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Vol. 8, Issue 1 – Holistic Approaches to Preventing HPV Infections and Related Diseases

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Walking With Our Ancestors

Many First Nations people believe that we walk alongside the spirits of our ancestors. Each day their indigenous knowledge and practices guide our walk towards health, the “good life.” To reach the good life, we must work together, walk together. This issue of the Journal of Aboriginal Health ( JAH) is an example of this, where a diverse group of about 60 individuals—from physicians to community members—have come together to advance what we know about preventing human papillomavirus (HPV) infections and related diseases.

The National Aboriginal Health Organization (NAHO) gives thanks to all parts of creation and all contributors who made this issue possible—the authors who submitted papers, the reviewers, the editorial board, its staff, and the production team. Also, thank you to the Public Health Agency of Canada (PHAC) and Health Canada for contributing funding, expertise, and social networks to this special issue.

Since 2004, the Journal has explored a wide range of themes, from the decolonization of health through indigenous knowledge and practice to First Nations communities in crisis. For the winter of 2012, NAHO is delighted to bring you this special issue in collaboration
with PHAC. According to the Society of Obstetricians and Gynaecologists of Canada, HPV is the most common sexually transmitted infection in the world. HPV infections can lead to diseases such as cervical cancer, the cause of an estimated 350 deaths in 2011 according to the Canadian Cancer Society. There is no national data on the incidence
and mortality of cervical cancer for First Nations, Inuit, and Métis, however regional studies indicate that the incidence of cervical cancer for Aboriginal women is higher compared to women in the general population.

Cervical cancer can be prevented with vaccination and screening. However, there is a paucity of information about HPV vaccination and screening rates for First Nations,
Inuit, and Métis women. The articles contained within these pages are a step towards filling these information gaps, and can inform and tailor policies, programming, and healthcare for First Nations, Inuit, and Métis people. JAH is the leading open-access and peer-reviewed journal on First Nations, Inuit, and Métis health. It publishes research articles, methodological articles, community reports, book reviews, and other substantive material. The Journal is accessible through the NAHO website and searchable academic databases such as Scirus, Index Copernicus, and Google Scholar.

On behalf of all those involved, I hope you enjoy this special issue. I also hope you will become a future part of this publication by sharing your research, subscribing to the
Journal, and most importantly, joining us as we walk with our ancestors towards better health

Nia:wen,
Simon Brascoupé
Acting Chief Executive Officer
National Aboriginal Health Organization
Ottawa, ON

Exploring HPV Infections and Cervical Screening With Multiple Lenses

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HPV is one of the most common sexually transmitted infections (STIs) and it is estimated that 70% to 75% of people will be infected over their lifetime. HPV infections can cause genital warts or cancers including cervical cancer. Most HPV infections will disappear on their own and regular cervical screening, most commonly using the Papanicolaou (Pap) test, can prevent cervical cancer by catching abnormalities early before they become cancerous.

A greater proportion of First Nations, Inuit, and Métis women are diagnosed with cervical cancer than women in the general population. Factors that may account for this are explored in two of the articles in this issue. The other articles explore ways to increase the acceptance of cervical screening among Aboriginal women, including an alternative method of screening and the creation of “ethical space.”

One of the themes of this issue is the influence of personal history on acceptance of HPV screening. The health of First Nations, Inuit and Métis people in Canada has been deeply impacted by colonization and its resultant intergenerational traumas. These traumas—and the general feeling of mistrust they caused—along with limited transport and child care support may represent barriers for accessing cervical screening. Elias and collaborators used the Manitoba First Nations Regional Longitudinal Health Survey to examine the association between traumatic life experiences (abuse, addiction, or other trauma) and access to healthcare, including cervical screening. They found that First Nations women who reported traumatic histories were more likely to have had a Pap test. This may be due to these women’s more frequent use of healthcare services, which in turn increased their likelihood of engaging in cervical screening.

On the other hand, Russell and Leeuw, who used a very different methodology to survey a small group of marginalized Aboriginal women living in northern British Columbia, identified traumatic life experiences as a barrier to cervical screening for many participants. Participants showed an increased awareness of HPV and cervical cancer after taking part in workshops that used creative arts to help convey the information. Their study also showed that healthcare provider sensitivity, access to culturally relevant education resources, child care support, and transportation are factors that may positively influence screening rates.

Cerigo and colleagues provided the results of their survey on the acceptance of and preference for selfcollection of cervicovaginal samples for HPV testing among a sample of Inuit women from Nunavik, Quebec. Their findings showed a preference for self-collection among the majority of participants, suggesting a better way to offer cervical screening to women who may be uncomfortable having a cervical sample taken by a healthcare provider.

