Evaluation of the Healthy Living Program

Background

The Healthy Living Program funds and supports culturally relevant community-based health promotion and disease prevention programs and services in First Nations and Inuit communities. Activities include promoting healthy behaviours and creating supportive environments in the areas of healthy eating, food security, physical activity, tobacco use, and chronic disease prevention, management and screening.

This evaluation focuses on the Healthy Living Program and its constituent programs^{Footnote 2}, hereafter referred to as sub-programs:

• Aboriginal Diabetes Initiative (ADI) aims to reduce type 2 diabetes in First Nations and Inuit communities through health promotion and disease prevention programs, services and activities delivered by community diabetes workers and health service providers.
• Canada's Tobacco Strategy (CTS)^{Footnote 3} - The Federal Tobacco Control Strategy (FTCS) – First Nations and Inuit component was a knowledge development initiative that began in 2014-15 and continued through the timeframe of this evaluation. It supported the development and implementation of comprehensive, holistic, culturally appropriate tobacco control projects that were focused on reducing non-traditional tobacco use, while maintaining respect and recognition for traditional forms and uses of tobacco within communities.
• Nutrition North Canada (NNC) Nutrition Education Initiatives funded through ISC support culturally appropriate retail and community-based nutrition education activities in eligible isolated northern First Nations and Inuit communities. Activities focus on increasing knowledge of healthy eating and developing skills in the selection and preparation of healthy store-bought and traditional food.

Evaluation Scope and Methodology

This evaluation covers the period from Fiscal Year 2013-14 to 2018-19 further to the Treasury Board requirements and includes each of the three Healthy Living sub-programs managed by FNIHB-ISC. The evaluation was undertaken to provide a neutral and evidence-based assessment of relevance, effectiveness, efficiency, lessons learned, and best practices, for the following activities: Aboriginal Diabetes Initiative, Canada's Tobacco Strategy, and Nutrition North Canada Nutrition Education Initiatives. Moreover, although not part of the original scope, the evaluation also incorporated more recent data and actions taken by ISC to address additional factors impacting programming, especially in the context of service transfer, climate change, and the COVID-19 pandemic.

The evaluation focused solely on First Nations communities. Due to a request by Inuit Tapiriit Kanatami for a distinctions-based approach for conducting evaluations, the Inuit element of the Healthy Living Program will be evaluated at a date to be determined.

The evaluation was conducted in-house by the ISC Evaluation Directorate. It relied on a mixed-methods approach^{Footnote 4} that included the following lines of evidence: a document and literature review; 19 key informant interviews with FNIHB-ISC staff (including national and regional office staff); 1 key informant interview with non-ISC government staff; 9 key informant interviews with Indigenous partner organizations (Tribal Councils, First Nations Health Service Organizations, etc.); 1 key informant interview with a non-Indigenous partner organization; 2 key informant interviews with representatives from First Nation communities and; an online survey of 168 individuals working in/with First Nations communities.^{Footnote 5}

As data collection occurred in the context of the COVID-19 pandemic with the resultant travel restrictions, direct site visits were not possible and were instead replaced by remote video/telephone interviews through various communication platforms.

Main Findings

Project Title: Evaluation of the Healthy Living Program

2.1 Program Description

The Healthy Living Program funds and supports culturally relevant community-based health promotion and disease prevention programs and services in First Nations and Inuit communities. Activities include promoting healthy behaviours and creating supportive environments in the areas of healthy eating, food security, physical activity, tobacco, and chronic disease prevention, management and screening. The Healthy Living Program evaluation focuses on the three sub-programs:^{Footnote 16} ADI, CTS, and NNC Nutrition Education Initiatives. The policy areas within Healthy Living of Nutrition, Chronic Disease Prevention and Injury Prevention were not included in the evaluation.

2.2 Program Objectives and Expected Outcomes

The objective of the Healthy Living Program is to address the greater risks and lower health outcomes associated with chronic diseases and injuries among First Nations and Inuit individuals, families, and communities.The following outlines the immediate, intermediate, and ultimate outcomes and objectives of the program, according to the program's logic model:

Immediate Outcomes

• First Nations and Inuit have capacity to support Healthy Living programming.
• First Nations and Inuit have access to Healthy Living programming.
• First Nations and Inuit have knowledge of Healthy Living issues and practices.

Intermediate Outcomes

• First Nations and Inuit are engaged in healthy behaviours.

Ultimate Outcome

• First Nations and Inuit Individuals and communities are healthier.

The logic model for the Healthy Living Program can be found in Appendix B.

In addition, the Healthy Living Program is in alignment with the following Calls to Action released by the Truth and Reconciliation Commission in June 2015^{Footnote 20}:

Call to Action #18: We call upon the federal, provincial, territorial, and Aboriginal governments to acknowledge that the current state of Aboriginal health in Canada is a direct result of previous Canadian government policies, including residential schools, and to recognize and implement the health-care rights of Aboriginal people as identified in international law, constitutional law, and under the Treaties.

Call to Action #19: We call upon the federal government, in consultation with Aboriginal peoples, to establish measurable goals to identify and close the gaps in health outcomes between Aboriginal and non-Aboriginal communities, and to publish annual progress reports and assess long-term trends. Such efforts would focus on indicators such as: infant mortality, maternal health, suicide, mental health, addictions, life expectancy, birth rates, infant and child health issues, chronic diseases, illness and injury incidence, and the availability of appropriate health services.

Call to Action #20: In order to address the jurisdictional disputes concerning Aboriginal people who do not reside on reserves, we call upon the federal government to recognize, respect, and address the distinct health needs of the Métis, Inuit, and off-reserve Aboriginal peoples.

2.3 Program Management and Key Partners

3.1 Scope and Evaluation Issues

This evaluation covers the period from Fiscal Year 2013-14 to 2018-19 further to the Treasury Board requirements and includes each of the three Healthy Living sub-programs managed by FNIHB-ISC. The evaluation was undertaken to provide a neutral and evidence-based assessment of relevance, effectiveness and efficiency of the Healthy Living Program, including, Aboriginal Diabetes Initiative, Canada's Tobacco Strategy (formerly the Federal Tobacco Control Strategy – First Nations and Inuit Component), and Nutrition North Canada Nutrition Education Initiatives. The evaluation  also sought to highlight best practices, challenges, lessons learned and recommendations to strengthen the Healthy Living Program and its sub-programs. The policy areas within Healthy Living of Nutrition, Chronic Disease Prevention and Injury Prevention were not included in this evaluation. Moreover, although not part of the original scope, the evaluation also incorporates more recent data and actions taken by ISC to address additional factors impacting programming, especially in the context of service transfer, climate change and the COVID-19 pandemic.

The evaluation focused solely on First Nations communities. Due to a request by Inuit Tapiriit Kanatami for a distinctions-based approach for conducting evaluations, the Inuit element of the Healthy Living Program will be evaluated at a date to be determined. Additionally, as responsibilities for federal health programs have been transferred to the First Nations Health Authority through the British Columbia Tripartite Framework Agreement on First Nation Health Governance, British Columbia does not fall within the scope of the evaluation.

The evaluation was conducted through the lenses of Gender Based Analysis Plus (GBA Plus) and the federal commitment to Truth and Reconciliation with Indigenous Peoples. The evaluation includes the above Healthy Living activities and initiatives undertaken in all jurisdictions across Canada, with the exception of British Columbia, and to a limited extent in the North, as outlined above.

3.2 Evaluation Design and Methods

The evaluation was conducted in-house by the ISC Evaluation Directorate. It relied on a mixed-methods approach that included the following lines of evidence:

• A document and literature review;
• Key Informant Interviews:
  • 19 key informant interviews with FNIHB-ISC staff (including national and regional office staff);
  • 1 key informant interview with non-ISC government staff;
  • 9 key informant interviews with Indigenous partner organizations (Tribal Councils, First Nations Health Service Organizations, etc.);
  • 1 key informant interview with a non-Indigenous partner organization;
  • 2 key informant interviews with representatives from First Nation communities; and;
• Online Survey:
  • an online survey of 168 individuals working in/with First Nations communities. Of the survey respondents who responded to the question on what their role was in the Healthy Living Program, 80% identified themselves as the following, in descending order of frequency: community health workers, health directors/managers, dietitians/nutritionists, and nurses. A variety of roles were mentioned by the remaining 20%, including  mental wellness workers, social workers and a range of other roles, with each being mentioned by only one individual.)

