Phase 1: Vision and relationships leading to problem identification
The project was conceptualized and developed through two years of “Vision and Relationships” dialogue with the participating communities. Ten consultation sessions were held with community leaders, health workers and community members (Figure 1). Four exposure − outcome dyads were identified by the communities as key factors driving respiratory health inequalities: i) the quality of housing and mold within the houses − asthma, especially in children; ii) smoking in general, and smoking in the homes resulting in environmental tobacco smoke (ETS) − chronic obstructive pulmonary disease (COPD); iii) overcrowding and infections − bronchitis; iv) body weight − obstructive sleep apnea (OSA). A Decision Makers Council consisting of Band Councilors, elders and youth was then formed to oversee the FNLHP. Table 1 is the logic model for the FNLHP which enumerates the four phases of the study, including how the four exposure-outcome dyads were assessed and will be addressed and redressed. An agreement was signed that addressed issues on co-ownership of data between researchers and communities and how confidentiality and privacy would be respected.
Phase 2: Baseline assessment ─ data collection and analysis
Phase 2 corresponds to the baseline survey, which has been completed. In each of the two participating First Nations communities the baseline assessment consisted of two stages. The first stage involved personal invitations via door-to-door canvassing to make people aware of the baseline survey and distribute brochures explaining the need and purpose of the study. The second stage consisted of the in-person administration of questionnaires and conducting clinical assessments. Before conducting the survey, a Certificate of Approval was obtained from the University of Saskatchewan’s Biomedical Research Ethics Board. Moreover, before implementing the second stage of this phase, informed written consent from all participants was obtained.
Questionnaire development and administration
Two questionnaires were administered to adults in the second stage of the baseline survey. These included a household questionnaire and an individual questionnaire. In developing the baseline assessment questionnaires (household and individual), PHF’s framework was taken into account by including questions that capture both individual and contextual factors (see Figure 2). However, before developing the questionnaires, feedback was obtained from community advisors (elders and health director) of both participating reserves. Community advisors also provided input about the best approaches for contacting participants; as well as collecting questionnaire and clinical assessment data from participants. Finally, a pilot study was then conducted to optimize the content and administration of the baseline questionnaires. Based on the pilot project responses, several survey questions were modified in the questionnaires that were finally used for the FNLHP baseline survey conducted between 2012 and 2013. Trained research assistants from each community undertook to personally invite every community resident (18 years and older) via door-to-door canvassing to visit the Health Centre in the community to complete the interviewer-administered questionnaires and to participate in clinical assessments. An identification number was assigned to each household using the community map. During their visit to the Health Centre, study participants were asked to identify their respective households on the map. An interviewer-administered survey consisted of asking a key informant from each household to provide household level information (household questionnaire). In addition, adults (18 years and older) who visited the Health Centre were also asked to complete the individual section of the questionnaire and invited to undergo pulmonary function and allergy skin prick testing.
The questionnaires were primarily designed to obtain information on individual and contextual determinants that could influence respiratory health. However, questions were also included to evaluate general respiratory health, including any history of other health conditions.
Baseline pulmonary function and allergy skin tests
All baseline clinical tests were conducted by trained health professionals. Sensormedics (Anaheim, CA) dry rolling seal spirometers [33-35] were used to obtain measures of forced vital capacity (FVC), forced expired volume in one second (FEV1), FEV1/FVC ratio × 100, and maximum mid-expiratory flow rate (FEF25–75). Measurements were taken according to the standards of the American Thoracic Society . Persons who demonstrated below normal tests were referred to their family physician for follow-up.
Allergy skin tests were conducted using the skin prick method with a panel of six non-food allergens: cat dander, local grasses, aspergillus sp, alternaria, house dust mite, cladosporium, along with control saline and histamine as the positive control. Standardized allergen extracts were used as recommended by the Academy of Allergy, Asthma, and Immunology . Also, the allergy skin test procedure was performed according to the recommended protocol of practice parameters for allergy diagnostic testing. Subjects were considered positive for atopy if one or more skin prick tests resulted in a raised wheal that is greater than 3 mm compared to the saline control.
Variables of interest
Outcomes of interest were from the survey as well as the clinical visit. The key clinical outcomes (self-reported doctor diagnosed) of the FNLHP from the survey are asthma, COPD, chronic bronchitis and OSA. The key outcomes from the clinical testing were the lung function measurements (FVC, FEV1/FEV1/FVC, and FEF25–75) obtained via spirometry to ascertain respiratory health.
The primary contextual factors associated with respiratory health outcomes are crowding (based on number of people who usually live in the household and number of bedrooms); socioeconomic status (assessed using total household income, household income adequacy, and perceived financial strain); socio-cultural factors (family social support, community social support, colonization [see Additional file 1]); access to health care services; and indoor air quality (assessed by response to questions about the quality of house – in need of major/minor repairs, water damage and dampness, mildew, and presence of proper ventilation, and indoor smoking). More importantly, in collaboration with the communities, we have included specific questions that delineate participants’ experiences and perception regarding colonization, residential school enrollment, racism and discrimination. These historical injustices will contextualize the associations between all other predictors and the outcomes of interest.
The primary individual factors being considered are the highest level of educational attainment, and lifestyle and behavioural factors, including smoking, physical activity, and alcohol consumption.
