Wisdom and influence of elders: possibilities for health promotion and decreasing tobacco exposure in first nations communities.

Varcoe, Colleen ; Bottorff, Joan L. ; Carey, Joanne 等

High rates of maternal smoking during pregnancy and postpartum and exposure of infants and children to secondhand smoke (SHS) are persistent health concerns that contribute to health disparities between Aboriginal (encompassing First Nations, Metis and Inuit people)1 and non-Aboriginal Canadians. (2,3) Aboriginal women are about three times more likely to be smoking during pregnancy as non-Aboriginal women. (4,5) Aboriginal households report that 32% (compared to provincial rates of 18%) of households with children under age 11 experience daily or nearly daily exposure to SHS. (6) Similar to indigenous populations worldwide, rates of cigarette smoking and exposure to SHS in Canadian Aboriginal communities are influenced by levels of poverty and community resources, geographic isolation, and historical and ongoing colonization. In spite of the above, there have been few studies of antenatal smoking and indigenous women. (7) Interventions aimed at supporting behavioural change for individuals, such as drug therapy and quit-lines, have been studied in Canadian Aboriginal contexts, but shown to have limited impact, (8-11) and recent legal and taxation policies to curb tobacco sales have had limited success. (12-14) There has been little study to develop context-specific public health interventions. Contemporary Aboriginal communities are actively seeking health and revitalization, in part through emphasizing culture and tradition. (15,16) Members of the Gitxsan First Nations were interested in finding ways to protect pregnant women and those with young children from cigarette smoke and to support women's tobacco reduction efforts. This participatory ethnographic study examined the research questions in Table 1; this paper reports on one context-specific strategy.

METHOD

Using an ethnographic approach within a participatory paradigm informed by decolonizing intent, (17,18) community health care providers partnered with academic researchers to explore interpersonal and system influences on smoking practices and exposure to SHS that increase health risk for pregnant and parenting women and their children and to develop meaningful strategies to support tobacco reduction and reduce SHS exposure. (19) Drawing on principles for conducting research with Aboriginal communities, (20,21) ethical approval was obtained from the community and the researchers' university.

Context

The six study communities were in Gitxsan Territory in rural northern British Columbia (Table 2). Cigarette smoking was prevalent, particularly among youth. (22,23) Economic factors of the reserve system coupled with limited employment income and poverty made tobacco both a source of income and a reasonably affordable source of pleasure. Further, financial factors and limited affordable recreational activities contributed to bingo being a popular social and fundraising activity that involved smoking and exposure to SHS in all but one community. Community leadership was diverse, encompassing band councils, elected chiefs and hereditary chiefs who operated through different mechanisms of influence, facing competing priorities that were not necessarily focused on health issues such as tobacco.

Data collection

Multiple participatory strategies were used (Table 3). Data were collected through individual and focus group interviews and participant observation of activities including community walks, prenatal programs, parenting and lunch programs. Participants were recruited using purposive sampling

to optimize diversity. As shown in Table 4, the 66 participants included 26 young women who were pregnant or parenting young children, 9 Elders, 6 youth, 10 adult community members and 15 key community members (KCM), all of whom had prominent roles and some of whom also were considered Elders by the community. Interviews and focus groups were conducted by a trained research assistant who was a young woman with children and a member of the Gitxsan Nation; about half of the sessions were co-conducted with other team members. All interviews were recorded and transcribed. Team members conducted participant observations and kept detailed field notes.

Data analysis

Data were analyzed using ethnographic techniques. (24,25) Team members read interviews repeatedly and identified and categorized meaning units. Categories were compared and contrasted to develop themes. Based on several initial interviews, an inductive coding scheme was developed through consensus. Interview data from diverse participants across all study communities were compared and field note data supplemented interview data to develop themes and descriptions. Investigator subgroups explored particular themes in greater depth. Procedures were documented to develop an audit trail regarding how conclusions were drawn. Community-based research team members participated in all aspects of analysis, and community members provided feedback through an interactive event that used the findings.

FINDINGS

Overall findings of this study highlighted how possibilities for tobacco reduction must be understood within the historical and socio-cultural context of tobacco use in rural First Nations communities and drew attention to context-specific strategies. (19) One such strategy identified throughout the study was to engage Elders. Although cultural erosion has affected the status of Elders, the latter continue to play dynamic and influential roles. Although some Elders smoked, and some expressed doubt about their potential for influence, success stories regarding tobacco control were routinely linked to Elders, and community members expressed hope that Elders could provide further leadership.

