The Social-Ecological Model and Cardiovascular Disease in Indigenous People

Heart disease is complex. Multiple factors affect one’s cardiovascular health, and therefore we should look at health promotion through multiple levels of influence. The influence of diet, physical activity, and smoking are key modifiable risk factors for cardiovascular disease. They will be discussed in relation to the disproportionately high prevalence of heart disease in the Indigenous population in Canada.

Social-ecological models (SEMs) of health acknowledge that multiple factors affect health (National Cancer Institute, 2005; Rural Health Information Hub, 2015). Then National Cancer Institute (NCI) and the Rural Health Information Hub, list these factors in five levels: intrapersonal, interpersonal, organization, community, and public policy. Each level impacts individuals and groups through behaviors and legislation that either promote or inhibit healthy behavior. SEMs emphasize the idea that health is affected at each level of influence and is a product of reciprocal causation (NCI, 2005). As a result of these two key concepts, there are several areas from which health interventions can be developed to promote healthy community members.

Cueva et al. (2020) discuss the use of a SEM to address the importance of food insecurity in American Indian communities. Those who experience food insecurity are more likely to consume food that is less expensive, lacking in nutrients, and is high in calories (Cueva et al., 2020). This is as a result associated with a greater risk of obesity: 42% of adult American Indians and Alaskan Natives are obese (Cueva et al., 2020). This is in part due to accessibility as those living on American Indian tribal lands are typically farther from grocery stores (in comparison to those who are not American Indian) and are less likely to have access to transportation (Cueva et al., 2020).

At an intrapersonal level, an edible school garden program and a traditional food education program were implemented into schools to provide education to students on culturally appropriate nutrition and farming practices. From an interpersonal level, the program brought together a wide range of community members through active participation to bring about behavioral and social change (Cueva et al., 2020). At a community level, farmers markets and local stores were able to sell and provide produce to community members (Cueva et al., 2020) as well as establish new partnerships. From an organizational level, schools worked with community farmers to encourage the knowledge and practice of growing healthy food (Cueva et al., 2020). And lastly, from a public policy perspective, wellness policies were implemented in schools to encourage healthy options for youth.

This application of a SEM to promote change for at risk communities is encouraging. Aside from obesity, Indigenous people in Canada are at a greater risk for other disease as well. Cardiovascular disease (CVD) is 50% more prevalent in Indigenous people in Canada when compared to non-Indigenous people (Leclerc et al., 2019; Foulds, Bredin & Warburton 2016). The mortality rate of CVD for Indigenous men is 30% for men and 75% for woman (Leclerc et al., 2019).

Common comorbidities impacting CVD include hypertension, dyslipidemia, diabetes mellitus, atrial fibrillation, and vascular cognitive impairments (Heart and Stroke Foundation, 2020). Leclerc et al. (2019) cited that up to 80% of Indigenous people living on reserve will developed diabetes mellitus at some point in their life. Obesity also tends to be prevalent in Indigenous people: 28% of First Nations living off reserves, 24% of Métis, and 28% of Inuit experience obesity (Leclerc et al., 2019). Anand et al. (2001) also noted that rates of smoking, hypertension, dyslipidemia, and diabetes were significantly higher among Indigenous people when compared to Caucasian Canadians. A SEM framework focusing on reducing the risk of CVD may be beneficial.

The Expanded Chronic Care Model (ECCM) is the framework primarily used in health discussions with First Nations partners in Canada to develop policy for chronic health conditions (see Figure 1). The previously used model, the Chronic Care Model, neglected to acknowledge the importance of community-based interventions and their role to encourage health promotion and disease prevention. The ECCM utilizes principles of the Ottawa Charter for Health Promotion emphasizing the importance of policy development to promote change of communities (as opposed to change in individuals). It also considers the social determinants of health and the affects they have on chronic diseases. Furthermore, the ECCM links the role of community-based interventions with that of the formal healthcare system.

