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UBC Theses and Dissertations

Health meanings, health status, and health needs of a Gitksan and Wet’suwet’en on-reserve population… Joseph, Rhea 1992

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HEALTH MEANINGS, HEALTH STATUS, AND HEALTH NEEDSOFA GITKSAN AND WET'SUWET'EN ON-RESERVE POPULATION IN B.C.ByRhea JosephB.H.E., The University of British Columbia, 1982A THESIS SUBMITTED IN PARTIAL FULFILLMENT OFTHE REQUIREMENTS FOR THE DEGREE OFMASTER OF SCIENCEinTHE FACULTY OF GRADUATE STUDIESThe Department of Health Care and EpidemiologyWe accept this thesis as conformingto the required standardTHE UNIVERSITY  OF BRITISH COLUMBIAOctober 1992© Rhea Joseph, 1992In presenting this thesis in partial fulfilment of the requirements for an advanceddegree at the University of British Columbia, I agree that the Library shall make itfreely available for reference and study. I further agree that permission for extensivecopying of this thesis for scholarly purposes may be granted by the head of mydepartment or by his or her representatives. It is understood that copying orpublication of this thesis for financial gain shall not be allowed without my writtenpermission.(Signature)Department ofHealth Care and EpidemiologyThe University of British ColumbiaVancouver, CanadaDate DE-6 (2/88)iiABSTRACTStakeholders in the changing environment of health care include Indian people inB.C. and Canada who are grappling with long standing problems of lowered health status.Today, potential for health improvements may be found in an opportunity for health systemchange. However, this change process is seriously hampered by incomplete and non-currenthealth information. This study addresses this information gap by obtaining and describingbase-line information on the health status and health needs of two Gitksan and Wet'suwet'enBands in B.C. via the meanings and interpretations they, themselves, attach to health.Study design includes two complementary methodologies: phenomenology andepidemiology. Qualitative data from other sources (e.g., Focus Group) supplement findings.Data collection occurred over an eighteen week period, May to September, 1991.In this study, phenomenology explores health meanings via in-depth interviews (N =9; theoretical, non-random sample). This investigation draws upon Kleinman's explanatorymodel of the health care system to explore and discover a unique culture's perception of thehealth phenomena. Qualitative data from verbatim interview transcripts were analyzedutilizing an open-coding technique with conceptual categories forming key data elements.Epidemiology, on the other hand, directs investigation into health status by means ofa health survey questionnaire (N = 97; stratified, random sample). Quantitative datadescribing personal health experiences were cross tabulated according to stratified categoriesof age, sex, tribal ancestry, and key variables identified in an epidemiologic model. Datawere further examined using the SPSSX statistical package.It was found that Gitksan and Wet'suwet'en people, though two distinct societies, holdsimilar views regarding their health experience which they describe in terms of wellness andwell-being. In only a few instances did ancestry make a difference in health status.iuThe Gitksan and Wet'suwet'en have a wholistic conceptualization of health with thespirit constituting a dominant force in the physical-mental-spiritual complex. The spirit alsointerconnects the individual with the family, house/clan, village, tribe, and the land. Whenwell and strong one has the ability to carry out daily activities, to engage in preferred leisureactivities, and to carry out social responsibilities. The wellness experience is accompanied bya positive sense of well-being. Though over lap exists in wellness and well-being, word usagesuggests that well-being is a distinct experience and is as important as being well.A majority of the Gitksan and Wet'suwet'en people in the study consider their healthgood and do not have limitations in their activities. However, strength may be seriouslyundermined by health related beliefs and choices that place people at risk for healthproblems. These health risks include poor nutrition, sedentary life-style, high rate of obesity,excess use of tobacco and alcohol, and low use of some preventive services including dentalcare and cancer screening for women. A lowered sense of well-being is also present and, atthe extreme, is seen in frequent occurrence of suicide thoughts and some attempts.These findings point to three areas of health needs: (1) mental health supports andservices, of which there is little; (2) drug and alcohol initiatives that address beliefs regardingwhat is normal drinking and that capture family and spousal influences on preferredbehaviours; and, (3) health education initiatives that extend beyond changing knowledge tobuild upon local health related beliefs and values in order to change behaviour.Study findings have important implications for health care and for future research intheory development and testing of health meanings. In particular, health care providers arechallenged to respectfully accept a wholistic world view that extends beyond individual healthto include other domains affecting wellness and well-being. Wholistic healing of theseinterconnected beings may hold some potential for improving the health of Indian people.ivTABLE OF CONTENTSSUMMARY^TABLE OF CONTENTS ^  ivLIST OF TABLES  viiiLIST OF FIGURES ^ACKNOWLEDGEMENTS  xiCHAPTER 1.0 INTRODUCTION ^  11.1 Refocusing Health Care in the Community ^  11.2 Health and Health Care for Indian People On-Reserve ^ 21.3 Problem Statement ^  31.4 Purpose of the Study  31.5 Research Questions ^  41.6 Definition of Terms  41.7 Thesis Outline ^  5CHAPTER 2.0 LITERATURE REVIEW ^  62.1 What is Health? ^  72.2 Health Measurement  142.3 Health Determinants ^  172.3.1 Nutritional Status  202.3.2 Child Health Status ^  242.4 Politics of Health Care Needs, Wants, and Demands ^ 262.5 Developments in Health Services for On-Reserve People  322.5.1 Health Care System for On-Reserve People^ 35V2.6 Health of Indian People: A Summary Description ^  382.7 Gitksan and Wet'suwet'en: A Social Description  402.8 Summary of the Literature Review ^  42CHAPTER 3.0 METHODOLOGY ^  443.1 Study Design ^  453.2 Investigating Health Meanings: Phenomenological Research ^ 473.2.1 In-depth Interview and Theoretical Sampling  483.2.2 Theoretical Sampling Criteria^  493.2.3 Data Analysis ^  523.3 Epidemiologic Research: Methods and Sampling ^  543.3.1 Survey Questionnaire- Personal Interviews  543.3.2 Randomized Sampling ^  553.3.3 Interviewing and Data Processing ^  573.3.4 Data Analysis ^  573.3.5 Key Respondent Questionnaire ^  583.4 Complementary Research Methods  583.4.1 Focus Group ^  583.4.2 Documentary Examination ^  593.5 Limitations ^  603.6 Summary  67CHAPTER 4.0 RESULTS ^  684.1 Gitksan and Wet'suwet'en Views on Wellness and Well-Being ^ 694.1.1 A Conceptual Model for Data Interpretation ^ 69vi4.1.2 Wholistic Interconnections in the Wellness Experience^ 704.1.3 Wellness and Well-Being Experiences ^  754.1.4 Wellness Experiences Strengthened and Protected ^ 804.1.5 Wellness Weakened ^  844.1.6 Unwell of Sickness Experiences Requiring Healing ^ 894.2 General Health Status ^  974.2.1 Demographic Characteristics of Study Group^ 974.2.2 Self-Rating of Health and Use of Health Care  1004.2.3 Two Week Disability and Accidents and Injury ^ 1044.2.4 Health Status ^  1064.2.5 Chronic Health Problems ^  1084.2.6 Activity Restriction  1094.2.7 Lifestyle: Tobacco, Alcohol, Exercise, Nutrition,and Dental Health ^  1104.2.8 Life in General  1254.2.9 Women and Child Health ^  1324.3 Focus Group Results: Summary Report  1384.4 Key Respondent Health Survey Results ^  1404.5 Field Notes and Documentary Review  1424.6 Summary ^  146CHAPTER 5.0 DISCUSSION ^  1475.1 Wellness and Well-being  1485.2 Health Status ^  156vii5.3 Gaps in Existing Programs and Services ^  1695.4 Local Responses to Health Issues  1715.5 Summary ^  172CHAPTER 6.0 SUMMARY, CONCLUSIONS, AND IMPLICATIONS FOR FUTURESTUDY ^  1746.1 Summary of Health Meanings According to the Gitksan and Wet'suwet'en ^ 1756.2 Summary of Health Status and Health Needs ^  1776.3 Conclusions ^  1806.4 Implications for Health Care ^  1816.5 Suggestions for Future Studies  182BIBLIOGRAPHY^  185APPENDIXA (1)^Letter of Initial Contact and Consent forIn-Depth Interview ^  195(2) Letter of Initial Contact to Households ^  198(3) Letter of Initial Contact to Random Sample Group^ 199(4) Consent to Participate in Focus Group  200(5) Consent to Participate in General Health Survey  202(6)^Consent for Key Respondent Survey: ^  203B Trigger Questions for Focus Group and In-Depth Interview ^ 204C (1)^General Health Survey, 1991: The Health of the Gitksanand Wet'suwet'en People ^  205(2)^Key Respondent Health Survey, 1991: The Health of theGitksan and Wet'suwet'en People  225D Estimated Sample Size for General Health Survey ^ 231E Interviewer Training ^  232F Supplementary Tables: General Health Survey ^  233viiiTABLE 1TABLE 2TABLE 3TABLE 4TABLE 5TABLE 6TABLE 7TABLE 8TABLE 9TABLE 10TABLE 11TABLE 12TABLE 13TABLE 14TABLE 15TABLE 16TABLE 17TABLE 18TABLE 19LIST OF TABLESDemographic Summary for the General Health Survey, 1991 ^ 98Self-Reported Health According to Sex, Age, and Presenceor Absence of Activity Limitations, 1991^  100Self-Assessments of Health, Happiness/Interest in LifeStress, and Satisfaction with Health.  101Use of Health Services in a Two Week and One Year Period ^ 103Two Week Disability ^  105Health Status According to Vision, Hearing, Speech, GettingAround, Use of Hands and Fingers, and Presence of Pain ^ 107Chronic Health Problems, 1991: Ages 15 Years and Over ^ 108Occurrence of Activity Limitations According to Sex  110Smoking Behaviour of Men and Women Ages 15 Years and Over ^ 111Relationship Between Smoking and Drinking ^  113Beliefs Relating to Alcohol Use ^  115Problems Encountered by Drinkers in the Past Year^ 116Seat Belt Use by Men and Women Driving on Public Highways andin the Village ^  117Type, Frequency, and Duration of Physical Activity in Past 3 Months^118Assessment of Intensity and Adequacy of Physical Activity ^ 119Body Mass Index (BMI) and Cut-Off Points for Men and WomenBetween 20 and 65 Years ^  120Proportion of Men and Women At-Risk for a NutrientDeficiency With Risk Determined by Intake 66 Percent Less ThanRecommended Amounts ^  122Description of Current Dental Health by Age Groupings ^ 123Dental Problems and Patterns in Access to Dental Care  125ixTABLE 20TABLE 21TABLE 22TABLE 23TABLE 24TABLE 25TABLE 26Employment Status of Men and Women Whose Main Activity inthe Past 12 Months Was Working at a Job ^  126Feelings Experienced During the Past 12 Months  130Occurrence of Thoughts and Acts Relating to Suicide ^ 132Women's Health ^  133Children Under 14 Years Included in the Survey andthe Proportion Assessed as Sick ^  135Percentage of Caregivers Identifying Functional Problemsand Proportion of Problems Attributed to a Sickness(N = 45) ^  136Comparison of Total Energy Intake and Energy Sources in Indian andNon-Indian Populations ^  166xLIST OF FIGURESFigure 1:^The Local Health Care System: Internal Structure.(Kleinman, 1980, p. 50) ^  13Figure 2:^The Diamond Model of Illness Causation. (Long, 1984, p.4) ^ 18Figure 3:^Relationship Between Health Needs and Health Programsand Services (Adapted from Nguyen, Attkisson, and Bottino,1983, p. 97) ^  28Figure 4:^Study Design  46Figure 5:^A Proposed Model for Describing Gitksan and Wet'suwet'enViews on Wellness and Well Being ^  71xiACKNOWLEDGEMENTSI am very grateful to my thesis committee, Dr. Godwin Eni (chairperson), Dr. ClydeHertzman, and Dr. Joan Anderson for the ongoing support and guidance provided during allthe stages involved in preparation of a thesis. I thank them for very generously creating timeto share their knowledge and expertise. In addition, Dr. Neil Guppy generously providedconsultative support as sampling procedures were being developed.I am indebted to my very special and loving parents, my brothers and sisters, andfriends who consistently provided support and encouragement and who unstintingly sharedtheir unique gifts to make my task easier.Preparation of this thesis would not have been possible without the support andinterest of the Gitksan and Wet'Suwet'En people. In particular, I would like to thankGeorge Muldoe, Don Ryan and Herb George for their early interest in and support of thisproject; and Marvin Sampson and Jack Sebastian for supporting my work in the villages. Inaddition, Frances Sampson and two volunteers - Lorna Brown, and Kay Baysinger - assistedimmensely in the field work by contacting people and applying the survey questionnaire.A special thanks is extended to the Gitksan and Wet'Suwet'En people who took thetime to answer the many questions posed in the survey questionnaires. Twelve people inparticular contributed immensely through their willingness to meet with me two to threetimes to talk about health and health experiences according to their unique perspective as aGitksan or Wet'Suwet'En.The research for this thesis was supported in part by the National Health Researchand Development Program through a National Health Fellowship to myself - Rhea Joseph.1CHAPTER 1.0INTRODUCTION1.1 Refocusing Health Care in the CommunityChange as a driving force in today's society is consistently present at the personal,community, and organizational levels. One of the most valued Canadian social programs -health care - has recently undergone scrutiny in most provinces with reports clearly outlining aneed, if not intent, for change. These Health Commission Reports (Saskatchewan 1990;Quebec 1990; British Columbia 1991) recognize the inadequacies of the existing curativemedical model for delivering health services and advance the belief of there being a need for asystem that is centred upon the people it serves. The assumption is the potential for improvinghealth increases if the health services and programs are responsive to and accessible within thesocial reality of consumers. This underlying assumption also influenced the 1978 policydecisions regarding health services for on-reserve status Indians (Health and Welfare Canada1978). In fact, this Policy created an environment for substantial change.Over the years, ongoing debate regarding health status of Indian people and means forboth preventing and managing health problems has remained a perplexing issue (Hodgson1980; Young 1982; Fritz and D'Arcy 1982). Even more central has been the question of howIndian people experience and respond to health and sickness (Hodgson 1980). Despitenumerous studies, these health related questions remain largely unanswered. Failure to fullycomprehend or describe these health experiences stem, in part, from use of biomedicalframeworks that are interpreted by the researcher (Enarson and Grzybowski 1986; Mao,Morrison, Semenciw, and Wigle 1986; Young 1982; Thompson 1990).This study addresses the above information gap by obtaining and describing base-lineinformation on the health status and health needs of the Gitksan and Wet'suwet'en "on-reserve"2status population in British Columbia via the meanings and interpretations they, themselves,attach to health. These findings are intended to support movements for change among theGitksan and Wet'suwet'en who, though two distinct cultures, share many common elements intheir social organization and institutions (Gisday Wa and Delgam Uukwm 1989).1.2 Health and Health Care for Indian People On-ReserveThe health of Indian people in Canada has been described as "alarming" and"deplorable" (Berger, 1980) this despite the facts that Canada is one of the most affluentWestern nations; Canadians enjoy one of the highest levels of health; and, the health caresystem is viewed as one of the best in the world (Rachlis and Kushner 1989). Infant mortalityrate, as a generally accepted indicator of population health, clearly demonstrate existingdisparities in health. In 1985, infant mortality among Indian people was twice as high as for thegeneral population, this despite marked improvements over the previous two decades (StatisticsCanada 1991).Repeatedly, research on Indian peoples in Canada demonstrate marked differences inhealth experiences when compared to the general population. Reports on health status showhigher suicide rates among Indian people (Health and Welfare Canada 1988; Cooper, Karlberg,and Adams 1991); higher incidence of active tuberculosis (Enarson and Grzybowski 1986);higher death rates from cervical cancer (Mao, Morrison, Semenciw, and Wigle 1986); highprevalence of diabetes mellitus, hypertension, and obesity (Young 1991; Montour 1985); and,high rates of arthritis and diseases of the respiratory system (Atkins, Reuffel, Roddy, Platts,Robinson, and Ward 1988; Health and Welfare Canada 1988).This persistent and unsatisfactory health status triggers major changes in the delivery ofhealth care programs and services to the status Indians both in 1962 and 1978. In 1962 we sawMedical Services Branch of Health and Welfare being given the mandate for providing health3care to the on-reserve population. Again, in the late 1970s, political pressures stemming fromthe whole question of health status and health care initiate developments in Health andWelfare's policy to transfer "control" of health services to Bands or groups of Bands south ofthe 60th parallel (Weaver 1981; Castellano 1982; Berger 1980; Health and Welfare Canada1989a). This invitation to engage in the health transfer process was multiconditional. The mostimmediate condition relates to development of a health service plan based on the community'sassessment of its health and health needs.1.3 Problem StatementIdeally, any change in the health care system is driven by a clear, shared meaning ofhealth and current health status data. However, there is no explicit health definition by Gitksanand Wet'suwet'en people themselves, nor is there literature describing the experiences of othertribal groups in Canada. Further, bands in general do not have complete or current healthinformation for its band members. In the past decade, Medical Services Branch of Health andWelfare attributes this information gap to their inability to accurately count the status Indianpopulation. Any Provincial or National initiatives to assess the health of Canadians generallyexclude on-reserve people largely because of jurisdictional issues. Where bands do have anopportunity to take part in general studies, bands often self-select out because of beliefs thatthey have been over studied; the questions asked are considered an invasion of privacy; or,bands have no control over how the information is used. As a result, there is no existing healthrelated instrument that has been either tested or used among Indian people.1.4 Purpose of the StudyThe existing gap in health information for two B.C. Bands is addressed in this study.Specifically, the purpose of the health study is to obtain base-line health services planning4information by assessing the health status and health care needs of a Gitksan and Wet'suwet'enon-reserve population. These findings are to be supported by investigation of health meanings.1.5 Research QuestionsThis study addresses four research questions, as follows:1. What does health mean to the Gitksan and Wet'suwet'en?2. What is the health status of Gitksan and Wet'suwet'en people living on-reserve?3. What are the health care needs of the on-reserve people?4. What gaps, if any, exist between health and health needs?1.6 Definition of TermsIn this study, the general term Indian is used when referring to the study subjects. Wordusage conforms with how Gitksan and Wet'suwet'en people refer to themselves. Alternativeterms include Native, Native Indian, First Nations, and Aboriginal. A reserve consists of a landarea that the Federal Government has designated for use and benefit by a group of Indianpeople. This group of people is referred to as a Band with people having a common interest inthe designated land and moneys held by the Federal Government (Hawley 1986).Indian people living on-reserve are status Indians with status being confirmed throughregistration with Indian and Northern Affairs and subsequent entry on a Band list (Hawley1986). Off-reserve people include status Indians living anywhere other than a designatedreserve.Though the terms reserve and reservation are often used to refer to a group of Indianpeople living on a specific land area, these terms have a negative connotation. The Gitksanand Wet'suwet'en people customarily refer to their communities as a village, as is done in thisstudy.51.7 Thesis OutlineThis introductory Chapter provides background on both the nature and extent of theproblem facing Gitksan and Wet'suwet'en people. Research questions posed in this studysupport movements for change by addressing existing information gaps in health meanings,health status, and health care needs of the study group.Chapter 2 reviews existing knowledge relating to both health meanings and healthmeasurement. From this review, it becomes clear that two approaches in investigation arenecessary. First, a phenomenological perspective provides qualitative data relating to the healthphenomena from the perspective of the Gitksan and Wet'suwet'en. Second, an epidemiologicapproach yields quantitative data describing health status. These findings become relevantwhen analyzed in terms of what health needs are and how choices for change are influenced bythe politics of health status and health care, both past and present. A brief social description ofthe Gitksan and Wet'suwet'en people provides background on the study population.The methodology, sampling procedures, and data analysis are discussed in Chapter 3and focus on the theoretical aspects of phenomenology and epidemiology. Further contextualinformation is provided with discussion of sampling procedures and limitations in methodology.Chapter 4 summarizes the results of the study in three major sections. The first sectionsummarizes findings related to health meanings while the second reports on results from thehealth survey questionnaire. The third second presents results from other data sources tosupport and extend information required to answer research questions posed in this study.The findings in this health study are integrated, analyzed, and discussed in Chapter 5.Here, comparisons are made with current health data from other Indian and non-Indian peoplein Canada. Chapter 6 contains a summary of findings, concluding remarks, and discussion ofimplications to health care and further research.6CHAPTER 2.0LITERATURE REVIEWThe literature review summarizes current knowledge relating to key aspects of thestudy being undertaken. In brief, the first two sections provide background information onhealth meanings and health measurement. The third major section directs attention to thestudy group through a summary description of current health statistics and health careresponses to their health experience. Finally, the study is focused with a brief socialdescription of the Gitksan and Wet'suwet'en people.In this review, examination of health meanings show an evolving conceptualization ofhealth that successively enriches the subjective nature of the definition but still leavesunanswered the question of what health means to different segments of society. In particularwhat does health mean to Indian people. This question guides inquiry into the healthphenomena which, according to Kleinman (1978), consists of beliefs and values that areculturally organized by three overlapping sectors in the health care system: the professionalsector, the popular sector, and the folk sector. This explanatory model for the health caresystem guides phenomenological research into the popular sector that has embedded in it thecultural beliefs and values that integrate the health experiences and responses to it.The second section of this Chapter reviews issues relevant to the health measurementprocess. In particular, literature stresses the importance of minimizing potential error thatmay be introduced through indirect and subjective assessment of the health experience. Thisindirect approach assembles information on a multitude of factors that affect health. Thesefactors are systematically organized in a generic epidemiologic model referred to as theDiamond Model. This Model guides the epidemiological component of the study whichexamines the distribution of disease and its determinants in a population. In this review of7factors affecting health, particular attention focuses on measuring nutritional status becauseof unique theoretical considerations. Measuring child health is also dealt with separately asthe information completes the description of the health of a population.Once synthesized, health information obtained through research establishes a basis forplanning health programs and services. At this level, both planners and the study populationmust be able to distinguish between health care needs, wants, and demands since theseconcepts determine level of response to the identified gaps in health services. Within thiscontext, health politics provides some explanation for who got what, when, where, and how.These politics are formalized through policy, an analysis of which takes on uniquecharacteristics as Indian health policy is developed, implemented, and subsequently reactedto by Indian people. This discussion of health politics is extended with a brief examination ofdevelopments in health care for on-reserve people and existing programs and services. Ageneral review of health outcomes experienced by Indian people demonstrate disparities andproblems in the social and economic structures. In this literature review, a brief socialdescription of the Gitksan and Wet'suwet'en people provides the reader with contextualinformation for the field work that is subsequently discussed in the next Chapter. First,background to relevant aspects of the study are examined in the following literature review.2.1 What is Health?If we are measuring health, what do we mean by "health"? While there are manygenerally accepted definitions for health in use today, there is no certainty that application tothe Gitksan and Wet'suwet'en people is either relevant or appropriate.An answer to this fundamental question - "What do we mean by health?" - is criticalboth from a research and health planning perspective. In research, the theoretical basis for8conceptualizing health guides selection of questions for inclusion in the health index or healthmeasurement tool. When operationalized, this health definition supports an analyticalrather than purely descriptive method for measuring health (McDowell and Newell 1987).Over the past several decades, the World Health Organization's (WHO) broaddefinition of health has customarily been adopted in Canada and other countries. WHO's1949 definition extends the concept of health beyond a focus on disease and illness bydescribing health as "... a state of complete mental, physical and social well-being and notmerely the absence of disease or infirmity." 1 While attempts have been made tooperationalize this definition, the focus for measurement varies as there is no consensus onwhich aspect contributes most to health: the mental, physical, or social aspects of being. Inaddition, the concepts of disease and infirmity have not been clearly distinguished.Despite the problems in operationalization, WHO's definition serves as an importantbench-mark in conceptualizing health. In fact, it set the groundwork for a subsequent holistichealth movement. This holistic approach to health began to receive increasing attentionduring the 1960s and 1970s and was refined by a 1974 Canadian document which clearlylinked lifestyle and environmental factors to health and sickness. Here, Lalonde (1974)proposed that the health status of Canadians might be improved only through their assumingmore responsibility for their health. A subsequent wellness movement focused on life-style,with individuals exhorted to make healthful choices in such areas as physical fitness, nutrition,and stress management. According to this conceptualization of health, health doesn't justhappen, it is created (Dexter 1988).This positive, holistic approach to health was expanded on by Health Minister Epp in1. World Health Organization, Basic Documents 38th Edition (Geneva: World HealthOrganization, 1990), 1.91986. In particular, Epp asserts that health is an evolving construct that represents "...aresource which gives people the ability to manage and even to change their environment." 2Although the five challenges (e.g. equity) derived from this view of health remains largelyunmet, the concept continues to be a central component to health initiatives beingundertaken today. For example, Ontario's health strategy is based on a positive vision ofhealth which directs planning in health promotion (Chenoy, Jackson, Hancock and Pierre1989). More recently, B.C.'s Health Commission Report (1990) speaks of health in terms of"well-being and happiness".Although WHO links the notions of health and well-being as early as 1945, therelationship remains poorly understood. According to Herbert and Milsum (1990) anemerging consensus is that "well-being implies an emphasis on the individual's perception orsense of wholeness." 3 These authors advance a conceptual model which demonstrates theoverlap between health and well-being. They also conclude that well-being necessarilycomprises a number of dimensions, including the physical, emotional, psychological, spiritual,and social aspects of being. In any case, works by McDowell and Newell (1987) and Herbertand Milsum (1990) clearly demonstrate that instruments used to measure health are distinctfrom instruments used to measure well-being.Ultimately, the question remains, "what does health mean". More specifically, whatdoes it mean to Indian people in Canada.2. Jake Epp, Achieving Health for All: A Framework for Health Promotion (Ottawa: Healthand Welfare Canada, 1986), 3.3. Carol Herbert and John H. Milsum, Measuring Health: The Documentation andEvaluation of Measuring Procedures Currently Used to Measure Well-being (Vancouver:University of British Columbia, 1990), 11.1 0This question remains largely unanswered. However, Tribes from different parts ofCanada do show some similarities in how they to respond to and speak about health andsickness. For example, the Manitoba Cree have a word for well-being ("Minoyawin") thatthey consider to be synonymous with health. Among these people, health related treatmentinvolves the body, mind, and spirit (Peguis First Nation, Manitoba 1991).For the B.C. Nimpkish people, good health is related to personal strength which inturn is linked to the strength of the community (Billy 1980). Historically, the Kwakuitl'shealth related beliefs and practices were directed to ensuring strength and preventingsickness. They believed there were two major causes of sickness both of which may becaused by supernatural beings. Cause is diagnosed by a shaman who may also be referred toas a traditional healer. One cause was a loss of the soul which may be due to a suddenfright. A shaman is able to catch the soul and put it back into the sick person. The othercause was the presence of a material object in a specific part of the body; entry is accidentalor thrown by a shaman. In some instances, the shaman was able to suck or pull out "what isbad" in a sick person, thus effecting a cure. Should the sick person die, the shaman losessocial status. A lower class shaman, or healer, may cure a sickness but not cause it (Codere1966). Treatment depended upon the cause and involved a shaman or healer andcommunity elders (Speck 1987).The Gitksan and Wet'suwet'en people in northwestern B C. link being healthy withbeing strong in body and in spirit. In the past, specific aspects of a child's training focusedon activities intended to develop strength. "As they [the child] matured, they were instructedto fast, rise before dawn, drink devil's club juice, run for miles and bathe in icy river water to11make them powerful and pure in mind and body." 4 Throughout life, adults followedspecific practices and rituals to maintain power in the body and spirit (Harris 1989).Among the Gitksan and Wet'suwet'en, all events, including sickness and death, have aclearly defined cause and effect. It is the shaman's responsibility to seek out the cause for asickness and to institute treatment. Treatment may be at the physical or spiritual level,depending upon the cause. Herbal remedies were used for routine ailments but difficultproblems required treatment by a medicine person (Gisday Wa and Delgam Uukw 1989;Harris 1989).Besides health related matters, the underlying philosophies and values that tribes inCanada do have in common explain relationships to the land and the creator. Valuesinclude respect for nature/land and man and a related need for balance or harmony; esteemfor elders; and, sharing and cooperation. A dominant belief relates to the spirit world andits linking of man, the creator, and nature/land (George 1991; Jones 1981; Gisday Wa andDelgam Uukw 1989). Each tribal group has its own history and belief system regardinghealth and sickness and the traditional treatment of sickness. These health related beliefsystems are imbedded in the larger cultural system. Here, a culture is considered to be asum of the learned beliefs, practices, habits, rules, norms, customs, rituals, etc. This everydayculture is expressed in the ways the people speak, words they use, looks, gestures, silencesand physical movements (Barrett 1984; Barclay 1986).An appropriate framework for exploring perceptions of the health phenomena fromthe perspective of a unique culture is described in Kleinman's explanatory model of thehealth care system. Findings from his cross-cultural studies (Kleinman 1978; 1980) and other4 Heather Harris, Children Are Our Future  (Hazelton: Gitksan-Wet'suwet'en EducationSociety, April 14, 1989), 97. Personal communication from David Harris.12anthropological researchers lead him to conclude that health care is a systematicallyinterconnected cultural system that integrates illness experiences and responses to it. Hesees that " It [the health care system] is both the result of and the condition for the waypeople react to sickness in local social and cultural settings, for how they perceive, label,explain, and treat sickness." 5Kleinman's conceptual model of the health care system (1980, p. 50; 1978, p. 422)focuses on internal factors that shape the system. While external factors such as political,social, economic, structural, historical and environmental determinants affect health care, hisinterest is in the inner workings of the system. These internal factors form the frameworkfor his explanatory model of the Local Health Care System which, according to Kleinman,can be altered to analyze different cultural conditions (Figure 1). Although the Model iscentred upon and activated by illness experiences, it also provides a framework for viewingand exploring health experiences and meanings.The model of the health care system (Figure 1) consists of three distinctive andoverlapping arenas of health and health care: the popular, folk and professional sectors ofcare. Within this model, the popular sector is represented as the largest in part becauseroughly 70-90% of all illness experiences are managed within this sector. The popular sectorcomprises several levels including the individual, family, social network, and communitybeliefs and activities. It is within this sector that the sick person and their family activatebeliefs and values about health and illness which determine entry into either the folk orprofessional sectors of the health care system.The professional sector comprises modern scientific medicine with social power resting5 Arthur Kleinman, Patients and Healers in the Context of Culture (Berkeley, Cal:University of California Press, 1980), 26.ProfessionalSectorFolkSectorPopular Sector:- Beliefs- Choices and Decisions- Roles- Relationships- Interaction Settings- (Social) InstitutionsFigure 1: The Local Health Cake System: Internal Structure (Kleinman 1980, p. 50).in professionals and their organizations. The dominance of this sector is such that the healthcare system has been equated with modern medicine and professional activities to theexclusion of the popular and folk sectors (Kleinman 1980; Rachlis and Kushner 1989).The third sector, the folk sector, includes such actors as shamans, herbalists, andhealers. These non-professional, non-bureaucratic specialists practice folk medicine eitherovertly or covertly depending upon dominant society's attitudes and perceptions.Kleinman's Model provides a useful framework for exploring perceptions of thephenomenon of health. In particular, it guides investigation into the Popular Sector of healthcare which, according to Kleinman (1980), is the least studied and most poorly understood.In his studies, he uses phenomenological research to investigate individual perceptions ofhealth to provide explanations for the health experience. This same qualitative researchmethod informs the research process for exploring Gitksan and Wet'suwet'en healthmeanings. Some understanding of cultural health meanings also provides a basis for1314describing and analysing the health status of the study population.2.2 Health MeasurementConsiderable debate rests in how to measure health. This debate stems largely fromthe complexity and abstract nature of health itself. By definition, measurement involvesassigning a generally accepted numeric value or scale to a variable; in this case, the variableis health. Since there is no standard scale for health, measurement must be indirect. Thisindirect approach involves assembling information on either single (e.g. body weight) ormultiple health related variables (e.g. body weight, nutritional status) which represent all or apart of the concept under study (McDowell and Newell 1987).According to Moriyama (1968), any instrument that is selected to measure healthshould be meaningful and understandable, sensitive to change, theoretically justifiable, andintuitively reasonable. Its component parts should be clearly defined, with each making anindependent contribution to the whole and the data necessary to calculate the measureshould be available or readily obtainable.The instrument of choice must also be reliable and valid. Reliability is concerned withobtaining consistent responses. A reliability test score indicates what proportion of aresponse is the result of random error. Methods for testing reliability involve applying twosimilar instruments at the same time or repeating the same question during one application(i.e., internal reliability). The degree of reliability needed depends upon the purpose of thestudy. Generally, a higher reliability (e.g., 0.90) is required if an individual's measurementoutcome determines treatment alternative in a clinical setting. Where group comparisons areinvolved, a lower reliability of 0.60 is considered acceptable (Bailey 1987).An instrument is valid if it measures what it is supposed to measure. For example a15valid health measure provides information on health and not on level of intelligence. Thereare several ways of measuring validity with the choice depending upon what researchinformation is to be obtained and how that information will be used. For example, ascreening test may require a higher validity score than a general health measurement score(Ware, Brook, Davies, and Lohr 1981).The easiest non-empirical validity test is face validity, also called content validity. Facevalidity is a matter of personal judgement and involves assessing whether items appear tomeasure what it is supposed to. In order to make this judgement, one must know thedefinition of the concept being studied and know whether items are relevant to that concept.According to Bailey (1987, p. 68), a face validity test of a health measurement instrumentmay be problematic because there is no generally accepted definition for health, the conceptis multidimensional, and the measure can be lengthy.More rigorous empirical validity tests (e.g., concurrent, construct) involve multiplemeasurements with test outcomes compared to a standardized instrument. Both lack of astandard health status measurement instrument and the nature of the current study placesempirical validity testing beyond the scope of this work. While face validity is considered aweak test, it remains the most practical.Over the past several decades, health information has been considered valid only ifobjective in nature. This preference derives from the dominant curative medical modelwhere objectivity relates primarily to observable behaviour or instrumentation (e.g., checkB/P with a sphygmomanometer) by a recognized technician (e.g., medical doctor). Today,with changing health values, subjective measures are becoming increasingly important. Themost common personal judgement regarding health is the self-rating of health as: excellent,very good, good, fair, or poor. Recent literature has shown that self-rated health is a reliable16and valid indicator of health that corresponds well with other measures of health (Ware1986). There are several advantages to using subjective measures to assess health status.Perhaps most critical is its validation of personal experiences in a system that is being re-oriented to focus on the people it serves. These insights into human concerns of pain andsuffering extend the concept of health to focus on quality rather than quantity of life. Also,these personal judgements influence when and where an individual will access the health caresystem. From a research perspective, subjective assessment also reduces research costsbecause highly trained technicians are not required (McDowell and Newell 1987).A major problem in subjectively measuring health is respondent bias. Individualresponse can vary with re-testing while responses may be exaggerated or under-estimateddepending upon personality traits. However, if health is viewed as a dynamic state withindividual traits forming a part of the health experience, then this variability remains anecessary part of the measurement process. Questions do arise, however, if measurementoutcome determines kind and amount of treatment an individual will receive. Here, thepurpose of the study requires a separation of subjective and objective measures. In this caseinstrument construction and statistical methods can disentangle these two distinct measures(McDowell and Newell 1987).The instrument selected to measure health may be specific or multidimensionaldepending on the purpose of the study. An example of a specific instrument is the Survey ofSmoking Habits: 1986 (Health and Welfare Canada 1986). This instrument focuses on asingle public health risk factor and indicates the major trends in smoking behaviour.In this current study, the general health of individual people is being assessedindirectly. Here, the abstract nature of health requires use of a multidimensional instrument.Such an instrument consists of several scaled variables that individually describe different17aspects of health. While attempts have been made to collapse multiple variables to a singlescore, this has had limited success because the single score becomes crude, difficult tointerpret, and misleading (Ware et al 1981).The following section reviews the multiple factors that affect health.2.3 Health DeterminantsThe process for measuring health generally involves an examination of the sicknessexperience rather than the positive health experience. This emphasis is consistent with theepidemiological perspective which examines the distribution of disease and its determinants.In epidemiological research, the first level of study usually has a descriptive orientation. Atthis level interest rests in providing an indication of factors associated with a particular healthstate. Once associations and descriptions are established, the second level of study involveshypothesis testing to investigate causes of the health occurrences. Finally, the third levelconcerns itself with active intervention in the health condition (Long 1984).A basic epidemiological model was proposed by Lalonde in 1974 to demonstrate majorfactors affecting health: Environment, human biology, lifestyle, and the system of health careorganization. This basic model supports a first level, descriptive study. Since 1974, the basicmodel has been further refined through synthesis of works by other health researchers. Oneexample of a synthesized, generic, epidemiological model is that proposed by Long (1984)and which he refers to as the 'diamond' model (Figure 2). In this model, health and illness isdepicted as being determined by the independent and interactive effects of four variables:Genetics/constitution, behaviour or lifestyle factors, the social and economic environment,and the health care system itself.According to the Diamond Model, the genetics and constitution determinants of healthGenetics/Constitution Socio-EconomicEnviromentHealth and Illness^Health Care ServicesflLifestyle/Personal BehaviourFigure 2: The Diamond Model of Illness Causation (Long 1984, p.4).deal with two categories of human biology. One category involves intra-uterine factorsincluding inherited genetic make-up (e.g., sex, hereditary disease) and maternal health (e.g.,fetal consequences of maternal smoking, drug use, etc.). The second category involves extra-uterine factors and include achievement of physical and mental growth potential and physicalchanges resulting from the effects of aging, stress, nutrition, and disease (World HealthOrganization 1986; Long 1984).Directly linked to this genetic/constitution component is the lifestyle factors. Thiscomponent represents the thrust of Lalonde's model where individual actions and behaviourplay a key role in health. This lifestyle and personal behaviour component includes suchhealth determining factors as diet, smoking, alcohol consumption, drug use, physical activity,and sexual behaviour. Long (1984) suggests this component also involves personal choicesthat relate to an awareness of the availability of health care, perceptions of the value ofhealth care, and individual perceptions of their health and tolerance of pain Within thiscontext, life-style may also involve reference to another group's behaviour - a referencegroup to whom the individual aspires to be like or to become a member of1819A second aspect of the environment involves social and economic factors. Thesefactors include membership in a specific cultural group; upbringing that extends fromculturally learned beliefs and practices; relationships with the dominant society, if one exits;place of residence; education, income and employment status; and, exposure toenvironmental and occupational hazards. These socio-economic determinants differ fromthe lifestyle dimension in that the individual has little control over the factors: i.e., the scopefor personal choice is restricted (Long 1984). For example, a single, pregnant woman'sincome may not provide for a nutritionally adequate diet, even though she recognizes itsimportance to the developing fetus.The final environmental factor involves the health care services. Within the contextof health determinants, services may either improve or cause an illness. According to Long(1984), these services include diagnostic, curative, palliative, and preventive aspects of care aswell as health education and promotion, and screening. An additional factor is afundamental access to all the health care services.In the Diamond model, the Figure (2) depicts a limited set of interactions. However,interrelationships form a complex web that is not readily portrayed. All of these factors actsingly or in a complex multicausal manner to affect health and illness. While all potentialhealth determinants may not be investigated during research, Long (1984) asserts they mustbe recognized and considered potential causes as study results are being interpreted.In conducting the first level descriptive study, the four key health determinants guideselection of items for inclusion in the health measurement tool. These four determinantsinvolve genetics/constitution, health care services, lifestyle/Personal Behaviour, and the Socio-Economic Environment. One important life-style health determinant is nutritional status, aninvestigation of which poses several methodologic problems that are discussed in the20following section. This discussion of health determinants is completed with a review ofmethodologic issues relating to the measurement of child health.2.3.1 Nutritional StatusOver the years, the importance of nutrition in maintaining good health has gainedincreasing acceptance. The phrase "You are what you eat" describes health, in part, ascurrent studies link excess or deficient nutrients with specific health conditions.The kinds of nutrition advice provided to the public has kept pace with the evolvingconceptualizations of health. It is generally recognized that improvements in health in theearly 1900's is attributed in part to improved nutrition. With infectious diseases undercontrol, advice progressed to focus on preventing nutrient deficiency and disease prevention.The preventative focus addresses specific etiology of a disease, as for example reducing therisk of iron deficiency anaemia by consuming sufficient quantity of iron rich foods.More recently, in the 1980's there has been a shift in the focus of nutrition educationfrom an exclusive focus on disease prevention to one of health promotion. This shiftcorresponds with a holistic conceptualization of health where health is viewed as a resourcethat is acted on by a multitude of forces including environmental and social factors (Dexter1988; Epp 1986). This thrust in health promotion addresses the underlying environmentalforces of daily life that promote or damage health. Within this context, adequate nutritionhas an health-enhancing potential in that it contributes to the vigour and vitality of peoplethus improving this 'resource' called health (Dexter 1990). Similarly, chronic diseasescurrently present the greatest threat to health and receives increasing attention in nutritioneducation initiatives.In responding to this changing environment, Health and Welfare Canada (1990a)21acted by revising and updating the Nutrition Recommendations for Canadians. Theserecommendations attempt to strike a balance between maximizing health potential andpreventing chronic disease.The Recommended Nutrient Intakes deal with recommended intakes of such essentialnutrients as energy, protein, fat, vitamins, and minerals. The recommended intakes aredesigned to meet the needs of all normal individuals: in meeting the needs of all, theexpectation is the recommendations exceed the needs of most. The related NutritionRecommendations deal with food intake patterns that is expected to provide the essentialnutrients in recommended amounts while also minimizing the risk of chronic diseases. Keystatements in the Nutrition Recommendations for Canadians indicate: diet should provideenergy consistent with the maintenance of body weight within the recommended range; thediet should include no more than 30% of energy as fat; and, the diet should provide 55% ofenergy as carbohydrate (Health and Welfare Canada 1990b).Assessment of the adequacy of food intake may be achieved by utilizing one of threemethodologies: surveys, surveillance, or screening. Of these three methodologies, the cross-sectional nutritional assessment best meets the study objective of describing the health of agroup of people. Two principle methods for assessing the nutritional status of individualsinvolve (1) food recalls and (2) dietary history and the food frequency questionnaire The 24hour food recall is designed to measure the quantity of individual foods consumed over a oneday period. By comparison, the dietary history attempts to estimate the usual food intake ofindividuals over a longer period of time. Similarly, the food frequency questionnaire providesqualitative descriptive information about usual food consumption patterns (Gibson 1990).This food frequency method was used in the current Ontario Health Survey (OntarioMinistry of Health 1989).2 2The 24 hour food recall is also an appropriate method for describing the averageusual intake for a large group of people provided random sampling is used and all the daysof the week are equally represented. However, there are several threats to reliability andvalidity. These threats include interviewer bias, memory lapses, incorrect descriptions offood, over or under-estimating portion sizes, and computational and coding errors.Minimizing sources of both random and systematic error involve training the interview staffand developing standard interviewing techniques and questionnaires. Probing questions andvisual aids may reduce error introduced by respondent memory lapses. More difficult tocontrol are systematic errors from wrongly coded weights of foods (Gibson 1990).Though dietary intake data has been severely criticized because of the random andsystematic errors which occur and because of misinterpretations, the data provides importanthealth related information. An evaluation of dietary data generally involves comparison withrecommended intakes to determine adequacy and not nutritional status. In order to describenutritional status, additional complementary methods must be used and include biochemical,anthropometric, and clinical indices. Gibson (1990) describes several methods for evaluatingnutritional adequacy and estimating an at-risk group. However, she concludes that none ofthe methods can accurately define an individual's degree of nutrient adequacy. While theprobability approach can provide an estimate of the prevalence of inadequate intake, datarequirements and research methods are beyond the scope of this study (Gibson 1990).Generally, an evaluation of single food recalls for a group of people involvesdescribing intake as a percentage of the corresponding recommended nutrient intake. Thisdescriptive method can overestimate the prevalence of inadequate intake since theRecommended Nutrient Intake can and does exceed requirements for some individuals. Acomplementary method involves describing individuals as being 'at-risk' if their intake falls2 3below an arbitrary 'cut-off' value. Though there is no rationale for the cut-off point, two-thirds of the recommended nutrient intake is frequently used. While this method reduces thepotential for overestimating the actual prevalence of inadequate intakes, misclassificationsstill occurs and is presently unavoidable (Gibson 1990).Directly related to food intake is current body weight which also provides an indicatorof current health status. Studies have shown that excess weight is associated withhypertension, diabetes, and heart disease. A recommended method for assessing obesity isthrough calculation of the Body Mass Index. This measure has epidemiological validity, isprecise, reliable, and accurate (Health and Welfare Canada 1988a).The Body Mass Index (BMI) is calculated as weight in kilograms divided by height inmeters squared. This measure has a high correlation with body fat and is independent ofheight. It's use is limited to men and women between the ages of 20 and 65 and is not validfor pregnant or lactating women or for individuals with gross abnormalities in leg-trunklength. Health and Welfare Canada has established guidelines to identify ranges ofacceptable, excess, and low weights in relation to health risks. The same cut off points in thisrange is appropriate for both men and women between the ages of 20 and 65. These cut ofpoints are (Health and Welfare Canada 1988a):Under 20 May be associated with health problems for some people;^20 - 25^Good weight for most people with lowest risk to health;25 - 27^May lead to health problems for some people;Over 27 Increasing risk of developing health problems such as diabetes, high bloodpressure and heart disease.In this study, the above cut-off points are adopted in assessing body weight of men andwomen between the ages of 20 and 65 years.Since good nutrition is consonant with good health, nutritional shortcomings or2 4inadequacies must be identified for at-risk groups. Information derived from a nutritionalassessment provides a rational basis for meeting the program and service needs of those whopose a health risk because of nutritional deficiencies.2.3.2 Child Health StatusWhen measuring the health of a group of people, information must necessarilyinclude children as they tend to be one of the highest users of health services. In addition,measurement of children's health could potentially provide critical indicators for the generalhealth of a population. Such a measure could prove useful in monitoring overall health,assessing differences in subgroups (e.g., non-Indian vs Indian), evaluating the impact ofdifferent delivery systems, and determining the efficiency and effectiveness of the deliverysystem (Lewis, Pantell, and Kieckhefer 1989). However, development of child healthmeasurement tools has lagged behind that of adults because of unique methodologic andsubstantive problems.Existing tools and methods for measuring children's health raise questions regardingspecificity and reliability. According to Fink (1989) clinical examinations do not satisfy arequirement for measurement reliability because of variation in subject response and theexaminer's approach. In addition, the selected tools and methods are dependent upon thepurpose of the research. One widely used method involves obtaining information about childhealth from a primary caretaker - usually the mother - through interview format. The healthinterview generally seeks to obtain information in four major areas: "... reports of specifichealth conditions; reports on symptoms whether or not they are related to a specific healthcondition; reports on restricted life activities associated with health problems; and general2 5and subjective measures of health." 