Back to the basics: Identifying and addressing underlying challenges in achieving high quality and relevant health statistics for indigenous populations in Canada

The prevalence of distress, depression, anxiety, and substance use issues among Indigenous post-secondary students in Canada

This study aimed to estimate the prevalence of mental illness and substance use among Indigenous students attending Canadian post-secondary institutions. We obtained data from the National College Health Assessment - American College Health Association Spring 2013 survey, which includes 34,039 participants in 32 post-secondary institutions across Canada. We calculated prevalence estimates with 95% confidence intervals (CI). We compared Indigenous and non-Indigenous students using age- and sex-adjusted prevalence ratios (PR) obtained from Poisson regression models. Of the total sample, 1,110 (3.3%) post-secondary students self-identified as Indigenous. Within the past 12 months, Indigenous students had higher odds of intentionally injuring themselves (PR = 1.53, 95% CI = 1.27-1.84), seriously considering suicide (PR = 1.32, 95% CI = 1.12-1.56), attempting suicide (PR = 1.74, 95% CI = 1.16-2.62), or having been diagnosed with depression (PR = 1.26, 95% CI = 1.08-1.47) or anxiety (PR = 1.18, 95% CI = 1.02-1.35) when compared with non-Indigenous students. Indigenous students also had higher odds of having a lifetime diagnosis of depression (PR = 1.31, 95% CI = 1.17-1.47) when compared with non-Indigenous students. Indigenous students were more likely to report binging on alcohol (PR = 1.10, 95% CI = 1.02-1.19), using marijuana (PR = 1.21, 95% CI = 1.06-1.37), and using other recreational drugs (PR = 1.32, 95% CI = 1.06-1.63) compared to non-Indigenous students. This study demonstrates that Indigenous students at post-secondary institutions across Canada experience higher prevalence of mental health and related issues compared to the non-Indigenous student population. This information highlights the need to assess the utilization and ensure the appropriate provision of mental health and wellness resources to support Indigenous students attending post-secondary institutions.

Influence of Preexisting Diabetes on Survival After a Breast Cancer Diagnosis in First Nations Women in Ontario, Canada

PURPOSE

Survival after a breast cancer diagnosis is poorer in First Nations women with a preexisting comorbidity compared with comorbidity-free First Nations women in Ontario, Canada. Given the high prevalence of diabetes in this population, it is important to determine whether preexisting diabetes is related to poorer survival after a breast cancer diagnosis.

METHODS

All First Nations women were identified from a cohort of First Nations people diagnosed with breast cancer in diagnostic periods-1995 to 1999 and 2000 to 2004-and seen at a regional cancer program (RCP) in Ontario. Preexisting diabetes status and other factors, such as age at diagnosis, body mass index, and stage at diagnosis, were collected from medical charts at the regional cancer programs. The association between preexisting diabetes and First Nations status was examined by each of the demographic, personal, tumor, and treatment factors using logistic regression models. Survival was compared between First Nations women with (n = 67) and without (n = 215) preexisting diabetes, adjusted by significant study factors using a Cox proportional hazards regression model.

RESULTS

The 5-year survival rate among First Nations women with diabetes was 59.8% versus 78.7% among those without diabetes (P < .01). Preexisting diabetes significantly increased the risk of death among First Nations women with breast cancer (hazard ratio, 1.87; 95% CI, 1.12 to 3.13) after adjustment for age group, period of diagnosis, body mass index, other comorbidities at diagnosis, and stage.

CONCLUSION

This study recommends awareness of this survival discrepancy among the treatment team for First Nations patients with breast cancer with preexisting diabetes.

Global goals and suicide prevention in the Circumpolar North

The purpose of this selective narrative review is to provide an overview of suicide and suicide prevention in the Circumpolar North and the relevance of global strategies and policies to these themes. We conducted a selective review of the English language literature on Arctic Indigenous mental health, suicide, and suicide prevention. We briefly present the social context, epidemiology, and risk and protective factors for suicide in the Arctic, with a focus on Indigenous peoples. We highlight a recent collaborative, intergovernmental response to elevated suicide rates in this region, the Reducing the Incidence of Suicide in Indigenous Groups - Strengths United through Networks Initiative, which used a consensus methodology to identify key outcomes for evaluating suicide prevention interventions in the circumpolar context. In relation to the Sustainable Development Goals, we examine recent policy developments in Indigenous-led suicide prevention and identify opportunities for strengthening policy, community interventions, and research. Globally, suicide prevention is a public health priority, and reducing the number of suicide deaths is a key target for sustainable development. Although overall and country-specific suicide rates have decreased since 1990, there remains wide variation at the regional and local level. This is particularly evident in the Arctic region known as the Circumpolar North, where Indigenous peoples experience marked disparities in suicide risk and suicide deaths compared to non-Indigenous populations. The factors that influence these variations are complex and often rooted in the social and economic consequences of colonization. The integration of science, community-based and Indigenous knowledge, and policies that address upstream risks for suicide will play an important role in suicide prevention alongside the growing number of Indigenous suicide prevention strategies tailored for specific populations.