As data collection occurred in the context of the COVID-19 pandemic with the resultant travel restrictions, direct site visits were not possible and were instead replaced by remote video/telephone interviews through various communication platforms. The pandemic also directly impacted the evaluators' ability to interview community partners. Given that many community partners were involved in the response to COVID-19, the evaluators were unable to fully engage them as planned. However, partner responses were given heavy weight when reporting results.

3.3 Limitations

Table 1 below outlines the limitations encountered during the implementation of the selected methods for this evaluation and the corresponding mitigation strategies that the evaluation team utilized to ensure that the evaluation findings are reliable and have been validated.

3.4 Indigenous Engagement

The evaluation employed FNIHB-ISC's engagement protocol, which calls for National Indigenous Organizations (in this case, the Assembly of First Nations) to review evaluation documentation at various stages of the process (methodology report, preliminary findings, and draft evaluation report) and comment/provide suggestions on the evaluation methodology, questions to be asked to help promote culturally appropriate evaluations for FNIHB programs. Additionally, regional Indigenous partners (e.g. health partnership tables, tribal councils) were engaged by FNIHB-ISC regional offices on a less-formal basis to provide supplementary input on community selection and evaluation methodology, which was then shared with the evaluation team.

3.5 Organization of the Findings

While this evaluation viewed the Healthy Living Program as a holistic entity, the key focus was, to a greater extent, on the performance of each of the three individual sub-programs, as there is little overlap amongst them from a management and operational perspective. For example, ADI is universally funded, whereas the NNC Nutrition Education Initiatives target eligible isolated northern communities. Also in contrast, with the transition from the FTCS to CTS, there was a switch from project-based funding to on-going funding. Of note is that a greater number of survey respondents acknowledged being involved with ADI than with either the CTS or NNC Nutrition Education Initiatives. As such, many of the evaluation's findings are sub-program-specific, as opposed to program-wide. Findings 1-11 may be considered to cross-cut two or more Healthy Living sub-programs, while the remainder are specific to each of the three sub-programs.

4.1 Program Relevance

The Healthy Living Program continues to remain relevant as the Regional Health Survey^{Footnote 22} conducted by the First Nations Information Governance Centre (FNIGC), reported that "nearly three-fifths (59.8%) of First Nations adults, one-third (33.2%) of First Nations youth, and more than one-quarter (28.5%) of First Nations children have reported having one or more chronic health conditions. Among First Nations children, the number of reported conditions shows a significant decrease from the RHS Phase 2 (2008/10)."^{Footnote 23} Of note is that diabetes continues to remain to be the most noted chronic health condition reported by the FNIGC among First Nations adults.

In July 2018, Diabetes Canada released their Diabetes 360 Report: A Framework for a Diabetes Strategy for Canada^{Footnote 24}, highlighting the significant health-crisis impacting close to 11 million Canadians that are living with prediabetes or diabetes. The Report states that, "for First Nations peoples, the risk of being diagnosed with diabetes is up to 80% and in some subgroups within this population, it is even higher."^{Footnote 25} For example, diabetes prevalence is 3-5 times greater for First Nations peoples living on-reserve, than non-First Nations Canadians. In addition, the rates of complications from diabetes are also higher for First Nations on-reserve than non-First Nations Canadians.^{Footnote 26} In contrast to the general Canadian population (in which the prevalence is predominately higher in men than women), First Nations women bear a heavier diabetes burden than First Nations men, across most age groups. In fact, Indigenous individuals that are diagnosed at an increasingly younger age, have greater severity at diagnosis, and experience poorer treatment outcomes in comparison to the general Canadian population."^{Footnote 27}

Prevalence of smoking amongst First Nations adults also remains relatively high, with the Regional Health Survey Phase 3 reporting that more than half (53.5%) of First Nations adults smoked cigarettes, with 40% saying they smoked on a daily basis.^{Footnote 28} Phase 2 of the Regional Health Survey reported that 56.9% of First Nations adults smoked cigarettes.^{Footnote 29} While this presents a small decrease in use, the three phases of the Regional Health Survey reported relatively stable prevalence of smoking in First Nations adults.^{Footnote 30} Comparatively, 14.8% of the general Canadian population smoke.^{Footnote 31}

In addition to the high prevalence rates of diabetes and smoking, three factors that contribute to the disproportionate health inequities in First Nations communities are notable. First, health inequities are deeply rooted in the historical relationship between First Nations communities and the health systems. In particular, the impacts of colonization have resulted in "a legacy of environmental dispossession, degradation of the land, substandard living conditions, inadequate access to health services, social exclusion and a dislocation from community, language, land and culture. These policies have been clearly linked to adverse health consequences for individuals and community."^{Footnote 32}

Second, the complex, inter-related nature of social determinants of health contributes to the serious health challenges that many First Nations communities continue to face. The Public Health Agency of Canada (PHAC) recognizes that health is determined by the complex inter-related nature of social determinants of health between social and economic factors, the physical environment and individual behaviour. PHAC has identified twelve social determinants of health: gender, culture, health services, income/social status, social support networks, education/literacy, employment and working conditions, social environments, physical environments, personal health practices and coping skills, healthy child development, and biology/genetic endowment^{Footnote 33}. In fact, 70% of online survey respondents either agreed or strongly agreed, that the Healthy Living sub-programs paid appropriate attention to integrating various social determinants of health, such as income, education level, and the physical environment Examples of this include: the HL Program taking into consideration different income levels when recommending healthy food purchases to clients, introducing targeted education activities to various age groups (elementary students, high school students etc.) and recommending physical activities that are available to those individuals living on-reserve.

Lastly, the inequitable distribution of economic resources combined with other social determinants of health has further contributed to food insecurity challenges faced by First Nations communities. Food insecurity challenges can be linked to the inadequate intakes of several nutrients, likely contributing to the disproportionate health inequities faced by First Nations communities. The First Nations Food Nutrition and Environment Study (2008-2018)^{Footnote 34}, found that, on average across all regions, 37% of all participating households on-reserve were food insecure, while regional prevalence ranged from 30.8% to 45.5% or up to more than 5 times higher than the prevalence of household food insecurity in the general Canadian population (which was 8.8% in 2017-18)^{Footnote 35}. For example, the PHAC has reported that First Nations peoples have a high prevalence of type 2 diabetes with 19%, double that of the general population. Additionally, the Canadian Journal of Public Health has reported that "a majority of First Nations households are not able to achieve a healthy diet either from the traditional food systems within their territory due to external considerations now compounded by the climate crisis, or from the market foodsystem due to financial constraints that limit access to diverse and high-quality market foods."

4.2 Mandate

The organization of Canada's health care system is largely determined by the Canadian Constitution. Roles and responsibilities are divided between the federal, provincial and territorial governments.

• Generally, provinces and territories have primary jurisdiction over the administration and delivery of health care services in their respective jurisdictions. Provinces and territories receive transfer payments from the federal government to provide universally accessible and publicly insured health services to all residents, including Indigenous Peoples.
• The federal government is responsible for enforcing the general standards provided in the Canada Health Act, respecting provincial health insurance plans. As well, Parliament has exclusive legislative authority for "Indians, and Lands reserved for the Indians" (Constitution Act, 1867, Section 91(24)).
• Indigenous communities also play a key role in the delivery of health services and programming.

It is important to note that the Canada Health Act, 1984, outlines the intent of Canadian health care policy in general and describes the conditions under which provincial and territorial governments qualify for the Canada Health Transfer. Further, section 3 of the Canada Health Act, 1984, states that Canadian health care policies are intended to ensure the physical and mental well-being of Canada's residents, and to facilitate reasonable access to health care, including Indigenous Peoples.

First Nations health jurisdiction is complex in nature. While the Constitution Act, 1867, and the Indian Act, 1876, identify jurisdictional responsibilities regarding Indigenous health care services, there is currently no legislation in place that provides clarity on the roles and responsibilities of different levels of governments in health care for Indigenous Peoples. It is important to note that under section 91 of the Constitution Act, 1867, the federal government has power to enact health legislation based on its "peace, order and good government" powers (e.g., laws pertaining to quarantine and national emergencies). In 2021, the Minister of Indigenous Services Canada was mandated to "co-develop distinctions-based Indigenous health legislation, backed with the investments needed to deliver high-quality health care for all Indigenous Peoples", which would improve access to high-quality, culturally relevant health services. Multiple streams of engagement are currently underway.