6 While each of the four distinct areas identified by Fink(1989) can potentially provide a health indicator, problem rests in classifying information in ameaningful way (Fink 1989).Recently, research into the psychological, social, and behavioral aspects of children'sfunctioning has received increasing attention (Fink 1989). An investigation of these threedomains operationalizes the concept of a child's health as the ability to participate fully indevelopmentally appropriate tasks. Though this focus in assessing child health appearspromising, significant questions remain regarding accuracy of information that is obtainedand knowledge of what age-appropriate functioning actually is (Lewis et al 1989).An additional problem arises where recent studies demonstrate low prevalence offunctional limitations in the general population. Though instrument and method vary, anAmerican study demonstrates functional limitations in 10% of children aged 0 - 13 years(N=2,152) (Eisen, Ware, Donald, and Brook 1979) while an Ontario Child Health Studyshow functional limitations in 19% of children aged 4 - 16 years (N=3,294) (Cadman, Boyle,Offord, Szatmari, Rae-Grant, Crawford, and Byles 1986). This low prevalence demonstratesa need for a large sample size before reliable conclusions can be drawn.In pursuing the functional conceptualization of child health and its measurement,Lewis et al (1989) re-adapted an adaptation of the Rand Corporation's Measure ofChildren's Health (Eisen, Ware, and Donald 1979). Rand Corporation's instrument wasdesigned to measure parents' perceptions of the impact of illness on their children'sfunctioning. Lewis et al's re-adapted instrument distinguishes between well and ill children,is appropriate for ages 0 to 16, and is not affected by demographic features of the parent6 Raymond Fink, "Issues and Problems in Measuring Children's Health Status in CommunityHealth Research," Social Science and Medicine, 29:6 (1989), 716.2 6(e.g. age, race, occupational status and education). Lewis et al (1989) tested their adaptationon a small sample of children (113) with a single chronic illness (asthma). Applicationmethod differed from the original interview format through use of a short, self-completedquestionnaire for parent use. Despite these limitations, authors conclude testing providespreliminary evidence of the internal consistency and construct validity of the adaptedmeasures.Portions of the Rand Corporation instrument was also used in a recent Ontario childhealth study. (Cadman et al, 1986) This study set out to determine the prevalence anddistribution of mental health problems in Ontario children aged 4 to 16 years. Methodologyincluded self-completed check-lists concerning 3294 children and, six months later, a blindclinical assessment of 194 randomly sampled children by a psychiatrist (Boyle, Offord,Hofmann, Catlin, Byles, Cadman, Crawford, Links, Rae-Grant, and Szatmari 1987). Resultsshow that 20% of Ontario children had a chronic health problem, with children of lowersocio-economic status being more likely to be affected. In addition, authors conclude theirfindings have implications for those who plan and provide services and programs for children(Cadman et al 1986).While both instruments derived from the Rand Corporations Measure of Child'sHealth warrant further field testing, ultimately choice is determined by both purpose of thestudy and available resources. In this study, measurement of child health is not the primarypurpose of the study. Rather, child health is explored because it completes a description ofpopulation health and ultimately affects kinds and amount of services provided.2.4 Politics of Health Care Needs, Wants, and DemandsAn assessment of health care needs involves identification and priorization of those2 7needs. At face value, the process appears straight forward. Problems arise when it becomesnecessary to distinguish between health care needs, wants and demands. An additional butunavoidable complicating factor is the politics of health care. Politics itself is a part of lifeand may be described as the art of creating the possible through skilful manipulation andcompromise (Marmor 1983). In the face of this reality, responses to consumer needs, wants,and demands necessarily requires an examination of political issues. In this context, healthpolitics provides explanation for who got what, when, where, and how.Within the health care system, the need for or gap in health services is identified froma variety of sources including the health consumer, key informants with specializedknowledge of community health (e.g., health workers, pastor, police), and professionals. Theprocess for identifying needs is conceptualized as an environmental monitoring system whichprovides early warnings for health service programs. The process also helps to identifyunrecognized or unmet needs. The interrelationship between health needs and services aredepicted in Figure 3. Here, a needs assessment is directed to describing previouslyunidentified needs and inappropriate programs services. Such a description contributes to ananalysis of resourcing to meet current needs.According to this conceptualization of health needs, an unmet need exists when aproblem has been identified; judgement is made that possible satisfactory solutions are notaccessible, are not currently adequate, or do not exist in the community; and, it is necessaryto reallocate existing resources and/or appropriate new resources (Nguyen, Attkisson, andBottino 1983).One method of distinguishing between need and demand has an economic focus.According to Cordes (1978), a demand for services is based entirely on economics (e.g., animpoverished community can address its health needs only through provision of direct or28Unidentified needsUnmet Needs or InappropriatePrograms/ServicesNeeds Met(1) Needs met throughself help groups(2) Needs met throughorganized servicesFigure 3: Relationship Between Health Needs and Health Programs and Services. (Adaptedfrom Nguyen, Attkisson, and Bottino 1983, p. 97)indirect subsidies). What is more relevant to the Canadian context of health care are thenotions of fairness and equity. Here, a demand may be influenced by interests in equityirregardless of costs or potential health outcomes (e.g., X Hospital has acquired an advancedtechnology so Y Hospital demands the same). It is more difficult to distinguish health care`wants' as value judgements become a predominant determining factor.As health care needs are identified, recommended methods for addressing the needwill vary according to whose perspective is dominant: health professionals, economists, or theafflicted individual. Cordes (1978) cautions planners to consider expected outcomes ofhealth care. These outcomes relate to the conceptualization of health and how interventionscontribute to or advance personal health experience to a higher desired leveL As initiativesare undertaken to achieve a desired level of health, consumer input in identifying needsnecessarily requires a consideration of both health related and health directed initiatives.For example, a health directed service may involve instituting pre-natal classes for single2 9teens while a health related initiative may involve community participation in providingliteracy or mother-tongue classes for the same group.Ultimately, distinguishing between and responding to health needs, wants, anddemands becomes an arena of influence for politicians, policy makers, interest groups, and,to a lesser extent, planners. In health politics where important values are discussed, foughtover and resolved, organizations play a key role in influencing outcome. These organizationspossess important resources of time, information, and expertise where the individual or smallinterest group do not. According to Marmor (1983), small interest groups are not likely toinfluence decisions but they can become involved and influential in the political process andpolicy development.Although politics and policy are commonly distinguished by definition and usage,Doern and Phidd (1988) argue they are, in many respects, the same thing. "... [Politics andpolicy] both deal with ideas and with the power to actually implement ideas in a world oflarge structures [i.e., government] and institutions and in the face of numerous uncertainties." 'Accordingly, policy may be considered a formal expression of decisions which incorporateideas, structures, and processes to achieve a desired change. The politics of health care thenbecomes a political/policy struggle where the stakes and contestants vary. The very act ofputting a policy into effect extends the struggle because goals vary (Marmor 1983).Policy itself is viewed in three different ways: there are policy statements or positions,policy actions, and policy outcomes. Gaps in these three levels can and do exist because apolicy statement may be symbolic; it may express a real intent but produce no action; it maybe altered in action; or it may be carried out but the desired results not achieved. Decisions7. Bruce G. Doern and Richard W. Phidd, Canadian Public Policy: Ideas, Structure, andProcess (Scarborough, Ont.: Nelson Canada, 1988), 19.3 0contained in a stated policy are the products of rationalization, bargaining, and theorganizational process itself. When operational policies diverge from stated ones, anappraisal of stated policy provides misleading substitutes for judgements of the operationalpolicy (Marmor 1983).In Canada, where Government holds a key position in provision of health care, healthpolicy appraisal must include political analysis of the social context of health care. Here,liberal beliefs in fairness and equity underpin the five conditions for the 1966 Medical CareInsurance program. These conditions require that the Program be (1) publicly administered,(2) comprehensive, (3) universal, (4) portable, and (5) accessible (Taylor 1986). A keyelement in this health policy focuses on access, this advancing a long standing belief thathealth may be improved through unhindered access to health care.One policy analyst (Leichter 1991) suggests that health policies up to the 1970s havebeen shaped by the issue of accessibility. However, a shift in policy focus began in 1974 withLalonde's discussion of a new perspective on health and health care. Here, Lalondeproposes health may be improved through better life-style choices and not through expandingaccess to health care. An underlying assumption is that "... a good deal of disease is self-inflicted, a product of our daily habits, and that individuals, through negligence, self-indulgence, and irresponsibility, contribute significantly to their own ill health or prematuredeath." 8 A further assumption is we can no longer afford to be so foolish.The new perspective on health sees the beginning influence of prevention andpromotion on health policy which extends through the 1980s and into the 1990s. Thisperspective effectively creates a new domain for governmental involvement in health and8. Howard M. Leichter, Free to be Foolish: Politics and Health Promotion in the UnitedStates and Great Britain (Princeton, NJ: Princeton University Press, 1991), 75 - 76.31health care. Political debate and conflict relates primarily to personal versus group rights.Unique policy conditions are directed at promotional practices that intrude at the personallevel; life-style related initiatives assume individual's with a disease are guilty of making thewrong choice; and, health problems are seen to be a sign of a weak character or immorality.One consequence of this health promotion focus is the manner in which health problemsbecome characterized and how they are responded to. We see this in the medicalization of asocial problem, as in the case of alcoholism (Leichter 1991).A harsher, socialist criticism of policy in prevention and promotion considers the life-style argument obscures sources of illness and disability in the environment. In addition, itplaces the burden of health on the individual and frees society from seeking the responsibilityof seeking a collective solution to the health problems (Waitzkin 1983). Other authorsillustrate problems arising from the life-style argument that often excludes a structuralcritique of contemporary society: for some, a healthy life-style may not be an option orhazards in the workplace are ignored (Small 1989; Marmor 1983; Leichter 1991).This exclusion of social reality may represent a non-decision on the part of policymakers engaged in the political process. These types of non-decision reveal the biases in thesystem; decisions are made about what not to include or present because of a belief it willnever get through the policy making process. Alternatively, stated policy may express theimportance of social structures in relation to health, however, operational policy may notaddress these factors. This is demonstrated in Epp's 1986 Framework for Health Promotionwhich recognizes the relationship of economic status to health. The stated policy challengesCanadians to address the issue but does not establish a process for creating change.An analysis of politics/policies in health care provides explanations for existing healthprograms and services. This process assumes a unique perspective as the issue of Indian32health in Canada is examined. Here, politics extends beyond health and inextricablyincorporates struggle and conflict in the social and economic domains.2.5 Developments in Health Services for On-Reserve PeopleSince 1867, with the signing of the British North American Act, health care for Indianpeople living on-reserve has been the responsibility of the federal government. During asubsequent 50 years, health comprised one component of Indian Affairs' generalresponsibility for matters relating to Indian and Inuit people in Canada. In 1945,responsibility for the health care of all Canadians, including Indian and Inuit, was transferredto the newly formed Department of National Health and Welfare. By the 1960's it becameapparent that the health of Indian people remained significantly poorer than that of thegeneral population. This poorer health is demonstrated by the Infant Mortality Rate. In1960, the Infant Mortality Rate for Indian people was 82:1000 live births; in 1961, the ratefor the general population was 27.2 (Statistics Canada 1991).Governmental response to the disparity in the health of Canadian sub-groups was toincrease efforts to narrow the health status gap by providing specialized programs andservices to the status Indian and Inuit. In 1962, this specialization was assigned to the newlyformed Medical Services Branch - a Branch that consists of several merged healthprogrammes, including Indian health.One of the first specialized programmes initiated by Medical Services Branch was theCommunity Health Representative (CHR) Program. Established in 1964, this Programinvolves the hiring and training of a community member to act primarily as liaison betweenvillage people and non-Indian health care workers. The CHR's major functions includedinterpreting and establishing links to enable the treatment oriented medical model to operate3 3within the context of the traditional culture.Indian people maintain that health care is an enforceable right stemming from theIndian Act and the Treaty 6 "medicine chest" clause which states "... That a medicine chestshall be kept at the house of each Indian Agent for the use and benefit of the Indians, at thediscretion of such Agent". 9 However, the federal government asserts it holds neitherstatutory or treaty obligation in the provision of health services to Indian people. Rather,benevolent policy makers make it possible for status Indians to access "free medical care"(Health and Welfare 1974; Shawana and Taylor 1988).Despite this position of limited and tenuous responsibility, the governmentdemonstrates its "good faith" by withdrawing the 1974 Policy of the Federal GovernmentConcerning Indian Health Services which was unanimously rejected by Indian people acrossCanada. This Policy, containing guidelines for uninsured health services (e.g., dental careand drugs), was seen to advance the intent of assimilation through federal governmentlimiting the extent of responsibility for Indian health. Health and Welfare withdrew theguidelines for Provision of Uninsured Health Benefits and replaced the guidelines withprofessional or medical judgement. The goal of a subsequent and new Indian Health Policywas to increase the level of health of Indian communities, generated and maintained by theIndian communities themselves (Health and Welfare Canada 1978).Besides modifying the contentious 1974 health policy, the government also respondsto general questions about Indian health by instituting two Commissions of Inquiry. TheGoldthorpe Commission at Alert Bay B.C. examined allegations of incompetence and9 Alexander Morris, "The Treaties at Forts Carlton and Pitt, Number Six," in The Treatiesof Canada with the Indians of Manitoba and the North West Territories, (Toronto: Belfords,Clarke, and Co., 1980), 355.3 4discrimination in local health services provided to Nimpkish Bands. The Berger Commissionset out to determine methods of consultation that would ensure substantive participation byIndian and Inuit in decisions affecting the provision of health care to them. Conducted overa 10 week period, this national Inquiry recommends an allocation of funds to support anational consultative process and a national conference on Indian health (Berger 1980). Thispublic commitment to consultation was also present within the Department of Indian andNorthern Affairs during the 1970s: a commitment that did not translate to action (Bostrom1984; Weaver 1981; Castellano 1982).Though not a recommendation, the Berger Report discusses strategies for revising thehealth care system and Indian peoples' role in the revisions (Berger 1980: 13-15) Thesedirections stem from a political analysis of the role of various tribal organizations: "... that thefit between needs and services, the appropriate distribution of services, and the countering ofhealth destroying dependency can best be achieved by introducing community control ofhealth programs and promoting community responsibility for sustaining health." 10These strategies support a governmental ideology of placing responsibility for solvingIndian problems in the hands of Indian people. Thus, the strategies develop into communitydemonstration projects. The expectation is the projects would provide a trial ground fortesting the health benefits of community control: projects that are adapted over time couldbe extended to other communities and regions (Castellano 1982).One Health Demonstration Project in Manitoba reported on progress in itsparticipative efforts. While the Band appears to have met some of its health relatedobjectives, it identifies specific problem areas. These problems relate to a restrictive time-10 Marlene Brant Castellano, "Indian Participation in Health Policy Development:Implications for Adult Education," Canadian Journal of Native Studies, 2:1 (1982): 115.35frame that limits potential for success; a lack of training and resources, particularly forHealth Committees; and restrictions created by inadequate financing and inflexible financialcontrols (Garro et al 1986). These problems and concerns are repeated and extended duringa 1987 National Health Transfer Conference (Assembly of First Nations 1988).The Health Transfer Policy was officially introduced in April 1986, the intent being totransfer the responsibility and funds for running most health care programs to thecommunity. At this time, health services available for transfer include the nursing program,CHR programs, medical and dental advise and care, health education, nutrition programs,and environmental health services. Transfer does not include non-insured Health Benefits,however, communities have the option of administering the medical transportation programthrough contribution agreements. The transfer process involves (1) community assessmentand planning, (2) negotiation, and (3) transfer (Health and Welfare Canada 1989a).Though apparently rational at face value, the criteria and conditions for transferevolved during the implementation process. This evolutionary process limited potentials forsuccess in transfer. Conditions included demonstration of community input into theassessment; shifting requirements for proposals and reports; development of a communityemergency response plan; and transfer at existing levels of resources (Assembly of FirstNations 1988).Despite political problems plaguing Health Transfer, the process is offered as one, ifnot the only means for improving the health of Indian people in Canada. This Policyassumes access to programs and services will improve health.2.5.1 Health Care System for On-Reserve PeopleThe on-reserve health care system involves Medical Services Branch, Provincial3 6Health, Indian and Northern Affairs, and Municipalities. This necessarily leads tojurisdictional disputes which result in inequality in service delivery and accessibility.Since 1962, Medical Services Branch of Health and Welfare has held primaryresponsibility for providing specialized programs and services to status Indians living on-reserve. These programs and services are generally delivered out of a Health Station locatedon-reserve with co-ordination and administration provided through a local off-reserve HealthCentre. A major component of health care has been and remains treatment oriented and isprovided by nursing personnel. The nursing staff also provide health education which islargely preventive in nature. Major nursing programs include maternal and infant health(e.g. pre-natal counselling; post-natal visits and new born examination; Denver Developmenttesting; and, immunization). Child and school health largely involve developmental follow-up, screening for specific conditions, and group education (e.g., sex education; AIDSawareness) (Health and Welfare Canada 1990c).The Community Health Representative (CHR) Program remains one of the keyprograms provided through Medical Services. Instituted in the mid 1960s, the program isnow administered by bands through transfer agreements undertaken between 1978 and 1980(Health and Welfare Canada 1980). Though Band Council is the employer, in manyinstances the nurse provides supervision and direction. Today, the CHRs in B.C. receivemodular training through the Sal'i'shan Institute for training. Training is general and largelydisease and treatment oriented.Community health services in B.C. are also provided by four health educators (staffingmaximum: five) and one nutritionist. Direct services are limited by geography and number ofbands (197) in the province. Both programs extend services through training and support forhealth nurses and CHRs. Bands also have access to Alcohol and Drug Councillors who are3 7part of the National Native Alcohol and Drug Abuse Program. A councillor may be on-staffor part of a shared service. When required, band members may be referred to a TreatmentCentre in the Province.A Dental Officer administers the Pacific Region's Dental Program In isolated areas,direct services are provided by contracted Dentists and Dental Therapists: otherwise,mainstream services are accessed. In B.C., the Environmental Health Program is carried outby four Environmental Health Officers. Officers largely provide a surveillance function.While these Officers may advise bands of health risks, municipal or provincial standards arenot enforceable because of jurisdictional issues (Health and Welfare Canada 1980).The Department of Indian and Northern Affairs concerns itself primarily with socialissues affecting Indian people living on-reserve. The Department jointly funds the Drug andAlcohol Abuse Program, supports the Social Assistance Program which parallels theProvincial Program, and through Welfare Services, provides adult home care and children-in-care services.Health services provided to status Indians through the Provincial health care programis fully reimbursed by the federal government. These services relate primarily toimplementation of the provincial health service plan and concern hospital services. Inisolated areas, there is a federal-provincial exchange-of-service arrangement. In otherinstances, provincial services (e.g., mental health) are provided to on-reserve people, with thefederal government compensating for costs. Submissions to the B.C. Royal Commission onHealth Care and Costs (1991) indicate this type of arrangement results in restricted accessand poorer quality of services.The federal-provincial jurisdictional dispute stems from Section 92(7) of theConstitution Act, 1867 (Canada. Department of Justice 1983). The federal government's3 8position describes health care as a provincial responsibility; federal provisions for health areby custom alone. While the provincial government maintains it would be more efficient toprovide one coordinated system of health care to all residents of the province such aproposal is rejected by Indian people. B.C. does not have an accepted policy relating tomatters affecting Indian people, thus a transfer would jeopardize the federal-Indianrelationship and could result in assimilation within provinces (B.C. Royal Commission onHealth Care and Costs 1991; B.C. Ministry of Health 1979; Assembly of First Nations 1988).This reluctant sharing of responsibility for Indian health contributes to inequities inkinds and amount of programs and services provided to status Indians. This systemicproblem further undermines the health of on-reserve people.2.6 Health of Indian People: A Summary DescriptionThe health of Indian people has been alternatively described as deplorable andalarming. These extreme descriptors are borne out by documented health statistics wherethe health of Canadians provides a base-line for comparison.Infant mortality rate, a generally accepted measure for population health, representsdeaths of infants under one year of age. In 1985, the Infant Mortality Rate for Indianpeople was 17.9 per 1,000 live births, this over two times higher than the rate for Canada(7.9). The rank ordered six leading causes of infant deaths for Indian people were suddenunexplained death; congenital anomalies; and birth asphyxia, anoxia, and hypoxia. The highinfant death rates experienced by Indian people remains high despite deaths having beenvirtually cut in half for both Indian people and the general population between 1976 and1985 (Health and Welfare Canada 1988).Life expectancy, the average number of years an individual is expected to live, has39also seen marked improvements for Indian men and women over the past several decades.However, by 1986 the gap between Indian and non-Indian life expectancy remains at 10.2years. In 1986, Indian Women had a 74 year life expectancy (Canadian women: 80 years)and for men, 63 years (Canadian men: 73 years) (Indian and Northern Affairs Canada 1989;Statistics Canada 1991).The suicide rate for Indian people is three times the national average, with suicideaccounting for one out of every ten deaths. However, individual bands have experiencedsuicide rates that are significantly higher than the national average. These multiple suicidesare referred to as a suicide epidemic. Males between the ages 15 and 24 comprise the highrisk group (Health and Welfare Canada 1988; Cooper, Karlberg, and Adams 1991).Age specific mortality rates for Indian people living on-reserve in seven Canadianprovinces (excluding B.C.) show rates for all causes up to 50 years of age were two to threetimes higher than the general population. Between 1977 and 1982, causes include infectiousand parasitic diseases; diabetes mellitus; alcoholic psychosis and alcoholism; pneumonia;kidney disease; and all major forms of accidents and violence. Mortality rates for all cancersites was lower than Canadian rates for both sexes, but deaths from cervical cancer wassignificantly elevated (Mao, Morrison, Semenciw, and Wigle 1986).Indian adults and children also experience excessively higher rates of infective andparasitic diseases. These diseases have been associated with conditions of socio-economicstress and over crowding and include hepatitis and tuberculosis (Enarson and Grzybowski1986). Gaudette (1989) reports that between 1985 and 1987, the average rate for new andreactivated T.B. is at least 5 and may be 10 times higher among Indians than in the Canadianpopulation as a whole.Of growing concern to Indian people is the rapidly increasing prevalence of Non-4 0Insulin Dependent Diabetes Mellitus (NIDDM). Prior to 1930, NIDDM was an unknowncondition among Indian people (Chase 1937; West 1974). Since then, most Canadianprovinces, including B.C., are reporting increasing rates (Martin and Bell 1990). Similarly,many Indian people are increasingly concerned about the prevalence of arthritis and systemiclupus erythematosus (Atkins, Reuffel, Roddy, Plans, Robinson, and Ward 1988).The contributing causes for poor health in general is related primarily to social andeconomic conditions. In 1988, 80% of native people lived below the poverty line withunemployment rates ranging from 60% in general to 90% in remote villages (Ramcharan1989; Indian and Northern Affairs 1989). Approximately 80% of Native students do notcomplete high school. In B.C. 41% of status Indians have less than a grade 9 education(B.C. Provincial Advisory Committee 1990). Nationally, low levels of achievement suggest aconservative estimate for functional illiteracy for on-reserve people is 45% as compared to30% for the general population (Canada. House of Commons 1990). Housing conditionsare generally sub-standard this demonstrated in a 1990 report which shows 29% of 5,100surveyed houses in B.C. villages were in poor overall condition (Melliship 1990).Though the health of Indian people has improved over the past several decadessignificant disparities exist when comparisons are made to the general population. Manyauthors attribute poor health status to social and economic conditions specific to on-reserveand systemic inequities in the larger society (Berger 1980; Fredere 1988; Speck 1987).2.7 Gitksan and Wet'suwet'en: A Social DescriptionIn this study, the health of the Gitksan and Wet'suwet'en is being investigated. Oralhistories of these peoples trace their presence in the valleys and mountains of the Skeenaand Bulkley watersheds for about 10,000 years. Though two distinct cultures, their habitation41of the transition zone between coastal and interior tribes has, over the centuries, resulted ina distinctive form of confederation. These two societies share many common elements intheir social organization and institutions. Similarities stem from inter-marriage, adoption,trade, and the adaptation and introduction of each other's ideas and practices (Gisday Waand Delgam Uukw 1989; Glavin 1990).The house and clan make up the central social units in the Gitksan and Wet'suwet'ensociety. A person is born into a particular house or clan according to laws of matrilinealdescent: all inheritance passes through the mother's line. The Gitksan have four clans andthe Wet'suwet'en, five: there are 76 Houses. Within each clan there are a number of relatedHouses: Houses derive their name from the fact that, in the past, members lived under oneroof. Gitksan operate primarily within the House system while the Wet'suwet'en identifymore strongly with clans. In the House, the members' relationships are known while in aClan relationships may or may not be known but there is an assumption that members arerelated (Gisday Wa and Delgam Uukw 1989).Authority rests with the hereditary chiefs of a House or Clan who may be female ormale. This authority is validated and enacted primarily in the feast hall - a central institutionof the Gitksan and Wet'suwet'en. The feast is given to mark all important occasionsincluding death, marriage, settlement of disputes, inheritance of a name and territory. "Thewitnessing and validation of the House's historical identity, territorial ownership and spiritpower is integral to the feast. But also integral is the House's demonstration of its prosperitythrough a distribution of its wealth. A House's wealth is directly linked to its territory." 1111 Gisday Wa and Delgam Uukw, The Spirit in the Land: Opening Statement of the Gitksan and Wet'suwet'en Hereditary Chiefs to Chief Justice McEachern of the Supreme Courtof British Columbia (Gabriola, B.C.: Reflections, 1989), 26.4 2In their land title court action, the Gitksan and Wet'suwet'en claim ownership andjurisdiction to 22,000 square miles of hereditary territory. This compares to the 45 squaremiles of reserve land assigned to the Bands in the early 1900s and presently inhabited bythree Wet'suwet'en and seven Gitksan villages (Gisday Wa and Delgam Uukw 1989). In1989, the Gitksan and Wet'suwet'en on-reserve population totalled 3,246: 117 males per 100females (Indian and Northern Affairs 1990).The Gitksan and Wet'suwet'en villages are located in a geographic area commonlyreferred to as the Hazeltons. Here, forestry is the backbone of the area's economy.Secondary industries include tourism, cattle ranching, and mining (B.C. Ministry of Health1989). In 1990, unemployment in the northwest zone, including the Hazeltons, was quoted at12%. This contrasts with unemployment among Gitksan and Wet'suwet'en which totalled65% in the same time period (Personal Communication, MacDonald 1991).Currently, the Gitksan and Wet'suwet'en Hereditary Chiefs are in Court to resolvethe question of the people's title to traditional territories (Gisday Wa and Delgam Uukw1989). This land mark court action is supported by local initiatives to exercise control ineducation, forestry, resource management, and the justice system (Gitksan and Wet'suwet'enEducation Society 1989; Glavin 1990). Although there have been some discussions aboutopportunities in health transfer, none of the nine villages have documented information onthe people's health and health needs. This descriptive study is intended to address theinformation gap.2.8 Summary of the Literature ReviewThis review of existing knowledge shows that while health definitions have evolvedconsiderably, there is no certainty that a universal definition of health reflects the beliefs and4 3values of the Gitksan and Wet'suwet'en people. This conclusion points to a need to exploretheir unique health meanings in order to both understand current health status and toestablish a rational basis for responding to findings in the health measurement process.Significant portions of this review provide background to key elements involved in thestudy being undertaken. This necessarily focuses on how health meanings may beconceputalized and how health itself might be measured. Two existing theoretical modelsguide research: Kleinman's explanatory Model of the health care system supports anexamination of health meanings while the Diamond Model helps to organize the multitude offactors that are relevant to an assessment of health status.An examination of the political nature of health care needs as well as developmentsin health care for Indian people provides some explanation for who got what, when, where,and how. These politics take on new meaning as Indian Health Policy institutes a processfor change that is intended to improve health experiences of these health care recipients.However, prior to any change, information gaps must be addressed. The following Chapterprovides details on the two approaches in research that address the information gap.4 4CHAPTER 3.0METHODOLOGYIn the previous chapter, literature review points to the importance of having thehealth concept clearly defined prior to selecting an instrument to measure health status.Lack of an operationalized term, both for mainstream society and for the Gitksan andWet'suwet'en in particular, points to a need for two approaches to this study. Thesecomplementary approaches are qualitative and quantitative in nature and utilize thephenomenologic and epidemiologic research perspectives.The complementary nature of phenomenology and epidemiology becomes apparentlargely within the context of the health care system which Kleinman (1978; 1980) describes interms of three distinct but overlapping domains: the popular, professional, and folk sectors.In this study, phenomenologic inquiry focuses on the popular sector to gain someunderstanding of the Gitksan and Wet'suwet'en people's beliefs and values regarding thehealth and sickness experiences. The epidemiologic perspective, on the other hand, seeks todescribe the distribution of disease among the same subjects but in a manner that is relevantto practices within both the popular and professional sectors (e.g., Gitksan and Wet'suwet'enpeople as well as health planners, doctors, nurses, etc). By combining these two methods ofstudy, meanings and potential responses to the health/sick experiences are shared by both thepopular and professional sectors, this effectively increasing the overlap described byKleinman (Figure 1, page 13). These shared meanings establish a basis for centering healthcare upon the people themselves.The following chapter briefly reviews the theoretical considerations inphenomenologic and epidemiologic research. Further details on study design demonstrateapplication of this theory. The Chapter finishes with a description of the limitations45encountered in applying the theory and how those limitations were handled to achieve thestudy objectives. First, a description of study design demonstrates how both qualitative andquantitative date contribute to the expressed purpose of this study: to obtain and describebase-line health information on the health status and health needs of the Gitksan andWet'suwet'en people via the meanings and interpretations they, themselves, attach to health.3.1 Study DesignIn this study, concurrent investigations provide both qualitative and quantitative data.Figure 4 outlines key aspects of the study including methodology, Models (2) and methods,and analytic procedures, all of which are synthesized to provide a description of healthmeanings, health status, and health care needs of the study group.At the outset, literature clearly supports the value of such a study. Upon initialcontacts, the Gitksan and Wet'suwet'en tribal executives readily commit to the study proposalbecause it contributed to their short and long term plans for change. However, all ninebands in the tribal group expressing interest in the initial stages of planning were unable tocarry through implementation of the study. In the end, two bands became primary studygroups with supplementary data coming from the other Gitksan and Wet'suwet'en bands.Qualitative data derives from an exploration of the health phenomena as viewed andexperienced by the Gitksan and Wet'suwet'en people. This aspect of the study draws uponKleinman's Model to guide the investigation. The principal method in this phenomenologicalresearch involves in-depth interviews. Nine men and women between the ages of 35 and 65and from five different bands, alternatively referred to as villages, contribute their knowledgeand experiences.The quantitative data obtained through survey methods provide statistical data on theFigure 4: Study DesignInformationNeeds IdentifiedBand RecruitmentMethodology Phenomenology(Health Meanings)Epidemiology(Health Measurement)Other(Supporting Data)Models andMethodsKleinman's Model(1) In-depth IntervieWsDiamond Model(2a)^Questionnaire(3) Focus Group-General Health-Food Recall-Child Health(2b) Questionnaire II-CommunityHealth(4) DocumentReviewAnalysisReport46Literature ReviewQualitative Data-Open coding andcategory develop-mentQuantitative Data-SPSSX softwareHealth meanings, health status and health care needs in a Gitksan andWet'suwet'en village in B.C.47health of the Gitksan and Wet'suwet'en people in three villages, two of which form primarystudy groups. Ninety-seven (97) randomly selected men and women between the ages of 15and 72 take part in the health survey. This epidemiological approach focuses primarily uponthe subjective experiences of the study population. A secondary health survey involved ten(10) men and women with extensive knowledge on community health. Two additionalcomplementary methods to epidemiologic research involve the focus group and documentaryexamination. Data from all sources contribute to a description of the health meanings,health status, and health care needs in a Gitksan and Wet'suwet'en village.The following sections of this Chapter review theoretical considerations for this studyand extends the concepts through entry into the cultural scene via field work.3.2 Investigating Health Meanings: Phenomenological ResearchThe phenomenological research design supports Kleinman's framework for explainingthe health care system in that it provides a means for understanding the individual's healthrelated perceptions and experiences. This qualitative research method utilizes individualresponses as data source. Here, the researcher and study subject jointly explore the meaningof phenomena, thereby producing data. This exploration forms the basis for constructing adescription of the experience under study - in this case, health (Oiler, 1986; Parse, Coyne,and Smith 1985).Although qualitative research is receiving increasing recognition for its contribution toscience, questions of rigor predominate the research process. In qualitative research, tests ofrigor include (1) truth value, (2) applicability, (3) consistency, and (4) neutrality (Guba andLincoln 1981). According to Sandelowski (1986) "The truth value of qualitativeinvestigation generally resides in the discovery of human phenomena or experiences as they48are lived and perceived by subjects...." 12 In other words, the study subject defines truthand not the researcher. In this type of research, the issue is one of credibility and notinternal validity.Threats to external validity relate primarily to representativeness. A theoreticalsampling process within a study population provides subjects who are members of orrepresentative of that group. This sampling method ensures findings apply to the studypopulation. Threats to representativeness are further minimized by rigorous handling andreporting of data.Consistency addresses the issue of reliability. In quantitative research, reliabilityrefers to the ability to duplicate findings. Guba and Lincoln (1981) argue that, in qualitativeresearch, the issue is not reliability but rather auditability. That is, another researcher canfollow an investigator's "decision trail" and arrive at the same or comparable conclusions(Sandelowski 1986).The last tests of rigour Guba and Lincoln (1981) describe involves neutrality, orfreedom from bias. They argue that it is possible for a researcher to minimize potentialbiases through confirmation of data. According to these authors, a researcher may achieveconfirmability by establishing auditable data, truth value, and applicability to the studypopulation (Sandelowski 1986; Guba and Lincoln 1981).3.2.1 In-depth Interview and Theoretical SamplingThe principal technique in phenomenologic research involves the in-depth interview12. Margarete Sandelowski, "The Problem of Rigor in Qualitative Research," Advances inNursing Science 8:3 (April, 1986), 30.49to explore the health phenomena. During the interview, subject response to descriptive,structural, and contrast questions pattern the speech event and facilitate a discovery of thesubject's cultural knowledge. The in-depth interview focuses on word usage, the assumptionbeing cultural meaning emerges from understanding how people use their ordinary language(Spradley 1979).A theoretical sampling strategy guides data collection in the in-depth interviewingprocess. Concurrent analysis establishes categories in the health domain with samplingstrategy ensuring representativeness of the categories and their relationships (Chenitz andSwanson 1986). According to this process, analysis guides decisions for follow-up interviewswith existing subjects and for introduction of new study subjects. Sample sizes are typicallysmall because of the large volume of data generated during the prolonged and intensivecontacts with the subjects (Sandelowski 1986). Although there is no set rule for determiningwhat constitutes sufficient data, another researcher suggests "The analyst can feel confidentthat the field has been thoroughly explored when no further categories emerge from thedata, the categories are dense and well developed, the same patterns are seen repeatedly,and there is variation." 13 These well developed and verified categories support aframework for conceptualizing the phenomena under study.3.2.2 Theoretical Sampling CriteriaIn this study, men and women 30 years and over were selected on the basis of their13. Julie Corbin, "Qualitative Data Analysis for Grounded Theory," in From Practice toGrounded Theory: Qualitative Research in Nursing, by W. Carole Chenitz and Janice M.Swanson (Don Mills, Ont.: Addison-Wesley Publishing Company, 1986), 93.5 0ability to speak authoritatively on traditional health related practices, beliefs, and values. Anpriori exclusion criteria selected out member from the same family (one exception),individuals with a history of training in the health care field, and individuals not of Gitksan orWet'suwet'en ancestry.Potential respondents for the in-depth interviews were identified by Band Council andthe CHR. An elite bias was avoided by their identifying band members whom they thoughtto be potential contributors but who were not always called upon in this type of study. Eachpotential respondent received a letter explaining the study and inviting them to participate.These initial contacts were made primarily by the Community Health Representatives(CHRs) to explain the purpose of the study and to provide some explanation of the kinds ofinformation being sought. Potential study subjects indicated their interest by returning aconsent to contact form (Appendix A-1). Upon receipt of consent to contact either a phonecall was made or, when a phone was not available in a household, personal visits were madewith the CHR present to make introductions.Sixteen (16) men and women were contacted over an 18 week period, with newcontacts sought as it became apparent more subjects were required to adequately explore theconcepts being discovered. Two men and three women refused outright to take part in thestudy because they didn't have time or because they believed they did not know enoughabout the subject under study. Another woman avoided responding to the invitation whileanother man agreed but failed to keep two interview appointments. This man expressedrelief when he was reminded that he was free to withdraw from the study whenever hewished. He immediately withdrew consent to participate. The 9 men and women whoagreed to take part in the study were from two Wet'suwet'en and three Gitksan villages.The nine consenting study subjects took part in 2 or 3 one hour tape-recorded51interviews. At the first interview, trigger questions were posed to initiate discussions.