The social determinants of healthy ageing in the Canadian Arctic

A better knowledge of the social determinants of health (SDH) promoting healthy ageing in Inuit communities is needed to adapt health and social policies and programs. This study aims to identify SDH associated with healthy ageing. Using the 2006 Aboriginal Peoples Survey (n = 850 Inuit aged ≥50 years), we created a holistic indicator including multiple dimensions of health and identified three groups of participants: those in 1) good 2) intermediate and 3) poor health. Sex and age-adjusted multinomial regression models were applied to assess the associations between this indicator and SDH measured at the individual, household and community scales. In comparison to APS respondents in the "Poor health" profile, those in the "Good health" profile were more likely to have a higher individual income, to participate in social activities, and to have stronger family ties in the community ; those in the "Intermediate health" profile were less likely be in a relationship, more likely to live in better housing conditions, and in better-off communities. Results indicate that SDH associated with the "Good health" profile related more to social relationships and participation, those associated with the "Intermediate health" profile related more to economic and material conditions.

"Nothing About Us, without Us." How Community-Based Participatory Research Methods Were Adapted in an Indigenous End-of-Life Study Using Previously Collected Data

La recherche en santé autochtone au Canada a été négligée dans le passé et qualifiée de problématique, notamment en raison du manque de collaboration avec les peuples autochtones. L'Énoncé de politique des trois Conseils sur l'éthique de la recherche avec des êtres humains décrit au chapitre 9 la conduite éthique de la recherche axée sur les Premières nations, les Inuits et les Métis. Les principes PCAP® des Premières nations (propriété, contrôle, accès et possession) soulignent l'importance majeure de l'engagement et de la gouvernance autochtones. En vue d'assurer que les buts et les activités de la recherche développée soient réalisés en partenariat complet et significatif avec les peuples et les communautés autochtones, il est possible de faire appel à des méthodes de recherche participative communautaire (RPC) intégrant leur plein engagement. Les recherches utilisant des ensembles de données secondaires, telles que les données administratives sur la santé recueillies en routine, ne devraient plus être exclues de cette approche. Notre objectif était de décrire comment notre équipe de chercheurs universitaires, alliée à un organisme national de santé autochtone, a adapté les méthodes de RPC dans le cadre d'un projet de recherche utilisant des données recueillies antérieurement pour examiner les lacunes dans la prestation de soins de fin de vie aux peuples autochtones en Ontario. Nous décrivons le processus d'élaboration de ce partenariat de recherche et expliquons comment l'intégration des principes de base et des processus de formation du savoir autochtones ont guidé cette collaboration. Notre partenariat de recherche, qui implique l'adaptation de méthodes de RPC, illustre un processus d'engagement qui pourrait guider d'autres chercheurs désirant mener des recherches en santé autochtone à l'aide de données déjà recueillies. Nous faisons aussi état d'une entente de recherche transparente, négociée équitablement entre un organisme national de santé autochtone et des chercheurs, qui pourrait servir de cadre pour des collaborations de recherche similaires. Il est essentiel de s'assurer que les perspectives autochtones soient au cœur des processus de recherche et qu'elles soient reflétées dans ceux-ci lorsque des données administratives sur la santé sont utilisées.

Indigenous health research in Canada has a chequered past and has been identified as problematic and lacking in appropriate collaboration with Indigenous people. The Tri-Council Policy Statement on Ethical Conduct for Research Involving Humans, Chapter 9 describes ethical conduct of research regarding First Nations, Inuit, and Métis Peoples. First Nations Ownership, Control, Access, and Possession (OCAP®) Principles highlight the necessity of Indigenous engagement and governance. To ensure that the aims and activities of the research being developed are in full and meaningful partnership with Indigenous peoples and communities, community-based participatory research (CBPR) methods provide a process in which full engagement is possible. Research utilizing secondary data sets, such as routinely collected health administrative data, should no longer be excluded from this approach. Our aim was to describe how our research team of academic researchers and a national Indigenous health organization adapted CBPR methods in a research project using previously collected data to examine end-of-life health care service delivery gaps for Indigenous people in Ontario. We describe the process of how we developed our research partnership and how grounding principles and Indigenous ways of knowing guided our work together. Through the adaptation of CBPR methods, our research partnership illustrates a process of engagement that can guide others hoping to conduct Indigenous health research using previously collected data. We also present a transparent research agreement negotiated equally by a national Indigenous health organization and research scientists, which can also be used as a framework for others wishing to establish similar research partnerships. Ensuring that Indigenous perspectives are central to and reflected in the research process is essential when using health administrative data.

The prevalence of cardiometabolic multimorbidity and its association with physical activity, diet, and stress in Canada: evidence from a population-based cross-sectional study

BACKGROUND

Cardiometabolic multimorbidity (CM) is defined as having a diagnosis of at least two of stroke, heart disease, or diabetes, and is an emerging health concern, but the prevalence of CM at a population level in Canada is unknown. The objectives of this study were to quantify the: 1) prevalence of CM in Canada; and 2) association between CM and lifestyle behaviours (e.g., physical activity, consumption of fruits and vegetables, and stress).

METHODS

Using data from the 2016 Canadian Community Health Survey, we estimated the overall and group prevalence of CM in individuals aged ≥50 years (n = 13,226,748). Multiple logistic regression was used to quantify the association between CM and lifestyle behaviours compared to a group without cardiometabolic conditions.