At present, the federal government provides health services to First Nations and Inuit as a matter of policy, as guided by the 1979 Indian Health Policy as well as the Indian Health Transfer Policy. The Indian Health Policy was adopted during a period of transition for FNIHB whereby FNIHB began to shift more towards helping communities gain more direct control over community-based health services rather than providing direct health care services. The Indian Health Policy also recognizes the interdependent nature of the Canadian Health system and identifies that two of the most significant federal roles are in public health activities on reserves and health promotion^{Footnote 36}. Further, the Indian Health Policy describes the importance of reinforcing relationships between multiple levels of government and increasing the capacity of Indigenous communities to "play a positive and active role within the Canadian health care system"^{Footnote 37}. As a result of the Policy, the federal government no longer directly provides services to First Nations people in the Northwest Territories, nor to the four Inuit regions: in Nunavut, the Inuvialuit Regional Settlement in the Northwest Territories, Nunavik in Quebec, and Nunatsiavut in Newfoundland and Labrador. Instead, federal government funding flows through transfer agreements with territorial governments and self-governments/land claim agreements.

During the Healthy Living evaluation timeframe, the Prime Minister implemented a recommendation from the Royal Commission on Aboriginal Peoples (1996) by dissolving Indigenous and Northern Affairs Canada, and replacing it with two new departments: Indigenous Services Canada (ISC) and Crown-Indigenous Relations and Northern Affairs Canada (CIRNAC). In 2017, Indigenous Services Canada assumed control of the First Nations and Inuit Health Branch, which was transferred from Health Canada. The Department of Indigenous Services Act (2019), provides for a legislative mandate for Indigenous Services Canada to work towards the transfer of departmental responsibilities and collaborate with Indigenous partners in all aspects of service delivery, including health.

In addition to the creation of the new ISC Department, the 2017 mandate letter to the Minister of Indigenous Services stated as one of the top priorities: "Lead work to create systemic change in how the federal government delivers health services to Indigenous Peoples in collaboration with the Minister of Health and the Minister of Crown-Indigenous Relations and Northern Affairs. Specifically, I would ask that you take an approach to service delivery that is patient-centred, focused on community wellness, links effectively to provincial and territorial health care systems, and that considers the connection between health care and the social determinants of health."^{Footnote 38}

Budget 2018 also laid out the renewal of the Tobacco Strategy. The budget called for distinctions-based approaches and stated that, "the Government of Canada recognizes that a distinctions-based approach is needed to ensure that the unique rights, priorities and circumstances of First Nations, Inuit and the Métis Nation are acknowledged, affirmed and implemented."^{Footnote 39} In line with this, the FTCS was redesigned as CTS and included a distinctions-based, Indigenous-specific component. ISC key informant interview respondents (national and regional) noted that distinctions-based approaches have and will better equip the program to meet the needs of communities.^{Footnote 40} The 2018 budget also highlighted the significant gaps in health outcomes between Indigenous and non-Indigenous people and the higher diabetes prevalence rate faced by Indigenous peoples.Budget 2018 specifically states that "infant mortality rates of First Nations and Inuit children are up to three times higher, diabetes rates are up to four times higher (than Indigenous people)…this gap in health outcomes can be narrowed, and providing access to quality health care close to home is an essential part of that change."^{Footnote 41} The 2016 federal budget also "allocated $64.5M over five years, beginning in 2016-17, and $13.8M per year ongoing to expand Nutrition North Canada (NNC) to support all northern isolated communities. This included funding to also expand NNC Nutrition Education Initiatives, managed by FNIHB, to newly eligible First Nations communities."^{Footnote 42}

5.1 Overall Achievement of Expected Immediate Outcomes

Immediate Outcome #1: First Nations and Inuit have capacity to support HL programming

An important component of enhancing the knowledge, skills and abilities of community workers is access to appropriate training and professional development opportunities. Both key informant interview respondents and survey respondents identified the importance of community staff accessing capacity building opportunities to better meet the needs of the local community.

The 2014 Evaluation of the First Nations and Inuit Healthy Living and Healthy Child Development, identified staff retention as a challenge in building community capacity, an issue that this evaluation has also noted continues to persist. Community-based capacity is increasing, however the high turnover of community-based staff is slowing that progress in some communities, whilst other communities have ongoing staff shortages to adequately deliver the sub-programs of the Healthy Living Program. Staff turnover has cost implications for communities with regards to training and capacity building as communities are often losing corporate memory, and there exists a constant need to train new staff.

Twenty-nine percent of survey respondents (n=92) indicated that training was sufficient, while 36% agreed that training is only somewhat sufficient to help them perform their jobs. At least 11% of survey respondents felt that training was not sufficient to support them in delivering Healthy Living sub-programs and 24% were not sure. Specific to the ADI program, 51% of survey respondents (n=80) agreed or strongly agreed that the ADI is succeeding in supporting efforts with regards to capacity building and training, 24% disagreed or strongly disagreed that the ADI is succeeding in supporting efforts with regards to capacity building and training and 25% were neutral.

A notable achievement of the ADI sub-program was the strong engagement of regional partners at their respective regional community of practice groups, which key informant interview respondents have referred to as "working groups." Key informant interview respondents across all regions expressed a high degree of satisfaction with this participatory working method and stated that the opportunities to build strategic partnerships with other colleagues at the national, regional and community levels have been beneficial.

As many key informant interview respondents noted, there is a strong desire for professional development opportunities, however the lack of appropriate funding has impacted the availability of professional development training opportunities for staff to further upgrade their skills and gain valuable knowledge across the sub-programs.

As a response to the COVID-19 pandemic, there was an increase in the participation of staff in remote communities accessing online training opportunities. This uptake was viewed by ISC key informant interview respondents as a positive, cost-effective means for staff to access training opportunities without having to physically travel to training sites. The community planning and program components^{Footnote 44} in the 2014 Evaluation of the First Nations and Inuit Healthy Living and Healthy Child Development, also concluded that Health Directors were making efforts to provide remote training opportunities for staff in remote communities in response to the inadequate training funds^{Footnote 45}.

Immediate Outcome #2: First Nations and Inuit have access to HL programming:

Access to the HL programming refers to the extent to which First Nations are able to offer the sub-programs in their communities, and for those that offer programs in their communities, the extent to which services were accessible for community members.

Funding arrangements are not program specific, rather they depend on the type of funding arrangement negotiated with the community or funding recipient. For example, in each community that the HL programming operates in, all the sub-programs (i.e., NNC, ADI, and CTS) can be found to be in the same funding arrangement.^{Footnote 46} However, the NNC Nutrition Education Initiative is only eligible in isolated northern communities based on the Crown Indigenous and Northern Affairs Canada (CIRNAC) determined eligibility criteria for the overall NNC program. Many key informant interview respondents, including ISC national and regional staff and community health staff, expressed concerns that the eligibility for Nutrition Education Initiatives funding was dependent on the First Nations community meeting eligibility criteria for the Nutrition North Canada subsidy administered by CIRNAC. If the community does not qualify for subsidies under CIRNAC, the community also loses eligibility for ISC funding for Nutrition Education Initiatives. Communities expressed the continued need for nutrition education after communities no longer qualify for the Nutrition North Canada subsidy, stating that nutrition education remains relevant.

Participation in the Healthy Living Program is open to all community members. At the same time, 36% of survey respondents (n=114) agreed or strongly agreed that the Healthy Living Program was reaching all community members (22% were neutral, 35% disagreed or strongly disagreed, 7% did not know). Impressively, from 2013-2014 to 2017-2018, the community-based reporting template (CBRT) has been reported to maintain strong client access levels. For example, the CBRT reported that 91.2% of First Nations communities provided HL Programs in 2017-2018 and 88.9% First Nations communities delivered physical activities in the same year (table 1).

Specifically regarding the ADI sub-program, key informant interview respondents highlighted that it is often difficult to engage with the working age population, given that programming typically occurs primarily during the standard working hours. Targeted programming that accommodated clients' schedules could improve participation of this group. It was also noted that in many cases, the same group of individuals consistently participates in the Program.

As of 2017-18, 56% of First Nations and Inuit communities had access to tobacco control activities,^{Footnote 47} 1578 new smoke-free spaces, and 129 new smoking-related resolutions.

