II Defining social determinants from an Aboriginal perspective
III Policy for transformation
IV Research for relevance
V Practice and partnership
-- Submitted by Holly Nathan, Communications, National Collaborating Centre for Aboriginal Health
First Nations, Inuit and Métis peoples in Canada bear a disproportionate burden of ill-health compared to non-Aboriginal Canadians, with significantly higher rates of chronic and infectious diseases, disability and premature death. The pressing question within and beyond public health is how best to address disparities that are increasingly recognized as “preventable, avoidable and unjust.” 
The National Collaborating Centre for Aboriginal Health (NCCAH) supports a renewed public health system in Canada that is inclusive and respectful of First Nations, Inuit and Métis peoples. Central to its program is a social determinants framework for addressing the underlying factors in disease and ill-health – the causes of the causes.  This approach promotes an understanding that improved housing, access to education, or cultural revitalization in effect constitute “complex clinical interventions” that can improve health outcomes. 
This article touches on the relevance of the social determinants model to Aboriginal health and highlights recent NCCAH activities to illustrate how a social determinants framework can influence policy, research and practice. It concludes with next steps, and provides links to related resources.
II Defining social determinants from an Aboriginal perspective
Why is a social determinants framework important to Aboriginal health?
Indigenous concepts of well-being extend beyond the absence of disease to an understanding of individuals living in harmony with others, their community, and the spirit worlds.”  A social determinants approach complements this more holistic, Indigenous understanding of health and well-being.
Most Indigenous peoples cite colonization as the single greatest contributor to cultural, geographic, economic and political dispossession.  While health professionals recognize the role of classic determinants such as income and housing on the health of populations in general, recent models identify Indigenous-specific determinants of health that reflect the complex legacies and ‘lived realities’ of the colonization experience.
The Assembly of First Nations’ Wholistic Policy and Planning Model of 2007, for instance, took a lead role identifying issues beyond the focus on health service delivery, and used First Nations-specific data to draw correlations between health and social determinants in a number of culturally relevant areas.  The NCCAH “web of being” model uses the image of a spiderweb to situate children, families and communities at the centre of interconnected strands of influences, systems and structures, emphasizing the well-being of children as a starting point for change. 
Indigenous scholar Dr. Charlotte Reading explains Indigenous social determinants in “distal, intermediate and proximate” terms and recently used her model to help explain why Aboriginal women are over-represented in new HIV diagnoses in Canada. She identified immediate health risks such as addictions and employment in the sex trade; intermediate causes such as intergenerational abuse; and historic and current colonial structures as distal influences that increase Aboriginal women’s exposure to the disease. Suggested interventions, as a result, target not only risk factors at the individual level, but broader contextual issues as well. 
Self-determination and the health of First Nations, Inuit and Métis peoples are intertwined. A social determinants approach suggests progress in reducing health inequities is best supported when Aboriginal peoples are able to advance self-determination over programs and initiatives that affect their health and well-being.  This strengthens the role of Indigenous knowledge in health, ensures recognition of cultural, historical and geographical diversity and builds on the strengths and resiliencies of individuals and communities.
III Policy for transformation
Social change cannot be fully realized unless supported by policy change.  Since its inception, the NCCAH has fostered collaborative relationships that cross traditional boundaries and silos in which the health system tends to work. As a result, the Centre has played a key role initiating broad policy dialogue in Canada in support of an integrated, coordinated and holistic approach to Aboriginal health across governments and civil society.
Internationally, the Centre facilitated Indigenous voices to the World Health Organization’s work on the social determinants of health, gaining recognition in 2008 for the empowerment of Indigenous peoples in policy, legislation and programs.  In Canada, the NCCAH convened two national gatherings, in 2008 and 2009, to determine how diverse sectors intersect in the health and well-being of Canada’s Aboriginal peoples, and what actions can accelerate change. Two documentary videos have been released that share learnings. 
In a unique partnership with UNICEF CANADA, the NCCAH drew new national public attention to the state of Aboriginal children’s health in Canada, who fare worse on every indicator of well-being than Canada’s children overall. This 2009 report emphasized a social determinants approach to addressing the health gap, and reached some 3,000 educators, 200 civil society organizations, all parliamentarians and more than 130 media outlets, promoting broad awareness in the public domain of the need for policy change.