(Appendix B) The set of predetermined questions helped to maintain a focus on the domainunder study, however, the direction and content of the interview was according to responsesof the study subject.Generally, when conversing with another Gitksan or Wet'suwet'en it is consideredimpolite to either interrupt before speech is completed or to ask too many direct questions.Consequently, open ended questions initiated the conversation and non-verbal responses orbrief interjections (e.g., "That's interesting"; "Oh") maintained the flow of conversation. Inthese directed conversations, meaning was sought through language usage, therefore, thequestion "Why?" was not used. In one instance, a 75 year old woman seemed to havetrouble hearing and when she did hear a question, she often pursued a health related topicimportant to herself. Respect for her interests and needs required that this stream ofconversation continue. In the end, her contributions proved rich in content.Four of the Gitksan and Wet'suwet'en men and women were interviewed in either aband or tribal office where they worked. A 64 year old Gitksan woman was on holidays fromwork in the public school system. She and the remaining four were interviewed primarily intheir homes. When in the home, it was not uncommon to have other family membersaround. However, they generally tried to discretely distance themselves from the interview toprovide some privacy.Often during the tape-recorded conversations, talk of health brought to the surfacepain and grief associated with a recent or past death: deaths often associated with sometragic circumstance. An elderly woman spoke at length about the untimely death of herhusband. At the second meeting, this woman was extremely uncomfortable and said she wasbeing asked questions about things she took for granted. Rapport could not be re-52established because of her level of discomfort so she was assured further interviews wouldnot be necessary.It was not uncommon to have the subject state out-right they would not talk abouttraditional healing practices or specific herbal remedies. This subject area was not relevantto the study and so posed no problem. In some instances conversation touched on theseareas: either the individual asked to have the recorder turned off or portions of the recordingwere erased. At the outset, participants were assured of the confidential nature of theinterviews and felt freer to talk because their names would not be linked with the material.Confidentiality were maintained by limiting access of transcribed material to the researcherand thesis committee and by erasing the tapes at completion of the study.Each interview was transcribed verbatim by the researcher herself and first levelanalysis undertaken prior to follow-up interviews. This follow-up contact was particularlyimportant because a lengthy discourse by the study subject often produced material that wasnot captured and expanded upon during the same interview. In this case, the follow-upinterview questions were directed at confirming, contrasting, and exploring conceptsintroduced at a prior interview.A total of 22 transcribed hours of tape were obtained. Three individuals wereinterviewed on three separate occasions. Two were interviewed twice and indicated they hadnothing more to add. Three others could only be interviewed twice because their timecommitments did not allow follow-up. One woman receiving sedatives felt she could notcontribute to her full potential and so was interviewed only once.3.2.3 Data AnalysisData analysis involved a process whereby the analyst interacts with data over time and53through various phases to generate an explanatory model for the phenomena under study.(Corbin, 1986) The constant comparative analysis technique initially involves a line-by-line,then paragraph-by-paragraph analysis. The process consists of iterative or repeatinginductive and deductive thinking modes. Here, ideas or tentative explanations are derivedand checked against existing data or new data sought to support or discount the hypothesis.Through this process, thinking moves to higher and higher levels of abstraction to arrive atan explanatory model for describing the phenomena (Corbin 1986).Categories form the major unit of analysis in this constant comparative analyticmethod. These categories consist of abstractions of phenomena observed in the data and arederived through questions the researcher poses to herself or the data. This questioningstrategy is complemented by the line-by-line analysis to identify health related events andfacts. Similar events and facts are grouped to form a single unit: the single unit is referred toas a category. The researcher coins a word or phrase to identify the category and, byinclusion, establishes relationships to describe or explain the phenomena (Corbin 1986;Spradley 1979). Generally, the coined words remained as true to content of the original dataas possible. During this analytic process, discovering and building or densifying categories isan ongoing process that is achieved through the researcher questioning herself and the dataand simultaneously posing descriptive, structural, and contrast questions to the study subject.The final stages of analysis involve developing linkages between categories and finallyidentifying the central categories of the phenomena. These themes form the basis fordescribing the phenomena under study.Both interviews and first level analysis occurred during the same time period as didthe health survey questionnaires This epidemiologic perspective is described in the followingsection.543.3 Epidemiologic Research: Methods and SamplingThe epidemiologic aspect of the study consists of a descriptive, cross sectional studydesign and provides quantitative data. The principal method involves two surveyquestionnaires (Appendix C-1, C-2). One Questionnaire examines personal health while thesecond examines community health. The questionnaires draw upon the Diamond Model(Long 1984) to order the factors affecting health. According to the Diamond Model, healthand illness is determined by the independent and interactive effects of four variables: (1)Genetics/constitution; (2) behaviour or lifestyle factors; (3) the social and economicenvironment; and, (4) the health care system itself. These four groupings supportexamination of the health experience beyond a personal context and include criticalenvironmental factors affecting health. The following section discusses the twoquestionnaires separately.3.3.1 Survey Questionnaire: Personal InterviewsThe personal health survey instrument stems from existing health measurement toolspreviously used in the general Canadian and American populations but not in the Indiancommunity. Items included in the instrument have face validity in that they are theoreticallyjustifiable and intuitively reasonable. Inclusion is not guided by pre-existing Gitksan orWet'suwet'en definitions of health because there is presently no recognized or accepteddefinition. Sources for the questionnaire items are as follows:1. The Ontario Health Survey (Ontario Ministry of Health 1989);2. Community Health Needs Assessment: Community Members Survey Questionnaire(Health and Welfare Canada 1989b);3.^Functional Status II-R Measure [Child Health] (Lewis, Pantell and Kieckhefer 1989).55The resultant 200 item instrument (Appendix C-1) was modified according to findings fromtwo Focus Group meetings. These small community meetings were exploratory in natureand provided information on common word usage and tentatively identified and confirmedhealth issues of relevance to the survey questionnaire and health needs assessment. Forexample, the term "sickness" is used rather than "illness," and health issues include poor foodhabits, lack of recreational facilities, and concerns about high rates of arthritis. The FocusGroup is a distinct qualitative research method that is further discussed in this Chapter.Upon revision, following Focus Group meetings, the instrument was pre-tested among11 Gitksan and Wet'suwet'en people living in the lower mainland. This pre-test assessed theclarity and understandability of the questions as well as provided a check for the meaning ofspecific words and items. In most cases, these pre-test subjects had recent and ongoingcontacts with families from their home village. As a result of this pre-testing, minor wordchanges were made prior to finalizing the instrument.3.3.2 Randomized SamplingThe survey was conducted among the residents of a Gitksan and a Wet'suwet'envillage with a combined on-reserve population of 425. The sample size was derived byformulae (Appendix D) and based on an estimated 60% of respondents 15 years and overrating their health as good or better. This sample was increased by 25% to adjust for anestimated 1 in 4 refusal rate. The sample frame (on-reserve men and women 15 years andover) was derived from a current Band Membership Registry which was loaded into D-BaseIII+ software and sorted by age and sex. A proportionate, stratified (band, age, and sex)random sample was obtained by applying a random numbers table to the sample frame.After stratification by band, sex, and age, and prior to randomization, the sample group in56ages 55 years and over was doubled to ensure adequate representation by this age group.A secondary Wet'suwet'en village with an on-reserve population of 567 was included.A sample of 15 was obtained through application of a random numbers table to an unsortedcurrent Band Membership Registry. Stratification was by sex.The calculated sample size was 215 adults. However, the actual sample size wasreduced to 180 as contacts in the village determined that roughly 20 percent of the samplegroup had moved out of the village either before or at the time of contact. This adjustmentoccurred despite on-reserve and off-reserve status being confirmed with Band Officeemployees prior to defining the sample frame.People were very interested in how their name came to be on the list of potentialstudy subjects. Upon explanation, they were satisfied with the random nature of theirselection and in a few instances said all the people in the village should be involved becausehealth is such an important issue. In one instance, a young male relative presented anaggressive front in wishing to protect a woman from possible intrusion into a particularlysensitive family concern. However, when learning of the random nature of selection (i.e., hehad the same chance of being selected as did she) as well as the confidential nature of theinformation, he calmly left the room and allowed the interview to proceed.Randomization also occurred in selecting a child for inclusion in the Child Healthcomponent of the Questionnaire. This randomization was employed to prevent respondent'sselective reporting on sick kids. All respondents provided the name, age, and sex ofdependent children under 15 years of age. These names were hand written on separatepieces of paper, placed in a bag, mixed, and the respondent withdrew one folded piece ofpaper. The child whose name was pulled from the bag was included in the study. Doublereporting was avoided by documenting the child's age, sex, and name and cross-checking the57list before interviewing other adults from the same family.3.3.3 Interviewing and Data ProcessingPrior to beginning the health survey, two community interviewers received two daystraining. (Appendix E) These interviewers were provided in-depth background informationin an attempt to establish and maintain their credibility as subjects raise questions regardingthe content and purpose of the study. The interviewers received weekly supervision andcompleteness of questionnaires monitored on an ongoing basis. Where necessary, arespondent was re-contacted to complete specific items in the questionnaire.General Band membership was informed of the health study through letters directedto the households. Selected respondents were further notified of their selection into thestudy and advised they would be contacted. Written consent was obtained from arespondent prior to an interview. Written parental consent was also obtained beforeapproaching respondents 17 years and younger (Appendix A-2,3,4). Confidentiality wasmaintained by storing consent forms separate from the completed questionnaire.Codes from the completed questionnaire were transposed to a coding sheet andbatches of coded sheets submitted to the University of British Columbia Computing Centerfor data entry. Upon completion of data entry, the data file was converted to a DBase IVfile and edited. Data were cross checked with the original questionnaire and the data baseedited as required. The Food Recalls were re-tested for consistency in food item coding andaccuracy in transposing figures to the coding sheets.3.3.4 Data AnalysisDescriptive data were cross tabulated according to stratified categories of age, sex,58and ancestry (Gitksan or Wet'suwet'en) and key variables described in the Diamond Model.Data were further examined using the SPSSX statistical package.The 24 Hour Food Recalls were analyzed with a customized nutrient analysis program(Nutrient Analysis Ver. 2.0: Margaret T. Behme). Prior to analysis, all consumed foods wereuniquely coded according to Health and Welfare Canada's Nutrient Value of Some CommonFoods (1987) the coding for which had been extended by Behme to include traditional foods(e.g., smoked, dry fish; moose meat; huckleberries, etc.). Adequacy of nutrient intake isassessed by comparison to Canada's Recommended Nutrient Intakes (Health and WelfareCanada 1990a). Respondents are considered at-risk for a nutrient deficiency if intake fallsbelow 66 percent of the Recommended Intake.3.3.5 Key Respondent QuestionnaireThe Key Respondent Questionnaire (Appendix C-2) is derived from the CommunityHealth Needs Assessment Manual prepared by Health and Welfare (1989b). ThisQuestionnaire extends the exploratory process in identifying health care needs. Respondentsconsist of Band employees, a pastor and band policing personnel who are believed to haveextensive knowledge on the general health of the village. Data are summarized with theDBase IV program.3.4 Complementary Research MethodsThe two complementary methods of research include focus groups and documentary review.These techniques extend information to include a community perspective.3.4.1 Focus Group59The focus group comprised a preliminary research method to explore Gitksan andWet'suwet'en common word usages for describing health. In addition, the method helped toidentify and confirm relevant health problems and issues. This information guided bothlanguage usage and item selection when compiling the health measurement tool.A focus group is a group interview where interaction within a group of 6 to 8 peopleis facilitated by a moderator. Interview transcripts comprise the data while groupinteractions provide insights into the topic of interest. The number of group interviews isdetermined by both research purpose and resourcing issues - time and money. Small groupsof 6 - 8 people allow greater input by each participant. In addition, the moderator can focusattention on the substance of the interview rather than on process (Morgan 1988).Sampling has a theoretical basis where selection concentrates on the populationsegment that will provide the most meaningful information. This technique introduces asampling bias that can be minimized through recognition that data do not represent a fullspectrum of opinions and experiences. Alternatively, recruitment may take into account theexpected differences within and between groups (Morgan 1988).In this study, group participants consisted of band members recruited by theCommunity Health Representative (CHR). Criteria for selection included age, sex andpotential for contributing in a small group setting. Recruitment focused on ensuringparticipation by men. Two Focus Group meetings were attended by 5 and 12 bandmembers. Data from these groups were summarized with findings complementing andenhancing other data sources.3.4.2 Documentary ExaminationSupporting documentation on social and health indicators was sought at the Gitksan60and Wet'suwet'en Office of the Hereditary Chiefs, Band Offices, and Medical Services' localHealth Centre and Health Stations. Generally, there proved to be very little informationavailable at any source. Where information did exist, access became a major impediment,particularly with regards to Medical Services Branch. Problems associated with access toinformation proved insurmountable given the political nature of the bureaucracy. Inparticular, not linking the study with a health transfer initiative did not give Medical Servicessufficient reason to cooperate within existing constraints of confidentiality of health records.For example, the local Health Center could have provided information on chronic healthproblems without releasing names or birth date but chose not to. This lack of informationposes real problems in any initiative to plan for health care in the villages.3.5 LimitationsPotential problems in this study arise from study design as well as inevitabledifficulties associated with applying theory in the real setting. This study is exploratory innature and combines phenomenology and epidemiology. Limitations experienced in the fieldrelate primarily to the General Health Survey Questionnaire.Though research plans were endorsed at the tribal level, village responsibility forproviding interviewers became a primary stumbling block. At the village level, funds werenot available to hire interviewers. With one exception, community health workers wereunwilling to undertake the responsibility for interviewing because of established commitmentto day-to-day work. This problem was compounded by village people's over-riding concernabout confidentiality. Personal health information could not be disclosed to an activecommunity member where trust was a problem. However, they were prepared to undertakethe interview with an individual whom they knew was associated with the Tribal Group and6 1whom they could trust. As a result, the majority of interviews (85 of 97) were completed bythe researcher herself.The Band List was used to develop the sample frame. However, this List isconsidered confidential information. Thus, in two cases, access to the Band List wasprovided on-site and only hard copies of the final sample removed from the Band Office.Prior to developing the sample frame, a band employee established whom on the list wasactually living in the village during the time of the study. Despite this screening process,about twenty percent of the random sample were not currently living in the village wheninitial contacts were being made. Often, people were away travelling or were on day-trips.The sample size had not been adjusted to account for high mobility within the population.Additional changes in the research plan related to application of the questionnaire.Concerns about literacy determined that the questionnaire be read out loud to the subject.The subject was provided with an enlarged print of response choices to limit the potential oftheir reading ahead and so possibly biasing their answer. However, both young and old oftenexperienced hearing problems and did not appreciate having the question re-read.Consequently, after the first 15 interviews, all subjects were provided with a copy of thecomplete questionnaire and followed along as questions were read out loud. This type ofparticipation increased their comfort level and speeded up the interview process. Read-ahead was not a problem.The exploratory nature of this study poses problems in and of itself as there is notsufficient knowledge upon which to base formulation of questionnaire items and languageusage. Selection of questionnaire items do not stem from the Gitksan and Wet'suwet'enviews of health but rather are drawn from existing pre-tested instruments that address amultitude of factors that affect health. The appropriateness of these items with respect to62local views of the health experience can only be clarified through future studies. Afundamental consideration to future research is the distinction between measuring healthstatus and measuring wellness and well-being (McDowell and Newell 1987; Herbert andMilsum 1990).Because this study is exploratory, it largely lays the foundation for future work andextends knowledge only in a limited sense. For example, a concurrent exploration of healthmeanings and health status leads to development of analytic categories only after the generalpattern of data has been looked at. This process necessarily underestimates the potentialimportance of critical elements relating to local views of the health experience.Methodology also has limitations normally associated with questionnaires, interviews,and respondent-interviewer interactions. An unavoidable part of a survey is the time delaybetween start and finish of a questionnaire by a sample population. In this study,questionnaires were applied over an eighteen week period, this increasing the potential forrespondent bias if individuals exposed to the questionnaire discuss the contents in public. Inaddition, the social context of respondents vary over this time period, and, if approachedduring a personal or family sickness experience, responses may be considerably different thanwhen they are well. To minimize these potential biases, respondents were requested not tospeak to others about questionnaire content. Generally, potential respondents were moreconcerned about whether questions would invade their privacy rather than specific content ofa health related question. The social context of the health experience was minimized tosome extent through respondent choice in participating. If unwell, they said so, and chose toparticipate at another time. In one case, a death in the village interrupted field work for aten day period at which time a band employee indicated it would be socially acceptable toresume the survey.63Responses to the questionnaire are also influenced by the reference time period. Inparticular, questions referring to a previous twelve month period are subject to recall bias.Further problem arises in changing references in time from months to days to years. Timereferencing problems are unavoidable given the nature of the factors being examined. Forexample, the adequacy of physical exercise can be assessed only over a period of monthswhile dental health problems are relevant within a much shorter time frame.An unavoidable factor in conducting a study is personal bias of the researcher. Thisbias may include personal health meanings associated with another culture as well associalization into the medical care system. In this study, personal bias is lessened to someextent by this researcher being a member of Wet'suwet'en society. This familiarity requiredcareful attention to phrasing of questions during in-depth recorded interviews to minimizeassumptions and avoid leading questions based on either local views or the medical model.Acceptance of respondent views also limited potential bias.These bias issues refer primarily to internal threats to validity. In qualitative research,Sandelowski (1986) considers truth value to be an appropriate test for rigor with credibilitycomprising the criteria for assessing study findings (Guba and Lincoln 1981). A qualitiativestudy is credible if study subjects recognize and accept descriptions as being true to theirexperiences. Credibility is further demonstrated if other people reading the findings findconfirmation when confronted with the experiences in the same study environment. A majorthreat to truth value is the long and close subject-researcher relationship that may beminimized by the researcher focusing on clearly separating his or her experiences from thatof the subject and in handling and interpreting data (Sandelowski, 1986). In this study, truthvalue was tested by presenting and discussing findings with Gitksan and Wet'suwet'en peopleon several occasions. Territorial leaders further tested truth by discussing the concepts with64local, traditional healers who also affirmed acceptability of the descriptions.Findings for both qualitative and quantitative data were brought to the attention ofGitksan and Wet'suwet'en leaders throughout the analytic phase of the study. In particular,this writer considered it important that presentation of findings remain true to data but donot create a situation that may have negative repercussions to the study group (e.g., createsocial embarrassment). For example, handling data relating to alcohol use became a majorconcern, and upon discussion with representatives in these two societies, a decision was madeto let stand in a public document those findings relating to frequency, quantity, and beliefs innormalcy of drinking patterns. These factors describe areas for needed social change andare thought to be no different from experiences in other cultures where alcohol useconstitutes a major social and health problem.The concept of "saving face" is an important and significant factor to both Gitksanand Wet'suwet'en on a personal and public level. This concept had particular relevance tofield work and recruiting respondents. When confronted with a question, people generallytry to avoid giving a response that might embarass the person asking the question or the oneresponding. This is seen where most people will not say "no" to an invitation to participatebut will either evade the issue (i.e., won't say "yes" or "no"), avoid contact, or not keepappointments. Over time in the field, these types of responses became accepted as implicitrefusals because of a need to distinguish between friendly invitation and perceivedharassment. This perception of a researcher showing disrespect for decisions not toparticipate would alienate band members at large. It is not clear, however, what proportionof the study group represented implicit refusals and what proportion simply representedfailure to contact at a mutually convenient time. This issue might have been clarifiedthrough longer time in the field, however, resourcing issues of time and money proved a65signficant deterrant.An a priori assumption to this study was that the use of the term "health" in theGeneral Health Questionnaire was both appropriate and relevant. However, findings fromthe in-depth interviews show that the abstract term "health" has little relevance. Rather,people say they are well when healthy and they speak of a sense of well-being. Despite thisapparent contradiction, items in the Questionnaire did not pose a problem because of thecontextual nature of the questions.In applying the General Health Questionnaire, some problems arose in word usageand wording of specific questions. For example, meaning of specific medical conditions werequestioned by a few people, as for example "goitre, thyroid, cataract, glaucoma, and lupus."Most commonly, respondents questioned what the word 'normal' meant in relation to alcoholusage (Do you feel you are a normal drinker?) Negative statements regarding mental healthcaused the most confusion as, for example, "My health gave me no concern." There was alsoproblem in understanding the meaning of such phrases as "I had no problem handling myfeelings" and "Many interesting things happened." In several cases, the 14 phrases found inQuestion 120 generated what appeared to be a response set (Appendix C-1).An extreme measure of mental health is the occurrence of suicide or attemptedsuicide. In examining this aspect of mental health, an introductory statement prepared thestudy subject for the topic and reduced threat by indicating this problem was notunusual. In addition, "taking your own life" was selected in place of "suicide" to soften thestatement. No one refused to answer the questions, nor did anyone appear to become toouncomfortable or upset by the questions. The transitional statement reads:"Health information on Indian people in Canada show that Indians take theirown life more often than do white people. It often happens that a person whois feeling very bad or depressed and who cannot see a clear way to dealing66with life's problems, might either think about or try to take their own life.Have you ever seriously thought about taking your own life?"Apparent discomfort did arise in areas the respondent felt especially sensitive about.For example, Question 2 relating to happiness in life caused a woman to cry and talk aboutproblems relating to unresolved grief. However, she invited completion of the questionnaireat another time: This was done. In other cases, questions on alcohol use caused somediscomfort on the part of only a few individuals.Additional problem arose with the question relating to highest level of education.Many respondents attended some community college, however, the question structure doesnot distinguish between those who completed grade 12 and those who have some primary orsecondary schooling. The extent of upgrading through community college is also not known.Questions relating to work history was particularly sensitive. (Appendix C, Question134-139,) In many cases, individuals considered their main activity to be working at a jobeven though this may have been 2-4 months in the past year. Attempts to clarify and correctthe response met with some displeasure, consequently answers were accepted at face value.Wording of this type of question needs to be given careful consideration prior to use inanother Indian population. A transitional paragraph to explain this question may be helpful.Often, on completion of the questionnaire, the respondent commented on the valueof the questionnaire from both a personal and community perspective. From a personalpoint of view, the questionnaire raised their awareness of health issues and in particularcaused them to evaluate their own health and health practices. Despite some apprehensionat the outset, respondents were increasingly willing to participate in the health survey afterother Band members had assured them of the acceptability of the questionnaire. This socialapproval was an important factor in the response rate that was achieved.673.6 SummaryThis study consists of two components. The phenomenological research design guidesthe qualitative aspect of the study. Here, subjects for in-depth interviews are identifiedaccording to a theoretical sampling technique and transcribed interview data analyzed by aconstant comparative process. Categories identified through this process form the frameworkfor describing health according to the Gitksan and Wet'suwet'en.The epidemiologic research component provides information on personal andcommunity health via health questionnaires. The general health survey comprises the centraltechnique and is complemented by findings from the focus group and documentary review.Though limitations in this study do exist both in the conceptualization and implementationphases, these problems do not seriously threaten the quality of data. The following Chapterpresents the results of this study.68CHAFFER 4.0RESULTSThe first section of this Chapter provides a description of health meanings accordingto the Gitksan and Wet'suwet'en. These health meanings are drawn from in-depth interviews(N = 9) and contribute to some understanding of the local health experience. Both anunderstanding and sharing of health values focuses attention on the desired state of being,provides a basis for developing health goals, and when applied in the health planningprocess, may facilitate an orderly and rational response to health care needs.The second major section in this chapter contains a summary description of the healthexperiences of 97 randomly selected men and women 15 years and over. Here, a multitudeof factors that can affect the health experience are examined in detail. This identification ofpersonal health problems forms one component in the process of identifying health careneeds. Supplementary tables summarizing results may be found in Appendix F.These results from the in-depth interviews and the general health questionnaire aresupported and strengthened by contributions from small community meetings referred tohere as focus groups. A short summary of key points made during these small groupmeetings begins the discussion of health needs at the community level. Further informationon community health needs is obtained from a questionnaire directed at key individuals whohave broad based knowledge on health within the community. These results support andextend the process of describing areas for needed change within the community as a whole.Finally, the chapter is concluded with an integrated summary of field notes anddocumentary review. These documents consist of findings from local health related reports.The field notes include excerpts from a daily journal as well as summary of discussions withGitksan and Wet'suwet'en who were not selected into the study.694.1 Gitksan and Wet'suwet'en Views on Wellness and Well-BeingResults from in-depth interviews involving nine men and women have been logicallyordered following intense, repetitive comparison of categories within and between transcripts.Scrutiny of and reflection on the participant's uniquely subjective views uncovered bothsimilarities and differences in the health experience. These similarities form the frameworkfor analysis where emerging themes have been ordered according to their relationship to thecentral concepts of wellness and well-being. This framework supports and guides discussionof the similarities and differences in the health experience, a process that gives bothspecificity and depth to the Gitksan and Wet'suwet'en views. Truth value of this account isachieved through reference to individual descriptions as they occur in the data.When both the Gitksan and Wet'suwet'en discuss or describe their state of wellness,they generally refer to their whole being. The whole being consists of physical, mental, andspiritual components with the spiritual nature being a dominant force. This spiritualitythreads throughout the well/unwell experience and grounds the beliefs and practices thateither strengthen or weaken the experience.4.1.1 A Conceptual Model for Data InterpretationThe key concepts of wellness and well-being are captured and expanded uponthrough exploration of five major themes:(1) wholistic interconnections - The individual is intimately connected to and affected byall aspects of the environment, extending from the family to the land itself;(2) wellness and well-being experiences - Individuals who are well describe themselves asstrong and express positive experiences of well-being (e.g., happy);(3)^wellness experiences strengthened and protected - Being well and strong are70considered a natural state with beliefs and practices directed at both strengtheningand protecting that state of being;(4) wellness weakened - Factors that can weaken a state of wellness primarily involveemotions and attitudes. This weakening causes one to be unwell or exposes theindividual to a sickness; and,(5) unwell or sick experiences requiring healing - Whether unwell and/or sick, it isgenerally recognized that a healing is required with the individual and extended familyinvolved in resolving the sickness experience.This wholistic view of wellness and well-being is outlined in Figure 5 with conceptualrelationships showing movement towards the common goal of being well and strong. Adetailed discussion follows this schematic representation. Data interpretations aresubstantiated by excerpts from transcripts to demonstrate a "decision trail." According toSandelowski (1986), this decision trail would result in another investigator reaching the sameor comparable conclusions given the same data and utilizing a similar analytic technique. Inthis report, specificity and depth is achieved through reporting on unique experiences thatrelate to a central that is common to the study group.4.1.2 Wholistic Interconnections in the Wellness ExperienceThe everyday, social greetings in the local Gitksan or Wet'suwet'en dialectsimmediately provide the researcher with some sense of how health is viewed andexperienced. The content of social greetings initiate exploration of the phenomena understudy. In the following verbatim accounts, we see how the "well" concept is central to theexperience and is expressed in terms of both the self and the environment7172(Note: P = Participant; P1, P2, etc. indicates different respondents: R = Researcher).R "When you meet another Gitksan person and you greet them in your own language,what do you say - what do you usually say to them?"P1 "How are you" or "[local dialect]".R "And, you are asking them ..."P1 "How are you? How they are doing ... [local dialect] covers the whole person."R "And how might people answer you?"P1 "A lot of them they don't ignore you when you ask them how they are doing. And ifthey're sick they usually tell that they are not feeling well."R "Are you aware of any Gitksan word for health?"P2 "For us, the well-being of a person ... when you meet somebody on the road, you greetthem with the regular "Hello" but before that it used to be "How are you doing?" ... andthen that person would answer "I am doing well" or he'd answer "I am not doing well"and then that would mean he is not feeling well ... that he's sick or is just tired orwhatever ... he's having a bad day. They say "[local dialect]" ... that means my wholebeing is feeling good, my insides and everything ... my whole body feels good and mywhole being." When they talk about feeling good, they talk about spiritually feeling goodas well as their mental and physical beings feeling good. And that greeting that Imentioned, thats how you would find out if a person was feeling sick or just feeling goodthats one way of finding out if they are healthy."R "What do you say when you meet a Wet'suwet'en person?"P3 [local dialect] "How are you" or "Are you well?"These inquiries into the state of wellness of a Gitksan or a Wet'suwet'en individual("Are you well?" or "How are you doing?") elicits response relating to either the 'wholebeing' or 'everything'. These responses directed exploration into two central concepts: thewholistic nature of the wellness experience as well as the wellness experience itself.When referring to the whole being, most respondents speak of the physical, mental,73and spiritual aspects that form the whole, while a few make references to the body and spiritalone. Above, we see where one respondent includes social relations in the wellnessexperience. Further reference to economics occur during a conversation with a Wet'suwet'enwoman who says "... and those who are poor people, they help each other until those whoare poor get better."An wholistic conceptualization of the health experience is both explicit and implicit.Implicit references occur as the respondent talks about the spirit, the body, and the mind.Another example of an explicit description occurs as follows:P1^"When we ask people about their health, we often ask them if they are strong.We will say "Is your strength back yet?" which indicates that when that questionis asked someone has not been well physically and the question is asked to seeif they had recovered from the illness that they had. As far as our view ofhealth, we tend to look at it from a wholistic point of view and in order for aperson to be defined as being healthy we look at four areas of our being. Welook at the body, mind, spirit and emotions ... these four parts of our beinghave to be aligned properly."When one is well, all parts of one's being are even, aligned, or balanced. Therelationship between the three central components of one's being are displayed in Figure 5.Here, the spiritual component is the largest to portray the apparent dominant nature of thisaspect of being. Though the majority of respondents refer to the spirit as being part of thewhole being, not all agree on the extent to which the spirit can negatively affect wellness.Some brush off the potential harm brought about by the spirit by saying the effect is purelypsychological; others are convinced of the real powers of the spirit. Age is not a factor ineither belief systems.When speaking of their spiritual nature, reference is made to the "inner being,""soul," or "spirit." In the diagram, the inner being is represented by the shaded area. Thissmall overlap between the body and spirit represents the precarious nature of this balance74As will be shown, the physical and spiritual beings separate very easily and, if not re-aligned,sickness may result.The spiritual level also provides focus for connection of the individual to their family,house/clan, people in the community, the tribal group as a whole, and ultimately, house/ clanor tribal territory. In Figure 5 this inter-connected relationship is portrayed as a spiral, withoverlap occurring at the spiritual level. This inter-connection is described as a wholisticrelationship and is built on a law of respect with the binding force existing within the spirit.This concept of interconnectedness occurs throughout the interviews where wellness atone level affects the wellness of all others. This is seen in the following excerpts.P1^"I think I am very fortunate with my own immediate family ... I'm raisinghealthy children. I have a healthy marriage."P2^"All my life I was never sick cause I always worked so hard for my childrendoing garden and everything. ... I want my children to be healthy."P3^"In our society we are a communal society and the way we used to live before,communally, people still feel the attachments they had when we lived in acommunal way and whenever they speak, they speak as if they are still in acommunal way, and if they are not doing too well, they will tell you they arenot doing too well, and that'll tell you they're in need of help ... for instancethey may not have enough food for their children and they will tell you that "Iam not doing too well."P4^"[Being well is] just getting doing a lot of things for yourself ... like looking afteryour family and also teaching younger ones how to do it. Cause I always relateit to my father cause he taught us to fish and to hunt and to show respect ...Respect for the land ... fish and garden. Cause everything comes from andgoes back to the land."From the data, it was noted that in the recent past, people were intimately linked withthe seasonal round and were conservative in their use of plant and animal life - nothing waswasted. This conservative practice reflects a respect for animals and stems from the people'sdependence upon animal life for their survival as well as their close association at the spiritlevel. The seasonal round intimately affects village life and continues to do so to this day.75These characteristics are seen in the following conversation excerpts.P1^"This elder was talking to me yesterday and he said ... "We fish, then we go pickberries, then we go hunt for our moose, and then we get the ground hog and goats."P2^"... they don't throw anything ... like bones, any kind of animal bones ... they don'tthrow it away. Animals they know everything; even what you think they'll know it"P3^"... To be a whole human being they still say you are strong if you uphold our lawsand if you are productive and help a lot of people out ... its how strong you are ingetting these things [berries and meat from wild life] from your land and using themand bringing them back and helping your own people and any excess would go intothe feast"Throughout the study, frequent references are made to training. Respondentsindicate that training of both a general nature as well as specific health related practices andbeliefs are undertaken primarily by grandparents, elders, and parents as well as aunts anduncles. It is generally recognized that grandparents and elders play a key role. However,with the loss of these people, training is becoming a general responsibility in the village.When referring to training by an elder, a Gitksan man describes the intense repetitionthat is involved. In addition, training is often expected to have some future effect. Theseconversations occur as follows:P1^"Every day they will say it to you ... and even if you're tired of hearing it you still haveto hear it because they say it to you every day ... even if you are a good person andyou do listen every day ... they'll say it to you because they say "You'll remember whatI am saying after I am gone" ..."P2^"Alcohol is one of the worst. One elder he talked about the alcohol ... "TheGovernment is setting up a trap for us." And this was said in the 1920s. I guess thatelder sat in the middle of a lot of young people ... sat around ... 11, 12, 13 years old.He said "If you don't listen to me, you're not going to be as old as I am. But, if youlisten to me you can make it." And out of the 15 people that sat in the circle, there isonly 3 alive today."4.1.3 Wellness and Well-Being ExperiencesNeither the Gitksan nor Wet'suwet'en dialects have a word for health. However, they76do speak of being either strong or tough both of which imply a state of being well. There isa marked preference for being strong as it represents considerable potential at all levels ofthe whole being. When strong, or tough, an individual is able to endure hardship or severeconditions with little negative effects; there is a capacity for hard work; the hard workingperson will not age as quickly though strength naturally diminishes with age; and, theindividual is protected from getting sick and when sick will recover quickly. When strong, anindividual is able to take care of themself and is able to help others, fulfil their role, andcontribute to family and society to their full potential.These frequent references to being strong or tough are seen in the followingconversations:R^"What is it like for you to be healthy?"P1^"Working hard ... in the bush packing ... every day go in the bush and hunting. Theynever stay home ... always walk ... packing and walk. They tough you know ... nobodyget any sickness, nothing. They used to be like that ... those who working hard theytough."R^"Is there a Gitksan word for health?"P2^"Gitksan word for health. Yeah there is. I think they call it "[local dialect]" ... meanshealthy. I mean ... yeah, healthy is "[local dialect]". When a baby is really strong Ialways hear people say ..."P3^"Usually you know if a person is sick they'll say he's strong, hell get through.And, when they are referring to somebody they'll say that person is strong andhe will never get sick or anything. Another way to say this person will neverget sick is another way of saying this person is healthy."Strength is valued in reference to several other aspects of being. In one instance itseems to relate to the life-force within an individual. This life force is part of the inner-being. By way of further comparison, one woman associates strength with power: "We have77the power to overcome the illness that has hit you." In some instances, strength andtoughness may relate specifically to level of energy and muscular capacity. One Gitksan mansays that at the time of death, a person is advised to "be strong": this he considers nonsensein light of the negative effects of unresolved grief upon the level of wellness.The value of strength extends beyond the individual and encompasses the family,house/clan, and tribal group. One man says that during a feast, strength of an individual andtheir house/clan is measured according to how well and extensively land, plant and animallife contribute to society and culture. Another says, "I think that once you get everybodyhealthy, you'll have a real strong village and in 15-20 years a strong Gitksan andWet'suwet'en nation. This is my dream, my goal, my vision."Although a few people interchange the word well and healthy, the abstract Englishword 'health' does not elicit a response. The possible irrelevance of the word health isdemonstrated in usage where a Gitksan elder refers to "the health thing."Being well or healthy is considered a normal state and is dynamic in nature: there arehigh and low levels of wellness. This normal and dynamic condition is apparent in thefollowing conversations.P1^"... I'm healthy ... I don't have high blood pressure like I used to do. And if Iwas lighter, I would be very healthy."P2^"I would say [my health is] very good. Its just I'm battling my weight right now. But Ifeel good, other than my shoulder, still quite active doing different things."R^"What would lead you to say your health was fair or poor?"P2^"I can't do anything that I like to do ... just doing things, slow right down."R^"Is being cured and healed the same thing?"78P3^"... If a person was sick they would say "[local dialect]" and if a person got well again... healed I guess you could say ... they say "[local dialect]" ... he's back to health again."