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The cedar project: using indigenous-specific determinants of health to predict substance use among young… Shahram, Sana Z; Bottorff, Joan L; Oelke, Nelly D; Dahlgren, Leanne; Thomas, Victoria; Spittal, Patricia M Sep 15, 2017

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RESEARCH ARTICLE Open AccessThe cedar project: using indigenous-specific determinants of health to predictsubstance use among young pregnant-involved aboriginal womenSana Z. Shahram1,8,9*, Joan L. Bottorff2,3, Nelly D. Oelke4, Leanne Dahlgren5, Victoria Thomas6,Patricia M. Spittal7 and For the Cedar Project PartnershipAbstractBackground: Indigenous women in Canada have been hyper-visible in research, policy and intervention related tosubstance use during pregnancy; however, little is known about how the social determinants of health andsubstance use prior to, during, and after pregnancy intersect. The objectives of this study were to describe thesocial contexts of pregnant-involved young Indigenous women who use substances and to explore if anIndigenous-Specific Determinants of Health Model can predict substance use among this population.Methods: Using descriptive statistics and hierarchical logistic regression guided by mediation analysis, the socialcontexts of pregnant-involved young Indigenous women who use illicit drugs’ lives were explored and the IntegratedLife Course and Social Determinants Model of Aboriginal Health’s ability to predict heavy versus light substance use inthis group was tested (N = 291).Results: Important distal determinants of substance use were identified including residential school histories, as well asprotective factors, such as sex abuse reporting and empirical evidence for including Indigenous-specific determinantsof health as important considerations in understanding young Indigenous women’s experiences with pregnancy andsubstance use was provided.Conclusions: This analysis provided important insight into the social contexts of women who have experiences withpregnancy as well as drug and/or alcohol use and highlighted the need to include Indigenous-specific determinants ofhealth when examining young Indigenous women’s social, political and historical contexts in relation to theirexperiences with pregnancy and substance use.Keywords: Canada, Aboriginal health, Women’s Health, Substance use, Addictions, Pregnancy, Maternal health, Socialdeterminants of health* Correspondence: sanashahram@gmail.com1Faculty of Health and Social Development, University of British Columbia,1147 Research Road, Kelowna, BC V1V 1V7, Canada8Present Address: Postdoctoral Research Fellow, Centre for AddictionsResearch of British Columbia, University of Victoria, PO Box 1700, STN CSCVictoria, Victoria, BC V8W 2Y2, CanadaFull list of author information is available at the end of the article© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Shahram et al. BMC Women's Health  (2017) 17:84 DOI 10.1186/s12905-017-0437-4BackgroundIn Canada, Aboriginal1, 2 mothers have been hyper-visiblein research, policy and intervention related to alcohol anddrug use during pregnancy, while the social contextsunderlying Aboriginal women’s substance use have oftenbeen ignored [17, 22] particularly as they relate to experi-ences with pregnancy. Due to imposed legislative and so-cial conditions, beginning with colonization, many youngAboriginal mothers are located at the intersections ofmultiple dimensions of social inequality that shape theirexperiences with substance use and parenting in complexways. However, there is a dearth of epidemiological datathat explores these contextual factors related to substanceuse before, during and after pregnancy, and quantitativedata which necessarily and explicitly attends to under-standing these broader determinants of substance use isneeded [22]. To understand these determinants acrosswomen’s lives in a more nuanced and contextualizedway, the typical research focus on substance use onlyduring pregnancy must be broadened to includepregnant-involved women’s life experiences with alco-hol and drug use before, during and after pregnancy.For the purposes of this research project, pregnant-involved was defined as having ever experienced a preg-nancy, regardless of pregnancy outcome or subsequentmothering role.The social determinants of substance useHeavy and frequent substance use by women typicallypeaks among women aged 18 to 24 years old, and ishighest among women with lower incomes and/or lowerlevels of education [1]. Women who use alcohol ordrugs problematically are also often living in high riskenvironments characterized by poverty, unstable hous-ing, food insecurity and unemployment, and often havehistories of abuse and psychological issues [17].Aboriginal women who use substances often face triplediscrimination and marginalization as women, Aborigi-nal people, and people who use substances [7]. Whencompared to the rest of Canada, the comparativelyyoung population of Aboriginal peoples bear a dispro-portionate burden of illness, poor health and violent lifeexperiences [6, 14], while also experiencing higher un-employment rates, and lower formal education attain-ment and incomes (with Aboriginal women havinglower incomes than Aboriginal men) [5, 4, 18]. WhileAboriginal young women have higher rates of problem-atic substance use in Canada than non-Aboriginal youngwomen [17], the contexts of use are explicitly linked tothese contemporary health and social inequities that arethe downstream manifestations of the colonial process(including social and cultural disruption, and historicaland intergenerational trauma) that continues to impactAboriginal peoples lives today [14, 15].The integrated life course and social determinants ofaboriginal health (ILCSD) modelIn 2009, the National Collaborating Centre for AboriginalHealth commissioned a report on the health inequalitiesexperienced by Indigenous peoples in Canada, which alsointroduced The Integrated Life Course and Social Determi-nants Model of Aboriginal Health (ILCSD) “as a promisingconceptual framework for understanding the relationshipsbetween social determinants