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The Health of Inuit, Métis and First Nations Adults Living Off-Reserve in Canada: The Impact of Socio-economic Status on Inequalities in Health
Introduction, findings, and conclusions
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Introduction
Over the past number of years, the proportion of Aboriginal people (First Nations, Métis and Inuit) in the Canadian population has been growing. According to the 2006 Census, Aboriginal people comprised 3.7% of the population, up from 2.8% only ten years prior.1 This increase has been shown to be driven, not so much by increased fertility rates, but rather by ethnic mobility, which refers to changes over time in the ethnic identity that individuals report.2 In other words, a greater proportion of Canadians are self-identifying as Aboriginal persons than did in the past.
On average, the Aboriginal population is considerably younger than the non-Aboriginal population. Nearly half (47%) of the Aboriginal population is under the age of 25, compared to less than one-third (30%) of the non-Aboriginal population (Figure 1).
Figure 1 Age distribution of Aboriginal identity and non-Aboriginal identity populations, Canada, 2006Despite being a younger population, the health and well-being of Aboriginal people in Canada is generally poorer than that of non-Aboriginal Canadians. For example, in 2001 the life expectancy of those living in Inuit-inhabited regions of the country was more than 12 years lower than that for the Canadian population as a whole,3 and those reporting Registered Indian status had significantly higher mortality rates than those who did not.4 First Nations and Métis adults tend to report poorer general health, are more likely to report chronic conditions such as diabetes, arthritis or high blood pressure, and are more likely to suffer an activity-limiting condition than non-Aboriginal adults.5-8
In addition to various health inequalities, there are also significant inequalities in terms of socio-economic resources and conditions between Aboriginal and non-Aboriginal people in Canada. According to the 2006 Census, non-Aboriginal Canadians reported higher personal incomes on average than did people who self-identified as Métis, Inuit or First Nations.9 There are also significant gaps in educational attainment, whereby Aboriginal people are less likely to complete high school or achieve postsecondary education than non-Aboriginal people.7,10-12
There is a large literature linking poorer socio-economic conditions with poorer health outcomes.13-21 Given this association, it is possible that the health inequalities experienced by First Nations, Métis and Inuit adults are the result of poverty and socio-economic disadvantage. Conversely, health disparities may persist even in the absence of socio-economic differences between Aboriginal and non-Aboriginal people.
Study objectives
To address such issues, the present study had three objectives:
- To describe the health and well-being of Inuit, Métis and First Nations adults living off-reserve, and to compare these characteristics to those of non-Aboriginal adults;
- To examine the contribution of socio-economic and lifestyle factors to the health inequalities between Inuit, Métis and First Nations adults living off-reserve and non-Aboriginal adults; and
- To examine the health-related impact of socio-economic and lifestyle factors for each of non-Aboriginal, First Nations people living off-reserve, Métis and Inuit adults.
Findings
Aboriginal people more likely to report poorer health outcomes
In general, Aboriginal people were less likely to report being in optimal health than non-Aboriginal people. First Nations, Métis and Inuit adults were all significantly less likely than non-Aboriginal adults to rate their health as excellent or very good or to report having no activity-limiting conditions (Table 1). First Nations and Métis adults were also more likely than non-Aboriginal adults to report that they had been diagnosed with a chronic condition. Conversely, this proportion was significantly lower among Inuit adults (Table 1).
Table 1 Self-reported health characteristics, by Aboriginal identity group, off-reserve population aged 20 or older, Canada, 2006/2007Looking at specific chronic conditions, in almost all cases First Nations and Métis adults were significantly more likely than non-Aboriginal adults to report having been diagnosed by a doctor with the condition (Figure 2). Conversely, Inuit adults were generally less or similarly likely to be diagnosed with a particular condition as compared to non-Aboriginal adults. The exceptions were experiencing the effects of a stroke and stomach or intestinal ulcers, where the prevalence of these conditions was significantly higher for Inuit adults. (See Appendix Table A for crude and age-sex adjusted prevalence rates of self-reported chronic conditions).
It should be noted that the questions regarding the presence of chronic conditions as asked in both the Canadian Community Health Survey (CCHS) and the Aboriginal Peoples Survey (APS) specify that the individual be diagnosed with a particular condition by a doctor or health professional. As such, these findings do not necessarily indicate that these individuals did not have these conditions; rather, they have not received a specific diagnosis from a doctor or health professional.