RESULTS

The overall prevalence of CM was 3.5% (467,749 individuals). Twenty-two percent (398,755) of people with diabetes reported having another cardiometabolic condition and thus CM, while the same was true for 32.2% (415,686) of people with heart disease and 48.4% (174,754) of stroke survivors. 71.2% of the sample reported eating fewer than five servings of fruits and vegetables per day. The odds of individuals with CM reporting zero minutes of physical activity was 2.35 [95% CI = 1.87 to 2.95] and having high stress was 1.89 [95% CI = 1.49 to 2.41] times the odds of the no cardiometabolic condition reference group. The odds of individuals with all three cardiometabolic conditions reporting zero minutes of physical activity was 4.31 [95% CI = 2.21 to 8.38] and having high stress was 3.93 [95% CI = 2.03 to 7.61].

CONCLUSION

The number of Canadians with CM or at risk of CM is high and these individuals have lifestyle behaviours that are associated with adverse health outcomes. Lifestyle behaviours tend to diminish with increasing onset of cardiometabolic conditions. Lifestyle modification interventions focusing on physical activity and stress management for the prevention and management CM are warranted.

Unmet health needs and discrimination by healthcare providers among an Indigenous population in Toronto, Canada

Objectives

Inequalities between Indigenous and non-Indigenous peoples in Canada persist. Despite the growth of Indigenous populations in urban settings, information on their health is scarce. The objective of this study is to assess the association between experience of discrimination by healthcare providers and having unmet health needs within the Indigenous population of Toronto.

Methods

The Our Health Counts Toronto (OHCT) database was generated using respondent-driven sampling (RDS) to recruit 917 self-identified Indigenous adults within Toronto for a comprehensive health assessment survey. This cross-sectional study draws on information from 836 OHCT participants with responses to all study variables. Odds ratios and 95% confidence intervals were estimated to examine the relationship between lifetime experience of discrimination by a healthcare provider and having an unmet health need in the 12 months prior to the study. Stratified analysis was conducted to understand how information on access to primary care and socio-demographic factors influenced this relationship.

Results

The RDS-adjusted prevalence of discrimination by a healthcare provider was 28.5% (95% CI 20.4–36.5) and of unmet health needs was 27.3% (95% CI 19.1–35.5). Discrimination by a healthcare provider was positively associated with unmet health needs (OR 3.1, 95% CI 1.3–7.3).

Conclusion

This analysis provides new evidence linking discrimination in healthcare settings to disparities in healthcare access among urban Indigenous people, reinforcing existing recommendations regarding Indigenous cultural safety training for healthcare providers. Our study further demonstrates Our Health Counts methodologies, which employ robust community partnerships and RDS to address gaps in health information for urban Indigenous populations.

Exploring Sex-Based Differences in Concussion Knowledge, Attitudes and Resources in Young First Nations Hockey Players: A Cross-Sectional Survey from Ontario, Canada

Objective:

Indigenous youth are vulnerable to concussion when playing hockey. A clear characterisation of sex differences among Indigenous youth could assist in tailoring future education programmes for prevention and management of concussion. The purpose of this study was to compare and contrast concussion knowledge, attitudes and resources in First Nations girls and boys playing recreational hockey.

Method:

The cross-sectional survey was conducted in partnership with a First Nations’ chief, other Indigenous community leaders and a tertiary care head injury clinic. In Canada, researchers engaging with Indigenous peoples are expected to adhere to principles of Ownership, Control, Access and Possessions. The study included Indigenous boys and girls between the ages of 10 and 18 years of age.

Results:

More girls attending the hockey tournament participated in the study as compared to boys (girlsn= 46, boysn= 29). More girls reported they had never experienced a concussion (73.9%), as compared to boys (58.6%) self-reports. Less than half of all study participants were able to identify some signs and symptoms of concussion such as vomiting/nausea, memory problems, fatigue and blurred vision and recognition of several concussion symptoms varied by sex.

Conclusions:

We created a unique partnership between Indigenous leaders and tertiary care clinic staff. Among Indigenous youth reasons for not reporting concussion symptoms to the coach varied by sex (although not reaching statistical significance), suggesting concussion education warrants tailoring for girls and boys.

Factors Associated with Low Birth Weight in Indigenous Populations: a systematic review of the world literature

Abstract Objectives: we aimed to identify etiological factors for low birth weight (LBW), prematurity and intrauterine growth restriction (IUGR) in the Indigenous Population. Methods: for this systematic review, publications were searched in Medline/PubMed, Scopus, Web of Science, and Lilacs until April 2018. The description in this review was based on the PRISMA guideline (Study protocol CRD42016051145, registered in the Centre for Reviews and Dissemination at University of York). We included original studies that reported any risk factor for one of the outcomes in the Indigenous Population. Two of the authors searched independently for papers and the disagreements were solved by a third reviewer Results: twenty-four studies were identified, most of them were from the USA, Canada and Australia. The factors associated were similar to the ones observed in the non-indigenous including unfavorable obstetric conditions, maternal malnutrition, smoking, and maternal age at the extremes of childbearing age, besides environmental factors, geographic location, and access to health care in indigenous communities. Conclusions: etiologic factors for LBW in Indigenous Population have been receiving little attention, especially in Latin America. The three outcomes showed common causes related to poverty and limited access to healthcare. New studies should ensure explicit criteria for ethnicity, quality on the information about gestational age, and the investigation on contextual and culture-specific variables.

