The Greenland population health survey 2018 - methods of a prospective study of risk factors for lifestyle related diseases and social determinants of health amongst Inuit

The intersection of social and Indigenous determinants of health for health system strengthening: a scoping review

The COVID-19 pandemic exposed long-standing gaps in health service systems and realities of environmental changes impacting Native nations and Indigenous communities in the US and circumpolar regions. Despite increased awareness and funding, there is limited research and few practical resources available for the work. This is a scoping review of the current literature on social determinants of health (SDOH) impacting Indigenous peoples, villages, and communities in the US and circumpolar region. The review used the York methodology to identify research questions, chart, and synthesize findings. Thirty-two articles were selected for full review and analysis. The articles were scoping reviews, evaluations, and studies. The methods used were 44% mixed (n = 14), 31% quantitative (n = 10) and 25% qualitative (n = 8). The synthesis identified four areas for discussion: 1) systemic and structural determinant study designs, 2) strengthening Indigenous health systems, 3) mapping the relationship of co-occurring health conditions and SDOH, and 4) emergent areas of inquiry. While the scoping review has limitations, it provides a snapshot of broad SDOH and shared Indigenous social determinants of health (ISDOH) to create tailored frameworks for use by tribal and urban Indigenous health organisations, with their partners, in public health and system strengthening.

Childhood conditions and mental health among youth and young adults in Greenland: a latent class analysis

Poor mental health among youth in Greenland is a major challenge, childhood conditions are critical for mental health later in life. The study aimed to examine the clustering of childhood conditions by considering risk and protective factors for mental health among youth and young adults in Greenland and to explore the relationship between these clusters and mental health outcomes in youth. The study included 565 participants aged 15-34 living in Greenland. Seven indicators including childhood adversities (ACEs), childhood residence, language, and cultural indicators (protective factors) were used to define clusters via latent class analysis (LCA). The associations between clusters and mental health outcomes (satisfaction with life (Cantrill's ladder), self-esteem, self-efficacy, loneliness, psychological distress (General Health Questionnaire) and mental illness (Kessler 6)) were assessed by logistic regression. Four clusters were identified through LCA. While most participants reported positive childhoods, 40% (in two clusters) experienced ACEs. The two clusters differed as more participants in one cluster had experienced protective factors than the other. ACEs were associated with increased odds of negative aspects of mental health in youth. However, participants who faced high levels of adversity and few protective factors also had reduced odds of positive aspects of mental health in youth.

Living with chronic obstructive pulmonary disease or type 2 diabetes in Greenland - a qualitative interpretive description study

Non-communicable diseases such as chronic obstructive pulmonary disease (COPD) and type 2 diabetes mellitus (T2D) represent major challenges for health systems all over the world. In an interview study, we explored patient experiences and perspectives of being diagnosed and living with COPD or T2D in Greenland. Participants (n = 24) were selected by purposeful sampling and recruited by phone. We conducted individual semi-structured interviews at the National Hospital in Nuuk and the four regional hospitals. Interviews were audio-recorded, transcribed verbatim, and analysed using interpretive description. Three themes emerged: shock and shame on receiving the diagnosis, coping with a changed life, and varying needs for care and communication. We found that being diagnosed with COPD or T2D required a rapid change in the participants' everyday lives and lifestyle behaviours. Some self-managed their disease well and were able to transfer their knowledge and integrate it into their daily lives, while others struggled to make lifestyle changes. Additionally, living with COPD or T2D could be related to silence and shame. The findings contribute to a better understanding of living with COPD or T2D in the Arctic region and the development of future, culturally-adapted patient education initiatives.

Reproducibility and validity of a 45 item food-frequency questionnaire for inuit in Greenland

Since 1993, dietary assessment has been carried out in Greenland as part of recurrent population health surveys. In preparation for the next survey in 2024, 91 participants from the survey in 2018 were selected for a validation study of the Food Frequency Questionnaire (FFQ). The 91 participants were reinterviewed 38-50 months after the first FFQ and invited to complete a food diary. As part of the 2018 survey, blood was analysed for mercury. The food diary was completed by 65 participants. The agreement between the two FFQ interviews was very good for macronutrients and fatty acids (p > 0.20), whereas the calculated intake of mercury was 22% higher in the second FFQ (p = 0.04) due to a higher intake of whale meat and muktuk (whale skin). The agreement between the second FFQ and the food diary was good for local food, imported meat and cakes/sweets/snacks but fruit and vegetables, dairy products, beverages and added sugar were significantly underreported in the food diary. Food items not included in the FFQ were identified from the food diaries. The correlation between the intake of marine mammals and blood mercury was moderate (Spearman's rho = 0.41-0.50; p < 0.0001). The results will inspire future dietary studies in the circumpolar North.