The case of diabetes
Although not the most commonly reported chronic condition, diabetes was significantly more prevalent among First Nations (9.3%) and Métis (7.5%) adults than among non-Aboriginal adults (6.5%) (Table 2). Conversely, diabetes was significantly less prevalent among Inuit adults (4.9%). Diabetes is a risk factor for reductions in functional health, while it also increases the risk of premature death. Complications due to diabetes may also result in blindness, amputation, ischemic heart disease, stroke and kidney failure.24
Diabetes is often broken down into types. Type 1 diabetes, sometimes referred to as insulin-dependent diabetes or juvenile diabetes, is a condition when the body produces little to no insulin and is usually diagnosed in children or young adults. Type 2 diabetes, sometimes referred to as non-insulin-dependent diabetes or adult-onset diabetes, is the most common form of the condition and occurs when the body cannot properly use the insulin it produces or cannot produce sufficient insulin. Type 2 diabetes is usually diagnosed in adulthood, although it can occur during childhood, and is generally treated through diet and exercise.24 Gestational diabetes is diagnosed during pregnancy, usually around the 24th week of pregnancy. Although gestational diabetes resolves after the birth of the baby, approximately 40% of women who are diagnosed with gestational diabetes go on to develop Type 2 diabetes later in life.25
The 2006 APS included information on the type of diabetes with which individuals were diagnosed, whereas the CCHS, for the most part, did not. However, type of diabetes could be imputed in the CCHS using other reported information (see Methods). Compared with non-Aboriginal diabetics, a significantly higher proportion of Aboriginal diabetics were diagnosed as Type 1, while a significantly lower proportion of Aboriginal diabetics were diagnosed as Type 2 (Table 2). Gestational diabetes was also significantly more common among First Nations, Métis and Inuit women than among non-Aboriginal women.
Among those with diabetes, Aboriginal adults were diagnosed at significantly younger ages than were non-Aboriginal adults (Table 2). When broken down into smaller age groups, Métis were significantly more likely than non-Aboriginal respondents to report being diagnosed with diabetes prior to age 20 (8.9% vs. 5.2%) or between ages 20 and 39 (21.1% vs. 14.1%) than were non-Aboriginal respondents (Figure 3). Furthermore, nearly a third of First Nations adults living off-reserve were diagnosed between the ages of 20 and 39. Conversely, whereas nearly a third (31.1%) of non-Aboriginal adults with diabetes were diagnosed with the condition at or after age 60, significantly fewer Aboriginal diabetics were diagnosed with the condition at later ages.
The proportion of adults using insulin for the treatment of diabetes was higher among Métis (27.8%) than among non-Aboriginal adults (20.9%; Table 2). The majority of individuals reported using some other form of medication to treat their diabetes, although the proportions were significantly higher for First Nations (81.9%) and Métis (82.1%) adults with diabetes than for non-aboriginal adults with the condition (72.4%; Table 2).
Accessing health professionals
While more than three-quarters of Aboriginal and non-Aboriginal respondents indicated that they had seen or talked to a doctor or nurse in the past year, proportions were significantly lower among First Nations, Métis and Inuit adults than they were among non-Aboriginal adults (Table 3). Although this represents relatively high levels of contact with doctors or nurses, the sources of care differed dramatically. Inuit, Métis and First Nations people living off-reserve were significantly less likely to have seen or talked to a family doctor in the past year, but were significantly more likely to have seen or talked to a nurse, than were non-Aboriginal people (Table 3). The difference was particularly marked for Inuit, where 55% of Inuit saw or talked to a doctor and 64% saw or talked to a nurse in the past year, compared to 77% and 11% of non-Aboriginal respondents, respectively (Table 3). What cannot be discerned from these data is whether or not the meeting with a health professional occurred face-to-face or over the telephone.
When specific health care services are unavailable in a community, it may be necessary for a person to be moved to another location in order to have access to the necessary services. In the APS, respondents were asked if they had been away from home for a period of a month or more and, if so, the reason for such an absence. Three percent of First Nations adults, 2% of Métis adults, and more than 5% of Inuit adults indicated that they had been absent from their home for a month or more in the past 12 months due to illness (Table 3).
