This study highlights several potential barriers toward adoption of healthy behaviours that exist in the Six Nations community. Specifically the built environment was viewed as being unfavourable to walking, access to healthy foods on the reserve was limited, and easy access to tobacco products was seen as problematic for the community.
While most respondents were satisfied living on the Reserve, participants identified the Reserve as being a difficult place in which to walk, having low street connectivity, poor aesthetics, and a higher potential for crime and traffic safety concerns. The ratings for neighbourhood walkability on the Six Nations reserve are very low in contrast to urban cities in Canada, where street connectivity, aesthetics, access to walking/cycling facilities and safety score above mid-point values on the NEWS questionnaire [29
]. The NEWS questionnaire has been used to assess walkability in rural regions also, but not yet in Canada. It may be expected that walkability scores may be lower in rural compared to urban regions, although this is highly context dependent [23
]. Enhancements to the walkability features of the Reserve may be an important target to increase physical activity among community members.
All participants purchased their groceries off of the Six Nations reserve, which is likely due to the greater availability and affordability of food. Six Nations respondents travel off of the Reserve more than 5 times per month in order to obtain a variety of food items, and spend approximately $151 per week on groceries alone, in contrast to the average total food expense of $140 per week in Ontario households [30
]. In addition, Aboriginal households in Ontario are reported to have markedly lower household incomes ($46,865) in comparison to the Ontario median ($60,455), suggesting a greater burden of food costs is carried by Aboriginal families [31
Overwhelmingly 90% of the community members reported tobacco use as being a problem in the Six Nations community especially among teenagers. Children and teenagers were perceived to have easy access to tobacco on the Reserve. Most participants are aware of smoking support programs, bans in public, advertisement laws, and health warnings on tobacco packaging. While most individuals indicated that bans on tobacco advertisements or increased law enforcement would be acceptable for reducing rates, only 3% were willing to tolerate increased taxation.
Prior studies of the association between contextual factors and health behaviours in non-Aboriginal communities such as physical activity, dietary intake, BMI, and tobacco use have produced mixed results. A recent systematic review of studies in which community-based interventions were initiated to improve community levels of physical activity reported inconsistent results, and emphasized the need for well-designed intervention studies [33
]. Prior studies have reported that food availability and affordability [34
] and presence of supermarkets [35
] are associated with healthy food purchases, whereas difficulty accessing produce and high quality groceries promoted the consumption of fast food [36
]. A recent systematic review of 28 studies, mostly from the United States showed that greater accessibility to supermarkets or less access to takeaway outlets was associated with a lower prevalence of overweight/obesity. However, no strong associations between the food environment and dietary intake were observed, with the exception of area-level deprivation where individuals who lived in low socioeconomic communities had a greater likelihood of having an obesogenic dietary intake [37
]. Thus while community perceptions and contextual factors are associated with weight status, the association between the community environment and health behaviours such as physical activity, dietary intake, and BMI will require larger studies involving more communities [37
]. For example, a fully powered study of the built environment on BMI would require inclusion of 12 Aboriginal communities, with at least 50 subjects per community to be able to detect a minimum 0.6 point difference in BMI between high versus low walkable communities (assuming an intraclass correlation of 0.09, and alpha of 0.05). Furthermore a recent review of intervention studies conducted among reserve dwelling Aboriginal people from the United States identified important components of successful community interventions designed to change health behaviours. These successful components include interventions targeted toward multiple levels including households, schools, community food suppliers as well as individuals, engaging and partnering with multiple community stakeholders and community members, and having an institutional base of support to ensure longevity of the health promotion program. They also highlight the importance of future research studies to study the effectiveness of community- based programs to change health behaviours and outcomes [38
Current literature regarding effective tobacco-related community interventions in Aboriginal communities is sparse. Our observation that advertisements promoting smoking and easy access to smoking for adults and children on the Six Nations reserve, together with the previous observation we reported of the high prevalence of cigarette smoking, makes it highly likely that the two characteristics are linked. However data from individual studies vary. For example, a community and school-based intervention among Native American children from 27 elementary schools and 5 states showed no influence of a community-based intervention including classroom lessons, media, and information sessions on rates of cigarette use [39
