Health Canada's Strategy Against Tuberculosis for First Nations On-Reserve – summary
Health Canada's Strategy Against Tuberculosis for First Nations On-Reserve has been developed to fight tuberculosis (TB) in First Nation communities. These are the people served by Health Canada's TB prevention and control services, either through funding to communities or health authorities that provide the services, or through services provided directly by Health Canada personnel. In Nunatsiavut, the First Nations and Inuit Health Branch also provides funding to the Nunatsiavut Government to complement the provincial services provided to Nunatsiavut's citizens.
Health Canada's Strategy is a technical document that will be used by health care professionals and administrators working in First Nation communities, and by Health Canada TB staff. More generally, Health Canada's Strategy has also been designed as a reference tool for anyone involved in TB prevention and control for First Nations and Inuit in Canada. This Strategy is closely aligned with the Guidance for Tuberculosis Prevention and Control Programs in Canada, the development of which is currently being led by the Public Health Agency of Canada, in collaboration with the provinces and territories, to provide an overall framework and guidance for TB-related activities across Canada.
Health Canada's Strategy is a renewal of the National Tuberculosis Elimination Strategy. The current approach is based on best practices and lessons learned, and has been developed in collaboration with First Nation and Inuit organizations, TB experts, provincial authorities, the Public Health Agency of Canada, and Aboriginal Affairs and Northern Development Canada.
What distinguishes the current Strategy from the previous Strategy is, mainly: the enhanced emphasis on performance measurement to clearly determine whether progress is being made and to change programs accordingly; a focus on vulnerable populations such as people infected with both HIV/AIDS and TB; and an emphasis on the need for stronger partnerships among Aboriginal, federal and provincial authorities.
What is tuberculosis?
Tuberculosis (TB) is an infectious disease caused by bacteria that spreads through the air when someone coughs, sneezes or, to a lesser degree, speaks. When TB enters the lungs, the immune system tries to either kill or suppress the bacteria. Suppressed TB is called latent TB infection (LTBI) and can become active at any time, but even more so in individuals whose immune system is weakened by other conditions such as HIV/AIDS.
If left untreated, active TB can lead to death. Tuberculosis can be cured with antibiotics, although it takes many months and several drugs for a full cure.
Health Canada's Strategy
While rates of TB among First Nations have decreased significantly over the past few decades, they remain high and progress in combating the disease in recent years has slowed. In 2009, the rate of TB in First Nations on-reserve was about 26 cases per 100,000, which accounts for about 8% of the cases in Canada.
Reducing TB in First Nations on-reserve will depend upon the strength of our shared commitment and on the focus given to implementing the approach set out in Health Canada's Strategy. Health Canada is mandated either to provide TB services or to assure that TB services are accessible to First Nations living on-reserve.
Tuberculosis has created a significant burden of loss and hardship for First Nation communities. It is a disease fuelled by social factors like overcrowding and poverty and it can flourish among at-risk groups such as people with HIV/AIDS, diabetes and mental health issues.
Before treatment was available in communities, patients with TB were sent away to sanatoria. It was there that many passed away, far from their communities and families. While this occurred in many Canadian communities, Canada's Aboriginal population was disproportionately affected by TB, which had a dramatic impact on individuals, families and communities. This experience continues to influence perspectives and attitudes towards the disease and, at times, the health care system.
Today's TB programs need to continue to demonstrate an understanding of the history of TB among First Nations in order to work with communities to increase awareness, to decrease stigma and discrimination against those with TB, and to provide programming that is culturally sensitive.
The Strategy focuses on three main themes in its approach to reducing the burden of TB: preventing, diagnosing and managing TB; targeting populations at greatest risk for TB; and developing and maintaining partnerships.
Principles of the Strategy
Achieve seamless TB prevention and control on- and off-reserve.
- Adopt evidence-based approaches and best practices.
- Address staffing and capacity issues.
- Adhere to public health principles and principles of patient rights and confidentiality.
- Align with the Canadian Tuberculosis Standards, the Guidance for Tuberculosis Prevention and Control Programs in Canada, and The Global Plan to Stop TB.
- Ensure First Nations on-reserve share control of health policies affecting them.
- Engage communities in developing and maintaining culturally appropriate TB program activities.
- Evaluate and assess on a regular basis to maintain effective programming.
- Collaborate with First Nations on TB prevention and control for their communities.
- Communicate with all partners and stakeholders.
- Cooperate to address issues that cannot be addressed by one program alone.
Theme 1: Preventing, Diagnosing, and Managing TB
The Strategy is based on high quality TB programming at the community and regional levels, in line with the Canadian Tuberculosis Standards. This includes activities such as:
- primary prevention
- latent TB infection (LTBI) identification and management
- early case finding
- contact identification
- treatment compliance (such as Directly Observed Therapy or DOT)
- surveillance (data collection, analysis and dissemination)
- targeted screening
- professional education and training
- community awareness initiatives
- development, application and evaluation of program strategies
Certain circumstances can make TB prevention and control more challenging in some communities. It is not always easy, especially in remote and isolated communities, for people to reach TB services. Another challenge is presented by the movement of people on- and off-reserve and from one community to another. A person with TB moving back and forth from the federal system (on-reserve) to the provincial system (off-reserve) is at risk of receiving incomplete treatment, unless the two health systems work closely together and share information efficiently.
The objectives of Theme 1 are to:
- Promote the provision of TB care in alignment with the Canadian Tuberculosis Standards.
- Decrease the transmission of TB in and across communities, while underscoring the importance of cultural competency.