and various health dimen-sions, as well as examining potential trajectories of healthacross the life course” (p.6, [19]). Importantly, the ILCSDlocates Indigenous health outcomes within the socio-political context of being Indigenous in Canada and in re-lation to the nested influences of distal (i.e. social, politicaland historical contexts), intermediate (i.e. health, educa-tion and community infrastructure and systems, environ-mental stewardship and cultural continuity) and proximal(i.e. physical, mental, emotional or spiritual health im-pacts) determinants, across the life course. The ILCSDmodel provides an opportunity to explore social determi-nants not previously examined in the epidemiologicalliterature focusing on pregnant-involved Aboriginalwomen [22].A better understanding of the social determinantsunderlying pregnant-involved Aboriginal women’s sub-stance use is needed to inform policies and programs.The research questions guiding this study were:This research study aimed to answer the followingquestions:1. What are the social contexts of the lives ofpregnant-involved young Aboriginal women whouse alcohol and drugs in British Columbia, Canada?2. Can the ILCSD Model’s social determinants of healthwithin distal, intermediate and proximal domainspredict heavy alcohol use, drug use (smoked) anddrug use (injected) in the previous six months amongpregnant-involved young Aboriginal women?Hypothesis #1: The influence of distal determinants oneach dependent variable (alcohol use, drug use (smoked)and drug use (injected), will be mediated by intermediateand proximal determinants.Hypothesis #2: The influence of intermediate determi-nants on each dependent variable (alcohol use, drug use(smoked) and drug use (injected), will be mediated byproximal determinants.MethodsA secondary data analysis was conducted using datafrom a baseline questionnaire that was administered in alarger project, the Cedar Project, to all participants atenrollment [25]. A descriptive quantitative design wasused, in addition to hierarchical logistic regressionShahram et al. BMC Women's Health  (2017) 17:84 Page 2 of 13guided by mediation analysis principles, to test theILCSD Model’s ability to predict heavy substance useamong pregnant-involved female participants.Data and study settingA secondary data analysis using survey data from a largerresearch study, The Cedar Project, was conducted. TheCedar Project is an ongoing prospective cohort study ofyoung Aboriginal men and women who use drugs in threecentres in British Columbia, Canada [25] (Table 2). TheCedar Project’s purpose is to explore HIV- and HCV- re-lated vulnerabilities among male and female Aboriginalyouth who use drugs. Recruitment for the project beganin October 2003 and is ongoing. Participants are recruitedthrough health care providers, street outreach workers,and word of mouth. Eligibility criteria for the Cedar pro-ject included self-identification as Aboriginal, being be-tween the ages of 14–30 years of age, and having smokedillicit drugs in the last week, or injected illicit drugs in thelast month, including crystal methamphetamine, crack-cocaine, heroin or cocaine, prior to enrolment. Salivascreens were used to confirm drug use. Table 1 shows acomparison of the three study sites for several relevantfactors related to the lives of pregnant-involved youngAboriginal women who live there.Data collection procedures for the Cedar Project havebeen detailed elsewhere [25]. This analysis is based onthe baseline questionnaire that is administered at enroll-ment to all Cedar Project participants to elicit socio-demographic characteristics, patterns of drug use, sexualvulnerability, use of services and to assess the risk fac-tors associated with Aboriginal youth’s elevated risk andtransmission of HIV and HCV.Cohort definitionIn order to understand women’s life contexts and experi-ences with alcohol and drug use before, during and afterpregnancy, this secondary analysis was restricted to“pregnant-involved women” defined as women who haveever been pregnant before the age of 30. Not restrictingthe sample to women who were currently pregnant, orany defined outcome of pregnancy, was a purposefuldecision to explore women’s life experiences with sub-stances and pregnancy more fully, while rejecting thenotion that women’s health is only of import if it relatesto the health of a foetus or child.For this analysis, the cohort was defined as all femaleparticipants under the age of 30 years who completed abaseline questionnaire between October 2003–July 2013and responded ‘yes’ to the question ‘Have you ever beenpregnant?’ The resulting study sample was 291. Anon-ymized data that included the following measures wasavailable for analysis.MeasuresBased on the ILCSD Model, indicators were selected thatwere deemed most relevant in measuring the proximal,intermediate or distal social determinants of health.Variables available for this analysis included measures ofsocio-demographic factors, pregnancy characteristics,survival sex3 involvement, sexual abuse histories, cul-tural continuity, the use of health care services, alcoholand/or drug treatment services, the use of any servicesin general, and measures of colonialism and historical orcultural trauma. Table 2 shows a summary of all in-cluded variables, as well as their definitions for furtherclarification.Dependent variablesThree dependent variables were used that measured theparticipants’ pattern of alcohol use, drug use (smoked)and drug use (injected) over the previous 6 months, re-spectively. Based on previous studies of people who useillicit drugs [9], heavy drug smoking or injecting was de-fined as those who reported smoking or injecting onceor more per day and light drug use was defined as usingless than daily (heavy vs. light use). Alcohol use over theprevious 6 months was defined as heavy for participantswho reported having 6 or more drinks on one occasionon more than a monthly basis, and light for participantshaving 6 or more drinks on one occasion once a month orless, based on the low risk drinking guidelines from theCanadian Centre on Substance Abuse and the informationTable 1 Comparison