The Social-Ecological Model of Health and Obesity Among Indigenous Canadians

As we have explored the definition of health, it is safe to say that health encompasses mental, physical, social and other realms that are influenced by the many determinants of health. The World Health Organization (1948), defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. There are many health models that exist to provide a framework for evaluating various health influences and how they interact with each other at many different levels and often simultaneously. This assignment will explore the social ecological model of health, the concern of obesity among Indigenous Canadians, the social determinants of health related to this disparity and how the social ecological framework can be applied to address the concern of obesity in the Canadian Indigenous Population.

The Social-Ecological Model is a theory based framework that is widely accepted in public health and looks at how people relate through relationships with family, individuals, groups, their environment and community. This model allows for understanding of the influences these relationships have on health and to identify and understand interventions to overcome these influences. (Golden, McLeroy, Green, Earp, & Lieberman, 2015)

The initial theory developed by Urie Bronfenbrenner was illustrated by a series of nesting circles that place the individual at the center surrounded by various systems with those believed to have the strongest influences at the center. (Kilanowski, 2017) As displayed in figure one, these circles incorporate multiple determinants of health and represent the spheres of influence that allow for a multi-level approach to interventions for changing behavior. White (2015) noted that “an approach that incorporates complementary interventions at several levels is more likely to achieve and sustain success over time than a single intervention” (p. 6).

Figure 1. Spheres of Influence in the Social Ecological Model of Health (White, 2015

According to White (2015), the social ecological model includes the following spheres of influence: individual, relationship, community, society and global influence. The individual level identifies personal and biological factors such as age, gender, education, income, and personal or family history. The relationship level looks at relationships, social networks and support systems that may increase or reduce a risk of experiencing a particular outcome. The third sphere of influence is community which looks at the settings where social relationships occur such work and school. The society or organization sphere looks at broader societal influences that help create a climate where health behavior is encouraged. The fifth sphere of influence is Global Influence or policy/enabling environment such as local, provincial, national or global policy or laws that have health implications.

To summarize, “the essence of the SE Model is that while individuals are often viewed as responsible for what they do, their behavior is largely determined by their social and economic environment” and “barriers to healthy behaviors are often shared across their community, even a society as a whole; as these are lowered or removed, behavior change becomes more achievable and sustainable” (White, 2015. p, 6).

The social ecological model of health can be utilized to explore the social determinants of health, their relationships and how they contribute to the health of many groups or populations. Canada’s Indigenous population consists of three groups: First Nations, Metis, and Inuit peoples. First Nations make up the largest of the three groups and are located on reservations, and other rural and urban communities below the Arctic. The second largest group, the Metis, live in Ontario and the western provinces and were the descendants of French and English fur traders that married Indian wives. The Inuit live in communities throughout Canada’s Arctic. It is well known in the literature that Indigenous Canadians have a lower life expectancy than the national average, and experience higher rates of chronic disease as well as higher rates of suicide, family violence and other self-destructive and violent behaviors. (Kolahdooz, Nader, Yi, & Sharma, 2015; Richmond, Ross, & Egeland, 2007)

One particular health issue that concerns the Indigenous Population is the fact that obesity and diseases associated with obesity are highly prevalent in the Indigenous populations of Canada, especially when compared with other populations or groups. Figure 2 displays the increased prevalence of obesity in the indigenous population when compared with non-indigenous populations in each province of Canada.

Figure 2. Prevalence of Self-reported Obesity of Aboriginal and non-Aboriginal Adults Aged 18 Years and Older (Canadian Institute for Health Information & Public Health Agency of Canada, 2011)

When applying a multi-level model to a particular health concern or population it is important to consider the social determinants of health as they influence and relate to the health disparity. Health Canada (2019) defines the determinants of health as “the broad range of personal, social, economic and environmental factors that determine individual and population health”. Some of the social determinants of health that contribute to obesity among the Indigenous population include: education, employment and income, housing environments, personal health behaviors, social support networks and culture. Understanding many of the social determinants of health that contribute to health disparities among the Indigenous population requires consideration of Canadian history after the 1867 Indian Act that resulted in significant trauma, emotional distress and mistrust as a result of colonization and the implementation of the residential school system. (Kolahdooz, Nader, Yi, & Sharma, 2015; Richmond, Ross, & Egeland, 2007)

Applying the social ecological framework to the health disparities of Indigenous Canadians allows an opportunity to look at many levels that relate to those disparities and the interactions between individual, environmental, community and global levels.

At the individual level factors that contribute to obesity among Indigenous Canadians include: non-modifiable factors such as: age, sex, and genetics; early life events; knowledge; attitudes and beliefs; culture and language. Some of the individual behaviors that contribute to obesity include diet, exercise, income and education.

At the interpersonal or relationship level things to take into consideration would include: the importance of family and social support networks including nature and Creator and how many of the health disparities can be linked to the systemic forces that contributed to the populations losing some of their connections to their culture, traditions and social support networks. (Richmond, Ross, & Egeland, 2007) Often the family feeding practices contribute to obesity and the family and peer support are often needed to achieve a healthy active lifestyle.