The Role of Elders

In the Gitxsan tradition, Elders are people knowledgeable about culture and tradition who can articulate "the way"--beliefs and expectations of the Gitxsan people. For example, Elders would know the Feast system and the relations among various clans. Elders are not always persons over a certain age, and not all older persons are considered Elders. Rather, Elders are those who have and show concern for others and the community and show leadership. The position of Elder in the Gitxsan nation is one of esteem and respect. However, the position is also influenced by politics. That is, certain Elders are more likely to be called upon than others because of their connections, and some people assert themselves as Elders rather than achieving that status through community recognition.

In the study communities, Elders were frequently invited to speak to youth in classrooms and share stories with children so as to maintain cultural knowledge. Importantly, participants thought Elders had a key role in guiding youth:

I tell children ... if an Elder comes and talks to you about some things you're doing, it's more than likely they're giving you a detour of your life you know, they're saying I've been down that road, don't bother with it, try something else because you're just wasting time and energy and probably sacrificing your health, your youth especially. [KCM]

In interviews, Elders expressed great interest in being more involved in their communities, particularly with youth. One said, "I would be interested in being available ... for example ... if there were teenage moms that just needed someone that they could talk to or spend time with." However, alongside the professed reverence for Elders, many participants, including Elders themselves, discussed the erosion of the role of Elders and declining respect.

I was taught to always respect Elders. And then when I see younger people totally disrespecting them in their tone of voice or just the way they speak to them, I just get really angry and frustrated inside and go, "didn't your parents teach you?!" [Young mother]

Despite these tensions, participants routinely identified Elders as an important possible source of influence.

Contemporary success stories linked to role of Elders

Enduring respect and concern for Elders and their instrumental role in positive tobacco control measures were evident in the data. For example, a locally produced anti-smoking poster was well known for the Elder's message: "We smoke fish, not tobacco." In one community, reports about efforts to establish smoke-free bingos in the community hall were directly linked to the support of Elders.

Well, I was surprised that it was an Elders' group that brought up that the bingos should be smoke-free. Like I thought I would have heard that from some moms, but I think I first heard it through an Elders' discussion. [Young mother]

In another community, a chief recounted banning smoking at feasts to protect the health of Elders:

When I became a chief and we were going to have a feast ... someone said to me, "gee, you know I don't really mind coming to feasts, but it's the smoke I can't stand," you know. So, there was an opportunity for me because I took the name, and I stood up there, and I said, "this is going to be a non-smoking feast because there are Elders that are here and they enjoy the companionship of everybody, but there's a big difficulty in smoking and most of our Elders are sick ... so no more smoking in our feast." So, there's been no smoking in most of all our feasts.... since '95, I think, when I took the name. [Elder]

In addition to successes at a collective or policy level, participants told stories of Elders being inspirational. One participant told how an Elder had thrown his cigarettes into the ocean, quitting smoking for good: "for kids to hear that, I think ... can be very inspiring to them, you know."

Elders as potential source of leadership

In discussing strategies for extending smoking restrictions to other settings and events, the importance of enlisting the support of Elders was a consistent theme. Community members, especially mothers, saw Elders as important allies in dealing with SHS. Ideas for their involvement ranged from role modeling non-smoking or respectful smoking to teaching broader traditions. With limited housing options, multiple generations often lived together, meaning that Elders had potential for influence directly in the home. Many noted that Elders with first-hand experiences of the harmful effects of smoking had made important changes that served as a model:

Most of the Elders that I talk to don't smoke or don't like it. They smoked so much in their lives that they just quit 'cause they're Elders now, and it's starting to affect their health. [Young mother]

Some Elders had stopped or reduced smoking for their grandchildren. Of those who continued to smoke, some were adamant that youth should not take up the habit and worried about children being exposed to SHS.

Although many talked about the importance of smoke-free community events to protect the failing health of Elders, those who wanted to extend smoking restrictions wanted Elders to do more.

I think once our Elders step in and show what needs to be done and stuff like, like even though our Elders don't smoke, but if they were to enforce no smoking here, like even right out of the bingo halls you know. It would step up and show that our Elders are serious... [Young mother]

Participants thought that drawing on Elders as a source of leadership in relation to smoking and exposure to SHS would not only be culturally appropriate, but also would be congruent with how the community understood the causes of smoking including loss of traditions, underemployment and boredom. One KCM emphasized the importance of such indirect measures and actively engaging the community, saying, "because then you're starting to look at underpinning issues and root causes rather than [something] as specific as changing eating or changing behaviour around smoking."