Disparities in health outcomes among seniors without a family physician in the North West Local Health Integration Network: a retrospective cohort study

BACKGROUND

The relationship between having a family physician and in-hospital and postdischarge health outcomes among older adults is unclear. We ascertained the proportion of seniors who did not have a family physician and were admitted to an Ontario tertiary care centre, and we determined the association between having/not having a family physician and in-hospital mortality, 1-year mortality and readmission after live discharge.

METHODS

This was a retrospective cohort study of community-dwelling seniors who were admitted to a medical service at Thunder Bay Regional Health Sciences Centre. We conducted regression analyses adjusted for demographic factors, prior health care utilization, and factors associated with the index admission to determine the association between family physician status and the study outcomes.

RESULTS

Among the 12 033 seniors admitted to hospital between Apr. 1, 2004, and Mar. 31, 2013, 40.7% lacked a family physician. Among those without a family physician, 8.0% (390/4899) died during the index admission and 15.8% (714/4509) died in the subsequent year. Adjusted regression models showed that not having a family physician was significantly associated with in-hospital mortality (odds ratio 1.56, 95% confidence interval [CI] 1.33-1.83). Regression models of all-cause 1-year mortality and readmission also suggested that lack of a family physician was associated with detrimental health outcomes (hazard ratio 1.14, 95% CI 1.04-1.26; subdistribution hazard ratio 1.17, 95% CI 1.10-1.24, respectively).

INTERPRETATION

Elders without family physicians were disadvantaged during their hospital admission as well as in the subsequent year. Additional interventions aimed at increasing the proportion of seniors admitted to hospital who are connected with a family physician are warranted.

Facilitators and barriers of sociodemographic data collection in Canadian health care settings: a multisite case study evaluation

Background

Despite growing awareness of the importance of social determinants of health, research remains limited about the implementation of sociodemographic data collection in Canadian health care settings. Little is known about the salient contextual factors that enable or hinder collection and use of social information to improve quality of care in clinical settings. This study examines the perceptions and experiences of managers and care providers to better understand how to support organizational efforts to collect and use sociodemographic data to provide equity-oriented care.

Methods

Case studies of three diverse urban health care settings employed semi-structured individual and group interviews with managers and care providers respectively to explore their experiences with implementation. Data was analyzed separately and in context for each site as part of an individual case study. A thematic analysis of interview transcripts was performed with an inductive approach to coding of segments of the text. Constructs of the Consolidated Framework for Implementation Research (CFIR) were used as an analytical framework to structure the data to support cross case comparisons of facilitators and barriers to implementation across settings.

Results

Several perceived facilitators and barriers to implementation were identified that clustered around three CFIR domains: intervention, inner setting and characteristics of individuals. Macro level (outer setting) factors were relatively unexplored. Sites were motivated by their recognition of need for social information to improve quality of care. Organizational readiness for implementation was demonstrated by priorities that reflected concern for equity in care, leadership support and commitment to an inclusive process for stakeholder engagement. Barriers included perceived relevance of only a subset of sociodemographic questions to service delivery, staff capacity and comfort with data collection as well as adequate resources (funding and time).

Conclusion

Although system level mandates were underexplored, they may accelerate adoption and implementation of sociodemographic data collection in the presence of organizational readiness. Standardized tools integrated into information systems and workflows would support adequately trained personnel. More research is needed to understand important factors in rural health settings and with clinical application to inform care delivery pathways.

Electronic supplementary material

The online version of this article (10.1186/s12939-018-0903-0) contains supplementary material, which is available to authorized users.

Tracking progress in suicide prevention in Indigenous communities: a challenge for public health surveillance in Canada

Indigenous peoples in Canada experience disproportionate rates of suicide compared to non-Indigenous populations. Indigenous communities and organizations have designed local and regional approaches to prevention, and the federal government has developed a national suicide prevention framework. However, public health systems continue to face challenges in monitoring the population burden of suicide and suicidal behaviour. National health data systems lack Indigenous identifiers, do not capture data from some regions, and do not routinely engage Indigenous communities in data governance. These challenges hamper efforts to detect changes in population-level outcomes and assess the impact of suicide prevention activities. Consequently, this limits the ability to achieve public health prevention goals and reduce suicide rates and rate inequities.

This paper provides a critical analysis of the challenges related to suicide surveillance in Canada and assesses the strengths and limitations of existing data infrastructure for monitoring outcomes in Indigenous communities. To better understand these challenges, we discuss the policy context for suicide surveillance and examine the survey and administrative data sources that are commonly used in public health surveillance. We then review recent data on the epidemiology of suicide and suicidal behaviour among Indigenous populations, and identify challenges related to national surveillance.

To enhance capacity for suicide surveillance, we propose strategies to better track progress in Indigenous suicide prevention. Specifically, we recommend establishing an independent community and scientific governing council, integrating Indigenous identifiers into population health datasets, increasing geographic coverage, improving suicide data quality, comprehensiveness, and timeliness, and developing a platform for making suicide data accessible to all stakeholders. Overall, the strategies we propose can build on the strengths of the existing national suicide surveillance system by adopting a collaborative and inclusive governance model that recognizes the stake Indigenous communities have in suicide prevention.

