Drinking water quality in Indigenous communities in Canada and health outcomes: a scoping review

Figures & data

Table I. Keywords (with synonyms) and syntax used for literature search

#1	Drinking water Drinking water quality OR water quality OR potable water OR healthy water OR drinkable water OR drink water OR drink OR safe water OR water OR suitable water OR palatable water OR edible water OR tap water OR fresh water OR water supply
#2	Indigenous communities Indigenous people OR Indigenous OR Aborigine OR Aboriginal OR Indigenous OR Native(s) OR Indigen* OR Indigenous people OR First Nations OR Metis OR Inuit Or Inuk
#3	Health Health outcomes OR wellness OR well being OR physical health OR mental health OR social health
#4	Challenges Challenge* OR limitation* OR gap* OR barrier* OR obstacle*
#5	Canada Canada OR North America
#6	#1 AND #2 AND #3 AND #5
#7	#6 AND #4

Table II. Additional websites used to identify grey literature for the scoping review

Source	URL/link
Public Health Grey Literature Sources (via OPHLA)	(www.ophla.ca/pdf/Public Health Grey Literature Sources.pdf)
Canadian Electronic Library: Canadian Public Policy Collection (CPPC)	www.library.usask.ca/find/connect.php?code=CELCPPC
Healthcare Standards Directory Online	www.library.usask.ca/find/connect.php?code=HCS
Centre for Indigenous Environmental Resources	www.yourceir.org
University repository for literature in Indigenous studies	Iportal.usask.ca

Fig. 1.  PRISMA (21) flowchart of study selection process. OPHLA: Ontario Public Health Libraries Association. CPPC: Canadian Public Policy Collection. CIER: Center for Indigenous and Environmental Resources (see Table II).

Table III. Summary of articles included in scoping review (n=16)