Since the completion of data collection, one of the largest bingo halls, attached to a school, was pressured by community action to become smoke-free. Community members noted that the protest that led to the change was initiated by a young mother and supported by community Elders. The women saw this change as significant, not only as symbolic of rising concern and action, but as affecting one of their limited social opportunities that in turn influenced their ability to reduce their own smoking.19

Study limitations

Conducting the study with one specific First Nation limits the applicability of the findings to other groups. The focus on tobacco reduction may have constrained participants who smoked from expressing certain viewpoints; however, collecting data in both individual and focus group formats and from people with a range of smoking experiences, increased data variation. Although generalizability is inappropriate given the sample size and specific context, the fit with other literature suggests these findings have applicability beyond the Gitxsan, particularly to other First Nations and to other health concerns beyond tobacco.

DISCUSSION

Although First Nations communities are diverse, representing over 50 different language groups and diverse multiple cultures,26,27 many communities share a high value for Elders and see them as spiritual leaders. First Nations also share the experiences of colonization--and while those experiences vary, all Aboriginal people were subject to colonial policies flowing from the Indian Act that eroded their cultures, languages, ways of life and access to material resources. Addressing these dynamics that have led to poor health for many people must be central to health promotion. Other researchers have argued that strengthening ethnocultural identity, community integration and political empowerment can contribute to improving mental health for Aboriginal people. (28-30) We suggest that these have broad health impacts and that engaging Elders is one key element in such strengthening. Researchers need to recognize Elders and their importance in conducting research--and a similar approach needs to be taken to tobacco control.

As interventions aimed at behavioural change have had limited impact on tobacco control, new models are required. Our findings indicate that for First Nations communities, drawing on the Elders may be a key strategy for such models. Rather than beginning with predetermined tobacco reduction strategies from other contexts, Elders may guide context-specific approaches, including using their own influence through multiple connections. Importantly, drawing on the wisdom of Elders contributes to cultural strength and therefore would be an approach that would help address what the participants saw as the root cause of smoking: cultural erosion.

Appropriate protocols and approaches to involving Elders will vary with each community and nation. Invitations to Elders to participate in health strategies such as tobacco reduction measures need to be made in the context of meaningful relationships. Local knowledge would be required both to know who to approach and how, and to build bridges to establish strong relationships with Elders. Programs to partner youth and Elders--helping Elders with firewood was suggested--could have multiple benefits. Understanding what constitutes an Elder and identifying which people are considered Elders by whom are prerequisite to seeking consultation. Existing community health advisories could be used to expand or formalize the role of Elders. Further, broad and multiple strategies are needed in order to involve Elders beyond those who are routinely identified to give input. In some contexts, consultation with as many Elders as possible might be appropriate; in others, a snowball approach to seek out diverse Elders might be best. Our experience suggests that concrete strategies such as insuring that bilingual community members are available to interpret, inviting family members together, and offering door-to-door transportation are essential.

Realistically enacting such an orientation to health promotion would require commitment at all levels. First, funding bodies such as Health Authorities could require guidance from Elders in relation to health programs, including those aimed at tobacco reduction. Bodies funding health research could specify similar requirements. Second, researchers and people implementing programs routinely could build in provisions for drawing on such guidance. In settings such as universities, colleges and some health care settings, Resident Elders are becoming increasingly formalized and paid positions, and such strategies might be adapted for community organizations, particularly if support is provided through program and research funding. Finally, service providers and community members could identify Elders who can provide wisdom and leadership.

Received: October 14, 2009

Accepted: January 27, 2010

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Colleen Varcoe, PhD, RN, [1] Joan L. Bottorff, PhD, RN, FCAHS, [2] Joanne Carey, MA, [3] Debbie Sullivan, bsn, MN, [4] Wanda Williams [5]

Colleen Varcoe, PhD, RN, [1] Joan L. Bottorff, PhD, RN, FCAHS, [2] Joanne Carey, MA, [3] Debbie Sullivan, bsn, MN, [4] Wanda Williams [5]

Author Affiliations

[1.] Associate Professor, School of Nursing, University of British Columbia, Vancouver, BC

[2.] Professor, Institute for Healthy Living and Chronic Disease Prevention, University of British Columbia Okanagan, Kelowna, BC

[3.] Research Coordinator, Institute for Healthy Living and Chronic Disease Prevention, University of British Columbia Okanagan, Kelowna, BC

[4.] Community Health Nurse, Gitsegukla Health Programs and Services, Gitsegukla, BC

[5.] Community Health Representative, Gitsegukla Health Programs and Services, Gitsegukla, BC

Correspondence: Dr. Colleen Varcoe, Associate Director, Research, University of British Columbia School of Nursing, T201-2211 Wesbrook Mall, Vancouver, BC V6T 2B5, Tel: 604-827-3121, Fax: 604-822-7466, E-mail: [email protected]

Conflict of Interest: None to declare.

