of Hamilton the % to of and Ontario compared % problems acute  years for in population the Hamilton of First Nations reported more  or andpopulation .% the of visits and room .% inemergency the .% previous  years to compared Hamilton Notwithstanding and Ontario respectively. populations this heavy use of services, room emergency the of Hamilton the rated population % First Nations fifollowing to led the have ndings ese quality care the of emergency Th as fair poor. or policy recommendation regarding health care access: traditional family treatment centres, urban Aboriginal child, youth and adult mental health funded strategies and maternal health, programs and services.

Cultural Safety: 7. Th at municipal, provincial and federal governments and health stakeholders develop and initiate policies towards the implementation of cultural competency and/ or cultural safety programs that are designed and delivered by Aboriginal people that 82 includes the recognition and validation of Aboriginal worldviews and full inclusion of Aboriginal healers, medicine people, midwives, community counselors and health COUNTS HEALTH OUR care workers in all collaborative eﬀ orts with western medicine.

Aboriginal Self-Determination of Health Care Delivery: 8. Th at municipal, provincial and federal governments recognize and validate the Aboriginal cultural worldviews (that encompasses the physical, mental, emotional, spiritual, and social well-being of Aboriginal individuals and communities) and that self-determination is fundamental and thus Aboriginal people must have full involvement and choice in all aspects of health care delivery, including governance, research, planning and development, implementation and evaluation.

children’s Health: Parents and caregivers of First Nations children in Hamilton highly value the transmission of First Nations culture and language to the next generation. For example, the OHC study found that % of parents and caregivers felt it was very or somewhat important for their child to learn a First Nations language and % of parents and caregivers felt that traditional cultural events were very or somewhat important in their child’s life.

Additional key study fi ndings regarding First Nations children’s health included the burden of chronic illness facing First Nations children in Hamilton; concerns regarding child development; and long waiting lists as a barrier to accessing health care. Asthma and allergies were the most commonly reported chronic conditions. Rates of asthma were twice as high for Hamilton First Nations children compared to general Canadian rates for children. Rates of chronic ear infections were also high. Twenty-two percent of parents and caregivers were concerned about their child’s development. While % of participants indicated that their child had seen a family doctor, general practitioner or pediatrician in the past  months (compared to % for the general Canadian population aged - years), there were a signifi cant number of reported barriers to accessing care. Th e number one barrier to receiving health care reported by child custodians was that the wait list was too long. In response to these fi ndings, we recommend the following policies: OUR HEALTH COUNTS 83 ) allowed for successful) allowed for RDS ) First Nations cohort measures. cohort ) First Nations ICES reseArcH: Th at municipalat partnershipprovincialin work and governments with urban Th Aboriginal and organizations agencies ensure that to urban Aboriginal children are their accorded human rights live in to and healthy communities homes and attend in healthy programs/schools exacerbate health chronic day that environments not do as such asthmaconditions and allergies. Th at municipalat provincialin collaboration work and withgovernments urban Th Aboriginal and organizations agencies urban reduce to Aboriginal health children’s status inequities eliminating by barriers urban to Aboriginal children accessing regular primary health waiting care, long reducing lists and responding the to increased health of prevalence as such asthma conditions in the urban Aboriginal child population with customized culturally appropriate primary health care programming. Th at municipal at provincial and boards,governments, including school recognize the Th importance term and funding commit of long andAboriginal resources towards language andchildren’s cultural programmingin collaboration with urban Aboriginal organizations and agencies. Completion of a community concept mapping project that identifi ed First Nations FirstNations ed that identifi project a community of mapping concept Completion health c domains. specifi a customized of and adult child First and Nations implementation Development health needs assessment survey which was administered adults behalf and on  to living community children  in members) the (total city Hamilton. of Successful linkage recruited theto cohort of Institute First Clinical Nations of Evaluative Sciences database. Statistically Driven Sampling ( Respondent rigorous Collaborative production of this project report. derivation of population based population derivation of estimates survey of and Institute Clinical for Evaluative Sciences ( • • • • • Urban First Nations organizations First Nations Urban and community in members Hamilton successfully partnered with provincial Aboriginal organizations and academic researchers in the collection, analysis management, governance, their and of documentation own urban healthFirst Nations database. Successful included: research outcomes 11. 10. 9. Th e Our Health Counts research project demonstrates that research can be done by Aboriginal people for Aboriginal community benefi t. As a result, we put forward the following policy recommendation regarding research:

12. Th at municipal, provincial and federal governments and urban Aboriginal organizations recognize the health status inequities and disparities of urban Aboriginal peoples living in the city of Hamilton and across the province and 84 advocate for funded urban Aboriginal specifi c applied health services research. COUNTS HEALTH OUR

sYstem PlAnning:

As highlighted in the introduction of this section, all of the above policy recommendations are prefaced on the need for the re-establishment of key relationships between municipal, provincial, and federal governments and urban Aboriginal local and provincial organizations. In particular there is a need to ensure that unresolved jurisdictional accountabilities do not continue to perpetuate unnecessary and resolvable health disparities for urban Aboriginal peoples. Such pressing and signifi cant health inequities are unacceptable given the relative aﬄ uence of Ontario and Canada globally. To address these devastating health and social inequities and disparities experienced by urban Aboriginal people today these fi nal policy actions are required:

13. Th at municipal, provincial and federal governments support interagency collaboration and cooperation amongst urban Aboriginal service providers towards the design and delivery of services and identifi cation of funding and research opportunities.

14. Th at municipal, provincial and federal governments collaborate with urban Aboriginal agencies and organizations and gain knowledge of the urban Aboriginal health determinants and health inequities and further acknowledge the urban Aboriginal communities right to self-determination in the control of planning, design, development and delivery of culturally specifi c health services, programs and policy. OUR HEALTH COUNTS 85 ,  . Ottawa: RCAP ] Ottawa : Statistics Canada,  ROM - CIHR,  CD s/research/InfoNote_Aboriginal.pdf [ PDF Knowledge Translation Casebook – Moving Knowledge Translation Casebook – - IPPH ., Sabin K., Saidel Implementation and T. Analysis Respondent of . Concept Mappingousand Planning for Oaks, and Evaluation. Th WMK ) /: Results) /: Adults, for and Children Youth Living in First Nations RHS . Variance Estimation, Design Eﬀ . Varianceects, Estimation, and Sample Size Design Calculations Eﬀ Respondent-Driven for Guidelines Health for Research Involving Aboriginal Peoples. CIHR, Ottawa: . MJ . CIHR Sampling. Journal Urban of Health: Bulletin Academy Medicine, of the of New York ; ():- Communities. Ottawa: First Nations Centre;  Translation in an Urban Inuit Community. CIHR population and public health knowledge into action. Ottawa – http://www.cihr-irsc.gc.ca/e/documents/ethics_aboriginal_guidelines_e.pdf (accessed June th, ) Prevention Program.  Driven Sampling: Lessons from the Field. Journal Urban of Health: Bulletin Academy the of New York Medicine,of ; ():- First Nation, Tungasuvvingat Inuit Family Resource Centre.Indigenous Knowledge Translation: Baseline Findings in a Qualitative Study the of ree PathwaysIndigenous Health of Knowledge in Th Communities in Canada. Journal Health of Promotion Practice press) (in Health Survey ( CIHR Information, Policy and Integration Unit, OntarioMinistry Community of and Social Services. Aboriginal Population,  Census Data Release. Info Accessed Notes,  (March). ; April Volume th, : http://www.trilliumfoundation.org/User/Docs/ California: Sage Publications,   Smylie Janet, Kelly McShane, Tungasuvvingat Inuit Family Resource Centre. Understanding Knowledge  Kahnawake Schools Diabetes Prevention Project. Code Research of Ethics. Kahnawake Schools Diabetes  Kane M and Trochim  Salganik  Statistics Canada.  Census: Aboriginal Peoples Canada. of  Smylie J., Nili Kaplan-Myrth, KellyOttawa McShane, Council, Métis Nation Pikwakanagan Ontario of –  First Nations Centre, National Aboriginal Health Organization. First Nations Regional Longitudinal  Royal Commission Aboriginal on Peoples. Appendix Guidelines Research B: Ethical for   reFerences   Abdul-Quader A., Heckathorn DD  McKnight C., Des Jarlais D., Bramson H., Tower L., Abdul-Quader A., Nemeth C., Heckathorn DD. Respondent-Driven Sampling in Study of Drug Users in New York City: Notes from the Field. Journal of Urban Health: Bulletin of the New York Academy of Medicine, ; ():-

 Heckathorn D. Respondent-driven sampling II: Deriving Valid Population Estimates from Chain referral Samples of Hidden Populations. Social Problems , ;- ()

 Statistics Canada. Community Profi les. Ottawa, ON: Statistics Canada. . Accessed April th,: http://www.statcan.ca/census-recensement//dp-pd/prof/-/details/ 86 Page.cfm?Lang=E&Geo=CSD&Code=&Geo=PR&Code=&Data=Count&SearchText= hamilton&SearchType=Contains&SearchPR=&B=All&Custom= COUNTS HEALTH OUR

 Social Policy and Research Council of Hamilton, Internal Data

 Indian and Northern Aﬀ airs Canada. Fact Sheet – Urban Aboriginal Population in Canada. Ottawa, ON: INAC . Accessed April th, : http://ainc-inac.gc.ca/ai/ofi /uas/fs/index-eng.asp

 Statistics Canada. Aboriginal Peoples in Canada in : Inuit, Métis, and First Nations,  Census. . Ottawa: Ministry of Industry. Statistics Canada catalogue number --XIE Accessed April th : http://www.statcan.ca/census-recensement//as-sa/-/pdf/--XIE.pdf

 Social Planning Network of Ontario. Ontario’s Social Landscape: Socio-demographic trends and conditions in communities across the province. . Accessed February  : http://www.spno.ca/ images/stories/pdf/reports/ontario-social-landscape-.pdf

 First Nations Information Governance Committee. First Nations Regional Longitudinal Health Survey (RHS) /: Results for Adults, Youth and Children Living in First Nations Communities, Second Edition. Ottawa: Assembly of First Nations; . Accessed February th, : http://www.rhs-ers.ca/english/pdf/rhs-reports/rhs--technicalreport-afn.pdf

 Neyer JR et al. Prevalence of Stroke – United States . MMWR. ; ():-. Accessed April th, : http://www.cdc.gov/mmwr/preview/mmwrhtml/mma.htm

 Remis R. Modelling the Incidence and Prevalence of Hepatitis C Infection and its Sequelae in Canada,  Final Report. Ottawa: Community Acquired Infections Division Centre for Communicable Diseases and Infection Control Infectious Disease and Emergency Preparedness Branch Public Health Agency of Canada, . Accessed April th,  : http://www.phac-aspc.gc.ca/sti-its-surv-epi/model/index-eng.phpt

 Phinney, J. Th e Multi-group Ethnic Identity Measure: A new scale for use with adolescents and young adults from diverse groups. Journal of Adolescent Research, , -.

 Krieger N, Smith K, Naishadham D, Hartman C, Barbeau EM. Experiences of discrimination: validity and reliability of a self-report measure for population health research on racism and health. Social Science and Medicine ;():-. Epub  Apr .

 Statistics Canada. Aboriginal Population Profi le. Ottawa, ON, . Accessed April th ,: http://www.statcan.ca/english/census/data/profi les/aboriginal/Index.cfm?Lang=E OUR HEALTH COUNTS 87 Royal Commission Aboriginal on Peoples. Ottawa: Minister and Supply of Services,  Geneva: United Nations. Accessed March th, i/en/drip.html. : http://www.un.org/esa/socdev/unpfi http://www.constitutionofcanada.com/constitution-act-.shtml Smylie J, Adomako P (eds). IndigenousSmylie Adomako J, Children’s P (eds). Health Report: Health Assessment in Action. Toronto: Saint Michael’s Hospital, . Human Resources and Social Development Canada, Public Health Agency Canada of and Indian and airsGovernment Canada.Northern Canada of Being Children Well Aﬀ report Canada’s of Young . – http://www.socialunion.gc.ca/well_being//en/page.shtml : th, April Accessed Ottawa: . JanetDr. Smylie, February  ResolvingPrinciple To Jurisdictional ecting Services Disputes Aﬀ to First Nations Children. Ottawa, . Accessed March th, : http://www.fncfcs.com/jordans-principle Highlights from the report of the   United Nations General Assembly. United Nations Declaration the on Rights Indigenous of Peoples.  Canada. Constitution Act Accessed . March th, :   McShane Health K, Smylie Adomako J, First of P. Nations, Inuit, and Métis Children in Canada In:   Statistics Canada, National Longitudinal Survey Children of special /, and data Youth run for  First Nations Child and Family Caring Society Canada. of Joint Declaration Support of Jordan’s for  Canada. Royal Commission Aboriginal on Peoples.People to people, nation to nation:

OUR HEALTH COUNTS 89

and AHAC research team to : processes, including the anticipates this research communities and their policy, s t a ﬀ ; PrinciPAls

and AHAC and AHAC to enhance capacity and leadership in program and service policy making, and AHAC and AHAC . OFIFC including the acknowledgement OFIFC of the parties; the planning, delivery, and evaluation. the community of involvement representatives as this project; analysis and dissemination survey of results. scientifi cally and scientifi culturally validated; Support OFIFC specifi c principles c of self-determinedspecifi data structures each of party; active research team members in all aspects of a series community-based of health data use management; responsibilities, mandates, and accountability of OFIFC Respect the individual and collective privacy rights Recognize the value and potential research of that is Recognize the value capacity of building all at levels; Recognize the complementary and distinct expertise, workshops Maintain mutual respect and accountability between Ensure the highest standards research of ethics, Agreement b. project will assist program and healthservice collaborators in the area of a. and AHAC among OFIFC analysis, and application through: conduct thisnes collaborative the research. defi It opportunity(ies) to develop research capacity OFIFC at desire Janet Dr. of Smylie and the OHC First Nation urban health information collection, r e s e A r c H • • • • • • • smH )/ Michael’s Michael’s )/ this day : : ”) ) . Th is agreement will . Th DUPLICATE ) FOLLOWS IN AS and and , as well as acknowledging the ( Agreement Between

and AHAC (//) (//) MADE Centre ( Hospital (“ oF

”: Development and Application of a WITNESSETH and AHAC Urban Aboriginal People in Ontario AGREEMENT THIS PurPose Project: “Our Health Counts”: Development and Ontario Federation Indian of Friendship Centres De dwa da dehs ney>s – Aboriginal Health Access Centre Research for Inner on City ( Research, Data, Statistics, and Publication Agreement Application of a Baseline Population Health Database for languages, knowledge, values, and rights to self- principles Aboriginal of collective and self-determined agreement. Th e agreement supports agreement. the information Th also provide a framework the for use data of collected needs OFIFC of Our Health Counts determination of OFIFC during is theagreement Research supports Project. Th fi nancial datais a not is management and governance. Th communitY— Baseline Population Health Database for Urban Agreement APPendiX A Th e purpose e of this agreement is to Th ensure that project the Aboriginal People in Ontario is respectful to the cultures, “ directed by OFIFC and AHAC to be involved. Any ProJect descriPtion (see page 91) presentations, workshops or conferences where SMH AGREEMENT: Project Team members wish to attend for purposes AND WHEREAS OFIFC and AHAC are developing a policy of discussing Our Health Counts shall involve OFIFC framework of principles for data collection, self- and AHAC representatives. determined data management, analysis, and 6. Th eOFIFC and AHAC Research Project dissemination; Representative(s) shall be able to provide a dissenting opinion of fi ndings. Any dissenting AND WHEREAS the OFIFC and AHAC principles will be opinions will be included as part of the overall articulated in a written format as a result of the gap in report in all publications and/or pertinent published 90 legislation applicable to OFIFC and AHAC clients and staﬀ or produced materials.

COUNTS HEALTH OUR with respect to the collective ownership and possession of 7. Utilizing the data gathered from this research data, statistics, and information; project by CRICH/SMH for secondary publishing will require specifi c written permission of OFIFC and AND WHEREAS OFIFC and AHAC wish to use this AHAC. CRICH/SMH is to protect the data and act as opportunity to build research capacity and/or provide stewards of this data on behalf of the rightful owner. research opportunities to its members and staﬀ by 8. OFIFC and AHAC are the rightful owners of all data working in collaboration with SMH and ICES; collected from the Hamilton First Nation community. CRICH/SMH will require OFIFC and AND WHEREAS OFIFC and AHAC would like to maintain a AHAC consent to maintain a copy of the data set with positive and good faith relationship with SMH and ICES; Drs. Smylie’s databank. CRICH/SMH will be required to protect the data from unauthorized use and act as NOW THEREFORE CRICH/SMH covenants and agrees as stewards on behalf of the rightful owner. OFIFC and follows for the consideration of the sum of One (.) AHAC have provided prior consent to Dr. Janet dollar paid to CRICH/SMH by OFIFC and AHAC, and other Smylie of the Centre for Research on Inner City valuable consideration, the receipt and suﬃ ciency of Health at St. Michael’s Hospital to maintain a copy which is hereby acknowledged; of the data sets generated by this project in 3. SMH and ICES acknowledges that any and all data accordance with the Study Protocol reviewed and collected by OFIFC and AHAC as a result of this approved by CRICH/SMH research ethics board and research project is rightfully owned by OFIFC and OFIFC and AHAC management for the purpose of AHAC on behalf of the Hamilton First Nation publishing research reports as set out herein and community. Utilization of the data collected for having access to a copy of the source data of such the purpose and by the means outlined in the research reports research proposal is acknowledged and granted by 9. Th is agreement is in force from the date of the last OFIFC and AHAC to CRICH/SMH in accordance with authorizing signature and CRICH/SMH agrees that the terms and conditions contained in this this agreement is irrevocable and shall ensure to the agreement. benefi t of and be binding upon CRICH/SMH its 4. OFIFC and AHAC agree to undertake the research employees, administrators and legal and personal roles, responsibilities and activities described in representatives. Appendix B. Funding for these activities will be 10. CRICH/SMH represents that they understand and provided by Ontario Federation of Indian agree to the terms contained within this agreement Friendship Centres as per their agreement with and such performance will not be unreasonably AHAC. withheld. 5. SMH and ICES agrees to the inclusion of project team 11. CRICH/SMH declares that it has been given the representative(s) from OFIFC and AHAC as co- opportunity to obtain independent legal advice with investigators and they will be acknowledged in any respect to the details of the terms evidenced by this and all publications, reports, documents, or other Agreement and confi rms that they are executing this written material from which this data is utilized. Th e Agreement freely and voluntarily. representative(s) from OFIFC and AHAC will be 12. CRICH/SMH will provide OFIFC and AHAC the included by CRICH/SMH in the complete research opportunity for review of any approved research process or to the level the representative(s) is reports before the submission of reports for OUR HEALTH COUNTS 91  Main St. East. Hamilton, ON descriPtion

: Ontario’s healthOntario’s information system in Authorized Signature Authorized ProJect Background: parties shall constitute the fully executed agreement. Copies collectively bearing the signatures all of Th is agreement may be executed in counterpart.Th infants, children, and families. Smylie Dr. believes that information. As a result her of experiences providing local, small region, and provincial policy makers. health services and programs may be improved by health researcher with an interest in improving health services and programs in First Nations Inuit and Métis managers, and policy makers with useful and relevant medical care to young Aboriginal families, she is De dwa de Centre dehs ney>s Health Aboriginal relevant urban Aboriginal population health data to enhancing communities providing by health workers, program especially interested in the health and wellbeing of Name and Title: Title: and Name Name and Title: Title: and Name order to provideorder accessible, useful, and culturally Dr. JanetDr. Smylie is a Métis family doctor and public Dr. Janet Smylie Janet Dr. Ontario Federation of Indian Friendship Centres Friendship Indian of Federation Ontario For, Dr. Arthur S. Slutsky Arthur Dr. For, De dwa de dehs ney>s Aboriginal Health Centre: Denis Compton LM K . ’ ’ . Authorized Signature Authorized OFIFC 18. AHAC

, / will REB , and CRICH and AHAC confi rm their confi agree to perform will be provided  SMH SMH / / and AHAC and AHAC , the Releasor, confi rms that if , thethey Releasor, confi , and CRICH , and CRICH : and Drs. Smylie cannot agree the on ON SMH / and AHAC and AHAC and AHAC agree to follow applicable privacy laws and be invited to write an editorial to accompany the limitation, the Tri-Council Policy Statement, transmit this Agreement facsimile by such or device, that the reproduction signatures of facsimile by or the research project. OFIFC time to time their respective study activities in accordance with the research proposal as the approved by SMH participant consent forms, and all applicable laws, promotion, advertisement, other or public publication. OFIFC a complaint about breach privacy of a copy this of Agreement bearing original signatures and the Canadian Institutes Health of Research announcement, whether written oral, or that accompanying manuscript. In the event that OFIFC and AHAC such similar device will be treated as bindingas if forthwith by courier. name is to be used regulations and to notify each other if either receives respect the for privacy individual of participants in regulations and guidelines, including without report to be submitted publication. for Notices to each Party shall be sent to: Neither party shall use thename the of other party originals and undertakes to provide all parties with content of the of content written report, OFIFC or its staﬀ in any publication, news release, itsor staﬀ endorses services, organizations products, or Involving Aboriginal all People”, as amended from without the prior written consent the of party whose weeks to review the research results and Guidelines, “Guidelines Healthfor Research MC NMC SMH CRICH Toronto, ON Toronto, OFIFC OFIFC OFIFC “Ethical Conduct Research for Involving Humans” Ontario Federation Indian of Friendship Centre Sylvia Maracle Toronto, St. Front East  Richmond  Street East MA E 17. 16. 15. 14. 13. key Adaptations: policy, program and health service collaborators in In order to meet our goal of improving Ontario’s the area of Aboriginal health information collection, health information system in order to provide analysis, and application through: a. the involvement accessible, useful, and culturally relevant urban of community representatives as active research Aboriginal population health data to local, small team members in all aspects of this project; b: a region, and provincial policy makers, we have series of community-based health data use designed several key adaptations, which will be workshops. implemented and evaluated during this two year 5. To provide a scientifi cally excellent and culturally adaptation program. Th ese include: relevant training and mentorship environment for 92 1. Community-based participatory action approaches Aboriginal health researchers at the to health data collection undergraduate, graduate, post-doctoral and new

COUNTS HEALTH OUR 2. Respondent driven sampling investigator level. 3. Longitudinal linkages to the ICES database Knowledge Dissemination, Application, and Contribution 4. Respectful health assessment survey to Future Projects 5. Data governance and management protocols 6. To support community-based, small region, provincial, and federal uptake and application of goal: health data generated through - above to First To work with provincial urban First Nations, Inuit, Nations, Inuit, and Métis health policies, programs, and Métis organizations and the Ontario Ministry of and services. Th is will include the establishment of Health and Long Term Care to adapt Ontario’s health an Aboriginal health data users group, which will information collection system so that it provides have open membership and allow diverse accessible, useful, and culturally relevant urban stakeholders input and access to data generated by Aboriginal population health data to local, small the project. region, provincial and federal policy makers. 7. To build on the outcomes of this study to design future longitudinal health studies in partnership objectives: with First Nations, Inuit, and Métis governing/ Formalizing Intersectoral Partnerships and Establishing organizational stakeholders as well as additional Priority Measures strategies to improve the quality of First Nations, 1. To formalize partnerships between the four core Inuit, and Métis health data in Ontario. urban Aboriginal provincial organizations, the 8. To share study results and adaptation processes with multidisciplinary academic team, the Ontario First Nations, Inuit, and Métis stakeholders in other Ministry of Health and Long Term Care (MOHLTC), provinces and territories and thereby contribute to and the Institute for Clinical Evaluative Sciences the development of urban Aboriginal health data (ICES) for this project through research agreements enhancement strategies. and data management/governance protocols. Th is will include the establishment of an Aboriginal team: Health Data Governance Council comprised of the Th is adaptation program brings together representatives four core urban Aboriginal provincial organizations. from Ontario’s four key urban Aboriginal health policy 2. To confi rm priority health domains and best and service delivery stakeholder organizations (Ontario indicators for each domain through these Federation of Indian Friendship Centres (OFIFC), Métis partnerships. Nation of Ontario (MNO), Tungasuvvingat Inuit (TI), Knowledge Development through Establishment of a Ontario Native Women’s Association (ONWA) and Population Health Data Base multidisciplinary biomedical and social science 3. To generate new health data sets reﬂ ective of these academics from fi ve diﬀ erent institutions (Centre for priorities for a sample of urban First Nations, Inuit, Research on Inner City Health (CRICH) - St. Michael’s and Métis adults and children using respondent Hospital; University of Toronto – Department of Public driven sampling, secure data linkage with ICES and a Health Sciences; ICES; University of Manitoba; and the respectful health assessment questionnaire. Indigenous Peoples Health Research Development Capacity Building, Training and Mentoring Program). Th e four urban Aboriginal organizations will 4. To strengthen capacity and leadership among work together as a coalition, with OFIFC taking the lead as Ontario’s urban Aboriginal communities and their signatory and acting as delivery agent for OFIFC, MNO, OUR HEALTH COUNTS 93 ), TI ), Métis), ) ), Donna), Lyons OFIFC TI ONWA ) ), Tungasuvvingat), Inuit ( ONWA ), Connie), Siedule ( MNO OFIFC ), Marianne), Borg ( MNO Sylvia Maracle ( Nation of Ontario ( Federation Indian of Friendship Centres ( McShane, Roseanne Nisenbaum, Dionne Gesink Law, Cornelia Wieman, Sanjeev Sridharan Ontario Native Women’s AssociationOntario ( Native Women’s O’Campo, Rick Glazier, Marcia Anderson, Kelly ( Core Aboriginal Organizational Ontario Partners: Aboriginal Core Aboriginal Organizational Research Members: Team Academic Research Members: Team Janet Smylie, Pat

and MNO since . Th e since . Th , supporting the interests and and CRICH biostatistics, psychiatry, internal medicine, and psychology. the research director and the (Smylie) core Aboriginal have dedicatedhave their careers to this area. and ONWA medicine, epidemiology, health database research, multidisciplinary academic research team brings together on existingon longstanding research partnerships between organizational partners Smylie –Dr. has been engaged in community based partnership research with TI community based Aboriginal health research and several experts from the disciplines public of health, family fi nancing for Tungasuvvingat Inuit. ThTungasuvvingat e nancingteam for will build Inuit. fi (Ottawa Council) since  and OFIFC All the of academic team members experience have in 94 APPendiX B COUNTS HEALTH OUR ices dAtA sHAring Agreement

dAtA sHAring Agreement ICES’ mandate now includes the conduct of THIS AGREEMENT made this th January,  clinical evaluative studies and health services research in order to improve the eﬃ ciency and eﬀ ectiveness of : physicians’ services and related health care services;

MOHLTC has entered into an agreement with a corporation having its head oﬃ ce at ICES to provide annual funding to ICES for the purpose of  Bayview Avenue, in the City of Toronto conducting such research;