Socio-economic and demographic profiles differ
While there are large health disparities for First Nations, Métis and Inuit adults, there are other important differences between these groups and non-Aboriginal adults in Canada. In general, Aboriginal people were younger, more likely to have less than a high school education, and more likely to have lower personal incomes than non-Aboriginal people (Table 4). While more than 2 out of 5 non-Aboriginal adults reported a personal income of $40,000 or more per year, a similar proportion of Métis, and more than half of First Nations and Inuit adults reported personal incomes less than $20,000 a year (Table 4). Furthermore, while nearly 60% of non-Aboriginal adults reported having a postsecondary degree, this proportion was significantly lower for First Nations (39.5%), Métis (44.3%) and Inuit (27.8%) adults.
There was also a differential pattern of residence across the country. First Nations adults living off-reserve were more likely to live in the Western provinces than were non-Aboriginal adults (46.8% vs. 29.3%). Métis were more likely to live in the Prairie provinces (47.6%), while Inuit were more likely to inhabit the Territories (53.3%) and the northern parts of Québec and Newfoundland and Labrador, which comprise the Inuit land claims regions. Furthermore, while the majority of non-Aboriginal respondents lived in urban areas (82.1%), the proportion of Aboriginal adults living in urban areas was significantly lower (Table 4). This was particularly true among Inuit, where the majority of individuals (78.5%) lived in rural or Arctic communities.
These geographic differences may be important determinants of health in that health care delivery can vary greatly by region. For example, none of the 52 Inuit communities in the North have year-round road access, and only a few have hospitals.12 In addition, many northern or isolated communities find it difficult to recruit and retain health care professionals.26 Furthermore, areas with a greater population density often have greater access to health care providers and medical resources. As such, many northern and isolated communities lack adequate health care access. Conversely, certain provinces (Newfoundland and Labrador, Québec) provide more physicians and medical facilities per capita than others.26 Therefore, geography can be viewed as an important determinant of health in terms of access to services.
Other aspects of a person's living environment can also significantly impact their health. Among Aboriginal people, 14% of First Nations adults living off-reserve felt that their water at home was not safe to drink. By comparison, nearly 12% of Métis adults and 15% of Inuit adults felt the same (Table 5). Furthermore, almost 1 in 5 First Nations adults living off-reserve (18.9%) and Métis adults (17.9%) said that their drinking water was contaminated during certain times of the year. This figure rose to more than one-third (35.9%) of Inuit adults.
Smoking and body mass index
Other known health risk factors include smoking and obesity. Smoking is known to increase the likelihood of developing numerous chronic health conditions as well as reduce an individual's life expectancy.28,29 In the present study, daily smoking was significantly more prevalent among Aboriginal adults than among non-Aboriginal adults (Table 6). This was particularly true among Inuit, where 60% of adults reported smoking on a daily basis.
Excess body weight has also been associated with poorer health and reduced life expectancy.30-34 The body mass index (BMI) is often used as an indicator of excess weight and is classified into four categories: (i) underweight (BMI<18.5), (ii) acceptable weight (18.5≤BMI<25), (iii) overweight (25≤BMI<30), and (iv) obese (BMI≥30). Based on self-reported height and weight, First Nations (27.5%), Métis (27.6%) and Inuit adults (25.4%) were significantly more likely to be obese than non-Aboriginal Canadians (16.9%). However, for various reasons, these cut-points may not be appropriate for use in Aboriginal populations (see Note to Table 6).
Income and education explain some but not all differences in health status
Because of the differences in socio-economic characteristics, one may question whether the health inequalities between Aboriginal and non-Aboriginal people may be minimized or erased if these differences were taken into account. To address this question, we used (logistic) regression models to examine the differences in health-related outcomes for First Nations people off-reserve, Métis and Inuit adults compared to non-Aboriginal adults both before and after controlling for various socio-economic and lifestyle factors.
Sequential models for general health status
The unadjusted model confirms what was found descriptively, namely that First Nations off-reserve, Métis and Inuit adults were all significantly less likely than non-Aboriginal adults to report being in excellent or very good health (Figure 4, unadjusted). After accounting for the effects of age and sex, this health discrepancy was even greater (Figure 4, step 1). This is due to the fact that, for Aboriginal and non-Aboriginal adults of a given age, Aboriginal adults were significantly less likely to report being in excellent or very good health. After adjusting for the effects of income and educational attainment (Figure 4, step 2), odds ratios were closer to, but still significantly lower than 1. However, other factors may also explain differences in health status. Further adjusting for daily smoking and body mass index rendered the odds of being in excellent or very good health for Métis and Inuit adults similar to that of non-Aboriginal adults, but not so for First Nations adults living off-reserve (Figure 4, step 3). Adjusting for having seen or talked to a doctor or nurse in the12 months prior to survey had little to no impact on the disparity between First Nations adults living off-reserve and non-Aboriginal adults (Figure 4, step 4), nor did taking into account living in an urban centre (Figure 4, step 5). After all adjustments, Métis and Inuit adults were as likely as non-Aboriginal adults to report being in excellent or very good health, while First Nations adults living off-reserve remained significantly less likely to do so. This indicates that, for First Nations people, other factors still account for the health inequities observed. Coefficients from the sequential step-wise models can be found in Appendix Table C.