Strategies for Supporting Smoking Cessation Among Indigenous Fathers: A Qualitative Participatory Study

There is a need for tailored smoking cessation programs specifically for Indigenous fathers who want to quit smoking.The aim of this study was to engage Indigenous men and key informants in guiding cultural adaptations to the Dads in Gear (DIG) cessation program. In Phase 1 of this qualitative participatory study, Indigenous men were engaged in group sessions and key informants in semistructured interviews to gather advice related to cultural adaptations to the DIG program. These data were used to guide the development of program prototypes. In Phase 2, the prototypes were evaluated with Indigenous fathers who were using tobacco (smoking or chewing) or were ex-users. Data were analyzed inductively. Recommendations for programming included ways to incorporate cultural values and practices to advance men’s cultural knowledge and the need for a flexible program design to enhance feasibility and acceptability among diverse Indigenous groups. Men also emphasized the importance of positive message framing, building trust by providing “honest information,” and including activities that enabled discussions about their aspirations as fathers as well as cultural expectations of current-day Indigenous men. That the Indigenous men’s level of involvement with their children was diverse but generally less prescriptive than contemporary “involved fathering” discourse was also a key consideration in terms of program content. Strategies were afforded by these insights for meeting the men where they are in terms of their fathering—as well as their smoking and physical activity. This research provides a model for developing evidence-based, gender-specific health promotion programs with Indigenous men.

Indigenous health disparities: a challenge and an opportunity

Summary

Clinical Indigenous health research is sparse and often not patient-centred. Despite a broad acknowledgement that Indigenous patients have unique clinical considerations, specific interventional research in Indigenous health is lacking.

Indigenous health disparities: a challenge and an opportunity

Summary

Clinical Indigenous health research is sparse and often not patient-centred. Despite a broad acknowledgement that Indigenous patients have unique clinical considerations, specific interventional research in Indigenous health is lacking.

Healthcare Utilization and All-Cause Premature Mortality in Hungarian Segregated Roma Settlements: Evaluation of Specific Indicators in a Cross-Sectional Study

Roma is the largest ethnic minority of Europe with deprived health status, which is poorly explored due to legal constrains of ethnicity assessment. We aimed to elaborate health indicators for adults living in segregated Roma settlements (SRS), representing the most vulnerable Roma subpopulation. SRSs were mapped in a study area populated by 54,682 adults. Records of all adults living in the study area were processed in the National Institute of Health Insurance Fund Management. Aggregated, age-sex standardized SRS-specific and non-SRS-specific indicators on healthcare utilization and all-cause premature death along with the ratio of them (RR) were computed with 95% confidence intervals. The rate of GP appointments was significantly higher among SRS inhabitants (RR = 1.152, 95% CI: 1.136–1.167). The proportion of subjects hospitalized (RR = 1.286, 95% CI: 1.177–1.405) and the reimbursement for inpatient care (RR = 1.060, 95% CI: 1.057–1.064) were elevated for SRS. All-cause premature mortality was significantly higher in SRSs (RR = 1.711, 1.085–2.696). Our study demonstrated that it is possible to compute the SRS-specific version of routine healthcare indicators without violating the protection of personal data by converting a sensitive ethical issue into a non-sensitive small-area geographical analysis; there is an SRS-specific healthcare utilization pattern, which is associated with elevated costs and increased risk of all-cause premature death.

Global incidence of suicide among Indigenous peoples: a systematic review

BACKGROUND

Suicide is the second leading cause of death among adolescents worldwide, and is a major driver of health inequity among Indigenous people in high-income countries. However, little is known about the burden of suicide among Indigenous populations in low- and middle-income nations, and no synthesis of the global data is currently available. Our objective was to examine the global incidence of suicide among Indigenous peoples and assess disparities through comparisons with non-Indigenous populations.

METHODS

We conducted a systematic review of suicide rates among Indigenous peoples worldwide and assessed disparities between Indigenous and non-Indigenous populations. We performed text word and Medical Subject Headings searches in PubMed, MEDLINE, Embase, Cumulative Index of Nursing and Allied Health (CINAHL), PsycINFO, Latin American and Caribbean Health Sciences Literature (LILACS), and Scientific Electronic Library Online (SciELO) for observational studies in any language, indexed from database inception until June 1, 2017. Eligible studies examined crude or standardized suicide rates in Indigenous populations at national, regional, or local levels, and examined rate ratios for comparisons to non-Indigenous populations.

RESULTS

The search identified 13,736 papers and we included 99. Eligible studies examined suicide rates among Indigenous peoples in 30 countries and territories, though the majority focused on populations in high-income nations. Results showed that suicide rates are elevated in many Indigenous populations worldwide, though rate variation is common, and suicide incidence ranges from 0 to 187.5 suicide deaths per 100,000 population. We found evidence of suicide rate parity between Indigenous and non-Indigenous populations in some contexts, while elsewhere rates were more than 20 times higher among Indigenous peoples.

CONCLUSIONS

This review showed that suicide rates in Indigenous populations vary globally, and that suicide rate disparities between Indigenous and non-Indigenous populations are substantial in some settings but not universal. Including Indigenous identifiers and disaggregating national suicide mortality data by geography and ethnicity will improve the quality and relevance of evidence that informs community, clinical, and public health practice in Indigenous suicide prevention.