[hereinaft er referred to as ICES“ ”] ICES has entered into a data sharing agreement with the MOHLTC for access to information, including -AND- personal health information, that is in the custody or control of MOHLTC for the purpose of conducting clinical evaluative studies and health services research; ’S ICES is a prescribed entity under section () of the Personal Health Information Protection Act, S.O. , c.  Sched. A (the Act) and O. Reg. / section () and warrants and represents that the personal health [hereinaft er referred to as the GOVERNING“ COUNCIL”] information requested in this agreement is necessary to conducting clinical evaluation studies and health services -AND- research;

/. pursuant to section () of the Act, the Health ’ Information Custodian may disclose to a prescribed  Richmond Street East entity personal health information for the purpose of Toronto, ON MC N clinical evaluation studies and health services research if the entity meets the requirements under subsection (). [hereinaft er referred to as CRICH“ ”] , c. , Sched. A, s. ();

ICES was established in  in order to carry ICES has in place the practices and procedures out research with respect to physicians’ services and necessary under subsection (). , c. , Sched. A, s. related health services on behalf of the Ministry of Health () to protect the privacy of individuals and the and Long Term Care (MOHLTC) and the Ontario Medical confi dentiality and security of personal health Association; information it receives; OUR HEALTH COUNTS 95 in may and may COUNCIL staff and the staff COUNCIL , cancer, and stroke. ) will the have opportunity , relevant CRICH and the GOVERNING COUNCIL scientists/staff with scientists/staff authorship. ) COUNCIL infarction, bypass surgery/angioplasty, heart primary care, visits with specialists) services failure, stroke, amputation, dialysis) medications, cardioprotective medications) chronic health status outcomes determinants health of and access to health diseases such as diabetes, cardiovascular disease, arthritis, COPD determinants health of and acute and ICES (as defi ned by ICES defi (as Chronic disease complications (myocardial Th e incidence prevalence and of chronic Th Emergency care Physician care (visits with and continuity of hospitalization c Age and gender specifi rates Medication use (glucose-lowering activities care preventative in Participation Accessned by to mental health care defi (as relationship e between socialTh . relationship e between social Th will only release requested measures and GOVERNING 3.1.9. 3.1.10. 3.1.1. 3.1.2. 3.1.3. 3.1.4. 3.1.5. 3.1.6. 3.1.7. 3.1.8. to review all research reports and publications that the discretion the of GOVERNING analyses to CRICH an aggregated cation format that prevents the identifi release Inuit specifi c measures c release and Inuitanalyses. specifi measures c release Métisand analyses. specifi relevant ICES reviewed scholarly manuscripts, will be created at of individuals. Th is doespreclude individuals.not of release the of Th Hamilton and the Inuit and Métis cohort in Ottawa. First c Nations,datasets. Inuit, Métis specifi willbe conducted the for First Nations cohort in variety measures of will be determined and analyses Th e ICES theAt request Tungasuvvingit of Inuit, ICES theAt request Métis of Nation Ontario, of ICES Research reports and publications, including peer All research reports and publications will credit the GOVERNING Th ese may include, but will not be limitedTh to: CRICH 3.7 3.2 3.3 3.4 3.5. 3.6

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RPDB to

RHS a copy the of Our Health Counts tHe

inFormAtion in the consideration the of promises

oF the First Nations, Métis, and Inuit people

and CRICH dataset). Th e database will dataset).contain Th the tHe

and GOVERNING the Information & Privacy Commissioner/ oF RHS

linkages of the OHC linked with the other administrative data, and a identifi Firsted Nations people livingidentifi in Hamilton permanently erased from ICES provide to ICES provision data, of including personal health information, to ICES and Inuit and Métis people living in Ottawa (see Schedule A for variables list). Th ere willSchedule be variables A for three Th list). services research behalf on the of GOVERNING name, date birth, of gender, OHIP Nations people living in Hamilton and Inuit and of theof project, in the  OHC clinical evaluative studies and health database and and baseline at  in  () () Respectful Health Survey response data self- of Respectful Health Survey dataset, (henceforth the Person Database ( Métis people living is cohort inwill Ottawa. be Th () years from baseline.() Following the completion CRICH to set the out terms and conditions governing the OHC COUNCIL shall use the personal health information collected use inFormAtion PurPose link the To OHC 3.0 3.1. purposes: them in October ; in Canada inherent have rights to self-government, parties hereto agree as follows: 2.0 2.1 and the er contained, mutual covenants the hereinaft security practices and procedures ICES of specifi c rights negotiatedas specifi in numbered the Treaties and under this agreement only as necessary the for following rights as outlined and enshrined in the Constitution Act of Canadaof (); Ontario dentiality has reviewed the and privacy, confi ICES 1.1 1.0 Th e purpose e of this agreement is: Th are prepared by CRICH before they are made public, submitted to the MOHTLC as per . below, or 5.4.1ICES will give access to personal health submitted for publication. Th e information in a form in which the GOVERNING COUNCIL will be provided a minimum of individual to whom it relates can be  days for this identifi ed only to the following persons: Mr. review unless otherwise agreed by GOVERNING Don DeBoer, Director, Data Management, COUNCIL Representatives shall be able to provide a Mr. Nelson Chong, Health Data dissenting opinion of fi ndings and any dissenting Administrator, and Mr Nicholas Gnidziejko, opinions will be included as part of the overall Analyst. 96 report in all publications and/or pertinent published or produced materials. 5.4.2 ICES will keep the personal health

COUNTS HEALTH OUR information in a physically secure location 3.8 Under its contractual obligation to the MOHLTC, ICES to which access is given only to the persons will provide the MOHLTC with copies of all reports mentioned in Section .., above. that have required the use of health care data obtained from the MOHLTC for the purposes of 5.4.3 Identifying numbers on linked OHC RHS compiling the information  days prior to Database will be encrypted immediately submitting such reports for publication or making aft er the data are fi rst read, and all working such reports public, as the case may be. Th e MOHLTC fi les will have only the encrypted number on shall keep all such reports confi dential. them.

4.0 mecHAnisms For trAnsmission 5.4.4 Th e data from CRICH, the GOVERNING 4.1 Th e parties shall mutually determine the method, COUNCIL and MOHLTC with identifying medium, frequency and timetable to be used with information about an individual will be respect to the provision of information under this copied by ICES to electronic media and agreement. Th ese parameters shall enable ICES to stored separately in a locked safe in a room meet its IPC-approved standards, must fi t with with security locks. Th e original media will available technology, and with availability of staff to be returned to the source or destroyed. eff ectively and securely manage the PHI. 5.4.5 ICES linked working fi les will not contain 5.0 conFidentiAlitY identifying information about an individual. 5.1 Th e personal information disclosed under this agreement is confi dential and mechanisms for 5.4.6 Other than the individuals named in Article maintaining the confi dentiality of this information .., the staff in ICES Information Systems, are described in Article .. the members of ICES’ Programming and Biostatistics team and ICES Scientists will be 5.2 Before disclosing any personal health information accessing the working fi les under this agreement, CRICH, the GOVERNING only in an anonymized form and will be COUNCIL and ICES shall exercise due caution in producing analyses required for providing only that personal health information that reports from such fi les. is determined to be necessary for the purpose set out in Article .. 5.4.7 All personnel of ICES shall sign a confi dentiality agreement to ensure that 5.3 ICES, in requesting personal information under this they do not disclose personal health agreement, warrants and represents that the information to any other person. In so doing, personal information is necessary for the purposes each person working for ICES acknowledges set out in Article .. that the disclosure of personal health information is grounds for immediate 5.4 ICES agrees to the following precautions and dismissal or termination. safeguards in handling confi dential personal information and personal health information: 5.4.8 In accordance with its privacy policy, ICES OUR HEALTH COUNTS 97

cease cease may cease are willing to terminAtion

And

COUNCIL COUNCIL COUNCIL and the GOVERNING shall cease using data. provides data identifi ed in this provides data identifi shall destroy all the data and notice in accordance with oBligAtions

CUSTODIAN

commencement shall cease and the GOVERNING of thisof agreement. , and the GOVERNING and the GOVERNING confi dentiality; and confi cation shallindemnifi survive the termination use and destruction the of information CRICH survivAl breach the by other party immediately notice. on before the date which on this agreement, any or part (a) (b) (c) procedures procedures the entire agreement is terminated not continues but terminated. the DATA termination, subject to Article .. all copies immediately, in accordance with ICES agreement, unless there is an amendment or mutual agreement the by parties. continue to disclose. disclosing data and ICES thisof agreement, as the case may be, is to be on pageon . cause, giving by ICES disclosing personal of information under Article ., disclosing any data more or one elements, without with respect to the remaining data elements which without cause least at on three months notice and on writing to the other party least at three months notice Th is agreement may be terminatedby eitherTh party is agreement may be amendedor terminatedTh on On termination the CRICH On termination, ICES and conditionsTerms relating to Notice intention of to terminate shall be given in Th is ectagreementon the shalldate set out takeTh eﬀ is ectagreement for long as as shall continue Th in eﬀ CRICH CRIHC COUNCIL Article . terms Agreement If

9.5 9.6 9.8 9.9 9.0 9.1 9.2 9.3 9.4 oF 10.0 10.0 11.0 11.1 10.1

except of the COUNCIL COUNCIL shall COUNCIL COUNCIL

and the GOVERNING and the GOVERNING

and the GOVERNING ArrAngements

Guidelines Research for with Aboriginal less. Information in sparse cells may be identifi cation of individuals. Th iscation of individuals.willnot identifi preclude the presentation First of Nations, reports soas to prevent the indirect combined with other cells cell to avoid observationsve () less.or counts fi of Inuit, and/or Métis specifi c datasets.Inuit, and/or Métis specifi Information in the cells will be suppressed when they contain fi ve () observationsve () or when they contain fi willonly present aggregated data in its employees identifi ed in Article .. employees identifi who are will advise CRICH will notify CRIHC will contact not any individual to whom will ensure that information no regarding the indirectly. indirectly. to ICES the data. terms and conditions set in out this agreement and taken to correct any such default and to prevent any personal health information relates, directly or to such amendments in writing. Any amendments the Personal Health Information Protection Act and the CIHR has access to identifying information, ICES as soon as has it become aware a breach of the of so made shall be consistent with the requirements of substitute that for person. notify CRICH responsible encrypting for the identifying numbers, recurrence. regarding confi dentialityregarding of health confi information. of theof steps cohort First of Nations people in Hamilton and doing linkages and storing, retrieving destroying or disclosed to any other party without the prior Peoples and shall be not contrary to any laws written authority of the GOVERNING Métis and Inuit people in Ottawa will be used or ICES ICES Th is agreement may be amended if the partiesTh agree Where a person specifi ed in ArticleWhere a person .longer specifi no . ICES ICES FinAnciAl

Amendments

5.8 5.7 5.6 5.5 6.0 this agreement. 7.0 7.1 . . Each party shall bear its own cost implementing of 11.2 Notice shall be deemed to have been suffi ciently 12.0 indemniFicAtion given seventy-two hours aft er it has been mailed, 12.1 ICES shall indemnify and save harmless the postage prepaid, or on the date of receipt where the GOVERNING COUNCIL and CRICH and the GOVERNING notice has been delivered by hand or by facsimile COUNCIL and CRICH’s Custodian’s directors, offi cers, transmission. employees, independent contractors, subcontractors, agents, and assigns from all costs, losses, damages, 11.3 Any notice or other communication required or judgments, claims, demands, suits, actions, causes of permitted to be given by either party to the other action, contracts, or other proceedings of any kind shall be sent to the following addresses: or nature based on or attributable to any disclosure 98 of personal health information to whom it relates If for : can be identifi ed by ICES or its directors, offi cers,

COUNTS HEALTH OUR Dr. David A. Henry employees, independent contractors, subcontractors, Chief Executive Oﬃ cer agents or assigns in contravention of this agreement. G Wing, Room , Th is provision survives the termination of this  Bayview Avenue, agreement. Toronto, ON MN M Phone: -- 12.2 CRICH and the GOVERNING COUNCIL shall indemnify and save harmless ICES and ICES’ directors, oﬃ cers, If for the : employees, independent contractors, subcontractors, Sylvia Maracle agents, and assigns from all cost, losses, damages, Executive Director judgments, claims, demands, suits, actions, causes of Ontario Federation of Indian Friendship Centres action, contracts, or other proceedings of any kind  Front St. or nature based on or attributable to any inaccuracy Toronto, ON MA E of the information provided by CRICH and the GOVERNING COUNCIL to ICES under this agreement. Connie Siedule Th is provision survives the termination of this Health Director agreement. Tungasuuvingat Inuit ADD IN ADDRESS hereto have executed this Agreement: Donna Lyons Health Director Métis Nation of Ontario  Old St. Patrick Street, Unit  Ottawa, ON KN G Per:

Authorized Signing Offi cer Witness Cora Lee McGuire-Cyrette Executive Director Print Authorized Signing Offi cer Name Date Ontario Native Women’s Association ADD IN ADDRESS ’ AND Per: If for Authorized Signing Offi cer Witness Janet Smylie Research Scientist Print Authorized Signing Offi cer Name Date Centre for Research on Inner City Health  Richmond St. Toronto, ON MC N OUR HEALTH COUNTS 99

Date

A . Per: Chief Executive Offi cer Chief Executive Offi David A. HenryWitness Print Authorized Signing Offi cer Name Print Authorized Signing Offi Date Date Date Witness Witness Witness S. . Per: Per: Per: ’ ’ Print Authorized Signing Offi cer Name Print Authorized Signing Offi Print Authorized Signing Offi cer Name Print Authorized SigningOffi cer Name Print Authorized Signing Offi / . Authorized Signing Offi cer Authorized Signing Offi Authorized Signing Offi cer Authorized Signing Offi cer Authorized Signing Offi 100 APPendiX c COUNTS HEALTH OUR First nAtions Adult And cHild surveY tool