of study site characteristicsCharacteristic Vancouver(Site A)Prince George(Site B)Interior(Site C)Urban/Rural Mix Large Urban Centre Small Urban Centre Urban-Rural MixHarm Reduction vs. AbstinenceService ModelsPrimarily Harm Reduction Harm Reduction Primarily Abstinence-BasedAboriginal Population* 40,310 (2% of total) 8855 (11% of total) 7050 (7.7% of total)On or Off- Reserve Living Primarily off-reserve Primarily off-reserve MixtureService Density Dense in downtown eastside Dense in downtown core Dense in Kamloops, Sparseeverywhere elseBased on 2006 Statistics Canada Census Data for Greater Vancouver, Prince George, and KamloopsShahram et al. BMC Women's Health  (2017) 17:84 Page 3 of 13Table 2 Self-Report Variable Classifications according to ILCSD Model and DefinitionsVariable names Variable definitionsProximal DeterminantsSocioeconomic Status (SES)Relationship Status Current relationship status.Highest Education Highest level of education completed.Income Monthly income from all sources (gov’t, work, and illegal sources).Survival Sex, ever Has the participant ever done survival sex work?IF YES,Age of 1st Survival Sex Age of participant the first time she did survival sex work.Survival Sex, last 6 Months Has the participant done survival sex work in the previous 6 months?Physical EnvironmentsHousing Stability Considered unstable if lived anywhere other than house or apartment in previous6 months (i.e. hotel, hostel, shelter, crack shack etc.).Homelessness Has the participant ever been on the street with no place to sleep for more than three nights?Age First Left Home Age the participant first left home to live on her own.Health BehavioursNumber of Pregnancies Number of times the participant has ever been pregnant (including abortions/miscarriages).Age of First Pregnancy Age of participant the first time she was pregnant.TraumaSexual Abuse, ever Has the participant ever been sexually abused? (Any type of forced sexual activity includingchildhood sexual abuse, molestation, rape, and sexual assault)IF YES,Age of 1st Sexual Abuse Age of participant the first time she was sexually abused.Sexual Abuse, reported Has the participant ever reported the sexual abuse to anyone?Sexual Abuse, repeated Has the participant been sexually abused again, since the first time?Sexual Abuse, last 6 Months Has the participant been sexually abused in the previous 6 months?Mothering ExperiencesChild Apprehended, ever Has the participant ever had any of her children apprehended by child and family services?Intermediate DeterminantsCultural ContinuityTaken from Parents, ever Has the participant ever been taken from her biological parents by child and family services?IF YES,Age 1st Taken from Parents Age of participant the first time she was taken from her biological parents.Language Does the participant speak her native or traditional language?Reserve, ever Has the participant ever been to a reserve?Cultural Substance Treatment Is the participant interested in more culturally specific substance use treatment?Services Used within the previous 6 monthsEmergency Room Visit Has the participant received health care from the emergency room (ER) in the previous 6 months?Admitted to Hospital Has the participant been admitted overnight to a hospital in the previous 6 months?Ambulance Has the participant received health care from an ambulance in the previous 6 months?Has the participant ever received any substance abuse treatment (including methadone)?Counselling Services Has the participant accessed a counsellor in the previous 6 months?Food Services Has the participant accessed food services in the previous 6 months?Visit with a Health Care Provider Visit Has the participant accessed a health care provider in the previous 6 months?Housing Services Has the participant accessed housing services in the previous 6 months?Needle Exchange Services Has the participant accessed a needle exchange in the previous 6 months?Shahram et al. BMC Women's Health  (2017) 17:84 Page 4 of 13available in the survey about alcohol use patterns [8](heavy vs. light use).Given that all the participants were women who useddrugs at enrollment, creating outcome variables to distin-guish between light and heavy use allowed for an explor-ation of the relationships between social determinants ofhealth and substance use. This was also particularly rele-vant given that pregnant-involved women who have a his-tory of heavy drug and/or alcohol use are more likely touse alcohol and/or drugs during pregnancy, and also,heavy use of substances during pregnancy specifically, isassociated with greater harms for both the mother and thefoetus [15, 21]. While this variable measures level of usewithin the past 6 months and, therefore, is not measuringuse during a pregnancy necessarily, it is nonetheless animportant and relevant measure to examine the impact ofthe social determinants of health on substance use amongpregnant-involved young Aboriginal women. Figure 1 de-picts the hypothesized relationship between the distal,intermediate and proximal determinants of health, andthe three dependent variables.Data analysisDescriptive statistics were used to describe the sample.Categorical variables were compared across the threestudy locations of the project using Pearson’s x2 test. Noexpected cell values were less than 5. Continuous variableswere analyzed using the Kruskal-Wallis one-way analysisof variance for non-parametric data. All reported p-valuesare two-sided and significant associations were deter-mined at the 0.05 cut-off point. Continuous variables wereinspected for outliers, and outliers were replaced with thevalue of two times the variable’s standard deviation. Multi-collinearity and linearity of the logit was also inspected be-fore conducting logistic regressions.Univariate logistic regression was conducted to iden-tify the determinants of health that were independentlyassociated with each of the outcome measures. In theTable 2 Self-Report Variable Classifications according to ILCSD Model and Definitions (Continued)Support Group Services Has the participant accessed a support group in the previous 6 months?Social Worker Has