Commercial tobacco and indigenous peoples: a stock take on Framework Convention on Tobacco Control progress

Background

The health status and needs of indigenous populations of Australia, Canada and New Zealand are often compared because of the shared experience of colonisation. One enduring impact has been a disproportionately high rate of commercial tobacco use compared with non-indigenous populations. All three countries have ratified the WHO Framework Convention on Tobacco Control (FCTC), which acknowledges the harm caused to indigenous peoples by tobacco.

Aim and objectives

We evaluated and compared reporting on FCTC progress related to indigenous peoples by Australia, Canada and New Zealand as States Parties. The critiqued data included disparities in smoking prevalence between indigenous and non-indigenous peoples; extent of indigenous participation in tobacco control development, implementation and evaluation; and what indigenous commercial tobacco reduction interventions were delivered and evaluated.

Data sources

We searched FCTC: (1) Global Progress Reports for information regarding indigenous peoples in Australia, Canada and New Zealand; and (2) country-specific reports from Australia, Canada and New Zealand between 2007 and 2016.

Study selection

Two of the authors independently reviewed the FCTC Global and respective Country Reports, identifying where indigenous search terms appeared.

Data extraction

All data associated with the identified search terms were extracted, and content analysis was applied.

Results

It is difficult to determine if or what progress has been made to reduce commercial tobacco use by the three States Parties as part of their commitments under FCTC reporting systems. There is some evidence that progress is being made towards reducing indigenous commercial tobacco use, including the implementation of indigenous-focused initiatives. However, there are significant gaps and inconsistencies in reporting. Strengthening FCTC reporting instruments to include standardised indigenous-specific data will help to realise the FCTC Guiding Principles by holding States Parties to account and building momentum for reducing the high prevalence of commercial tobacco use among indigenous peoples.

Innovating for Transformation in First Nations Health Using Community-Based Participatory Research

Community-based participatory research (CBPR) provides the opportunity to engage communities for sustainable change. We share a journey to transformation in our work with eight Manitoba First Nations seeking to improve the health of their communities and discuss lessons learned. The study used community-based participatory research approach for the conceptualization of the study, data collection, analysis, and knowledge translation. It was accomplished through a variety of methods, including qualitative interviews, administrative health data analyses, surveys, and case studies. Research relationships built on strong ethics and protocols to enhance mutual commitment to support community-driven transformation. Collaborative and respectful relationships are platforms for defining and strengthening community health care priorities. We further discuss how partnerships were forged to own and sustain innovations. This article contributes a blueprint for respectful CBPR. The outcome is a community-owned, widely recognized process that is sustainable while fulfilling researcher and funding obligations.

Who is research serving? A systematic realist review of circumpolar environment-related Indigenous health literature

BACKGROUND

Addressing factors leading to health disparities in the Circumpolar North require approaches that consider and address the social determinants of health including on-going colonization. Today, colonization and related policies and processes, continue to manifest in the marginalization of Indigenous knowledge, particularly its use in research; however, Indigenous populations have moved from being research subjects to leaders and consumers of environmental health research. Given the tensions that exist between how health research is conducted, how the results are mobilized, and who has control and access to the results, we examine how peer-reviewed environment-related Indigenous health research in the Circumpolar North is serving the needs of Indigenous communities, governments, and organizations.

METHODS

A modified systematic-realist literature review was conducted. Three databases were searched for peer-reviewed literature published from 2000 to 2015. Articles were included if the research focused on the intersection of the environment and health in Northern Canada and/or Alaska. A total of 960 unique records were screened for relevance, and 210 articles were analysed.

RESULTS

Of these relevant articles, 19% discussed how Indigenous peoples were engaged in the research. There was a significant increase in reporting participatory, community-based methods over time; the proportion of articles reporting community-engagement varied by research topic; quantitative research articles were significantly less likely to report community-engaged methods; and most articles did not clearly report how the results were shared with the community.

CONCLUSION

The results raise a number of questions for the field of Circumpolar environment-related Indigenous health research, including whether or how authors of peer-reviewed literature should (or should not) be obliged to describe how research is serving Northern Indigenous communities. The results are intended to stimulate further conversations and bridge perceived dichotomies of quantitative/qualitative, Western/Indigenous, and empirical/community driven research approaches, as well as underlying assumptions that frame health research.

Unlocking First Nations health information through data linkage

Introduction

The importance of Indigenous data sovereignty and Indigenous-led research processes is increasingly being recognized in Canada and internationally. For First Nations in Ontario, Canada, access to routinely-collected demographic and health systems data is critical to planning and measuring health status and outcomes in their populations. Linkage of this data with the Indian Register (IR), under First Nations data governance, has unlocked data for use by First Nations organizations and communities.

Objectives

To describe the linkage of the IR database to the Ontario Registered Persons Database (RPDB) within the context of Indigenous data sovereignty principles.

Methods

Deterministic and probabilistic record linkage methods were used to link the IR to the RPDB. There is no established population of First Nations people living in Ontario with which we could establish a linkage rate. Accordingly, several approaches were taken to determine a denominator that would represent the total population of First Nations we would hope to link to the RPDB.

