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Background to the Iiyiyiu Aschii workshop

My participation in the symposium on the Ottawa Charter (World Health Organization, 1986) that took place in October 2006 during the 10th Journées Annuelles de Santé Publique (JASP) conference was intertwined with my new role teaching public health to the Program Officers in the Department of Public Health of the Cree Board of Health and Social Services of James Bay. Having completed my residency training in Community Medicine at McGill University in June 2006, my first position as a Public Health Physician was a maternity leave replacement for Dr. Faisca Richer, who had developed a curriculum for public health capacity building in the Cree Board of Health and Social Services. Since I had a strong interest in health promotion, and had recently attended the 6th Global Conference on Health Promotion in Bangkok in August 2005 as a Next Generation Rapporteur (World Health Organization, 2005), it was decided that the first training that I would give would cover promotion and prevention strategies for improving population health (Health Canada, 2001). While preparing the course materials for the training to be held in July 2006, I was approached by Véronique Laberge Gaudin, a nutritionist working in the Chisasibi Office of the Public Health Department, who asked whether I would be interested in collaborating on the preparation of a workshop for the JASP Ottawa Charter symposium that would focus on Aboriginal health issues. Thus my role in the symposium involved co-authoring the materials for the workshop, providing opportunities for developing and piloting the workshop that were integrated into the public health trainings, and co-facilitating one of the workshop small groups on the day of the symposium.

Preparing the Iiyiyiu Aschii workshop using a participative approach

The preparation of the workshop for the Ottawa Charter symposium was as much of a learning experience as the actual workshop itself. Each of the Program Officers who attended the trainings and helped to prepare the workshop also work full-time planning and implementing public health programs in the Cree region in relation to the Quebec Public Health Plan (Ministry of Health and Social Services, 2003). The Program Officers bring with them a wide range of expertise and experience as they come from very varied backgrounds geographically (e.g. Quebec, rest of Canada, Africa, Middle East, etc.), culturally (Aboriginal, non-Aboriginal), professionally (nursing, dentistry, nutrition, communications, environmental studies, etc.) and academically (high school diploma, college degree, undergraduate studies, graduate studies). It was clear from our discussions that many of the day-to-day public health activities in the region are consistent with the approach promoted by the Charter. As one of the public health staff pointed out, “we are already ‘doing’ the Ottawa Charter even if we do not always refer to it in an explicit way.” It was considered that the five axes of the Ottawa Charter provide a useful conceptual framework for categorizing certain public health activities that are already being carried out and for identifying areas where more work can still be done.

Thus the development of the workshop was a participative and iterative process that extended over four months. It was decided that the focus of the workshop should be on using the Ottawa Charter for the prevention of diabetes, which is one of the foremost and rapidly growing public health concerns in the Cree region (Kuzmina and Dannenbaum, 2005), in many Aboriginal communities across North America and in the rest of the world (Young et al., 2000; Acton et al., 2006).

Contents of the Iiyiyiu Aschii workshop

The final workshop consisted of a welcome prayer recited in the Cree language and an introductory PowerPoint presentation in English, followed by two small group discussions, and finally a plenary session to provide feedback and to distill key take-home messages. The overall objectives of the workshop were:

• 1. To understand Cree concepts of health and wellness,
• 2. To explore historical and cultural influences on Cree health and health-related factors (knowledge & behaviours),
• 3. To demonstrate the use of the Ottawa Charter for the prevention of diabetes
  in Cree communities, and
• 4. To identify opportunities and challenges in using the Ottawa Charter to promote health.
  

A great deal of thought went into the preparation of the PowerPoint presentation. In particular, it was considered that health promotion in general, and the use of the Ottawa Charter in particular, must consider the context in which it is being applied. During one of the lengthy discussions on this subject, one of the Cree Program Officers explained that certain health promotion strategies, such as the widely promoted campaign to eat 5 to 10 fruits and vegetables per day, would be even more effective in the Cree region if it is adapted for the local context. He explained that the Cree people used to be nomadic hunter-gatherers who ate a diet according to the seasonal availability of different foods, consisting mostly of fish, traditional meats (e.g. wildfowl, moose, etc.) and berries. The Cree concept of health was tied in with being able to live off the land and feed one’s family (Adelson, 2000). Increasingly, Western influences have permeated the Cree culture and diet, with both positive and negative effects. These contextual and historical factors that are central to developing effective public health strategies were a major focus of the PowerPoint presentation and were also reflected in the overall objectives of the workshop.