Sequential models for likelihood of being diagnosed with at least one chronic condition
A somewhat different pattern emerges when we examine the likelihood of being diagnosed by a doctor with at least one of 9 chronic conditions: arthritis, asthma, cancer, diabetes, emphysema, heart problems, hypertension (high blood pressure), effects of a stroke, and stomach or intestinal ulcers. While adjusting for age and sex further exacerbates the disparities between First Nations adults living off-reserve, Métis adults and non-Aboriginal adults, this adjustment clarifies that, for Inuit and non-Aboriginal adults of the same age, Inuit adults are significantly more likely to have been diagnosed with at least one chronic condition (Figure 5, step 1). This was not clear from simple descriptive statistics that did not take into account the different age structures of these populations (Table 1). Further adjusting for income and educational attainment in step 2 brought all groups closer to parity with the non-Aboriginal population. In fact, this adjustment rendered any differences in the likelihood of being diagnosed with a chronic condition between Inuit and non-Aboriginal adults statistically non-significant. Further adjustments for smoking and body mass index (Figure 5, step 3), having seen or spoken to a doctor or nurse in the past year (Figure 5, step 4) or living in an urban location (Figure 5, step 5) resulted in small changes towards parity with non-Aboriginal adults for First Nations off-reserve and Métis adults, although their odds of being diagnosed with a chronic conditions remained significantly higher than that of non-Aboriginal adults. For Inuit adults, adjusting for these factors resulted in significantly lower odds of being diagnosed with a chronic condition compared to non-Aboriginal adults. As previously noted, the wording of the questions involved in this analysis required that the individual be diagnosed by a doctor. As such, this analysis does not indicate that these individuals did not have these conditions, but rather that they had not been diagnosed as such. Coefficients from the sequential step-wise models can be found in Appendix Table E.
Sequential models for diabetes, asthma and arthritis
Rather than examine the odds of having one of several chronic conditions, we also examined the odds of being diagnosed with three specific chronic conditions: diabetes (Figure 6), asthma (Figure 7), and arthritis (Figure 8). Unadjusted prevalence rates of these conditions indicated that First Nations and Métis adults were significantly more likely than non-Aboriginal adults to have been diagnosed with each of diabetes, asthma and arthritis. Conversely, Inuit adults were significantly less likely to have been diagnosed with diabetes or arthritis, but were equally as likely to have been diagnosed with asthma, as non-Aboriginal adults. After adjusting for the different age distributions between these populations (step 1), the likelihood of being diagnosed with diabetes for the Inuit population was similar to that in the non-Aboriginal population (Figure 6), whereas the likelihood of being diagnosed with arthritis exceeded that for non-Aboriginal adults (Figure 8). In the case of each condition, while adjusting for socio-economic (income and education), lifestyle (smoking and body mass index), access to health professionals (having seen a doctor or nurse in the past year) and place of residence (urban) eliminated any differences between Inuit and non-Aboriginal adults in the likelihood of being diagnosed with the condition, First Nations and Métis adults remained significantly more likely to be diagnosed with these conditions. Coefficients from the sequential step-wise models are found in Appendix Tables G, I and K for diabetes, asthma, and arthritis, respectively.
Factors associated with health outcomes different for Aboriginal and non-Aboriginal adults
From the previous sequential step-wise models, it was shown that certain health disparities between Aboriginal and non-Aboriginal people could be diminished, but not necessarily eliminated, by controlling for the effect of various socio-economic and demographic factors. However, the impact of these factors may not be the same across Aboriginal identity groups. Initial analyses found several significant interactions of these factors with Aboriginal identity in the models. Therefore, separate models for each identity group were run and estimates across models were compared (for technical description of analysis methodology, see Technical notes).
Logistic models were conducted separately for each Aboriginal identity group (non-Aboriginal, First Nations off-reserve, Métis and Inuit) to estimate the likelihood of reporting each of the previously examined health outcomes: excellent or very good general health (Table 7), diagnosed by a health professional with one of several chronic conditions (Table 8), diagnosed with diabetes by a health professional (Table 9), diagnosed with asthma by a health professional (Table 10), and diagnosed with arthritis by a health professional (Table 11).