the participant accessed a social or welfare worker in the previous 6 months?Service BarriersHousing Denied, due to drug Use Has the participant ever had housing denied due to her drug use?Service Denied, due to drug use Has the participant ever had a service denied due to her drug use?Barriers to Services Does the participant feel there are barriers to accessing services she needs?Service NeedsService Needed, last 6 months Has the participant been in need of any service, in the previous 6 months?Distal DeterminantsColonialismResidential School, parents Has either of the participant’s parents attended residential school?Residential School, family History Has anyone in the participant’s family (excluding parents) attended residential school?Number of Family Members Number of known family members (excluding parents) who attended residential schoolCaregiver Addiction Did any of the participant’s caregivers have drug or alcohol addiction problems?Survival Sex History Did anyone in the participant’s family do survival sex work?Fig. 1 Hypothesized relationship between variables based on the Integrated Life Course and Social Determinants Model of Aboriginal HealthShahram et al. BMC Women's Health  (2017) 17:84 Page 5 of 13adjusted Model I for each dependent variable, significantvariables at the p < 0.05 cut-off in univariate analysiswere entered into multivariable logistic regression ana-lysis using the Enter method in SPSS. All models wereadjusted for age.In the adjusted Model II for each dependent variable,variables that remained significant in Model I were en-tered as blocks according to their hypothesized relation-ship based on the ILCSD Model to test for any mediatedeffects to support the model. The most common methodfor testing mediation involves four steps: First, there isshown to be a significant relationship between a pre-dictor and outcome; second, there is shown to be a sig-nificant relationship between the mediator and thepredictor; third, there is shown to be a significant rela-tionship between the mediator and the outcome; and,fourth, there is shown to be a significant reduction inthe strength of the relationship between the predictorand the outcome when the mediator is added to themodel [3, 13]. In this analysis, there were no signifi-cant relationships between any predictor variables andhypothesized mediator variables (step two of medi-ation analysis), so further mediation analysis was notpossible beyond showing the results of the full modelsin Model II. Both unadjusted and adjusted odds ratiosand 95% confidence intervals were obtained using lo-gistic regression.ResultsThe sample for this secondary analysis included 291pregnant-involved young Aboriginal women: 154 (52.9%)completed their baseline questionnaires in Vancouver,111 (38.1%) completed their baseline questionnaires inPrince George, and 26 (9%) completed their baselinequestionnaires in the Interior region of BritishColumbia. The median age of participants was 24 yearsold, and the majority of participants were single (64.4%),had not completed high school (79.5%), and were livingin unstable housing situations (66.2%). Also, the majorityof women had ever been homeless (65.9%), while 67.7%of women had ever been sexually abused and the medianage of first sexual abuse was six years old (range 1–20 years old).Descriptive resultsTable 3 shows comparisons of all the included social de-terminants of health based on location of the partici-pant, and addresses the first research question of thisstudy. Participants in Vancouver were older and morelikely to have ever been homeless, while participants inboth Vancouver and Prince George were more likelythan Interior participants to have been taken from theirbiological parents, to have participated in survival sexever or in the last six months, to have lower monthlyincomes, to be interested in culturally specific treatmentoptions, and to have accessed a needle exchange or a so-cial/welfare worker in the last six months. Vancouverand Prince George participants were less likely thanInterior participants to speak a traditional language, tohave visited the emergency room or have been treatedby an ambulance in the past six months, and to haveaccessed a counsellor in the last six months. Participantsin Prince George left home for the first time at a youn-ger age, and were more likely to state that they hadneeded any social or health service or had accessedhousing services in the previous 6 months.Testing the ILCSD model for predicting heavy versus lightsubstance useIn order to address the second research question, theILCSD Model’s ability to predict heavy versus light sub-stance use was assessed for each dependent variable. Ifvariables remained significant even after block entry ac-cording to the ILCSD model, then there was no evidenceof mediation occurring.Heavy versus light alcohol useTable 4 shows the results from the univariate and multi-variate logistic regression analyses conducted withpattern of alcohol use as the dependent variable. In uni-variate analyses, participants who lived in Vancouverand Prince George were significantly less likely to havemore than six drinks in one occasion more than once amonth than participants who lived in the Interior (OR0.33, 95% CI 0.13, 0.82; OR 0.35, 95% CI 0.14, 0.88 re-spectively). Participants who had reported their sexualabuse to somebody, were also less likely to have morethan six drinks in one occasion more than once a month(OR 0.40, 95% CI 0.22, 0.73). In Model 1, multivariatelogistic regression was conducted, where both interviewlocation and sexual abuse reporting were entered as co-variates in the model. Vancouver participants were sig-nificantly less likely than participants in the Interior touse alcohol more than monthly (OR 0.30, 95% CI 0.12,0.77) and having reported sexual abuse was also protect-ive (OR 0.38, 95% CI 0.21, 0.71). Model II tested theILCSD Model using the block entry shown in Fig. 1.Since both determinants remained statistically signifi-cant, their direct effects seem to override any mediationexpected according to the ILCSD model.Heavy versus light smoked drug useTable 5 shows the results from