9. How many children do you have? QuestionnAire: HAmilton First nAtions

rds screening Questions rds Questions 1. Coupon  Presented: Th ese next questions are about gathering information on your personal network. We will use this information to 2. Do you self-identify as being First Nations? determine how long we will continue to recruit research ☐ YES participants. ☐ NO [end interview] ☐ DON’T KNOW [end interview] 1. How many First Nations people do you know by ☐ NO RESPONSE [end interview] name who currently live in the city of Hamilton [Not including those who live on-reserve] 3. Do you live in Hamilton? ☐ ☐ ☐ ☐  of people ☐ YES ☐ DON’T KNOW ☐ NO [end interview] ☐ NO RESPONSE ☐ DON’T KNOW [end interview] ☐ NO RESPONSE [end interview] 2. What is your relationship to the person who gave you the coupon? (read out list) 4. OHIP  ☐ Relative ☐ Girlfriend/boyfriend; partner or spouse 5. DOB ☐ Friend ☐ Acquaintance 6. Participant Name ☐ Stranger ☐ DON’T KNOW ☐ NO RESPONSE 7. Do you have First Nation children that are under your care and reside with you? introduction ☐ YES Th e Respectful Health Assessment Survey RHAS( ) for ☐ NO [SKIP TO NEXT SECTION] Urban First Nation people living in Hamilton Ontario is directed, operated, controlled and owned by De dwa da 8. Would you be willing to complete the child portion dehs nye >s and the Ontario Federation of Indian of the survey? (inform them it will take an additional Friendship Centres on behalf of the First Nations people  minutes ask we will be asking for all their living in Hamilton. children under the age of ) ☐ YES ☐ NO [Skip to next section] OUR HEALTH COUNTS 101

(please specify) (please (please specify) (please (please specify all ages) Show Card ). ] ] TO TO SKIP SKIP [

[ ] TO SKIP

: RESPONSE RESPONSE RESPONSE RESPONSE RESPONSE [  of children  of ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ What is your reserve and or band aﬃ liation if any? What is your reserve and band or aﬃ NO RESPONSENO DON’T KNOW NO DON’T KNOW NO DON’T KNOW NO DON’T KNOW DON’T KNOW NO Married Separated Divorced, marriage annulment Widowed Cohabiting, common law Never married DON’T KNOW NO YES NO ☐

household? d. ☐ ☐ ☐ manyHow children have? do you ☐ ☐ OTHERS ☐ ☐ manyHow these of children currently live in your ☐ ☐ What language do you speak most o home? en at What language speak do you most o ☐ ☐ What is your marital status? ( ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ had you anyHave children? ☐ ☐ 5. 9. 6. 7. . How old are. How your children? 4.        

was ] ] END END TO TO is to obtain accurate, ] ? SKIP SKIP

[ [ END

TO 1: sociodemogrAPHics

SKIP

RESPONSE [ RESPONSE Non-status DON’T KNOW NO Status (Registered Indian according to the NO DON’T KNOW NO YES RESPONSE

Indian Act) ☐ ☐ ☐ ☐ What Cree, is Mohawk?) your Ojibway, Nation (e.g. ☐ ☐ ☐ Are you: Are First you Nations? ☐ DON’T KNOW NO MALE FEMALE TRANSGENDER OTHER is collected using a Computer Assisted Personal

(including Housing, socioeconomic stAtus, stAtus, socioeconomic Housing, (including section And Food securitY) Children survey and ( Under) c.

b. ☐ ☐ a. What is your gender? ☐ ☐ ☐ ☐

Adult survey RHAS How doHow you self-identity In what year born? you were 3. in Hamilton. Th is data inwill Hamilton. be usedFirstby Th Nations two sections: has been reviewed and De approved by dwa da dehs nye 2. service e RHAS providers and community members. Th useful health data the for First Nations population living community e RHAS survey interviewers. Th organizations and services in Hamilton to advocate for enhanced e survey resources consists andof better Th Interview system. Th e data is gatheredInterview by trainedsystem. Th developed in partnership with Hamilton First Nation A. demographics

>s and>s the Our Health Counts Governing Committee. 1. Th e Th e main objectiveof RHASthe Th • • 10. What is the highest level of schooling you have ever ☐ OTHER (e.g., rental income, scholarships, Indian completed? Please choose one from the following Aﬀ airs support for school) categories. (Show Card ). (please specify) ☐ Less than grade  ☐ DON’T KNOW ☐ Some high school ☐ NO RESPONSE ☐ Completed high school ☐ Some trades or technical training (college) 13. Do you have any additional thoughts/comments? ☐ Completed trades or technical training (college) ☐ Some university 102 ☐ Completed university ☐ Some post-graduate education

COUNTS HEALTH OUR ☐ DON’T KNOW ☐ NO RESPONSE

11. Which of the following best describes your current employment status? Please choose one from the following categories. (Show Card ) ☐ Part-time B. Housing and mobility ☐ Full-time 1. Which of the following best describes the type of ☐ Seasonal dwelling you live in? Please choose one from the ☐ Self-employed following categories. (Show Card ) ☐ Homemaker ☐ Single house (not attached to any other dwelling) ☐ Any other informal paid work such as ☐ Semi-detached, duplex house, row house, or babysitting, housekeeping townhouse ☐ Student ☐ Self-contained apartment within a single ☐ Retired detached house ☐ Unemployed ☐ Apartment or condominium in a low rise ☐ DON’T KNOW building or apartment block (<  storeys) ☐ NO RESPONSE ☐ Apartment or condominium in a high rise building or apartment block (>  storeys) 12. inking about the total income for all household ☐ Homeless [Skip to ] members, from which of the following sources did ☐ Transition (ie. Couch surfi ng, shelter, welfare your household receive any income in the past residence, drug treatment centre) [Skip to ] months? Please select all that apply. (Show Card ) ☐ Other: ☐ Wages and salaries (please specify) ☐ Income from self-employment ☐ DON’T KNOW [Skip to ] ☐ Employment insurance ☐ NO RESPONSE [Skip to ] ☐ Worker’s compensation ☐ Child Tax Benefi t 2. For how long have you lived in your current home? ☐ Provincial or municipal social assistance or ☐ ☐ YEARS ☐ ☐ MONTHS welfare ☐ DON’T KNOW ☐ Child support ☐ NO RESPONSE ☐ Alimony ☐ Money from family on a regular basis 3. For how long have you lived in the city of ☐ Benefi ts from Canada or Quebec Pension Plan Hamilton? (if the participant has lived in Hamilton ☐ Retirement pensions, superannuation and more than once, specify that this refers to the time annuities since the respondent last moved to Hamilton). ☐ Old Age Security and Guaranteed Income ☐ ☐ YEARS ☐ ☐ MONTHS Supplement ☐ DON’T KNOW ☐ Dividends and interest (e.g., on bonds, savings) ☐ NO RESPONSE OUR HEALTH COUNTS 103

(please specify) (please

RESPONSE RESPONSE RESPONSE RESPONSE Yes, minorYes, repairs are needed (missing loose or major repairsYes, are needed (defective DON’T KNOW NO YES NO DON’T KNOW NO Excellent GoodVery Good Fair Poor DON’T KNOW NO A married common or with couple law NO A married common or with couple law NO A married common or with couple law children A married common or with couple law children unrelated more or personsTwo Other: DON’T KNOW NO No, onlyNo, regular maintenance is needed

Show Card ) home withhome mice, rats roaches? or including desirable remodeling additions) or provided by your home’s heatingprovided your by system? home’s Is it: ☐ ☐ ☐ ☐ In the last years, had you a problem in have your ☐ ☐ ☐ ☐ In general, rate do you the how day-to-day comfort ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Is your dwelling in need any of repairs? (Not oor tiles, bricks shingles, or ﬂ defective steps, railing siding, or etc.) plumbingelectrical or wiring, structural repairs oors ceilings, or to walls, etc.) ﬂ children children andadditional family parents, (ie. uncles, aunties, brothers, sisters, grandparents, cousins etc.) and additional family parents, (ie. grandparents, sisters, brothers, aunties, uncles, cousins etc.) (painting, furnace cleaning, etc.) ( (Show Card ) ☐ 9. 10. 11.

(please specify) (please

PEOPLE

Show Card )

MORE RESPONSE RESPONSE RESPONSE RESPONSE TIMES One adult person living alone One adult with children One adult with children and additional family  PEOPLE  PEOPLE  OR DON’T KNOW NO  PEOPLE  PEOPLE  PEOPLE  PEOPLE  PEOPLE  PEOPLE  PERSON Occupied your by rent-free household where no Other DON’T KNOW NO Owned without a mortgage your by household Owned with a mortgage your by household Rented your by household Native Housing Native Homes Inc.) (ie.Urban DON’T KNOW NO DON’T KNOW NO ROOMS ☐

☐

household? Please choose from one the following hallways and rooms used solely business for in your household? including the kitchen, bedrooms, includingnished the rooms kitchen, bedrooms, in attic basement, or etc. Do count not bathrooms, purposes.) categories. ( would like would know to the total number rooms, of ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Which the of following best describes your ☐ ☐ ☐ ☐ ☐ ☐ Including yourself, many how people currently live ☐ How manyHow rooms are there in your (We home? ☐ ☐ ☐ ☐ Is your home: (Show Card ) ☐ ☐ ☐ ☐ How manyHow times in moved you have the past years? ☐ ☐ ☐ brothers, sisters, grandparents, parents, (ie. aunties, uncles, cousins etc.) member owns and is rent no charged other social housing ☐ ☐ ☐ 8. 5. 6. 7. 4.

12. How concerned are you about poor air quality in ☐ More than  years your home due to things like dampness, mold, ☐ DON’T KNOW pollution, or bad air exchange/venting? Are you: ☐ NO RESPONSE (show card ) ☐ Very concerned 18. Do you believe that your ability to engage in ☐ Somewhat concerned preventative health activities (i.e. regular exercise, ☐ A little concerned going to the doctor or nurse for health screening ☐ Not concerned at all tests, accessing preventative dental care) has been ☐ DON’T KNOW a ected by nancial hardship? 104 ☐ NO RESPONSE ☐ Yes ☐ No (Skip to Next Section)

COUNTS HEALTH OUR 13. How much do you spend monthly on shelter costs ☐ DON’T KNOW (Skip to Next Section) [including rent/mortgage, utilities, repair, ☐ NO RESPONSE (Skip to Next Section) upkeep]?  19. How long has this been going on? (show card ) ☐ DON’T KNOW ☐ Less than  month ☐ NO RESPONSE ☐ - months ☐  months to  year 14. How o en do you have to give up important things ☐  year to  years (ie. buying groceries) in order to meet shelter- ☐ More than  years related [housing] costs? (read list) ☐ DON’T KNOW ☐ Several times a month ☐ NO RESPONSE ☐ Once a month ☐ A few times a year c. nutrition, water Quality, and Food security ☐ Never [Skip to ] 1. Do you eat a nutritious balanced diet? (show ☐ DON’T KNOW [Skip to ] card ) ☐ NO RESPONSE [Skip to ] ☐ Always ☐ Almost always 15. How long has this been going on? (show card ) ☐ Sometimes ☐ Less than  month ☐ Rarely ☐ - months ☐ Never ☐  months to  year ☐ DON’T KNOW ☐  year to  years ☐ NO RESPONSE ☐ More than  years ☐ DON’T KNOW 2. Which of the following statements best describes ☐ NO RESPONSE the food eaten in your household in the past months: (Show Card ) 16. It has been shown that nancial hardship can have ☐ You and others always had enough of the kinds an impact on health. Do you believe that your of food you wanted to eat overall health and well-being has been a ected by ☐ You and others had enough to eat, but not nancial hardship? always the kinds of food you wanted ☐ Yes ☐ Sometimes you or others did not have enough ☐ No [Skip to ) to eat ☐ DON’T KNOW [Skip to ) ☐ Oft en you or others did not have enough to eat ☐ No Response [Skip to ) ☐ DON’T KNOW ☐ NO RESPONSE . How long has this been going on? (show card ) ☐ Less than  month ☐ - months ☐  months to  year ☐  year to  years OUR HEALTH COUNTS 105 ) Show Card )

/ WEEK / WEEK / WEEK / WEEK / WEEK / WEEK show card / WEEK RESPONSE RESPONSE RESPONSE  DAYS  DAY  DAYS  DAYS  DAYS  DAYS  DAYS  DAYS DON’T KNOW NO Good Fair Poor DON’T KNOW NO All the of time Most the of time Some the of time A little the of time the of None time DON’T KNOW NO

least do minutes moderate of vigorous or four aspects your of life? (Physical, emotional, be all once,at is a total but least at of minutes makes a sweat. up work you Based this on activity? ( mental and spiritual) ( physical activity? is activityphysical activity? can be part of Moderateper activity day. includes brisk de nition, many how days per week at do you de work,transportation, recreation, or and need not walking, example; for and vigorous activity ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ feelen do you that are you in balance in the o How ☐ ☐ ☐ ☐ ☐ ☐ ☐ On average, many how days per week do do you minutes moderate of more or vigorous or 3. 2.

wHen

” HAPPens

BAlAnce

oF wHAt

) 2: “ out

RESPONSE RESPONSE RESPONSE Are NO neverI have needed to to such go a place DON’T KNOW YES Very GoodVery Excellent DON’T KNOW NO Yes No running have Don’t water/tap water YES NO DON’T KNOW NO NO

show card PHYsicAl, mentAl, And emotionAl HeAltH HeAltH emotionAl And mentAl, PHYsicAl, ProBlems section for drinkingfor year round? family member friends or place, a food bank, or is vegetables, fruit, berries, nuts, herbs—in or about the issues discussed have we so end] far?[open any other place] people your age, would you say your health is: we garden? garden? doesn’t have enough to eat? [ is could be a to enough doesn’t have [ eat? to your yard, your on balcony in or a community ☐ Please rate your health. Compared other to ☐ ☐ ☐ any have Do you additional thoughts/comments Do you considerDo you the tap water in your safe home ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Does anyone in your household grow food—that Do you have a place have Do you if go your to or family you ☐ ( 3. 5. 6. A. general Health status and exercise and status Health A. general 4.