Child welfare and residential school policies are among those that have contributed to poverty, marginalization and intergenerational trauma. The multi-jurisdictional nature of the health care system continues to block effective health care delivery. A framework for working with federal, provincial, and territorial authorities, and First Nations, Inuit and Métis, is part of a necessary strategy for change, supported by strategic collaborations and networks among civil society, the private sector, communities, research institutions and governments.
As highlighted in the UNICEF Canada report, addressing health disparities experienced by First Nations, Inuit and Métis is a “huge challenge and requires a collective Canadian effort to tackle them.” 
IV Research for relevance
The newly released "Growing Up In BC" report, a joint effort of the B.C. Representative for Children and Youth and the Provincial Health Officer, identifies 30 indicators of well-being, and for the first time in Canada establishes a baseline of data to measure progress in improving the circumstances and outcomes for children and youth.  The study noted that Aboriginal children are six times more likely to be admitted to care than non-Aboriginal children and show the lowest scores of any group in education achievement tests. Dr. Margo Greenwood, expert consultant to the report and NCCAH Academic Leader, said this speaks to underlying issues rooted in a colonial past. “This demands a closer scrutiny of the data and compels one to task: what are the realities, current and historical, that frame the lives of children? How do we measure those realities? How do we assess the impact of cultural differences?” 
The seminal Chandler and Lalonde study in 1998 established a link between cultural continuity and health, finding communities that were active in preserving and rehabilitating their cultures had dramatically lower rates of youth suicide.  Researchers are increasingly asking: what are the links between health benefits and educational attainment among Aboriginal peoples? Between health and language revitalization?  Their answers can help inform policy and practice that is relevant to First Nations, Inuit and Métis communities.
Significant shifts in the research landscape in Canada are currently underway that ensure inclusion and recognition of First Nations, Inuit and Métis values and culture. As Dr. Malcolm King, scientific director of the Institute of Aboriginal Peoples Health, part of the Canadians of Health Research (CIHR) noted, research capacity in Aboriginal health in 2000 was almost non-existent; currently, research centres are located across the country.  Building on this, CIHR has made it a priority to support research that addresses the health challenges of Aboriginal peoples and other vulnerable populations. As well, CIHR worked with First Nations, Métis and Inuit communities across the country to develop the world's first “Guidelines for Health Research Involving Aboriginal People " in 2008.
Communities are also taking control of their own research agendas. In Ontario, for instance, Manitoulin Island First Nations communities have established a community-based volunteer research committee whose members ensure research projects affecting their peoples are relevant, involve communities and are culturally sensitive. “We are currently looking at how to make [an asthma school health project with the Sudbury public health unit] a community-based initiative,” said Pamela Williamson, executive director of the Manitoulin Noojmowin Teg Health Centre. “For us, that’s the only way research can be successful – if it is fully integrated and engaged with the community.”
Turning research goals into action requires fostering this kind of community engagement, addressing training and capacity building in communities and supporting research team development. “Research needs to lead to health outcomes, and to programs and policies that are culturally appropriate and thus able to make a real difference,” said Dr. King. 
V Practice and partnership
Frontline practitioners need support to provide culturally competent and relevant programs and services as understanding of Aboriginal health in its broader contexts grows. Public health professionals require protocols for working in partnerships, professional development skills to work with Aboriginal peoples and cultures, and access to culturally relevant materials to support and guide initiatives.
The NCCAH recently partnered with Canadian optometrists and the Vision Institute of Canada in drawing national attention to the potential for soaring rates of diabetes-related blindness among Aboriginal peoples. In its support of a new vision screening initiative in B.C. for Aboriginal children on and off-reserve, the NCCAH used a social determinants of health approach to shed light on risk factors for health, barriers to care, and the need for preventive health education to support program delivery. As a result, the NCCAH recommended a holistic approach to screening services through greater community engagement and First Nations involvement in decision-making processes for improved service uptake.  The provincial program is also recognizing community strengths by including training of lay screeners, especially in more isolated areas with limited access to health professionals. This work is informing national discussions.