In many cases, and as a result of the COVID-19 pandemic, the HL Program has successfully pivoted to providing programming online by leveraging communications technology and social media (for example, cooking classes delivered via Facebook rather than in-person). This has also allowed for new clients who would not otherwise have access to targeted activities to attend online activities. While this has worked effectively in some areas, there continues to remain accessibility challenges for community members living in remote areas with limited internet access.

Immediate Outcome #3: First Nations and Inuit have knowledge of HL issues and practices:

Due to the COVID-19 pandemic, the evaluation team was unable to conduct direct site visits for this evaluation. However, relevant to this outcome, the RHS reports that 59.2% (2015-16) of First Nations adults with diabetes, attended a diabetes clinic. The pandemic also directly impacted the evaluators' ability to interview community partners and thus determine the achievement of this outcome. In addition, since many community partners were involved in the response to COVID-19, the evaluators were unable to fully engage them as planned. That being said, limited qualitative and quantitative evidence was provided in the key informant interview and survey responses presented throughout this evaluation, that suggests that First Nations and Inuit have knowledge of HL issues and practices.

5.2 Operational Effectiveness^{Footnote 48}

Key informant interview and survey respondents reported that the Healthy Living Program is operating effectively. In fact, 54% of survey respondents (n=91) stated that the quality of the Healthy Living Program and sub-programs has improved or significantly improved over the last five years. Some of the reasoning for this improvement included increased communication between community health representatives, continuity of the program and relationship building with clients over time. However, a majority of survey and key informant interview respondents identified a need for additional funding as a primary challenge. The funding constraints limited access to screening and management tools, training opportunities, and salary increases, which has led to difficulties in retaining ADI community-based program staff.

The previous evaluation noted that the HL Program was responsive to community health needs and priorities, allowing communities to tailor sub-programs to meet their needs. The survey respondents stated that many staff believe that the sub-programs are operating effectively. This includes 58% of the survey respondents that indicated they were involved in the ADI sub-program (n=79), 53% of survey respondents involved in CTS sub-program (n=30) and 52% of survey respondents involved in NNC Nutrition Education Initiatives sub-program (n=25) who either strongly agree or agree that the programs are operating effectively.

Given the flexibility in programming and services across regions, it has been challenging to determine the programs overall effectiveness and the extent to which expected outcomes have been met as described in the logic model^{Footnote 49}. An ISC key informant interview respondent articulated the challenge that evaluators faced by stating that "The extent to which [the program is] achieving these priorities is at the discretion of the community. Some First Nations are investing more in training or building knowledge capacity. Others are investing more in developing programming to deliver".

5.3 Community-Led Program Design

One of the strengths of the Healthy Living Program lies in its design and delivery model being unique to each community, allowing for communities to define their evolving health needs and health priorities.^{Footnote 50} As a result of the diversity that exists in programming across communities and in targeted activities, it is difficult to determine if the program is effectively reaching all community members in all the regions where it operates. It is also unclear if a GBA Plus assessment was conducted at either the national or regional levels to support programming. Given that a GBA Plus analysis was not made available to evaluators, this evaluation will instead highlight the engagement and participation of various demographics in program activities, as well as opportunities or challenges that may exist. It is also unclear if all or most communities are engaging in strategies to reach harder to reach groups (i.e. working age population, 2SLGBTQIA+ peoples, or at-risk youth). A number of  survey respondents reported that it is common to have the same clients attending different targeted program activities and/or accessing program services. Although there have been great improvements made by the program to reach all community members, there are still challenges in reaching those most in need of services.

When survey respondents (n=114) were asked about the degree to which the Healthy Living Program was reaching all community members, only 36% of survey respondents agreed or strongly agreed. Of note, 75% of survey respondents agreed or strongly agreed that there are service gaps that affect clients from accessing programming, services and activities, with 65% of survey respondents agreeing or strongly agreeing that there are efforts underway to close those gaps. There are various factors that contribute to gaps in services, including resource constraint challenges, hiring and retaining staff, and remoteness of some communities. For example, key informant interview respondents and survey respondents identified the service gap of the need to incorporate culturally relevant approaches in programming. This service gap was also mentioned in the previous 2014 Evaluation of the First Nations and Inuit Healthy Living and Healthy Child Development. Many community leaders and staff have indicated that there is "a growing recognition in their communityof the health and well-being benefits of their traditional activities and diets, and indicated thatsteps were being taken to incorporate language programming, traditional teachings, traditional foods, and other traditional aspects into programming"^{Footnote 51}. For the ADI and the NNC Nutrition Education Initiatives specifically, key informant interview respondents highlighted the need for culturally relevant practices and resources to be more directly integrated into programming, as well as to promote integrated healthcare models whereby various healthcare providers (i.e., registered dietitians and nurses) collaborate to a greater extent than at present.

In key informant interviews, respondents have expressed that they actively employ various strategies to reach as many individuals as possible in their communities. For example, some communities have collaborated with other event organizers in their communities to promote diabetes awareness and education to a mass audience, while other communities have in the past provided incentives to clients for their attendance (i.e., prizes). A regional ISC employee in a key informant interview highlighted the potential reach of the program, stating that the "Healthy Living programs have the potential to reach everyone in the community – from the well population to the very sick; from babies to Elders – across the lifespan". They noted that some communities have gone to great lengths to include harder-to-reach populations in their programming by "providing child-care, transport and prizes for participating like food vouchers or food".

Key informant interview respondents have also acknowledged that it is easier to reach seniors, individuals that are unemployed, and homemakers in accessing and participating in programs and services. To better accommodate participant needs and increase the attendance of harder-to-reach groups, it was suggested by a key informant interview respondent that educational pamphlets for Elders can be translated in local languages, peer-led learning opportunities for youth should be increased, and access to exercise therapists for individuals with varying physical limitations should be provided.

It is difficult for many communities delivering Healthy Living programming to reach the 30 to 50 year-old age group to access and participate in program services, since they are either likely engaged in work or child-rearing activities during the programs' standard operating hours. Since many program activities take place during the day, it is less likely for individuals to take time off work to attend. As highlighted by a key informant interview respondent: "The challenge is timing. Not everyone can reach sessions at 2 p.m.. How do we effectively reach people when people are working? It makes for a long day to offer programming at 7 p.m., but I see the value in prevention".

COVID-19 brought several challenges to the delivery of the Healthy Living Program, including pivoting activities to online platforms. While this has caused access and participation challenges for some community members, it has also allowed for new clients who otherwise would not have attended targeted activities to participate in online activities. One key informant interview respondent underscored the COVID-19 related challenges, stating: "I think there have been great improvements to reach out to all community members, but it is still not often reaching those most in need of services. I also feel there has been improvement in collaboration and this will ultimately reach more members. I do, interestingly, see a different uptake since COVID in that different members are joining in local programming via Zoom verses the "usual" group that join events in person".

5.4 Complementarity among Healthy Living Sub-Programs

ISC key informant interview respondents, both in the national and regional offices spoke to the complementarity of the Healthy Living sub-programs. The sub-programs inherently focus on lifestyle factors that increase the risk for chronic disease, be it nutrition, smoking, or exercise. One ISC regional office key informant interview respondent stated that "prevention is prevention, every single health program should overlap." Many survey respondents also noted that collaboration was key to delivering holistic care.

The Healthy Living sub-programs, particularly the ADI and the NNC Nutrition Education Initiatives, complement each other well. 61% percent of survey respondents (n=114) agreed or strongly agreed that the program areas within Healthy Living are collaborating, with some survey respondents noting that this is often the case, since staff members were often responsible for multiple Healthy Living sub-programs. The majority of national and regional ISC key informant interview respondents, who worked on ADI and NNC Nutrition Education Initiatives spoke to their complementarity. For example, a national office key informant interview respondent expressed that: "With ADI and NNC, they are the perfect complement. In Manitoba region, and other regions as well, NNC and ADI were amalgamated. There is one worker for both or two workers that worked closely together. They amalgamate cooking classes, or land activities, or going into schools. There are also joint events and trainings for the workers." This sentiment was also corroborated by the previous Healthy Living Evaluation.