[local dialect]" means he is back to the normal way of living where as he was downbefore ... he is back to the normal way of living. If they say "[local dialect]" ... he isbetter ... he is back to normal."P4^"I have had a lot of surgery when I was younger but after that's all corrected, Ilive a normal life so I expect I will go on until I'm old enough to retire."Level of wellness is assessed by both the individual and others. A person may beconsidered well according to their physical appearance and their level of independence. Oneman suggests that a large body size is preferred because you look strong and the large sizeinfers wealth stemming from the land. Another woman gives an example of a 70 year oldwoman who refuses help in shovelling out her driveway in the winter and who is consideredhealthy or tough. Also, "... A 110 year old man is assessed as quite healthy even though hedoesn't appear to be. He'll sit through feasts. He still speaks on issues and with quite a bitof clarity."When well a person is able to do anything, especially what one wants to do, isindependent, and contributes to family and society. Hard working people can maintain ahigh level of output with little rest and are not held back by minor problems, such as a cold.This ability to do anything or to do what one wants to do is expressed in several ways.P1^"When I am able I like to do what I want to do rather than be sickly you knowand I'm not able to go and do what I want to do. To me its living a full life tobe able to go and work and be healthy enough to do it. Really, its a joy to goout and do work."P1^"They always tell us to get up early in the morning, do our chores, get it over with, outof the way, out of your mind and then relax and enjoy yourself. Sometimes [...] and Iwould go fishing just to relax."P2^"Being healthy ... provide for your family and helping other people who are notwell off and who are not healthy, especially elders. ... I think for myself, I canprovide for my family and still have some fun doing the different things I need79to do for [myself]."P3^"If you healthy you can do anything, even you work hard you can get up thesame."P4^"What is it like to be healthy? Well for one, it feels good to be healthy ... notbeing laid up in bed or sick in any way ... being able to get around and do thethings you want to do."Three individuals express their capability in terms of doing normal, routine activities.What is normal is "... like working in the yard, everyday household chores, putting up foodfor the winter." Being able to do these things are taken for granted by many, though peopleare cautioned against doing so.A Gitksan man speaks of a well family and a well community. Here, wellness involvesproviding support in crises, celebrating together, and open, trusting communication. WithinGitksan and Wet'suwet'en society, hard working people have a high social value. However,having fun and relaxing are also considered important to being a balanced, whole person.While individuals are expected to work hard and contribute to family (especially elders) andsociety to their full potential, it is recognized that potential varies according to level ofwellness. Less than 100% participation is accepted with the understanding that the person isnot completely well. However, an expectation is that participation will change along withimproving circumstances. This need to work and be busy is further expressed by a 40 yearold man who says his health is very good: "It's just I'm battling my weight right now. But Ifeel good, other than my shoulder, still quite active doing different things." By contrast, hishealth would not be too good if he couldn't move around and do things. By way of furthercomparison, two women suggest that when well, there is no pain and no sickness, and themind is clear and free of guilt.Often, the term "well-being" appears to be used in place of the word "well" or80"healthy." However, descriptors for a positive well-being are distinct from descriptions ofwellness. This apparent interchange occurs as follows.P1^"I am in difficulty with my health" is what they mean. That's with their well-being ... it's not up to par in other words." "I'm not doing good with my well-being." Because there is no word that I could think of right now for health."P2^"There are people doing many different positive things like the study you aredoing ... its addressing the well-being of our people ..."The wellness experience is described in terms of a positive sense of well-being. Whenwell, a person will say their whole being feels good, their body feels good, or they feel well.Many expressed the experience in terms of being happy with one Gitksan elder saying beinghealthy is a joyful experience. By comparison, a man describes the experience as a sense ofphysical lightness while a Wet'suwet'en elder says "It's just like nothing." One is also atpeace and there is no guilt because responsibilities have been carried out. Feeling goodabout one's self and what one does is considered very important. This involves valuing selffor unique gifts that are developed for individual and society benefit. This basis for sharingand cooperation strengthens the sense of interconnectedness within and between the twosocieties.4.1.4 Wellness Experiences Strengthened and ProtectedThe importance of being well and strong is demonstrated in some of the beliefs andpractices directed at strengthening and protecting this state. Many of these beliefs andpractices touch upon the spiritual aspect of being and thread throughout both the well andunwell experiences.The Gitksan, and to some extent Wet'suwet'en, believe that if you follow correctpractices you can expect to be well. These practices relate primarily to the spiritual and81physical nature. Through developing the spiritual aspect of being, the mental side isstrengthened. This is reflected in the notion that each person has an inner being thatcontains the potential for being well and can be strengthened to the benefit of the individual.These references to strengthening the wellness experiences occur as follows:P1^"And to be a whole human being they still say you are strong if you uphold ourlaws and if you are productive and help a lot of people out."P2^"I think mentally ... spiritually you've got to start on that part first ... then themental, then the physical I think. Cause once you start to deal with thespiritual part there are so many different things you can do and mentally youget stronger ... and physically, you can work on that later. But I say spirituallyyou have to work on that and you get stronger inside and mentally you gettough."P3^"If you want to maintain a healthy lifestyle it is really important to learn how toconnect with the spirit level. Our creator does give very specific instructions tohis people and sometimes problems come along because we have not beenpaying attention to the instructions given to us. If we worked at being healthythen we can't expect any other result than being healthy."Practices that increase level of wellness involve meeting the physical needs andinclude eating properly, keeping clean, going to bed early to ensure adequate rest, andgetting up early. The intent of getting up early is to work and be productive. Of particularvalue is the caring for and contributing to the immediate and future needs of the familyand/or house/clan. This cooperation and sharing are important contributors to a sense ofwell-being.The importance of work and keeping busy is demonstrated in a story for lazy people.This story further demonstrates the importance of respecting all living things and shows thatconnections at the spirit level can have both negative and positive effects.P1^"There was four brothers ... it was time for them to go mountain goat hunting. Whenthe other brothers went up the mountain, they couldn't wake [the younger brother up]so they just left. I don't know what they did when they get mountain goats but theywere told to just roll them down the mountain until they get to the bottom withoutskinning them." That night the youngest brother misused the head of the goat in a82disrespectful manner. The next day all four brothers went up the mountain again.When high above a drop, the youngest brother's foot slipped and he rolled down themountain. "There was not a scratch on him . just the blood filled up the skin ...cause he rolled down from way up the mountain. They all just went down and theretheir brother was laying by the camp. That's why they never laugh at anything whatthey eat. It doesn't pay to be lazy."Respect for all forms of life establishes a foundation for being well. A part of respectinvolves the importance of talking nice and being kind to other people, particularly to thosewho are not well and in need. According to a Gitksan man and woman, both social relationsand personal wellness are strengthened by focusing on positive thoughts, attitudes, andbehaviours.From a spiritual perspective, this aspect of being can be strengthened throughpurification rituals (e.g., sweat, bathe with herbs, fast, pray, smudge, and meditate). TheGitksan in particular may engage in a ritual preparation of the day to strengthen and balancethe whole being.Wellness protection occurs primarily at the physical and spiritual levels. Physically, anindividual is responsible for staying healthy. One is expected to take care of one's self byeating properly, getting adequate rest, getting up early, exercising and working. The personis expected to read their body's needs and do what is needed to ensure he or she remainswell. For example, "Some people need longer rest periods than others." In the past, whencontribution by each member ensured survival, personal responsibility was critical ... "Theycount on every member to know how to take care of their health ... make sure that they stayhealthy as much as possible." In addition, the Gitksan caution people against taking intotheir body anything that is not going to do them any good. This concept of protectingwellness occurs throughout the directed conversations with some examples as follows:P1^"I know my parents were really interested in the health thing - that they makesure we drink our milk when we were young so that we don't get broken bones83and vegetables they were quite into that and get up early in the morning anddo chores and go to school."P2^"My grandmother worried how we eat ... even though we eat a lot of fish Ididn't get tired of it cause it was cooked differently. As a youngster I was toldto go to bed early and get a good night's sleep ... don't run around late atnight. And I did what they told me ... not to run around and not to drink."P3^"I rarely ever do [get sick] but then I always ... for me I'm always doing littlethings ... using traditional medicines. I did that ... I made a concoction ofdifferent Indian medicines and everybody got sick around me ... they all got theflu and a cold and everything and I was the only one who didn't get sick."Herbs were used on a daily basis for protection against sickness and evil spirits or toimprove luck. This involves boiling particular plants and drinking the tonic to, for example,clear the blood; or, bathing with the liquid; or, physically carrying special items on theperson. This practice continues.Some Gitksan undertake a daily, morning ritual to ensure the whole being remainsbalanced. The morning ritual is "... a time when you talk to the creator and ask him forassistance in what you need to do, ask him for direction, ask him for strength. And if thereare rituals that you have to do to strengthen any special part of your being, then that isusually the time when it is done." Usually, these rituals would have been prescribed by ahealer. This daily preparation and other purification rituals strengthen the physical, mental,and spiritual levels so that evilness around you can't touch you.Carrying out family and social responsibilities protects and strengthens one's sense ofwellness. For example, "I try to help others because I feel it is important to in my own mind... in my own mind I have a clear mind, a healthy mind. You don't feel guilty about things ifyou go out and help." A Gitksan and Wet'suwet'en elder stress the importance of keepingkids from running around late at night to protect them from being harmed at the spirit level.These distinct beliefs and practices that strengthen and protect wellness operate84largely at the physical and spiritual levels of being. However, wellness can also be weakenedat the physical, mental, or spiritual aspects of being. Weakening at one level affects allothers with potential harm ultimately extending beyond the individual into the family,house/clan, and community.4.1.5 Wellness WeakenedFactors that detract from wellness relate primarily to attitudes and behaviours withattitudes referring to emotions and mental set. During the in-depth interview, many refer toa decrease in wellness, this suggesting there is a movement downward from a position ofstrength or a higher natural state. For example:"If you can't contribute towards a house, strengthening the house, it is notproductive and that to me is not healthy and even when you drink that is nothealthy ... when you smoke that is not healthy ... it ... its no good ... it willshorten your life. A saying is "You are not doing the right thing, you are doingsomething that'll go against your health, it will weaken you and therefore it willshorten your days."According to these beliefs, level of wellness is weakened by being cruel; beingdepressed, sad, or feeling bad; not respecting other people or animals; feeling hurt and angryfrom current or past situations (e.g., residential school); low self-esteem and beingstereotyped; feeling guilty and unresolved grief; jealousy, bad-mouthing and gossiping;focusing on negative thoughts and experiences; dependency; and, poor or inadequatecommunication.Particular note is made of the harm brought about by low self-esteem, no pride, andhurts from the past that reduce people's coping skills. "The people have no self-esteem andonce they're taught that everyone is equal ... no one is better and that they have what's insideof them to attain goals other people have. It's a lot of coping skills." These effects are85reported on by two counsellors who describe "hit and run tactics" of those seeking help. Thecouncillor becomes overwhelmed and oppressed by this negative experience and thoseseeking help do not develop coping skills and, in many cases, remain dependent.From the physical perspective, not taking care of one's self will weaken one's level ofwellness. The Gitksan say not to take certain things into your body because it will lead to anearly death. This includes such things as alcohol and drugs. Being lazy and not engaging inhard physical activity or work of some type also presents potential problems. Within thevillages, housing and crowded living conditions are a well recognized source of health andsocial problems. A Wet'suwet'en woman says "I believe that people need their privacy andits just not possible because of the shortage of homes. That tends to lead to a lot of alcoholproblems too because people get so frustrated and rather than beat them, you join them ...that kind of attitude."From the spiritual perspective, a major threat to wellness involves separation of thebody and spirit/soul If a person is startled or frightened, the soul leaves the body and theaffected person becomes susceptible to other sicknesses, including death from accidents.This situation is related largely to lack of respect for another person that, in some cases, mayresult in negative or bad thoughts being directed toward the offender, this threatening andweakening their wellness. Many references are made to the possible causes of the soulleaving the body, and include the following:P1^"That's another way of getting sick ... when your soul leaves you and that has todo with the spiritual self. If for instance you had a car accident ... the soulleaves them ... these people they start getting ... they get really sick ... they getreally sick ... deathly sick. If they don't remedy the situation again they willeventually die."P2^"And when your get sick by somebody you know like old people like him ... is aboy maybe scared him you know."86The transition from being well to unwell and/or sick involves an accident or simplygetting sick (e.g., develop cancer). In three instances involving both Gitksan andWet'suwet'en there is mention of an attack involving abrupt onset of the problem. Theattack is by something at the physical or spiritual level, this taking away from wholeness andmaking a person sick. Here, cause and effect are clearly linked.Results from the interviews suggest that in the past, sickness was not common.People died from an accident or lived to a very old age. Although a Wet'suwet'en elder saysthere was "... no sickness, nothing ... even the kids." she did go on to say "... A lot of kidsbetween us [two sisters and a brother] they died you know and only 3 of us we're alive so mydad scared ... they don't want me to get died." Two types of sickness described by thiswoman involve snow blindness and skin rash, both of which have identifiable external causesand are of limited duration. From the spiritual perspective, a young girl beginningmenstruation has considerable power that is both contained and strengthened throughfollowing highly restrictive food and social practices. During this time she has potential toinadvertently cause sickness for many, including the Indian doctor.Today, a physical problem is referred to primarily as a sickness or, in some cases, anailment. In a few instances, specific problems are referred to as an illness or disease (e.g.,AIDS or lupus). When speaking of a sickness, there is no distinction between minor andmajor problems: a cold is a sickness as is arthritis and cancer. The sickness causes one to besick. For example, when a Gitksan inquires about how another is doing, if the answer is "Iam not doing good," the follow up question may be "What is hurting you," or anotherinterpretation is "What is your sickness?" Also, in describing her experience, a Wet'suwet'enelder says "... my sore throat and that cold stuck ... can't spit it out."At the physical level, cause relates largely to acquiring a sickness, such as diabetes,87lupus, arthritis, the cold, and flu. The cause of these sicknesses may be related to a germ, asin the case of TB; or, catching cancer from a sick person or acquiring it through use ofcontaminated land food or over use of store-bought foods. Alcohol use is considered asickness and is seen as one of the biggest killers. Use usually marks the start of familybreakdown, a situation that also causes sickness in the family especially when use becomes away of life. Alcohol also interferes with the spiritual connection with the land. Today,people don't have "lingering illness"; rather, they die suddenly from tragic accidents related toalcohol. Sickness and death are referred to in the following manner:P1^"Cause we never used to get sick [the elder] said" ... he pointed that out to me ... "Ithink when we start buying all these store bought food, everybody is coming downwith cancer, arthritis, everything. Before we never used to have that."P1^"I think its just a breaking down part of the body ... I guess its a disease setting intothe joints. They talk about arthritis. I think they call cancer a disease cause a lot ofpeople are scared to go near a cancer patient cause they don't want to catch it. Ikeep telling them its not contagious. They just stand by the door when they come tovisit. I just tell them to go right up and talk about different things."P2^"Just only people die you know ... just an accident that's all, drown or grizzly bear killor kill each other for jealous or for trap line ... that's only time people died they said,no sickness, nothing."P2^"These days I believe too much stuff you know ready cooked in a container and somefreezing food, that's the one I believe a lot of people die on cancer. Lately its comingout you know. My daughter that's what they die on them."P3^"I've heard a few young people complain about being sick, not feeling well, all theywant to do is sleep and they're hurting and they're always afraid it might be what Ihave. I've told them what I have [rheumatoid arthritis] is not contagious."P1^"Alcohol is one of the biggest killers of our people I think. You talk about familybreakdown, that's where it starts ... alcohol."P4^"A B.C. Band did a survey of all the deaths that happened in the community and youcould tell when it started not being a death from natural causes. It was alcohol anddrugs. Now-a-days you very rarely hear of someone dying of natural causes."Other factors that cause sickness include stress; an unbalanced life (e.g., push self and88become run down); residential school experiences; sexual, physical, or mental abuse; andunresolved grief. A Gitksan woman describes the deep and long lasting anger brought aboutby her husband's death in the hospital where he did not receive appropriate care. Thisanger coupled with an inability to grieve caused pain in her chest. The pain was finallyrelieved when she was able to cry.Level of wellness also naturally decreases with aging. During this process, the physicalbeing breaks down and the individual is said to be doing poorly. With age, breath becomesshort and mobility decreases.At the spiritual level, cause of sickness relates largely to separation of the body andsoul or inner being. This may occur as a result of a minor fright, a traumatic experience, orinadvertent or deliberate harm brought about by someone with power. These occurrencesare described as follows:P1^"And when your get sick by somebody you know like old people like him ... may a boyscared him ... they [gasp] ... just like some kind of wind get into you so thats from theold people done that. And the next day they get sick, real sick. Now, these days theydon't care about each other ... they touch them at the back its the worst one ... its nogood for old people."P1^"I remember myself I was about 12 years old, my dad trapping every year ... that placewhere we go just foot trail and later on that white guy they got land close to my dad'strap line. They make a road for wagon and some stems still on road and when weuse that road we use team of horses. I was too young to walk long ways ... my momhe walk behind the team and myself, I was right by my dad. You know how it is ... ahill, big hill and the trees half burn and dry and you see way down. And the wagonjust about tip over by that stump on the road. Thats where I get scared and I getsick."P2^"You have to be careful around people with strong power because they may takepossession of your soul or even part of it. That's another way of getting sick ... whenyour soul leaves you and that has to do with the spiritual self. If for instance someonehad a car accident ... a traumatic experience ... their soul leaves them and it maywander around that area where you had that accident. They get really sick, deathlysick. If they don't remedy the situation they will eventually die."P2^"Two years ago, my brother, my cousin, and another cousin of mine they nearly89drowned. They were just hanging onto the boat and my other cousin had a life-jacketon and he couldn't make it to the boat. The boat spilled over and he went down therough side and he kept on going under the water ... he only had the life jacket onthats why he made it. And, he started getting sick, he was having nightmares. I toldthem that their spirit might have left them. I told my aunt there is a way of healingthem."P3^"One of the things they tell us all the time is not to frighten an elder. Again, I neverrealized why until recently ... that its because of the chance of a separation of thespirit from the physical body. If you do ... if you frighten them then you literally canscare them to death because of a separation that can occur between the spirit and thephysical body."P3^"I think the Prairie people are very quick to handle separation of the body and spirit... even if you were to trip and fall then they do it right on the spot. Our people tendto be slow in handling the realignment of the body, mind, spirit, and emotions."P4^"If you are cruel to an animal, it will bestow bad luck on you and you might get sickor break a leg ... in some cases you might even lose your life."There is often a deliberate and extensive seeking of cause of a sickness. An examplesis provided by a Gitksan elder with a back problem who says ... "Sometimes I ask myselfwhat did I do wrong to be like this. Or, what did I do to anybody." She frequently referredto the hard work she did in caring for her many children and finally, her deathly sickhusband. Despite doing what she considered to be the right thing, two children died duringearly adulthood. She says "That's what gets me ... "Why me?" ... I look after my kids."4.1.6 Unwell of Sickness Experiences Requiring HealingAn individual may be not well and sick or not well but not sick. Both Gitksan andWet'suwet'en dialects have a word for 'sick'. A Gitksun description of the experience may be"I am in difficulty with my well-being" or "I am not feeling good, strongly" (literal translation)this response indicating they are very sick. Alternatively, they may say they are not sick, butare having other difficulties that are troubling them. These may relate to social or economicproblems.90Measurement of level of un-wellness relates largely to limitations in physical mobility(e.g., bed-ridden or in a wheelchair). For example, a person tolerates a range of excess bodyweight as long as it does not interfere with what has to be done. By comparison, arthritis hasgreater restrictions on physical mobility and so has a greater negative effect on level ofwellness. A Gitksan elder says:P1^"I've had cast on my feet before, but I used to manage to get around and take thingsand do things and sit and work with my hands. But when something is wrong with myhands that was really awful. So I'm so glad I don't have arthritis or anything likethat."P2^"Usually our people will try to do things for themselves, you know they are veryindependent in that way. But sometimes they may be incapacitated in that they can'twalk or their arthritis might be to the point where they can hardly stand up or liftsomething up. They'll say "I'm at the point where I can't really move around anymore." And if they're sick they'll say the same thing, it doesn't have to be arthritis."An additional indicator for being sick involves having to take pills or medication. Thesick person may also experience pain.The most consistent description of a sick experience has to do with separation of thebody and spirit. With the spirit gone, one is not whole or "just a shell." At this time, theperson doesn't want to eat, throws up, only wants to lay down, can't sleep, and hasnightmares. If intervention does not occur, death may result.When unwell and sick, an individual is described as being weak: they can't movearound or have to stay in one spot. Weakness is related to both energy level and muscularstrength. Weakening occurs with age, in sickness, and near death. This is seen in thefollowing excerpts from conversations:P1^"If our elders are ill they also go very quickly when they get very low ... they don'tlinger. My grandmother didn't want to be a burden."P2^"The nearest thing would be how strong that person is would indicate how healthythey are. They say [local dialect] ... this person is not strong any more, and thereforeyou would get an indication of how old this person is. This person is elderly and they91can't get around as they used to do when they were younger. That would be anindication that they are no longer healthy and that they are getting on in age."When unwell or sick, a person can't do anything or can't do what he/she likes to do.Responsibilities are not carried out, dependency develops, and one becomes a burden. Inthis state, the individual says they are "held back." Being held back refers primarily to thephysical being but also relates to growth potential at the spiritual and mental levels. Thisdecrease in ability is referred to in the following mannerR^"What do you consider the most troubling part about not being healthy?P1^"Not being able to help yourself and not being able to do what you want to do thatyou enjoy. I can't even do much cooking because I couldn't lift anything hot. Andthat's really bothersome to me."A negative sense of well-being commonly describes the unwell or sick experience.Generally, an individual may say they are not feeling good or not doing too good. Thesickness experience is described as depressing: the Gitksan have a saying that the heart islow. This sadness results in part because of possible restrictions in physical mobility andability to do things. Also, a sense of guilt arises from being a burden to the family. Onefeels useless. An individual is described as hurting inside and there is a sense of socialisolation: nobody cares. The following accounts illustrate descriptions of negative well-being:P1^"Even doing your own hair is hard when you don't have a hand to do it. They saywhen you are healthy you don't even think of those things. You know, you just take itfor granted that you can always do them until the time when you open your eyes. "Ohwhy did I think that just going to go on, that nothing would ever stop me from doingit." And then an accident happened and that was it. I felt really - how can you put it- feeling kind of trapped you know. I can't do the things I like to do."R^"So if you had people that were willing to come in and help you do these things, likefix you hair and put up fish and cook for you ... was that OK with you. Did you feelOK about that?"92P1^"Ah it was OK but you still feel kind of useless. You feel like you are just there, youknow. It is not really living as far as I am concerned, because when I can't do formyself, what is the point of being there. You know, I'd rather do for myself than tohave people wait on me because that's not really living, that's really more like avegetable as far as I'm concerned. I wouldn't want to be that way. I like to go on onmy own, you know. To me, I'm not a person that wants to depend on other people ...even though it is kind of nice if they're willing to do things for me. In my own mindthat's it, you know, being useless. I don't think I like that feeling."P2^"If they are sick they usually tell that they are not feeling well. And the bad one iswhen I feel my back hurts so much. I want to throw up and just cry."P3^"When you talk to people now it comes back to the way we were treated ... we'rebeing kept on our thumb ... when you do that to people you don't feel good and don'teat properly ... there's just nothing, you just go through the motions of living ... there'sno purpose in living."P4^"My grandmother's death was very, very quick ... she suffered the last month. I wouldalways hear her tell people she was not feeling very good but her actions never tellme that. Like if you're not feeling good you usually go to bed but she got up and sheworked continuously."P5^"In listening to our elders, a state of depression is an example of just hanging on tonegative experiences and allowing it to pile up and allowing them to take control ofyou rather than you take control of the situation. They didn't have a word fordepression ... we do have another phrase that describes your state of health or yourfeeling and that is when you say [local dialect] ... which means that your heart is low."When a sickness occurs, everyone in the family, including children, are responsible forhelping out and caring for the sick. A Gitksan elder describes how, when she was a child,she was responsible for disposing of the sputum from her aunts and uncles who had TB. Inspeaking about her grandfather, another Gitksan elder says "... his second wife was not ableto look after him, so my Mom brought him in and he was really a sick man. He died at ourplace. He couldn't take care of himself, so my mother took care of him. Mom even put hisbed up in the front room so that we'd be around him and then he won't be lonely."This responsibility for the sick and elderly involves the immediate and extended familyas well as the community at large. This participation in recovery and care is demonstrated93by the Gitksan where people go "to help the sick person." Excerpts from two conversationsillustrate this point:P1^"Whenever anyone was ill different members of society would come and spend sometime in the room where the sick person is. And as many people as possible wereencouraged to be in the room."P2^"It is important to me to go and visit sick people and say nice things to them and tryand get them to feel better for themself as well."P3^"We like to see other people from the outside ... they make us feel better. This oldman ... he never seen nobody around ... he live way up in the hill in village andnobody visit him and nothing. So he took that shotgun out and he went out to theplatform and "bang." So start to everybody run up to the house ... they think he shothimself. They come in and ask him "What happen?" "Oh, you people never see meeven say hello to me or nobody visit me, nothing. So, what you think. I shot: youeverybody come in here. That's what I did for. I like to see you people."While family and community contribute to the care of the sick and weak, an individualis also expected to help themself in regaining their strength. The sick are expected to carryon and assume their responsibilities as much as possible despite aches and pains. Sufferingfrom cancer is extreme and so legitimately interrupts family and social responsibility. Bycomparison, people who complain about minor aches and pains are not well regarded. AGitksan elder says "Some tend to use any kind of disease as being a crutch that they hangonto just so that people feel sorry for them and instead of having their clear thoughts"When engaged in struggle with a sickness, the affected person may undertake a courseof action so the sickness does not beat them. On recovery, they may say they "beat it" as, forexample, in the case of a Wet'suwet'en elder with diabetes. A Gitksan man describes hisexperience with a shoulder and back problem. Neither of these problems slow him down; hejust has to look after himself and make sure he does everything right. He says "... and I haveto move around ... I can't let this thing beat me. Even when I talk to people and they'resuffering and they say "I can't let this thing beat me ... I can't let this pain beat me"."94Today, when a sickness occurs, there are several possible courses of action. Choiceinvolves getting help at the hospital; seeing a traditional healer who has known and strongpowers in healing; obtaining help within the family or house/clan where some individuals mayhave limited powers in healing; using self-care by, for example, taking herbs or repairing owndentures; or, doing nothing.The arrival of the medical doctor marks the decline of the local, powerful, andpractising Indian doctor or halal Though there is an acknowledged dependency on MedicalDoctors and the hospital, there is also some distrust. While level of distrust appears to bedeclining, some still believe there is an intent to harm: the people are turned away from thehospital and care is denied or inadequate even when the sick and their family perceive thereto be a serious problem. This intent may be related to local views of inexperienced doctorsin training who provide lower levels of care than in the city as well as prejudiced behaviouron the part of some doctors. However, there is also expression of gratitude for doctors whoeither do try or are willing to try to help and who are trusted.One noted problem is Medical Doctors do not deal with the whole being. They don'trelate to the whole body but rather to a sick part. A Gitksan elder relates her disastrousencounters when her husband was receiving dialysis. During the course of his treatment, hehad frequent spells where he "falls sort of in a coma." He was brought to the hospital manytimes but just sent home because they couldn't find anything wrong. "And then they'd tellme that I am tired of taking care of him on the machine that's why I was seeing things that'snot there. They even got me to talk to a psychologist trying to find out why I refused to lookafter him any more. And I said as long as you find out what is wrong with him, I will gladlytake him home and take care of him the way I was doing before."One of the coma like spells occurred in a Vancouver hospital: the nurses called the95orderly and put him to bed. "The next day that specialist came in ... "What are you doinghere" he said, "There is nothing wrong with you, you can go." They didn't even check himout They just released him and he said "Get me out of here." That's what really hurt, whenthey treat you like that ..." Six weeks later, when he fell in a coma he broke his elbow andrequired surgery: after surgery he died of a massive stroke. An autopsy showed, much to theamazement of the doctors, small blood clots in his lungs and brain: he had been having smallstrokes despite being on a medication to slow down blood clotting. "I'm laying a lot ofshortcomings on the doctors at times. They take too long in trying to find out certain things.I knew there was not the kidney problem, it was something different But, they know it all."In this situation, family input was not respected.Of particular note is a story that demonstrates a Medical Doctor's inability todiagnose problems related to separation of the body and spirit A Wet'suwet'en elderdescribes her experience as a child when she was frightened while riding in a horse drawnwagon with her father.P1^"They took me down to hospital ... Dr. --- was there. They put me in the hospitalfor couple of days ... check me all over everything ... I'm not sick ... they send mehome. Twice I was in hospital for that ... sometimes I cry at night ... I'm scared, crywhen I woke up. ... [Strong Indian doctor and old people] they took it [object] backfrom my mouth... If they didn't do it to me, I gonna die no time."A strong Indian doctor or halait can help a sick person by working at the physical andspiritual levels of being. Practice commonly involves seeing at the spirit level and dreaming.By these means, the problem is diagnosed, method of treatment identified, and sicknessoutcome predicted. The healers work together in a group with elders present and childrenexcluded as observers. The sick person must believe and is often directly involved in therituals: in some cases, the person causing the sickness also participates.Today, there are no known local Indian doctors or halaits with this degree of power.96However, there are strong doctors located outside the territory. These people are mostcommonly sought by elders and by families where a serious sickness is present (e.g., cancer).More commonly, there are individuals who can dream and give advise (like a psychologist),who can recommend and provide herbal remedies, or who can intervene when the body andspirit are separated. There are a variety of techniques for returning the spirit to the body,however, these techniques are held confidential by the practitioner.When healed, a sick person returns to a normal way of living or a whole life, and iswell again. This return to normal is described as being strong once again. Although healingis most commonly referred to, some people interchange the words heal and cure. Healinggenerally occurs first at the spiritual level and can be complete. This is followed by physicaland mental healing that may or may not be complete and depends upon the cause.Besides personal healings, there is also a recognition of a general need for healing ofthe family, village, and tribal groups. At the house/clan and tribal level, a Gitksan suggeststhis healing is dependent upon strengthening connections with the traditional territories.Ultimately, strength is determined by adherence to cultural beliefs and practices.These descriptions of the health phenomena according to the Gitksan andWet'suwet'en correspond with Kleinman's cultural model of the health care system. Inadopting his explanatory model of the health care system as a basis for exploring healthmeanings, we see how language usage provides some explanations of the local healthexperiences and responses to being well or sick. The intent was to focus only on the popularsector of this explanatory model, however, interviews progressed to provide some indicationsof the role of the folk sector or traditional healers and their practices. In the followingsection, further descriptions of personal health experiences are obtained from summarydescriptions of findings from a multidimensional questionnaire974.2 General Health StatusThe General Health Questionnaire comprises the second major information source inthe health study. This section summarizes the multitude of factors that may affect health.These factors reflect the four categories contained in the epidemiologic model referred to inthis study as the Diamond Model (page 18). The Four categories and examples from theQuestionnaire are: (1) Genetics/constitution - e.g., sex and tribal ancestry; (2) Lifestyle/Personal Behaviour - e.g., tobacco use and physical activity; (3) Socio-Economic Environment- e.g., education and employment; and, (4) Health Care Services - e.g., physician visits andhospitalization. Both tables and text present a summary of findings. Additional supportingtables may be found in Appendix F. The following section describes in detail the findings forthe General Health Survey. Some of the problems arising from the extensive Questionnairehave been previously discussed in Chapter Demographic Characteristics of Study GroupA description of the health experiences of Gitksan and Wet'suwet'en people reflectthat of 97 men and women, 15 years and over. Overall participation rate was 54 percentwith equal proportions of men and women being represented. Table 1 summarizesparticipant ancestry, a designation that is used to distinguish groups in this report.A small proportion of respondents were of Gitksan-Wet'suwet'en ancestry or 'other.'People identifying their ancestry as Gitksan-Wet'suwet'en lived in a Wet'suwet'en village buthave a Gitksan mother or can trace Gitksan ancestry in the maternal branch of the familytree. Nine women from other tribal groups had married into Gitksan or Wet'suwet'ensociety and include: two Carrier; one Coast Salish; one Shuswap; three Tsimshian; oneStaloh; and one Metis.98TABLE 1Demographic Summary for the General Health Survey, 1991Sex^No.^Average^Tribal Ancestry (No. (%))Respondents^AgeGitksan^Wet'suwet'en^Gitksan -^OtherWet'suwet'enMale 48 37.6 24 (50) 18 (38) 6 (12) 0Female 49 33.3 17 (35) 21 (43) 2 (4) 9 (18)TOTAL 97 35.4 41 (42) 39 (40) 8 (8) 9 (9)Clans represent the central unit of social organization in the Gitksan andWet'suwet'en societies and are potentially important health resources. Respondents in thisstudy belong to four major clans: Wolf, fireweed, frog and small frog clans. The comparableHouse system is equally important, however, a total of 76 Houses within a small samplegroup limits its statistical usefulness (see Table Fl, page 233).Place of residence either on or off-reserve has often been a questionable factorregarding health status of Indian people. While about three-quarters of the people had livedoff-reserve during the past 15 years (1975-1990), age was a factor with younger people livingless time off-reserve than older people. About half the people living off-reserve had movedback within the past 5 years. Of this number, only a small proportion included peoplereturning to the village because they had regained status through Bill C-31 (n = 10). Priorto implementation of this Bill in 1986, men and women who lost their status for technicalreasons subsequently became eligible to apply for re-instatement on the Band MembershipList (Hawley 1990). Overall, 12 percent of the population were Bill C-31 members. Thissubgroup could potentially provide useful answers to many questions regarding comparativehealth status. Unfortunately, numbers were too small to be of statistical value (see Table F2,99page 233).Age was also a factor in educational achievement. When age did make a differencein hypothesis testing, age was subsequently controlled for by restricting educational categoriesto 45 years or less. This control removed the age effect. Neither sex nor tribal ancestryrelates to highest level of educational achievement. About one-third of all respondents hadsome secondary or high school (between Grades 9 and 12); ten percent had completedGrade 12; 19 percent, some college; and 11 percent completed college or had someuniversity. The eight point scale for educational achievement was subsequently collapsed tothree categories for further analysis: (1) no formal schooling to Grade 8; (2) Grade 9 throughto completed Grade 12; and, (3) some community college to a University degree (see TableF3, page 233).A further factor relating to education and age involves attendance at a residentialschool. About one in four people reported having attended a residential school at sometime. The average number of years in attendance by these respondents was 3.3 years(Standard deviation: 3.2 years; range 0 - 12 years). Generally, respondents over 45 yearsspent twice as many years in a residential school as did those between 25 and 44 years.Neither sex nor ancestry made a difference in attendance (see Table F4, page 234).Respondent's main activity over the past 12 months comprised a final socio-demographic factor in assessing health. About 43 percent were working at a job, 19 percentlooking for work, and 17 percent going to school. The remaining 21 percent were occupiedin other ways, including keeping house and hanging around. Sex was a factor with more meneither working or looking for a job and about half the women either going to school orkeeping house (see Table F5, page 234).In the following sections, the main socio-demographic factors utilized in assessing100health include tribal ancestry, age, sex, education, and main activity in the previous year.4.2.2 Self-Rating of Health and Use of Health CareSelf assessment of health comprises one of the key variables in the study. Thissubjective measure is of particular value as it provides some indication of when an individualis likely to access the health care system. This subjective measure involved askingrespondents to rate their health as "excellent," "very good," "good," "fair," or "poor." Healthratings by sex and age grouping are summarized in Table 2.TABLE 2.Self-Reported Health According to Sex, Age, andPresence or Absence of Activity Limitations, 1991.Self-Rating (%)No.^ExcellentRespondentsVeryGoodGood Fair PoorAll Ages 97 7.3 34.0 37.1 19.6 2.1Male 48 10.4 31.1 31.1 22.9 4.2Female 49 4.1 36.7 42.9 16.3 ---Age Groups:15 - 24 28 7.1 46.4 25.0 17.9 3.625 - 34 23 4.3 30.4 47.8 17.4 ---35 - 44 25 32.0 44.0 24.0 ---45 and over 21 19.0 23.8 33.3 19.0 4.8Activity Limitation Present or Absent:Yes 11 9.1 36.4 45.5 9.1No 86 8.1 37.2 37.2 16.3 1.2Among the Gitksan and Wet'suwet'en, there were no significant differences in healthratings according to sex, age, education, tribal grouping, clan membership, band membershipSelf-Rating by Scales * (No. Respondents)Questionnaire Item 1 2 3 4 51. Health rating 7 33 36 19 22. Level of happiness 47 37 8 4 13. Level of stress 8 45 37 7 N/A4. Satisfaction with health 28 49 17 3 N/A101re-instatement through Bill C-31, or attendance at a Residential school. 14 Neither did thepresence of pain nor degree of happiness affect perceived health. However, health ratingwas significantly different in the presence of limitations in kind or amount of activity. (Table2) Hypothesis to explain differences in health rating stem from findings regarding healthmeanings. Hypothesis state the presence of pain, activity limitations, and experiences ofhappiness and interest in life made no difference in health rating.As seen in Table 3, people rating their health as "good" or better tended to be mostsatisfied with their health. People rating their health lowest had limitations in activity andwere also significantly less satisfied with their health. Conditions of happiness and stress arealso summarized in Table 3.TABLE 3Self-Assessments of Health, Happiness/Interest in Life, Stress, and Satisfaction with HealthNote: Questions and Scales in Appendix C-1.* Scale 1: Excellent; Happy and interested in life; Not Very stressful; Very SatisfiedScale 2: Very good; Somewhat happy; Fairly Stressful; Somewhat SatisfiedScale 3: Good; Somewhat unhappy; Not very stressful; Not too satisfiedScale 4: Fair; Unhappy with little interest in life; Not at all stressful; Not satisfiedScale 5: Poor; So unhappy life is not worth while; Not ApplicableMost of the respondents (49 percent) were happy and interested in life. Both sexeswere happier if working at a job, going to school or if retired. However, women tended tobe less happy if keeping house (see Table F5, page 234).14. In this thesis, "significance" refers to the 5% level as determined by the X2 test.102One-quarter of the people averaging 33 years did not plan to do anything over thenext year to improve their health. Lack of a plan was not associated with perceived level ofhealth: individuals with a fair-poor health rating were as likely to have no healthimprovement plan as those with higher health ratings (see Table F6, page 235). Oneexplanation for this situation was provided by a 27 year old male who stated he has no plansfor improving his health because he lives from day to day. By order of frequency fromhighest to lowest, individuals planned to: increase exercise, lose weight, improve their eatinghabits, quit or reduce smoking, and decrease alcohol intake. Those with a single healthimprovement plan most frequently cited a need to attend to a medical care matter that wasbeing put off (e.g. take iron pills, have eyes checked, have knee operated on). About 10percent of all respondent also cited social and economic plans involving higher levels ofeducation and either going back to or continuing to work.One indicator for health status involves use of health services. This examination ofuse of health services considered only four primary sources of care: Medical Doctors,Community Health Nurse, Community Health Representative, and traditional healers.The medical doctors have offices in the local hospital at Hazelton. The Community HealthNurse travels from the town of Hazelton and spends an average of two hours a week in thevillage. Distance to the villages range from 3 to 20 miles. The Community HealthRepresentative is a band member who lives and works in the village full time. Finally, use ofa traditional healers services would involve travel to a neighbouring tribal territory. Table 4summarizes use of these services in a two week and one year period.In the 14 days prior to completion of the questionnaire, over one-quarter ofrespondents (n=27) had gone to either see or talk to a medical doctor. The decision to seea physician was not influenced by age, sex, education or perceived level of health.103TABLE 4Use of Health Services in a Two Week and One Year PeriodUsage Over time Sex Services (Number)MD* CHN* CHR* Traditional HealerNightsIn-HospitalPast 14 days Male 14 3 5 0 N/AFemale 13 3 4 0Total 27 6 9 0 N/APast year: Users by sex Male 39 8 14 2 13Female 44 13 12 3 11Past year: Total usage Male 178 11 33 3 80by sex Female 283 46 31 5 61Average usage in one Male (N=48) 3.7 0.2 0.7 0.1 1.7year Female (N=49) 5.8 0.9 0.6 0.1 1.2Overall yearly Average Average 4.8 0.6 0.7 0.1 1.5* MD = Medical Doctor; CHN = Commuity Health Nurse; CHR = Community HealthRepresentativeThe main reasons for the visit concerned a sickness or health concern or a medical check-up(n=10). During this two week time period, both the Community Health Nurse (CHN) andCommunity Health Representative (CHR) had been seen or spoken to less frequently.Study participants who sought the services of the CHN were significantly younger than thosewho did not (28 versus 36 years). By comparison, those seeing or talking to the CHR were,on average, 55 years old. Reasons for seeing the CHN or CHR include obtaining: healthadvise, forms for glasses, follow-up care by the CHN, pain medication or medication for acold; and, dental problems. None of the respondents had seen or talked to a traditionalhealer in this two week time period.Over the long term, physician services had been utilized for an average of 4.8 visitsper person per year (N=97). However, about 10 percent of the people had not seen adoctor at all; approximately half (47 percent) made between 1 and 3 visits; and, 4 individuals104receiving counselling attended the doctor's office once or twice a month. During this sametime period, CHN and CHR services received comparable usage. Over three-quarters ofrespondents had not utilized CHN services at all while two-thirds had not sought care fromthe CHR. Respondents most frequently cited seeing the CHN and CHR either once ortwice during the past year. During this same 12 month time period, five individuals soughthelp from a traditional healer for a total of eight visits.Further use of health services over a one year period involved over-night stays in thehospital (see Table 4). One-quarter of respondents reported spending a night in thehospital. Approximately half of this in-patient time was three days or less. Three surgerycases required in-hospital stays of two and three weeks: the longest in-patient time followedemergency gall bladder surgery with post-operative complications. The total population of 97respondents had an average in-patient time of 1.5 days per person.4.2.3 Two Week Disability and Accidents and InjuryAn assessment of short and long term disability resulting from sickness, accidents orinjury supports an estimation of the number of bed-days or cut-down-days. This level ofassessment shows that a two week short term disability had no effect on perception of health.Table 5 summarizes bed days and cut-down days by sex.About one in five incidents requiring bed rest resulted from an accident or injury.Most people stayed in bed because of a cold or the flu. Others (6 percent) reported achronic health problem including lupus, back problem, an ear problem that caused dizziness,anaemia, and varicose veins. Most of these people with a chronic condition had to cut downon things they usually do during the remaining two week period.Overall, approximately one-quarter of respondents had to cut down on things they105usually do because of their health. Individuals generally limited in the kind or amount ofactivities they could engage in were most likely to have to cut down on things they usually do.