Development of a curriculum on the health of Aboriginal children in Canada

Who are the Aboriginal peoples in Canada? How many Aboriginal peoples live in Canada? What are the health conditions faced by Aboriginal children? What are some of the basic things I should know as a health practitioner in treating Aboriginal children? These are all important questions that many paediatricians would like to know, but where does one get this information? Until recently, there has been very little formal teaching on the health of Aboriginal peoples in medical schools and residency programs but things are slowly changing. In 2009, the Indigenous Physicians Association of Canada (IPAC) and the Royal College of Physicians and Surgeons launched teaching programs on Aboriginal health for residency training in family medicine, psychiatry and obstetrics and gynecology (1). In the same year, IPAC and the Association of Faculties of Medicine launched a curriculum for all medical schools in Canada on Aboriginal health (2). Since May 2011, paediatric residents have had formal teaching on the health of Aboriginal children in Canada. In December 2005, a summit was held on the health of First Nations, Inuit and Métis children and youth. Approximately 160 delegates (Aboriginal and non-Aboriginal) from across Canada shared their views on the health of Aboriginal children. The ideals that were discussed at that summit were summarized in the document The Principles of the Health of First Nations, Inuit and Métis Children and Youth (3). One theme that emerged was that health care providers know very little about Aboriginal peoples in general and even less about their health care needs. At the same time, a curriculum on healthy, active living for children in Canada was being developed by the Canadian Paediatric Society (CPS) to be taught at all paediatric residency programs. It was believed that a curriculum on the health of Aboriginal children aimed at paediatric residents was feasible and would be a great way to increase the knowledge base of paediatricians in training. The First Nations, Inuit and Métis Health Committee of the CPS decided to undertake the task of creating this curriculum. I took the lead role with help from Dr Sam Wong, Dr Heather Onyett and Dr David Goldfarb. Data from the curriculum was pieced together from various reports and publications. We did not believe an extensive literature search would be beneficial given the limited data in this field. In fact, we obtained our most pertinent data from the reports of our Aboriginal partner organizations (4–6). There were limited data from traditional literature searches. The curriculum went through many transformations. Probably the most unique aspect of this curriculum was that input was received from 10 national Aboriginal organizations from early on in the process through to completion. There were two face-to-face meetings with the organizations plus revisions performed electronically. In many ways, it exemplifies the ideal that is recommended in working with Aboriginal peoples. The project was essentially requested by Aboriginal peoples at the summit in 2005, and Aboriginal peoples were partners throughout the completion of the project (7,8). The curriculum went through a trial run with the paediatric residents in Kingston (Ontario) and their feedback was also essential to the completion of the curriculum. It seemed like the hard work was over once the curriculum was actually completed, but the next phase proved to be equally challenging. How do you get this information to all paediatric residents in Canada? The biggest hurdle was finding funding, which was graciously provided by the National Collaborating Centre for Aboriginal Health (9). We decided to identify a local ‘champion’ from each paediatric residency training site to teach the curriculum across the country (we continue to search for a ‘champion’ from the Université de Laval, Laval, Quebéc). The ‘champions’ were brought to a central location in May 2011 for a train-the-trainer session. To date, at least six programs have been taught the curriculum and we hope most will have been taught by the time of publication. To the best of our knowledge, this is the first time a curriculum on the health of Aboriginal children in Canada has been taught across the country. 1,172,790 people identified as an Aboriginal person in the 2006 census (10) According to the 2006 census, the average age of Aboriginal peoples was 27 years compared with 40 years for the average age in Canada (10) 54% of Aboriginal peoples live in urban areas (10) The Inuit infant mortality rate is two to four times higher than the average Canadian rate (11) The tuberculosis rate among Inuit is 185 times the Canadian rate (12,13) Iron deficiency rates in children can be as high as 32% in some Aboriginal populations (14) In 2001, 41% of Aboriginal children (<14 years of age) in Canada were living in poverty (national rate 11.7%) (15) First Nations children were seven times more likely to be in foster care between 2005 and 2007 compared with non-Aboriginal Canadian children (5% versus 0.67%) (16) The content of the curriculum is not limited to statistics but also includes guidelines for treating Aboriginal children, ideas for advocacy, discussions regarding the importance of culture and discussions about the resiliency of Aboriginal peoples. It is not meant to highlight the difficulties