Results

Overall, 201,678 individuals in the national IR database matched to Ontario health records by way of the RPDB, of which 98,562 were female and 103,116 were male. Of those First Nations individuals linked to the RPDB, 90.2% (n=181,915) lived in Ontario when they first registered with IR, or were affiliated with an Ontario First Nation Community. The proportion of registered First Nations people linking to the RPDB improved across time, from 62.8% in the 1960s to 94.5% in 2012.

Conclusion

This linkage of the IR and RPDB has resulted in the creation of the largest First Nations health research study cohort in Canada. The linked data are being used by First Nations communities to answer questions that ultimately promote wellbeing, effective policy, and healing.

Measuring cancer in indigenous populations

It is estimated that there are 370 million indigenous peoples in 90 countries globally. Indigenous peoples generally face substantial disadvantage and poorer health status compared with nonindigenous peoples. Population-level cancer surveillance provides data to set priorities, inform policies, and monitor progress over time. Measuring the cancer burden of vulnerable subpopulations, particularly indigenous peoples, is problematic. There are a number of practical and methodological issues potentially resulting in substantial underestimation of cancer incidence and mortality rates, and biased survival rates, among indigenous peoples. This, in turn, may result in a deprioritization of cancer-related programs and policies among these populations. This commentary describes key issues relating to cancer surveillance among indigenous populations including 1) suboptimal identification of indigenous populations, 2) numerator-denominator bias, 3) problems with data linkage in survival analysis, and 4) statistical analytic considerations. We suggest solutions that can be implemented to strengthen the visibility of indigenous peoples around the world. These include acknowledgment of the central importance of full engagement of indigenous peoples with all data-related processes, encouraging the use of indigenous identifiers in national and regional data sets and mitigation and/or careful assessment of biases inherent in cancer surveillance methods for indigenous peoples.

Primary care intervention to address cardiovascular disease medication health literacy among Indigenous peoples: Canadian results of a pre-post-design study

CONTEXT

Cardiovascular diseases (CVD) are a leading cause of illness and death for Indigenous people in Canada and globally. Appropriate medication can significantly improve health outcomes for persons diagnosed with CVD or for those at high risk of CVD. Poor health literacy has been identified as a major barrier that interferes with client understanding and taking of CVD medication. Strengthening health literacy within health services is particularly relevant in Indigenous contexts, where there are systemic barriers to accessing literacy skills.

OBJECTIVE

The aim of this study is to test the effect of a customized, structured health literacy educational program addressing CVD medications.

METHODS

Pre-post-design involves health providers and Indigenous clients at the De dwa da dehs nye>s Aboriginal Health Centre (DAHC) in Ontario, Canada. Forty-seven Indigenous clients with or at high risk of CVD received three educational sessions delivered by a trained Indigenous nurse over a 4- to 7-week period. A tablet application, pill card and booklet supported the sessions. Primary outcomes were knowledge of CVD medications and health literacy practices, which were assessed before and after the programe.

RESULTS

Following the program compared to before, mean medication knowledge scores were 3.3 to 6.1 times higher for the four included CVD medications. Participants were also more likely to refer to the customized pill card and booklet for information and answer questions from others regarding CVD.

CONCLUSIONS

This customized education program was highly effective in increasing medication knowledge and health literacy practice among Indigenous people with CVD or at risk of CVD attending the program at an urban Indigenous health centre.

A cross-sectional analysis of the relationship between diabetes and health access barriers in an urban First Nations population in Canada

OBJECTIVE

This study explores the relationship between health access barriers and diabetes in an urban First Nations population in Canada.

DESIGN

Data from a self-identified urban First Nations population were collected using respondent-driven sampling (RDS). As no clear approach for regression modelling of RDS data is available, two logistic regression modelling approaches, including survey-based logistic and generalised linear mixed models, were used to explore the relationship between diabetes and health barriers of interest, including access to healthcare, food, housing and socioeconomic factors.

SETTING

Hamilton, Ontario, Canada.

PARTICIPANTS

This cross-sectional study used data collected from the Our Health Counts study, in partnership with the De dwa da dehs nye>s Aboriginal Health Centre, which recruited 554 First Nations adults living in Hamilton using RDS.

RESULTS

After adjusting for covariates, multivariable regression techniques showed a statistically significant relationship between a self-reported diagnosis of diabetes and a lack of culturally appropriate care among urban First Nations peoples (OR: 12.70, 95% CI 2.52 to 57.91). There was also a trend towards a relationship between diabetes and not having a doctor available in the area, feeling that healthcare provided was inadequate and a lack of available healthcare services in the area.

CONCLUSIONS

Urban First Nations peoples who felt the health service they received was not culturally appropriate were more likely to have diabetes, compared with those who did not feel the service they received was culturally inappropriate. Establishing more healthcare services that integrate First Nations cultures and traditions could improve access to care and the course of treatment for urban First Nations peoples living with diabetes.

Our Health Counts Toronto: using respondent-driven sampling to unmask census undercounts of an urban indigenous population in Toronto, Canada

OBJECTIVES

To provide evidence of the magnitude of census undercounts of 'hard-to-reach' subpopulations and to improve estimation of the size of the urban indigenous population in Toronto, Canada, using respondent-driven sampling (RDS).