The workshop hinged on the PowerPoint presentation, which provided an introduction to the main issues and set the scene for the small group discussions of the opportunities and challenges of using the Ottawa Charter in practice. The PowerPoint was presented by Véronique Laberge Gaudin, Solomon Awashish and Paul Linton and is now available online (URL: "http://www.inspq.qc.ca/jasp/archives/pdf/2006/JASP2006-Ottawa-VLaberge-Gaudin19-1.PDF"). The presentation was divided into three main sections: 1) background information on the Cree Nation of James Bay Northern Quebec, 2) a multi-media presentation to provide an introduction to the historical and cultural context in Iiyiyiu Aschii, and 3) an explanation of the increasing concern over the growing diabetes epidemic. The content of the presentation is summarized in Box A.

Following the PowerPoint presentation there were two small group discussions, one on the opportunities and challenges for using the Ottawa Charter in promoting greater physical activity and the other one in promoting better nutrition. Although the turnout was rather low, participants in the workshop came from diverse backgrounds and the discussion was lively and interesting. There were several case studies provided (see Box B for an example of one of the case studies), and participants selected one of the case studies to focus on. Participants had the opportunity to discuss their own experiences, and also to learn about what goes on in other communities. The main take-home messages were then presented and discussed in the plenary session.

Key messages from the Iiyiyiu Aschii workshop to take to Vancouver

In the plenary session at the end of the workshop, the key messages were as follows:

• The projected impact of the diabetes epidemic is tremendous, both in terms of the social cost, as well as the financial cost of providing expensive health services such as dialysis.
• To a large extent, the diabetes epidemic is preventable by modifying dietary and exercise habits through behavioural and environmental change, as well as tackling the underlying social determinants of health.
• The Ottawa Charter is still considered to be a useful tool for conceptualizing and planning public health activities. Although the focus up to now in Iiyiyiu Aschii has largely been on reorienting health services and personal preventive practices, more needs to be done to develop supportive environments and build healthy public policy through partnerships within and beyond the health sector.
• All interventions for promoting Aboriginal health should be participative, empower communities and consider the historical and cultural context.

Follow-up since the Iiyiyiu Aschii workshop

In the short time since the workshop, one of the Program Officers has already used the Ottawa Charter framework for a presentation on the importance of physical activity that was made to the Cree Grand Council, and others have raised the issue of health promotion in work-related discussions. Only time (and rigorous evaluations) will tell whether this approach to health promotion will become more explicit in public health planning, and more importantly, whether it will also improve population health and reduce inequities, both within the Cree communities and in comparison to other regions. Nonetheless, the level of interest in using the Ottawa Charter in Iiyiyiu Aschii has certainly increased, and many employees of the Public Health Department are awaiting the Vancouver conference with great excitement and anticipation.

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Box A: Summarized contents of workshop PowerPoint presentation

Iiyiyiu Aschii is the traditional land and home of the Cree Nation of James Bay in Northern Quebec. Iiyiyiu Aschii literally means “land of the people.” Currently, there are approximately 14,000 Cree living in 9 communities spread across a territory two-thirds the surface area of France. This includes 5 communities along the coast of James Bay and Hudson’s Bay as well as 4 inland communities North-West of the Saguenay-Lac-St-Jean Region (see Figure 1). The demographic curve of the Cree population resembles that of a developing country with the majority of the population less than 30 years of age. There are major social problems affecting the Cree communities including addictions, unemployment and a high-school dropout rate double that of the rest of Quebec (Torrie et al, 2005). Thus there are multiple geographic, cultural and social challenges for the Cree Board of Health and Social Services of James Bay, which is responsible for providing medical, social and public health services in the region. However, there are also many protective factors to draw upon. Despite the difficult transition period when the previously nomadic population was settled into communities, traditional ways of life have been retained with 97% of the population continues to speak Cree and 79% still engaging regularly in hunting, trapping and fishing activities. As well, in 1975, the James Bay Northern Quebec Agreement (JBNQA), which confers administrative powers to the Cree, was the first modern treaty signed between a government and an Aboriginal group.