1. B. chronic Health conditions I would now like to ask you about certain chronic health Read through the entire list of conditions and answer conditions that you may have. We are interested in “long- ‘yes’ or ‘no’ term conditions” which are expected to last or have already lasted  months or more and that have been List conditions that have lasted at least  months or diagnosed by a health care provider. are expected to last at least  months. Yes = Y 1. Have you been told by a health care provider that No = N you have any of the follow health conditions? DON’T KNOW = DK 106 If Yes, Please answer follow-up questions No response = R

condition told tHAt You HAve or iF Yes: COUNTS HEALTH OUR Been diAgnosed witH: Asthma N Y DK R Have you had any symptoms N Y DK R or attacks in the last 12 months? In the past 12 months have N Y DK R you taken medication for asthma (i.e. inhalers, nebulizers, pills, liquids or injections) Arthritis N Y DK R In the past 12 months, did you N Y DK R ever have pain in your joints (i.e. hips, knees, hands) that limited the amount or type of activity that you were able to do? Heart disease N Y DK R Stroke N Y DK R Liver disease N Y DK R High Blood Pressure N Y DK R In the past month have you N Y DK R taken medication for high blood pressure Hepatitis B N Y DK R Hepatitis C N Y DK R Allergies N Y DK R Chronic bronchitis, N Y DK R Emphysema, or COPD (Chronic Obstructive Pulmonary Disease) Attention Deﬁ cit N Y DK R Disorder/ Attention Deﬁ cit-Hyperactivity Disorder (ADD/ADHD) Learning disability N Y DK R

2. Do you have diabetes (as diagnosed by a health 4. In the last month, did you take pills to control your care provider) blood sugar? ☐ YES ☐ YES ☐ NO [SKIP TO question   ] ☐ NO ☐ DON’T KNOW [SKIP TO question  ] ☐ DON’T KNOW ☐ NO RESPONSE [SKIP TO question  ] ☐ NO RESPONSE

3. Do you currently take insulin for your diabetes? 5. In the past months, has a health care ☐ YES professional tested you for haemoglobin ☐ NO “A-one-C”? (An “A-one-C” haemoglogin test ☐ DON’T KNOW measures the average level of blood sugar over a ☐ NO RESPONSE month period.) ☐ YES ☐ NO OUR HEALTH COUNTS 107

(please specify) (please

RESPONSE RESPONSE [Skip to next section] RESPONSE    thanMore  DON’T KNOW NO    thanMore  DON’T KNOW NO YES NO DON’T KNOW NO Fall Burn Poisoning Near-drowning Animal bite c crash as a passenger Road traffi c crash as a driver Road traffi c crash as a pedestrian Road traffi Other DON’T KNOW response No 

had a lower respiratoryhad a lower tract infection (ie. had an upper respiratory tract infection cough, (ie. infection)? list) (read pneumonia)? (read list) (read pneumonia)? please indicate which theof followingwas the cause this of injury? Show Card ) cold, bronchitis, ear infection, sore throat, sinus ☐ ☐ ☐ ☐ ☐ ☐ In the past months, many how times you have ☐ ☐ ☐ ☐ ☐ ☐ u vaccine? received you Have the HN ☐ ☐ ☐ ☐ For yourFor most serious injury in the past months, ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ In the past months, many how times you have ☐ 3. 5. 2. 4. ] ] ) SECTION SECTION ] NEXT NEXT show card TO TO SECTION illness

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NO YES NO DON’T KNOW NO YES NO DON’T KNOW NO  or more years more  or ago DON’T KNOW NO DON’T KNOW NO Less than month one ago  month to less than  year ago  year to less than  years ago YES NO YES NO DON’T KNOW YES NO DON’T KNOW NO DON’T KNOW NO

have made temporarilyhave you sensitive light.) to irritations? professional tested your urine protein for (i.e. professional checked your feet any for sores or your eyes were dilated? ( is procedure would your eyes dilated? were ( or allor her pregnancy of with you? Microalbumin)? ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ injured you inWere the past months? ☐ ☐ ☐ Did your mother consume alcohol during any part ☐ ☐ When was the last time? ( ☐ ☐ ☐ Have you ever you hadHave an eye exam where the pupils of ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ In the past months, has a health care ☐ ☐ In the past months, has a health care inJurY 8. 9. 6. c. 7.

1. 10. 6. What was the reason(s) you did not receive the 5. For each child, how long did you breastfeed? vaccine? (Check all that apply) (Show card ) Child : ☐ ☐ months ☐ ☐ years ☐ I was not a member of the listed ‘at risk’ groups Child : ☐ ☐ months ☐ ☐ years ☐ I was worried about the side-eﬀ ects of the ☐ Up to  Children vaccine ☐ DON’T KNOW ☐ My health care provider (ie. doctor/nurse/clinic) ☐ NO RESPONSE did not have the vaccine or ran out of the vaccine For Men and Women: ☐ Th e wait to get the vaccine was too long 6. Without revealing test results, have you ever been 108 ☐ I didn’t have time in my schedule to go and get tested for ? the vaccine ☐ YES

COUNTS HEALTH OUR ☐ I didn’t have transportation to go and get the ☐ NO vaccine ☐ DON’T KNOW ☐ I don’t trust my health care provider ☐ NO RESPONSE ☐ I already had the ﬂ u ☐ DON’T KNOW 7. Have you ever had a sexually transmitted ☐ No Response infection? ☐ Other ☐ Yes (please specify) ☐ No [SKIP TO NEXT SECTION] ☐ DON’T KNOW d. sexual and reproductive health. ☐ No Response For Women: 1. Have you ever had a Pap test? (A Pap test is a test 8. Have you ever been diagnosed and treated for: performed by a doctor, nurse, or nurse practitioner (show card ) where a sample of cells is taken from the cervix.) ☐ Chlamydia ☐ YES ☐ Genital herpes ☐ NO [SKIP TO QUESTION ] ☐ Genital warts ☐ DON’T KNOW [SKIP TO QUESTION ] ☐ Gonorrhea ☐ NO RESPONSE [SKIP TO QUESTION ] ☐ Syphilis ☐ Other 2. When was that last time you had a Pap test? (please specify) ☐ Months ago ☐ Years ago e. Ability ☐ DON’T KNOW 1. Are you limited in the kinds or amount of activity ☐ NO RESPONSE you can do at home, work or otherwise because of a physical or mental condition or health For Women with children: problem? (read list) 3. Did you breastfeed any of your children? ☐ Y e s , o ft e n ☐ YES ☐ Yes, sometimes ☐ NO [SKIP TO QUESTION ] ☐ No ☐ DON’T KNOW [SKIP TO QUESTION ] ☐ DON’T KNOW ☐ NO RESPONSE [SKIP TO QUESTION ] ☐ No response

4. If yes, for how many children? 2. Do you su er from blindness or serious vision ☐ ☐  of children problems that can’t be corrected? ☐ DON’T KNOW ☐ YES ☐ NO RESPONSE ☐ NO ☐ DON’T KNOW ☐ NO RESPONSE OUR HEALTH COUNTS 109 ] ] ] QUESTION QUESTION TO TO

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kinds activitiesof can you do? Are currently you undergoing treatment ☐ ☐ ☐ ☐ Has this condition limited the amount or ☐ ☐ ☐ ☐ YES NO DON’T KNOW NO YES NO DON’T KNOW NO (other than(other medication) this for condition?

care it? for of anof emotional mental or health problem? d. c. Did this delay or prevent from you getting health ☐ ☐ ☐ ☐ Have you ever you experiencedHave discrimination because ☐ ☐ ☐ ☐ 3. 4. (Show card? (Show ) ] ] TO TO

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condition? ☐ ☐ ☐ ☐ Are currently you taking medication this for ☐ ☐ At what age were you rst told? what At age you were ☐ NO DON’T KNOW NO DON’T KNOW NO YES Excellent Good Fair Poor Unsure YES DON’T KNOW NO NO

b. hearing aid problems have hearing or when there is background noise)? that a psychological have you and/or mental health you rate your mental health a. disorder? (i.e. Depression, anxiety)

☐ ☐ ☐ ☐ ☐ ever you beenHave a health by told care worker ☐ ☐ ☐ ☐ ☐ ☐ Compared other to would people how know, you Do you su er from hearing impairment (i.e. need su Do you a

☐ ☐ ☐ ☐ 3. F. mental and emotional Health emotional and mental F. to ensure that there are adequate and appropriate services 2. answer any questions you do not want to answer. Th e answer any questions want do not you to answer. Th for Firstfor Nations in Hamilton. Anything say you will remain completely confi dential. confi remain completely reason are why we askingthese questions is that want we emotional health. Please remember to have do not you

1. Th e next e section asks about your personalTh mental and Th e following questions ask about how you have been feeling during the past  days.

5. About how o en during the past days did you [If A THRUOUGH J are ‘None of the time’, then skip to next feel [Insert A through J here]. Would you say all of section] the time, most of the time, some of the time, a little of the time, or none of the time?

All oF most oF some oF A little oF none oF don’t no tHe time tHe time tHe time tHe time tHe time know resPonse 110 A Tired out for no good reason? COUNTS HEALTH OUR B Nervous? Skip to D C So nervous that nothing could calm you down? D Hopeless? E Restless or ﬁ dgety? Skip to G F So restless you cannot sit still? G Depressed Skip to I H So depressed that nothing could cheer you up? I That everything is an effort? J Worthless?

6. During the past days, how many days out of b. Tried hard not to think about it or went out of were you unable to work or carry out your normal your way to avoid situations that reminded you activities because of these feelings? of it? ☐  of days ☐ YES ☐ DON’T KNOW ☐ NO ☐ NO RESPONSE ☐ DON’T KNOW ☐ NO RESPONSE g. Post-traumatic stress disorder 1. In your life, have you ever had any experience that c. Were constantly on guard, watchful, or easily was so frightening, horrible, or upsetting that, in startled? the past month, you: ☐ YES ☐ NO a. Have had nightmares about it or thought about ☐ DON’T KNOW it when you did not want to? ☐ NO RESPONSE ☐ YES ☐ NO d. Felt numb or detached from others, activities, ☐ DON’T KNOW or your surroundings? ☐ NO RESPONSE ☐ YES ☐ NO ☐ DON’T KNOW ☐ NO RESPONSE OUR HEALTH COUNTS 111 nr dn ] 4 3 2 1

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[ RESPONSE RESPONSE YES NO DON’T KNOW NO YES NO DON’T KNOW NO

about the issues discussed have we so end] far?[open Have you ever you thoughtHave about committing suicide? ☐ ☐ ☐ ☐ ever you attemptedHave suicide? ☐ ☐ ☐ ☐ any have Do you additional thoughts/comments 3. 5. 4. ” Are

wHo

3 :

RESPONSE RESPONSE YES NO DON’T KNOW NO YES NO DON’T KNOW NO

reclAiming section statement, please tell ifstatement, me you: committed suicide? cut yourself, burned yourself, taken poison or overdosed on medications) ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ever you harmedHave yourself purpose? on (e.g. Has a close friend family or member ever () Strongly() agree Disagree Agree () Strongly () () disagree “ 9 I have a lot of pride in First Nations. Now, I am going to read you several statements about your First Nations identity. Aft er each Aft identity. First Nations your several about I am you read to statements going Now, 3 I have a clear sense of my cultural background as a First Nations person and what 5 I am happy that I am First Nations. 6 I have a strong sense of belonging First to Nations community. 8 In order learn to more about being First Nations, I have often talked other to 2 I am active in organizations or social groups that include mostly First Nations people. Nations. First about people ceremonies, etc singing drumming, feasts, customs. and traditions, history, that means for me.