- Collect, analyze and manage data on TB in a consistent and standardized manner in order to assess progress towards goals and to evaluate program performance.
- Work collaboratively with provincial health authorities in all regions to create a more seamless system to prevent, diagnose and manage TB in First Nation communities.
- Investigate possible solutions to address professional staff shortages and high staff turnover rates.
Theme 2: Targeting Populations at Greatest Risk for TB
Conditions such as HIV/AIDS, diabetes, mental health issues and addictions are major issues for many First Nation communities. These issues have the power to increase the risk of getting TB, with mental health issues or addictions putting people at a greater risk of not completing their course of TB medication.
Remote and isolated communities are by their nature at greater risk for TB because, in terms of health care, their challenges can include: limited access to TB care in a timely and consistent fashion; limited access to laboratory resources for timely diagnosis; and a lack of available TB expertise and staff. Living in overcrowded housing or with other medical conditions can also put people at a greater risk for TB.
The best approach to reaching these vulnerable sub-populations involves stronger ties and better coordination among all levels of government, across departments and programs and with communities so that we move towards an integrated, holistic and comprehensive public health system.
The objectives of Theme 2 are to:
- Identify sub-populations that are at greatest risk of contracting, transmitting or suffering from more serious forms of TB and develop strategies for these sub-populations that align with local epidemiology.
- Work with communities to provide targeted, enhanced TB programming to populations that are identified as having prolonged high rates of TB or as being at a higher risk of contracting or experiencing complications from TB.
Managing tuberculosis can often be difficult. When people are living in overcrowded houses with poor ventilation, or have medical conditions such as HIV/AIDS or mental health issues, they may be at higher risk of developing TB if they come in contact with the bacteria. This is especially true in communities that experience high rates of TB over prolonged periods. In addition, medical conditions like HIV/AIDS and mental health issues can complicate the treatment of TB.
Theme 3: Developing and Maintaining Partnerships
The health system serving First Nations on-reserve is multi-jurisdictional. Federal, provincial and Aboriginal/community health authorities must work together for communities to have access to effective TB prevention and control services. When these systems are not aligned, there are problems with case and contact management, which can result in diagnosis being delayed. The Strategy operates on the principle of closer collaboration and communication.
Fully comprehensive tuberculosis care is rarely available within a First Nation community; a person with TB needs to seek special medical care, which most of the time means going to a provincial health facility. TB services provided within First Nation communities need to be integrated with provincial health systems for the services to be consistent. Where there is a lack of integration between systems, there can be barriers to access and inefficiencies.
All regions of Health Canada have established relationships with their provincial counterparts. Many First Nation communities have direct relationships with either the province as a whole or with specific provincial health structures such as Regional Health Authorities or Public Health Units. At the national level, partnership with the Assembly of First Nations is important for issues such as providing a First Nations perspective as well as mobilizing First Nations leadership on the issue of TB. An effort to clarify, strengthen and maintain these essential partnerships is central to the Strategy.
Partnerships are also the key to addressing the social determinants of health such as housing, employment, income and education. The social determinants of health can have a major impact on the spread of TB by increasing the risk of transmission, infection and progression from latent infection to active disease. Health Canada's partnerships with communities and with other federal departments, most notably the Public Health Agency of Canada and Aboriginal Affairs and Northern Development Canada, are essential in addressing the impact of the social determinants of health.
The objectives of Theme 3 are to:
- Foster community involvement and shared ownership of TB prevention and control activities.
- Clarify roles and responsibilities for TB prevention and control through stronger partnerships and collaborations with the provinces and communities in order to maximize the contribution of each partner.
- Increase awareness of TB and related issues through education and public health messaging for health workers, communities and other relevant stakeholders.
- Align TB programming with other public health programs and related activities in order to increase the effectiveness of program delivery and public health messages.
- Address the link between TB and the social determinants of health through partnerships and collaboration with departments, programs and organizations that focus on issues such as housing, food, education, employment and air quality.
Partnerships include those that enable the sharing of data among communities, provinces and Health Canada to create greater transparency and accountability. The Strategy promotes sharing data with partners involved in TB programming as well as those affected by the disease.
Reporting on Progress
A key objective of the Strategy is to collect, analyze and manage data on TB in a way that is consistent so that progress can be measured and performance can be evaluated. Health Canada's regional offices collect data on TB surveillance and program performance. As part of the Strategy's implementation, Health Canada will develop an evaluation framework to help guide program assessment and evaluation.
Performance measurement and program evaluation are two standard practices that are essential for determining whether a strategy is effective in meeting its goals, targets and objectives and whether ongoing programming is able to adapt and adjust to changing circumstances and needs. Keeping partners and stakeholders informed is an important component of any program assessment.
For TB, progress will be tracked through surveillance and programmatic data. This will allow programs to see how trends in data such as rates of TB and treatment completion change over time. Programs will also be able to determine the effectiveness of activities such as community awareness campaigns and educational products. Overall, this will serve each program individually while leading to a collection of best practices and lessons learned that can be shared across programs and partners.
- Performance Measurement - The process of developing and using measurable indicators to systematically track and assess progress made in achieving predetermined goals (Health Canada, Policy on Evaluation, 2010).
- Program Evaluation - The systematic collection and analysis of evidence on the outcomes of programs to make judgments about their relevance, performance and alternative ways to deliver them or to achieve the same results (Treasury Board, Policy on Evaluation, 2009).
- Surveillance - The ongoing process of the systematic collection of pertinent data, the consolidation of the data in an orderly manner, the evaluation of this data and the prompt dissemination of results to those who need to know, particularly those who are in a position to take action.
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