The majority of factors seemed to have similar effects across models for each of the health outcomes. However, a few factors stood out as having different effects according to Aboriginal identity group. One such factor was gender. Among non-Aboriginal adults, men were significantly less likely than women (OR=0.9) to report being in excellent or very good health (Table 7). Conversely, for First Nations, Métis and Inuit adults, men and women were similarly likely to report being in excellent or very good health. The estimates for First Nations and Inuit adults differed significantly from the model for non-Aboriginal adults (Table 7). Furthermore, whereas non-Aboriginal men and women were equally as likely to have been diagnosed by a doctor with at least one chronic condition (OR=1.0), men were significantly less likely to be diagnosed with a chronic condition than women among First Nations (OR=0.8), Métis (OR=0.8) and Inuit (OR=0.7) adults (Table 8). And while non-Aboriginal men were significantly more likely to have been diagnosed with diabetes than women, Aboriginal men and women were equally as likely to have been diagnosed with the condition, whether First Nations (OR=1.0), Métis (OR=1.2) or Inuit (OR=0.9) adults (Table 9).
Across the five outcomes examined, body mass index categories had differential effects across Aboriginal identity groups on three outcomes: self-rated health (Table 7), being diagnosed with at least one chronic condition (Table 8), and being diagnosed with arthritis (Table 11). In these models, the effects of overweight and obesity categories were different from the effects among non-Aboriginal adults for First Nations and Inuit adults, particularly the latter. Such findings may indicate that the BMI cut-points used in the general population may not be appropriate for First Nations or Inuit people, an argument that has been made by others.35
In the same way, other characteristics had different health impacts across Aboriginal and non-Aboriginal populations, as well as across First Nations, Métis and Inuit populations.
Discussion and conclusions
In general, the health of Aboriginal adults is poorer than that of non-Aboriginal adults. Inuit, Métis and First Nations adults living off-reserve were less likely to report being in excellent or very good health and were more likely to report at least one activity limitation than were non-Aboriginal adults. There were also differences in the likelihood of being diagnosed with several or specific chronic health conditions. These health gaps were further exacerbated after taking into account the younger average age structure of the Aboriginal population.
This health gap is narrowed in certain cases after taking into account socio-economic characteristics such as income and educational attainment. However, in most cases, Inuit, Métis and First Nations adults living off-reserve remained in poorer health than non-Aboriginal adults even after socio-economic, health care access and lifestyle risk factors were taken into account.
The fact that health inequalities remain for Aboriginal people relative to non-Aboriginal Canadians indicates that other factors are at play. Some have argued that proximal factors – factors that have a direct impact on health – such as behaviour and socio-economic characteristics are limited in their ability to explain health disparities. Rather, factors that have an indirect effect on health, such as the health care system and, more specific to Aboriginal people in Canada, factors of racism and social exclusion may play an important role in generating and maintaining health inequalities.36,37 Such factors are, however, difficult to conceptualize and measure and were, therefore, not addressed in the present study.
The fact that income and education levels could not fully explain the differences in health status between Aboriginal and non-Aboriginal adults is not an indication that these factors are unimportant. Low income and education have been shown, in this study and in others,19-21,38 to be associated with poorer health outcomes. At a very basic level income is reflective of one's ability to access resources, and those with higher incomes generally have access to higher quality resources. Such resources may include high-quality housing, transportation, adequate nutrition, and access to clean water, all of which can impact health. Achieving higher education may increase one's knowledge of healthy lifestyles and of the health care system and how to navigate it.
This study also demonstrated that factors typically associated with health in the general population do not act in the same way for First Nations, Métis and Inuit adults. For example, male gender was significantly associated with higher rates of diabetes in the non-Aboriginal population. However, there was no difference in the likelihood of being diagnosed with diabetes among men and women for First Nations, Métis and Inuit adults. There were also differences among First Nations, Métis and Inuit groups in relation to various measures of health. Such findings indicate several things. First, the factors associated with health among non-Aboriginal adults are not necessarily the same factors that affect the health of Aboriginal people, nor do these factors have the same effect on health. Second, there are also important differences between First Nations, Métis and Inuit adults in terms of the factors that impact health, which highlights the importance of examining these identity groups separately and not using a pan-Aboriginal approach when examining health.
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