4 I think a lot about how my life will be affected because I am First Nations. 7 I understand pretty well what being First Nations means me. to 10 10 I participate in cultural practices, such as pow wows, Aboriginal day events, 11 I feel a strong attachment towards First Nations. 12 I feel good about my First Nations background. 1 nd out more I have spent about time First trying Nations, ﬁ to such as our H. suicide H. there are adequate and appropriate services First for 2. asking these questions is that want we to ensure that answer any questions want do not you to answer and you upsetting. Please remember that to have do not you Nationsin Hamilton. canreason e takewe why are a break any at time. Th

A. 1. Th e following e section questions may have Th that may be 7. During the past days, have you had a drink of section 4: “disconnection beer, wine, liquor or any other alcoholic beverage? From wHo we Are” ☐ YES substance use ☐ NO [SKIP TO QUESTION ] Th e following section may have questions that may cause ☐ DON’T KNOW [SKIP TO QUESTION ] mild distress. Please remember that you do not have to ☐ NO RESPONSE [SKIP TO QUESTION ] answer any questions you do not want to answer and you can take a break at anytime. 8. On how many days of the did you drink? ☐ ☐ 112 1. At the present time, do you smoke cigarettes? 9. What was the average number of drinks per day on (read list) those days that you drank? One drink includes one

COUNTS HEALTH OUR ☐ Not at all beer, one glass of wine or one shot (ounce) of hard ☐ Daily [Go to question ] liquor. ☐ Occasionally [Go to question ]  of drinks ☐ ☐ ☐ No response ☐ DON’T KNOW ☐ NO RESPONSE 2. Have you ever smoked cigarettes? (Current non- smokers only) 10. During the past months, how o en have you had ☐ Yes, daily or more drinks on one occasion? One drink ☐ Yes, occasionally includes one beer, one glass of wine or one shot ☐ No [SKIP TO QUESTION ] (ounce) of hard liquor. (Show card ) ☐ DON’T KNOW ☐ Never ☐ No response ☐ Less than once per month ☐ Once per month 3. On average, how many cigarettes do you currently ☐ - times per month smoke each day? ☐ Once per week *Approximate if necessary* ☐ More than once per week ☐ ☐ ☐ Every day ☐ DON’T KNOW 4. At what age did you begin smoking cigarettes? ☐ NO RESPONSE (Age in years) ☐ ☐ B. substance use - illicit drugs and 5. In the past months, how many times have you Prescription drugs tried to quit smoking? (For current smokers and Th e following questions are about substance abuse that ex-smokers) (Show card ) includes both illicit and prescriptions drugs. Th e questions ☐  (never tried to quit) may not apply to you. We are asking all research ☐  –  tries participants these questions. Our intent is to use the ☐  –  tries information collected to ensure there are adequate resources ☐  or more tries and services in the community. Remember anything you ☐ DON’T KNOW say will remain completely confi dential. Answering ☐ No response questions honestly will assist us to bring about change.

6. Do you have a smoke free home? (Show card ) 1. Have you used any of the following substances in the ☐ YES – COMPLETELY SMOKE FREE last months (Includes prescription drugs if they ☐ YES – THERE ARE SMOKERS LIVING IN THE were used without a prescription or out of keeping HOME, BUT THEY SMOKE OUTSIDE ONLY with how they were prescribed)? For each, please select ☐ NO the answer that best describes your frequency of use. ☐ DON’T KNOW ☐ NO RESPONSE For the substances you selected in , what is the drug or combination of drugs you are currently using the most? [Choose only one drug or one combination of drugs.] OUR HEALTH COUNTS 113 RESPONSE RESPONSE RESPONSE RESPONSE RESPONSE RESPONSE RESPONSE RESPONSE RESPONSE RESPONSE RESPONSE RESPONSE NO KNOW DON’T NO YES NO KNOW DON’T NO YES NO KNOW DON’T NO YES NO KNOW DON’T NO YES NO KNOW DON’T NO YES NO NO YES NO KNOW DON’T NO YES NO KNOW DON’T NO YES NO KNOW DON’T NO YES NO KNOW DON’T NO YES NO KNOW DON’T NO YES NO KNOW DON’T NO YES DON’T KNOW DON’T

☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ RESPONSE YES NO DON’T KNOW NO

your spouse, partner, close or friend? ☐ ☐ ☐ ☐ Have you ever you sharedHave needles with anyone including 3. ] ] YeAr montH montH A week A dAY tHe most ABout ABout ABout 2-3 2-3 ABout ABout currentlY

2-3 times/ times/ 2-3 A once A times times once using SECTION SECTION ]

RESPONSE RESPONSE RESPONSE RESPONSE RESPONSE RESPONSE RESPONSE RESPONSE RESPONSE RESPONSE RESPONSE RESPONSE NEXT NEXT YES NO DON’T KNOW NO NO DON’T KNOW NO YES NO DON’T KNOW NO YES NO DON’T KNOW NO YES NO DON’T KNOW NO DON’T KNOW NO YES NO DON’T KNOW NO YES NO DON’T KNOW NO YES NO DON’T KNOW NO YES YES NO DON’T KNOW NO YES NO DON’T KNOW NO YES NO DON’T KNOW NO YES NO

TO TO SECTION ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐

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TO / SKIP [ RESPONSE YES NO DON’T KNOW NO / Angel dust

Ritalin Ritalin Freebase Freebase Ecstasy PCP Marijuana Marijuana Inhalants (glue, Specify: Specify: Sedatives/ Downers Other Opiates (Percodan, (Percodan, Opiates Combination Combination Codeine/ Morphine/ Morphine/ Codeine/ Cocaine/Crack/ Cocaine/Crack/ Chewing tobacco tobacco Chewing (Valium etc.) (weed, grass)/Hash grass)/Hash (weed, gas, paint) Acid/ LSD Amphetamines Have you ever you usedHave a needle inject to any illicit drug? ☐ ☐ ☐ ☐ Tylenol 3, Fentanyl, etc.) Talwin item item

c. Health services Th e following section asks questions about access to 2. Overall, how would you rate the availability of health services. Please remember that you do not have to health services in your community? (Show card ) answer any questions you do not want to answer and you ☐ Excellent can take a break at anytime ☐ Good ☐ Fair 1. How would you rate the level of access to health ☐ Poor services available to you compared to Canadians ☐ DON’T KNOW generally? (please read list) ☐ NO RESPONSE 114 ☐ Same level of access ☐ Less access

COUNTS HEALTH OUR ☐ Better access ☐ DON’T KNOW ☐ NO RESPONSE

3. During the past months, have you experienced any of the following barriers to receiving health care? Read each item and mark all that apply. Yes no don’t no know resPonse Doctor not available in my area Nurse not available Lack of trust in health care provider Waiting list too long Unable to arrange transportation Diffi culty getting traditional care (e.g. healer, medicine person or elder) Not covered by Non-insured Health Benefi ts (e.g. service, medication, equipment) Prior approval for services under Non-Insured health benefi ts (NIHB) was denied Could not afford direct cost of care/service Could not afford transportation costs Could not afford childcare costs Felt health care provided was inadequate Felt service was not culturally appropriate Chose not to see health professional Service was not available in my area Other

4. Have you accessed emergency care for yourself in 5. How would you rate the quality of the emergency the last months? care you received at that time? Would you say it ☐ YES was… (show card ) ☐ NO [SKIP TO QUESTION ] ☐ Excellent ☐ DON’T KNOW [SKIP TO QUESTION ] ☐ Good ☐ NO RESPONSE [SKIP TO QUESTION ] ☐ Fair ☐ Poor ☐ DON’T KNOW ☐ NO RESPONSE OUR HEALTH COUNTS 115 Please specify) Please specify) Please ) ( ( SHAY RESPONSE RESPONSE RESPONSE RESPONSE practitioner and/or traditional healer) health care, education, housing) recovery program) exchange) circles, drumming, teaching, healers, grief Alcohol Worker Lifelong care program Arts,courses Dance and Craft Food and Clothing bank Other program DON’T KNOW NO Primary Health Care (physician, nurse Advocacy Services issues (for with income, Complementary Services (naturopath, needle Mental Health (Counseling and addictions) raditional Health program (women’s/men’s Outreach (transportation services) Other program DON’T KNOW NO Employment Services Alternative Education ( Court Worker Within the past  months Within the past  months Within the past  months Longer than year a ago DON’T KNOW NO YES NO DON’T KNOW NO

a health service? of theof following programs: all (check that apply) De dwa da dehs ney>s Aboriginal Health Centre Hamilton Regional Indian Centre ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ How long ago didHow this card (show happen? ) ☐ ☐ ☐ ☐ ☐ ☐ Has this stopped delayed or from you returning to ☐ ☐ ☐ ☐ In the past months participated you have in any 10. 11. 12. ] ] Show cardShow ) ] ] ] QUESTION QUESTION

TO TO TO TO SKIP SKIP SKIP SKIP [ [ [ [ QUESTION ] (community health representative) RESPONSE TO TO NO Immediate family member Other family member Friend Traditional healer Familydoctor Psychiatrist CHR Nurse Counselor Psychologist Social worker Crisis line worker DON’T KNOW SKIP SKIP

RESPONSE [ RESPONSE RESPONSE no ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ DON’T KNOW NO YES NO Excellent Good Fair Poor DON’T KNOW NO DON’T KNOW NO Yes No [

hospital any at time in the past years? received that at say time? was it you … Would telephone about an emotional mental or health issue di kepterently, waiting) a health by professionaldi or problem to any problem to or the of following: Answer ‘yes’ or would rate you the quality the of hospital care you First Nations? ☐ ☐ Have you ever you beenHave treated unfairly treated (e.g. ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ inking your of most recent hospital how stay, ☐ spent night one you Have as more or a patient in a ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ In the past months, seen you have talked or the on Yes (e.g. doctor, nurse, doctor, (e.g. dentist, etc.) because are you (Show card(Show ) ‘no’ for each‘no’ person/professional. ( 8. 9. 6. 7.

Native Women’s Centre 3. Have you had any di culty accessing any of the ☐ Community Counselling health services provided through the Non-Insured ☐ Woman Abuse Education Program Health Bene ts Program () provided to status ☐ Transitional Housing and Supports First Nations and Inuit persons through Health ☐ Emergency Outreach (food and clothing) Canada. ☐ Aboriginal Healing and Outreach Program Read all options and check all that apply. Note: “Other (AHOP) Medical Supplies” includes: wheelchair, magnifying ☐ Other program aid, walker, crutches, cane, artifi cial limb, modifi ed (Please specify) kitchen utensils, modifi ed clothing or shoe, special 116 ☐ DON’T KNOW cushions. Show Card ☐ NO RESPONSE ☐ N o D i ffi c u l t i e s

COUNTS HEALTH OUR ☐ Medication Southern Ontario Aboriginal Diabetes Imitative ☐ Dental Care ☐ Foot care program ☐ Vision Care (glasses) ☐ Diabetes Prevention program ☐ Hearing aid ☐ Other program ☐ Other Medical Supplies (Please specify) ☐ Transportation services or costs (air or road) ☐ DON’T KNOW ☐ Other ☐ NO RESPONSE ☐ DON’T KNOW ☐ NO RESPONSE d. Access to traditional medicine 1. Do you use traditional medicine? ☐ YES section 5: “imPActs oF ☐ NO [SKIP TO QUESTION ] coloniZAtion” ☐ DON’T KNOW [SKIP TO QUESTION ] ☐ NO RESPONSE [SKIP TO QUESTION ] Th e following section may have questions that may cause mild distress. Please remember that you do not have to 2. Have you had any of the following di culties answer any questions you do not want to answer and you accessing traditional medicines? Read list. Mark can take a break at anytime. all that apply. Show Card ☐ N o D i ffi c u l t i e s A. residential school ☐ Do not know where to get them 1. Were you ever a student at a federal residential ☐ Can’t aff ord it school, or a federal industrial school? (federal ☐ Too far to travel industrial schools were schools for young men that ☐ Concerned about eff ects mostly operated in the prairie provinces and the ☐ Do not know enough about them United States) ☐ Not available through health centre ☐ YES ☐ Not covered by non-insured health benefi ts ☐ NO [SKIP TO QUESTION ] (Health Canada) ☐ DON’T KNOW [SKIP TO QUESTION ] ☐ Other program ☐ NO RESPONSE [SKIP TO QUESTION ] (Please specify) ☐ DON’T KNOW 2. Do you believe that your overall health and well- ☐ No response being has been a ected by your attendance at residential school? Show Card ☐ YES, negatively impacted ☐ YES, positively impacted ☐ NO impact ☐ DON’T KNOW ☐ NO RESPONSE OUR HEALTH COUNTS 117 ] ] TO TO SKIP SKIP , negative impact , positive impact [ RESPONSE RESPONSE RESPONSE impact Very strong eff ect strongVery eff DON’T KNOW No response YES NO DON’T KNOW NO Within the past  months Within the past  months Within the past  months Longer than a year ago DON’T KNOW NO ect eff No ect Little eff ect Some eff ect Strong eff Yes No [ DON’T KNOW No response Settled Unsettled in (i.e. negotiation, awaiting decision) DON’T KNOW No response YES YES DON’T KNOW NO NO

are First Nations? your traditional lands? Show Card claims? community’s land claim(s)? of unfairof treatment? card (Show ) esteem? Show Card wellbeing has been a ected dislocation by wellbeing from has been a ☐ ☐ ☐ Have you ever you beenHave treated unfairly because you ☐ ☐ ☐ ☐ long ago wasHow your last experience this of type ☐ ☐ ☐ ☐ ☐ ☐ ectedHas that your self- experience negatively a ☐ ☐ ☐ ☐ Does your communityhome land more or one have ☐ ☐ ☐ ☐ What is the current status your of home ☐ ☐ ☐ ☐ believeDo you that your overall health and ☐ ☐ ☐ ☐ ☐ 3. 3. d. discrimination d. 2. 2. c. dislocation from traditional lands traditional from dislocation c. 1. 1. ] ] SECTION SECTION ] NEXT NEXT TO TO SECTION SKIP SKIP [Skip to next section] [

[Skip to next section] [ NEXT TO SKIP , negative impact , positive impact , negatively impacted negatively , impacted positively , RESPONSE impact [Skip to next section if to  & ] No RESPONSE RESPONSE impact [ RESPONSE RESPONSE NO YES YES NO DON’T KNOW YES NO DON’T KNOW NO NO YES YES NO DON’T KNOW Your cousinsYour Other relatives NO DON’T KNOW NO Your grandfathers Your mother Your father Your current Your spouse partner or brothers sisters or Your aunts uncles or Your Your grandmothersYour NO DON’T KNOW NO YES

has been a ected the by involvement child of has been a family attending residential school? Show Card being has been a ected a member by your of being has been a involved in the care your of one children? of protection agencies in your family? Show Card Society, Catholic Family Services) ever been Society, Catholic Family Services) ever involved in your care a child? when were you federal industrial school? Select all that apply. ever student a federal a at residential school a or Show Card ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ believeDo you that your overall health and wellbeing Has a child protection agency Children’s (ie. Aid ☐ a childWas protection agency (i.e. Children’s Aid ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ believeDo you that your overall health and well- ☐ ☐ ☐ ☐ ☐ ☐ Were any the of followingWere members your of family ☐ ☐ ☐ ☐ ☐ 3. 3. B. child Protection agency involvement 2. 4.