Table 1. Research Questions

1. How does the social and physical context (i.e., gender, age, culture,
   living on reserve, rural/urban) influence young pregnant and
   parenting Aboriginal women's tobacco use, and young women's and
   children's exposure to SHS by other smokers?

2. What strategies do young Aboriginal women use to reduce tobacco use
   and to minimize SHS exposure for themselves and their children?

3. What factors and processes need to be considered in designing
   interventions, programs and policies to support smoke-free spaces
   and tobacco reduction that will benefit young pregnant and parenting
   Aboriginal women?

4. What are community reactions to knowledge gained about the
   experiences of young pregnant and parenting women related to
   tobacco, and identified strategies and priorities for tobacco
   reduction?

5. What are the challenges and opportunities for providing smoke-free
   environments for young pregnant and parenting Aboriginal women and
   their children as viewed by community members?

6. How can the research process and the findings inform the development
   of context-specific strategies and action plans for tobacco
   reduction that address the needs of young pregnant and parenting
   Aboriginal women and their children?

Table 2. Community Profile (31)

Population              Study villages range from 480 to 2000

Distances               75 km between the largest village and the
                        closest urban centre with airport, shopping,
                        hospital, recreation facilities (population
                        approximately 5,000)
                        Study villages are clustered within a 60 km
                        radius.
Income and Employment   Average annual income
                          Women: $9100-$14,688
                          Men: $8144-$10,816
                        Unemployment rate 30-50%

Table 3. Participatory and Context-appropriate Strategies

Phase          Strategy

Recruitment    * Community-based team members (community health nurse
                 [CHN], community health representative [CHR], research
                 assistant) recruited in multiple community venues
                 (e.g., health fairs, job fairs)
               * Family members welcomed to participate together
                 (e.g., cousins, mother and daughters, sisters)

Interviewing   * Community-based First Nations team members present at
                 all interviews with First Nations members
               * Series of small group interviews held with young
                 women to enhance comfort
               * Food routinely provided
               * Gitxsan-speaking team member present for Elders focus
                 group (interpreting intermittently)

Analysis       * Analysis conducted throughout data collection
               * All team members (community-based and academic)
                 engaged throughout (from initial analysis to writing
                 of papers)
               * Multiple methods used to take developing analysis to
                 community (regular newsletters, video, community
                 events) for feedback

Knowledge      * Participatory community event using actors and video
Exchange       * Regular newsletters

Table 4. Participant Demographics *

                             n Participation           Age

Young women (all parenting;  26 2-4 individual and     17-34
  3 pregnant at time of        small group interviews  (m ([dagger])
  interview)                                           =24.8)

Key community members (KCM)  15 Individual interview   32-64
  (e.g., Public/Community    (13 female; 2 male)       (m=51)
  health nurses, community
  health representatives
  [CHR], family
  facilitators, addiction
  counsellors, educators,
  managers)

Elders                       9 Focus group interview   63-87
                             (8 female; 1 male)        (m=75)

Community members            10 Focus group interview  27-61 (m=43.5)
  (recruited to increase     (7 female; 3 male)
  representation from all
  communities)

Youth                        6 Focus group interview   13-17
                             (3 female; 3 male)        (m=15.3)

                             Smoking Status

Young women (all parenting;  Ex-smoker (n=7)
  3 pregnant at time of      Occasional (n=9)
  interview)                 Daily (n=10)

Key community members (KCM)  Never smoked (n=7)
  (e.g., Public/Community    Ex-smoker (n=2)
  health nurses, community   Occasional (n=5)
  health representatives     Daily (n=1)
  [CHR], family
  facilitators, addiction
  counsellors, educators,
  managers)

Elders                       Never smoked (n=4)
                             Ex-smoker (n=2)
                             Occasional (n=2)
                             Daily (n=1)

Community members            Ex-smoker (n=3)
  (recruited to increase     Occasional (n=3)
  representation from all    Daily (n=4)
  communities)

Youth                        Never smoked (n=4)
                             Ex-smoker (n=2)

* all participants were members of Gitxsan First Nation except 4

Key Community Members

([dagger]) m=mean