Community Engagement & The Mental Health Needs of Aboriginal

Communities

Dr. Cornelia WiemanIHRDP

Dalla Lana School of Public Health University of Toronto

OPOP 2008 Annual RetreatSeptember 19, 2008Sudbury, Ontario

What is community engagement?

“people working collaboratively through inspired action and learning to create and realize bold visions for their common future” - Tamarack Institute for

Community Engagement

http://tamarackcommunity.ca/g2.php

Why engage with Aboriginal communities?

• according to Vancouver Coastal Health:– to assess the needs of the community– to improve services based on community feedback– to target the most effective resources for the community– to foster healthy communities through self-help and peer

support approaches– to be publicly accountable

• to improve services, programs and policies & build capacity to reduce health disparities and raise Aboriginal health status

http://www.vch.ca/ce/

How do we begin the process of community engagement?

• Community Health Advisory Committees – CHAC• community partnerships• community development activities• capacity building

Community engagement & the mental health needs of Aboriginal

communities

clinical servicesprogramspolicies

research

MHCC

TRC

health human resources

cultural safety

The Aboriginal population

[2006 census]

In the 2006 Census, >1.7 million people reportedat least some Aboriginal ancestry – this representsabout ~5.4% of the total Canadian population

First Nations~698,000

Metis~390,000

Inuit~50,000

total Aboriginal identity population = 1,172,790

Determinants of Health:including historical trauma & the ongoing effects of

colonization

▪ physical▪ economic▪ cultural▪ social▪ psychological

Trauma

The Globe & Mail, Saturday February 3, 2007

Racism

“So what is itabout us thatyou don’t like?”

Suicide rates in Canada:First Nations vs. Canadian population

StatsCan – 2001 Census data

Suicide rates differ by tribal council

and by language group

this suggests the importance of identity this suggests the importance of identity riskrisk

and protective factors that may account for and protective factors that may account for somesome

of the differences across communitiesof the differences across communities

First Nations Regional Health Survey

Youth Mental Health, Personal Wellness & Support

(Wieman, Minich, Ritchie & Burning, 2005) Depression: 78.8% report not feeling depressed for >2 weeks

44.3% females aged 15-17 yrs reported depression vs 22.1% males

28% females aged 11-14 yrs reported depression vs 13.3% males

reports of sad, blue or depressed feelings for >2

weeks (%)(n=4546)

79%

21%

no yes

2002-2003 iterationOf data collection

First Nations Regional Health Survey

Youth Mental Health, Personal Wellness & Support(Wieman, Minich, Ritchie & Burning, 2005)

youth reporting suicidal thoughts (%)

(n=4694)

79%

21%

no yes

youth reporting previous suicide

attempts (%)(n=4735)

90%

10%

no yes

Suicidality:*

* for all youth age groups, females endorsed suicidal thoughts & previous attempts at significantly higher rates than males

Six Nations Mental

Health Services:

a community-based mental health clinic

suicidedepression

post-traumaticstress

grief & loss

conflict

stress

“woman in mourning”

self-esteem

identity

Clinic Staff

program supervisor mental health nurses (6) mental health outreach worker general psychiatrist (adults & geriatrics) child & adolescent psychiatrist research assistants, summer & med students, residents

Our Clients

Six Nations band members (on-reserve) all ages psychiatric disorders psychosocial problems concurrent medical problems concurrent substance abuse

Referral Sources

physicians, nurses, social workers (~16%)

self-referral (>50%) family members police / First Response hospitals / ER psych service clinical staff of other

agencies - eg. Ganohkwa’ Sra’, Children’s Aid Society (~28%)

Services Offered

mental health crisis response services

psychiatric consultation, assessment & follow-up

case management for the seriously mentally ill

education & support for clients & families

education, support & awareness programs within the community

supportive housing (4)

Traditional Healing

a true partnership based on

sharing, mutual recognition, respect

The Two Row Wampum

The multidisciplinary team

client

GP

specialist(s)

pharmacist

family

nursingetc

traditionalhealer

voc/rehab

Education & Support for

Clients & Families ~10% of clients initially present seeking

education or information family sessions at client’s request need for culturally-relevant literature,

pamphlets, educational materials lending library of books, tapes and videos quarterly newsletters with topics of interest staff will accompany clients and/or family members to

other community or outside-community events (eg. support groups - mood disorders, bereavement, suicide etc.)

mutual aid group for depression

Education, Support & Increased Awareness for the Community community workshops: biannually

eg. Men’s Conference; Anxiety; Grief & Depression awareness weeks: Mental Health Awareness Week

(eg. spa days), Mental Illness Awareness Week community events: Six Nations Pow-Wow community newpapers: regular columns regarding

mental health issues community radio station: Phone-In Show traumatic event debriefings, crisis intervention &

sharing/healing circles Courage to Come Back Awards

Service Delivery Issues at the Level of Individuals

Overcoming the Barriers to Delivering Mental Health Services

providing culturally-sensitive care improving access to services western medical models: diagnosis & treatment optimizing continuity of services maintaining confidentiality increasing individuals’ sense of empowerment

& autonomy improving consumer awareness

Service Delivery Issues at the Level of the Community

Overcoming the Barriers to Delivering Mental Health Services

complex socio-political context within

complicated administrative structure of the community

working collaboratively with traditional healers & other service professionals (eg. CAS, police)

overcoming the stigma of mental illness

advocating for the community needs – how we fit into the local/regional mental health system

lack of Aboriginal health professionals & viability of practice within reserve communities

Future Directions & Initiatives

Early Intervention in Psychosis Program

enhanced crisis response services

counsellors on-site ACT team including

First Nations perspectives

court diversion program recruitment/retention

strategies

Lessons Learned

it is possible to deliver effective mental health services in our communities

there continue to be barriers, stereotypes & difficulties accessing services

we need ongoing support, evaluation & education

Aboriginal Health Human Resources

Aboriginal Physicians in Canadain Canada, ~150 Aboriginal MDs – mostly FPsin Ontario, ~12 practising Aboriginal MDs & only 21 med students in 5 med schoolsthere are >22,000 MDs in Ontario: there should be at least 375 Aboriginal MDsneeded in remote, rural & urban areasRCAP (1996) recommended 10,000 Aboriginal health professionals be trained in the next 10 years .....