]. In a Cochrane review of community interventions targeting adult smoking by mass media, smoking policy, and smoke-free environments, had no effect on the prevalence of smoking [40
]. The COMMIT randomized control trial of 11 communities in Canada and the United States did not change heavy smoker quit rates, but had a minimally significant influence on light-to-moderate smokers consuming less than 25 cigarettes per day [41
There is strong evidence that increased taxation from a population perspective is associated with lower smoking rates, and it seems reasonable to assume that with increased taxation and decreased access to cigarettes, the rates of smoking on the Six Nations reserve would decline. The use of tobacco on the Six Nations reserve is complex. Registered Indians or bands on reserve are exempt from sales taxes for goods and services as outlined by section 87 of the Indian Act [42
]. Although First Nations can implement taxes on tobacco sales under the First Nations Sales Tax (FNST), only nine communities have chosen to do so [43
]. Many First Nations governments are dependent on federal fiscal transfers to account for more than 90 percent of their revenue. While local taxation of cigarettes could serve as a means for alternative and stable revenue of the elected Six Nations council, without a clear mechanism to enforce this policy, this strategy for tobacco control is not likely to be successful [44
]. Increased price of tobacco is associated with lower tobacco use (price elasticity) in non-Aboriginal communities where smoking rates have decreased 2-4% for every 10% increase in price [45
]. Opposition to tobacco taxation among First Nations is partly attributed to the strong historical, cultural, and economic ties to the tobacco industry. Successful tobacco control policies such as those advocated by the World Health Organization’s Framework Convention on Tobacco Control include common features such as banning all forms of promotion of tobacco products, price increases through taxation, strong prominent health warnings on packaging, banning sales to children, and enforcement of tobacco policy by law including implementation of quotas [47
]. Presently on the Six Nations reserve these control policies do not exist – which does not bode well for the future health of this community given that the use of tobacco use among adults, pregnant mothers and children is substantially higher than in most other communities in Canada.
The World Health Organization and other health advocacy groups cite the aggressive global marketing of risky products and behaviors, particularly those targeting children and youth, as key factors in bringing tobacco, alcohol, and unhealthy processed foods into households worldwide [48
]. In our survey, Six Nations community members recognized the excessive advertising of tobacco products and easy access for teenagers. However they did not embrace the idea that taxation may decrease use of tobacco. The community leadership in health must galvanize the community sentiment toward the adverse effects of tobacco on health, and persuade the local government to take a tough stand against the easy availability and access tobacco, especially among children and youth. The future health of Six Nations depends on the community’s involvement and ownership of new initiatives to target maladaptive health behaviors [48
The small sample size of this study limited examination of direct associations between community level factors and individual behaviours. The evaluation tools we used may be too narrow to encompass all potential community level factors which impact on individuals health behaviours, as we relied on participants perception of their environment and not objective measures of the community. Other studies have shown that collection of both perception and objective measures of contextual factors enhances the ability to study influences of environment on health, and future studies should consider including both types of measures [49
]. Furthermore our participants likely represented a more health conscious segment of the community (based on comparison of their higher household income and lower smoking rates to the general population) which may have influenced their responses to our questions. The effects of the off-reserve environment on Aboriginal health behaviours were not considered. In addition, the on-reserve environment is also extensive. The influence of contextual factors in schools and at the workplace would be relevant for analysis, as well as micro environmental components such as food quality, grocery store set-up, and restaurant menus [52
]. Finally, the influence of multiple environments, including social, political and cultural factors, may overpower the independent influence of physical environment on behaviours. Inter-household sharing is a common practice in First Nations communities, suggesting the importance of studying the social environment on individual health behaviours [15
This study highlights potential areas of interest for future study of contextual factors and community interventions. Our results suggest that interventions to improve reserve walkability, increase healthy food advertisements and nutrition education, and to reduce access and affordability of tobacco products may reduce the burden of chronic diseases faced by this community. Efforts should be made to find culturally appropriate community interventions that target health behaviours. Modifications to contextual factors have been attempted by other Aboriginal communities with successful intervention leading to increased access to fitness centers, use of walking trails, development of gardening programs, and improved food stores [53