the univariate and multi-variate logistic regression analyses conducted with pat-tern of smoked drug use as the dependent variable. Inunivariate analyses, daily or more use of smoked drugswas independently associated with living in Vancouver,being single, having unstable housing, having moreShahram et al. BMC Women's Health  (2017) 17:84 Page 6 of 13Table 3 Comparison of Proximal, Intermediate and Distal Determinants between Participants in Vancouver, Prince George and theInteriorCharacteristic Vancouver(n = 154)n (%)Prince George(n = 111)n (%)Interior(n = 26)n (%)p-value Total (%)(N = 291)n (%)Proximal DeterminantsMedian age at enrollment, years (range) 24 (16–30) 23 (15–30) 23 (16–30) 0.024 24 (15–30)Single 107 (69.9) 67 (60.4) 12 (48) 0.280 186 (64.4)Did not complete high-school 121 (79.1) 84 (77.1) 24 (92.3) 0.220 229 (79.5)Median monthly income, dollars (range) 558 (80–13,000) 850 (40–10,100) 1035 (100–5000) 0.023 748 (40, 30,000)Survival sex, ever 116 (76.8) 77 (72) 10 (38.5) <0.001 203 (71.5)IF YES, (n = 203)Median age of first survival sex, years (range) 16 (11–28) 16 (9–27) 17 (12–23) 0.303 16 (9–28)Survival sex, last 6 months 89 (57.8) 65 (58.6) 5 (19.2) 0.001 159 (54.6)Unstable Housing (last 6 months) 109 (71.2) 70 (63.1) 13 (50) 0.071 192 (66.2)Ever lived on the streets (>3 nights) 116 (75.3) 62 (56.4) 13 (50) 0.001 191 (65.9)Median age first left home, years (range) 16 (8–22) 14 (8–19) 16 (12–21) 0.001 15 (8–22)Median number of pregnancies (range) 2 (1–5) 2 (1–5) 2 (1–5) 0.238 2 (1–5)Median age of first pregnancy, years (range) 17 (12–25) 17 (10–24) 18.16 (13–24) 0.068 17 (10–25)Ever sexually abused 102 (66.2) 80 (72.1) 15 (57.7) 0.315 197 (67.7)IF YES, (n = 197)Median age first sexually abused (years) (range) 6 (1–18) 8 (2–19) 9 (3–20) 0.057 6 (1–20)Child apprehended, ever 72 (49.7) 47 (44.3) 8 (36.4) 0.430 127 (46.5)Intermediate DeterminantsEver taken from biological parent 104 (67.5) 75 (67.6) 11 (42.3) 0.036 190 (65.3)IF YES, (n = 190)Median age first taken from biologicalparents (range)4 (1–17) 5 (0–14) 6 (1–13) 0.666 5 (0–17)Speak traditional language 21 (13.6) 22 (20) 12 (46.2) <0.001 55 (19)Ever been to a reserve 121 (81.2) 98 (89.1) 25 (96.2) 0.056 244 (85.6)Interested in more culturally specific treatment 77 (50) 72 (64.9) 8 (32) 0.004 157 (54.1)Substance Use Treatment, Ever 110 (71.4) 92 (82.9) 22 (84.6) 0.057 224 (77)Services used within the previous 6 monthsEmergency Room Visit 49 (31.8) 53 (47.7) 15 (57.7) 0.005 117 (40.2)Admitted to Hospital 32 (21.1) 22 (19.8) 9 (34.6) 0.245 63 (21.8)Ambulance 37 (24) 20 (18) 12 (46.2) 0.010 69 (23)Counselling Services 25 (16.2) 39 (35.1) 13 (50) <0.001 214 (73.5)Food Services 85 (55.2) 58 (52.3) 12 (46.2) 0.669 136 (46.7)Visit with a Health Care Provider Visit 77 (50) 58 (52.3) 13 (50) 0.933 148 (50.9)Housing Services 35 (22.7) 48 (43.2) 7 (26.9) 0.002 201 (69.1)Needle Exchange Services 73 (47.4) 85 (76.6) 4 (15.4) <0.001 129 (44.3)Support Group Services 9 (5.8) 11 (9.9) 4 (15.4) 0.189 24 (8.2)Social Worker 68 (44.2) 69 (62.2) 6 (23.1) <0.001 148 (50.9)Denied housing due to drug use 45 (29.4) 24 (21.6) 7 (26.9) 0.363 76 (26.2)Denied service due to drug use 37 (24) 18 (16.2) 6 (23.1) 0.294 61 (21)Have barriers to accessing services 13 (8.5) 7 (6.3) 4 (15.4) 0.315 24 (8.3)Needed a service, last 6 months 100 (65.8) 93 (83.8) 18 (69.2) 0.005 211 (73)Shahram et al. BMC Women's Health  (2017) 17:84 Page 7 of 13pregnancies, having your first pregnancy at a youngerage, having participated in survival sex ever or in the lastsix months, having been denied a service due to druguse in the last six months, and have had either parent at-tend residential school. In Model I, all variables thatwere statistically significant at the 0.05 cut-off were en-tered into the logistic regression as covariates. In thismodel daily or more use of smoked drugs was independ-ently associated with being single (OR 2.36, 95% CI 1.09,5.08), having unstable housing (OR 2.17, 95% CI 1.03,4.58), and having had either parent attend residentialschool (OR 4.10, 95% CI 1.17, 14). In Model II, statisti-cally significant variables from Model I were entered inblocks as shown in Fig. 1 to test the ILCSD Model. Allvariables remained significantly associated, suggesting noevidence of mediation.Heavy versus light injected drug useTable 6 shows the results from the univariate and multi-variate logistic regression analyses conducted with pat-tern of injection drug use as the dependent variable. Inunivariate analyses, daily or more use of injection drugswas independently associated with a higher number ofpregnancies, survival sex in the last six months, and hav-ing ever received treatment. Having received sexualabuse counselling, attending support groups in the lastsix months, and having experienced barriers to servicesin the last six months were all protective. In Model I, allvariables that were statistically significant at the 0.05cut-off were entered into the logistic regression as covar-iates. In Model 1, having ever received substance usetreatment and number of pregnancies were no longersignificantly associated with daily or more injection druguse. In Model II, statistically significant variables fromModel I were entered in blocks as shown in Fig. 1 to testthe ILCSD Model. All variables remained significantlyassociated, suggesting no evidence of mediation.DiscussionThis study reports on empirical support for the importanceof integrating socio-historical contexts into models of de-terminants of substance use and supports a counter-narrative to the current pathologizing discourse in Canada,where “Aboriginal Status” is often cited as a determinant ofhealth on its own [16]. Instead, by using an Aboriginal-specific model, it was possible to explore how determinantsthat uniquely impact Aboriginal health in Canada (includ-ing residential school histories, racism, and intergenera-tional trauma) have differentially impacted the healthstatus and experiences of Aboriginal women, in anappropriately nuanced and fluid manner. This is one of thefirst studies to evaluate an Aboriginal-specific socialTable 3 Comparison of Proximal, Intermediate and Distal