Figure 1

The Expanded Chronic Care Model

Note: From "Preventing and Managing Chronic Disease in First Nations Communities: A Guidance Framework" by Indigenous Services Canada, 2018, p. 18 (https://publications.gc.ca/site/eng/9.840823/publication.html). Copyright her Majesty the Queen in Right of Canada, as represented by the Minister of Indigenous Services Canada, 2018.

There are several guiding principles that should be included when using the ECCM for disease prevention in context with First Nations communities (Indigenous Services Canada, 2018). Health interventions should be culturally sound, be person and family centered, be community driven, be evidence based, use health promotion and population health principles, include the Indigenous determinants of health, be done in collaboration with existing agencies and partners, be sustainable, and include accountabilities for all involved (Indigenous Services Canada, 2018).

The First Nations Health Authority (FNHA) in British Columbia has created several guides and has many resources to encourage healthy eating, physical activity, and culturally appropriate tobacco use. Applicable policies to promote these healthy behaviors will also be examined from a SEM perspective.

The FNHA encourages eating close to nature by avoiding processed foods; emphasizing fruits, vegetables and leans meats; consuming traditional foods such as berries, seafood, wild game, and roots; avoiding sugary drinks; and practicing mindful eating. The FNHA encourages physical activity by means of walking. They encourage the use of a pedometer and provide suggestions on how to increase activity by 200 steps per day to reach a goal of 10,000 steps per day. For tobacco use, the FNHA stresses that tobacco should be reserved for rituals, ceremonies, and prayers. They continue by stating that is should be a respected practice and recreational use can result in disease and addiction. From an intrapersonal view, the guidelines for healthy eating, physical activity, and tobacco use can educate and influence behaviors of individuals.

From an interpersonal level, the FNHA guidelines can impact families through encouraging traditional meals (opposed to processed foods) at family gatherings. Families can also benefit by going on walks together or perhaps challenging one another to walk more steps per day. As for smoking, families can encourage and support each other to smoke only for traditional use. This will decrease each family member’s exposure to first and second-hand smoke.

From a community level of influence, community gatherings can limit processed food and instead encourage the sharing of more traditional based foods. The sharing of how to prepare traditional dishes can also be beneficial. Walking groups can also be organized as a means of socialization while building healthy habits. Community fun runs/walks for social causes may also be utilized if deemed beneficial by community members. Respected members of the community can also encourage and remind youth of the importance of appropriate tobacco use during traditional ceremonies where tobacco is used.

From an organization perspective, health organizations can collaborate with local elders to address concerns. This approach has been observed between a health authority and community elders where suggestions of “no pop zones” at community and youth programs were discussed (Island Health, 2015). Decreasing the accessibility to sugary drinks was also discussed by limiting the amount of pop machines (Island Health, 2015).

Organizations to help facilitate Indigenous communities to engage in sport and recreation activities have also been created. Nationally, the Aboriginal Sport Circle is a non-profit organization that promotes sport and physical activity to Aboriginal people. In British Columbia, the Indigenous Sport, Physical Activity & Recreational Council (ISPARC) provides community development and preventative health to Indigenous communities and families. To promote the use of tobacco as traditional instead of recreational, the podcast Tobacco Nation partners with a physician, a professor, elders, and community members to explore tobacco while discussing the topics of cancer, community, tradition, and youth (FNHA).

From a public policy view, policies should be put in place to avoid targeting youth and to enable healthy options. For nutrition, media should avoid targeting sugary drinks and snacks to children. This includes advertisements that use television characters that entice younger generations. Importantly, legislation should be put in place to not only permit access to quality foods, but to ensure drinking water on reservations is safe to consume. This is vital as Island Health (2015) noted that elders were concerned with the safety of drinking water.

There are several policies in place to encourage sport and recreation in Indigenous communities. In 2019, the Government of Canada (GoC) announced $8.9 million in funding per year to promote sport and activity in Indigenous communities. This was recently reviewed in June of 2021: $17.8 million would be allocated to Indigenous sport from 2021-2023. This was in part to address the Truth and Reconciliation Commission of Canada’s call to Action (7, 19, 38).