Information was obtained on covariates such as age, sex, body mass index (BMI), waist circumference, and an extensive list of co-morbidities [see Additional file 1].
Phase 3: Action – address (community-level) and redress (policy-level)
The address-redress phase forms the crux of the FNLHP, where critical community and policy-level interventions informed by baseline assessment results will be implemented to address and redress the issues (exposure-outcome dyads) identified in the logic model (Table 1). With this phase currently being rolled out, a broad implementation structure to address and redress the exposure-outcome dyads has been identified:
Housing-asthma: To improve housing conditions by providing tools to reduce dampness and mold, the main focus of the interventions are to provide sustainable tools to improve housekeeping, to devise ways to reduce dampness and mold, and facilitate the adoption of the “Outdoor living room”─ to encourage the elimination of indoor smoking in households with children. Although the ultimate aim of these interventions is to prevent asthma, based on the data obtained by the baseline survey, identification and treatment of asthma, especially in children, is a priority.
Smoking-COPD: Interventions to reduce smoking in the community with a specific emphasis on schools.
Infections-bronchitis: Interventions to improve hygiene, and increase immunization and flu vaccination rates to ultimately reduce the risk of respiratory illnesses such as bronchitis.
Body weight-OSA: To develop upstream interventions which address the obesity pandemic and redress access to health care services specific to the diagnosis and management of OSA.
These interventions are in the preliminary stage of development and will evolve and mature as the FNLHP progresses.
Interventions in action
Housing conditions are known to be associated with respiratory outcomes such as respiratory infections, bronchitis and asthma in First Nations populations. Little is known about the housing conditions responsible for respiratory conditions in Saskatchewan First Nations reserves. Adult participants were asked if they would like to have environmental assessments of their homes. Of the positive responses, 144 homes underwent environmental assessments. Environmental assessments included an interviewer administered housing survey, floor dust collection, and temperature and relative humidity measures. Homes were visited between January and April 2014. Household survey and floor dust data are electronically entered and in the process of being analyzed. Floor and air samples will be assessed gravimetrically and for endotoxin and beta 1–3 glucans.
Green light program
The Green Light Program is an evidence-informed and community driven community-level intervention which identifies and celebrates homes that are smoke-free . The objectives of this program are: (i) To celebrate the number of smoke-free homes and increase the number of smoke-free homes by 10% per year; (ii) To engage Elders/mentors/role models/community members in supporting policy related to the misuse of tobacco and community change; (iii) To decrease the rate of tobacco mis-use by 10% per year among all age groups and particularly in youth, pregnant women and seniors; and (iv) To increase cessation strategies by 10% a year among individuals mis- using tobacco. Within the context of this work, tobacco mis-use is defined as non-traditional use of tobacco by First Nations and Métis peoples. Traditional use of tobacco in First Nations and Métis communities is “sacred” and has cultural, medicinal, and spiritual implications which are to be respected, whereas casual or recreational use is mis-use.
Addressing and Redressing Obesity-OSA
To address obesity, a two-tiered intervention is being adopted to increase long term physical activity and promote consumption of nutritious food. Toward achieving and sustaining this goal, partnerships with the participating First Nations communities will be used to incorporate not only specific Indigenous knowledge, but also culturally safe and meaningful practices that focus on building community capacity. Similarly, to address OSA, the emphasis will be on utilizing community partnerships to again implement a two-tiered intervention ─ an educational program that not only raises awareness about the long term impact of OSA, but also provides skills in self-administration of a validated questionnaire that highlights the symptoms indicative of OSA risk. This ability to recognize the symptoms of OSA is a critical step in its diagnosis because evidence strongly suggests that an overwhelming majority of the population suffering from OSA do not utilize diagnostic services due to lack of awareness.
To redress obesity, the focus is again on combining Indigenous Knowledge with evidence of food insecurity and the lack of access to places for physical activity in First Nations communities to improve sustainable access. Finally, to redress OSA, it is imperative to appreciate the historical and jurisdictional complexity of healthcare provision to First Nations. Under the Canadian Constitution, healthcare is a provincial responsibility; however, “Registered Indians” are considered under the federal system . As a result, healthcare for First Nations is a complex and complicated endeavour, with services being delivered by the First Nations and the provinces but funded by the federal government, with differing policies and practices, particularly for OSA . Thus, in redressing OSA, a review of healthcare coverage, clinical practices and healthcare utilization is being conducted by interviewing key stakeholders. This multi-dimensional evidence will be combined to identify key gaps in policies and practices that effect First Nations peoples’ ability to utilize medical services for OSA.
Based on 2011 Canada Census we used a sampling frame of 321 households and 810 adult residents in Community A, and 259 households and 760 adult residents in Community B. We obtained baseline data from 432 adults (living in 173 households) in Community A and 442 adults (living in 233 households) in Community B (see Table 2).
Response rates were determined for each of the participating communities. Descriptive results based on pooled data from the participating communities are presented in this manuscript. Statistical analysis was conducted using IBM SPSS Statistics version 21 (IBM Corporation, Armonk, New York). For baseline survey data, descriptive statistics (in terms of frequencies and mean ± standard error) were computed.