Determinants between Participants in Vancouver, Prince George and theInterior (Continued)Distal DeterminantsAt least one parent attended Residential School 73 (47.4) 49 (45) 9 (34.6) 0.478 131 (45.3)Residential School Family History 104 (68) 81 (73) 22 (84.6) 0.198 207 (71.1)Median number of family members in ResidentialSchool (range)4 (1–19) 3.5 (0–36) 5 (0–29) 0.648 3 (0–36)At least one caregiver with drug or alcoholaddiction124 (81) 87 (78.4) 30 (76.9) 0.813 231 (79.7)Family history of survival sex 50 (43.1) 39 (52) 5 (50) 0.474 94 (46.8)For continuous variables, range is reported instead of percentageTable 4 Univariate and Multivariate Modeling for Alcohol Use among Participants (N = 210)Monthly or less(n = 144)N (%)More than monthly(n = 66)N (%)Unadjusted OR(95% CI)Adjusted OR Model I(95% CI)Adjusted OR Model II(95% CI)LocationInterior 11 (7.6) 13 (19.9) Reference Reference ReferencePrince George 61 (42.4) 25 (37.8) 0.35* (0.14, 0.88) 0.38 (0.14, 1.01) 0.38 (0.14, 1.01)Vancouver 72 (50) 28 (42.4) 0.33* (0.13, 0.82) 0.30* (0.11, 0.78) 0.30* (0.11, 0.78)Sex Abuse ReportedNo 55 (38.2) 40 (60.6) Reference Reference ReferenceYes 89 (61.8) 26 (39.3) 0.40** (0.22, 0.73) 0.40** (0.21, 0.74) 0.40** (0.21, 0.74)Overall Percentage Correct for Adjusted Models 70.5 70.2*p < .05, **p < .01Shahram et al. BMC Women's Health  (2017) 17:84 Page 8 of 13determinants model to identify predictors of substance useamong pregnant-involved Aboriginal women. The inclu-sion of variables that measured the lifelong and future im-pacts of colonialism and cultural continuity provide a morecomplete picture of the social determinants of substanceuse, from an Aboriginal-specific perspective. Given the lackof previous research in this area that includes and explicitlyacknowledges the important contexts of substance useamong young pregnant-involved Indigenous women [22],this study is a timely and important contribution to the re-search landscape.In testing the ILCSD Model, important independentrisk and protective factors for heavy substance use wereidentified. Among participants who had ever beensexually abused, having reported sexual abuse to anyonewas found to be associated with lower alcohol use. Intheir study, Draucker et al. [10] also found that disclos-ing abuse was the main way participants were able tomake sense of their experiences and to heal.Women’s substance use is often positively correlated totheir partner’s use [20]. However, being in a relationshipwas associated with lower smoked drug use. Havingspoken anecdotally with community workers and womenwho use injection drugs, they suggested that for manywomen, their partners initiate their first use of injectiondrugs, as well as continue to inject for them, and so thereis the possibility that single women have higher use ofsmoked drugs because they have not progressed toTable 5 Univariate & Multivariate Modeling for Drug Use (Smoked) among Participants (N = 285)< Daily (n = 49)N (%)≥ Daily (n = 236)N (%)Unadjusted OR(95% CI)Adjusted ORModel IAdjusted ORModel IILocationInterior 9 (18.4) 16 (6.8) Reference Reference –Prince George 24 (49) 86 (36.4) 2.01 (0.79, 5.13) 1.11 (0.33, 3.71) –Vancouver 16 (32.7) 134 (56.8) 4.71** (1.79, 12.29) 3.45 (1.00, 12.00) –Relationship StatusLegally Married 24 (49) 66 (28.1) Reference Reference ReferenceCommon Law 3 (6.1) 2 (0.9) 0.24 (0.04, 1.54) 0.15 (0.01, 2.00) 0.26 (0.03, 1.93)Widowed/Separated/Divorced 2 (4.1) 3 (1.3) 0.55 (0.09, 3.47) 0.93 (0.06, 12.47) 0.53 (0.08, 3.58)Single 20 (40.8) 164 (69.8) 2.98** (1.54, 5.76) 2.40* (1.11, 5.20) 3.08** (1.58, 6.02)Housing Stability, last 6 monthsStable 25 (51) 71 (30.2) Reference Reference –Unstable 24 (49) 164 (69.8) 2.41** (1.29, 4.5) 2.02 (0.95, 4.31) –Median Number of PregnanciesNumber (SD) 2 (1.3) 2 (1.4) 1.29* (1.02, 1.63) 1.46 (1.00, 2.13) –Median Age of First PregnancyYears (SD) 18 (2.6) 17 (2.6) 0.89* (0.77, 0.98) 0.92 (0.78, 1.09) –Sex Work, EverNo 22 (45.8) 58 (25) Reference Reference –Yes 26 (54.2) 174 (75) 2.54** (1.34, 4.82) 1.54 (0.54, 4.42) –Sex Work, last 6 monthsNo 32 (65.3) 96 (40.7) Reference Reference –Yes 17 (34.7) 140 (59.3) 2.75** (1.44, 5.22) 1.77 (0.61, 5.13) –Service Denied due to Drug Use, last 6 mosNo 45 (91.8) 181 (76.7) Reference Reference –Yes 4 (8.2) 55 (23.3) 3.42* (1.18, 9.93) 3.04 (0.97, 9.54) –Residential School, ParentsNo 31 (63.3) 125 (53.4) Reference Reference ReferenceYes, one 4 (8.2) 53 (22.6) 3.29* (1.11, 9.77) 4.12* (1.20, 14.20) 3.67* (1.21, 11.45)Yes, both 14 (28.6) 56 (23.9) 0.99 (0.49, 2.01) 1.00 (0.42, 2.36) 0.99 (0.47, 2.08)Overall Percentage Correct For Adjusted Models 87.0 83.2*p < .05, **p < .01Shahram et al. BMC Women's Health  (2017) 17:84 Page 9 of 13injection drug use. Further research on this topic wouldbe beneficial. The association between parental residentialschool attendance and increased use of smoked drugs isan indicator of the importance for understanding inter-generational trauma and the perpetuation of harmsamong young Aboriginal women as well as the impacts offoster care involvement, which is understood as directlylinked with residential school histories.Having participated in survival sex in the last 6 monthswas associated with daily or more injection drug use.This relationship could be bi-directional because womenmay be participating in survival sex to support theirheavier use, or they may be using drugs more heavily tocope with survival sex. Also, having a higher number ofpregnancies, having received sex abuse counselling andattending a support group in the last six months, wereall protective against more than daily use of injectiondrugs. These results again suggest that attending to sex-ual abuse trauma can be protective, and that peer sup-port is also a promising strategy for some women. Theresults also suggest that pregnancies can be protective,possibly because women reduce drug use for the preg-nancies, and/or because of increased supports duringpregnancy. Finally, having experienced barriers to anyservices (health and supportive) was also associated withlower injection drug use. This may be because thosewho are heavier users are less aware of or connected toservices to perceive