For smoking cessation, policies specific to Indigenous people are lacking. However, free nicotine replacement therapy and prescription medications are available from the FNHA. Policies for general smoking cessation are available. In 2020 the GoC committed to $330 million over five years to decrease the number of Canadians who smoke and to warn younger generation of the harms of smoking. Target audience of this mission include members of the LGBTQ+ community, youth, and Indigenous people. Furthermore, in May of 2021, the GoC announced $3million in funding as part of a social marketing approach to increases smoking cessation. This is in partnership with the Canadian Cancer Society, The Canadian Lung Association, the Canadian Public Health Association, and the Heart & Stroke Foundation of Canada. Together with those goals of the Canada’s Tobacco Strategy, the GoC hopes to decrease tobacco use to less than 5% by 2035.

Using the social-ecological model of health, it is observed how changes to diet, physical activity, and smoking can impact the cardiovascular health of Indigenous people. The importance of changes at a variety of levels is seen. It is apparent that these changes are important to decrease the risk of CVD the risk is more prevalent in Indigenous people of Canada when compared to non-Indigenous people. The policies in place should hopefully positively impact their health status, but future research will be required to determine the effectiveness.

References

Anand, S. S., Yusuf, S., Jacobs, R., Davis, A. D., Yi, Q., Qerstein, H., Montague, P. A., & Lonn, E., (2001). Risk factors, atherosclerosis, and cardiovascular disease among Aboriginal people in Canada: The study of health assessment and risk evaluation in Aboriginal peoples (SHARE-AP). LANCET-LONDON-, 9288, 1146-1153.

Cueva, K., Lovato, V., Carroll, D., Richards, J., Speakman, K., Neault, N., & Barlow, A. (2020). A qualitative evaluation of a community based, culturally relevant intervention to promote healthy food access in American Indian Communities. Journal of Community Health, 45(3), 458-464. https://doi.org/10.1007/s10900-019-00760-4

First Nations Health Authority. (n.d.). Respecting tobacco. https://www.fnha.ca/wellness/wellness-and-the-first-nations-health-authority/wellness-streams/respecting-tobacco

First Nations Health Authority. (2014). Healthy food guidelines for First Nations communities. https://www.fnha.ca/WellnessSite/WellnessDocuments/Healthy_Food_Guidelines_for_First_Nations_Communities.pdf#search=heart%20disease

Foulds, H. J. A., Bredin, S. S. D., & Warburton, D. E. R. (2016). The vascular health status of adult Canadian Indigenous peoples from British Columbia. JOURNAL OF HUMAN HYPERTENSION 30(4), 278-284.

Government of Canada. (2021). More sport opportunity for youth in Indigenous communities. https://www.canada.ca/en/canadian-heritage/news/2021/06/more-sport-opportunities-for-youth-in-indigenous-communities.html

Government of Canada. (2019). The government of Canada invests to expand sport and physical activity programming in Indigenous communities. https://www.canada.ca/en/canadian-heritage/news/2019/05/the-government-of-canada-invests-to-expand-sport-and-physical-activity-programming-in-indigenous-communities.html

Heart and Stroke Foundation of Canada. (2020). Risk and Prevention. https://www.heartandstroke.ca/heart-disease/risk-and-prevention

Indigenous Services Canada. (2018). Preventing and managing chronic disease in first nations communities: A guidance framework. https://publications.gc.ca/site/eng/9.840823/publication.html

Island Health. (2015). Setting the table. https://www.fnha.ca/WellnessSite/WellnessDocuments/VIHA-Setting-The-Table.pdf

Leclerc, A.-M., Basque, A., Miquelon, P., & Rivard M.-C. (2019). Cardiovascular disease prevention: A scoping review of healthy eating and physical activity among Indigenous peoples in Canada. Canadian Journal of Cardiovascular Nursing, 29(2), 26-37.

National Cancer Institute. (2005). Theory at a glance: A guide for health promotion practice. (2nd ed.). National Institute of Health

Rural Health Information Hub. (2015, May 4). Ecological models.https://www.ruralhealthinfo.org/toolkits/health-promotion/2/theories-and-models/ecological