ID Authors Year (Citation #)	Topic	Design: method Data type N Response rate	Site^a (FN=First Nation)	Summary of findings	Limitations
A Tam et al. 2015 (22)	Iodine status of Eeyou Istchee community members of northern Quebec, Canada, and potential sources	Quantitative: Cohort study Primary data 750 participants No data on what % of those selected for the study declined	Six Cree FNs in PQ	Correlation between higher consumption of tap water (in First Nation communities) and local spring water (in the bush) and lower levels of Urinary Iodine Concentration (UIC) and increased risk of iodine deficiency disorders -suggesting these water sources contained lower iodine levels.	Individual variations in UIC measurement. Iodine content in water sources was not analysed with reference to iodine content across other Canadian water sources.
B Dupont et al. 2014 (23)	Drinking water management: Health risk perceptions and choices in FNs and non-FNs communities in Canada	Quantitative: Participatory research Primary data 301 FN (ON) 86 FN (SK) 1,307 Non-FN 23.5% for non-FN 41% for SK FN community. Response rates not reported for ON FN communities.	Four FNs communities: Six Nations; New Credit; Oneida FN ON Muskoday FN SK	Explored the perspectives on health risks from tap water and bottle water. ON FN more likely to believe bottled water safer than tap water, more likely to express water and health concerns related to tap water consumption and to report illnesses related to drinking tap water, and more likely to spend more on bottled water. Residents of the Saskatchewan FN community were less likely to than non-FN respondents for all parameters above.	Selection bias or volunteer bias for survey responders. Could not evaluate the response rate for Oneida, ON surveys.
C Hanrahan et al. 2014 (24)	Water insecurity in Indigenous Canada: A case study of Illness, Neglect, and Urgency	Mixed methods: Case study Primary data Water testing: one PDWU and seven dug out wells Interviews/Focus Groups: One community Number of participants not reported	Black Tickle-Domino NL	Water samples contain high level of carcinogenic disinfectant by-products. Turbidity was high (no figures given), which may have been due to its high iron content and natural organic matter. Black Tickle residents confirmed high rates of diabetes, obesity (80% of female study participants) owing to high rates of sugary beverage consumption as alternative to drinking water.	Not peer-reviewed. No limitations reported. Conference proceeding. Methods not documented in detail.
D McClymont Peace and Myers 2012 (25)	Community-based Participatory Process, Climate Change and Health Adaptation Program for Northern First Nations and Inuit in Canada	Qualitative: Participatory research Evaluation study 15 visits to three communities (five visits in each) and three capacity building workshops after the visits	Whitehorse, YK; Yellowknife, NT, and Ottawa, ON; with participation from FNs, government representatives, and other related organizations across YK, NT, ON	Evaluation of programs and capacity building workshops for northerners to promote research tools and policy measures on climate change and water quality among northern Indigenous communities.	Funding and delays in execution of the workshops. No specific data collected or reported on water and health.
E Spence and Walters 2012 (26)	Risk perception and drinking water in a vulnerable population	Quantitative: Cross-sectional Survey Secondary data from 2001 Aboriginal Peoples Survey 17,506 individuals from 123 FN reserves in Canada	FNs across Canada selected for the 2001 Aboriginal Peoples Survey	Using multiple logistic regression models, assessed the determinants of risk perception of drinking water in the home among FN on reserve in Canada. Variables associated with greater perception of risk for drinking water in the home included being female, being highly educated, having children less than 15 years of age, being in poor health, having less attachment to Aboriginal culture, living in a residence requiring major repairs, reporting water contamination during the previous year or being uncertain of the contamination status of water, and residing in specific geographic areas.	Smaller reserves were not included. Limitations in survey tool on concepts and measures associated with risk perception of drinking water. Under-reporting of FN perception regarding health risk related to drinking water based on survey structure.
F Harbinson 2012 (8)	Graduate level Independent Study project: An Analysis of Water Quality and Human Health Issues in First Nations Communities in Canada	Qualitative: Case study Content analysis Secondary compilation of current literature from local agencies, government and other documents No data analysis	Case studies from three First Nations communities summarized: Kashechewan ON Yellow Quill SK Fort Chipewyan AB	Results showed higher rates of certain diseases among First Nation communities than other Canadian citizens, reported to be related to exposure to poorer water quality.	Not a peer-reviewed. Where information was missing or authors deemed it to have questionable authenticity, this was noted in the report. The authors recommended caution when generalizing findings of the case studies to other Canadian populations or
					First Nations communities, as the factors influencing the water and health quality could be significantly different.
G Harper et al. 2011 (27)	Weather, Water Quality and Infectious Gastrointestinal Illness in Two Inuit Communities in Nunatsiavut, Canada: Potential. Implications for Climate Change	Quantitative: Participatory research Primary and Secondary data Ecological, water quality and health records data. No individual person or household data collected.	Two Inuit communities: Nunatsiavut: Nain and Rigolet in NL	Study analysed and compared data on weather, water quality and health in Nunatsiavut FN community. Poisson regression was used to examine associations between weather events and infectious gastrointestinal disease (IGI) clinic visits. Results showed a higher number of IGI related clinic visits in the summer and fall months) and when high levels of water volume input 2 and 4 weeks prior.	Missing weather and water quality data. Inability to identify the origin of gastro illness. Gender differences in illness were difficult to sort out from clinic use. Not possible to exclude patients who visited more than once for same illness.