Zehbe and colleagues investigated the foundation for the development of an “ethical space” in collaboration with First Nations communities in northwest Ontario. The authors used a participatory action research approach based on respectful and meaningful collaboration with First Nations women, healthcare providers, leaders, and other community members. Through a series of engagements with community members, the authors designed a study that was both scientifically sound and accepted by the communities involved.

While there are still gaps in our understanding of HPV and its impacts on First Nations, Inuit, and Métis people, this issue of the Journal expands our knowledge and points to possible best practices for the prevention of HPV-related diseases, including cancer. Notably, in the context of HPV infections and cervical screening, this issue highlights the importance of culturally relevant and gender-sensitive Exploring HPV Infections and Cervical Screening With Multiple Lenses This issue of the Journal of Aboriginal Health ( JAH) explores human papillomavirus (HPV) infections and cervical screening in First Nations, Inuit, and Métis populations from a holistic perspective. This vantage point recognizes that health is a balance among the physical, mental, emotional, and spiritual aspects of life. This issue also acknowledges that health is influenced by more than personal health practices, including socioeconomics, access to care, and other social determinants of health. Editorial 6 Journal de la santé autochtone, mars 2012 screening programs.

It is important to continue building partnerships to explore the acceptability, accessibility, understanding, and uptake of HPV immunization in First Nations, Inuit, and Métis communities. Available vaccines can prevent up to 70% of cervical cancers caused by HPV and are recommended for girls nine years and older, as well as males between nine and 26 years of age, including males having sex with males. Obstacles such as those identified in this issue’s studies may hinder the dissemination of knowledge about and access to HPV vaccination. However, the studies point to a number of ways to identify and mitigate barriers to HPV immunization, helping to bring good health closer to the grasp of Aboriginal women in Canada.

Integrated HPV Working Group of the Federal Government Editorial

When the Data Does Not Match the Story:

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Do Trauma and Addictions Issues Really Characterize Poor Cervical Cancer Screening Uptake Among Manitoba First Nation Women Living On-Reserve?

By Brenda Elias1, Madelyn Hall1, Say P. Hong1, Erich V. Kliewer1,2,3

1University of Manitoba

2CancerCare Manitoba

3British Columbia Cancer Agency

Aboriginal women in Canada have higher rates of cervical cancer than non-Aboriginal women, and they are less likely to have regular cervical cancer screening (Pap smear). Some studies have suggested a link between traumatic life experiences such as childhood abuse and being less likely to have a Pap smear, while others have found that Aboriginal women face more barriers in accessing health care services. Some older First Nations women have said that they feel excluded by cervical cancer screening programs, and that those with a history of trauma, addiction, or mental health challenges are less likely to have regular Pap smears.

For this study, the authors used data from the 2002/2003 wave of the Manitoba First Nations Regional Longitudinal Health Survey, which looked at the health status of First Nations living on-reserve in several communities throughout Manitoba.  The authors used this data to see if there was a connection between traumatic life experiences, addiction, and/or mental health concerns and lower rates of Pap smear testing. They found that women with a history of suicidal thoughts or attempts and women who used more than one addictive substance were in fact more—not less—likely to have had a recent Pap smear. One possible explanation is that these women are more likely to be in regular contact with health care services, increasing their access to cervical cancer screening programs.

Because of the large proportion of women in the study who reported substance abuse, which puts them at higher risk for cervical cancer, and the low Pap smear testing rates among Aboriginal women overall, the authors stressed the need for more culturally appropriate, gender-sensitive health care services for First Nations women.

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Intimate Stories: Aboriginal Women’s Lived Experiences of Health Services in Northern British Columbia and the Potential of Creative Arts to Raise Awareness About HPV, Cervical Cancer, and Screening

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By Virginia L. Russell, BSc (hons), MSc[1] and Sarah de Leeuw, BFA, MA, PhD[2]

Many Aboriginal people face significant barriers in accessing health services, including screening for cervical cancer. These can be anything from geographical isolation, to lack of knowledge about screening, to feelings of discomfort about the medical system. The authors of this paper sought to identify what some of those barriers are for Aboriginal women living in northern British Columbia, using qualitative research methods that allowed the women themselves to tell their stories. Many participants came from underserved and marginalized backgrounds, often with a history of victimization. They completed questionnaires exploring their experiences in cervical cancer screening as well as gauging their knowledge about HPV and its connection to cervical cancer. Several women also took part in monthly arts-focused workshops designed to further identify the challenges they face and raise their awareness about HPV. Women in the study initially showed a somewhat low awareness about HPV and cervical cancer (although higher levels of formal education were associated with increased knowledge about HPV), but this improved after they took part in the arts-based workshops. Experiences of gendered victimization, feelings of disempowerment, and difficult life circumstances emerged as the main barriers to cervical cancer screening for the women in the study. Sensitivity from health care providers, culturally appropriate education, and assistance in childcare and transportation were all identified as ways to increase cervical cancer screening among Aboriginal women.