1. 4. Have you ever been the victim of an ethnically or 7. Have you ever been treated unfairly because of racially motivated attack (verbal or physical abuse your gender? to person or property)? Response options: (show ☐ YES card ) ☐ NO ☐ Yes, verbal – within the past  months ☐ DON’T KNOW ☐ Yes, verbal – more than  months ago ☐ NO RESPONSE ☐ Yes, physical – within the past  months ☐ Yes, physical – more than  months ago 8. Do you have any additional thoughts/comments ☐ No about the issues we have discussed so far?[open end] 118 ☐ DON’T KNOW ☐ Refuse

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5. Do you believe that your overall health and wellbeing have been a ected by racism? ☐ YES ☐ NO [SKIP TO QUESTION ] e. violence and Abuse ☐ DON’T KNOW Th e next section asks you about experiences about family ☐ NO RESPONSE violence. You may encounter questions that you cause mild distress. Please remember that you do not have to 6. If so, how? Can you share an example with me? answer any questions you do not want to answer and you [OPEN ENDED?] can take a break at anytime. Again we would like to remind you that anything you say will remain completely confi dential.

1. Do any types of violence occur in your community? ☐ Yes ☐ No [SKIP TO QUESTION ] ☐ DON’T KNOW [SKIP TO QUESTION ] ☐ NO RESPONSE [SKIP TO QUESTION ]

2. What kinds of violence occur in your community (check all that occur)?

Yes no don’t no know resPonse Family Violence If YES, proceed to questions 3 to 5. Violence related to crime and criminal behaviour in the community Violence related to racism/discrimination Lateral violence (violence directed laterally from one community member to another as a result of rage, anger and frustration from being constantly put down). OUR HEALTH COUNTS 119

resPonse know don’t no no IMPACT [skip section] to end of [skip section] to end of HIGH Yes IMPACT IMPACT IMPACT [skip section] to end of RESPONSE IMPACT RESPONSE YES NO DON’T KNOW NO EXTREMELY HIGH MODERATE LITTLE NO DON’T KNOW NO Yes iF Has this happened in the last year?

about con ict in think your household. We is it of about con and/or neglect in your community? card (show ) neglect in your community? concern in the community. feel Do you comfortable sharing your experiences today? We are wonderingWe if can you share experiences ☐ ☐ ☐ ☐ Can list you some the of impacts violenceof and/or Overall, would rate how you theimpact violence of ☐ ☐ ☐ ☐ ☐ ☐ ☐ 8. 6. is important to remember that this is a test, not so there that to have answer do not you any question do not you are right no wrong or answers. Please remember that all conﬂ ict may experienced have you in yourhousehold.conﬂ It want to answer. your answers dential will and remain completely confi 7. Th e following e questions ask you about stressTh and even resPonse

know don’t no resPonse resPonse ] ] no know don’t no know don’t no don’t Yes no QUESTION  QUESTION no TO

TO Yes

SKIP Yes SKIP [ [ QUESTION TO SKIP RESPONSE Yes No [ DON’T KNOW NO

people in your community who are neglected? community? Has anyone in your household….. ☐ ☐ ☐ ☐ Who are the people who are neglected? Sometimes abuse includes neglect. Are there What kinds family of violence occur in your Physical Restricted your actions? your Restricted Had sex when they didn’t Physically hurt you? Husband/Male Husband/Male Partner Elders and children Partner Elders Mental/emotional feel like it? Insulted or talked down you? to Sexual Screamed or cursed at you? Other Relatives Others Children Wife/Female Wife/Female partnerWife/Female partner and children and and children

Threatened you with harm? 3. 5. 9. resources and emergency contacts in your neighbourhood. confi dential. require If you assistanceconfi in dealing with following the issues,we canprovide you with a listof appropriate 4.

Answer each item as carefully and as accurately as can. you Please remember that all your of answers are strictly 10. Is there anything you would like add about ☐ Alcohol and drug abuse personal violence in your house hold? [open ended] ☐ Shortage of community health and/or social service workers ☐ Disregard for First Nations needs ☐ Other program ☐ DON’T KNOW ☐ NO RESPONSE

2. What are the main strengths of your community? 120 11. What kinds of support are needed in your (Show card ) community to address personal violence?[open ☐ Family values

COUNTS HEALTH OUR ended ] ☐ Awareness of First Nations culture ☐ Social connections (community working together) ☐ Community/health programs ☐ Traditional ceremonial activities (e.g powwow) ☐ Low rates of suicide/crime/drug abuse ☐ Good leisure/recreation facilities ☐ Elders ☐ Use of First Nation language 12. Are you interested in seeking personal violence ☐ Education and training opportunities services if they are available in your community? ☐ Natural environment [open ended] ☐ Strong economy ☐ Strong leadership ☐ Other: ☐ DON’T KNOW ☐ NO RESPONSE

B. community services 1. Do you think there are adequate community resources available for: Please answer yes or no for each of the following section 6: “lAck oF government resPonsiBilitY” ☐ ☐ ☐ ☐ Family violence A. lack of government responsibilty ☐ ☐ ☐ ☐ HIV prevention 1. What are the main challenges your community is ☐ ☐ ☐ ☐ Pregnant women currently facing (check all that apply)? Show Card ☐ ☐ ☐ ☐ Legal services ☐ ☐ ☐ ☐ Th eLGBTTQQI community ☐ Education and training opportunities (Lesbian, Gay, Bisexual, ☐ Housing Transgender, Two-Spirited, ☐ Culture Queer and questioning ☐ Poverty ☐ ☐ ☐ ☐ Youth ☐ Control over decisions ☐ ☐ ☐ ☐ Single men ☐ Natural environment ☐ ☐ ☐ ☐ Suicide prevention ☐ Recognition of treaty rights oﬀ -reserve ☐ ☐ ☐ ☐ Pandemics such as HN ☐ Funding ( s w i n e ﬂ u ) ☐ Health ☐ Crime 2. Can you list areas for which community resources/ ☐ Employment/number of jobs services are particularly lacking?: ☐ Legal problems including incarceration ☐ Family breakdown including apprehension of children OUR HEALTH COUNTS 121

IS dk PREGNANCY - PRE

HER RESPONDENT IF WAS INCHES ☐

no 1g 1e 1g 1d 1e ☐ a WHAT check box for #1 section next

check box for #1 section next

FEET . ☐

, ASK HER CENTIMETRES KILOGRAMS LBS ☐ RESPONSE RESPONSE RESPONSE ?]

☐ ☐ ☐

☐ NO DON’T KNOW NO DON’T KNOW , to  ,, to , , , to , , to , to, , , to , to, , , to , to , , , and over DON’T KNOW NO ☐ ☐ ☐

Yes ☐ How tallHow are without you your shoes on? ☐ ☐ ☐ weigh? much do you [ How ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ PREGNANT WEIGHT check box for #1 1f 1c 1b 2. 1. and proceed to section next check box for #1 and proceed to section next and proceed to check box for #1 and proceed to section next and proceed to section next check box for #1 and proceed to

is a is an ). Th e BMI Th ). BMI or You Are unsure… PovertY weigHt

, would it amount $20,000 to or more? , would it amount $80,000 or more? , would it amount $50,000 to or more? , would it amount $10,000 to or more? , would it amount $15,000 to or more? , would it amount $40,000 to or more? And And

is above the normal range then are you at NO YES NO YES NO YES , to , , to , No personal No income to ,

think your of total personal income, before deductions, from all sources. Please look these at categories and tell which me range falls it into ☐ ☐ ☐ For theFor year endingDecember , , please (Show Card (Show ) iF know You don’t

HeigHt 1 g If 1 f If 1 e If 1 c If 1 d If 1 b If 1 a it …would amount $30,000 to or more? income d. the ratio your of height and BMI weight. Your indicator your of appropriate weight your for height and is reliable a more indicator body of fat than just weight the disease more eﬀ ectively. the disease eﬀ more private area where can you weigh yourself and then write the number down a piece on paper. of have diabetes,have losing weight and trying to keep your alone. measure your Body Mass Index ( measure body of fat based a formula on that calculates greater risk developing for type  diabetes. If already you really well. Th ere are only a few questions left . ere only are few a questionsreallyleft well. Th c. If your BMI Finally, with your permission, would we like to measure weight as near to normal as possible can manage you help your height and weight. Will be using this information to category one Check only

To make feel you comfortable, more To there is a scale in the 1. We are almost fi nished the survey are almostWe you and fi are doing Participant education section (adult survey) 2. Did the participant show any signs of di culty in Survey will now educate the participant to recruit here. reading the response cards? ☐ No Coupons given: ☐ Some ☐ A lot Coupon Coupon 3. How con dent are you in the overall validity of the Coupon information collected in this interview? Honorarium Provide Yes ☐ ☐ Completely Confi dent 122 Amount given ☐ Some Doubts ☐ No Confi dence COUNTS HEALTH OUR interviewer imPression items 4. Other Comments: (to be completed by the interviewer after completion of the survey adult survey complete)

1. Please rate the participant’s orientation to the interview on a scale of to ,where is very poor and is very good on the following items: Interest Cooperation Ability to understand Ability to recall Ability to formulate/articulate a response Sincerity/truthfulness OUR HEALTH COUNTS 123 Read ]

Year Year Year Read List ] ] [Skip to ] Month Month Month Number Read List OHIP Other Yes [SkipNo to ] DON’T KNOW ResponseNo [Skip to ] Male Female English French First Nations Language ] sPeAking

Read De nitions De Read language? [ day-to-day life? (please choose [ only one) Day Day Day List ☐ Can the child understand speak or a First Nations ☐ ☐ ☐ ☐ Please list all First Nations Languages spoken: Is your child male female? or [ ☐ ☐ Which language(s) does the child use in his her or ☐ ☐ ☐ , radio), engaged, radio), in conversations, write paragraphs/text 8. 6. section B: language language B: section 7. 4. Child  Child   Child   Child’s TV Year Year Please specify) Please ( version and is deleted before the

Month Month understand main idea everyday of speech ( Fluent intermediAte BAsic A Few words n/A Fluent intermediAte BAsic A Few words n/A no diﬃ culty understanding spoken word, carrying diﬃ no complex on conversations, write complex reports/letters/etc. understand basic phrases, ask simple questions (‘where am I?’), and write basic sentences Adoptive parent parent Foster Other program Birth parent Grandparent Step parent (including common-law step Sister or brother

HeAltH surveY HeAltH parent) survey is saved.) used the for CAPI one) [Readone) List] our HeAltH counts: HeAltH our cHildren’s resPectFul Day Day How wellHow can the child understand and speak the language? [ A few words: understand can or speak a few words (hello, goodbye, etc) Basic: Intermediate: ☐ ☐ ☐ What is the child’s date birth? of ☐ ☐ ☐ ☐ What is the name the of child? What is your relationship the to child? (Choose Fluent: nAtion lAnguAge First understAnd understAnd First : Survey should be administered to adults who have 3. 9. section A: Personal A: section 2. our cHildren YoutH” And our current custody the of child whom the for surveyis being completed NB Child   Child   Child  

If answer,no is writeinformation in ‘the is child’. (Th

1. “imPortAnce oF giFts oF 10. How important is it for the child to learn a First section c: education Nations language? [Read List] 13. Has the child ever attended an Aboriginal Head ☐ Very important Start Program? [Read List] ☐ Somewhat important ☐ Yes ☐ Not very important ☐ No ☐ Not important ☐ DON’T KNOW ☐ DON’T KNOW ☐ No Response ☐ No Response section d: general Health 124 11. How important are traditional cultural events in 14. Does the child live in a smoke-free home? [Read the child’s life? [Read List] List]

COUNTS HEALTH OUR (Cultural events vary, but may include powwows, ☐ Yes, completely smoke free sweat lodges, and community feasts) ☐ Yes, smoke outside ☐ Very important ☐ No ☐ Somewhat important ☐ DON’T KNOW ☐ Not very important ☐ No Response ☐ Not important ☐ DON’T KNOW 15. In general, would you say that the child’s health is: ☐ No Response [Read List] ☐ Excellent 12. Who helps the child understand their culture? ☐ Very Good [Read List] ☐ Good (Check all that apply) ☐ Fair ☐ Grandparents ☐ Poor ☐ Parents (mother and/or father) ☐ DON’T KNOW ☐ Aunts and uncles ☐ No Response ☐ Other relatives (siblings, cousins, etc.) ☐ Friends section e: Health conditions ☐ School teachers 16. Have you been told by a health care professional ☐ Community Elders that the child has any of the follow health ☐ Other community members conditions? ☐ No one ☐ DON’T KNOW If yes, what age was the diagnosis given? ☐ No Response ☐ Other program If Yes, are you currently undergoing treatment(s) (Please specify) or taking medication(s) for these conditions?

Read through the entire list of conditions and answer ‘yes’ or ‘no’ List conditions that have lasted at least  months or are expected to last at least  months.