Survey respondents have also underscored the complementarity and strong linkages between ADI and NNC Nutrition Education Initiatives in the survey, stating: "ADI and NNC work well together, and it's great that the funding can overlap in many ways to support similar projects" and "The ADI and NNC try to work together at times doing workshops on healthy cooking and harvesting and preparation of tradition foods off the land". ISC regional key informant interview respondents noted the importance of addressing food security to tackle diabetes prevention and management, with one regional key informant interview respondent stating, "there is a clear aspect of ADI that is food security related". Survey respondents also highlighted the complementarity that exists between ADI and CTS: "Often times, Diabetes and Tobacco Cessation programs go hand in hand together to meet the needs of the client. Often times with prevention, we want to support and educate a diabetic smoker to help quit their use of commercial tobacco so that they don't get secondary conditions such as hypertension or cancer, and help a smoker reduce their use or quit so that they don't become a type 2 diabetic and to adapt healthier choices such as eating better, exercising, self-care, stress reduction etc".

Outside of the program itself, there are many linkages across levels of government and with partner organizations. Within the department, Healthy Living is complemented by the Non-Insured Health Benefits program which offers several diabetes treatment supports including medications, blood glucose test strips, medical supplies, and equipment (medical devices, medical transportation, etc.). Across government, the Healthy Living Program works both with Health Canada on CTS and CIRNAC for NNC. The FNIHB National Office works and collaborates with both the Assembly of First Nations and Inuit Tapiriit Kanatami to inform the Healthy Living program.

6.1 2014 Healthy Living Evaluation

The 2014 Cluster Evaluation covered both the Healthy Child Development and the Healthy Living Program^{Footnote 52}, and as such the recommendations within referred to both program areas. Responsible for the implementation of the Management Response Action Plan (MRAP), FNIHB has reported that the recommendations have been addressed and implemented.

The evaluation identified three recommendations which were approved by Health Canada's Deputy Minister in February 2015 (FNIHB was previously part of Health Canada). Below are the status of each of those recommendations last reported in January 2018:^{Footnote 53}

6.2 Program Management Structures and Division of Responsibilities

The Healthy Living program management structure is organized as such: FNIHB staff at the National Office within the National Capital Region lead strategic, program policy development and planning, working closely with FNIHB regional offices and First Nations partners at the national level (i.e., National Indigenous Organizations). FNIHB Regional Offices play a lead role in supporting communities with program delivery as requested by working with First Nations partners at the regional and local levels. They are also responsible for the management of funding arrangements, program performance monitoring, and information roll-ups. Finally, the FNIHB Northern Region works directly with the territorial governments and self-governing First Nations in Yukon and selected communities within Northwest Territories to negotiate funding arrangements for health programming, and ensures that First Nations partners are engaged in decision-making. There is a wide variation in the Healthy Living management structures and operations at the regional levels.

FNIHB's Senior Management Committee is the main decision-making forum for the Branch on issues related to policy development and priority setting. This committee consists of representation from senior management at both the national and regional offices and representatives from the Assembly of First Nations. In addition to this committee, The HL Program collaborates with national and regional First Nations organizations and other stakeholders to ensure that there is representation in the program decision-making.

The communities or Tribal Councils are funded through funding arrangements to support the implementation and delivery of the Healthy Living Program. Community or Tribal Council support includes building their internal capacity through the hiring and managing of community program staff, providing office space and program resources to staff, and working with regional offices to provide training for local staff.

Key informant interview respondents at both ISC national and regional levels have highlighted that the current program management structures and division of responsibilities between national, regional, and community levels allows for the Healthy Living Program to achieve desired results. Specifically, the variation in management structures at regional levels has allowed for some regional offices to develop responsive and flexible structures that meet the needs of the communities they support. In addition to the management structures creating a conducive environment for the HL Program to operate and achieve desired results, the evaluation also inquired about best practices that have improved the overall efficiency of the program as it relates to the program governance and management.

Many ISC national and regional key informant interview respondents and survey respondents have shared best practices that have improved the efficiency of the HL Program including (but not limited to):

• Territorial governments have established community wellness and health divisions which are entirely First Nations led. They have their own body of knowledge and expertise in-house and are well known in their communities;
• Communities taking on the lead role of implementing sub-programs, and receiving capacity building and other support from regional offices as needed; and;
• Maintaining strong relationships between regional offices and community staff.

Additionally, Indigenous partner organizations have also highlighted that having access to additional mentorship support from their respective regional offices may potentially improve the overall efficiency of the HL Program

6.3 Community Health Planning Process

The community health planning processes aim to meet the unique health needs of First Nations and Inuit communities. This process are not unique to the Healthy Living Program and are in fact processes that FNIHB implement across programs. Several key informant interview respondents highlighted that they have robust community health planning processes^{Footnote 54} in place and are well integrated in many community-level activities, focusing on encouraging the collaboration of multi-disciplinary teams, and allowing communities to drive their own needs and priorities. Regional offices have noted in key informant interviews that they often receive diverse community health plans (CHP), since the plans often reflect the communities' capacity and resources. In the survey, some respondents spoke to the importance of the CHP and addressing community needs, with one respondent stating that "each of the Health Programs are part of our work plans that we plan based on what is available funding-wise...they are designed to complement each other as a whole in addressing the community's needs based on what we can afford to do". Encouraging communities to drive their own needs is an important aspect of the CHP process, a survey respondent expressed that: "our community health plan has identified chronic disease as a priority area and goals and objectives have been set to meet these".

Key informant interview respondents have shared best practices that have been employed to increase the efficacy of community health plans as it relates to the HL program. These include (but are not limited to):

• Utilizing dietitians and diabetes nurses to support stronger linkages between need and priorities of communities and ensuring the voices of communities are more present throughout activities;
• Ensuring the inclusion of the social determinants of health; and
• Including the community in the development of the community health plans and ensuring consistent community representation for an extended period of time, as it helps to retain corporate knowledge.

78% of survey respondents (n=78) agreed that the Healthy Living Program was well incorporated into the community health planning process in their respective communities. There was a mixed response from survey respondents on whether they were aware of the incorporation of HL sub-programs in community health plans. Some respondents highlighted they were intimately involved in the process and worked towards identifying community priorities vis a vis HL sub-programs, while other respondents were either not aware or not involved in the plan development (i.e., employed by a Tribal Council).

6.4 Financial Resources

Two barriers facing many of the communities delivering the Healthy Living sub-programs are access to adequate financial resources and the provision of additional training opportunities. Funding constraints have a negative impact on both the recruitment and retention of community-level talent, and access to financial resources to support professional development training opportunities for staff are limited. Funding has been stagnant (i.e., not keeping up with inflationary pressures, and the increased needs of the program) for many years, leading to unmet needs of the program and little to no increase in salaries at the community levels, contributing to high turnover rates and vacant positions. The lack of financial and human resources faced by communities, has also impacted the program's potential loss of corporate/ institutional knowledge when, for example, when staff depart.^{Footnote 55}

A significant number of key informant interview respondents highlighted the impact of inadequate financial resources on continuing programs, with one key informant interview respondent stating that "from a community point of view, the funds haven't increased over time. There's not enough funding for program delivery. The other challenge is the constant turnover of staff. Often times, the salary is not competitive and staff turnover is a problem in the delivery of the program".Similarly, a survey respondent acknowledged the human resource impact on the program, stating that "staff turnover makes it difficult to continue programming over a long period". Other respondents have suggested an increase in funding would allow for communities to have access to in-house professionals, with one key informant interview respondent stating that it would be beneficial to "not have people needing to travel out to see health professionals if they could see their own dietitians in the community. There isn't funding for it currently and it makes it a challenge for people to achieve their goals and follow the best practices when you don't have those resources available". Sharing a similar response, one survey respondent shared a similar perspective on the need for in-house professionals:"working out of a tribal council and needing to travel to communities to provide professional support. Having professional staff working out of each clinic would be much more successful". Additionally, an ISC regional key informant interview respondent expressed that "major staff turnover means that a constant need for [re-]education, [since] the new staff don't have an adequate understanding of the program or base knowledge to be able to transfer it out. The fact that they wear many hats especially in smaller communities, so they're pulled between many programs".

The survey (n=92) indicated that 29% of the respondents felt that training was sufficient, while 36% agreed that training is only somewhat sufficient to help them do their jobs.  At least 11% of staff felt that training was not sufficient to support them in delivering HL programs and 24% did not know. For example, survey respondents also suggested the need for a wide variety of training that is relevant to the type of work staff are engaged in. Survey respondents also identified a need for traditional-based training, physical activity training, trauma-informed approaches, nutrition-based training including cooking skills, withdrawal and support (addictions), gardening, and mental health training.