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[1] Graduate of the Community Health Sciences Program, University of Northern British Columbia, corresponding author: russellv@unbc.ca, 3333 University Way, Prince George, B.C.V2N 4Z9 Phone: (250) 981-4405

[2] Assistant Professor at the Northern Medical Program, University of Northern British Columbia. Faculty of Medicine, University of British Columbia.

HPV Detection by Self-Sampling in Nunavik, Quebec: Inuit Women’s Sampling Method Preferences

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By Helen Cerigo MSc1, Mary Ellen Macdonald PhD4, Eduardo L. Franco PhD1, 2 and Paul Brassard MD MSc1, 3

Screening for cervical cancer is most often done with a Papanicolaou (Pap) smear, where a health care provider uses a swab to collect cells from the cervix. In areas where few women take part in cervical cancer screening programs, self-sampling of cervicovaginal cells has been suggested as a way to increase participation in screening. The authors of this study wanted to find out whether Inuit women in Nunavik, Quebec—an area with high rates of HPV infection and cervical cancer—preferred provider-sampling or self-sampling. A total of 93 women participated in the study, both collecting their own samples and undergoing a standard Pap smear test with a nurse practitioner. Participants completed questionnaires about which method they preferred and why. The authors also looked at socio-demographic and lifestyle variables such as education level and medical history to see if there was any association with sampling method preference. Self-sampling was preferred by 56% of women in the study, and was associated with having less than a grade 9 education. Women who had completed at least grade 9 tended to prefer provider-sampling. Among women who preferred to collect their own sample, reasons for their preference included increased comfort and privacy. Women who preferred sampling by a health care provider expressed concerns that they might not be able to correctly collect their own sample and many  found provider-sampling easier and more convenient. Women in this study were recruited from a cohort that was already involved in regular cervical cancer screening, so the results may not be applicable to unscreened women in Nunavik. The results do suggest, however, that self-sampling may have the potential to increase participation in cervical cancer screening programs, especially among women who are uncomfortable with Pap smear testing.

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1 Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine, McGill University

2 Division of Oncology, Faculty of Medicine, McGill University

3 Department of Medicine, Faculty of Medicine, McGill University

4 Division of Oral Health and Society, Faculty of Dentistry, McGill University

Ethical Space for a Sensitive Research Topic: Engaging First Nations Women in the Development of Culturally Safe Human Papillomavirus Screening

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By Ingeborg Zehbe1,2,3*,Marion Maar4*, Amy J. Nahwegahbow5, Kayla SM Berst1,2, Janine Pintar1,2

First Nations women are widely under-screened for HPV infection and cervical cancer. This may be due to issues around screening for a sexually transmitted infection. These issues may include experiences of stigmatization, feelings of shame, and fear of lack of privacy when results are reported in very small communities. Any HPV research in First Nations communities must be done in a sensitive, respectful, and culturally appropriate way, preferably involving community members themselves. In studying ways to promote HPV and cervical cancer screening in First Nations communities in Ontario, the authors of this paper used a participatory action research (PAR) approach, which involves collaboration between the research team and the people the research is supposed to benefit. The authors also used First Nations scholar Willie Ermine’s concept of ethical space—where groups with separate worldviews come together to recognize differences and negotiate mutual understanding—in their approach to working with the communities. Through a series of engagements with community members to introduce, develop, and refine the proposed research, the authors were able to create a study that was both scientifically sound and accepted by the community.  A pilot study was completed in one First Nations community with a larger, randomized trial scheduled to begin in ten additional communities involving up to 1,000 women. Although the PAR/ethical space approach may be more time- and resource-intensive, involving local women, health care providers, leaders, and other community members helps ensure acceptance by and benefit to the First Nations communities involved in research.