(Chi-square: p < 0.00057) The most frequent cause for reduction in activity relate to backproblems (n=5), weight problem (n=3), rheumatoid arthritis (n=2) and, anaemia/tired(n=2). About one in three attributed their health problem to an accident or injury.TABLE 5Two Week DisabilityBed-days or Cut-down days Sex (No.) Population Average(N=97)Male Female TotalBed-days 8 8 16Total bed-days 36 17 53 0.5Average bed-days 4.5 2.1 3.3Cut-down days 11 11 22Total cut-down days 73 77 150 1.5Average cut-down days 6.6 7.0 6.8Any assessment of accident or injury necessarily underestimates the occurrence asonly survivors are included. This study found that approximately 50 percent of the men andwomen had an accident or injury over the previous one year period. Age was a significantfactor for accidents involving bicycles (n=6; average age 21 years) and sport injuries (n=14;average age 25 years). Though not statistically significant, older people were more likely tobe involved in accidents as a pedestrian or when walking (average age 41 years).The most frequently occurring accidents involved a car, van, or truck (n=5);pedestrians; and, bicycle riders. Accidents serious enough to limit normal activitiescommonly involved falls, cuts, and alcohol. There were two cases of burns, one poisoning,one overdose, and one accident involving firearms. About one in five accidents were alcohol106related. Less than 10 percent of all accidents happened while working at a job or business.Despite the high rate of accident or injury, less than one in five of the peoplereporting an accident sought care in the hospital's emergency department. The resultinginjuries or health problem commonly involved muscle/joint injury or fracture (n=19),abrasions (n=7), or back injury (n=4): 6 cases reported no injury.4.2.4 Health StatusThis section on health status was designed to measure the usual ability in six areas ofhealth: vision, hearing, speech, ability to get around, use of hands and fingers, and pain anddiscomfort. Table 6 summarizes results in each of these categories.Age affected vision to some extent, with older people having difficulty reading smallprint (43 years) and younger people have difficulty seeing at a distance (39 years). None ofthe respondents indicated inability to read was a factor in not being able to see well enoughto read newspaper type print. Three cases averaging 53 years could not read despitecorrective lenses: one had cataracts. Though age was not a factor, significantly more womenthan men (33 versus 13 percent) had a problem with distance vision.Two-thirds of the people with poor hearing were under 45 years. Almost all of thosewith a hearing problem said they could hear well when talking to one person in a quiet roomand without a hearing aid. However, these people often required repetition of words orphrases and sometimes visibly strained to hear.Although one in five people had trouble being understood when speaking tostrangers, problems were entirely related to enunciation patterns: voice pitch was either toolow or the individual mumbled or stuttered. Only one elder had a problem speaking Englishwhile two others believed their accent caused the problem. When adjusting for ages under10745 years, half with a speech problem were teenagers.TABLE 6Health Status According to Vision, Hearing, Speech,Getting Around, Use of Hands and Fingers, and Presence of PainCategory Presence of Condition(No.)Yes No Don't KnowVision: Able to read- without corrective lens 60 37 0- with corrective lens 33 3 1Vision: Able to recognize friend across road- without corrective lens 75 22 0- with corrective lens 22 0 0Hearing: Able to hear in group conversation- without hearing aid 83 14 0- with hearing aid 4 0 10Hearing: Able to hear one person in quiet room- without hearing aid 12 2 0- with hearing aid 2 0 0Speech: Understood completely when- talking to strangers 78 19 0- talking to people know well 19 0 0Speech: Understood partially when- talking to strangers 17 2 0Getting Around:Able to walk without difficulty and without mechanical support 94 3 0Require mechanical support 2 1 0Hands and Fingers:Need help due to limited use of hands and fingers 1 96 0Pain and Discomfort:Usually experience pain or discomfort 38 59 0Individuals requiring mechanical support (leg braces or wheelchair) to get around didnot require the help of others. However, help was needed by the one case involvinglimitations in use of hands and fingers.Experiences of some pain or discomfort was unrelated to age or sex. Half of therespondents experienced pain or discomfort of sufficient intensity that they could not takepart in some or most activities. Activity limitations due to pain did not affect self-rating of108health (see Table F7, page 235).4.2.5 Chronic Health ProblemsSelf-reported morbidity provides an indication of the prevalence of disease in thepopulation. Table 7 summarizes the most commonly occurring conditions reported on. Agewas a significant factor in self-reporting of several chronic conditions as demonstrated by theT-test level of significance. Ancestry was significant in allergy related diseases. Here, peoplewith Gitksan or combined Gitksan-Wet'suwet'en ancestry reported the presence of allergiesand arthritis. The single reported case of Lupus Erythematosus was of Gitksan-Wet'suwet'enancestry. Sex was relevant only in the presence of recurring back pain.TABLE 7.Chronic Health Problems, 1991: Ages 15 Years and OverCondition No.RespondentsAverageAgeT-Test for AgeSignificanceSkin allergies or other skin disease * 11 44 p < 0.04Hay fever or other allergies 17 39Arthritis • 15 45 p < 0.0004Lupus Erythematosus 1 45Serious trouble with back pain 26 36Recurring back pain: not serious ♦ 10 38Serious problem with joints or bones 30 44 p < 0.000Chronic bronchitis or persistent cough 7 42TB - inactive/positive test 8 36High blood pressure 18 46 p < 0.000Heart disease and circulatory problems 8 51 p < 0.025Diabetes 2 51Urinary problems 7 51 p < 0.035Stomach ulcer 4 48Other digestive problems 8 47 p < 0.043Cataract or glaucoma 6 67 p< 0.000Chi Square Tests: p < 0.05* Occurs with Gitksan (n=7) and combined Gitksan-Wet'suwet'en (n=4) ancestry.• Occurs with Gitksan (n=10) and combined Gitksan-Wet'suwet'en (n=3) ancestry.• On average, women (n=7) with recurring back pain are younger (20 yrs) than men (58 yrs).109There was a high rate of double counting in categories for arthritis, back pain, andserious problems with joints or bones. About one in three arthritis cases reported havingserious back pain and serious problems with the joints or bones. When arthritis was not afactor, half the people with serious problems with the joints or bones also said they hadserious back pain. Adjustments were not made in reportings for the three categories.Age was a factor in reporting chronic conditions. The three leading conditionsaffecting men and women under 45 years are hay fever or other allergies, back pain, and,chronic bronchitis. For those over 45 years, the three main conditions involve high bloodpressure, heart disease, and arthritis. Other conditions reported on include single cases withrheumatism, asthma, thyroid problem, and one report of abnormal cervical cells requiringminor surgery. There were no reports of either epilepsy or cancer. Health rating wassignificantly affected by the presence of serious problems with joints or bones. Theseindividuals rated their health lower than those who did not have the problem. Bycomparison, neither the presence of arthritis, allergies, back pain, nor high blood pressuremade any difference in self-assessment of health.In a final check for reporting of long term health conditions, about one in six peoplesaid they had additional problems besides that previously reported on. The majority ofreported conditions were associated with some degree of pain and include back pain,headaches (n=5), and aching joints. In addition, two men said alcoholism was a healthrelated problem for them.4.2.6 Activity RestrictionQuestions relating to activity restriction distinguish people who have limitations due toan impairment or long-term physical or mental condition. These questions are intended to110identify groups of individuals whose health is poor enough to disable them or limit thequality of their life. The occurrence of activity restrictions are summarized in Table 8.TABLE 8Occurrence of Activity Limitations According to SexType of Limitation Sex (No.)Total (%)*Male FemaleNeed help with personal care 2 1 3Confined to bed or chair for most of day 4 2 6Limited in kind or amount of activity 4 7 11Activities limited at home 2 3 5Unable to do most household chores 1 1 2Activities limited at work or school 3 2 5Unable to work or go to school 1 0 1Limited in leisure pursuits 2 1 3* Percentages and respondent numbers correspond because the sample size is 97Half of the people confined to a bed or chair also required personal care. Theserespondents rated their health as "fair" with conditions involving lupus and wrist injuryresulting from a suicide attempt: one was an elder of 77 years. Overall, 3 percent of thepopulation has extreme limitations while 8 percent experience limitations at home and workor school. As shown in Table 2, these respondents with activity limitations rated their healthsignificantly lower. The duration of the limitations, whether in months or years, had noeffect on perceived level of health. An accident or injury caused the limitations in activity fortwo-thirds of the respondents (7 cases out of 11): half of these involved a back injury.4.2.7 Lifestyle: Tobacco, Alcohol, Exercise, Nutrition, and Dental HealthExercise and nutrition are important determinants of overall health while smokingand alcohol use are well known health risk factors. Smoking is a known risk for heart111disease, respiratory problems and cancer: alcohol consumption becomes a health risk factorwhen it is abused. Alcohol consumption is also related to accidents, social problems andfamily problems. These factors, as well as dental health and driving safety, are discussed inthe following section.Smoking Habits: Approximately two-thirds of the respondents are current smokers. with an age trendoccurring in smoking behaviour. (Table 9) Though smoking decreases with age, one in threeadults over 45 years smoked cigarettes. Twenty percent (20 percent) had never smoked atall while 17 percent previously smoked daily but had successfully quit the habit. Educationdid not affect rates despite the fact that the less educated were mostly older people. Whenadjusted for age, education remained un-associated with smoking practices (Table 10).TABLE 9Smoking Behaviour of Men and Women Ages 15 Years and OverAge Current Smoker Current Smoker Status Non Smoker Non-Smoker(No.) (No.) (No.) History (No.)Daily Occasionally Smoked NeverDaily Smoked15-24 years 23 11 12 5 2 325-34 years 17 9 8 6 2 435-44 years 14 7 7 11 5 645-54 years 6 2 4 5 3 255-64 years 1 0 1 4 1 365+ years 1 0 0 4 3 1TOTAL 62 30 32 35 16 19Men and women began smoking daily at an average of 18 years with initial useranging from 10 to 41 years. These daily users smoked an average of 11 cigarettes a day:two out of three smoked 10 cigarettes a day while one-third smoked 12 - 30 cigarettes per112day. Almost all daily smokers believed it somewhat or very likely their habit would lead to ahealth problem. Half of these daily smokers tried to quit smoking in the past year. Neitherage nor sex was a factor in this decision to try to quit smoking: most significant was belief inthe potential harm of smoking. People who believed it very likely that smoking would leadto a health problem were more likely to try to quit smoking than those who believed itsomewhat likely health would be harmed. Those who held strong beliefs about the potentialharm of smoking and tried to quit smoking were primarily in the Grades 9 to 12 educationalgrouping (see Table F8, page 235).Over half of the occasional smokers (n = 32) used to smoke daily. In this occasionalsmoking group, significantly more men than women used to smoked daily: they also smokedmore (e.g. 40 to 60 cigarettes/day). Current occasional smokers used to smoke daily at anaverage age of 18 years and quit smoking daily at 24 years. These occasional smokers used tosmoke an average of 14 cigarettes with a large proportion smoking 20 to 60 cigarettes a day.Overall, men tended to have significantly more friends that smoked than women.People ages 15 - 24 had the most friends who smoked. This pattern corresponds witheducation level (see Table F9, page 236).About 7 percent of the people smoked pipes, cigars or cigarillos, almost all of whomwere men (average, 40 years). Less (4 percent) used snuff or chewed tobacco. Two menaveraging 66 years used snuff daily while another 2 men averaging 25 years used snuffoccasionally. About one in three people said some of their friends used snuff or chewedtobacco.The well known association between smoking and alcohol consumption is observedamong the Gitksan and Wet'suwet'en people (Table 10: x2 = 20.4: p < 0.03). In this study,significantly more weekly drinkers are smokers (88 percent) than are non-drinkers (30113percent). None drinkers are also most likely to have not smoked at all. Table 10summarizes drinking patterns. Also, see Table F10, page 236.TABLE 10Relationship Between Smoking and DrinkingDrinking Patters Smoking HabitTotalDaily Occasionally Not At AllMore than twice a week 4 5 1 10Once a week 7 5 2 141-2 times a month 9 11 11 31Less than once a month 6 8 5 19Non drinker 4 3 16 23Alcohol Consumption: For the purposes of this report, an individual is termed a current drinker if theyreported consuming an alcoholic beverage at least once in the past 12 months. According tothis definition, about eight out of ten people (76 percent) currently drink. (Table 4)Generally, a drink was equivalent to one bottle of beer.Not counting small sips, men and women began to drink at 17 years, with age rangingfrom 8 - 35 years. Significantly more men than women are drinkers and, though notstatistically significant, more people in the 25 - 34 year age group regularly drink alcohol. Inaddition, men and women looking for a job tend to drink the most. Education appeared tobe related to drinking, however, age adjustment to under 45 years eliminated the spuriousassociation. Though 23 percent of respondents indicated they currently do not drink,approximately one in three of the former drinkers previously consumed more than 12 drinkson a regular basis.Over the past 12 months, one in four people drank on a weekly basis while about 30114percent drank once or twice a month (Table 11). In assessing drinking patterns over a oneweek period, the weekly drinkers consumed 12 drinks per person while the monthly drinkersconsumed 5 drinks per person (T-Test: p < 0.023). When averaged over the total samplegroup, the men and women drank 5 bottles of beer per person with women drinkingsignificantly less than men (3 versus 7 drinks respectively). Sex was also significantly relatedto an assessment of friends drinking patterns. Women considered only a few or none oftheir friends drank too much while men thought most of their friends drank too much.Overall, one in four of the current drinkers believed it very likely drinking would leadto health problems. However, the amount people drank significantly affected their beliefs inthe potential harm of alcohol. On average, people drinking once a week or more oftenbelieved it somewhat likely their drinking would lead to a health problem for them. Bycomparison, people drinking less than once a month believed it very unlikely their drinkinghabits would harm them (Table 11). Men perceived significantly greater potential harm totheir health than women: men also drank more frequently than women (Table F11, page237).An additional belief relates to normalcy of drinking patterns. People who drank mostfrequently were more likely to consider their drinking normal than those who drank leastoften (Table 11). This same significant gradient is seen when respondents report on hownormal friends and relatives consider their drinking to be. In other words, if an individualbelieved their drinking was normal, then they perceived that friends and relatives had thesame belief about their drinking pattern. People generally thought their drinking was notnormal when compared to friends or parents who drank more than they.Over 80 percent of the drinkers reported trying to reduce the amount they drink overthe past year. However, this decision to try to reduce alcohol intake was unrelated to beliefs Sex^Potential Harm^Normal^Try to Reduce(%) to Health (%)^Drinker (%) Drinking (%)Drinking Pattern: Male Female Likely Unlikely Yes No^Yes NoWeekly^(n=23) 67 33 65 35 79 21 79 21Monthly^(n=30) 16 15 50 50 58 42 87 13Less Often (n=18) 26 74 33 67 34 63 79 21115about the potential harm of alcohol, sex, age, education, or drinking pattern. Rather, thisattempt was directly and significantly related to a belief in personal control over drinking andoccurrence of family or spousal problems arising from drinking. Almost all of the peoplewho believed they could control their drinking or who reported a family problem actuallytried to reduce intake.TABLE 11Beliefs Relating to Alcohol UseMen and women hold similar beliefs about their drinking, however, men experiencemore negative effects from alcohol use (Table 12). Similar beliefs are held regardingnormalcy of their drinking pattern, perceptions about family and friend assessment of theirdrinking, and both sexes believe they are able to stop drinking when they want to. However,men who drank on a weekly basis were more likely to report that families worried abouttheir drinking; family problems occurred; they had trouble at work; and were arrested fordrunk behaviour or drunk driving. Age was a factor in arrests for drunk driving with menover 40 being arrested. In addition, men who drank most frequently were more likely to beadmitted to hospital.Support systems used in dealing with alcohol problems, by order of highest usage,involve seeking help from another, attending AA meetings, and attending an AlcoholTreatment Center. The few who did attend a Center continue to drink alcohol. Attendance116TABLE 12Problems Encountered by Drinkers in the Past YearAlcohol Related OccurrencesPast 12 MonthsSexMale(n=39)Female(n=35)Comments regardingsignificance% tried to reduce alcohol intake 80 85% feel are normal drinker 62 57% say friends and relatives consider their 66 54drinking normal% have families that worry 51 23 x 2: p < 0.01% say able to stop drinking when want to 87 97% attended Alcoholics Anonymous 15 11% attended Alcohol Treatment Center 8 9% went to another person for help 21 14% experienced family or spousal problems 44 26% got into trouble at work 23 6 x 2: p < 0.04% neglected obligations at home or work for 21 11two or more days% in a hospital for drinking 13 7% arrested for drunk behaviour 36 3 x 2: p < 0.0004% arrested for drunk driving 31 3 x 2: p < 0.002at either an AA support group or a Treatment Center is unrelated to drinking pattern orbeliefs in the potential harm of alcohol. Only age was significantly related to attendance atAA meetings: men averaging 54 years were more likely to attend. In seeking informalsupport systems in the community, significantly more Gitksan people went to another forhelp in dealing with their drinking problem. There is also a trend showing more Gitksanpeople accessing support through attendance at AA meetings and Treatment Centers.Seat Belt Use: Drinking and driving is a well known high risk behaviour. Another noted risk relatesto none use of seat-belts when driving or a passenger. Table 13 summarizes use of seat beltaccording to driver status in the previous 12 months. Both men and women are more likely117to use seat belts when driving on public highways. There is a significant age gradient in useof seat-belts when driving on public highways. Almost all drivers under 24 years and over 45years always used seat belts: the 35 - 44 year age group were least likely to always use a seatbelt. Most drivers said they buckled-up when driving public highways because of thefrequent road-checks for seat belt use. There was no difference in usage according toclassification as drivers or non-drivers. However, significantly more Gitksan people alwaysused their seat belts when a passenger in a motor vehicle.TABLE 13Seat Belt Use by Men and Women Driving on Public Highways and in the VillageUse Seat Belt (%)Driver Status and Location Always Most Times Rarely NeverMale Drivers: (n = 34)- driving on public highways 71 27 0 3- driving in the village 44 18 21 18Female Drivers: (n = 27)- driving on public highways 78 15 4 4- driving in the village 44 33 7 15Passenger Status: (N = 97)- drove vehicle past year (n = 61) 69 25 3 3- non-driver (n = 36) 53 33 11 3Physical Activity: A third lifestyle choice affecting health involves regular physical exercise. Mostbenefit is achieved if the exercise occurs at least 3 times a week, takes place for a continuous20 minutes, and is of sufficient intensity that it causes heart rate to increase to a targetedlevel. Though an attempt was made to screen for intensity according to sweating andbreathing more heavily than normal, it is unclear if respondents were successfully screened inor out of subsequent exercise related questions.Approximately three-quarters of respondents reported engaging in active physical118exercise during the previous 3 month period (Table 14). Women primarily walked forexercise while men jogged. Age was also a significant factor in choice of activity with peopleover 35 years walking and people under 35 jogging. With respect to duration, people over45 years commonly walked for at least 30 minutes on a daily basis. Though many reportedwalking for long periods, it is unclear if this was a continuous exercise period or if there weremany starts and stops. It also appeared that men exercised for significantly longer periodsthan women during each event. However, when controlling for sports such as baseball, therewas no significant difference in duration of exercise between the sexes. These sport eventsare screened out because intense activity is sporadic and generally of short duration.TABLE 14Type, Frequency and Duration of Physical Activity in Past 3 MonthsOccurrence No. Resp. Type of Activity (%)Walk Run/Jog Class/Home Ride Bike BallSex: *- Male 36 28 39 11 8 14- Female 32 53 9 19 16 3Frequency:- daily 17 53 12 18 18 0- 4-6 times/week 22 41 32 14 5 9- 1-3 times/week 29 31 28 14 14 14Duration:- more than one hour 24 42 25 4 8 21- 30 min. - one hour 33 49 18 18 12 3- 15 - 30 min 11 9 46 27 18 0* Sex made a difference in main activity (one choice): x 2 = 12.3: p < 0.02Level of physical effort in work or daily activities as well as an assessment ofadequacy varied significantly by sex (Table 15). Women's level of effort was light tomoderate in intensity and was largely considered to be too little. Men on the other handwere satisfied with adequacy of physical effort regardless of intensity. Overall, people who119rated their level of physical effort as light also believed their activity was too little. Incontrast, moderate to heavy daily effort was considered the right amount. About one in tenwere unable to assess the level of effort in their physical activities.TABLE 15Assessment of Intensity and Adequacy of Physical ActivitySex^Adequacy^No. Resp.^Intensity of Physical Activity (%)Light Moderate Heavy Don't KnowMale Too little^17^41^24^18^18Right Amount^31^16 39 32 13Female Too Much^4^0^50^25^25Too Little 22^46 41 0 14Right Amount^22^14^73^9^5Nutrition: Energy expended through physical activity directly influences body weight. Two formsof activity account for energy expenditures: routine daily activities and planned leisure timeactivities. About half of the women who rated their daily physical effort as light to moderatehad significantly higher body weights. Though men tended to have weight patternscomparable to women, their body weight was unrelated to perceived level of daily physicaleffort. In other words, men who considered their daily physical effort to be heavy were aslikely to be overweight as those men who rated their effort as light. Neither men norwomen's beliefs about adequacy of exercise was related to body weight.Measure of weight status is important because of the association between weight andhealth. Body Mass Index (BMI) provides a means for assessing obesity and is calculated asweight in kilograms divided by height in meters squared. In this study, cut-off points forassessing body weight for both men and women between 20 and 65 years is according to thatestablished by Health and Welfare (1988a). These cut-off points are as follows:120Under 20 May be associated with health problems for some people;20 - 25^Good weight for most people with lowest risk to health;25 - 27^May lead to health problems for some people;Over 27^Increasing risk of developing health problems such as diabetes, high bloodpressure and heart disease.None of the women in the study were known to be pregnant; one breast-feeding woman wasweaning; and, there were no noted abnormalities in leg-trunk length.The height for men and women was significantly different, with men averaging 1.7meters (5 ft. 7 in.) and women, 1.6 meters (5 ft. 3 in.). Gitksan or Wet'suwet'en ancestrymade no difference in average heights. However, people with Gitksan ancestry aresignificantly heavier.Table 16 summarizes current and desired body weight according to the above cut-offpoints. Age is a significant factor with over half of the men and women between 35 and 65having a body weight that places them at risk for diabetes, high blood pressure, and heartdisease (see Table F12, page 237). Through weight loss, 2 out of 3 people would achieve alow health risk status (i.e. BMI less than 25). Considerably more women (50 percent) thanmen (33 percent) want to lose weight. With success, the proportion of women at riskdecrease, however, men tend to remain in an at-risk category (BMI 25 - 27).TABLE 16Body Mass Index (BMI) and Cut-Off Pointsfor Men and Women Between 20 and 65 YearsBMI No. Resp. Current Weight Status (%) No. Resp. Desired Weight Status (%)(n=76) (n=76)Male (n=37) Female (n=39) Male (n=37) Female (n=39)Under 20 2 2 2 2 0 520 - 25 30 41 38 46 46 7425 - 27 11 22 8 17 40 527 - 30 10 8 18 9 13 1030 - 35 13 22 13 3 2 5Over 35 10 5 21 1 2 0121About one in five men and women prefer a body weight that places them at greatestrisk for developing health problems (BMI over 27). This preference is demonstrated by awish to maintain current weight regardless of level of obesity. One young man had a currentBMI under 20 but indicated he wished to gain weight Two women showed a preference fora body weight which yields a BMI under 20.Besides energy expenditure, body weight is also a direct result of energy intake.These two factors of "energy in and energy out" by no means completely explain anindividual's body weight, however, other factors are beyond the scope of this study (e.g.,efficiency of energy usage). In assessing their food intake, about 75 percent of respondentsbelieved they could improve their health by changing their eating habits. Significantly morewomen than men held this belief, however, the belief was unrelated to their current bodyweight Neither age, education, nor ancestry made any difference in assessing the potentialbenefit of changes in food patterns.Total nutritional adequacy, including energy intake, was assessed by means of a 24Hour Food Recall. This food recall was recorded for five days of the week, excluding fridayand saturday. Attempts to carry out interviews during saturdays and sundays proved largelyunsuccessful. Each of the five remaining days (sunday to thursday) representedapproximately equal proportions of respondents.An assessment of risk for nutrient inadequacy is based on a 66 percent cut-off pointwith intake compared to a Recommended Nutrient Intake (Health and Welfare Canada1988) that is based on standardized age and weight According to this criteria, people withan intake below 66 percent of the Recommended intake are considered at-risk (Gibson1990). Table 17 summarizes data according to sex and nutrient while Tables F13 and F14122(page 238, 239) in the Appendix provide complete data by age and sex.About two-thirds of the men and women were at risk for a calcium and Vitamin Adeficiency while about half risk a Folate deficiency (Table 17). Women are also at high riskfor an iron deficiency. Generally, people with energy intake below 1800 kcal are at risk ofhaving insufficient intakes of such nutrients as iron and calcium. This is most apparent forwomen 25 years and over who have an average energy intake of 1600 calories and haveconsiderably higher proportions at risk for a deficiency. Men on the other hand have higherenergy intakes and are largely able to meet nutrient requirements with noted exceptions(Tables F13 and F14, page 238, 239).TABLE 17Proportion of Men and Women At-Risk for a Nutrient DeficiencyWith Risk Determined by Intake 66 percent Less Than Recommended AmountsSex Nutrient (%)Energy Calcium Iron Vitamin A Vitamin C Riboflavin FolateMale (N = 48)Female (N = 49)Average14252062656464928655158261822192522444947Energy is provided by protein, carbohydrate, and fat. Nutrition recommendationsfor Canadians state the diet should include no more than 30% of energy as fat and no morethan 10% as saturated fat. Also, the diet should provide 55% of energy as carbohydrate(Health and Welfare Canada 1990b). Food Recalls for the Gitksan and Wet'suwet'en peopleshow that 33 percent of total energy is provided by fat: 35 percent of total fat consists ofsaturated fat. Salmon, in a variety of forms, was a major source of protein for about one infive men and women of all ages. Carbohydrate contributed to 53 percent of total energy.Generally, a high proportion of carbohydrate was in the form of simple sugars (e.g., regular123pop, table sugar, etc.).Both fibre and cholesterol constitute important parts of a healthful diet. The highconsumption of simple sugars may explain, in part, the fairly low intake of fibre for both menand women (average: 6 grams). Though not a nutrient, fibre plays an important role inregulating gastrointestinal function. Cholesterol, on the other hand, is a fatty substancefound in animal fats. Men and women consumed an average of 340 mg of cholesterol perday (360 mg and 310 mg respectively). Because of its relationship with coronary heartdisease, it is recommended that cholesterol intake be reduced to 300 mg per day or less(Health and Welfare Canada 1990a).Dental Health: Food choices form an important part of overall dental health. As important aredental hygiene practices and regular dental care from dentists or dental hygienists. Table 18summarizes data on current dental health. Age is a significant factor with young peoplebeing most likely to have their own teeth and no dentures (average 28 years). By 40 years,one in three people have partial plates. There is a significant gradient in the proportion ofpeople with partial plates up to 45 years. After 45 years, the majority of respondents had .TABLE 18Description of Current Dental Health by Age GroupingsDental Health No. 15 - 24 Years 25 - 34 years 35 - 44 Years 45 Years plusResp. (%) (%) (%) (%)Own teeth and no dentures 53 47 34 13 6Own teeth and one or moredenture(s) or bridge(s)31 10 16 52 23No teeth and full upper andlower dentures12 0 0 17 83124complete upper and lower dentures (average 55 years): one woman of 50 years had no teethand no dentures.Ability to bite and chew some foods provide an indication of the condition of teeth ordentures. In this study, chewing an uncooked carrot or firm meats and biting and chewing afresh apple was a problem for less than 10 percent of respondents. Again, age was asignificant factor (average 58 years). These eating problems primarily affected people withcomplete upper and lower dentures. An elder with his own teeth and another elder with noteeth or dentures could not chew a fresh, uncooked carrot or bite an apple, but could chewfirm meat.During the past month, the most commonly occurring dental problem for people withsome or all of their own teeth was pain in teeth from hot, cold, or sweet foods or liquids.(Table 19) In this sub-group (n=84), one-third reporting pain averaged 29 years and wereyounger than those who did not experience such pain (T-test: p < 0.04). Young people(average 25 years) also most commonly reported having a toothache. Neither pain in the jawjoints nor sore or bleeding gums were related to age. Sore or bleeding gums was the secondmost commonly reported dental problem.About 30 percent of respondents had not seen a dentist in the past year with mostsaying they didn't go because there was nothing wrong. Age was a factor with older people(average 42 years) saying there was nothing wrong or they were too busy while youngerpeople (average 24 years) said they were afraid or couldn't make an appointment. Twothirds of the people who had not seen the dentist in the past year said they only went to thedentist when they had pain or other trouble. A small proportion said they usually visited thedentist at least once a year for check-ups (see Table F15, p 240).125TABLE 19Dental Problems and Patterns in Access to Dental CareDental HealthOwn Teeth:^Own Teeth and^No Teeth and Complete% (n = 53)^Denture(s) or Bridge(s):^Dentures:% (n = 31)^% (n = 12)Dental Problems Past 12 months:-Toothache 23 6 N/A*-PaM in Teeth From 40 23 N/ASome Foods and Liquids-Pain in Jaw Joints 11 16 33-Pain or Discomfort N/A 19 67From Dentures-Sore or Bleeding Gums 32 13 25DENTAL CARE ACCESSED:-Within Last 6 Months 51 42 8-6 Months to 1 Year 24 32 33-1 to 2 Years 22 13 8-3 years or More 2 13 50* N/A = Not applicable4.2.8 Life in GeneralSocial and economic factors as well as mental health form an important part of totalhealth. In this study, economic factors are assessed indirectly and focus only on employmentor primary activities engaged in during the past year. Social factors include contacts withfamily and friends and community involvement. Finally, mental health factors focus onfeelings experienced within the past year.Less than one in four people working at a job were actually fully employed andworked more than 10 out of 12 months (Table 20). A discrepancy in respondentclassification of work occurs where the respondent may be currently working full time but thejob is a term project. Workers were equally divided between semi-skilled and skilledoccupations. Two times more men than women listed working at a job as their primary126activity. An age gradient is seen in level of skill associated with type of work: people under24 years were largely involved in unskilled activities; 25 - 34 years were semiskilled; and 35 -44 were skilled.TABLE 20Employment Status of Men and Women Whose Main Activityin the Past 12 Months Was Working At a JobEmployment Status Number ofRespondentsSex (%)Total(No.(%))Male(n=24)Female(n=18)Months Worked:0- 3 3 (7) 8 64 - 6 11 (26) 25 287 - 9 7 (17) 20 1110 - 12 21 (50) 46 56Work Was Mostly:Full time 29 (69) 71 67Part time 6 (14) 8 22Seasonal 7 (17) 21 11Skill Level: *Skilled 17 (40) 46 33Semi-skilled 21 (50) 46 56Un-skilled 4 (10) 8 10* Skilled = small business operator, artisan, heavy duty mechanic, program manager, etc.Semi-skilled = heavy machine operator, office worker, carpenter, cannery worker, etc.Un-skilled = labourer, taxi-driver, etc.About three-quarters of respondents lived in single family homes. The remainingone-quarter had two families or, in a few instances, three families living in the same house.Here, a family consists of a man, woman and their dependent children or a single parent andthe children. Many households included a young, unmarried, male boarder. Single familyhouseholds were least likely to feel crowded, however, one out of ten respondents in thisgroup said their house was too crowded. Having two families in the house was generally notconsidered a significant problem. More problematic was having three families present.127Regardless of the number of family units present, about one in four respondents consideredtheir living accommodation to be too crowded (see Table F16, page 240).Social aspects of life that may affect health include contact with family and friends,social activities, and community involvement (see Table F17, page 241).In assessing numbers of relatives that one felt close to, problem arose in defining arelative. Some respondents included children as a relative while others considered only theiraunts, uncles, cousins, and grandparents to be a relative. Despite this definitional problem,respondents had an average of 12 relatives that they felt close to. One third of therespondents had 4 or less relatives that they felt close to. Sex made a significant differencewith men counting more close relatives than did the women. Though not statisticallysignificant, women who married a Gitksan or Wet'suwet'en man had less relatives that theyfelt close to. People generally saw their relatives at least once a week, an exception beingwomen from other Tribal groupings such as Staloh or Carrier (See Table F17, page 241).Another important source of social support involves friends. By definition, a closefriend means people one feels at ease with, can talk to about private matters and can callupon for help. On average, respondents had 5 friends, however, respondents were morelikely to have no friends (14 percent) than no family members (3 percent) that they felt closeto. A majority of the respondents with no friends were women. Sex also made a significantdifference with men reporting more friends than women. As in the case of family,respondents also saw their friends at least once a week (see Table F17, page 241).Leisure activities respondents engaged in tended to be sedentary in nature. While thetwo most frequently identified activities for men and women involved walking or jogging andsports, these activities are largely seasonal. Non-seasonal activities involved art work andbeading, watching TV, and bingo. Less than 5 percent had no leisure activity that they128regularly engaged in while one out of three identified at least 2 activities. Over the previoustwo months, people largely spent their leisure time with others. Less than 10 percent spenttheir leisure time by themselves. Women from tribal groupings other than Gitksan orWet'suwet'en spent more of their time by themselves. On the whole, people were somewhatsatisfied with their social life with neither age, sex nor ancestry making a difference.About 70 percent of respondents had children of their own, the vast majority ofwhom (80 percent) were very satisfied with their relationship with their children. Neithersex, age, education, nor ancestry made any difference in this relationship. Over half of therespondents were presently married or living with someone. Only sex made a difference indegree of satisfaction with the relationship. Significantly more men than women were verysatisfied (see Table F17, page 241).Twelve (12) percent of respondents under 35 years have children and are currentlynot married or living with anyone. Three times as many women as men might be classifiedas single parents with women being younger than men (average 23 years versus 29 years).Besides close family and friends, an important part of social support is havingsomeone to confide in and help out in time of need. About eight out of ten people felt theyhad someone they could confide in or talk to freely about their problems. Education made adifference in this aspect of social support in that people with some post-secondary educationwere most likely to have a confidant. Though not statistically significant, the remaining 20percent lacking this type of support were primarily under 24 years and over 45 years. It wasmore common for people to have someone to help them in a time of need rather than tohave someone to talk to. Here, 88 percent considered they had either family or friends whocould help them out (see Table F17, page 241).Social support also extends into the community where involvement in voluntary and129support groups increases potential sources for help. Examples of voluntary groups includechurch and school groups, child care group, village fund-raising group, support group, orsocial club. Over half of the respondents were a member of a group or organization withabout one in three people saying they regularly attended meetings. Education made adifference in participation with significantly more members having a grade 9 - 12 level ofachievement. Ancestry was also a factor in that Gitksan people were most likely to attendgroup meetings on a regular basis. Other people were as likely to attend as not attend.Participation in committee work was influenced by age with people over 35 years being mostlikely to take active part in leadership. About one in four people under 35 years wereactively involved in committee business. When controlled for age, education also made adifference in leadership with people having some post-secondary education being more likelyto be involved at the committee level than people with grade 12 or less.Only 15 percent of respondents actually participated in support groups. Supportgroups identified include Young Adults, Lupus, AA, Women's support, and Young Moms.Reported levels of participation were too low to be of statistical value.One potential indicator of a need for support groups is that of mental health status.In this study an assessment of mental health consisted of a series of 14 questions referring tohow the individual felt during the past 12 months (Questionnaire: Appendix C-1). Test forinternal reliability gave a Cronbach Alpha score of 0.70 this demonstrating the index wasreliable: that is, responses were similar when questions were asked in two different ways.The 14 statements relating to feelings, the proportioning of time, and responses aresummarized in Table 21 with statistically significant factors noted.Generally, about 40 percent of the respondents had some concerns about their health,had trouble handling their feelings, were lonely, and had lowered interest in daily events.130TABLE 21Feelings Experienced During the Past 12 MonthsFeelings Proportion of Time (%) SignificanceHardlyEverLessThanHalfTimeMoreThanHalfTimeMostTimesA Full of pep, energy 3 28 40 29 * Women had low energy levelsmore often than menB Health gave noconcern31 21 18 30C No problem handlingfeelings17 26 23 35 + Older people are able to controlfeelings most timesD Life was rather boring 46 31 18 5 * People with Grade 12 or lessfound life boring more oftenE Felt rather low 30 44 19 7 • Women felt low more oftenF^Felt tense 33 42 17 8 * Women felt tense more oftenG Felt cheerful 7 13 39 40H Felt lonely 39 32 10 19 * Women felt lonely more oftenI^Took effort to controlfeelings33 28 22 18J^Interesting thingshappened23 21 27 29K Worried about health 41 28 11 20 * Highest education of Gr. 9 - 12worried more oftenL^Felt exhausted, wornout43 34 17 6M Felt reasonably relaxed 9 21 36 34N Felt loved, appreciated 7 12 29 52* x2 p < 0.05* x2 p < 0.01+ iC 2 p < 0.007+ T-test p < 0.03About half that number, or roughly 23 percent of the people experienced lowered energylevels and often felt exhausted; felt low, tense, unhappy, and bored; and generally feltunappreciated. Within these categories, about 7 percent felt exhausted, sad, tense,unhappy,and unloved on a regular basis. Women in particular were troubled more often bylowered energy levels, and feeling low, tense, and lonely. Education made a difference in131worry about health and being bored. People with a Grade 12 or less tended to be boredmore often and people whose highest educational achievement was Grades 9 - 12 worriedabout their health most. Age was a factor only in handling feelings with older people havingless trouble than the younger people.Creation of a mental health or well-being scale shows high or low levels of well-beingmade no difference in health rating. However, people experiencing lower well-being tendedto be less happy, experienced more stress, and were less satisfied with their health. Thisscale is constructed through: reverse coding statements so high and low ratings are consistent(Table 21: D, E, F, H, I, K, L); summing and averaging scores for the 14 variables;examining a frequency table to determine cut-off points for high and low levels; and,conducting Chi-square tests for significance. Table F18 (page 242) in the Appendixsummarizes results for tests of significance.Mental health issues relating to suicide and thoughts of suicide may be found in Table22. Approximately one in three people entertained serious thoughts of suicide at one time:half such events occured in the past year. Over the long term, significantly more womenthan men had some serious thoughts about taking their own life. However, in the shortterm, or within the past year, thoughts of suicide were not affected by sex (i.e., men andwomen were equally likely to have seriously thought of taking their own life). In addition,neither age, education, nor ancestry made a difference in this type of thinking. What didmake a significant difference was people who had thought of suicide often felt exhausted,worn out or at the end of their rope (Chi Square: p < 0.02).About one in five (20 percent) actually tried to take their own life. These attempts atsuicide were unrelated to current age, education, sex or ancestry. Over the past 12 months,there were four cases of attempted suicide (4 percent). Age made a difference in132TABLE 22Occurrence of Thoughts and Acts Relating to SuicideEvents No. Resp. Sex (No. (%))Male FemaleEver seriously thought about taking own life 37 10 (18%) 27 (73%)Thoughts of Suicide occurred in past 12 months 16 3 (19%) 13 (81%)Ever tried to take own life 20 6 (30%) 14 (70%)Happened in past 12 months 4 1 (25%) 3 (75%)Family friend or relative took own life in past 10 1 (10) 9 (90%)12 monthsthese recent suicide attempts where the small proportion who actually tried were an average of 19 years(range: 15 - 31 years) in comparison to 32 years for those who did not (T-test p < 0.03). From a mentalhealth perspective, those attempting suicide felt low most of the time, this significantly different than thosewho had not actually made the attempt. Statistically, neither sex nor ancestry made a difference in theseattempts. About ten percent of respondents had a family member or friend take their own life in the pastyear with significantly more women than men reporting such an incident4.2.9 Women and Child HealthHealth choices women may make relate largely to cancer prevention and involvebreast examination and pap smears. Table 23 summarizes women's preventive health andbreastfeeding practices.Age was a factor in breast examination by a doctor or nurse with women receivingthis type of care being significantly older than those who did not: 41 versus 30 years. (T-Test:p < 0.004). Although almost all women had seen a doctor at least once in the past year,examinations tended to focus on older women. However, only half of the women over 40years reported having their breasts examined when they had gone to see the doctor at leastonce during the past year.Neither age nor education was a factor for the 60 percent of women who had been133shown how to examine their own breast. About one third of these women carried out thishealth preventive practice on a regular basis. In this grouping, older women were most likelyto examine their own breasts at least once a month: younger women self-examined onceevery two to three months (46 versus 29 years: t-test p < 0.014).TABLE 23Women's HealthAge Grouping (No. (%))Total15 - 19 Years 20 -39 Years 40 - 67 YearsBreast examined by Dr./Nursein past 12 months:Yes 1 (14) 9 (30) 7 (58) 17 (35)No 6 (86) 21 (70) 5 (42) 32 (65)Have been shown how toexamine own breast:Yes 0 (0) 23 (77) 7 (58) 30 (61)No 7 (100) 7 (23) 5 (42) 19 (39)Frequency self breast exam:At least once/month 0 (0) 3 (14) 4 (57) 7 (23)Once every 2 - 3 months 0 (0) 5 (23) 0 (0) 5 (17)Less often 1 (100) 14 (63) 3 (43) 18 (60)Pap Test done in past 2 years:Yes 2 (29) 25 (83) 9 (75) 36 (73)No 5 (71) 5 (17) 3 (25) 13 (27)Gave birth to child:Yes 1 (14) 25 (83) 11 (92) 37 (76)No 6 (86) 5 (17) 1 (8) 12 (24)Breastfed last child:Yes 1 (100) 20 (80) 4 (36) 25 (51)No 0 (0) 5 (20) 7 (64) 12 (49)Length of breastfeeding:1 - 3 months 1 (100)* 5 (25) 1 (33) 7 (29)4 - 6 months 0 (0) 4 (20) 2 (66) 6 (25)more than 6 months 0 (0) 11 (55) 0 (0) 11 (46)* New born babyConsiderably more women reported having a pap smear in the past year. Over halfhad the test in the past year: three-quarters in the past two years. The average age for134frequent testers was 35 years.There is a significant age difference in users and non-users of Oral Contraceptives(The Pill). Less than 20 percent of women use The Pill and are younger than non-users (25versus 35 years: T-test p < 0.003). Excessive body weight and tobacco use are risk factors inthe use of the pill. One Pill user was classified overweight (BMI 29) but was a non-smokerwhile other Pill users who smoked daily or occasionally had an average BMI of 23. In theseinstances, one of two potential risk factors were present.The majority of women who gave birth breast fed for 6 months or more. Only agemade a difference in this practice with younger women being more likely to have breastfedthan older women (30 versus 43 years: T-test p < 0.05). There were 15 children born in thepast 5 years (1986 - 1991) 13 of whom had been breastfed. This rate is roughly equivalent to9 out of 10 children being breastfed. Over half of these women said they breastfed for morethan 6 months. Children born before 1985 were more likely to be breastfed between 1 and 6months. One woman thought she might be pregnant at the time the questionnaire was beingapplied.Children's Health: More women than men reported on the health of a child aged 14 years or younger.