An increase in program funding would also allow for communities to focus on implementing a holistic and comprehensive approach to addressing chronic disease,  rather than a focusing on individual risk factors. Moreover, an overall consensus exists in health care literature that chronic disease management and primary care that promotes wellness, screening, and other preventive care results in improved outcomes and lower overall health care costs.^{Footnote 56} This could be an area for further analysis that the evaluation was not able to conduct.

Key informant interview respondents also expressed concerns about inadequacy of funding for Nutrition Education Initiatives given the high price of food in the North, and the travel expenses for workers that service multiple communities. Ultimately, these high food prices make cooking classes, and other engagement sessions expensive, and increase program costs. Additional funding is also needed to facilitate training for staff.

Prior to 2018-19, the CTS operated through proposal-based funding which presented problems in staff retention and medium and long-term program planning. With the transition from the FTCS to CTS in 2018-19, the program adopted a distinctions-based approach. This included a switch from proposal-based funding to on-going funding. It is presumed that consistent funding will reduce staff turnover as salaries will be able to be anticipated for the upcoming years. A national office key informant interview respondent highlighted the importance of stable funding for CTS: "It takes persistence, involvement of leadership and partnerships. It's important to have consistent funding, so projects are going from year to year knowing what their future would look like".

Despite a move away from proposal-based funding, respondents from the regional offices highlighted that the CTS remains insufficiently funded, especially in regards to staffing requirements. Regional staff noted that frontline health care workers are busy with other priorities, and that funding is required to support health care workers assigned specifically to the tobacco program.

6.5 Performance Measurement Systems

The program relies on a number of data sources to track and measure performance. Some of this data is collected directly through the program, while other data is made available through external sources, such as the Regional Health Survey. Below are the various data points available to the program and the challenges associated with them.

• The community-based reporting template (CBRT)^{Footnote 57} is a reporting requirement associated with certain contribution agreements between First Nation communities and FNIHB. The CBRT encompasses several program areas, such as healthy child development, communicable disease control and management, home and community care, mental wellness, and healthy living. The CBRT was first developed in 2008-2009, and since then it has undergone several iterations. For the 2018-2019 reporting period, 314 communities in Canada completed the HL Program's CBRT reporting requirement. This includes communities in Alberta, Saskatchewan, Manitoba, Ontario, Quebec, and Atlantic regions. As a result of the diverse funding agreements across sub-programs, reporting requirements vary from community to community, and not all communities are required to use the CBRT as a reporting tool.^{Footnote 58} Throughout key informant interviews, community workers expressed the importance of collecting and utilizing the CBRT to not only fulfil their funding requirements but also to provide a snapshot of the community's health and well-being. Conversely, there is also an expressed need from partner organizations to further improve the CBRT, as it does not collect information at a sufficiently detailed level for communities to effectively track performance and achievement of results. For example, based on CBRT reporting in 2015-16, 93% (n=317) of communities held healthy eating awareness/education sessions, 91.5% (n=270) reported offering the same session in 2017-18, and in 2018-19 it was reported that 91% (n=314) of the communities that reported to deliver HL program, held healthy eating awareness/education sessions. CBRT data collected from communities may not be sufficiently detailed enough to support communities in systematically collecting and utilizing quantitative data to better tailor programming to their own health needs and priorities.

As well, the CBRT data collected is not inclusive and it does not have comprehensive data for all performance indicators across all communities. Key informant interview respondents have also called for increased performance measurement systems to support client information management, with one respondent stating: "having a database that supports the tracking of client information for our small community…many of our clients have a physician so our involvement is limited outside of promotion and primary prevention." Challenges around data limitations were also corroborated by the previous 2014 Evaluation of FNIHB's Healthy Living and Healthy Child Development Community Planning Program Components,^{Footnote 59} which concluded that: "performance measurement has improved, particularly for measuring intermediate and long-term outcomes. However, focus on performance indicators and data collection that support immediate outcomes, specifically the reach and access of HL and HCD programs could be enhanced to better support program monitoring, for planning and reporting".

• A significant secondary data point for the HL Program is obtained through the First Nations Regional Health Survey (RHS), a large cross-sectional survey administered by the First Nations Information Governance Centre (FNIGC)^{Footnote 60}, a non-profit First Nations organization. The RHS is the only national First Nations health survey in Canada and produces important innovations in computer-assisted interviewing, culturally appropriate questionnaire content, sampling, and field methods. The survey was administered in 2002-03, 2008-10 and in 2015-16 among First Nations populations living on-reserve and in northern communities. The RHS is also the first national survey that explicitly implements the First Nations principles of OCAP^{Footnote 61}. The RHS collects information from the majority of First Nations on-reserve communities on a select range of topics and by age cohorts - children (0-11 years), youth (12-17 years) and adult (18 years and older). The 2019 National Report of the First Nations RHS employs 64 indicators that have been tracked and gradually refined and expanded for over 20 years^{Footnote 62}. Of particular note for the HL programming, the  survey collects high level information on diabetes, physical activity, food security, nutrition, health and chronic conditions. While the RHS is a robust mechanism for monitoring high level health outcomes every five years, it is typically available only at the national level and does not provide sufficient details about what is working and what is not at the sub-program and regional and community levels and specific Healthy Living outcome level data.
• Additionally, the NNC Nutrition Education Initiatives utilize an annual reporting template completed by eligible funding recipients. Communities collect and report data related to NNC Nutrition Education Initiatives programming, specifically on nutrition knowledge and awareness among clients, retail-based nutrition knowledge and awareness, food skills development, traditional food knowledge and skills, and healthy food access. For example, during the 2018-19 reporting period, 4,700^{Footnote 63} activities were delivered by First Nations and Inuit funding recipients and in total there were 49,000^{Footnote 64} participants that attended nutrition activities. The limitation of this data collection tool was not determined by the evaluators.

6.6 Funding Arrangements

The ADI program funding arrangement varies across regions, with most communities having flexible or block funding contribution approaches. Some key informant interview respondents have expressed that block funding is preferred as it allows for greater flexibility and reduces reporting burdens. There are also a few communities that are in set contribution agreements (less flexible in how funding is utilized). A key informant interview respondent explained that some communities prefer set contribution agreements over funding agreements that allow for more financial flexibility, because set contribution agreements ensure that funds are specifically earmarked for the ADI. Thus, set contribution agreements allow for some communities to ensure funds are utilized for a specific program as opposed to utilizing funds to meet potentially changing community priorities and needs. Key informant interview respondents supporting ADI and CTS have reported that while the funding arrangements are appropriate, the current funding amounts are inadequate and do not match their needs, emphasizing in key informant interviews the challenges this creates in retaining professional staff and the overall impact in the delivery of services.

Across NNC eligible communities, the funding model varies. For example, the recent Horizontal Evaluation of Nutrition North Canada states that in some cases, the funding is directly provided to communities while in other cases, funding arrangements are provided to other governments (i.e., tribal councils, territorial governments, etc.) to support various eligible communities. With the NNC Nutrition Education Initiatives, ISC and the Public Health Agency of Canada (PHAC) provide funding and support to eligible communities for the delivery of retail and community-based nutrition education activities. Communities then decide which NNC nutrition education activities they wish to implement based on their own needs and priorities.

With the transition from the FTCS to CTS in 2018-19, the program adopted a distinctions-based approach (this is discussed in further detail in Finding 9). Despite a move away from proposal-based funding, key informant interview respondents highlighted that the program remains insufficiently funded, especially in regards to staffing requirements. They note that since front line health care workers are busy with other priorities, additional funding is required to support health care workers assigned specifically to the tobacco program.

7.1 Aboriginal Diabetes Initiative (ADI)

7.2 Canada's Tobacco Strategy (CTS)

7.3 Nutrition North Canada Nutrition Education Initiatives (NNCNEI)

7.3.1 Program Eligibility Requirements

Finding 15: The flexibility of the Nutrition North Canada Nutrition Education Initiatives is a contributing factor in the program's success, despite challenges reported with the program's eligibility requirements.