DESIGN

Respondent-driven sampling.

SETTING

The study took place in the urban indigenous community in Toronto, Canada. Three locations within the city were used to recruit study participants.

PARTICIPANTS

908 adult participants (15+) who self-identified as indigenous (First Nation, Inuit or Métis) and lived in the city of Toronto. Study participants were generally young with over 60% of indigenous adults under the age of 45 years. Household income was low with approximately two-thirds of the sample living in households which earned less than $C20 000 last year.

PRIMARY AND SECONDARY OUTCOME MEASURES

We collected baseline data on demographic characteristics, including indigenous identity, age, gender, income, household type and household size. Our primary outcome asked: 'Did you complete the 2011 Census Canada questionnaire?'

RESULTS

Using RDS and our large-scale survey of the urban indigenous population in Toronto, Canada, we have shown that the most recent Canadian census underestimated the size of the indigenous population in Toronto by a factor of 2 to 4. Specifically, under conservative assumptions, there are approximately 55 000 (95% CI 45 000 to 73 000) indigenous people living in Toronto, at least double the current estimate of 19 270.

CONCLUSIONS

Our indigenous enumeration methods, including RDS and census completion information will have broad impacts across governmental and health policy, potentially improving healthcare access for this community. These novel applications of RDS may be relevant for the enumeration of other 'hard-to-reach' populations, such as illegal immigrants or homeless individuals in Canada and beyond.

A comparison of virological suppression and rebound between Indigenous and non-Indigenous persons initiating combination antiretroviral therapy in a multisite cohort of individuals living with HIV in Canada

BACKGROUND

This study compared time to virological suppression and rebound between Indigenous and non-Indigenous individuals living with HIV in Canada initiating combination antiretroviral therapy (cART).

METHODS

Data were from the Canadian Observational Cohort collaboration; eight studies of treatment-naive persons with HIV initiating cART after 1/1/2000. Fine and Gray models were used to estimate the effect of ethnicity on time to virological suppression (two consecutive viral loads [VLs] <50 copies/ml at least 3 months apart) after adjusting for the competing risk of death and time until virological rebound (two consecutive VLs >200 copies/ml at least 3 months apart) following suppression.

RESULTS

Among 7,080 participants were 497 Indigenous persons of whom 413 (83%) were from British Columbia. The cumulative incidence of suppression 1 year after cART initiation was 54% for Indigenous persons, 77% for Caucasian and 80% for African, Caribbean or Black (ACB) persons. The cumulative incidence of rebound 1 year after suppression was 13% for Indigenous persons, 6% for Caucasian and 7% for ACB persons. Indigenous persons were less likely to achieve suppression than Caucasian participants (aHR=0.58, 95% CI 0.50, 0.68), but not more likely to experience rebound (aHR=1.03, 95% CI 0.84, 1.27) after adjusting for age, gender, injection drug use, men having sex with men status, province of residence, baseline VL and CD4⁺ T-cell count, antiretroviral class and year of cART initiation.

CONCLUSIONS

Lower suppression rates among Indigenous persons suggest a need for targeted interventions to improve HIV health outcomes during the first year of treatment when suppression is usually achieved.

Indigenous and tribal peoples' health (The Lancet-Lowitja Institute Global Collaboration): a population study

BACKGROUND

International studies of the health of Indigenous and tribal peoples provide important public health insights. Reliable data are required for the development of policy and health services. Previous studies document poorer outcomes for Indigenous peoples compared with benchmark populations, but have been restricted in their coverage of countries or the range of health indicators. Our objective is to describe the health and social status of Indigenous and tribal peoples relative to benchmark populations from a sample of countries.

METHODS

Collaborators with expertise in Indigenous health data systems were identified for each country. Data were obtained for population, life expectancy at birth, infant mortality, low and high birthweight, maternal mortality, nutritional status, educational attainment, and economic status. Data sources consisted of governmental data, data from non-governmental organisations such as UNICEF, and other research. Absolute and relative differences were calculated.

FINDINGS

Our data (23 countries, 28 populations) provide evidence of poorer health and social outcomes for Indigenous peoples than for non-Indigenous populations. However, this is not uniformly the case, and the size of the rate difference varies. We document poorer outcomes for Indigenous populations for: life expectancy at birth for 16 of 18 populations with a difference greater than 1 year in 15 populations; infant mortality rate for 18 of 19 populations with a rate difference greater than one per 1000 livebirths in 16 populations; maternal mortality in ten populations; low birthweight with the rate difference greater than 2% in three populations; high birthweight with the rate difference greater than 2% in one population; child malnutrition for ten of 16 populations with a difference greater than 10% in five populations; child obesity for eight of 12 populations with a difference greater than 5% in four populations; adult obesity for seven of 13 populations with a difference greater than 10% in four populations; educational attainment for 26 of 27 populations with a difference greater than 1% in 24 populations; and economic status for 15 of 18 populations with a difference greater than 1% in 14 populations.

INTERPRETATION

We systematically collated data across a broader sample of countries and indicators than done in previous studies. Taking into account the UN Sustainable Development Goals, we recommend that national governments develop targeted policy responses to Indigenous health, improving access to health services, and Indigenous data within national surveillance systems.

FUNDING

The Lowitja Institute.