(24 women; 16 men) However, sex did not make a difference in responses (see Table F19,page 242). Sampling technique ensured that children were not double counted and well andsick kids had the same chance of being selected in. About 30 families were represented, 26of which had 3 children or less under 14 years. These families had 64 children under 14years, 40 of whom were included in the survey. Primary caretakers included two parents,single parents, and grandparents. Single parents generally lived with parents, thus children135were also under the care of grandparents. The survey did not distinguish status of theprimary care taker.One-third of the surveyed children were considered sick with the most frequentlyreported problem being a cold (n = 7). The four children with dental problems includedthree under 2 years who also had a cold: these 3 were said to be teething. The ages of thechildren and proportions reported sick are shown in Table 24.TABLE 24Children Under 14 Years Included in the Surveyand the Proportion Assessed as SickAge Total (No.) Male(No.)Female(No.)Assessed SickNo. (%)0 - 12 Mo. 2 2 1 (50)1- 5 Years 11 6 5 4 (36)6 - 10 Years 9 10 5 5 (26)11 - 14 Years 8 6 2 1 (13)TOTAL 40 23 17 13 (33)An assessment of child functioning in the physical, psychological, and social domainsdistinguished the sick from the well. A functional problem is related to sickness if a highpercentage of adults identify the problem and a high percentage also considers the problemto be related to a sickness. In Table 25, this is observed for the child who seems sick andtired. Forty (40) percent of the children seemed sick and tired• half these children (50percent) were also thought to be sick.Functional assessments were unrelated to sex, age, education, or caregiver's ancestry.Though numbers are small, trends indicate parents consider some of the functional problemsto be the result of a sickness while others are not. For example, 75 percent of the childrendo not sleep through the night because of a sickness while only 10 percent react to things by136crying (Table 25). The three problems most frequently identified by parents include actingmoody, seeming unusually difficult, and reacting to things by crying. The responsible adultfrequently indicated these problems were the result of being spoiled. By comparisonfunctional problems resulting from a sickness include seeming sick and tired; and, beingirritable. The attributions of functional problems to a sickness may reflect, in part, therelatively minor nature of child sicknesses (e.g., cold, fever, ear infection, and dental/teethingproblems). The study did not include a 9 year old boy who had leukaemia and died duringthe latter part of the field work.TABLE 25Percentage of Caregivers Identifying Functional Problemsand Proportion of Problems Attributed to a Sickness (N = 45)Problems Percentage IdentifyingProblem (No. (%))Percentage AttributingProblem to Sickness (No. (%))Eat well 7 (16)* 1 (14)Sleep well 10 (22) 2 (20)Contented and cheerful 8 (18) 4 (50)Act moody 31 (69) 6 (19)Communicate what want 6 (13) 1 (17)Seem sick and tired 18 (40) 9 (50)Occupy self 17 (38) 3 (18)Lively and energetic 2 (4) 1 (50)Irritable 19 (42) 6 (32)Sleep through night 4 (9) 3 (75)Respond to attention 7 (16) 1 (14)Difficult 29 (64) 4 (14)Interested in what happening 6 (13) 1 (17)React by crying 30 (67) 3 (10)Note: 7 of 45 children (16%) did not eat well: Only 1 out of the 7 (14%) did noteat well because of a sickness.When controlled for sick kids (n = 13), Cronbach's alpha for the 14 items assessingspecific functional areas was 0.72. This score indicates the series of 14 questions had internal137consistency. That is, similar questions had similar responses (See Table 25 for 14 items).However, there was no correlation between the specific functional questions and all thegeneral health questions. These general health questions included visits to the doctor,general health assessment, degree of parental worry, and pain or distress experienced by thechild. Missing school days could not be assessed because of summer holidays. A testing ofrelationships between single general health questions and the 14 specific functional questionsshowed correlation only with the degree of pain or distress experienced by the child. Here,Cronbach's alpha was 0.75.Only six of the reportedly sick children were brought to see a Medical Doctor duringthe previous 14 days. At this time, two colds were diagnosed as bronchitis. During this twoweek period, children were more likely to be brought to the Community HealthRepresentative rather than the Health Nurse. Most visits related to obtaining medicine oradvice for a child with a cold. None of the children were brought to see a traditional healer.Long term assessment of the general health of the children was unrelated to acutesicknesses in a two week period. All of the children reported as sick had a health rating ofgood to excellent. On average, their health was considered very good. This child assessmentwas unrelated to the men and women's assessment of their own health. However, adultswho rated the child's health as good to fair tended to worry somewhat about the child'shealth. An 18 year old woman who rated her 1 year old son's health as fair worried a greatdeal about his health. In general, adults worried the most if the child had experienced painor distress in the previous 14 days or if they believed their child usually caught what wasgoing around. More women than men believed the child was able to resist sicknesses verywell. Few adults considered their child to be less healthy than other children regardless ofthe presence of a short term sickness.138This section on child health completes data summary for the general healthquestionnaire. In the following two sections, village health is the primary focus ofdiscussions. First, findings from the village meetings are summarized and this is followed bya summary description of the Key Respondent Questionnaire Finally, the Chapter iscompleted with field notes and a review of documents on health related matters.4.3 Focus Group Results: Summary ReportParticipants at two village meetings, referred to here as a focus group, involved bothmen and women between 20 and 75 years. These two hour meetings largely involveddiscussion of health experiences, health issues, and priority health concerns. Participants alsorated the present and future, desired health of the village.When discussing health experiences, both positive and negative terms are used. Froma positive perspective, a healthy person feels good about him/her self, has a positive attitudeabout life, is happy, and there is love present. In addition, the individual, family, and villageis strong and caring and help is available. Negative descriptors involve there being nophysical problem, no pain, "no drawbacks," and one is not miserable. Participants furtherdescribe being healthy in terms of the individual being able to do anything and taking part invillage activities.The sick experience involves being depressed, worried, alone, a burden to the family,and there is pain. A problem arises in describing level of sickness in that there is noagreement on what being really sick means. Some might take this to mean near death whileothers might simply refer to there being a need for medical attention by a specialist.Participants rated the health of their village as "fair" and in 2 - 5 years would like tosee improvement to achieve a "good" to "very good" rating. However, the health of people in139their village was rated as "good" when making a comparison to other Gitksan andWet'suwet'en villages.Health issues and concerns refer to matters that negatively affect health and need tobe resolved in order for level of health to be improved. Both groups identified numeroushealth concerns relating to the individual, family, and village. Time restrictions did not allowfor consensus development as usually occurs in this type of setting. Therefore, issues aregrouped under 3 headings, with the first considered the most important.First Priority: high level of unemployment;drug and alcohol addictions;lack of traditional healing;poor education - it is too easy for kids to drop out of school and not enough isdone to keep them in school;abusive behaviours;willingness to accept less than the best.Second Priority: drug and alcohol addictions;hours at the bar are too long - want to shorten with no sunday openings;there are no health goals to work towards;youth have a self-identity problem with conflict between Gitksan and Westernsociety;inadequate housing;unemployment;poor communication within and between families;physical health problems (described as physical breakdown).Third Priority: poor education - it is too easy for kids to drop out of school and not enough isdone to keep them in school;mental health problems;-^abusive behaviours;- poor communication within and between familiesThough not listed as a priority, concern was expressed regarding care provided by thelocal hospital and medical doctors. One opinion was that if a sick person goes to thehospital for help and is not admitted despite empty beds, then the hospital and doctors are140not doing their job. In addition, the doctors do not demonstrate sufficient care and concernfor the sickness experience of the people. They minimize the sick experience and tell thesick person to either come back in a week or to take an aspirin. There is also questionabout the extent to which prejudice results in poorer care being provided to Indian peoplewho form a majority of the population in the area.Possible means for improving health focus on the individual, family, and village. Forthe individual, there is a need for health education; improved communication and life/copingskills; support groups for both the young and old; and, prevention in alcohol, drugs, andgambling addictions. Healing in the family requires making home life a priority. Belief isthat if there is a strong home, people will feel good and this will extend into the village. Inorder to strengthen the village, members have to be directly involved in the decisionsaffecting their current and future situation. Specific activities to bring the village togetherinclude examples of inter-generational sports and social gatherings to acknowledgecontributions by members.4.4 Key Respondent Health Survey ResultsThe key respondent questionnaire was self-completed by 10 individuals, 7 of whomwere band employees: 5 Gitksan and 2 Wet'suwet'en. These individuals were selected on thebasis of their broad based knowledge of health related matters. Respondents include BandManager, Social Worker, Native Police, Pastor, Health Nurse, and Community HealthWorker (CHR).Respondents rated the health of the people in their village as being "good" incomparison to other Gitksan and Wet'suwet'en villages. However, people in the village wereseen to live in a fairly stressful environment. The primary source of stress was141unemployment and alcohol abuse. The second leading source of stress largely involves socialrelations and includes poor communication, physical abuse, and level of responsibility. Oflesser importance, but nevertheless a source of stress, are family breakdown, poor nutrition,lack of recreation opportunities/ facilities, and lack of privacy coupled with gossip.The 10 major health-related problems in the villages are seen to be: alcohol and drugabuse; poor nutrition; emotional illness; abusive behaviours; family planning and birthcontrol; chronic illness due to old age; mental health problems; poor housing conditions; and,incidence of violence. When weighted, the five top priorities from highest to lowest are:alcohol and drug abuse, poor nutrition, emotional illness, abusive behaviours, and chronicillness due to old age. Although alcohol and drug abuse is consistently identified as a majorhealth related problem, alcohol abuse is thought to be more serious than is drug abuse. Useof drugs such as marijuana and hash is viewed as a fairly serious problem.Most respondents consider there are health needs in the village that are not beingmet. The major unmet need concerns counselling in both alcohol and drug abuse and inmental health. Additional needs relate to care for the elderly and family supports as well asa general need for health education. There is general agreement that there are no healthservices or programs that could be reduced. However, all believe there are programs andservices that could be enriched. Areas requiring enrichment involve counselling for drug andalcohol abuse as well as mental health. There is also a need for improved recreationalopportunities and more workshops in health education.While voluntary self-help groups do exist, the most frequently cited example isAlcoholics Anonymous. There is also a weight watchers group and a support group forindividuals affected by lupus and arthritis. Social support groups also exist for young moms,women, and youth. Band members will travel to another village to attend an Alcoholics142Anonymous Group meeting, however, most respondents did not know if band members doattend other types of group meetings in neighbouring villages.4.5 Field Notes and Documentary ReviewIn this final section, the intent is to provide additional information on both healthconcerns and current health programs and services available to the study population. Asplanning is undertaken to respond to identified needs, a comparison of existing services toidentified needs demonstrate areas for potential action. Source of data include field notes aswell as a limited number of health related documents. These field notes have a journalformat and consist of descriptions, impressions, and summary of informal discussionsregarding health. Unfortunately, there was a distinct lack of documented health informationavailable, or where available, proved inaccessible.Regarding personal health, there is a particular concern about the prevalence ofarthritis, lupus erythematosus and cancer. This village concern is seen in a "Submission tothe Royal Commission on Health Care and Costs" where a call is made for a study todetermine the probable [causes] contributing to the high prevalence of diseases such as lupusand cancer (Gitksan Wet'suwet'en Government 1990). At the time of this study, a workingmember of the Lupus Support Group indicate there are 12 known cases of lupus in the area,9 of whom are from Gitksan villages and two from non-Indian communities. Most diagnosisoccurred in the past 5 years though there is one known case with a 10 year history of lupus(Per Community Health Worker).When lupus became a known health problem, people at first thought the conditionwas arthritis "coming on" and it took years for the doctors to pinpoint the problem. Affectedpeople became highly frustrated because they went to the doctor frequently and began to143think the problem was in their head because the doctor could not identify the problem. Nowit is felt the doctors will readily diagnose lupus. At present, it is not unusual to find morethan one family member with lupus (e.g., father and daughter).Beliefs about the possible cause of lupus vary. Some people talk about how thedisease first became known following the presence of an affected woman from anothercountry who was visiting in the area. A Gitksan-Wet'suwet'en man describes the start pointof the disease with a time, five years previous, when he was working in the local forest andobtained what he thought to be a bug bite on his chest. Following this incident, "two smallbruises" appeared on his chest and remained for several months. Another Gitksan man witha diagnosis of lupus experienced extensive progression of the disease. He believes hisdreams saved him: he dreamt of a large steel hypodermic that he associated with penicillinhe received as a child. He was able to convince the doctors that he needed penicillin totreat his sickness. He received "massive" doses of the drug and subsequently recovered.Today, some people are questioning if the real problem is Lyme Disease brought on by abite from an infected deer tick.The extent of the problem of arthritis is seen in the Gitksan study village whereeight people have rheumatoid arthritis and two have arthritis (per Community HealthRepresentative). In the Wet'suwet'en village, there is one woman with rheumatoid arthritisand another with arthritis, both of whom are disabled with the disease. It is not uncommonto have unaffected family members exhibit some degree of anxiety about developing thedisease. In some cases the unaffected member seems fatalistic about getting arthritis becauseit is in the family. One unaffected, middle-aged man said he has taken to wearing gloves incold weather to delay or prevent onset of the disease.Though there were no reported cancer cases in the study, there is considerable144concern about an apparent increase in cancer related deaths. The most recent was a nineyear old Gitksan-Wet'suwet'en male child who had leukaemia.When an individual becomes sick, they generally utilize health services at the localhospital. Wrinch Memorial hospital is owned by the United Church of Canada. TheHospital has 28 acute and 4 extended care beds and has 6 salaried physicians, medicalstudents, and visiting specialists. Associated with the hospital is a Dental Clinic and MentalHealth Services. The Dental Clinic has 2 full time dentists and one dental hygienist andMental Health Services has one full time and three part time counsellors.Mental Health Services is primarily funded by Provincial Health with the FederalGovernment providing approximately one-third of the funding through a fee-for-servicearrangement. Four Gitksan and Wet'suwet'en villages are party to this agreement, with acounsellor spending about one-half day per week in the village. People from the fourremaining villages, including the two study villages, obtain services within the hospital setting.Often, people prefer to go to the hospital because of concerns about confidentiality.Generally, villages that make the most requests for services receive the most. The presentingproblem for both the non-Indian and Indian community is alcohol abuse, however, underlyingproblems are said to include dependencies, sex abuse, and family violence. Local villagepriorization of workshop topics for 1991-1992 identify family violence, parenting, self-esteem,self-healing programs, and teen programming as areas of need (Halkett 1991).Village people attempting to deal with their alcohol problem have the choice ofattending a Treatment Center in the local area or at other sites in the Province. This Houseof Purification focuses on the individual, has 16 beds, provides a six week program, and has atwo month wait period. Other Treatment Centers in the Province have about a three monthwait period, with at least one having a family orientation. The House of Purification145provides limited follow-up because of staffing constraints and the large geographic servicearea. Problem rests in measuring success following attendance at the Center because of adefinitional problem regarding success. Generally, it is felt that a return to drinking is not afailure because people have acquired other skills. The two study villages have access toalcohol counsellors through the Community Access Program that is currently being evaluated.Both villages are requesting their own, on-site counsellors (per Director, House ofPurification; Community Access Program Counsellor).Informal care for the sick and troubled is also provided within and by the village. Anexample is the sweat lodge in a Gitksan village that is receiving increased usage despite itbeing an adapted Cree practice. In addition, an Elders Group and a Family Support Servicewith elder input seeks to address health and social matters in the villages (per CommunityHealth Worker).Perceptions of accessibility to services directly affects who seek and receive care innon-Indian settings. With regards to hospital services, a visiting 64 year old Carrier womanrefused to see a doctor for a bladder infection because of her overriding fear of encounteringencountering discriminatory behaviour from a doctor she did not know and trust. Rather,she chose to travel several hours by car to reach her family doctor whom she knew wouldtreat her well. By the end of her journey, the bladder infection extended into the kidneysand required lengthy bed rest and medication. In this case she chose to risk her healthrather than risk discriminatory and potentially lower quality care. Another case involves thegrandchild from the Wet'suwet'en study village. The 19 year old girl receiving an abortion atMills Memorial Hospital in Terrace had her uterus perforated and, because of delayedtreatment, subsequently died from complications resulting from haemorrhage. This case iscurrently being investigated by the B.C. College of Physicians and Surgeons (Bell 1992). The146family of the deceased girl indicate the Surgeon in question was known to relate to Indianpeople in a "cold" manner.4.6 SummaryThe Gitksan and Wet'suwet'en have a wholistic conceptualization of health. They saythey are strong and well when they are able to do anything. This state is accompanied by apositive sense of well-being. Conversely, when sick or unwell the individual can't do whatthey want, are depressed, feel isolated, and feel they are a burden to their family. Thesefindings correspond with the self-assessment of health where people limited in the kind ofamount of activity they could engage in rated their health as "poor" or "fair " The presenceof a health condition alone did not make a difference to self-rating of health, the exceptionbeing problems with the joints or bones.Findings from the General Health Questionnaire show distinct problem areasincluding risks for nutrient inadequacies; excess body weight with an associated risk of heartdisease, hypertension, and diabetes; high rate of tobacco and alcohol use; dental health; and,mental health. Data from other sources show marked agreement in areas of need includingMental Health Services, health education, initiatives to deal more effectively with theproblem of alcohol abuse, family and social supports, poor nutrition, and unemployment. Inthe following chapter, these findings and issues are discussed within the context of change tobetter address health issues and so improve experiences of wellness and well-being.147CHAPTER 5.0DISCUSSIONToday, Indian people in B.C. and all of Canada are faced with opportunities tochange their health programs and services. However, these changes must be soundly basedon health beliefs and current health status to ensure some degree of success in healthimprovements,. This study provides some baseline health information that can contribute tosuch a movement for change in the two study villages.Change takes on a special character in Gitksan and Wet'suwet'en territory in light ofthe meanings and interpretations they, themselves, attach to health. Indeed, these viewssupport a process for change that centers upon the strengths of traditional health relatedbeliefs and practices. While these findings have merit in and of themselves, this writeracknowledges that initial descriptions of the Gitksan and Wet'suwet'en views on the healthexperience necessarily risks over-simplifying a complex issue. However, such a risk isnecessary to begin exploring this uniquely cultural experience.In this Chapter, discussion of study results first focus upon the Gitksan andWet'suwet'en views on wellness and well-being. Particularly significant is the wholisticconceptualization that incorporates body, mind, and spirit at the personal level but alsoextends to the family, house/clan, tribal group, and, ultimately, the land itself. From anwholistic perspective, interconnectedness is critical because expressions of wellness are notlimited to self but include significant others. This wellness experience may be strengthenedand protected according to unique beliefs and practices. However, wellness may also beweakened and ultimately, sickness results. Both formal and informal responses to the well,unwell or sick experience constitute the [health] care system.The second major area of discussion focuses on results of the health survey. In this148discussion, four categories in the Diamond Model provide a framework for organising factorsthat affect health status (see p. 18). The categories in this epidemiological model are: (1)constitution/ genetics, (2) life-style/behaviour, (3) social and economic factors, and (4) healthcare. These findings are compared and contrasted with health data for Canadians and othernative Indians where ever possible.The Chapter finishes with brief discussion of existing health services and gaps inservices. The following Chapter summarizes findings, and identifies main conclusions of thestudy as well as implications to health care and future research.5.1 Wellness and Well-beingHealth semantics, or the way people talk about and view their health experienceconstitute a key element in the health care system. Health related words and how they areused to communicate a concept are society dependent. From this perspective, one of theinadequacies of the dominant medical model is a failure to extend the medical languagebeyond a technical, diagnosis based system to reflect the experience and beliefs of healthcare users (Good 1977). In order for health care to be successful, it must reflect the valuesand be responsive to the belief system of the service users. This is especially true to theGitksan and Wet'suwet'en society.When the Gitksan and Wet'suwet'en people speak of their health experience, theyspeak of being well, unwell, or sick: the active term "healthy" is also frequently used. Theaffective component is expressed as a sense of well-being, either positive or negative. Theseexperiences, however, are seldom spoken of in isolation but rather also refer to and areinfluenced by social reality and extend from the personal to the land itself. According to thisperspective, the Gitksan and Wet'suwet'en have an internal (personal) and external149(environment) conceptualization of wellness and well-being that are inextricablyinterconnected. This internal and external view constitute the wholistic nature of the healthexperience.From an individual perspective, "wholistic" refers to the whole being and comprises amental-physical-spiritual complex. This spelling form clearly reflects the Gitksan andWet'suwet'en references to the whole being and contrasts with the common, mainstreamform - "holistic" (LeShan 1984; Alster 1989). Though depicted as distinct entities (Figure 5,page 71) the whole being is a single unit. This integration is seen in the above references tothe whole being as well as traditional healing practices where the halait or Indian Doctor,while operating from the spirit level, institutes a healing process that involves the body, mind,and spirit.In mainstream society, the holistic movement is seen as something new and offers amultitude of teachings and activities to improve health. Both conventional and exoticresponses in this movement include, for example, fitness, nutrition, homeopathy, andnaturopathy, to name only a few. These practices operate from similar sets of beliefs andgoals where the holistic perspective considers an individual to be more than a sum of itsparts: a human being is a whole and any threats to that wholeness will cause him/her tosicken (Leshan 1984; Alster 1989).Increasingly, these conventional and exotic responses to the wellness movementappear on the market. However, consumers are warned of possible bogus claims that haveno scientific basis and where motivation may be pure profit. In a health care system whereresources are finite, it becomes critical to evaluate both practitioners and procedures toensure claims are valid. Safe-guards may include requiring practitioners to be part of aprofessional body and to have a recognized, sound scientific background (LeShan 1984).150Further safe-guards may include analysis to determine if teachings and practices conformwith traditional beliefs and values.Though the holistic movement claims to view the individual as whole, references toones being necessarily speaks of parts: body, mind, or spirit While the spirit is consideredan integral part of being, little is said about how spiritual breakdown shows itself as a healthproblem and how it can be treated. Often, it is considered in conjunction with thepsychological aspects of being. Proponents also consider human wholeness to be the normalstate, however, activities focus on moving an individual toward wholeness or a greater degreeof wholeness (Alster 1989).Similarities and differences are found in the Gitksan and Wet'suwet'en experiences.Study findings show the individual consists of a mental-physical-spiritual complex, however,the spirit constitutes a dominant force that interconnects the individual with theirenvironment Another area of difference relates to the spiritual nature where problemsmanifest itself in distinct and negative physical experiences that, if left unattended, couldeither result in a sickness of increasing severity or even death.Today, when the Gitksan and Wet'suwet'en people speak of being well, they relatethis to an ability to do what one wants to do. This concept implies a goal setting and goalachievement orientation with a strong physical or functional component and is distinct from aview of health as an absence of disease. According to this perspective, people with activitylimitations rated their health lower than those with no limitations. In addition, presence of achronic health problem alone was not sufficient to negatively affect perceived health. Thissuggests perceived seriousness of a health condition may be related to the extent to which itinterferes with an ability to do things.This experience of being well reflects the notion of balance or harmony within all151aspects of being. Such a view must be distinguished from the wellness movement thatextends from mainstream holistic perspectives and form a central part of Canada's HealthPromotion initiatives. The operating premise in Health Promotion is the individual isresponsible for their own health state and if the correct decisions for self-care are made,health and wellness will improve. Examples of morally correct choices include eating a lowfat diet, exercising regularly, and not smoking (Labonte and Penfold 1981; Dexter 1988).These wellness promoting initiatives hinge upon education regarding best possible choices.However, adoption of this Health Promotion initiative in search of wellness poses problemsto people such as the Gitksan and Wet'suwet'en. In their case, and many others, socialreality does not support what is considered the best choice and can potentially create anothervictim-blaming episode. Examples of underlying inequities include a lack of physical exerciseopportunities and recreational facilities, lower educational achievements, loweredemployment potential and attendant poverty. These and other social and political inequitiescreate an environment that do not support mainstream health promotion initiatives despiteits sound and even noble goals of increasing wellness (Small 1989; Leichter 1991; Labonteand Penfold 1981)."Wellness" and "well-being" are current buzz words that crop up repeatedly in healthcare today. At present, writers and researchers advance the notion that health and well-being are associated but distinct experiences (Nordenfelt 1987; Herbert and Milsum 1990;Alster 1989). This also appears to be the case for the Gitksan and Wet'suwet'en peoplewhere interchange of words and word usage suggests that while wellness and well-beingoverlap, they are two distinct experiences. For example, the statement "I am in difficultywith my well-being" suggests well-being is equally important.Being well is usually associated with a sense of positive well-being. The Gitksan and152Wet'suwet'en may refer to their physical side feeling strong and good, they are happy, feelgood about themselves, and are at peace. Though happiness describes the state of wellness,it does not appear to be either a necessary nor sufficient cause for being well. Put anotherway, happiness can occur in either the presence or absence of being well. One Wet'suwet'enwoman says that though happiness is important it is not an essential part of the wellnessexperience. She says "... I guess our ancestors didn't dwell so much on being as happy asworrying about day to day existence and preparation of food for the winter." According tothis description, where survival was a goal, the ability to carry out family and socialresponsibilities was more important than whether one was happy carrying out those duties.Today concern for survival is less an issue, this possibly changing the value or importance ofhappiness in the well-being experiences.These concepts of ability and happiness are discussed in detail by Nordenfelt (1987).In his works, he proposes a holistic, welfare theory of health where, in a given set ofcircumstances, an individual is able to achieve their "vital" goals. Within this context, vitalgoals incorporate meeting basic needs (e.g., food and shelter) as well as achieving life goalsthat are set during the course of a lifetime (e.g., an athlete strives to win a medal). Thesevital goals "... are those states of affairs the realization of which are necessary and jointlysufficient for his minimal [happiness]." 16 According to this theory, some minimal level ofhappiness is part of goal achievement, with both standard circumstance and minimalhappiness determined by a society. Where sickness is a complement of health, he furthersuggests that a person is sick to some degree if there is some vital goal that is not achievable16. Lennart Nordenfelt, On the Nature of Health: An Action-Theoretic Approach, edited byH. Tristram Engelhardt Jr. and Stuart F. Spicker (Boston: D. Reidel Publishing Company, 1987),145.153under a specific set of circumstances.This [wholistic], welfare theory of health may have relevance to the Gitksan andWet'suwet'en since considerable value is attached to being able to do anything, includingbeing an active and contributing member of a family, house/clan, and society. Such a socialcontext of wellness and well-being necessarily extends the concept into the economic,political, and educational spheres where inequities in Canadian Society may inhibitachievement of life goals that extend to mainstream society (Frederes 1988; Speck 1987) .When these goals are or remain unattainable, well-being may be negatively affected and, atthe very least, result in some measure of unhappiness. Despite its apparent merit andrelevance to Gitksan and Wet'suwet'en, the theory needs further exploration in research.A critical question asked by a First Nation man regarding health was: "What makes aperson healthy and what is it that keeps that person healthy?" 17 This question potentiallyfinds its answer in a traditional view of wellness where cultural beliefs and practices aredirected at both strengthening and protecting an inherent quality found in humans. That is,a person is born with the potential for being well but must comply with cultural laws andpractices to strengthen that attribute. Such efforts maintain wholeness, balance, andharmony.Wellness may be strengthened by attending to physical, mental, and spiritual needs.Examples of these needs include consuming a nutritionally adequate diet; getting adequaterest; practising good hygiene; working hard and productively; feeling good about one's selfand personal achievements; and, respecting all forms of life this including human beings,17. This question was posed during discussions at the Health Transfer Conference held inMontreal in 1987.154plants, and animals. This law of respect constitutes an important part of spiritual wellnessand it is said that by strengthening the spirit, the mental side is also strengthened.The process brings a person to a natural or normal state where one is then able to do whatone wants to do. Aside from spiritual beliefs and practices unique to this study population,these practices are consistent with many described in the holistic movement (Leshan 1984;Alster 1989).Being well is considered a natural state and when well, the objective becomes one ofprotecting wellness. Personal responsibility is an important part of wellness protection,however, individual choices are respected and, in a sense, one is free to be foolish. Whereintervention is called upon because "the right thing" is not being done, such action isundertaken in a spirit of caring.In some respects, wellness protection beliefs and practices compare to some healthpromotion activities in mainstream society. One of the characteristics of health promotion,and perhaps the source for greatest criticism, is the future orientation of outcomes that aredifficult to measure. For example, the public is exhorted to refrain from smoking tobacco toprevent lung cancer (Dexter 1988). In Gitksan and Wet'suwet'en society, an example of acomparable health protection activity involves training of youth by elders. Intense repetitionconstitutes part of this training and in many cases is prefaced by the remark "If I didn't careabout you, I wouldn't be saying this to you."Presumably, training will have prepared adults to carry out their responsibility forprotecting and maintaining their wellness. Unfortunately, this is not always the case. Inmany instances, social and mental health problems as well as poor coping skills are attributedto residential school experiences. It is not uncommon to hear residential school attendeesbeing referred to as a "lost generation." People taken from their family at age 6 and kept in155Residential Schools for several years had limited if not incomplete exposure to their culturaltraining. The consequences of these loses are not restricted to former students themselvesbut extend into future generations (Moran 1987).A loss of a sense of well-being, regardless of its cause, represents a movement awayfrom a desired or natural state. This shifting from the desired state is often described as adownward movement. In this paper, this downward movement is described as a weakeningof a former position of strength. Thus, wellness and well-being may be weakened, thisresulting in an unwell and/or sick experience. In either case healing is required.Factors that detract from wellness and well-being experiences relate primarily tonegative mental and spiritual experiences, conditions or attributes. In addition, failure totake care of physical needs will also detract from the wellness experience. All of thesefactors threaten wholeness or a position of strength. This often results in a sickness.Today, when Gitksan and Wet'suwet'en people consider themselves sick, theycommonly seek help at the local hospital. Problems associated with this medical care systemare well documented by many authors, most recently by Rachlis and Kushner (1989). Itappears that, from a Gitksan and Wet'suwet'en perspective, one of these problems relate tohealth care workers, especially doctors, focusing on a specific part of the body to theexclusion of the whole being. This is seen in the case where kidney failure was a sole focusof attention, this possibly contributing to an untimely death. In addition, respect shownduring interpersonal communications, especially with the sick has a direct effect on a sense ofwell-being. Though most physicians operate under real time constraints and heavy workloads, nevertheless, caring and consideration of subjective health experiences as well as thesick's expectations regarding modes of care/treatment constitute essential components ofresponsive health care. Within this context, access to health care will be influenced by either156perceived or real prejudiced attitudes and behaviours of health care workers. Where accessto care is delayed because of an unwillingness to have to deal, once again, with prejudice, thesickness or disease may progress. Progression of a sickness or disease will affect recoveryrate and costs, both financial and human.These findings that relate to health meanings are extended in the following sectionwhere health status is discussed and comparisons made to other studies.5.2 Health StatusAn unavoidable consequence of conducting a health study is the sickness experience isfocused on rather than the positive health experience. Though this focus has the potential ofpresenting a bleak picture it remains a necessary process in identifying health problems.These clearly explicated health problems establish a basis for initiating health care responsesto effect change and so improve the health experience in the study population.In the following section, findings are organized and discussed according to the fourcategories that make up the Diamond Model (page 18). This framework organizes factorsaffecting health into the following categories:(1) Social and economic factors including cultural background and up-bringing, place ofresidence, education, and income and employment status;(2) Genetics/constitution including sex, hereditary disease, and changes resulting from theeffects of aging, stress, nutrition, and disease;(3) Life-style factors including diet, smoking, alcohol consumption, physical activity, andchoices relating to peers or reference groups; and,(4) Health Care Services including use of diagnostic, curative, and preventive aspects ofcare as well as health education and promotion, and screening.1571. Social and Economic Factors: A subjective evaluation of current health constitutes a key variable in this study withthe expectation being that at least 40 percent of respondents would rate their health as "fair"or "poor." However, it was found that 22 percent rated their health in this manner.Hypothesis testing according to local explanations for the wellness experience provides partialexplanation for the lower than expected rate of health assessment as "fair" or "poor".Study findings show people rated their health lower if they had trouble with bonesand joints and/or were limited in the kinds or amounts of activities they could engage in. Thisreflects local views on the health experience where one is well or healthy if one has theability to do anything. Of note however, are findings that neither pain nor happiness andinterest in life made a difference in health rating. It is possible that happiness and pain arepart of but not conditional to the well or unwell/sick experience.Health ratings in this study as "fair" or "poor" (22 percent) compare to findings for aCree study group in northern Ontario (22 percent) but is lower than for a Nuu-Chah-Nulthgroup on Vancouver Island (47 percent) and is higher than for the Canadian population (12percent) (Young 1982; Per Simon Reed, Manager Nuu-Chah-Nulth Health Board; Healthand Welfare Canada 1988, page 31) This comparison suggests considerably more Indianpeople experience lower or poor health in comparison to the general population. Thiscomparison also suggest the Nuu-Chah-Nulth may be worse off. What is not clear, however,is the basis for these self-assessment (aside from the subjects in this study).Loss of human potential in a society is seen both in total hospital days as well bed orcut-down days. In this study, between 15 and 20 percent were not able to achieve their fullpotential because of a sickness or disability. Of particular note are the number of cut-downdays associated with accidents resulting in back injury. About seven of the twenty-two people158who cut done on their normal activities had an accident or injury, five of whom developedback problems. This suggests back-injury prevention may be one area to focus on tomaximize human potential and, perhaps more importantly, to improve well-being.A well recognized factor affecting overall health is that of social support systems.Within this context, a social support consists of resources provided by other persons. Thesesupports act to both enhance the health experience and protect against the harmful effects ofsickness and stress (Cohen and Syme 1985). In this study, it was not surprising to find thatrespondents had more family members they were close to than friends. This is expectedgiven the extended family relationships in the villages. Of note is the finding that womenfrom other tribal groupings (e.g., Carrier, Staloh, etc.) had fewer family members that theyfelt close to, and, generally, women tended to have less friends. Such a restricted socialsupport system may place women from other tribal groupings at some risk.In Gitksan and Wet'suwet'en society, support systems occur at several levels. In thesesocieties, the house and clan form the central units for social organization. Both publisheddata and field observation clearly demonstrate responsibilities of a mother-clan and father-clan in the event of death. By way of explanation, if a Fireweed clan member dies, themother-clan is Fireweed and the father-clan might be Wolf or any other clan. These clanroles and responsibilities are clearly distinguished at a death feast (Glavin 1990). From acommunity perspective, "rallying" to provide assistance and support in the face of tragedy wasapparent in a drowning incident involving a non-Indian child. In addition, interviews in thisstudy show where family responsibilities rest during a sickness. Less clear, however, are theresponsibilities and roles of the house or clan members at the time of a sickness, though it isrecognized there are both. These roles and responsibilities would have to be distinguished asinitiatives are undertaken to improve wellness and well-being in an wholistic manner159Potential sources of social support also include voluntary and support groups. Whilemany of the respondents indicated they were a member of some type of group, few attendedregularly. In addition, participation in committee work seemed to be restricted to peopleover 35 years or members with highest levels of education. As community resources aredeveloped both participation and leadership by all segments of society need to be developedto maximize potential contributions of society as a whole.Sex made a difference in negative well-being experiences with women being moretroubled by lowered energy levels, feeling sad, tense and lonely. Where thoughts of suicideprovide an extreme indication of negative well-being it is also significant that more womenthan men entertained thoughts of suicide. However, attempts were unrelated to sex, age, orancestry.Study findings suggest women are at greater risk than men. Women tend to havefewer social supports; are less satisfied with their relationship if married or living withsomeone; have a more pronounced feeling of lowered well-being in specific areas; may bemore prone to having thoughts of suicide; and may be more likely to attempt suicide.However, acceptance at face value may be erroneous. It is possible that women are moreaccustomed to assessing their condition and talking about it than men. A purely unscientificand intuitive interpretation of male responses to sensitive items in the questionnaire suggestmen tend to give socially acceptable responses. These factors were explored in detail byBriscoe (1982) who shows that men and women express feelings and symptoms differently.While applicability of findings to Gitksan and Wet'suwet'en is justifiably questioned,nevertheless, sex differences in expression must be considered as responses too mental healthissues are instituted. Accordingly, it would be safer to assume that men and women havecomparable need.160These diminished well being experiences by women correspond with other findings inthe literature. In B.C., where suicide rates are 3 to 5 times higher than the generalpopulation, suicide events show women are more likely to attempt suicide than men (Cooper,Karlberg, and Adams 1991).Increasingly, reports on the health of Indian people in Canada show mental health tobe a major concern, with health system responses generally considered inadequate (Assemblyof First Nations 1989; Health and Welfare Canada 1988). The Gitksan and Wet'suwet'enprovide an additional case in point. In this study, field notes, in-depth interviews, andquestionnaires show many references to mental health concerns, including poor coping skills,poor or inadequate communication skills, family violence, and unresolved grieving. Wherefeelings experienced in the previous 12 months provided some indication of well-being, thisstudy shows that about 40 percent of the respondents experienced some form of negativewell-being. However, 7 percent appear to be most troubled by frequent feelings ofexhaustion, sadness, tension, unhappiness, and isolation (being unloved). Though MentalHealth Services at Wrinch Memorial Hospital provides counselling services to village people,several concerns seem to affect accessibility. These concerns include distance to the hospital,availability and expertise of counsellors, and need to keep personal problems private.Other social and economic factors over which one has limited control includeemployment, education, and structure of a family unit. These factors pose risk to both thewellness/health and well-being experiences and must be considered as planning initiatives areundertaken. In this study, about 60 percent of men and women have less than a Grade 12level of education and only 22 percent are fully employed (i.e., work at least 10 out of 12months). Approximately 10 percent of households with children are single parent familieswith three out of four headed by a woman under 35 years.161Child health was determined through reports by parents, grandparents, and fosterparents. In this study, it was found that one-third of the children reported on wereconsidered sick with the sickness being relatively minor in nature (an exception is two kidswith bronchitis). The series of 14 questions relating to functioning in the physical,psychological, and social domains successfully identified sick kids. Despite a statisticallyacceptable test for internal consistency, the relationship of lowered functioning to a sicknesswere somewhat weak this possibly reflecting the relatively minor nature of the sicknesses.Over the long term, the health of all children was rated as very good.2. Genetics and ConstitutionIn this study, sex and ancestry rarely made a difference to findings. Where hereditywas a factor, it appears that Gitksan may be more prone to developing arthritis, obesity, andhypertension. Literature shows arthritis has a known heredity component and obesity isinfluenced by heredity. In addition, hyper-tension is commonly associated with obesity(Young 1991; Atkins et al 1988; Bouchard, Perusse, Leblanc, Tremblay, and Theriault 1987).Sex made a difference largely in relation to mental health and drinking patterns.With respect to overall health status, a particular area of concern relates to the highoccurrence of hearing problems in the younger segment of the population. People under 25years were as likely to have a hearing problem as people over 46 years. However, few havea hearing aid. Respondent straining to hear in a quiet room suggests they may be over-estimating their hearing capability. More people may need hearing aids than were reported.Self-reporting is commonly used in determining prevalence of health conditions in thepopulation and is also accepted here as an indication of the magnitude of health problems.Though self-reporting of chronic conditions raise questions regarding reliability, in part162because questions or conditions may not be understood, one study among B.C. sawmillworkers suggest that reliability in self-reporting of some chronic conditions (e.g. arthritis andhypertension) is good (Teschke, Hertzman, Hershler, Wiens, Ostry, and Kelly 1992).In this study, the occurrence of chronic health problems in the 45 years and overgroup parallels that occurring in the general population as well as other Indian groups inCanada. These include circulatory problems and high blood pressure (Health and WelfareCanada 1988; Rachlis and Kushner 1989; Young 1991). Tentative comparison of knownCree and Ojibwa hypertensives in northern Canada to this study group shows some similarityin prevalence (Cree/Ojibwa, 14.6 percent: Gitksan/Wet'suwet'en, 18 percent). Young (1991)concludes the Cree and Ojibway have a higher prevalence of hypertension compared to theCanadian population. His study also links hypertension to obesity and parental history, ashave other studies (e.g., Dustan 1985). This association is also seen among the Gitksan andWet'suwet'en between 20 and 65 years: people assessed as obese (Body Mass Index over 27)had the highest reporting of hypertension (11 of 16 cases, or 69 percent).Other chronic conditions that are of concern to the Gitksan and Wet'suwet'en includearthritis (16 percent) and systemic lupus erythematosus (12 in a population of 3,500). Theextent of the concern is seen in the call for investigation into a possible cause for the highrates of these two conditions. In this study, there are indications that people with Gitksanancestry may be at greater risk than the Wet'suwet'en for acquiring both arthritis and lupus.A Vancouver Island, Nuu-Chah-Nulth study on Rheumatoid Arthritis show a prevalence rateof 1.4:1000, this comparable to other north American Indians (Atkins, Reuffel, Roddy, Platts,Robinson, and Ward 1988). Though the Gitksan and Wet'suwet'en report what appears tobe a higher prevalence of arthritis, it is not possible to draw conclusions because of differingstudy methodology (e.g., self-reporting versus retrospective study). These Vancouver Island163people also report a 0.5 percent prevalence of systemic lupus erythematosus, this alsocomparable to other Indian groups. A crude estimate of prevalence for Gitksan andWet'suwet'en suggest their rate may also be comparable. While there is no known cause forlupus, research shows there are hereditary and environmental factors involved (Morton,Gershwin, Brady, and Steinberg 1976).Often, the health status of Indian people is compared to that of Third WorldCountries because of high rates of infant mortality and death rates from infectious andparasitic diseases (e.g., Postl 1986). Increasingly, it is becoming apparent that chronic healthconditions of Western society are affecting Indian people in comparable or, in some cases,higher rates than the general population. This suggest Indian people are experiencing theworst health conditions of both worlds.3. Life-Style FactorsToday, it is generally recognized that life-style choices are an important contributor tooverall health status. These choices relate to tobacco and alcohol use, physical exercise,nutrition, and dental health. In this study, all of these choices pose some risk particularlywhen findings are related to cause-effect studies found in the literature. However, whenassessed according to the Gitksan and Wet'suwet'en views where health/wellness is attributedto ability, there may be a perceived lower threat than literature would suggest.Tobacco use has a long standing and well documented linkage with lung cancer(Collishaw and Myers 1979). In this study, it was found that there are twice as manysmokers among the Gitksan and Wet'suwet'en (64 percent) as there were in the 1990 generalCanadian population (32 percent). This Canadian telephone survey also showed B.C. tohave the lowest prevalence of smokers: 28 percent (Health and Welfare Canada 1991).164Highest tobacco use occurs in the 15 - 24 year age group. This risk group and similarproportions of daily and occasional smokers indicate possible areas for action to decreasethis risk behaviour. Here, action may focus on shifting the occasional smoking category intonon-smoker groups, with education and peer pressure comprising possible thrusts in theinitiative. These initiatives must necessarily consider the potential harm of smoke in theenvironment as well as access to the product.Beliefs relating to alcohol use are the most perplexing. Overall, people seem tounderestimate the potential harm of alcohol and consider it normal to drink regularly. Thisbelief system may be a critical factor for women in child-bearing years who may drinkinfrequently but still may pose harm to a developing fetus.About eight out of ten (76 percent) Gitksan and Wet'suwet'en currently drink alcohol.This is directly comparable to a 1989 Canadian telephone survey which showed that 78percent of adult Canadians are current drinkers. However, in B.C. there were more drinkers(83 percent) in the general population (Health and Welfare Canada, 1990d). There are alsodifferences in quantity of alcohol consumed. When compared to the 1989 Canadian drinkingpattern of 3.8 drinks per person, Gitksan and Wet'suwet'en men and women consumedabout twice as many drinks per person (Health and Welfare 1990d).In this study, the term "normal" drinking was left to the respondent to define.Generally, those who reported their drinking pattern as not normal compared their habit tofriends or parents. As important are the beliefs relating to ability to control drinking andsocial pressures that influence decisions to reduce alcohol intake. Alcohol users at highestrisk for potential harm include men between the ages of 25 and 34 years. All of thesefactors, including the effectiveness of existing support and treatment systems (e.g., AAsupport groups, counsellors, and treatment centers), must be considered as the problem of165alcohol use and abuse are addressed in the villages.About one in five reported accidents involved alcohol. This is particularly troublinggiven the high rate of deaths among Indian people due to injury and poisoning: between1980 and 1984 the B.C. rate for status Indians was twice as high as for the generalpopulation. Studies suggest that alcohol is a contributing factor (Health and Welfare Canada1988). More relevant, perhaps, is the real pain and sorrow expressed in the villages whererecent and past tragic, untimely deaths are directly attributed to the effect of alcohol.An additional health risk relates to excess body weight, this directly linked to physicalactivity and food intake. In this study, obesity was assessed through calculation of Body MassIndex with risk determined according to categories established by Health and WelfareCanada (1988a). According to this assessment, about half the men and women between theages of 35 and 65 had a Body Mass Index of 27 or greater, this placing them at risk forhypertension (high blood pressure), diabetes, and heart disease.It appears men are unclear about what an adequate level of physical activity is, whatweight range is most appropriate for them (judged according to calculated BMI based ontargeted weight), and the importance of food intake to overall health. In addition, thepossible effects of heredity on level of obesity may be seen among the Gitksan who tend tobe larger than the Wet'suwet'en. Energy intake alone does not offer a tentative explanationfor excess body weight as total calories consumed tended to be comparable to or lower thanrecommended amounts. However, low activity levels coupled with an inheritedpredisposition may be contributing factors. This influence of heredity has been welldocumented and is seen most recently in a study by Bouchard and Tremblay (1990).When addressing the health risk associated with obesity, these above factors suggest atarget group might be men and women 35 years and over, with particular attention directed166to educational needs of the men. However, prevention must start in the younger age groups.This necessarily ties in with a lack of recreational facilities for the Gitksan and Wet'suwet'encommunities where climate determines both amount and timing of physical exercise (e.g.,walking and jogging) as well as leisure activities that tend to be sedentary in nature.While physical activity provides some explanation for current body weight, asimportant is the kind and amounts of food consumed. A comparison of percentagedistribution of total calories according to dietary content of carbohydrate, fat and proteinshows that 4 tribal groups in northwestern B.C. may conform better with Canadian NutrientRecommendations than the Canadian population in general. This is particularly true fordietary fat (Bell, P. 1992; Campbell and Horton 1991). Though the Gitksan andWet'suwet'en people consume 52 percent of total calories as carbohydrate, a considerableproportion is in the form of simple sugars. These comparisons are summarized in Table 26.Some caution is necessary in interpreting findings as methodology is considerably differentfor each study group. Differences involve method (e.g., Food Recall versus food expenditurediary) and sampling (non-random, random, and census).TABLE 26Comparisons of Total Energy Intake and Energy Sourcesin Indian and Non-Indian PopulationsEnergy and Energy NUTRIENT CONTRIBUTIONS TO TOTAL ENERGYSources Gitksan/Wet'suwet'en *^Woyenne Health Center • Canadians •Energy Intake (Kcal) 2163 2091 2433Carbohydrate Gm (%) 284 (52%) 258 (49%) 287 (47)Fat Gm (%) 88 (33%) 77 (33%) 108 (40%)Protein Gm (%) 76 (14%) 90 (17%) 85 (14%)* Current study: N = 97, ages 15 and over; Gitksan and Wet'suwet'en people.