Community level factors would take into consideration things like: household income, physical household environment, food security, community events, school environment, safe play grounds and access to health clinics. It is important to note that on average Indigenous People have lower income levels, higher poverty rates, higher dependency on financial aid, higher unemployment rates, lower levels of education and inappropriate housing which can all contribute to obesity rates. (Kolahdooz, Nader, Yi, & Sharma, 2015)

The society level of the framework would include local and national policy related to the health of Indigenous Canadians such as the residential school system and most recently the Government of Canada undid the Department of Indigenous and Northern Affairs Canada to create two new ministries: Indigenous Services and Crown-Indigenous Relations and Northern Affairs to improve services and close the socioeconomic gap while working towards the self-determination of Indigenous Canadians. (Philpott, 2018).

The Global Influence or Policy sphere often include larger influences such as the United Nations, the World Health Organization or other major public policies or laws that affect the health of Indigenous People. Some examples of influences that relate to the concern of obesity among the indigenous population include the historical relationship between colonization, Aboriginal-settler relations, including forced assimilation, and the Indian Act legislation that determines federal government obligations and regulates the management of lands, monies and resources. (Wilk, & Cooke, 2015; Willows, Hanley, & Delormier, 2012) Another example of global influence would be the publication on the health of the Indigenous Population in relation to the determinants of health called the United Nations Sustainable Develop Goals and Indigenous Peoples in Canada (Odulaja, & Halseth, 2018).

Willows, Hanley, & Delormier (2012) illustrated in Figure 3 how the social ecological model can be utilized to understand weight related issues in Aboriginal children in Canada. They recognized reciprocity between levels and ways the different levels can influence healthy eating, weight status, active living and it also identifies how many of the micro and macro factors that influence the risk for obesity are related to Canada’s history of colonization of Aboriginal people.

Figure 3. Socioecological Framework & Obesity Among Aboriginal Canadians (Willows, Hanley, & Delormier, 2012)

Utilizing a multi-level approach allows for a better understanding of the complex issues that contribute to health disparities among a population or group of individuals. By taking into account the reciprocal relationships between levels we are better able to plan interventions to address health disparities and increase the success of those interventions.

References

Canadian Institute for Health Information & Public Health Agency of Canada. (2011). Obesity in Canada: A joint report from the Public Health Agency of Canada and the Canadian Institute for Health Information. Retrieved from: https://www.canada.ca/en/public- health/services/health- promotion/healthy-living/obesity-canada.html

Golden, S.D., McLeroy, K.R., Green, L.W., Earp, J.L., & Lieberman, L.D. (2015). Upending the social ecological model to guide health promotion efforts toward policy and environmental change. Health Education & Behavior, 42(1), 8S-14S.

Health Canada. (2018). Social determinants of health and health inequalities. Retrieved from

https://www.canada.ca/en/public-health/services/health-promotion/population- health/what-determines-health.html.

Kilanowski, J.F. (2017). Breadth of the socioecological model. Journal of Agromedicine, 22(4), 295-297. DOI: 10.1080/1059924X.2017.1358971

Kolahdooz, F., Nader, F., Yi, K.J., & Sharma, S. (2015). Understanding the social determinants of health among Indigenous Canadians: priorities for health promotion policies and actions. Global Health Action, 8: 27968. DOI:10.3402/gha.v8.27968.

Odulaja, O.O., Halseth, R. (2018). The United Nations sustainable development goals and Indigenous peoples in Canada. Retrieved from https://www.nccah-ccnsa.ca/docs /determinants/RPT-UN-SDG-IndPeoplesCanada-Halseth-Odulaja-EN.pdf

Philpott, J. (2018). Canada’s efforts to ensure the health and wellbeing of Indigenous peoples. The Lancet, 391(10131), 1650-1651. DOI: https://doi.org/10.1016/S0140- 6736(18)30179-X.

Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946; signed on 22 July, 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April, 1948.

Richmond, C.A., Ross, N.A., & Egeland, G.M. (2007). Social support and thriving health: A new Approach to understanding the health of Indigenous Canadians. American Journal of Public Health, 97(9), 1827-1833.

White, F. (2015). Primary health care and public health: foundations of universal health systems. Medical Principles and Practice, 24(2). DOI: 10.1159/000370197.

Wilk, P., & Cooke, M. (2015). Collaborative public health system interventions for chronic disease prevention among urban Aboriginal Peoples. The International Policy Journal, 6(4). DOI: 10.18584/iipj.2015.6.4.3.

Willows, N.D., Hanley, A.J., & Delormier, T. (2012). A socioecological framework to understand weight-Related issues in Aboriginal children in Canada. Applied Physiology, Nutrition, and Metabolism, 37(1), 1-13. DOI: 10.1139/h11-128.