An Ontario-wide

Strategy to increase the number of Aboriginal physicians

A community-based initiative

that partners with governments,

academic institutions &

Aboriginal health & education

organizations

2020 Vision: Key Elements

recruitment of medical school candidatesaccess to medical schools: admissionsinstruction / medical school preparednessplacements and internshipsstudent support while attending medical schoolpost-graduation placement of Aboriginal traineesevidence-based research to measure the impacts of the Strategyperformance & evaluation of the Strategy

Advancing the Aboriginal

mental healthresearch agenda &

building capacity

CIHR-funded CIHR-funded National Network National Network for for Aboriginal Mental Health Aboriginal Mental Health ResearchResearch (NAMHR) (NAMHR)

www.mcgill.ca/namhr

http://www.cihr-irsc.gc.ca/e/documents/ethics_aboriginal_guidelines_e.pdf

Qaujivallianiq inuusirijauvalauqtunik ‘Learning from lives that have been lived’

Nunavut suicide follow-back study

November 2005

Age-standardized suicide rates for

males in Canada, 2001

17.9 11.9 16.5 15.4 22.7 26.411.9 16.6 18.1 21.9 16.0

29.9 36.5

131.9

208.4

020406080

100120140160180200220

Canada (all), provinces/territories and Nunavik

av

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an

nu

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icid

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source: Statistics Canada, freepub 82-221-XIE

NOTE: 3-year averages

Resilience Study #1CIHR-Suicide NET

McCormick & Wieman (2006)

cross-national study of suicide attemptersqualitative narratives of suicide attempt(s) & decision to now live5 sites x 25 narratives/siteBC - Musqueam (west), Saskatoon or Winnipeg (urban), Six Nations (central), Iqualuit (north), Eskasoni (atlantic)

Resilience Study #2CIHR – International Collaborative Indigenous Health

Research Partnership GrantWieman & Kirmayer (2006)

qualitative narratives of past recipients of the National Aboriginal Achievement AwardFirst Nations, Metis & Inuit – recognized by the Aboriginal community14 recipients/year: 12 career, 1 youth, 1 lifetimeawarded 1994 – present (potential pool of 182 recipients)barriers & enablers to success

Discrimination in the

Health Care System FNIRHS 1997: In Manitoba,

16% felt they had been discriminated against by healthcare workers inside thecommunity; 30% by hcwoutside the community

in Labrador, 96% felt they were treated with respect by hcw inside the community; 89% by hcw outside the community

NAHO Opinion Poll 2004: 56% feel Aboriginal peoples are treated as well as non-Aboriginal people in the health care system

The Assault on Aboriginal Healing Traditions

Revitalization of Traditional Healing

Practices – RHS 2002/03

13.5

45.740.8

good some no

% ofrespondents

The spectrum to cultural safety

• cultural sensitivity: self-exploration & a learning process of beginning to understanddifferences

• cultural competence: awareness, attitudes (beliefs & values), knowledge, & skills

• cultural safety: recognizes power imbalances in health care relationships; empowers people by acknowledging that everyone’s knowledge & reality is valid & valuable; facilitates open communication; fosters respectfulness

so why practise culturallysafe care?

• misconceptions/stereotypes/stigma• eg. the case of “Mrs. S”• disparities in health status between

Aboriginal people & general Canadian population• closing the gap: access & utilization of health services

research at the University of Toronto

• Smith, Sacher & Wieman (2008)“Measuring the impacts of medical students’ understanding of culturally competent care with First Nations, Inuit and Metis Peoples”

• Hulliger & Wieman (2008)“Medical students’ perspectives on cultural competency training in undergraduate medical education: focusing on Aboriginal health”

• Bechamp & Wieman (2008)“Views of community informants regarding competencies required by healthcare providers to ensure adequate access to healthcare by Toronto’s Aboriginal population”

Seeking Bimaadiziiwin

Thunderstone Pictures Inc. & Shebandowan Films

Sharing Tebwewin: Culturally Competent Health Care for First

Nations

Thunderstone Pictures Inc. & Shebandowan Films

http://www.firstnationinitiative.ca/

Canada’s Truth & Reconciliation Commission

• Justice Harry LaForme (Chair), Claudette Dumont-Smith & Jane Brewin Morley – Commissioners

• formally established June 1, 2008

• 5-year mandate• will hear stories & facilitate

healing & reconciliation

Mental Health Commission of Canada

• First Nations, Inuit & Metis Advisory Committee

• 4 projects:– Cultural safety– Ethical framework– Protection of Indigenous

Knowledge– Moving beyond stigma

“Never doubt that a small group of thoughtful committed citizenscan change the world. Indeed, it is the only thing that ever has.”

- Margaret Meade

questions?