H Patrick 2011 (9)	Uneven access to safe drinking water for First Nations in Canada: Connecting health and place through source water protection	Theoretical/Qualitative: Case and Content analysis No primary or secondary data analysis	Neskantanga ON	Exploration of health promotion through examination of access to safe drinking water showed that source water protection in addition to water quality monitoring through technology is vital in maintaining health of First Nation communities.	No limitations reported.
I Ekos Research Associates 2011 (28)	Technical report (Health Canada): Perceptions of Drinking Water Quality in FN Communities and General Population	Quantitative: Cross-sectional Primary data 674 + 227 FN residents on reserves and 706 residents from non-FN small communities 15% response rate for small communities and 21% response rate for FN reserves. Missing data not reported.	FNs and other small communities across Canada including all provincial regions and the territories	Underlines the difference in confidence levels between FN and non-FN for drinking water quality. Analysis showed FN residents are less confident (variable figures with reference to water source, water quality and households) about the quality of water they received than residents from non-FN communities.	Not peer-reviewed. Brief telephone interviews used to collect data. Language barriers.
J Anderson 2010 (4)	Technical report: Aboriginal Women, Water and Health: Reflections from 11 First Nations, Inuit and Métis grandmothers	Qualitative: Participatory research Interviews Primary data 11 grandmothers	BC, AB, SK, ON, Nunavut, Labrador.	Interviews highlighted the importance of water as a spirit and its traditional role in promoting health.	Not peer-reviewed No limitations reported except for use of phone interviews rather than in person for women from Labrador.
K Lebel and Reed 2010 (29)	Case study of the Capacity of Montreal Lake, Saskatchewan to Provide Safe Drinking Water by Applying a Framework for Analysis	Mixed methods: Case study, interviews, public workshop, document analysis, water quality testing 1 community 5 interviewed and 16 in workshop	Montreal Lake FN, SK	Established an analytical framework for evaluating the capacity of FNs community to provide safe drinking water, and sustaining its water quality; applied framework to case study community where no serious deficiencies in the management of drinking water were found.	Applying the framework (built from indicators from literature in FN and non-FN communities) in a community where drinking water was a risk may have resulted in bias.
L Bernier et al. 2009 (30)	On-site microbiological quality monitoring of raw source water in Cree community of Mistissini	Quantitative: Case study Primary water quality data collected on sites 74 water samples from 12 water sources plus 21 samples from portable water containers 24 households	Cree people of Mistissini PQ	Assessed the use of multiple indicators (E. coli and Enterococci) in microbiological water quality monitoring of source water in a Cree community. Results revealed that several storage practices decreased the microbiological quality of raw source water and thus drinking water-related health outcomes.	Technological constraints limiting the use of culture-based methods in water quality monitoring.
M Simpson et al. 2009 (6)	The Responsibilities of Women: Confronting Environmental Contamination in traditional territories	Decolonizing Qualitative: Participatory research Primary data from culturally-sensitive and community-owned focus groups Number of participants not reported	Two FN communities: Asubpeechoseewagong Netum Anishinabek (Grassy Narrows) and Wabauskang, ON	Described experiences and perspectives of women elders on water and land contamination and impact to health of Indigenous communities. No causal relationship was reported however scenarios of environmental contamination and health outcomes were highlighted.	No limitations reported.
N Smith et al. 2007 (31)	Public Health Evaluation of drinking water systems for First Nations reserves in Alberta, Canada	Quantitative: Cross-sectional Primary data from water samples, and survey of risk evaluations. 56 water systems and Environmental Health Officer and water treatment plant operator for each community	FNs across AB	Risk perception evaluation of 56 water supply systems showed 50 to be termed as high risk, five medium risk and one low risk using numerical score systems and health risk indicators.	Took conservative approach to situations of cumulative risk, and underreporting of gastrointestinal illness, and likely protective immunity from long-term exposure were limitations.
O Jin and Martin 2003 (32)	Hepatitis A Among Residents of First Nations Reserves in British Columbia, 1991–1996	Quantitative: Cohort Secondary data from health agency records 50,787 records in the 1994 water and sewages survey and 49,756 records from the 1993 survey	257 FN reserves belonging to 197 bands across BC	Incidence of hepatitis A among residents of FN reserves twice as high as the crude incidence in the general population of BC for study period An association between increase hepatitis A incidence and greater numbers of persons per housing unit (i.e. crowding and water use) showed a relative risk of 6.7 (95% CI 4.3–10.5).	Small sample
P Maclean 2002 (33)	Thesis: Source Water Characteristics and the Incidence of Gastroenteritis in Aboriginal Communities	Mixed method: Cohort Primary data from surveys 74 + 32 +37+28 = 171 reflecting an average retention rate of 78.5% at the end of the study	Bonaparte Band, Neskonlith Band, and Kamloops Band BC	Explored drinking water sources and unreported diarrheal illness and the potential relationships between water treatment types (chlorination and filtration) and the incidence of unreported diarrheal illnesses, in the three First Nation communities. Incidence rates of unreported diarrhoeal illnesses from cluster groups were comparatively low in residents with disinfection only, shallow infiltration and drilled wells with no significant difference in incidence between Kamloops and Neskonlith communities (0.84 per person year and 0.80 per person year, respectively).	Limited length of study. Uncontrolled use of multiple water sources offers protection. Under-reporting of symptoms. Selection bias minimized by random sample. Non-blinding of study subjects. Failure to pre-screen study subjects for pre-existing health conditions and immune deficiencies may have also biased results.