any barriers. Similarly, if thosewomen are not accessing services as much as womenwho use less, then they would not have had an oppor-tunity to encounter any barriers to services.Women who participate in sex work in BC have re-ported that histories of injection drug use further com-pounded risks in women’s lives and added to barriers toparenting, while limited access to appropriate non-judgmental services to support their needs as womenwho participated in survival sex work and who useddrug mitigated access to environments or services thatsupport them as pregnant women/parents [11]. Survivalsex work may therefore be confounding or contributingto the other associations with injection drug use.The mediation relationships between determinants ac-cording to the ILCSD Model, were not supported, withseveral caveats: first, data were not collected with theintention to test this model, and variables fit into themodel retrospectively did not represent all parts of themodel; second, the model was not designed specificallyto explain substance use or women’s health, but foroverall health and wellness of Aboriginal peoples; and,lastly, the participants in this sample were a small groupof street-entrenched and street-recruited women facingextraordinary risks in their day to day lives and were notrepresentative of the larger Aboriginal women popula-tion in Canada. Conducting this analysis comparingwomen who do and do not use substances may providea more robust test of the model.Understanding Indigenous health in Canada within thecontext of colonial practices both past and present [12]Table 6 Univariate and Multivariate For Drug Use (Injected) among Participants (N = 184)< Daily (n = 76)N (%)≥ Daily (n = 108)N (%)Unadjusted OR(95% CI)Adjusted ORModel 1Adjusted ORModel 2Median Number of Pregnancies (SD) 3 (1.46) 2 (1.37) 0.77* (0.63, 0.95) 0.80 (0.62, 1.02) –Survival Sex, last 6 monthsNo 37 (48.7) 32 (29.6) Reference Reference ReferenceYes 39 (51.3) 76 (70.4) 2.25** (1.22, 4.15) 2.75** (1.13, 4.74) 2.71** (1.40, 5.23)Sex Abuse CounsellingNo 48 (63.2) 88 (81.5) Reference Reference ReferenceYes 28 (36.8) 20 (18.5) 0.39** (0.2, 0.76) 0.42* (0.20, 0.87) 0.35** (0.17, 0.71)Substance Use Treatment, EverNo 12 (15.8) 31 (28.7) Reference Reference –Yes 64 (84.2) 77 (71.3) 2.15* (1.02, 4.52) 1.73 (0.77, 3.91) –Support Group, last 6 monthsNo 66 (86.8) 104 (96.3) Reference Reference ReferenceYes 10 (13.2) 4 (3.7) 0.25* (0.08, 0.84) 0.22* (0.06, 0.79) 0.20* (0.06, 0.70)Service Barriers, last 6 monthsNo 65 (85.5) 103 (96.3) Reference Reference ReferenceYes 11 (14.5) 4 (3.7) 0.23* (0.07, 0.75) 0.20* (0.06, 0.72) 0.21* (0.06, 0.73)Overall Percentage Correct for Adjusted Models 72.5 69.4For continuous variables, standard deviation is reported instead of percentage*p < .05, **p < .01Shahram et al. BMC Women's Health  (2017) 17:84 Page 10 of 13is needed. Poverty, homelessness, housing instability, lackof education, involvement in the child welfare system,visits to the emergency room, survival sex work, and sex-ual abuse were all important predictors of substance usein the study sample. Given the relationship of all of thesefactors with historical and contemporary colonizationpractices (and that over 70% of the sample had a familyhistory of residential school attendance and addiction), theintergenerational impacts of residential schooling, addic-tion, survival sex and trauma must foreground any deeperunderstanding of substance use among young Aboriginalwomen. Explicit attention to these factors has been de-cidedly absent from the literature examining substance useamong Indigenous women [19], while a lack of meaningfuldata that captures the distinct sociopolitical, historical andgeographical contexts of Indigenous women’s lives has lim-ited discussions on these topics [2, 12].Multiple perspectives and models, in addition to theILCSD Model, including for example The IndigenistStress-Coping Model (on which The Cedar Project isbased) [26], will likely be needed to capture the complex-ity of young Indigenous women’s experiences with bothpregnancy and substance use. As evidenced by this study,these contextual factors are paramount to creating a fullerunderstanding of substance use and pregnancy. Further,highlighting the structural and social determinants of sub-stance use provides actionable targets for interventionsthat can support women and their children. Importantly,by including the variables in this analysis related towomen’s socio-political-historical contexts, we were ableto present a fuller depiction of women’s actual lives, inkeeping with previous qualitative findings from work withthis same population [23, 24]. Indeed, a common criticismof quantitative research is its inability to produce rich andcontextualized data. By developing methods for capturingand measuring Indigenous-specific determinants ofhealth, such as intergenerational trauma, foster care andracism experiences, it will be possible to provide richerand more useful empirical data to support and developunderstandings in this area of research. Racism, whileplaying an important role in the health and well-being ofIndigenous peoples in Canada [2], for example, can beparticularly challenging for groups that have experiencedmarginalization throughout their lives (like women in thisstudy) to even identify, let alone quantify. As more re-search stresses the importance of understanding the roleof Indigenous-specific social determinants in the healthand well-being of Indigenous people in Canada [12], how-ever, this work is important, timely and necessary.Strengths and limitationsThis study had several strengths. The Cedar Project’s cri-terion for defining Aboriginal Status was any individualwho self-identified as Metis, Aboriginal, First Nations,Inuit, and status and non-status Indians. This type ofself-identification, therefore, was more inclusive and wasalso in keeping with post-colonialism approaches in re-search. This data set included variables surrounding fostercare involvement, residential schooling histories, andsexual abuse questions which allowed for more culturallyappropriate and nuanced analyses. The Cedar ProjectPartnership