• Source: Bell, 1992; N = 198, ages 19 and over; Wet'suwet'en, Babine, and Carrier people.▪ Source: Campbell and Horton, 1991; N = 4,774, all ages; general Canadian population.167In reporting the apparent nutrient intake of Canadians, Campbell and Horton (1991)call for a broad-based sustained effort to address the problem of high fat intake. Though thepeople in this current study could benefit from a further decrease in fat intake, perhapsequally as problematic is the sugar content of the diet. In this case, a target for action maymore appropriately focus on increasing complex carbohydrates (e.g., whole wheat cereals)and decreasing simple sugars (e.g., table sugar). This change would contribute to an increasein total fibre consumed.Besides modifying carbohydrate intake, Gitksan and Wet'suwet'en must also addresspotential problems in general eating patterns, particularly where total energy intake isinadequate. The high risk for a calcium deficiency is consistent with low intake of Milk andMilk Products. These findings are expected given the well known problem of lactoseintolerance commonly experienced by people of Indian ancestry. However, with educationand purposeful action, it is possible to modify eating habits to compensate for theintolerance. Low consumption of fruits and vegetables explain, in part, risks for inadequaciesin Vitamin A, Vitamin C, as well as Folate. This low consumption of fruit and vegetables, aswell as milk products further contribute to inadequacies in Riboflavin, a B Vitamin (Healthand Welfare Canada 1990a).4. Health Care Services: Once describing themself as sick, care is sought from local health care workers,including physicians, health nurses and Community Health Workers. Though recall may be afactor in describing access, this study suggests that use of physician and hospital servicescompares to that of the general population in B.C. and Canada (British Columbia RoyalCommission on Health Care and Costs 1991; Institute for Health Care Facilities of the168Future 1987). Less clear is use of community health services since this study did not examinecontacts within group settings as would occur in an educational workshop. Though thesegroup interactions do occur, indications are that both quantity and quality of suchinteractions may not meet the expectations of the village people.A preventive service that appears to be under-utilized is that of dental services.Dentition deteriorates with age, with most people over 45 years having partial plates. Thismay be partly attributed to the fact that people tend to go to the dentist only when there is aproblem. Perhaps as important may be views on the aging process where it may beconsidered normal to lose teeth as one ages. Though the in-depth interviews suggest thataging is accompanied by a weakening and loss in physical capacity, these interviews did notexplore all aspects of aging (i.e., dental health). Data from the study suggest access to aDentist is not the problem, rather, there may be a need for education.Further health issues relating specifically to women involve breast self-examinationand pap smear test. Women who had seen a doctor in the past year were more likely toreceive a pap test than to have their breast examined (26 percent versus 18 percent). Age isa factor with women over 40 at increased risk for breast cancer. Though about sixty percentof women had been shown how to self-examine for changes in breast tissue, only one out ofthree carried out the technique routinely, with older women checking more frequently thanyounger women. Potential targets for action include the 40 percent of women who had notbeen shown this self-care technique as well as the ten percent who had been shown but donot carry out the practice.Results from this study suggest Gitksan and Wet'suwet'en women are high users ofPap testing for changes in cervical cells. However, confirmation from data other than self-reporting may be necessary to establish this fact. About 75 percent of women had a pap test169within the previous two year period. This self-reporting is considerably higher than thatfound in a recent B.C. study involving other native Indian women in the Province. In thisB.C. study, about 50 percent of the sample (N = 4,400) had a pap test within a previousthree year period (1988-1990). A further comparison to the general B.C. population suggestsGitksan and Wet'suwet'en women may use this screening program at a rate comparable tothe general population. Over the same three years, about 85 percent of women in B.C.utilized the screening program (per Dr. Greg Hislop, publication pending).Findings also show that over two-thirds of women breastfed their last child. Smallnumbers (four) prevent an assessment of breastfeeding practices for births in 1990-1991.However, over a five year period, there are indications that more women are breastfeedingand for longer periods when compared to the 1983 breastfeeding rates for B.C.'s on-reservewomen (Health and Welfare Canada 1985). Promotion of breast feeding has been a longstanding and apparently successful Maternal/Child health initiative by Medical Services fieldstaff. However, continued efforts may be required to maintain these high rates.In this health survey, numerous problems and potential problems have beenidentified. The Gitksan and Wet'suwet'en now face the challenge of priorizing andresponding to these issues. The following discussion presents one method for initiating theseprocesses.5.3 Gaps in Existing Programs and ServicesGaps in the health care system exist when a health need is identified and is currentlynot being addressed or is being addressed inadequately. For the purposes of this study,health care needs exist when a problem has been identified; judgement is made that possiblesatisfactory solutions are not accessible, are not currently adequate, or do not exist in the170community; and, it is necessary to reallocate existing resources and/or appropriate newresources (Nguyen, Attkisson, and Bottino 1983). According to this accepted definition ofhealth need, study findings suggest need exists in several areas.Repeatedly, findings show a major area of need rests in the area of mental health.This problem is compounded by Medical Service Branch not having a Mental HealthMandate: instead the Province is relied upon to meet needs (Community Mental HealthCommittee, Wrinch Memorial Hospital 1990). Problems with this type of servicing wasidentified in the B.C. Commission on Health Care and Costs (1991) and is repeatedlyreferred to in other studies and reports (Assembly of First Nations, 1988). This servicingproblem is evident in the Gitksan and Wet'suwet'en territory where a few villages have a fee-for-service agreement with Mental Health Services. Service variability is explained in part bythe fact that villages requesting the most services are likely to be included in this agreement.Here, politics explains who gets what kinds of services.A general need for mental health services is raised throughout this report. Ofparticular concern is the apparently high rate of people who seriously think about suicide andwho subsequently make the attempt. This whole issue of suicide necessarily ties in withreported concerns about the seriousness of unresolved grief (Community Mental HealthCommittee, Wrinch Memorial Hospital 1990; Cooper, Karlberg, and Adams 1991).Closely linked to this issue of mental health is that of alcohol use and abuse. Thoughthere are several existing programs and services for dealing with this issue, it is not clear ifthese initiatives are effective. The biggest challenge may rest in addressing beliefs regardingpotential harm of alcohol and beliefs regarding a normal drinking pattern.A second major area of need rests in the area of health education. Currently, localhealth staff provide health education, however, a general feeling is educational initiatives are171inadequate. Both health study results as well as supplementary data support the need foreducation in many areas including tobacco use, food habits, physical exercise and weightcontrol, back injury prevention, and self-care practices for women. Rather than dependingon "imported" health educators alone, it may be possible to capture the influence of eldersand clan and house leaders in modifying health related beliefs and behaviours. This may beespecially appropriate in the areas of tobacco and alcohol use as well as family violence.Perhaps most critical to improving wellness and well-being are responses toeducational and economic concerns. It is worth noting that village people don't focus onlyon more and better programs to improve their wellness/well-being experiences. Instead,education and employment issues hold prominent spots in priorized needs. These social,mental health, economic, and educational issues are generally recognized contributors to thehealth condition of Indian people in Canada (Frederes 1988; Castellano 1982; Speck 1987) .5.4 Local Responses to Health IssuesSince the Gitksan and Wet'suwet'en people hold an wholistic conceptualization ofwellness and well-being, it is critical that health needs be identified within all levels of societyand responses appropriate to each level be considered and addressed in an integratedmanner. As such, needs identification must occur at the individual, family, house/clan,village/community, and tribal level. In this report, information relates primarily to theindividual, with some references made to the family and village. Further attention must bedirected to the house/clan system and tribal grouping. Such a process necessarily assumesthat needs at one level may not be directly relevant to another level. For example, at thetribal level a need may relate to issues in self-government while at the personal level a needmay relate to living with and managing diabetes. Regardless of which level of society172identifies and responds to an unmet need, all must advance local values regarding wellnessand well-being (Nguyen, et al 1983).Fragmentation of responses to identified needs may best be avoided by setting aclearly defined health goal. Findings from this study provide a basis for development of thegoal, however, it will be important that community members be directly involved in theprocess. Concepts for consideration include the notions of strengthening and protectingwellness. Capturing these concepts to initiate responses to the many problems may supportdevelopment of a system that focuses on the positive aspects of wellness rather than on thesick experience. These problems include tobacco and alcohol use, dietary inadequacies,excess body weight, low physical activity, sedentary leisure activities, and negative well-beingexperiences. Perhaps as important may be the appropriateness of these concepts to otherdomains including education and employment. This inclusion may help to break down thelong standing problem of compartmentalizing issues and responses within the villages(Assembly of First Nations 1989).5.5 SummaryThis descriptive study set out to establish base-line data on the health status andhealth care needs of a Gitksan and Wet'suwet'en population. Findings are supported by aninvestigation into health meanings according to this same group of people.The explanation of health meanings in this study provide some basis for moresensitive and improved communication between health care professionals and the Gitksanand Wet'suwet'en people. But, perhaps more importantly, this assembly and systematicorganization of existing knowledge assists local initiatives in responding to the unwell or sickexperience. Most promising is the wholistic conceptualization of the well/unwell experience173which presents a potential for establishing a positive response to challenges identified in thisstudy.The health survey clearly demonstrates several areas of needed action. Someproblems may prove more resistant to change than others. Nevertheless, it is clear that thereis a desire for improvement. Data from a variety of sources in this study continuallyrecognize the importance of a coordinated, broad-based response that incorporates allaspects of the environment. This necessarily includes initiatives in education, employmentopportunities, territorial land concerns, as well as social changes to modify or eliminatedestructive attitudes and behaviours. Ultimately, the Gitksan and Wet'suwet'en people mustpriorize the health problems and determine for themselves the best possible means foreffecting change.174CHAPTER 6.0SUMMARY, CONCLUSION, AND IMPLICATIONS OF THE STUDYA need for health system change has received increasing prominence among healthcare analysts, planners, and researchers (British Columbia Royal Commission on Health Careand Costs 1991; Rachlis and Kushner 1989). However, in order for health planning to betruly responsive to the needs of consumers, there must be clear and shared meanings abouthealth. These shared meanings increase the likelihood of health services and programs beingresponsive to and accessible within the social context of the consumer.In the preceding chapters, the rationale for this study was established on the basis ofa need for information to support health system changes within the health care system for agroup of Indian people living in villages in northwestern B.C. This need for change is seenin the persistently low health status of Indian people as demonstrated by infant mortalityrates that remain twice as high as for the general population. Though research continuallydescribes the unsatisfactory health experiences, descriptions are hampered by manyresearchers' use of the biomedical framework for interpreting results. This study addressesthis information gap by obtaining and describing base-line information on the health statusand health needs of the Gitksan and Wet'suwet'en "on-reserve" status population in B.C. viathe meanings and interpretations they, themselves, attach to health.An examination of the current state of knowledge in the literature review clearlydemonstrated a need for two research approaches in this study in order to both discoverhealth meanings and to describe the health status of the population under study. These twoapproaches involve a phenomenological and epidemiological perspective. Phenomenologyexplores the health phenomena from the perspective of a unique culture via tape-recorded,in-depth interviews of nine Gitksan and Wet'suwet'en men and women. Epidemiology, on175the other hand, describes current health status by means of a health survey questionnaireinvolving 97 men and women. Additional qualitative data from a variety of sources (e.g.,Focus Groups) substantiate and extend findings in order to describe health needs.The qualitative data from the phenomenologic component of the study involved aconstant comparative technique and occurred in several stages from the highly specific line-by line analysis to increasingly abstract conceptualizations. Categories formed the primarydata elements with word usage remaining true to that of study subjects (Corbin 1986;Spradley 1979).Quantitative data from the epidemiologic aspect of the study were cross tabulatedaccording to demographic characteristics and further analyzed utilizing the SPSSX statisticalpackage. Supporting qualitative data from other sources were summarized and areincorporated in discussions of epidemiologic findings.The following sections summarize key findings from these two aspects of the study.6.1 Summary of Health Meanings According to the Gitksan and Wet'suwet'enThe Gitksan and Wet'suwet'en, though two distinct cultures, share many commonelements in their social organization and institutions. This sharing of ideas and values has anextensive historical basis and, according to findings in this study, includes health meanings.The Gitksan and Wet'suwet'en have a wholistic conceptualization of the healthexperience. At the personal level of this wholistic scheme, the whole being incorporates thephysical, mental, and spiritual components with the spirit constituting a dominant force.Indeed, the spirit centres wholistic interconnections of the individual with the broaderenvironment. This wholistic world view sees the individual intimately connected to thefamily, House/Clan, village, tribe, and land.176Though neither study group dialects have a word for health, they do refer to theexperience in terms of wellness and strength where one has the ability to do anything. Beingstrong has considerable personal and social value. When strong, one is able to resist sicknessand recover quickly once sick. From a social perspective a strong person is able to workhard, maintain independence, and contribute to family and society. When well and strongthe Gitksan and Wet'suwet'en say they are able to do anything including carrying out normaldaily activities, engaging in preferred leisure activities, and meeting social responsibilities.A positive sense of well-being describes the state of wellness with descriptorsincluding feeling good physically, being happy and at peace, and having high self-esteem.Though overlap exists between the wellness and well-being experiences, word usage suggeststhere is also a distinction that assigns comparable importance to both states.The potential for being well and strong is thought to be an inherent part of anindividual who then becomes responsible for both strengthening and protecting that state.This life-long process of strengthening and protecting wellness focuses largely on the physicaland spiritual aspects of being.The state of wellness may be undermined or weakened by factors that relate to thephysical, mental, and spiritual nature. From the physical and mental perspective, thesefactors include attitudes and behaviours with attitudes referring to emotions and mental set(e.g., unresolved grief, low self-esteem, not respecting others). From the spiritualperspective, the spirit may separate from the whole being through fright, trauma (e.g., neardrowning or car accident), or ill-will on the part of another. With the spirit separated,wholeness is lost, the individual experiences distinct physical symptoms, and becomessusceptible to sickness and even death if the spirit is not returned to the body.When unwell or sick, a person is not able to do what he/she wants to do.177Responsibilities are not carried out, dependency develops, and one becomes a burden. Theperceived seriousness of a condition relates to the extent to which it interferes with an abilityto do things. For example, arthritis may be considered more serious than excess body weightbecause arthritis "holds you back". This unwell or sick experience is described as depressing,feeling useless, being socially isolated, and hurting inside. Pain may also be present.An explainable cause is sought for any sickness. However, regardless of cause,healing is required. Today, healing involves both traditional and modern methods andmedicines. Though there is an acknowledged dependency on modern medicine, someexperiences in the health system provide grounds for loss of trust. The basis for theseexperiences stem from a lack of respect for the beliefs and practices of a unique culture andlack of respect for the view point of a lay person acting within the dominant medical model.6.2 Summary of Health Status and Health NeedsThe majority of Gitksan and Wet'suwet'en people (78 percent) say their health is"good" or better. Those who rate their health as "fair" or "poor" have limitations in the kindsof activities they can engage in. According to local views of health and the healthexperiences, Gitksan and Wet'suwet'en people are well in the sense that they are largely ableto do what they want to do. However, level of wellness and strength are being underminedby several factors that pose risks.Ancestry largely made no difference in the health experience with noted exceptions ofa hereditary condition (arthritis) and obesity where both appear toprimarily affect theGitksan. Men and women also had comparable physical health experiences. There is anoted problem in hearing ability, this affecting many men and women under 45 years. Lessthan 5 percent of the population experience some level of disability resulting from a chronic178health condition or old age. Chronic conditions affecting those over 45 years includearthritis, heart disease and high blood pressure.Both men and women over 35 years are at risk for heart disease, high blood pressure,and diabetes because of body weight. The problem of excess weight appears to relate moreto a sedentary life-style rather than excess caloric intake. Energy intake generally metrecommended amounts for age and standard body weight. However, both men and womenare at risk for nutrient inadequacies (calcium, vitamin A, and folate) and women are morelikely to be at risk for an iron deficiency.Tobacco and alcohol use pose considerable health risks. Two out of three men andwomen currently use tobacco while four out of five currently consume alcohol. Sex made adifference only in patterns of alcohol consumption with more men drinking more alcoholmore often. Smokers largely believe there is potential harm in tobacco use and try to reduceuse in relation to this belief. While men believe there is greater potential harm in theiralcohol intake than do women, this belief is unrelated to attempts to reduce alcohol intake.Generally, men and women were most likely to try to cut back on alcohol use because theybelieve they can control consumption and because use caused family or spousal problems.Perhaps even more significant is beliefs regarding normalcy of drinking where those whodrink the most consider their drinking normal and those who drink least say their drinkingpattern is not normal. Given high usage of alcohol by men, it is not surprising they are mostlikely to encounter problems within the family unit, at work, and with the law.Both bed-days and cut-down-days show men and women are equally likely to take tobed when sick. However, men stay in bed longer once they have taken to bed while womenstay in bed for shorter periods. Follow-up cut-down days is similar for both sexes.Women have significantly different health experiences as well as sex specific health179protection choices involving use of pap testing for cervical cancer, breast self-examination,and breast feeding. Reports in this study indicate women are more likely to have pap testingdone than to self-examine breasts for early detection of cancer. Few women use birthcontrol and, upon birth of a child, breast feed for six months or more. Sex specific healthinformation was not obtained on men. From a social and mental health perspective, womenappear to be at greater risk than men. However, this must be interpreted with caution asdifferences may reflect male-female differences in communication patterns.Social and economic factors over which an individual has limited control also affectshealth status and well-being. In this study, about 60 percent of men and women have lessthan a Grade 12 and only 22 percent are fully employed. Also, three out of four singleparent families are headed by women under 35 years.A final environmental factor involves use of health care services. In this study, use ofboth doctor services and hospital beds is comparable to the general population user rate.While people have access to both a Community Health Nurse and a Community HealthRepresentative, these services have low individual user rates. Traditional healers are usedless often because there is no local and powerful halait or Indian Doctor.Preventive and screening aspects of care involve dental health and pap testing forearly detection of cancer. Women in this study had cervical cancer screening rates that arecomparable to screening rates for the B.C. population. Use of preventive dental healthservices appears to be low. Generally, men and women tend to seek dental care when aproblem exists. This may explain the steady loss of teeth with age and eventual use of partialand complete dentures by almost half of the people over 45 years. An additional contributoris the high consumption of simple sugars.A final description of population health involves the child. In this study about one in180ten children had an acute sickness that did not affect overall assessment of child health statusby the care giver.Additional supporting data identify both concerns and needs that relate to wellnessand well-being. Of particular concern is high unemployment, poor educational achievementby the young, alcohol abuse, high incidence of violence and abusive behaviours, and mentalhealth/emotional problems. Needs include health education, improved communication andlife/coping skills, mental health services, and prevention in alcohol and gambling addictions.6.3 ConclusionsAccording to their definition of health, Gitksan and Wet'suwet'en might considerthemselves well because only one in ten are limited in their ability to do things. However,when well-being is a factor in assessing health, considerably more (four times higher) mightbe considered unwell. These interpretations differ from a biomedical framework where thevast majority of respondents may be considered at risk for many health problems (e.g., lungcancer, heart disease, diabetes, malnutrition, etc.).The Questionnaire examining personal health experiences successfully describedphysical health. In this study, results of statistical testings for internal reliability suggest theinstrument may adequately measure physical health. However, very little data were obtainedon well-being or mental health experiences. Though data on physical health make importantcontributions to the existing model for health care, questions of validity arise since itexamines only part of the total health experience. In order for health planning to be trulyresponsive to local consumer needs, both wellness and well-being may require equal weightand attention when health measurement is undertaken.Gitksan and Wet'suwet'en views on wellness and well-being as well as their181experiences in the dominant health care system suggest there is a need for more than onemodel to both view and respond to sickness. This conclusion corresponds with Kleinman'sexplanatory model of the health care system where most sickness experiences are attended toin the popular sector and where the folk sector also contributes to care of the sick.6.4 Implications for Health CareFindings from this study have implications for health care providers, the medicallydominated health care system in the larger society, and health and social planners in Gitksanand Wet'suwet'en territory.The Gitksan and Wet'suwet'en highly value the show of respect accorded to oneanother when both well and sick. This respect and care becomes even more importantduring a sickness experience when a previously independent person has to ask for help fromeither doctors or nurses. Cultural sensitivity on the part of health care providers becomes anessential part of acceptable communication patterns and behaviours both of which affect thewell-being experiences of the sick and their family.Use of traditional healing practices has been largely private and hidden. Increasingly,however, practitioners are becoming known and, in some cases, will provide care inconjunction with a medical doctor. Respect for and acceptance of use of herbs and healingpractices pose a challenge to all health care providers.The Gitksan and Wet'suwet'en people hold an wholistic conceptualization of thewellness experience which shows interaction at several levels and extends from the individualto the land itself. When unwell or sick, help is sought within the family, extended family, andother tribal groups as well as Medical Doctors. This necessarily requires a system responsethat incorporates and validates all components of the cultural system of health care. Such a182system presents a major challenge to health professionals who typically hold power andcontrol and are generally unwilling to share these attributes with non-professionals (Rachlisand Kushner 1989). Though current health care funding requires participatory planning onthe part of provider and consumer, the concept requires further testing to determine how farpower holders in health care are actually willing and able to go in sharing decision makingwith non-professionals.The Gitksan and Wet'suwet'en consider both wellness and well-being to be equallyimportant. Today, the existing health care system focuses primarily on sickness and, thoughmental health is receiving increasing attention, initiatives are uncoordinated and inconsistent(B.C. Royal Commission on Health Care and Costs 1991). These mental health issues relatelargely to well-being experiences. It is possible that initiatives to address well-being may belargely health related rather than health directed. An example of a health related activityinvolves providing Gitksan or Wet'suwet'en language classes for young mothers; a healthdirected initiative may include nutrition workshops to plan meals that provide adequate iron.The wholistic conceptualization has particular implications for the Health TransferInitiative by Medical Services Branch of Health and Welfare. Repeatedly, Indian peoplehave pointed to problems that arise when health, social, and economic issues arecompartmentalized and dealt with separately (Assembly of First Nations, 1988) It is possiblethat Transfer of Health Services within the existing framework and at existing level ofresources would only perpetuate the system and continue to negate wholistic views of thewellness experience. Though Bands are invited to develop and apply new models for healthcare services potential for success is questionable given these limitations for Transfer.6.5 Suggestions for Future Studies183This study provides a first level examination of the health experiences of a culturallydistinct group of people. The descriptive nature of this study sets out only to provide anindication of factors associated with a particular health state. Though the study is based ontheory, findings do not set out to either prove nor disprove these theories. Instead, findingssupport and extend existing knowledge. This is particularly true for Kleinman's explanatorymodel of the health care system. Kleinman describes the health care system as a culturalsystem where three sectors are activated by an illness experience: the popular, professional,and folk sectors. Extensive research has focused on the professional sector with littleattention directed to the popular sector. According to his conceptualization, the popularsector includes the health beliefs, practices, and values of the people. (Kleinman, 1978;1980)In this study, an initial exploration of health meanings utilizes the phenomenologicalperspective of research. Findings suggest the Gitksan and Wet'suwet'en have a uniqueinterpretation of the health experience. These descriptions establish a basis for a secondlevel of study involving hypothesis testing. Data from this study and other sources mayprovide the basis for developing a theory that explains Gitksan and Wet'suwet'en views onwellness and well-being. Alternatively, it might be worthwhile to explore the appropriatenessof Nordenfelt's holistic, welfare theory of health (1987). The Gitksan and Wet'suwet'endescribe being well/healthy in terms of an ability to do anything, this similar to Nordenfelt'sproposal that health involves a person's ability, under standard circumstances, to achievetheir "vital" goals.The second stage of research involving theory testing may also extend to other tribalgroups in B.C. At face value, there are indications that the notion of well-being and valuefor strength is a feature that is present among other Indian people. (Billy, 1980; Peguis First184Nation, Manitoba, 1991) It would unquestionably be of benefit to health planners if it wereclearly established that Indian people assess their health in terms of ability with seriousnessof a condition determined by the extent to which physical mobility is interrupted.Hypothesis testing may also extend to specific health conditions, including arthritisand systemic lupus erythematosus. Findings from this study suggest the Gitksan may have agenetic predisposition to these conditions, however, further investigation would be requiredto prove or disprove these findings. This type of a study would extend knowledge of theseconditions and is unlikely to make a difference in either incidence or treatment. At present,there is no known cause for arthritis or lupus though both are influenced by geneticinheritance. Genealogy charts currently being developed in Gitksan and Wet'suwet'enterritory provides a potential resource in studies involving hereditary factors and disease.Quantitative data from this study refer only to the two primary villages of study.However, an absence of differences between the two major sample groups as well as a smallsupplementary Wet'suwet'en sample suggests common features may also be found in theremaining eight Gitksan and Wet'suwet'en villages. 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Canadian Journalof Public Health. (January/February) Vol. 83 No. 1: 71-72.Thompson, Molly. (1990) "Heavy Birthweight in Native Indians of British Columbia."Canadian Journal of Public Health. (November/December) 81: 443 - 446.Waitzkin, Howard. (1983) The Second Sickness: Contradictions of Capitalist Health Care.New York: The Free Press.Ware, John E., Robert H. Brook, Allyson R. Davies, and Kathleen N. Lohr. (1981)"Choosing Measures of Health Status for Individuals in General Populations."American Journal of Public Health, June, 71(6): 620 - 625.Ware, John E. Jr. (1986) "The Assessment of Health Status." In Applications of SocialScience to Clinical Medicine and Health Policy, edited by Linda H. Aiken and DavidMechanic. New Brunswick: Rutgers University Press, p. 204 - 228.Weaver, Sally M. (1981) Making Canadian Indian Policy: The Hidden Agenda: 1968 - 1970.Toronto: University of Toronto Press.West, K.M. (1974) "Diabetes in American Indians and Other Native Populations of theNew World." Diabetes, 23(10): 841 - 855.World Health Organization. (1990) Basic Documents. 38th Edition. Geneva: WorldHealth Organization.Young, T. Kue. (1982) "Self-Perceived and Clinically Assessed Health Status of Indians inNorthwestern Ontario: Analysis of a Health Survey." Canadian Journal of PublicHealth, July-August, 73:272-277.Young, T. Kue. (1991) "Prevalence and Correlates of Hypertension in a Subarctic IndianPopulation." Preventive Medicine, 20: 474-485.195APPENDIX A (1)Letter of Initial Contact and Consent for In-Depth InterviewDearI am a graduate student at the University of British Columbia and am working towards aMaster of Science in Health Services Planning and Administration. At present I am workingon a thesis which involves a health study in the Gitksan and Wet'Suwet'En villages. Myfaculty advisor at UBC is Dr. Godwin Eni.Part of this health study will involve my learning about what health means to the Gitksan andWet'Suwet'En people. Information on what the word 'health' means will play an importantpart in understanding what the health survey shows about the health of the people.I am inviting you to take part in the study to give your view of what health means and howyou experience it. If you agree to take part, I would like to interview you in your home orany location convenient for you so that I can learn about your views.Each interview will be tape-recorded so that I can pay full attention to what you are tellingme. Each interview will last about one hour. I would like to interview you 3 or 4 timesduring a 4 month period. Repeat interviews will be done so that we can discuss your viewsin detail. All the information obtained in these interviews will be kept confidential; yourname will not be identified in any conversation or written material.You are under no obligation to take part in the study and would be free to withdraw at anytime during the interviews. Withdrawal will in no way affect your access to either band ormedical programs and services. You may refuse to answer any questions that I may ask youduring the interviews, and you may request that any portion of the tape be erased.If you have any questions or would like more information about this study, you may contactme at the following address or by telephone.Rhea JosephNew Hazelton, B.C.VOJ 2J0Tel: 842-5372OR Dr. Godwin Eni, Program DirectorThesis SupervisorDepartment of HealthCare and EpidemiologyFaculty of MedicineMather Building5804 Fairview AvenueVancouver, B.C., V6T 1W5Tel: 1-228-4464Attention: Rhea JosephIf you wish to meet with me to discuss the study and your contribution, please sign the196If you wish to meet with me to discuss the study and your contribution, please sign theconsent form attached below and drop it off at the Band Office. This form will be returnedto me and I will then contact you to arrange a mutually agreed upon time for the meeting.----CUT^ CUT---Consent to Contact FormI understand that Rhea Joseph will be carrying out the health study and that her FacultyAdvisor at UBC is Dr. Godwin Eni (1-228-2366). I agree to allow Rhea Joseph (842-5372)to contact me regarding her study. I acknowledge receipt of this consent to contact form.Name (Print):Signature:  Date:197A Study of the Health Status and Health Care Needs of aGitksan and Wet'suwet'en Population in British ColumbiaI have spoken with Rhea Joseph about her health study among the Gitksan andWet'suwet'en people. I understand that her Faculty Advisor is Dr. Godwin Eni, UBC (1-228-2366).I understand that the information obtained from this study will be used to plan for ways inwhich the health concerns and health care needs of the reserve people could be dealt with.My contribution to this study will involve giving my views of what health and being healthymeans.I understand that Rhea Joseph will interview me 3 or 4 times, for about one hour each time,and over a 4 month period (May to July). I understand that my identity will be keptconfidential and my name will not be identified in any conversation or written material. Iunderstand that I may refuse to answer any questions that I may be asked during theinterviews, and that I may request that any portion of the tape be erased.I understand that my decision to take part in this study will not affect my access to and useof any band and medical programs and services. If I withdraw from the study at any time,there will be no consequences to my access to and use of the band and medical programsand services either now or in the future. I acknowledge that this study has been adequatelyexplained to me and that Rhea Joseph (842-5372) will answer any questions that I may haveat any time during the study. I acknowledge receipt of the information and consent forms.Print Name:Signature:  Date:198APPENDIX A (2)Letter of Initial Contact to HouseholdsDear Band MembersI am a graduate student at the University of British Columbia and a member of theHagwilget Band. I will be doing a health study as part of the Master of Science Degree inHealth Services Planning and Administration.The health study will involve the Gitksan and Wet'Suwet'En villages. Chief and Council havegiven me permission to approach the people in^ Band to include members in thestudy.The study is being done to obtain information on the general health and health care needs ofpeople living in the ^ village. This health information could be used to plan forways in which the health concerns and health care needs of the village people could be dealtwith. The study is not part of the Health Transfer Program for Medical Services.Some of the Band members who are 15 years and older will be asked to take part in thestudy. Persons who have been chosen by chance will be asked questions about their healthduring an interview. The interview will be done by (name) and will last around 80 minutes.These interviews will be done during the months of May to July.Band members have the right to refuse to take part or to withdraw at anytime. Withdrawalwill in no way affect the person's access to or use of either band or medical programs andservices either now or in the future. At no time will the name of an individual be connectedwith any of the answers to the questions.In May, a letter will be sent to those persons who have been chosen to take part in thestudy. They will then be contacted by (name) to arrange an interview time.If you have any questions you may leave a message for me at the Band Office (842-^) orcontact me at the following address or by telephone:Rhea Joseph^OR Dr. Godwin Eni, Program DirectorNew Hazelton, B.C.^Thesis SupervisorVOJ 2J0 Department of Health Care andTel: 842-5372 EpidemiologyMather Building5804 Fairview AvenueVancouver B.C. V6T 1W5Tel: 1-228-4464Attention: Rhea Joseph199APPENDIX A (3)Letter of Initial Contact to Random Sample GroupDearI am a graduate student at UBC, in my final year of the Master of Science program inHealth Services Planning and Administration. Part of my studies involves a health surveywhich will take place in the Gitksan and Wet'Suwet'en villages. Chief and Council haveconsented to participation by the^ Band.The complete study findings will be summarized in a report and a copy provided to BandCouncil. The health information in the report will be presented in a manner that is usableby band members, Band Council, or the Tribal Group. This health information may be usedto begin planning ways to meet the health care needs that are identified in the study.All of the Band members 15 years and older had an equal chance of being selected to takepart in the study. YOUR NAME HAS BEEN SELECTED BY CHANCE. You will becontacted and the time for an interview arranged. During the interview, you will be askedquestions about your health and health practices. Your viewpoint is important. The information that you provide about your health will help to ensure that a complete picture ofthe health of the Band is obtained.During the months of May to July, ^ will be in touch with you to arrange a suitabletime to interview you. The interview will take about 80 minutes. Your name will not belinked to any of the findings. You have the right to refuse to take part in the study or towithdraw from the interview at any time. Your withdrawal will in no way affect your accessto and use of Band or medical programs and services either now or in the future.If you have any questions or concerns, you may leave a message for me at the Band Office(842-^), or contact me at the following address or by telephone:Rhea Joseph^OR^Dr. Godwin Eni, Program DirectorNew Hazelton, B.C.^Thesis SupervisorVOJ 2J0 Department of HealthTel: 842-5372 Care and EpidemiologyFaculty of Medicine5804 Fairview AvenueVancouver, B.C., V6T 1W5Tel: 1-228-4464Attention: Rhea JosephAny contribution you make to this study is important and appreciated very much.200APPENDIX A (4)Consent to Participate in Focus GroupDearI am a graduate student at the University of British Columbia and am working towards aMaster of Science in Health Services Planning and Administration. Part of my course workinvolves a health study which will be done among the Gitksan and Wet'suwet'en people.Chief and Council have given me permission to approach the people in the^Band to include members in the study. Health information obtained from this study may beused to begin planning ways to meet the health care needs that are identified in the study.The first part of the study will involve a meeting with some band members so that I maylearn more about the health views, health concerns, and health care needs of the bandmembers. Information from this meeting will be used in the questionnaire for the healthsurvey. I am inviting you to take part in this meeting. The date, time, and place for themeeting is as follows:DATE: ^ (approximately 2 hours)TIME: PLACE:Your participation in the meeting is voluntary. Your name will not be linked to informationeither in conversation or written material. At any time during the meeting, you may leave.Your withdrawal will in no way affect your access to and use of Band or medical programsand services either now or in the future. The meeting will be tape recorded so I can pay fullattention to what is being said. However, the tape recorder may be turned off at any time orparts erased should any participant so wish. The tape will be destroyed within 6 monthsafter the conclusion of the study.If you have questions regarding this meeting or the study, you may contact me at thefollowing address or by telephone:Rhea Joseph^OR^Dr. Godwin Eni, Program DirectorNew Hazelton, B.C.