The pressing need for education of frontline professionals is a growing concern in Canada. The NCCAH has partnered with the Canadian Paediatric Society to develop Aboriginal health curriculum aimed at educating medical paediatric residents in universities throughout Canada. The curriculum is currently being adapted to reach family physicians. Work continues on this front through the Many Hands, One Dream partnership.
In addition, the NCCAH is supporting broad access to a database of research abstracts containing over 1,300 summaries of peer-reviewed research articles of relevance to Aboriginal health. The NEARBC (Network Environments for Aboriginal Research BC) website database covers a wide range of categories, including mental health, chronic disease, and child and maternal health, and is a national model for sharing information with those on the frontlines.
The NCCAH continues to build on a foundation supporting a cross-sectoral and holistic approach to First Nations, Inuit and Métis health in Canada that ensure inclusion and voice in policy, research and practice. As public health systems endeavored to meet the challenge of the H1N1 pandemic of 2009/2010, we saw how the flu virus was aggravated for many First Nations communities by issues such as poverty, overcrowded housing, and lack of access to, or control of health services. Similarly, diseases like tuberculosis are on the rise among Inuit and First Nations peoples, showing clear links to housing and other social and economic issues. These challenges help underscore the significance of bringing diverse sectors together in activities that foster new and creative linkages, build on strengths, strengthen voice, and coordinate change.
2. Marmot, M. (2005). Social Determinants of health inequalities. Lancet 365, 1099-104.
3. King, M., Smith, A., & Gracey, M. (2009). Indigenous health part 2: the underlying causes of the health gap. Lancet, 374, 83.
4. Ibid, 76
5. Smylie, J. (2009). The health of Aboriginal peoples. In D. Raphael (Ed.), Social Determinants of Health: Canadian Perspectives, 2nd edition. (pp. 280-301). Toronto: Canadian Scholars Press.
6. Reading, J.L., Kmetic, A., Gideon, V. (2007). First Nations Wholistic Policy and Planning Model. Assembly of First Nations Discussion Paper for WHO Commission on Social Determinants of Health.
7. Greenwood, M., & Place, J. (2009). Executive summary: The Health of First Nations, Inuit and Métis Children in Canada. In Aboriginal children’s health: leaving no child behind, Canadian Supplement to the State of the World’s Children (p. 7). Canadian UNICEF Committee.
8. Reading, C. (2010). Social determinants of Aboriginal health: The case of Aboriginal women and HIV/AIDS. Presentation at Canadian Public Health Association Centenary Conference, Public Health in Canada: Shaping the Future Together. Toronto, Ontario.
9. Commission on the Social Determinants of Health. (2008). Closing the gap in a generation: Health equity through action on the social determinants of health. Final report of the Commission on the Social Determinants of Health. (pp. 155-159). Geneva: World Health Organization.
11. Commission on the Social Determinants of Health. (2008). Closing the gap in a generation: Health equity through action on the social determinants of health. Final report of the Commissioin on the Social Determinants of Health. Geneva: World health Organization.
12. See: http://www.nccah.ca, or email firstname.lastname@example.org to request a copy.
13. Greenwood, M., & Place, J. (2009). Executive summary: The Health of First Nations, Inuit and Métis Children in Canada. In Aboriginal children’s health: leaving no child behind, Canadian Supplement to the State of the World’s Children (p. 6). Canadian UNICEF Committee.
14. Representative for Children and Youth, Office of the Provincial Health Officer. (2010). Growing Up in B.C. http://www.hls.gov.bc.ca/publications/year/2010/growing-up-in-bc.pdf
15. Ibid, p. 18-19.
16. Chandler, M.J., & Lalonde, C. (1998). Cultural Continuity as a Hedge against Suicide in Canada’s First Nations. Transcultural Psychiatry 35, 2: 191-219
17. King, M., Smith, A., & Gracey, M. (2009). Indigenous health part 2: the underlying causes of the health gap. Lancet, 374, 83.
18. King, M. (2010). Community-Based Intervention Research as pathway to health equity for First Nations, Inuit and Métis. Presentation at Canadian Public Health Association Centenary Conference, Public Health in Canada: Shaping the Future Together. Toronto, Ontario.
20. Atkinson, D., (2010). Aboriginal preschool vision screening in BC – closing the health gap. Canadian Journal of Optometry, 72, 4: 21.