Adapting to life in the modern age has had both positive and negative consequences. The use of new technologies such as satellite phones allows families to stay in contact even when out “in the bush” (i.e. off hunting, fishing or trapping in the wilderness). However, fast food and big cars, as well as a high cost of living, have also taken their toll. In particular, the transition to a more sedentary lifestyle and the increasing reliance on “store-bought food” has led to a rapid rise in the incidence of obesity and diabetes. Currently, one third of the Cree population is overweight and over half are clinically obese (defined as a body mass index greater than 30), with only 14% of the population having a healthy body weight (Bobet, 2001). Up until the late 1970’s there were no cases of diabetes in the Cree territory. There was not even a Cree word for diabetes, which is now translated as “sweet blood.” However, over the last two decades, the prevalence rates of diabetes have risen from 4.1% in 1989 (Brassard et al, 1993) to 15.0% in 2005 (based on Cree Diabetes Surveillance data). The age-adjusted prevalence rates in the Cree region (22.4%) are now over four times higher than in the rest of Quebec (4.9%), thus the Cree epidemic is far greater and growing at an even faster pace than what is already considered to be an epidemic of diabetes in the rest of the province (Kuzmina and Dannenbaum, 2005). Already there is a small dialysis unit at the Chisasibi hospital, and this is just the tip of the iceberg unless dramatic action is taken. A diabetes action plan for the Cree region was launched in 2001, and it includes provisions for developing activities in the areas of surveillance, primary prevention, education and training, clinical care and support, as well as evaluation and research. Nonetheless, greater preventive efforts are needed to reduce or at least slow down the rising prevalence rates. Such interventions should be culturally sensitive, build on Cree knowledge and expertise, and empower the Cree community.

Figure 1: Map of Iiyiyiu Aschii

Source: Torrie et al. (2005)

Box B: Excerpt from a small group case study

Mary is a 28-year-old mother of three children. She is Cree and has lived in James Bay, Northern Quebec, all her life. When she was young she was very slim, but in her teens she put on weight, and even more so after she got married and started having kids.

Mary now has a body mass index (BMI) of 34, and was recently diagnosed with impaired fasting glucose, a precursor to diabetes. Her doctor told her that losing even a few pounds and being more active could greatly improve her blood sugar levels, and could prevent or at least postpone a diagnosis of diabetes.

During, her last pregnancy, Mary had gestational diabetes. At that time she saw a doctor, nurse nutritionist and Community Health Representative and attended some workshops in the community on topics such making baby food and low-fat cooking.

Even if Mary knows what healthy foods to choose, sometimes she finds that eating healthy is difficult. Some days, she wishes to try new foods but then, when she goes to her community grocery store, there are very limited choices. She also likes traditional foods. She knows that fish and game meats are healthy, but since her husband works full time in the community, he no longer has time to go fishing and trapping for the family.

When Mary tries to eat better and be more active, she feels pressure from her husband and her mother. They believe that she is not eating enough and will not have enough energy to take care of the family. She thought about going to the local gym to do some exercise a couple of times in the week but the children take up a lot of time.

Notes

1. Iiyiyiu Aschii is the traditional land and home of the Cree Nation of James Bay in Northern Quebec. Iiyiyiu Aschii literally means “land of the people”.

2. This paper is written in the first person perspective of the first author. However, the content of the workshop described here reflects the work of all of the co-authors.

3. The multimedia presentation consists of photos with the narration provided by Solomon Awashish, a staff member of the Cree Board of Health and Social Services of James Bay who was born and raised in Iiyiyiu Aschii. The presentation can be obtained by contacting the author.

Acknowledgements

We would like to thank the Program Officers and other staff members in the Department of Public Health of the Cree Board of Health and Social Services of James Bay for their generous comments and suggestions during the preparation of the workshop and of this paper.

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