^Thesis SupervisorVOJ 2J0 Department of HealthTel: 842-5372 Care and EpidemiologyFaculty of MedicineMather Building5804 Fairview AvenueVancouver, B.C., V6T 1W5 (228-4464)201Consent to Attend Community MeetingI will attend the community meeting at the Band Hall, on (Date), and beginning at (time).Name (print) ^Signature: Date:Note: Return signed consent to^Questions may be directed to Rhea Joseph, student investigator (842-5372), or Dr. GodwinEni (1-228-2366) Faculty Advisor at UBC.202APPENDIX A (5)Consent to Participate in General Health Survey(Interviewer read to subject)A health study is currently being done among the Gitksan and Wet'Suwet'En people. Thestudy is being carried out by Rhea Joseph, a UBC Graduate Student (842-5372) and with theadvise of Dr. Godwin Eni, UBC Faculty Advisor (1-228-2366). The study will obtaininformation on the people's health and health care needs. A select number of people ages15 years and over will be interviewed to obtain this health information. Chief and Councilhave consented to participation by the ^ Band.The health information obtained from this study can be used by the Band and Tribal Councilto plan ways to assist people in becoming healthier and staying healthy.It is estimated that the interview will take about 80 minutes and can be completed duringtwo interviews, if you wish. During the interview I will ask you questions about your healthand health practices. All of your answers will be kept confidential and your name will neverbe linked to any of the information. Your participation is voluntary. If you choose to stopthe interview, your withdrawal will not affect your access to or use of Band or medicalprograms and services either now or in the future.A: Parental Consent for Survey Participants Ages 15 to 17 years I^ (name of parent) acknowledge receipt of this consent form. Iunderstand the nature of the study and I(mark one)^Consent^to my child's participation inDo not Consent^this study.(Date)^ (Print Name)(Signature)B: All Survey Participants sign below:I acknowledge receipt of this consent form. I understand the nature of the study and agreeto take part.(Date)^(Print Name)(Signature)203APPENDIX A (6)Consent for Key Respondent Survey:A general health study is currently being done among the Gitksan and Wet'suwet'en people byRhea Joseph, UBC Graduate Student (842-5372) and with the advise of Dr. Godwin Eni, UBCFaculty Advisor (1-228-2366). The study will establish basic information on the Gitksan andWet'suwet'en's health and health care needs. This community health study also includes aquestionnaire which is to be completed by some band employees and health professionals.Information provided by these key individuals will provide additional information on the healthand health care needs of the people on-reserve.The health information obtained from this study can be used by the band and tribal group toplan ways to assist people in becoming healthier and staying healthy.It should take you about 1/2 hour to complete the attached questionnaire. You have the rightto refuse to participate or to withdraw at any time. Withdrawal will in no way affect your accessto or use of Band or medical programs and services either now or in the future. All of youranswers will be kept confidential and your name will never be linked to any of the information.Your participation is voluntary.Name (print): ^Signature: Title: ^Date:204APPENDIX BTrigger Questions for Focus Group and In•Depth InterviewI.^Trigger Questions for Focus Group: 1. Is there a Gitksan/Wet'suwet'en word for health?2. What is it like for you to be healthy?3. If you are not healthy, how do you describe yourself?3. What are the main health concerns in the community?4. In your view, what causes these health concerns?5. In your view, what is needed to improve the health of the community?II.^Trigger Questions for In-Dkepth Interviews: 1. Is there a Gitksan/Wet'suwet'en word for health?2. What is it like for you to be healthy?3. When do you consider yourself to be healthy? ... Please explain4. What things in life are important for your health? ... Give reasons5. In your view, what causes or contributes to a loss of health?6. In your view, what things in life are important for regaining health once it is lost?205APPENDIX C (1)I. General Health Survey, 1991The HealthofThe Gitksan and Wet'suwet'en PeopleIDENTIFICATION:Band NameRecord IdentificationDate...Thank you for agreeing to take part in this health survey. The completed questionnaire will provide proof of your consent toparticpate.SECTION A: YOUR HEALTH^ SECTION B: HEALTH CARE USE To begin, I would like to ask you some general questions^Now, I would like to ask you some questions about your useabout your health.^ of health care.1 In general, compared to other persons your age, would^6 a) During the last 14 days, did you see or talk to ayou say your health is ...^ medical doctor about your health?2061 ^ Excellent2 ^ Very good3 ^ Good4 ^ Fair5 ^ Poor2 Which of the following best describes how you usuallyfeel?1 ^ Happy and interested in life2 ^ Somewhat happy3 ^ Somewhat unhappy4 ^ Unhappy with little interest in life5 ^ So unhappy that life is not worthwhile3 As a whole, would you describe your life as ...1 ^ Very stressful2 ^ Fairly stressful3 ^ Not very stressful4 ^ Not at all stressful4 How satisfied are you with your health?1 ^ Very satisfied2 ^ Somewhat satisfied3 ^ Not too satisfied4 ^ Not at all satisfied5 Is there anything you plan to do over the next year toimprove your health?(specify 3 plans) ^1 ^ Yes2 ^ No ^> Go to Question 7b) What was the main reason for this contact?1 ^ Sickness or health problem2 ^ Mental health problem3 ^ Medical check-up4 ^ Shots or vaccinations5 ^ Pre or post-natal care6 ^ Other (specify)^7 a) During the last 14 days, did you see or talk to theCommunity Health Nurse about your health?1 ^ Yes2 ^ No ^> Go to Question 8b) What was the main reason for this contact?1 ^ Sickness or health problem2 ^ Mental Health Problem3 ^ Medical check-up4 ^ Shots or vaccination5 ^ Pre or post-natal care6 ^ Other (specify)^8 a) During the last 14 days, did you see or talk to theCHR (Community Health Representative) aboutyour health?1 ^ Yes2 ^ No ^> Go to Question 91207b) What was the main reason for this contact?^14 Did you spend any nights as a patient in a hospitalduring the last 12 months?(specify) ^1 ^ Yes2 ^ No > Go to Section C 9 a) During the last 14 days, did you see or talk to atraditional healer (Indian doctor) about yourhealth?15 How many nights did you spend in a hospital duringthe last 12 months?1 ^ Yes2 ^ No > Go to Question 10^ Nights (estimate number)88 ^ Don't knowb) What was the main reason for this contact?(specify) ^Now, I'd like to ask you about your contacts during the last 12months with the health care system.10 During the last 12 months, how many times did yousee or talk to a medical doctor about your health?Times (estimate number)0 ^ None8 ^ Don't know11 During the last 12 months, how many times did yousee or talk to the Community Health Nurse aboutyour health?Times (estimate number)0 ^ None8 ^ Don't Know12 During the last 12 months, how many times did yousee or talk to the CHR (Community HealthRepresentative) about your health?SECTION C: TWO WEEK DISABILITYThe next questions refer to your level of activity in the past 14days.16^During the past 14 days, did you stay in bed all ormost of the day because of your health? (Includeany nights spent in hospital)1 ^ Yes2 ^ No ^> Go to Question 2017 How many days?^Days (estimate number)18^What was the health problem responsible for yourstaying in bed?(specify health problem)^19^Was this the result of an accident or injury?1 ^ Yes2 ^ NoTimes (estimate number)^ 20^Were there any other days during these 14 days0 ^ None^ that you cut down on things you usually do8 ^ Don't know because of your health?13 During the last 12 months, how many times did yousee or talk to a traditional healer (Indian doctor)about your health?Times (estimate number)0 ^ None8 ^ Don't know1 ^ Yes2 ^ No ^> Go to Section D21 How many days?Days (estimate number)2208Interviewer check item:1 ^ Yes answer(s) to Questions 24 to 26^> Go to Question 272 ^ No answers to Questions 24 to 26------> Go to Section Ea) In a car, van, or truck^1 0 2 0b) On a motorcycle 1 0 2 0c) On a snowmobile or all-terrain^1 0 2 0vehicle (ATV)d) As a pedestrian or when walking 1 0 20e) On a bicycle^1^2^f) On a boat 10 2 025^Other than the accidents already mentioned, didyou have an accident while taking part in gamesor sports?1 ^ Yes2 ^ No26^Other than the accidents already mentioned, inthe past 12 months did you have an accidentserious enough to limit normal activities andinvolving...Yes^No1 0^2 01 0^2^1^ 2 01 0 2 01 0 2^1 0 2 01 0 2^a) Fallsb) Burnsc) Poisonsd) Cutse) Firearmsf) Overdoseg) Alcohol22 What was the health problem responsible for yourcutting down on things you usually do?(specify health problem) ^23 Was this the result of an accident or injury?1 ^ Yes2 ^ No 27 Did any of the accidents already mentioned happenwhile working at a job or business?SECTION D: ACCIDENTS AND INJURYThe next few questions concern accidents and injuries whichmay have occurred during the last 12 months.24 During the last 12 months, did you have anaccident...Yes No1^Yes2 No28 What were the injuries or health problems thatresulted from the accidents?(specify type of injuries or health problems)29 During the past 12 months, did you receive healthcare in the emergency room of a hospital for anyaccident or injury?1 ^ Yes2 ^ NoSECTION E: HEALTH STATUSThe next set of questions ask about your usual ability incertain areas, such as vision, hearing, and speech.E-1 Vision 30 Are you usually able to see well enough to readordinary newspaper type printing without glasses orcontact lenses?1 ^ Yes ^> Go to Question 332 ^ No8 ^ Don't know (i.e. not able to read)31 Are you usually able to see well enough to readordinary newspaper type printing with glasses orcontact lenses?1 ^ Yes ^> Go to Question 332 ^ No8 ^ Don't know (i.e. not able to read)320932 Are you able to see at all?^ E-3 Speech 1 ^ Yes^ 40 Are you usually able to be UNDERSTOOD completely2 ^ No^> Go to Question 35^ when speaking with strangers?1 ^ Yes^> Go to Question 4533 Are you able to see well enough to recognize a friend^2 ^ Noon the other side of the road without glasses orcontact lenses?41 a) Are you usually able to be UNDERSTOOD1 ^ Yes ^> Go to Question 35^ partially when speaking with strangers?2 ^ No1 ^ Yes2 ^ No34 Are you usually able to see well enough to recognizea friend on the other side of the road with glasses orcontact lenses?1 ^ Yes2 ^ NoE-2 Hearing 35 Are you usually able to hear what is said in a groupconversation with at least three other people withouta hearing aid?1 ^ Yes ^> Go to Question 402 ^ No36 Are you usually able to hear what is said in a groupconversation with at least three other people with ahearing aid?1 ^ Yes ^> Go to Question 382 ^ No37 Are you able to hear at all?b) What is the main reason for you not beingUNDERSTOOD when speaking to strangers?(specify) ^42 Are you able to be UNDERSTOOD completely whenspeaking with those who know you well?1 ^ Yes^> Go to Question 452 ^ No43 Are you able to be UNDERSTOOD partially whenspeaking with those who know you well?1 ^ Yes^> Go to Question 452 f:1 No44 Are you able to speak at all?1 ^ Yes2 ^ No1 ^ Yes2 ^ No^> Go to Question 4038 Are you usually able to hear what is said in aconversation with one other person in a quiet roomwithout a hearing aid?E-4 Getting Around 45 Are you able to walk around the village withoutdifficulty and without mechanical support such asbraces, cane or crutches?1 ^ Yes2 ^ No> Go to Question 401 ^ Yes2 ^ No> Go to Question 5139 Are you usually able to hear what is said in aconversation with one other person in a quiet roomwith a hearing aid?1 ^ Yes2 ^ No46 Are you able to walk at all?1 ^ Yes2 ^ No^> Go to Question 49421047 Do you require mechanical support such as braces,^55 Which one of the following sentences best describescane or crutches to be able to walk around the the effect of pain or discomfort you usuallyvillage?^ experience?1 ^ Yes2 ^ No48 Do you require the help of another person to be ableto walk?1 ^ Yes2 ^ No49 How often do you use a wheelchair ?1 ^ Always2 ^ Often3 ^ Sometimes4 ^ Never50 Do you need the help of another person to getaround in the wheelchair?1 ^ Yes2 ^ NoE-5 Hands and Fingers51 Do you usually have the full use of two hands andten fingers?1 ^ Yes ^> Go to Question 542 ^ No52 Do you require the help of another person because oflimitations in the use of hands or fingers?1 ^ Yes2 ^ No ^> Go to Question 5453 Do you usually require the help of another personwith...1 ^ Some tasks2 ^ Most tasks3 ^ Almost all tasks4 ^ All tasksE-6 Pain and Discomfort54 Are you usually free of pain or discomfort?1 ^ Yes ^ )Go to Question 562 ^ No1 ^ Pain or discomfort that does not prevent anyactivities2 ^ Pain or discomfort that prevents a fewactivities3 ^ Pain or discomfort that prevents someactivities4 ^ Pain or discomfort that prevents most activitiesSECTION F: CHRONIC HEALTH PROBLEMSNow, I would like to ask you some questions about long termphysical health problems that you might have.56 Answer "yes" or no to the following questions.Do you have: YES NOa) Skin allergies or other skindisease?1^ 2^b) Hay fever or other allergies? 1^ 2^c) Serious trouble with back pain? 1^ 2^d) Arthritis? 1^ 2^e) Lupus? 1^ 2^f) Rheumatism? 1^ 2^g) Other serious problems with thejoints or the bones?1^ 2^h) Paralysis or speech problems dueto stroke?1^ 2^i) Asthma? 1^ 2^j) Emphysema or chronic bronchitisor persistent cough?1^ 2^k) TB 1^ 2^I) Epilepsy? 1^ 2^m) High blood pressure orhypertension?1^ 2^n) Circulatory problems or problemswith blood circulation?1^ 2^o) Heart disease? 1^ 2^p) Diabetes? 1^ 2^q) Urinary problem or kidney disease 1^ 2^r) Stomach ulcer? 1^ 2^s) Other digestive problems? 1^ 2^t) Goitre or thyroid problems? 1^ 2^u) Eye problems, for examplecataract or glaucoma?1^ 2^v) Cancer? 1^ 2^If yes, what type? (specify type ofcancer)521157 Do you have any other type of long term health^b) From what age have you been limited in yourproblem?^ activities?1 ^ Yes2 ^ No ^8 ^ Don't know }Go to Section G77 ^ From birth^ Age (write number)58 What are your other long term or chronic healthproblems?(specify other type of health problem)64 a) Does your health limit your activities at home?1 ^ Yes2 ^ No ^> Go to Question 65b) Are you unable to do most everyday householdchores?SECTION G: ACTIVITY RESTRICTION^1 ^ Yes2 ^ NoThe next set of questions refer to restrictions in activity whichare the result of health problems.59 Do you need the help of another person withpersonal care such as eating, bathing, dressing, orgetting around inside the house, because of anyimpairment or health problem?1 ^ Yes2 ^ No60 Do you need the help of another person in lookingafter personal affairs, doing everyday householdchores, going shopping or getting around outside thehouse, because of any impairment or healthproblem?1 ^ Yes2 ^ No61 Are you usually able to go out in good weather?1 ^ Yes2 ^ No62 Are you usually confined to a bed or chair for mostof the day because of your health?65 a) Are your activities at school or work limitedbecause of your health?1 ^ Yes2 ^ No ------> Go to Question 66b) Are you unable to work or go to school?1 ^ Yes2 ^ No66 Are you limited in other activities such as leisure timepursuits or transportation to and from work andschool because of your health?1 ^ Yes2 ^ No67 What is the main health problem causing you to belimited in your activities?(specify health problem) ^1 ^ Yes^ 68 Was this the result of an accident or injury?2 ^ No63 a) Compared to other people of the same age ingood health, are you limited in the kind oramount of activity you can do because of a long-term physical or mental condition or healthproblem?1 ^ Yes2 ^ No69 a) Are there any other health problems which limityour activities?1 ^ Yes2 ^ No > Go to Section H1 ^ Yes2 ^ No ^> Go to Section H680 Do you smoke pipes, cigars, or cigarillos ...1 ^ Daily2 ^ Occasionally3 ^ Not at all ^ 1 ^ Daily2 ^ Occasionally3 0 Not at all> Go to Question 7571 At what age did you begin to smoke daily?1 ^ Yes2 ^ No } Go to Question 7975 Have you ever smoked cigarettes daily?1 ^ Yes2 ^ No ^> Go to Question 79212b) What other health problems causes you to limit^77 At what age did you stop smoking daily?your activites?Age(specify other health problems besides thatmentioned in Question 67)78 How many cigarettes a day did you usually smoke?Number of cigarettesSECTION H LIFESTYLE^79 How many of your friends smoke cigarettes?The next set of questions ask about lifestyle choices andbehaviours which can affect health.H-1: SMOKING: 70 At the present time, do you smoke cigarettes ...1 ^ All of them2 ^ Most of them3 ^ About half of them4 0 A few of them5 ^ None of them^ Age72 How many cigarettes do you smoke each day now?^ Number of cigarettes73 How likely do you think it is that your smoking willlead to health problems for you?1 ^ Very likely2 ^ Somewhat likely3 ^ Somewhat unlikely4 ^ Very unlikely74 Have you tried to quit smoking in the past 12months?81 Do you use snuff or chew tobacco ...1 ^ Daily2 ^ Occasionally3 0 Not at all82 How many of your friends use snuff or chewtobacco?1 ^ All of them2 ^ Most of them3 ^ About half of them4 ^ A few of them5 ^ None of themH-2: ALCOHOLWhen the following questions refer to a drink it means:1 bottle of beer (12 oz. or 360 ml.), OR1 glass of wine (4-5 oz. or 120-150 ml), OR1 small shot of liquor or spirits with or withoutmix (1-1 1/2 oz.)83 Have you ever taken a drink of beer, wine, liquor, orother alcoholic beverage?76 At what age did you begin to smoke daily?^ 1 ^ Yes2 ^ No^> Go to Question 92^ Age721384 Not counting small sips, at what age did you startdrinking alcoholic beverages?90 In the past 12 months have you tried to reduce theamount you drink?Age 1^^ Yes2 ^ No85 In the past 12 months, have you taken a drink ofbeer, wine, liquor or other alcoholic beverage? The next questions concern drinking and problems related toyour drinking during the last 12 months.1 ^ Yes ^> Go to Question 872 ^ No 91^a) Do you feel you are a normal drinker?1 ^ Yes86 Did you ever regularly drink more than 12 drinks in aweek?2 ^ No1 ^ Yes ^ (.Go to Question 922 ^ No ^b) Does your family worry or complain about yourdrinking?1 ^ Yes87 a)^In the past 12 months, how often did you drinkalcoholic beverages?2 ^ No1 ^ Everyday2 ^ 4 to 6 times a week3 ^ 2 to 3 times a week4 ^ Once a week5 ^ Once or twice a month6 ^ Less than once a monthc) Do your friends or relatives think you are anormal drinker?1 ^ Yes2 ^ Nod) Have you attended a meeting of Alcoholicsb) Beginning with yesterday, how many drinks did^ Anonymous (AA) because of your drinking?^you have in the last 7 days?^1 ^ Yes^ Drinks (Estimate number) 2 ^ No77 ^ Never88 How likely do you think it is that your drinking willlead to health problems for you?1 ^ Very likely2 ^ Somewhat likely3 ^ Somewhat unlikely4 ^ Very unlikely89 In your opinion how many of your friends would yousay drink too much?1 ^ All of them2 ^ Most of them3 ^ About half of them4 ^ A few of them5 ^ None of theme) Are you always able to stop drinking when youwant to?1 ^ Yes2 ^ Nof) Have you attended an Alcohol Treatment Centrebecause of your drinking?1 ^ Yes2 ^ Nog) Has drinking created problems with your spouseor other family members?1 ^ Yes2 ^ No8214h) Have you got into trouble at work because of^93 What did you do? (check one)drinking?1 ^ Yes2 ^ Noi) Have you neglected your obligations, your familyor your work for two or more days in a rowbecause you were drinking?1 ^ Yes2 ^ Noj) Have you gone to anyone for help about yourdrinking?1 ^ Yes2 ^ Nok) Have you been in a hospital because of yourdrinking?1 ^ Yes2 ^ NoI) Have you been arrested, even for a few hours,because of drunk behaviour?1 ^ Walk2 ^ Run or jog3 ^ Exercise in a class or at home4 ^ Ride a bicycle5 ^ Ride a stationary bicycle6 ^ Other (specify) ^94 In the past 3 months, how often did you take part inthis activity?times per weekORtimes per month7 ^ Less than once a month8 ^ Don't know95 About how much time did you spend on eachoccasion?1 ^ More than one hour2 ^ Between 45 minutes and one hour3 ^ Between 30 and 45 minutes4 ^ Between 15 and 30 minutes5 ^ 15 minutes or less6 ^ Don't know1 ^ Yes^ 96 Which of the following best describes the level of2 ^ Nom) Have you been arrested for drunk driving ordriving after drinking?1 ^ Yes2 ^ No143: EXERCISE:The following questions refer to physical exercise.92 In the past 3 months, did you take part in activephysical exercise, that is, exercise which made yousweat or breathe more heavily than normal?1 ^ Yes2 ^ No ^> Go to Question 96physical effort in your work or daily activities?1 ^ Light, such as office work, driving, sitting, ...2 ^ Moderate, such as carpentry, walking, ...3 ^ Heavy, such as pushing or carrying heavyobjects, ...4 ^ Don't know97 Overall, do you consider the amount of physicalactivity you get to be ...1 ^ Too much2 ^ Too little3 ^ The right amountH-4: DRIVING AND SAFETY:98 Have you been the driver of a car, truck, or van in thelast 12 months?1 ^ Yes2 ^ No^> Go to Question 101921599 How often do you fasten your seat belt in a motor^104^During the past month have you had any of thevehicle when you are driving off-reserve?^ following dental health problems?1 ^ Always2 ^ Most of the time3 ^ Rarely4 ^ Never100 How often do you fasten your seat belt in a motorvehicle when you are driving on-reserve?1 ^ Always2 ^ Most of the time3 ^ Rarely4 ^ Never101 How often do you fasten your seat belt when you area passenger in a motor vehicle?1 ^ Always2 ^ Most of the time3 ^ Rarely4 ^ NeverSECTION I DENTAL HEALTHNow, I would like to ask you some questions about yourdental health practices.102 Which of the following best describes your currentdental health?1 ^ I have my own teeth and no dentures2 ^ I have my own teeth and one or moredenture(s) or bridge(s)3 ^ I have no teeth and full upper and lowerdentures or plates4 ^ I have no teeth and no dentures103 Are you usually able to:a) Chew a piece of fresh, uncooked carrot?1 ^ Yes2 ^ Nob) Chew firm meats such as steaks or chops?1 ^ Yes2 ^ Noc) Bite off and chew a piece from a whole freshapple?1 ^ Yes2 ^ NoYES NOToothache^ 1^ 2^Pain in teeth from hot, cold, or^1^ 2^sweet foods or liquidsPain in the jaw joints^1^ 2^Pain or discomfort from dentures 1^ 2^Sore or bleeding gums^1^ 2^105^How long has it been since you last saw adentist, dental therapist or other dental careprovider?1 ^ Within the last 6 months ---- Go to2 ^ 6 months to 1 year ^ Section J3 ^ 1-2 years4 ^ 3-5 years5 ^ More than 5 years6 ^ Don't know106^What was the main reason that you did not visita dentist in the last year?1 ^ Too busy2 ^ Nothing wrong3 ^ Afraid or dislike dentists4 ^ Don't know a dentist5 ^ Unable to make an appointment6 ^ A dentist's office is too far away7 ^ Physical or medical problems preventedyou from going8 ^ Other (specify) ^107^How often do you usually see a dentist or dentaltherapist?1 ^ Regularly (i.e. at least once a year forcheck-ups)2 ^ Less than once a year (i.e. every 2-3 years)3 ^ Only when I have pain or other troubleSECTION J: YOUR LIFE IN GENERAL The following questions refer to your life in general.108^Not counting the people you live with, how manyrelatives do you have that you feel close to?Relatives (estimate number)10216109 During the past 12 months how often did you see any^115 a) Do you have children of your own?of these relatives?1 ^ More than once a week2 ^ Once a week3 ^ Once a month4 ^ Several times a year5 ^ About once a year6 ^ Never110 Not counting the people you live with or yourrelatives, how many close friends would you say thatyou have? (By close friends, we mean people thatyou feel at ease with, can talk to about privatematters and can call upon for help.)_____ Close friends (estimate number)00 ^ None ^> Go to Question 1121 ^ Yes2 ^ No^> Go to Question 116b) How satisfied are you with your relationship withyour children?1 ^ Very satisfied2 ^ Somewhat satisfied3 ^ Somewhat unsatisfied4 ^ Very unsatisfied116 a) Are you presently married or living withsomeone?1 ^ Yes2 ^ No^> Go to Question 117111 During the past 12 months how often did you seeyour close friends?1 ^ More than once a week2 ^ Once a week3 ^ Once a month4 ^ Several times a year5 ^ About once a year6 ^ Never112 During the past 12 months what types of activities orhobbies have you usually taken part in during yourleisure or free time?(specify type of activity or hobby)^8 ^ Don't know113 Which one of the following best describes how youspent your leisure time during the past 2 months?1 ^ Almost all of it by myself2 ^ More than half of it by myself3 ^ About half of it by myself and half of it withothers4 ^ Almost all of it with others114 How satisfied are you with your social life?1 ^ Very satisfied2 ^ Somewhat satisfied3 ^ Somewhat unsatisfied4 ^ Very unsatisfiedb) How satisfied are you with this relationship?1 ^ Very satisfied2 ^ Somewhat satisfied3 ^ Somewhat unsatisfied4 ^ Very unsatisfied117 Among your friends or your family, is there someoneyou confide in or talk to freely about yourproblems?1 ^ Yes2 ^ No118 Among your friends or in your family is theresomeone who can help you in a time of need?1 ^ Yes2 ^ No119 a) Are you a member of any voluntary group ororganization, such as church and school group,child care group, village fund-raising group,support group, or social club?1 ^ Yes2 ^ No ^> Go to Question 120b) Do you regularly attend meetings of thesegroups?1 ^ Yes2 ^ No11217119 c) Are you a member of any committees in these^d) What support group ( e.g. Lupus, Weight Control,groups or organizations?^ Alcoholics Anonymous) do you belong to?1 ^ Yes^ (specify) ^2 ^ No0 ^ NoneInterviewer Instructions: Show the answer sheet and read out loud the four possible answers to the following statements. Havethe person refer to this sheet and select his/her answer after you read aloud the following statements.120 Would you tell us how you felt during the past 12 months?Hardly Less^More Mostever^than^than^of thehalf^half^timethe^thetime^timea) I have been full of pep and energy^1^b) My health gave me no concern 1^c) I had no problem handling my feelings^1^d) Life was rather boring^1^e) I felt rather low^ 1^f) I felt tense, or on edge^ 1^g) I felt cheerful and light hearted^1^h) I felt quite lonely^ 1^i) It took some effort to keep my feelings under control^1^j) Many interesting things happened^ 1^k) I was worried about my health 1^I)^I felt exhausted, worn out or at the end of my rope^1^m) I felt reasonably relaxed^1^n) I felt quite loved and appreciated^1^2^ 3^ 4^2^ 3^ 4^2^ 3^ 4^2^ 3^ 4^2^ 3^ 4^2^ 3^ 4^2^ 3^ 4^2^ 3^ 4^2^ 3^ 4^2^ 3^ 4^2^ 3^ 4^2^ 3^ 4^2^ 3^ 4^2^ 3^ 4^121 Health information on Indian people in Canada showthat Indians take their own life more often than dowhite people. It often happens that a person who isfeeling very bad or depressed and who cannot see aclear way to dealing with life's problems, mighteither think about or try to take their own life.Have you ever seriously thought about taking yourown life?1 ^ Yes2 ^ No^> Go to Question 125122 Did this happen during the past 12 months?1 ^ Yes2 ^ No123 Have you ever tried to take your own life?1 ^ Yes2 ^ No ------> Go to Question 12512218124 Did this happen during the past 12 months?1 ^ Yes2 ^ No125 Have you had a family member or close friend taketheir own life in the past 12 months?1 ^ Yes2 ^ NoSECTION K: SOCIO-DEMOGRAPHI INFORMATION 130 Have you established residence on-reserve as aresult of changes to the Membership Section of theIndian Act (Bill C 31)?1 0 Yes2 ^ No131 What was your date of birth?Month Day Year132 What is the highest level of education that you haveever completed?The questions in the following section will allow comparisons^1 ^ No formal schooling ^> Go to Question 134to be made between different groups of people.^ 2 0 Some primary school (grades 1 to 8)3 ^ Primary school (completed grade 8)126 Are you...^ 4 ^ Some secondary or high school (grades 9-12)5 ^ Completed secondary or high school (completedgrade 12)1 ^ Gitksan2 ^ Wet'Suwet'En^ 6 0 Some community college, technical college, or3 ^ Other (specify)  ^ nursing program7 ^ Completed community college, technical college, ornursing127 What is your clan membership?^ 8 0 Some university (not completed)9 ^ University degree (completed)1 ^ Wolf^ Bachelor, Masters, or PhD2 ^ Fireweed3 ^ Frog4 0 Small frog^ 133 a) Did you ever attend a Residential School duringgrades 1-12?5 ^ Eagle6 ^ Beaver1 0 Yes7 ^ Other (specify) ^ 2 ^ No ^> Go to Question 134128 a) Have you ever lived off-reserve?^b) At what ages did you attend Residential School?1 ^ Yes2 ^ No Age (estimate: e.g. 10-16 years of age)> Go to Question 131b) How many of the past 15 years (1975-1990) haveyou lived off-reserve?134 What was your main activity during the last 12months? Was it... (Mark only one)1 ^ Working at a job ^> Go to Question 1371^^ 1 year or less 2 ^ Looking for work2^^ 2 to 5 years 3 ^ Going to school3^^ 6 to 10 years 4 ^ Keeping house4^^ 11 years or more 5 ^ Retired129 Did you establish residence on-reserve before or6 ^ Not working, not looking for work, not going toschool (i.e. hanging around)after 1986? 7 ^ Other (specify)1 ^ Before 19862 ^ After 198613219135 Have you ever worked?^ 143 In the past 12 months have you had your breastsexamined by a doctor or nurse?1 ^ Yes2 ^ No ^> Go to Question 140136 Did you work at a job or business at any time duringthe last 12 months?1 ^ Yes2 ^ No ^ Go to Question 140137 During how many of the last 12 months were youworking?1 CI Yes2 ^ No144 Have you ever been shown how to examine yourbreasts?1 ^ Yes2 ^ No ^> Go to Question 146145 How often do you examine your own breasts?Months (estimate number)^ Would you say...138 Was the work mostly...1 ^ Full time2 ^ Part time3 ^ Seasonal1 ^ At least once a month2 ^ Once every 2-3 months3 ^ Less often4 ^ Neve146 When did you last have a Pap smear test forcancer?139 What type of work was this?(specify) ^140 How many families live in the same house as you ona permanent basis? (One family includes a man,woman and their dependent children; or, a single parentand the children)1 ^ Within the past year2 ^ 1 or 2 years ago3 ^ More than 2 years ago4 ^ Never5 ^ Don't  Know147 Do you take either of the following types of pills?Families (specify number)^ a) Oral contraceptives (THE PILL)141 Overall, do you feel overcrowded in the house inwhich you live...1 ^ Most of the time2 ^ Often3 ^ Sometimes4 ^ Occasionally5 ^ Never1 ^ Yes2 ^ Nob) Female hormones1 ^ Yes2 ^ No148 Did you ever give birth to a child?SECTION L: WOMEN'S HEALTH142 Interviewer check item:Respondent is:Female 1 ^ ^> go to Question 143Male^2 ^ ^> go to Section M1 ^ Yes2 ^ No ^> Go to Question 151149 a) When was your last child born?Month Year14149 b) Did you breast-feed your last child? SECTION M. NUTRITION 151 How tall are you without shoes?OR2201 ^ Yes2 ^ No c) How long did you breastfeed your last child?Feet Inches^Centimetres1 ^ Less than 1 month2 ^ 1-3 months3 ^ 4-6 months4 ^ More than 6 months5 ^ Don't know152 How much do you weigh?^ OR ^Pounds^Kilograms153 How much would you like to weigh?150 Are you pregnant now?  ^OR ^Pounds Kilograms1 ^ Yes2 ^ No 88 ^ Don't know8 ^ Don't know (i.e. might be, but not sure)154 Do you think you could improve your health bychanging your eating habits?1 ^ Yes2 ^ No8 ^ Don't know15221155 A person's health can be affected by the kinds and amounts of food they eat and the beverages they drink. In the nextsection you will be asked to identify all the foods you ate and drank in the past 24 hour period (i.e. yesterday).Interviewer check item:The 24 HOUR FOOD RECALL is for^1 ^ Monday^5 ^ Friday2 ^ Tuesday^6 ^ Saturday3 ^ Wednesday 7 ^Sunday4 ^ Thursday156 24 HOUR FOOD RECALLTIME  FOOD DATA ENTRY INFORMATIONNUTRIENT QUANTITYList kinds and amounts of foods eaten in 24 hours.Includemargarine,all fluids as well as such items as sugar,salad dressing, etc.Energy (kcal)Energy (Kj)Protein (g)CHO (g)Fat (g)Sat'd fat (g)Cholesterol (mg)Calcium (mg)Iron (mg)Vitamin A (RE)Thiamin (mg)Riboflavin (mg)Niacin (NE)Folacin (mcg)Vitamin C (mg)Fibre (g)Trad. FoodTrad. FoodTrad. FoodTrad. Food16222SECTION N: CHILD HEALTH^158 The ages and sex of all children 14 years andyounger are... (Male=M; Female =F)This final section concerns the health of children 14 years andyounger.^ Age Sex157 Are you responsible for the care of a child 14 yearsor younger?1 ^ Yes2 ^ No ^) Close the interview by thanking theindividual. Read the statement at the end of theinterview form.Age Sex159 I would now like to ask you some questions about the health of the male / female (Interviewer circle one) child aged ^ years.This child's name is160 The following are some statements that mothershave made to describe their children. Answerthese statements thinking about (child's name) the last 14 days.Ask questions inPart 2 if a starred (*)answer was chosen inPart 1.2:this due to asickness?PartWasSome ofthe timeAlmostalwaysYes Some-timesNo2^* 3^ 10 2^ 3^2^* 3^ 1^ 2^ 3^20* 3^ 10 2^ 3^20* 30* 10 2^ 3^2^* 3^ 1^ 2^ 3^2^* 3^* 1^ 2^ 3^2^* 3^ 1^ 2^ 3^2^* 3^ 1^ 2^ 3^2^* 3^* 1^ 2^ 3^2^* 3^ 1^ 2^ 3^2^* 3^ 1^ 2^ 3^2^* 3^* 1^ 2^ 3^2^* 3^ 1^ 2^ 3^2^* 3^* 1^ 2^ 3^Part 1During the last 14 days how often did(child's name) Never orrarelya) Eat well^ 10*b) Sleep Well 1^*c) Seem contented and cheerful^10*d) Act moody^ 10e) Communicate what he/she wanted 1^*f) Seem to feel sick and tired^1^g) Occupy him/herself^1^*h) Seem lively and energetic^1^*i) Seem unusually irritable 1^j) Sleep through the night^1^*k)^Respond to your attention^1^*I)^Seem unusually difficult 1^m) Seem interested in what^1^*was going on around him/hern) React to things by crying^1^17223164 b) What was the main reason for this contact?(specify) ^165 a)^During the last 14 days, did you see or talk toan Indian doctor about (child's name) health?Interviewer check one item:1 ^ Yes or Sometimes answer(s)to Part 2 above^> Go to Question 1612 ^ No answers to Part 2 above^> Go to Question 1621 ^Yes161 In your opinion, what kind of sickness did (child's^2 ^No ^> Go to Question 166name) have? (i.e. name the sickness)(Specify)  ^b)^What was the main reason for this contact?(specify) ^162 a)^During the last 14 days, did you take or send(child's name) to a medical doctor because ofhis/her health? 166 a) Does (child's name) attend school?1 ^ Yes^ 1 ^Yes2 ^ No^Go to Question 163^2 ^No ^> Go to Question 167b) How many days of school did (child's name)b)^According to the medical doctor, what was the^miss in the last 14 days because of his/herhealth problem that caused (child's name) to health?be sick?(estimate number)(specify)167 In general, would you say (child's name) health is ...8 ^ Don't know163 a)^During the last 14 days, did you see or talk tothe Community Health Nurse about (child'sname) health?1 ^ Excellent2 ^ Very good3 ^ Good4 ^ Fair5 ^ Poor1 ^ Yes2 ^ No > Go to Question 164168 During the last 3 months, how much have youworried about (child's name) health?b)^What was the main reason for this contact?(specify) ^164 a)^During the last 14 days did you see or talk tothe Community Health Representative about(child's name) health?> Go to Question 1651 ^ A great deal2 ^ Somewhat3 ^ A little4 ^ Not at all169 During the last 3 months, how much pain or distresshas (child's name) health caused him/her?1 ^ A great deal2 ^ Some3 ^ A little4 0 Not at all1 ^ Yes2 ^ No18224170^Would you say...a)^(child's name). health is excellentb) (child's name) seems to resistsickness very wellc) (child's name) seems to be lesshealthy than other childrenyou knowd) When there is somethinggoing around, (child's name)usually catches itTrue MostlytrueDon'tKnowMostlyFalseFalse1^ 2^ 3^ 4^ 5^1^ 2^ 3^ 4^ 5^1^ 2^ 3^ 4^ 5^1^ 2^ 3^ 4^ 5^These questions end the interview. Thank you for the time you have contributed to this study of thehealth and health care needs of the Gitksan and Wet'suwet'en people.COMMENTS;19225APPENDIX C (2)II. Key Respondent Health Survey, 1991The HealthofThe Gitksan and Wet'suwet'en People226Name of Village: ^Record IdentificationDate:Thank you for taking part in the health study. The completed questionnaire will provide proof of yourconsent to participate.INSTRUCTIONS: Use a ballpoint pen and make a check mark in spaces provided for your answer(e.g. _ Yes). Where a written answer is required, print clearly.1^In general, compared to neighbouring Gitksan and Wet'suwet'en villages, would you say thestate of health of the people in ^ village is ...1^Excellent2_____^Very good3^Good4 Fair5^Poor2 a) As a whole, would you describe life on-reserve as ...1234----Very stressfulFairly stressfulNot very stressfulNot at all stressful Go to Question 3b) What do you consider to be the 3 main sources of stress for people living in the village?(specify; (1) is the most important)(1)^  (most important)(2)(3) ^12273 a) What In your opinion, are the major health-related problems in the village? (Check all thatapply)01^Physical impairments (handicaps)02 Poor nutrition03^Alcohol or drug abuse04 Problems related to childbirth05^Problems related to post-natal care06 Family planning and birthcontrol07^Physical illness08 Emotional illness09^Unsanitary conditions on-reserve10 Poor housing conditions11^Accidents and injuries12 Incidence of violence13^Child sexual abuse14 Chronic illness due to old age15^Personal hygiene16 Mental health problems, e.g. suicides, violence17^Other (specify) ^b) Of the problems identified above, what do you consider to be the 5 most Important healthrelated problems?(specify; (1) is the most important)1   (most important)2 ^3 45   (lesser importance)4 a) In the past 4 months, are any band members known to have used any of the following drugswhile on-reserve? (Mark all that apply)1_ Marijuana or hash2^Cocaine or crack_3_,LSD (acid)4_ Speed (amphetamines, uppers)5_ Heroin (dust, horse, junk, smack)6_ Glue, solvents or gasoline7_ Other (specify:^8^Don't know ^> Go to Question 52228b) How serious a health related problem do you consider the use of drugs on-reserve?1_ Very serious2_ Fairly serious3 _ Not very serious4^Not at all serious_c) Do you consider drug use or alcohol use to be a bigger health related problem? (mark one)1_ Drug use2_ Alcohol use5 a) Are there health needs in the village that are not being met?Note: An unmet need exists when a problem has been identified; judgement is made that possiblesatisfactory solutions are not accessible, are not currently adequate, or do not exist in the village.1^Yes2 No ^8^Don't know ^ Go to Question 6b) In your opinion, which health needs are not being met?(specify)^(1) ^(2)(3)^(4)(5)^c) Which 3 unmet health needs do you consider the most Important?(specify; (1) is the most important)1   (most important)2332296 a) In your opinion, are there any health services or programs for village people that can bereduced?1_ Yes2^No^8 Don't know ^ Go to Question 7b) Which health services or programs can be reduced?(specify)7 a) In your opinion, are there any health services or programs for village people that should beexpanded or enriched?1^Yes2 No^8^Don't know^Go to Question 8b) Which health services or programs in the village should be expanded or enriched?(specify)8 a) Are there any voluntary, self-help groups (e.g. weight control) in the village?1^Yes2 No ^8^Don't know ^ Go to Question 9b) What are the known voluntary, self-help groups in the village (i.e. on-reserve)?(specify)42309 a) Do band members attend any self-help groups off-reserve?1^Yes2 No ^8^Don't know ^ Go to Question 10d) What self-help group(s) do band members attend off-reserve and what Is the location (e.g.town or other village)?(Specify)^Name of Self-Help Group Location10^Are you...1^Gitksan2 Wet'Suwet'En3^Other (specify) ^COMMENTS:5231APPENDIX DEstimated Sample Size for General Health SurveyAn estimate of the sample size is based on the key study variable self assessed health whichis scaled on a five point scale (excellent, very good, good, fair, and poor). For the purposesof this study, it is estimated that 60% of respondents would rate their health as good orbetter. The estimate is derived from two studies involving on-reserve people aged 15 yearsand over: (1) in isolated villages in nor-western Ontario, 74% (N=477) rated their health asgood (Young, 1982); and, (2) among the Nuu-Chah-Nulth people on Vancouver Island, 53%(N=427) rated their health as good to excellent (per Simon Read, Manager of Nuu-Chah-Nulth Health Board)Calculations are according to the Krejcie and Morgan (1970) formula with computationsdemonstrated by Isaac and Michael (1989, p.192). The formula is as follows:S =  X2 NP (1 - P) ^, whered2 (N - 1) + X2P (1 - P)S = required sample sizeN = the given population sizeP = 0.6 or the proportion of population that rates its health as good or betterd = 0.08, or 8% allowable errorX2 = 3.066 for one degree of freedom at a 92% confidence^level.In application, where N=210, a sample size is as follows:S =^(1.751)2 210 (0.6 (1 - 0.6)) ^= 75(0.08)2 (210 - 1) + (1.751) 2 (0.6 (1 - 0.6))In this study a random sample size of 75 is needed for a population of 210 such that 60% ofthe sample will be within +/- .08 of the population with a 92% level of confidence.If the estimated response rate is 75%, then the adjusted sample is: S = 75/0.75 = 100There is no adjustment made for a sample design effect. The technique involving stratifiedrandom sampling reduces the likelihood of random error. Therefore, if a sample designeffect had been calculated, then a smaller sample size would be required.APPENDIX EInterviewer Training: AgendaA Study of the Health Status and Health Care Needs ofa Gitksan and Wet-suwet-en On-Reserve Population in B.C.Date: May 15 and 16, 1991Time: 0900-1630 hoursPlace: GWES Office, Main floor classroomHazelton, B.C.AGENDA:Time^TopicWednesday, May 15 ^0900-0930^IntroductionDescription of study - 4 parts0930-1100^Techniques and procedures in interviewing.Rule: Confidential Information1100-1200^Questionnaire structure and purpose of nine sections1200-1300^Lunch1300-1330^Self-complete questionnaire1330-1600^Detailed review of Questionnaire1600-1630^Closure: Review main points covered and answer questionsThursday, May 160900-0930^Review day planDiscuss interview techniques and procedures0930-1130^24 Hour Food Recall - Lecture and PracticeDemonstration and Practice of food measurement1130-1200^Discussion - Questionnaire and Food Recall1200-1300^Lunch1300-1500^Role Play to Practice an interview - form pairs1500-1600^Feedback and discussion of interview practice1600-1630^Handout interviewing kitDiscuss time plan for interviewing and weekly follow-up. Closure.232233APPENDIX FSupplementary Tables: General Health SurveyTable FlClan Membership and Age Groupings According to Tribal AncestryCategory Gitksan(No.)Wet'suwet'en(No.)*Gitksan-Wet'suwet'en (No.)Other Tribes(No.)Total(%)Clan Membership:Wolf 15 7 4 0 27Fireweed 11 3 2 4 21Frog 15 11 2 1 30Small Frog 0 15 0 0 15Other 0 3 0 4 7TOTAL 41 39 8 9 97 (100%)Age Groupings:15-19 years 2 8 2 2 1415-24 years 7 7 0 0 1425-34 years 12 7 2 2 2335-44 years 10 11 1 3 2545-54 years 5 4 2 0 1155-64 years 2 0 1 2 565+ years 3 2 0 0 5* Respondents identifying a combined Gitksan-Wet'suwet'en ancestry were members of the Wet'suwet'en village.Table F2History of living Off-Reserve Between 1975-1990 and Bill C-31 StatusLived Off-Reserve Past 15 Years:Residence Established as Result of Bill C-31Yes (No.) No (No.) Not Applicable (No.) Total (%)Yes 10 60 2 * 74No 0 0 25 26Total 10 60 27 97 (100%)* Respondents had lived on-reserve prior to regaining status through Bill C-31Table F3Educational Achievement by AgeEducational Categories 15-24 Years (No.) 25-34 Years (No.) 35-44 Years (No.) 45+ Years (No.) Total(%)No Formal Schooling 0 0 0 1 1Some Primary School 3 0 2 8 13Completed Grade 9 2 1 2 4 9Completed between Gr. 9-12 13 10 5 6 35Completed Grade 12 5 4 1 0 10Some College 3 4 11 1 20Some University 2 4 2 1 9Completed University 0 0 2 1 2Total 28 23 25 21 97(100%)234Table F4Attendance at Residential School According to Demographic Characteristics and Health Assessment.History of Attendance (No. andAverage Years)Non Attendance (No)Ancestry: Gitksan 9 (3.8 years) 31Wet'suwet'en 12 (2.3 years) 28Other Tribes 6 (5.0 years) 11Total 27 (3.3 years) 70Age: 15-24 Years 1 (2.0 years) 2725-34 Years 9 (1.6 years) 1435-44 Years 7 (2.1 years) 1845 Years plus 9 (6.1 years) 11Sec: Male 13 (3.2 years) 34Female 13 (3.4 years) 36Health Rating Excellent 2 4Very Good 9 24Good 12 24Fair 3 16Poor 0 2Table F5Sex Differences in Experiences of Happiness and Interest in Lifeas Affected by Main Activity in Past 12 Months.Happiness Main Activity in Past 12 Months (No. Respondents) Total No.(% overall)Working Lookingfor WorkGoing toSchoolKeepingHouseRetired OtherHappy and Male 14 4 3 0 4 2 27 (49%)interested in Life Female 11 1 4 2 2 0 20Somewhat happy Male 9 7 0 0 0 0 16 (38%)and interested in life Female 7 2 4 7 0 1 21Somewhat unhappy Male 1 0 2 0 0 0 3 (8%)Female 0 2 2 1 0 0 5Unhappy with little Male 0 0 2 0 0 0 2 (4%)interest in life Female 0 0 0 1 1 0 2So unhappy life is Male 0 0 0 0 0 0 0 (1%)not worthwhile Female 0 1 0 0 0 0 1Total by activity Male 24 12 6 0 4 1 48 (49%)Female 18 6 10 11 3 1 49 (51%)Total 42 18 16 11 7 3 97 (100%)235Table F6Relationship Between Health Rating and Health Improvement PlanSelf Rating of Health (No. of Respondents)Health Improvement Plan Excellent Very Good Good Fair Poor Total (%)Yes One Plan 0 5 3 4 0 12%Two Plans 0 11 10 5 1 29%Three Plans 6 9 10 8 0 33%No Plans 1 7 13 3 1 26%Table F7Self-Rating of Health According to Effects of Pain or DiscomfortPain or Discomfort Self-Rating of HealthTotalExcellent Very Good Good Fair PoorDoes not preventactivities0 3 3 1 0 7Prevents a fewactivities0 4 3 3 0 10Prevents someactivities0 5 4 5 0 14Prevents mostactivities0 0 3 2 2 7Total experiencingpain or discomfort0 12 13 11 2 38No pain ordiscomfort7 21 23 8 0 59Table F8Daily Smokers Use, Beliefs Regarding Potential Harm, and Attempts of Quit the HabitFactors No. No. CigarettesSmoked (Range)Beliefs in Likelihood of Harm to Health Tried to QuitPast 12 MonthsVeryLikelySomewhatLikelySomewhatUnlikelyVeryUnlikelyYes No11 9 (3-15) 4 6 1 0 8 315-24 years25-34 years 9 12 (5-30) 3 5 0 1 4 535-44 years 7 13 (3-20) 3 3 1 0 1 645+ years 3 11 (6-20) 2 1 0 0 2 1Total 30 11 (3-30) 12 15 2 1 15 15Education:•Grade 1-8 2 18 (15-20) 2 0 0 0 0 2Grade 9-12 15 10 (3-20) 6 8 0 1 9 6Post Secondary 10 12 (3-30) 2 6 2 0 4 6Sex:Male 12 11 (5-20) 5 7 0 0 5 7Female 18 11 (3-30) 7 8 2 1 10 8• Adjusted for age under 45 years.Table F9Proportion of Friends Who SmokeCategories Proportion of Friends Who SmokeTotalAll Most Half A Few NoneSex - Male 9 28 5 5 1 48- Female 11 15 9 14 0 49Smokers - Male 7 20 3 1 1 32- Female 10 9 7 4 0 30: •15-24 years 10 14 1 2 1 2825-34 years 2 11 5 5 0 2335-44 years 3 12 6 4 0 2545+ years 5 6 2 8 0 21Education: ••Grade 1-8 3 5 0 1 1 10Grade 9-12 10 19 4 6 0 39Post secondary 2 13 8 5 0 28• Chi Square = 20.8: p < 0.05•• Chi Square = 15.8: p < 0.05: Controlled for age under 45 yearsTABLE F10Distribution of Smokers and DrinkersCategory No. Respondents %Smokers%DrinkersTotal 97 64 76Male 48 67 81Female 49 61 71Age Group:15 - 24 years 28 82 7925 - 34 years 23 74 8735 - 44 years 25 56 8445 years and over 21 38 52Education:•Grade 8 and less 13 71 70Grade 9 - 12 42 72 76Post Secondary 30 63 93• Age adjusted for under 45 years236Table FllBeliefs of Potential Harm of Alcohol in Relation toDrinking Patterns of Men and WomenDrinking Pattern Beliefs Regarding Potential Harm of AlcoholVerylikelySomewhatlikelySomewhatunlikelyVeryunlikelyDon'tknowMale:Weekly 15 9 7 2 0Monthly 9 2 4 2 1Less Often 1 2 0 1 1Female:Weekly 0 2 5 1 0Monthyl 2 2 4 5 0Less Often 2 1 0 11 0Sex makes a difference in beliefs: Chi square = 33.3; p < 0.007TABLE F12Body Mass Index (BMI) for Current and Desired Body Weightfor Men and Women Between 20 and 65 YearsBMI No. Resp. Age Groupings in Years (No.)20 - 24.9^25 - 34.9(n = 14)^(n = 23)35 - 44.9(n = 25)45 - 54.9(n = 11)55 - 65(n = 5)Current: •Less than 20 2 2 0 0 0 020 - 25 32 11 8 6 4 325 - 27 11 0 8 2 1 0Greater than 27 33 1 7 17 6 2Desired:Less than 20 2 1 0 1 0 020 - 25 46 10 13 14 6 325 - 27 17 2 8 4 3 0Greater than 27 13 2 2 6 2 2• Chi Square = 36.1: p < 0.0003237238,..oE-..Ci4* il.*.^$ $ « « ,,,^„, ,, cr,^A-. ..zzzzkk., "''—— N 4^kI.4 S 0 0 < $ $ $ $ < 0 0 .0 0 © 0 0 (^zv, $6, ... $ a ^zzzzzit-^in^-'^'- 'n,-.  IIC......itI(_ ^ ..8^ I! $ $ $ $ $ $ c, IQ. ce) A co '4 e. 7.. $..„....,^- .'d Z Z Z Z Z Z 't^I's .. 47' NN csi Z17,ecoO — © 5_, •are^N^ts,:.^MM IN-^0^V:)^A^M^NI^en^0...,^,91^,^'CU^3^"^ill N'^1f2^4.1^"^.Mr ^+1^isrl^0^0•~—'7-1^r...^+Iv n^.11 11 +I^+I +I^+I0.^cn 41^+I^+I^a +I^0^+1^+I^+1^+I^so0 +I^,-. N N F.' 0 ' In P —, ' —, -. --. M 'r^m ,^en^,--1^.-■^soEg^A^n- ,...) 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Zrei * ,i)_u=5^ma'<<<<<*^*sA ,-,^2 <,..., ,c2. ,=.iZZZZZ24,--.•-■—■,4 * A ziP';')AR 4'.H A::2 ,4.. 7, F t,;1^ 1 7. r a r4+..-r +4a^+I^+I^+I^+I^,_,^+I^4.1^.1.1^+I^+I^+I^.0.cn +I^+I^+I^co)+I^m 2 ^In ,51 — n rn' ,c,6, — ,% ,,..^A.1 n^R AA^en^t...^©—••• • • •wi^v •.. • ••ea^..--,ealao^i;,^/1.., ..7. ,^2^.... ., p c,^PI^E la^I,a m 4^g . .t,^1., , < 11, .^3 u 1— — .g.,^2 .r) 2 s ri^, .= 1 ,_,^c laa.s...' 5 •-• .1^E c 5^2^ I^E. C^t.,a i .? Q C 2 85 ..•^"6^0.^r.r.^,i,^c^5^.5^2^iy,^*1^5^.,-5Z^c.fl ti.^C ar:^d e e *^(5"?.•''g^i72 '2^2 ''' ir.6ma W5.)•c8OTable F15Reasons for Not Seeing a Dentist in the Past 12 Monthsand Usual Practices in Dental VisitsNo. Resp. Sot (%)Male^FemaleReasons:Too busy 6 50 50Nothing wrong 11 82 18Afraid or dislike dentists 3 66 33Don't know a dentist 1 0 100Unable to make appointment 3 33 66Other 4 33 66Usually see a dentist:Regularly 7 29 71Less than once a year 1 100 0Only when have pain or trouble 20 70 30Table F16Feelings of Overcrowdedness in Single and Multiple Family HomesNo. Families No. Resp.^Feeling of Being Overcrowded (%) Most times^Often Sometimes Occasionally NeverOne^ 71^10^4^16^11^59Two 21 29 5 28 10 28Three 5^60^20^20^0^0Total^97 16 5 19 10^50240Table F17Social Conditions and Experiences of Men and Women 15 Years and OverConditions and Experiences No. Resp. Sex (No. (%))Male (N = 49) Female (N = 48)Average No. family members feel close to • 97 15 10Frequency in visiting family members:More than once a week 56 25 (45%) 31 (56%)Once a week 18 13 (72%) 5 (28%)Once a month 7 6 (86%) 1 (14%)Several times a year 9 3 (33%) 6 (67%)About once a year 3 1 (33%) 2 (67%)Average No. close friends •• 97 7 3Frequency in visiting close friends:More than once a week 42 20 (48%) 22 (52%)Once a week 22 10 (46%) 12 (54%)Once a month 6 4 (67%) 2 (33%)Several times a year 6 3 (50%) 3 (50%)About once a year 5 5 (100%) 0 (0)How spent leisure time:Almost all by self 5 4 (80%) 1 (20%)More than half by self 5 0 (0) 5 (100%)Half by self, half with others 40 19 (48%) 21 (52%)Almost all with others 46 24 (52%) 22 (48%)Satisfaction with social life:Very satisfied 27 18 (67%) 9 (33%)Somewhat satisfied 55 25 (45%) 30 (55%)Somewhat unsatisfied 12 3 (25%) 9 (75%)Very unsatisfied 3 2 (67%) 1 (33%)Have children of own 67 29 (43%) 38 (57%)Satisfaction with relationship with children:Very satisfied 53 24 (45%) 29 (55%)Somewhat satisfied 12 4 (33%) 8 (67%)Somewhat unsatisfied 12 1 (50%) 1 (50%)Presently married or living with someone 54 25 (47%) 29 (53%)Satisfaction with relationship:Very satisfied 30 20 (67%) 10 (33%)Somewhat satisfied 18 5 (28%) 13 (72%)Somewhat unsatisfied 6 0 (0) 6 (100%)Have someone to confide in 79 36 (46%) 43 (54%)Have someone to help in time of need 86 44 (51%) 42 (49%)Member of a voluntary group 51 26 (51%) 25 (49%)Regularly attend meetings 34 18 (53%) 16 (42%)Member of a committee 26 13 (50%) 13 (50%)241Table F18High and Low Levels of Well-Being and Relationships to Health ExperiencesHealth Experience Well-Being SignificanceLow (%) High (%)Health Ratinx:Excellent 1 (3) 6 (10) X2 = 2.7; p < 0.61Very good 12 (32) 21 (36)Good 15 (39) 21 (36)Fair 9 (24) 10 (17)Poor 1 (3) 1 (2)Total 38 (100%) 59 (100%)Happiness and Interest in Life:Happy 10 (26) 37 (63) X2 = 15.6; p < 0.003Somewhat happy 18 (47) 19 (32)Somewhat unhappy 6 (16) 2 (3)Unhappy with little interest 3 (8) 1 (2)So unhappy life not worthwhile 1 (3) 0 (0)Level of Stress in Life:Vety stressful 6 (16) 2 (3) X2 = 11.3; p < 0.01Fairly stressful 22 (58) 23 (39)Not very stressful 9 (24) 28 (47)Not at all stressful 1 (3) 6 (10)Satisfaction With Health:Very satisfied 5 (13) 23 (39) X2 = 13.3; p < 0.004Somewhat satisfied 19 (50) 30 (51)Not too satisfied 12 (32) 5 (8)Not at all satisfied 2 (5) 1 (2)Thought of Taking Own Life inPast 12 Months:Yes 10 (56) 6 (32) X2 = 2.16; p < 0.14No 8 (44) 13 (68)242


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