Yes = Y No = N DON’T KNOW = DK No Response = R OUR HEALTH COUNTS 125 ] NR NR NR NR NR NR NR NR NR NR NR NR NR NR

R R R R R R R

DK DK DK DK DK DK DK DK DK DK DK DK DK DK DK DK DK DK DK DK DK Read List ) [ Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N diAgnosed going treAtment Yes No DON’T KNOW No Response

frequently and/or last a long time that the child has chronic ear infections ear or problems? (Chronic ear infections happen Have you been you Have a health by told care professional ☐ ☐ ☐ ☐ NR NR NR NR NR NR NR NR NR NR NR NR NR NR

R R R R R R

19. DK DK DK DK DK DK DK DK DK DK DK DK DK DK DK DK DK DK DK DK DK Y N Y Y N N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y Y N Y N Y N Y N Y N Y N Y N 16. told tHAt You HAve: Age wHen 17. 18. iF Yes, under- ) Y N , FAS , FASE ] TO DK FASD SKIP [ ) ] TO ] SKIP Yes No [ DON’T KNOW ResponseNo

Read List past months? [ How manyHow ear infections has the child had in the Since Birth, has the child ever had an ear infection? ☐ ☐ ☐ ☐ Dermatisit, atopic ecxema Diabetes ( Disorder Alcohol Fetal Blindness or serious vision problems Y N Hearing impairment Defi cit-Hyperactivity Defi Disorder Heart Condition Heart Condition Kidney Disease Hepatitis (If yes what type: Learning Disability Physical Disability (other than visual condition Speech/Languageculties diffi Cognitive or Mental Disability Chronic Bronchitis Cancer and/or hearing impairment) Autism Attention Defi cit Disorder/Attention Attention Defi Asthma Anxiety/Depression Anemia Allergies Active Inactive DK Inactive Active

Type A Type B Type C Type Tuberculosis (if yes isTuberculosis it

18. 17. 20. Does the child take the following medications? 24. Has your child seen a dentist, dental therapist, or (check all that apply) [Read List] orthodontist in the past months? [Read List] ☐ YES Y n dk nr ☐ NO Asthma Drugs (inhalers, ☐ DON’T KNOW NO RESPONSE puffers, ventolin) ☐

Antibiotics 25. During the past months, have you experienced Antihistamines any of the following barriers to receiving health 126 Ritalin (or other ADD meds) care for the child? (please answer for each question) [Read List] Vitamins COUNTS HEALTH OUR Note: NIHB or non-insured health benefi ts is the Traditional Medicines Health Canada program that provides support to help cover health care costs – medications, dental section F: injury care, vision care, medical supplies/equipment, etc. 21. Has the child required medical attention for a

serious injury in the last months? [Read List] A. Access BArrier Y n dk nr Yes ☐ B Doctor not available ☐ No (If no go to section G). ☐ DON’T KNOW C Nurse not available ☐ No Response D Waiting List is too long E Unable to arrange 22. What type of injury(ies) did the child have? For transportation example, was it a burn, a broken bone, etc. (Please F Diffi culty in getting select all that apply) [Read List] traditional care (e.g. healer ☐ Broken or fractured bones Medicine person, or Elder) ☐ Poisoning G Not covered by non-insured ☐ Burns or scalds Health Benefi ts(NIHB) ☐ Injury to internal organ H Prior approval of non-insured ☐ Dislocation Health Benefi ts was denied ☐ Dental injury I Could not afford direct cost ☐ Major sprain or strain of care/services ☐ Hypothermia, frost bite J Could not afford ☐ Minor cuts, scrapes or bruises transportation costs ☐ Repetitive strain K Could not afford childcare ☐ Concussion costs ☐ Other program L Felt health provider was (Please specify) inadequate ☐ DON’T KNOW M Chose not to see health ☐ No Response care professional N Service was not available section g: Access in my area 23. Has your child seen a family doctor, general practitioner or pediatrician in the past months? 26. Has your child participated in any of the following [Read List] programs: (check all that apply) ☐ YES ☐ Niwasa Aboriginal Head Start Program ☐ NO ☐ Ontario Early Years Centre ☐ DON’T KNOW ☐ Aboriginal Healthy Babies, Healthy Children ☐ NO RESPONSE Program ☐ at Hamilton Regional Indian Centre ☐ at Ontario Native Women’s Association OUR HEALTH COUNTS 127 ] ] ] ] Read List Read List ) Read List Please specify) Please Please specify) Please specify) Please ( ( ( Read List SURVEY CHILD FINISH -C program staff -C program staff DON’T KNOW No Response Speech/Language Emotional Social Other program DON’T KNOW No Response Family member Doctor Nurse Traditional healer Psychologist Physiotherapist Occupational therapist Speech Language therapist Teacher Head Start Program Staff Healthy babies, health children program staff Ontario Early Centre Years program staff CAP Other program staff Other program Yes No DON’T KNOW Response No Yes No ( DON’T KNOW No Response Physical Mental/Intellectual

and/or social [ development? all (check about? that [ apply) your child’s physical, mental, emotional, spiritual vaccinations/immunizations? [ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ accessDid you any the of following supports? ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Has the child received his/her routine (regular) ☐ ☐ ☐ ☐ ever you hadHave a concern about the progress of ☐ ☐ ☐ ☐ What areas concerned development you of were ☐ ☐ (check all(check that [ apply) 3. section i: child development child section i: section H: child immunizations child section H: 2. 1. 1.

nr GO :

dk Y n Please specify) Please ( and Child Nutrition Initiative

RESPONSE [Skip to next section] RESPONSE YES NO DON’T KNOW NO YES NO DON’T KNOW NO Aboriginal FASD Other program Hamilton Regional Indian Canada Centre’s Hamilton Regional Indian AKWE Centre’s LendingNiwasa and Toy Resource Program

specialist in the past months? getting your child this to specialist appointment? general practitioner program or worker see to a ☐ ☐ ☐ ☐ encounterDid you any the of following barriers in ☐ ☐ ☐ ☐ Did your child attend this specialist appointment? ☐ ☐ Has your child been referred their by family doctor, ☐ ☐ ☐ program Action Program Children for Program the appointmentthe the referring doctor and/or appointmentthe time specialistthe Referral letter didn’t get to inadequate specialist was Felt Other (please specify) Could not afford transportation afford not Could Could not afford childcare Chose not see to specialist specialist ofﬁ ce make to specialist ofﬁ specialist doctor regarding schedule attend to the specialist appointment

Transportation not available not Transportation the to through getting Trouble messages from getting Trouble nding time in my Trouble fi nding ce the specialist’s offi Trouble fi 29. 28. 27.

4. Did you encounter any of the following barriers? Participant education section (children survey) Remember, that we are talking about barriers you Survey will now educate the participant to recruit here. might have encountered when seeking support for any developmental concerns you may have had about Coupons given: your child. (check all that apply) [Read List] Coupon A. Access BArrier Y n dk nr Coupon B Health provider not available Coupon Honorarium Provide Yes C Waiting List is too long ☐ Amount given 128 D Unable to arrange transportation

COUNTS HEALTH OUR E Diffi culty in getting traditional interviewer imPression items care (e.g. healer, Medicine (to be completed by the interviewer after person, or Elder) completion of the survey child survey complete) F Assessment (ie. developmental 1. Please rate the participant’s orientation to the standards/scales) were culturally inappropriate interview on a scale of to ,where is very poor and is very good on the following items: G Service was otherwise culturally inappropriate Interest Cooperation H Not covered by non-insured Health Benefi ts (NIHB) Ability to understand Ability to recall I Prior approval of non-insured Health Benefi ts was denied Ability to formulate/articulate a response Sincerity/truthfulness J Could not afford direct cost of care/services 2. Did the participant show any signs of di culty in K Could not afford transportation costs reading the response cards? No L Could not afford ☐ childcare costs ☐ Some A lot M Felt health care provided ☐ was inadequate 3. How con dent are you in the overall validity of the N Chose not to see health care professional information collected in this interview? Completely Confi dent O Service was not available ☐ in my area ☐ Some Doubts ☐ No Confi dence 5. Is there anything else about your child’s health 4. that you feel is important and would like to Other Comments: mention? [open ended] OUR HEALTH COUNTS 129 workers AIDS / intervention with clients, health workers, and incompetent lawyers and judges leading to the high transexual/queer/questioning community promotion health needs Local (ie. health integration networks) health care providers additives and programs and equipment in Aboriginal Health Centre spirited/lesbian/gay/bisexual/transgendered/ services ts/Indian non-insured by health benefi Shortage of doctors and nurses Shortage of HIV Need increased for services and employment Need to increase funding health for professionals Lack direct of response First for Nations health Lack transportation of to and from health services Lack trust of First by Nations individuals in their caregivers opportunities people for with illness and/or disabilities Inadequate resources and for inclusion two- of Inadequate coverage medication of and health Inappropriate family assessment tools and culturally Infant Health years) (- department services Health funding systems that marginalize Aboriginal Pre-prenatal, prenatal and postnatal health workers who areseeking assistance their for clients Community level suicide prevention and Child health years) (- Child health years) (- Waiting times medical for tests and operations Waiting time ambulance for and emergency Youth health years)Youth (- A ff a i r s Access to information regarding nutrition and food • • • • • • • • • • • • • • • • • • • • and AIDS psychiatrists and mental health assessments time programs health Suff ering from multiple chronic diseasesSuff the at same Stress Syndrome/Fetal Alcohol Eff Syndrome/Fetalects Alcohol Eff schizophrenia) mental health and addiction issue) funding needed (i.e. programs disappear, poor upgrade their skills regarding First Nations communication and culture receiving care naturopath, (i.e. traditional healing) Need training for and education hospitals at Need increased for awareness alternate of ways of Need for holistic defi nitions approachesand Need to holistic for defi Nations people who are in need health of care Negative impacts clients on short of term program continuity service of providers, resultant High incidence HIV of discouraging of program attendance) High Blood Pressure Heart Disease and Stroke C Hepatitis Fetal Alcohol Spectrum Disorder/Fetal Alcohol Mental illness (including depression and Obesity Concurrent disorders (i.e. suff ering fromConcurrent both a disorders suff (i.e. Cancer Enhanced funding health for promotion workers to Education as a determinant health of Environmental allergies Discrimination against and stereotyping First of Diabetes Th e need e to enhance evaluationof servicesTh and Access to mental health services, including Arthritis concePt mAPPing stAtements APPendiX d • • • • • • • • • • • • • • • • • • • • • • • incidence of apprehension of First Nations children • Lack of recognition of First Nations community by child protection services knowledge and experience (i.e. Too much emphasis • Disruption and loss of positive First Nations identity instead on non-Aboriginal academic systems) • Disproportionate number of children under the care • Access to traditional spirituality and culture of and/or apprehended by child protection agencies • Community impacts of community workers and and the impact of this on family and community board members in need of personal growth • Low self-esteem • Lack of funding for traditional art, drawing and • Lack of understanding of First Nations culture by language mainstream • Th e need to return to traditional culture and • Development of identity and self-awareness lifestyles (i.e. traditional roles, ceremonies, parenting 130 • Disconnection from family and community and its skills)

COUNTS HEALTH OUR impacts on mental and physical health • Th e need to care for land/environment in order to • Dealing with social isolation in urban areas have human health • Need to understand our children as gift s from the • Work overload for community service workers creator that we need to take care of • Need for government to understand First Nations • Need to improve the ability of individuals to engage culture in order to appropriately allocate funds and in stable relationships programs • Need to move away from a victim mentality towards • Enhanced funding and training for holistic and self-effi cacy spiritual healing • Impacts of dislocation from traditional lands and • Th e need for enhanced services and supports for unresolved land claims, including overcrowding, youth inadequate housing and spiritual impacts • Th e importance of kinship systems/extended family • Need for recognition by persons living on-reserve to health that persons living off - reserve are still part of the • Th e need for urban specifi c pandemic preparedness community that builds on traditional First Nations worldviews • Th e failure of government to recognize First Nations • Impact of domestic violence on individuals, families, and to accept fi duciary responsibilities/inherent and communities rights • Intergenerational trauma, including the impact of • Th e need for enhanced ability of First Nations residential schools individuals to self-advocate • Lateral violence (i.e. Violence between peers in First • Need for recognition of the cultural diff erences Nations community and/or organizations) between First Nations • Disproportionate rates of incarceration • Mobility of First Nations and the challenges this • Inadequate services for domestic violence creates for tracking • Intergenerational abuse • Spiritual awareness/spiritual health • Elder Neglect and Abuse OUR HEALTH COUNTS 131 the same health care provider) to poverty) health care health inability (i.e. to care self,for inability to see housing, talking circles) addition to housing the for «hard to house» Smoking services inmates for and past inmates minimum wage access on to services families mental health issues leads to inability leads to work maintenance result increasing of poverty Need improved for access to health and social Need improved for legal services Lack programs of and supports single for men (i.e. children and youth resulting in missed/wrong Impact inadequateof social assistance and Healthy and safe water diagnosis Increasing number female of sex trade workers as a Houses in need repair/Inadequate of home Inadequate housing First for Nations seniors housing Inadequate/overcrowded Poverty facing female single parents and their Focus survival on rather than preventative health Food security Mental health stigma as a barrier to accessing mental Culturally inadequate assessment processes for Cycle poverty of poverty (i.e. leads to stress leads to Drug addiction prescription) (non Too much or too much or many prescriptionToo medication(s) Th e impacthomelessnessof and/or transienceon Th Th e need e provide to a supportivefoundation in Th Alcohol addiction Addiction to prescription drugs • • • • • • • • • • • • • • • • • • • • • • a da dehs dw ny e e> D s

A b e or tr igi en nal Health C