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1Probe Development and Biomarker Exploration, Thunder Bay Regional Research Institute, Thunder Bay, Ontario, Canada

2 Biology Department, Lakehead University, Thunder Bay, Ontario, Canada

3Health Sciences Division,Northern Ontario School of Medicine, Thunder Bay, East Campus, Ontario, Canada

4Human Sciences Division,Northern Ontario School of Medicine, Sudbury, West-Campus, Ontario, Canada

5School of Public Health,University of Waterloo, Waterloo, Ontario, Canada

Volume 7, Issue 1 – Social Networks and Health

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The National Aboriginal Health Organization (NAHO) is pleased to celebrate the tenth issue of the Journal of Aboriginal Health (JAH). This issue provides examples of how health is influenced and shaped by social networks, in addition to other determinants of health.

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Introduction – Celebrating 10 Issues of the Journal of Aboriginal Health

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Welcome to the tenth issue of the Journal of Aboriginal Health! The National Aboriginal Health Organization (NAHO) gives thanks to all parts of creation and the many contributors who made this issue possible—the authors, the reviewers, the editorial board, its staff, and the production team. Also, nia:wen kowa (thank you) to Health Canada for providing core funding and supporting initiatives like the Journal of Aboriginal Health.

Thousands of years ago, the Peacemaker brought the warring Iroquois nations the concept of ganigonhi:oh (the good mind), which means a mind that cultivates peaceful and loving thoughts. NAHO brings you this body of work with a good mind. The Journal of Aboriginal Health is a peer-reviewed journal that shares success stories in First Nation, Inuit, and Métis health, discusses issues and opportunities, and provides the latest information and research of interest to First Nations, Inuit, and Métis. It publishes in-depth analyses of health research and issues with full citation of sources; facilitates informed discussions on new research, recent publications, and projects; and explores health determinants from the perspectives of First Nations, Inuit, and Métis.

Since the release of the first issue of the Journal of Aboriginal Health in 2004, a number of themes have been explored, including the governance of Aboriginal health,population health and the determinants of health, the health of urban Aboriginal people, Aboriginal women’s health, First Nations communities in crisis, and the decolonization of health through Indigenous Knowledge and practice. For 2011, NAHO is delighted to bring you the next issue of the Journal themed “social networks and health.”

In the coming year, NAHO looks forward to exploring new themes with you, such as Indigenous Knowledge and health, as well as making the Journal more accessible by indexing it with searchable academic databases. To ease the burden on Mother Earth, NAHO also plans to publish the Journal online.
The Journal of Aboriginal Health is an open access journal, meaning it is free to anyone who has access to the Internet. The NAHO invites you to join our 2,000 plus subscribers and download your copy of the Journal at www.naho.ca/jah.

On behalf of all those involved, I hope you enjoy this tenth issue. I also hope you will become a future part of this publication by sharing your research, experience, creativity, and knowledge. Let us bring our minds together to create a bright future for present and future generations.

Nia:wen kowa,

Paulette C. Tremblay, PhD
Chief Executive Officer
National Aboriginal Health Organization
Ottawa, ON

Editorial – Social Networks and Health

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At the end of a talk, our People often say “All my relations.” These three words are a declaration that we—people, the four-legged animals, and all of nature—are all connected and related. But how do these connections or social networks influence health?

This collection of papers represents a weaving together of diverse discourses on health. While one paper discusses the attitudes of Aboriginal young people toward pregnancy and fertility, another tackles the issue of suicide attempt among Māori youth in New Zealand. Within this diversity, there are common threads that weave each of these papers together.

One, of course, is health. In the Anishinaabe culture, “mino bimaadzwin” (the good life) is a holistic conceptualization of health, where health is a balance between the physical, mental, emotional, and spiritual realms of life. It is also a life that is lived according to the seven grandfather teachings of wisdom, love, respect, bravery, honesty, humility, and truth.

The second common thread is the concept of connections or social networks. As individuals, we are all a part of intricate, complex, and ubiquitous social networks that tie us to family, friends, organizations, and so on. These social networks have a significant influence on our health. Research by Nicholas A. Christakis and James H. Fowler has shown that obesity is contagious—if you have a friend who is obese, your risk of obesity goes up by 57 percent (Christakis & Fowler, 2007). They’ve also shown that happiness is contagious (2008). And perhaps the most devastating example of the power of social networks is suicide contagion. People are connected, so their health is
connected.

Each article in this issue of the Journal of Aboriginal Health tells a story about how we negotiate mino bimaadzwin in a post-colonial and increasingly connected world. They also provide examples of how our health is influenced and shaped by our social networks, in addition to other determinants of health.

In a qualitative study conducted by Karen M. Devries and Caroline J. Free, we see how Aboriginal young people share views on planning for pregnancy, having children, and how these relate to condom and contraception use. This study has important implications to improve sex education programs and reduce rates of sexually transmitted infections.