but rather point out the facts and encourage change. The table of contents from the two-part curriculum will give you an idea of the full content. Table of contents for the two-part curriculum on the health of Aboriginal children in Canada Table of contents for the two-part curriculum on the health of Aboriginal children in Canada Evaluation is an extremely important part of the process for any type of teaching. There were two things we wanted to know from the residents: is this teaching useful for you and will you remember any of it in the long run? So far there is a resounding ‘yes’, and most residents believe it was very useful for their current practice (75.4% rated 4 or 5 out of 5) and for their future practice (79.9% rated 4 or 5 out 5) as well. In fact, 89.2% of the residents gave the curriculum a high rating when asked about their overall opinion of the curriculum. For the second, and more important, question of retaining this information, we handed out a pretest on the day of the curriculum, which the residents all completed. Several weeks later, the residents received an e-mail directing them to complete the identical post-test online. The results from the tests are just starting to come in and there are a few key findings: There was an improvement in the number of correct responses on 14 of 20 questions from pretest to post-test On six of 20 questions, the answers were either unchanged or fewer residents had the correct response from pretest to post-test The questions that did not improve or had a worse performance involved more difficult concepts regarding Aboriginal peoples (eg, differences in medical funding for Aboriginal peoples compared with non-Aboriginal Canadians remains a difficult concept) We are still early in the evaluation phase, and it is too preliminary to draw any firm conclusions from these limited data, but we are hopeful that the residents are learning and retaining this information. Ultimately, we hope this will improve overall care for Aboriginal children. Putting together this type of information is very time consuming and, by the time we finalized the curriculum, several new reports had just been released and thus could not be included in the curriculum (16–18). It is clear that we will need to update the curriculum with some of this new information, and we will perform a more extensive literature review as well. Some topics (eg, food security) could not be included in this first edition due to space limitations, and this will need to be addressed. Our first step, however is to evaluate the feedback from the residents and the results of the pre- and post-tests. Obviously, in the long run we hope that this curriculum will promote a lot of reflection for our future paediatricians and, more importantly, improve the quality of care for Aboriginal children in Canada. Although I had a lot of help, I was basically the main author of the curriculum. As a First Nations person, I have to admit that I struggled with many of the facts that I learned. The first struggle was realizing how little data there are on the health of Aboriginal children in Canada. It makes me wonder why there are so few quality data on this important population with many health discrepancies. Not only is there a need for more research, but we must do a better job of basic public health surveillance in partnership with Aboriginal peoples. Many of the facts were also difficult to learn. Finding out that the population of Aboriginal peoples dropped by 80% to 90% between 1492 and the early 20th century was a surprise (19,20). Learning about the funding discrepancies that have led to the number of Aboriginal children in foster care as mentioned above was difficult (funding for First Nations child welfare on-reserve comes from the federal government and is significantly lower per capita than provincial funding for child welfare for any child off-reserve) (16). Both the Royal Commission on Aboriginal Peoples in 1996 (19) and the blueprint from the Kelowna Accord in 2005 (21) made several recommendations to improve the overall health and social status of Aboriginal peoples. Realizing that few of these recommendations have been followed through remains very difficult to understand (22,23). We continue to hear words from the government that the health and well-being of Aboriginal peoples is a priority. To date, those words have not translated into significant, long-standing improvement, but I remain hopeful that Aboriginal children will someday be on an equal status with their non-Aboriginal counterparts. I like to think the curriculum will play a role in that process. In 2011, the CPS launched the first curriculum on the health of Aboriginal children in Canada. The curriculum is intended for paediatric residents and will be available to each paediatric training site in Canada. It is unique in that it encompasses feedback from First Nations, Inuit and Métis national organizations. The curriculum focuses not only on health statistics but was also designed to teach residents the holistic aspect of health care. Preliminary feedback is excellent thus far. We are hopeful that the curriculum will not only inform residents of many important facts on the health of Aboriginal children in Canada, but will also inspire them to work with Aboriginal peoples to improve the long-term health of their children.

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