actively maintains the quality of their data andtry to minimize any reporting bias through the extensivetraining of their Aboriginal interviewers, assurances ofconfidentiality and availability of support services.This study also had several limitations. Analysis waslimited to previously collected data based on self-reportthat was cross-sectional, limiting conclusions about caus-ation. Recruitment was non-random and there was noway to determine non-response bias. The limited focus ofthe study population means that generalizations to thegeneral population of young Aboriginal women could notbe made. Finally, it is unclear if women in the study useddrugs and/or alcohol during their pregnancies.ConclusionThis analysis provided insight into the social contexts ofwomen who have experiences with pregnancy as well asdrug and/or alcohol use and highlighted the need to in-clude Indigenous-specific determinants of health whenexamining young Aboriginal women’s social, political andhistorical contexts in relation to their experiences withpregnancy and substance use.Endnotes1Collectively refers to the original people of NorthAmerica, including the three distinct groups of FirstNations (historically referred to as Indian), Metis and Inuitpeoples (Constitution Act, 1867). Over 1.4 million individ-uals in Canada identify themselves as an Aboriginal per-son (Statistics Canada, 2011).2The terms Aboriginal, First Nations, Indigenous, StatusIndian and Indian are used in accordance with the termused by the cited authors. Otherwise, the authors use theterm Indigenous to acknowledge Indigenous peoples ofCanada’s international legal rights under the UN Declar-ation of the Rights of Indigenous Peoples.3The practice of people who are homeless or otherwisesocially disadvantaged in society, trading sex for food, aplace to sleep, or other basic needs, including drugs.AcknowledgementsThe authors would like to thank Mabel Louie for her mentorship and guidance toS.Z.S throughout the research process. In addition, the authors thank Martin T.Schechter for his contribution to the retrieval and maintenance of the CedarProject dataset. Finally, the authors would like to acknowledge the incrediblecontribution of women in the Cedar Project to this research, and to acknowledgetheir strength and resilience in facing extraordinary challenges.Shahram et al. BMC Women's Health  (2017) 17:84 Page 11 of 13FundingS.Z.S was supported through a CIHR Institute for Aboriginal People’s HealthDoctoral Award (Funding number: 121,268) to complete this research as partof her PhD dissertation research project. S.Z.S was supported by the EquityLens in Public Health CIHR Research Project (Funding Number: 116,688)through a Postdoctoral Research Fellowship to prepare this manuscript.Availability of data and materialsThe datasets generated and/or analysed during the current study are notpublicly available due to the possibility of compromising individual privacy,but are available from the corresponding author on reasonable request.Authors’ contributionsSZS led the conceptualization of this study, and conducted the data analysis andmajor preparation of this manuscript. JLB contributed to the conceptualization ofthe study, the data analysis plan, and major elements of the preparation of thismanuscript. NDO and LD provided guidance and insight to the data analysis andinterpretation of findings and provided feedback and edits for the final versionof this manuscript. VT (Research Coordinator, The Cedar Project) and PMS(PI, The Cedar Project) were integral to the data collection for the data set used,establishing ethical protocols, guiding the data retrieval and analysis plan, andinterpretation and dissemination of the results. The Cedar Project Partnershipoversees all research conducted with Cedar Project participants and wereintegral to all parts of this research study. All authors reviewed and approvedthe final manuscript.Ethics approval and consent to participateThe Behavioural Research Ethics Board at the University of British Columbia andthe Cedar Project Partnership Ethics Review committee, that oversees researchconducted with Cedar Project participants, approved this research protocol. TheCedar Project Partnership also oversaw the analysis plan and helped with theinterpretation of the results. All participants provided informed consent.Consent for publicationN/ACompeting interestsThe authors declare that they have no competing interests.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims in publishedmaps and institutional affiliations.Author details1Faculty of Health and Social Development, University of British Columbia,1147 Research Road, Kelowna, BC V1V 1V7, Canada. 2Institute for HealthyLiving and Chronic Disease Prevention, and School of Nursing, Faculty ofHealth and Social Development, University of British Columbia, 1147Research Road, Kelowna, BC V1V 1V7, Canada. 3Faculty of Health Sciences,Australian Catholic University, Melbourne, Australia. 4School of Nursing,Faculty of Health and Social Development, University of British Columbia,1147 Research Road, Kelowna, BC V1V 1V7, Canada. 5Department ofObstetrics & Gynaecology, Faculty of Medicine, University of British Columbia,1190 Hornby Street 4th Floor, Vancouver, BC V6Z 2K5, Canada. 6WuikinuxvNation, The Cedar Project, Vancouver, Canada. 7School of Population andPublic Health, University of British Columbia, 2206 East Mall, Vancouver, BCV6T 1Z3, Canada. 8Present Address: Postdoctoral Research Fellow, Centre forAddictions Research of British Columbia, University of Victoria, PO Box 1700,STN CSC Victoria, Victoria, BC V8W 2Y2, Canada. 915890 Greenhow Road,Oyama, BC V4V 2E6, Canada.Received: 2 June 2016 Accepted: 28 August 2017References1. 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American Journal of Public Health.2002;92(4):520–524.•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services •  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submitSubmit your next manuscript to BioMed Central and we will help you at every step:Shahram et al. BMC Women's Health  (2017) 17:84 Page 13 of 13


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