Terryann C. Clark and colleagues found similar results in their random survey of Māori students in New Zealand exploring risk and protective factors for suicide attempt. Their findings highlight the importance of family in shaping health. For example, having a close friend or family member die by suicide was a significant risk factor for suicide attempt, and being connected to family not only reduced the risk of suicide attempt, but reduced it across all levels of risk, not just at higher levels of risk.

In a qualitative study by Peter J. Hutchinson and colleagues, we are introduced to six communities, or social networks, and their experiences around establishing tobacco control policies (TCPs). The authors identified three main factors that influence the success of TCPs, which were most strongly illustrated in three different community halls used for bingo: economic drivers, the smoking majority, and community and grassroots support. This study suggests that when smokers are the majority in a network, they hinder the success of TCPs, and when people in the network support the ban of smoking, TCPs are more likely to succeed.

John F. Anderson and colleagues explore place-based learning communities (PbLCs), which are dialogue-based networks, and how these can be used to support a community’s ability to generate its own research projects and co-produce locally relevant knowledge with other researchers. This article suggests that PbLCs can be used to strengthen connections within a network. The Health Integration Project Planning Committee, which is a partnership between the First Nations community of Sts’ailes, the Fraser Health Authority, and researchers at the University of Victoria and the University of British Columbia, implemented the principles of PbLCs in a primary health care project, and this resulted in an intimate, trusting partnership.

A qualitative study by Jude Kornelsen and colleagues describes the birth experiences of women in rural First Nations communities before and after the loss of local maternity services. They found that many of the women felt a sense of isolation, alienation, and powerlessness as a result of having to give birth at a referral centre. However, most of the women showed resilience by proactively seeking answers about the decline of services, or trying to mitigate their feelings of isolation and estrangement at the referral centre (e.g., by bringing along family members and returning home as soon as possible).

This diverse collection of papers shows us that our health, from our attitudes towards pregnancy and fertility to our risk of attempting suicide, is influenced by our social networks. This network phenomenon suggests that all of us have the potential to be healthy, resilient and powerful people in our networks, and encourage the spread of positive health behaviours. It also compels us to rethink the ways we promote and advance the health of First Nations, Inuit and Métis, and suggests some innovative approaches to public health.

All my relations,

Camille Lem, BScN, RN, MEd
Editor
Journal of Aboriginal Health
National Aboriginal Health Organization
Ottawa, ON

 

REFERENCES

Christakis, N. A. & Fowler, J. H. (2007). The spread of obesity in a large social network over 32 years. The New England Journal of Medicine, 357(4), 370-379.

Christakis, N. A. & Fowler, J. H. (2008). Dynamic spread of happiness in a large social network: Longitudinal analysis over 20 years in the Framingham Heart Study. British Medical Journal, 337, a2338. doi:10.1136/bmj.a2338.

“It’s Not Something You Have to Be Scared About”: Attitudes towards Pregnancy and Fertility Among Canadian Aboriginal Young People

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by Karen M. Devries and Caroline J. Free

Overview

Aboriginal young people in Canada are more likely to contract sexually transmitted infections (STIs) and become pregnant compared to other young Canadians. Unprotected sex is the main cause of pregnancy and many STIs.

In order to improve sex education programs, the researchers interviewed 30 Aboriginal young people in British Columbia in both rural and urban settings. This study presents the young people’s views on planning for pregnancy, having children, and how these relate to condom and contraception use.

  • Perceived community norms: Participants perceived some negative stigma around adolescent childbearing, but believed that their family would still welcome and help care for new children.
  • Desire for pregnancy: Most participants wanted to delay pregnancy until they were ready for the responsibility. Ideas around “readiness” included leaving adolescence, finishing high school, having an income, or having a stable emotional environment, e.g., being in a serious relationship.
  • Condom and contraception use: In short-term relationships, condom use was consistent. In longer, more serious relationships, contraception use was mixed. Some young people decided to stop using condoms without substituting alternatives, voicing concerns about the safety and efficacy of hormonal birth control. In these cases, the possibility of having children was accepted although not actively desired.
  • Role of family: Many participants lived without both parents. There were mixed reactions to these disrupted family relationships; some participants wanted to be more responsible than their parents and provide a stable environment for their children, and some described risky sexual behaviour in terms of both health and emotional well-being.

Implications

Although adolescent pregnancy was not viewed as desirable, many participants perceived positive norms or feelings of “readiness” toward having children. This could create situations where unprotected sex was likely to occur. Sex education must take into account these beliefs and behaviours to improve success and reduce rates of STIs.

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