^aProvincial and territorial abbreviations used: AB: Alberta, BC: British Columbia, NL: Newfoundland and Labrador, NT: Northwest Territories, ON: Ontario, PQ: Quebec, SK+ Saskatchewan, YK: Yukon Territory.

Table IV. General attributes of publications included in the scoping review (n=16)

Characteristic	Number (n=16)	%	Article ID numbers^a
Publication year
2000–2004	2	13	(O, P)
2005–2009	3	19	(L, M, N)
2010–June 2014	11	69	(A–K)
Publication type
Journal article or conference proceeding	12	75	(A–E, G, H, K–O)
Thesis or academic report	2	13	(F, P)
Technical report	2	13	(I, J)
Indigenous Nation
First Nations	12	75	(A, B, F–I, K–P)
Inuit	3	19	(C, D, E)
Other (Metis, Mohawk,  Cree, Ojibway, etc.)	1	6	(J)
Drinking water terminology
Drinking water	12	75	(A–G, I, K, M, O, P)
Safe drinking water	2	13	(H, L)
Both	2	13	(J, N)
Definition of health
Reported in article	2	13	(J, M)
Cited elsewhere	3	19	(F, I, P)
Not reported	11	69	(A–E, G, H, K, L, N, O)

^aRefer to Table III for key to study titles and authors.

Table V. Methodological characteristics of publications included in the scoping review (n=16)

Methodological characteristic	Number (n=16)	%	Article ID numbers^a
Research design
Participatory research	5	31	(B, D, G, J, M)
Case study	4	25	(C, F, K, L)
Cross-sectional studies	3	19	(E, I, N)
Cohort	3	19	(A, O, P)
Theoretical research only	1	6	(H)
Research data
Primary data	11	81	(A–C, G, I–P)
Secondary data	4	25	(E–G, O)
Not reported	2	13	(D, H)
Study type
Quantitative	8	50	(A, B, E, G, I, L, N, O)
Qualitative	5	31	(D, F, H, J, M)
Mixed	3	19	(C, K, P)
Drinking water quality assessment
Assessed qualitatively	5	31	(B, C, H–J)
Both qualitatively and quantitatively	7	44	(A, F, G, K, L, N, P)
Not assessed	4	25	(D, E, M, O)
Limitations to safe drinking water mentioned?
Yes	14	87	(A–D, F–L, N–P)
No	2	13	(E, M)

^aRefer to Table III for key to study titles and authors.

Table VI. Health outcomes related to drinking water described in publications included in the scoping review (n = 16)

Health issues described in identified articles	% (Frequency)	Article ID numbers^a
Gastrointestinal infections	75 (12/16)	(A–C, E–H, K, L, N–P)
Birth defects and developmental problems (genetics)	31 (5/16)	(A, C, F, O, P)
Skin problems	31 (5/16)	(C, F, I, J, P)
Obesity	19 (3/16)	(C, F, P)
Diabetes	19 (3/16)	(C, F, P)
Cancers	19 (3/16)	(C, F, P)
Infant mortality	13 (2/16)	(F, P)
Mental stress	13 (2/16)	(F, P)
Neurological problems	13 (2/16)	(A, F)
Hypertension	6 (1/16)	(F)
Heart diseases	6 (1/16)	(F)
Liver diseases	6 (1/16)	(F)
Kidney problems	6 (1/16)	(F)
Immunopathy and autoimmune diseases	6 (1/16)	(F)
Thyroid disease	6 (1/16)	(A)

^aRefer to Table III for key to study titles and authors.

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