The overall goal of the NNC - Nutrition Education Initiatives^{Footnote 83} is to complement existing NNC programs with a nutrition focus by supporting retail and community-based nutrition education initiatives. In doing so, the NNC - Nutrition Education Initiatives aims to encourage and increase knowledge of healthy eating habits and develop skills for the selection and preparation of healthy foods in fully eligible First Nations and Inuit communities. NNC – Nutrition Education Initiative is community driven, with programming varying from community to community. The program is flexible, allowing for communities to choose the types of activities that serve their needs. From annual program reporting, between 2013-14 and 2018-19, funding recipients delivered almost 18,000 nutrition education activities such as promotion of healthy food knowledge, food skills development, in-store taste tests and grocery store tours, and traditional food harvesting and preparation. In 2018-19 alone^{Footnote 84}, at the community level, over 4,000 nutrition education activities were delivered to more than 44,000 participants, and an estimated 70% of funding recipients indicated that community members had increased their knowledge of healthy eating and skills and were choosing and preparing healthy food.

Approximately half (52%) of survey respondents agreed or strongly agreed that the NNC Nutrition Education Initiatives were operating effectively (n=25). As well, survey respondents^{Footnote 85} and key informant interviewees reported successes in the integration and promotion of traditional foods in the Nutrition North Canada Nutrition Education Initiatives programming and working closely with the ADI program. Access to traditional foods and supporting knowledge transfer/exchange is important to the development of food sovereignty in all communities^{Footnote 86}. This includes cooking with traditional foods in cooking classes, planting and maintaining community gardens, and promoting traditional hunting practices. This is in-line with the recommendations from the First Nations Food, Nutrition and Environmental Study which supports the promotion of traditional food systems to tackle issues of food security/sovereignty^{Footnote 87}. The study found traditional foods to have multiple core values for First Nations, both cultural, spiritual, and traditional, and called for the support of First Nations-led healthy food education^{Footnote 88}. During the 2018-19 data collection period, the CBRT reports that among the communities that reported delivering a HL program (n=314), 57% provided school-based feeding programs, 63% provided food vouchers, 51% provided good food boxes, 65% provided community gardens, 40% provided grocery store tours, 91% provided healthy eating awareness/education, 79% provided tradition harvesting/food preparation, and 89% provided cooking session/classes.

The recent Horizontal Evaluation of Nutrition North Canada^{Footnote 89} found that given the nature of initiatives funding, inadequate data collection and reporting makes it difficult to attribute particular results of Nutrition Education Initiatives to the NNC program. However, it did report that the growing incidences of participation suggest that there is widespread interest in healthy eating. Thus, it can reasonably be concluded that participants are likely acquiring knowledge and skills to eat healthier. As another way to attribute probable program success, the relationships between the program funding and the extent of participation was highlighted in the evaluation, suggesting that increased investment expanded education initiatives to more communities (see figure below)^{Footnote 90}.

Text alternative for Figure 1: Incidences of Participation Relative to Funds Spent on Nutrition Education Initiatives Funded by NNC between 2012-13 and 2016-17

Figure 1 is a mixed line and bar graph that compares the incidences of participation relative to funds spent on nutrition education initiatives funded by Nutrition North Canada (NNC) between 2012-13 and 2016-17.

In 2012-13, the NNC program spent $2,614,280 and had 24,000 participants. In 2013-14, the NNC program spent $2,659,880 and had 26,000 9participants. In 2014-15, the NNC program spent $2,626,323 and had 38,000 participants. In 2015-16, the NNC program again spent $2,626,323 and had 38,000 participants. In 2016-17, the NNC program spent $3,145,573 and had 55,000 participants.

The evaluation found that there is a higher demand for certain types of activities such as traditional food knowledge and skills and retail-based nutrition knowledge and awareness. The evaluation of Nutrition North Canada^{Footnote 91} also found that activities where food was offered were often the most favoured, be it cooking classes or food tasting, and that targeted cooking classes for school children and Elders were often successful.^{Footnote 92}

Many key informant interview respondents expressed concerns around the eligibility for Nutrition Education Initiatives. Funding is currently dependent on the First Nations community meeting eligibility criteria for the NNC subsidy administered by CIRNAC. Key informant interview respondents expressed that the NNC - Nutrition Education Initiatives remains relevant for all communities. Key informant interview respondents also expressed that the current eligibility criteria does not meet the needs of many communities with one partner organization respondent, with one stating: "some of our drive-in communities are four-plus hours from a town with a grocery store and because they're not fly-in, they're not eligible for Nutrition North". Key informant interview respondents also expressed the needs to expand the eligibility criteria to allow for a wider range of communities to receive this program.

With the increasing prices of food in the north, coupled with travel expenses for community workers that service multiple communities, key informant interview respondents have all expressed concerns regarding the inadequacy of funding for the NNC Nutrition Education Initiatives. Ultimately, these high food prices make cooking classes, and other engagement sessions expensive for the program. When asked what the key challenges in delivering NNC Nutrition Education Initiatives were, many survey respondents highlighted funding concerns, for example: "lack of funding, can't hire full-time staff",insufficient funding", and "staffing and housing for contractors who travel here". Additional funding was also noted to be required to facilitate training for staff.

8.1 Best and Preferred Practices

A number of best and preferred practices^{Footnote 93} have been identified for the Healthy Living program. Contributing to the success of these best practices (to varying degrees) have been the following key principles:

• A flexible program design and delivery allows staff to implement culturally relevant activities to the local community and its members;
• A flexible program design and delivery allows for increased accessibility and better engagement from community members;
• Activities rooted in community-led design and delivery have a higher rate of success and positive outcomes;
• Encouraging the roll out of the HL program across multiple service providers (doctors, hospitals, community groups);
• A significant number of community partners have suggested that having an Indigenous cultural support worker would greatly enhance the inclusion of cultural/ traditional teachings and practices in HL sub-programs at the community level;
• Encouraging partnerships with other ISC programs/ services that would create more opportunities for increased collaboration and for natural partnerships to take hold with the aim of having less communities working in silos; and;
• Lastly, integrating a chronic disease approach in HL sub-programs, and focusing on implementing a holistic approach to addressing chronic disease. 

8.2 General Best Practices Identified

The following best practices (not exhaustive) are a collection of practices identified by key informant interview respondents that have shown success in the delivery of the Healthy Living Program and that have the potential to be implemented across the HL sub-programs^{Footnote 94}. 

Incorporating Traditional Tobacco Practice

• The integration of traditional tobacco into the program was the most widely reported best practice by regional and community partners in key informant interviews relating to CTS. This includes growing and harvesting tobacco, providing elder-led teachings of traditional tobacco, and promoting the use of traditional tobacco grown without chemicals. Carson et al. emphasized the importance of developing programming with community members and where possible, involving Indigenous health care workers in the delivery of the program^{Footnote 95}. Multiple regions highlighted the significance of engaging Elders to teach youth of the sacred medicine of traditional tobacco. A key informant interview respondent noted that by teaching traditional versus commercial tobacco use, the program is able to take a culturally informed harm reduction approach to tobacco use. Informants emphasized the need for the program to be flexible to adapt to community needs and traditions.

Intra-Regional ADI Working Groups:

• An achievement of the ADI is the strong engagement of regional partners at their respective regional community of practice groups, which some key informants have referred to as "working groups". Partners across most regions expressed a high degree of satisfaction with this participatory working method and stated that the opportunities to build strategic partnerships with other colleagues at both the regional and community levels have been beneficial.

Land Based Activities:

• Communities across the country have shifted more towards land-based activities and integrating an environmentally focused approach to education. Communities have focused on reaching various participants (children, youth, elders), specifically exposing community members to traditional harvesting practices and traditional foods.

NIDA Resource Booklet:

• The National Indigenous Diabetes Association (NIDA) developed a resource booklet titled "Gifts from our Relations"^{Footnote 96}, a food guide that highlights commonly consumed traditional foods (both plants and animals) that can be found on Indigenous lands. It provides practical guidance and insight into original food consumption as a means to reduce type 2 diabetes in First Nations communities. The focus of the resource booklet highlights how various consumed traditional foods (i.e., fish, seafood, seaweed, rice, plants, berries) provides specific vitamins for those living with diabetes and looking to self-manage the disease through diet. This is found to be highly beneficial by many of the community partners interviewed as the guide was developed by two nutritionists and these are viewed by ADI staff as resources materials that are familiar to Indigenous clients. 

8.3 Regional Specific Best Practices

Manitoba: Partnership Models

• Diabetes Integration Project (DIP): The Diabetes Integration Project in Manitoba is a mobile diabetes care and treatment model that was developed to provide services on-reserve to support First Nation adults living with type 2 diabetes to prevent, screen, and/or delay the complications of diabetes. The DIP has maintained strong relationship with other community initiatives to ensure there is limited duplication of services. A barrier within DIP is that it is only available in a third of the Manitoba communities and without additional financial investment, many of the other communities across the province will not have access to the mobile clinics.
• Food Security Coordinator: The Four Arrows Regional Health Authority has been employing a full time Manitoba First Nations food security coordinator since 2011, who acts as liaison for all 63 First Nations communities in Manitoba. This position promotes and increases awareness about food security, supports food sovereignty and empowers communities to produce food locally (through gardens, greenhouses and raising livestock) and through sustainable ways, encourages the continuation of traditional food sharing networks. The training and support provided by this position is offered through various means such as telehealth sessions, by email, telephone, on-line, and when possible, through community visits. ISC provides funding for the position through the ADI.
• Tribal Diabetes Coordinators (TDC): The TDC role supports community ADI workers in capacity development at the tribal council level so that they can provide increased support to their communities. The TDC is commonly supported by a nurse, dietician, or diabetes related specialist. This is a role that communities find beneficial as TDCs act as a "go to resource" for ADI staff and can provide staff with technical support. There is also an opportunity for knowledge mobilization and has helped to reduce staff turnover rates among ADI workers.

Atlantic Region: Screening and Management

• Diabetes Self-Management Journey: The Atlantic region delivers the "Diabetes Self-Management Journey," an annual program that is offered in each province by a diabetes community consultant in partnership with diabetes educators from the local regional health authority, pharmacy and community elders. Communities are invited to send participants living with diabetes and their respective support individual (family member, friend etc.) to attend a 3-5 day culturally-relevant diabetes self-management workshop that focuses on topics that support the individual living with diabetes including nutrition, medications, physical activity, menu planning, traditional foods, mental wellness, etc. The journeys provide evidenced-based recommendations and enhance self-management skills for individuals living with diabetes and their support person. The region has received positive feedback from community members living with diabetes on this educational program. It is also viewed by community partners as a beneficial opportunity for people to share and learn together with people who are living with diabetes. The Atlantic region has been providing this annual education for over 15 years.

Alberta Region: Food Security Activities

• Food Security: The Prevention Program Committee of Alberta Co-Management developed the Alberta First Nation Food Security Strategy through their Food Security Working Group. The development of this strategy followed a number of steps including an environmental scan of learnings and practices from food security initiatives in a First Nations or Indigenous context. The development of this strategy also involved a series of community engagement sessions, where all First Nations in Alberta were invited to participate, as well as a series of stakeholder consultations. Creating this Food Security Strategy by Alberta First Nations is one of the first steps towards achieving food sovereignty and control.
• The Alberta First Nations Food Security Working Group in partnership with the Alberta First Nations Elders' Advisory Group developed an Alberta First Nations Food Sovereignty Declaration in order to increase access to traditional foods in community programs and facilities.

8.4 Lessons Learned (General Guiding Principles)

The following are general guiding principles regarding lessons learned in community programming design, as shared in key informant interviews:

• It is important to focus on meeting the individual where they are along the health spectrum;
• Relationship building is key in community development work and it is important to focus on building relationships with community members first, rather than solely focusing on the behavioural/ biomedical aspects of ADI;
• When programs focus on creating an environment that is culturally safe and trauma-informed for community participants, it helps to build trust and relationships;
• Integrating cultural practices into Healthy Living activities, such as Indigenous storytelling, can be a powerful and empowering tool for learning and sharing intergenerational experiences and knowledge;
• An ability to adapt programming to meet the needs and circumstances of a community is desirable for Healthy Living. What may be effective for one Nation/ community may not be effective for another; and
• The ADI programs that have community champions are seen to be highly effective at helping to build community level ownership.

9.1 Climate Change

The effects of climate change on the Healthy Living Program are potentially significant, especially in the context of remote and isolated communities. Key informant interview respondents noted that there are two elements to consider in terms of climate change effects as they relate to HL Programs: impacts on the food supply chain and changes in the availability of traditional or country foods as a result of changes to the environment and ecosystems. Both of these have the potential to impact the availability of nutritious foods that are important elements of the ADI and NNC Nutrition Education Initiatives, as well as food security itself in northern, remote and isolated communities.

Firstly, climate change has an impact on food security, and as a result can impact the HL Program. Many community-based activities supported through HL sub-programs seek to improve access to and availability of nutritious food, for example by incorporating healthy store bought and traditional foods, and supporting gardening. Survey respondents and key informant interview respondents noted that climate change is causing a less reliable food supply chain, as once reliable ice roads used for transport of food are increasingly impassable or are in operation for a shorter period of time due to late freeze-up/early melting. This has the potential to delay delivery of nutritious and healthy foods (i.e., fruits and vegetables) required to mitigate the effects of diabetes and other chronic health conditions whose treatment is positively influenced by diet.

Secondly, impacts such as changes in animal migration patterns, extreme weather conditions, and temperature changes have had an impact on the local availability of plants and animals leading to deleterious effects on food security. Survey respondents  also noted that due to climate change, the migration patterns of game animals have been altered in some cases, which is increasingly deleterious for those communities whose food security relies more on the availability of traditional country foods as a larger portion of a healthy diet. Survey respondents also highlighted in the survey the need to increase collaboration with schools to promote healthy eating: "there are still some gaps with grocery stores in Northern communities keeping [their] stock up. Cannot find fresh fruit and vegetables in the stores. Not much opportunity for the school curriculum to allow time for Diabetic educator to do teaching on healthy eating. Schools are a vital part of learning about healthy eating and need to collaborate more with the Dietitian and Diabetes Educator".

9.2 Service Transfer

Readiness for transfer of Healthy Living programming directly to communities was found to be varied, but overall, key informant interview respondents highlighted that work needs to be done before the program would be ready for service transfer. Indeed, the fact that many communities over all regions are incrementally moving towards flexible funding arrangements may be viewed as a positive step in the service transfer continuum. Still, there remain hurdles. Most significantly, key informant interview respondents cited that the role that ISC provides in terms of financial oversight (i.e., management tools, databases, etc.) is not yet being transferred to community health directors and staff, which is an important administrative aspect of service transfer. This factor impedes the ability of ISC regional offices to adapt to changing community need-based priorities. Additionally, concerns were raised by key informant interview respondents around the likelihood of additional funding requests being approved once service transfer is complete. The current bidirectional relationship between the federal government and communities fosters accountability to ensure that Healthy Living programs are adequately funded. Without this relationship, some respondents expressed concerns that additional funding requests may not have as much priority.

9.3 Early Impacts of COVID-19

The COVID-19 pandemic has marked effects on Healthy Living programming, just as it has on society and programming initiatives as a whole. The greatest impact noted by key informant interview respondents and survey respondents has been that many planned activities (e.g., gathering in groups for activities such as cooking classes, school engagements) have effectively been delayed or put on hold. The reasons for the delays include community access restrictions/physical distance measures for non-community members; redeployment of community health workers to the COVID-19 response; and capacity limits within structures where programming would normally occur. Indeed, community priorities have generally been re-directed to focus on mitigating the spread of the virus, which has removed resources away from not only health-related programming, but also in other areas served by ISC (i.e., infrastructure). Additionally, COVID-19 has further amplified the food security challenges faced by many vulnerable communities, for reasons noted above.

In many cases, the Program has successfully pivoted to providing programming online by leveraging communications technology and social media (for example, cooking classes delivered via Facebook rather than in-person). While this has worked effectively in some areas, it has been more difficult in remote areas with limited internet access. It is not clear from key informant interviews whether emergency COVID-19 funding was provided to the Healthy Living programs, or how it may have been utilized. However, due to the flexible nature of Healthy Living funding, respondents noted that in some cases it has been utilized to augment and support COVID-19 relief efforts.

Aside from the above, an additional and significant reality to consider that could potentially impact the Program in the future are the potential effects of COVID-19 on the Indigenous population in general. According to the National Advisory Committee on Immunization, Indigenous individuals are also more likely to have underlying health conditions (for example, diabetes) that could make a bout of COVID-19 more deadly. The proportion of Canadians who identify as Indigenous and have at least one underlying medical condition associated with an increased risk of severe COVID-19 is higher compared to other Canadians for every age category above 20 years of age. Exacerbating this is the reality that Indigenous and remote communities face increased COVID-19 risks due to possible aggravating conditions, such as limited access to clean water, lack of health professionals/services, a high prevalence of chronic diseases, and crowded living conditions.