Lung function measurements in the Greenlandic Inuit population: results from the Greenlandic health survey 2017-2019

Background

Little is known about lung function in Inuit. The aim of this study was to describe lung function and the prevalence of obstructive and restrictive lung disease among Inuit in Greenland.

Methods

During the 2017-2019 Health Survey, spirometry, with forced expiratory volume in the first second (FEV1), forced vital capacity (FVC), and FEV1/FVC ratio in liters (L), and percent of predicted value (pred%) were recorded according to Global Lung function Initiative standard reference values (GLI). Smoking history was obtained. Obstructive spirometry was defined as FEV1/FVC <70%. Restrictive spirometry was proposed by FVC < 80% and FEV1/FVC >90%.

Results

Based on validated spirometries, 795/2084 persons were included in this cross-sectional, descriptive study. Of those, 54.6% were current- and 27.7% former smokers. In Inuit, normal lung function was higher than predicted GLI (FEV1 107.2 pred%/FVC 113.5 pred%). In total, 106 (13.3%) were found to have an obstructive lung function measurement and 11 (1.4%) had a restrictive pattern. Among current smokers, the prevalence of obstructive lung function was 16.4%. An accelerated decline in lung function was observed > 50 years old (y.o), compared to <50 y.o.

Conclusion

This study indicates that Inuit has higher absolute lung function values than standard GLI, despite the large proportion of smokers, which indicate a need for Inuit reference values in the daily clinical praxis. The high prevalence of obstructive lung function and rapid decline in lung function indicates the need for fucus on health issues that may affect lung health in Greenland.

Analysis of admixed Greenlandic siblings shows that the mean genotypic values for metabolic phenotypes differ between Inuit and Europeans

BACKGROUND

Disease prevalence and mean phenotype values differ between many populations, including Inuit and Europeans. Whether these differences are partly explained by genetic differences or solely due to differences in environmental exposures is still unknown, because estimates of the genetic contribution to these means, which we will here refer to as mean genotypic values, are easily confounded, and because studies across genetically diverse populations are lacking.

METHODS

Leveraging the unique genetic properties of the small, admixed and historically isolated Greenlandic population, we estimated the differences in mean genotypic value between Inuit and European genetic ancestry using an admixed sibling design. Analyses were performed across 26 metabolic phenotypes, in 1474 admixed sibling pairs present in a cohort of 5996 Greenlanders.

RESULTS

After FDR correction for multiple testing, we found significantly lower mean genotypic values in Inuit genetic ancestry compared to European genetic ancestry for body weight (effect size per percentage of Inuit genetic ancestry (se), -0.51 (0.16) kg/%), body mass index (-0.20 (0.06) kg/m2/%), fat percentage (-0.38 (0.13) %/%), waist circumference (-0.42 (0.16) cm/%), hip circumference (-0.38 (0.11) cm/%) and fasting serum insulin levels (-1.07 (0.51) pmol/l/%). The direction of the effects was consistent with the observed mean phenotype differences between Inuit and European genetic ancestry. No difference in mean genotypic value was observed for height, markers of glucose homeostasis, or circulating lipid levels.

CONCLUSIONS

We show that mean genotypic values for some metabolic phenotypes differ between two human populations using a method not easily confounded by possible differences in environmental exposures. Our study illustrates the importance of performing genetic studies in diverse populations.

Increasing health inequality among Inuit in Greenland from 1993 to 2018: Different patterns for household assets, urbanization and a sociocultural index as indicators of social position

Income inequality affects population health and wellbeing negatively. In Greenland, health inequality has been shown to exist among social groups, regionally and according to urbanization, and between Inuit and migrants from Denmark. The purpose of the study was to compare the changes in health inequality from 1993 to 2018 according to three measures of social position, i.e. a socioeconomic measure (household assets), a measure of urbanization and a composite sociocultural index. We hypothesized that social inequality in health increased parallel to the increasing economic inequality in Greenland. The sample was based on four population health surveys conducted among the Inuit in Greenland in 1993, 2005-2010, 2014 and 2018. The total number of interviews was 9024 and the total number of individuals interviewed was 5829, as participants were invited to several surveys as part of a cohort. As statistical measure of social disparity we used the slope index of inequality (SII) adjusted for age and sex. Analyses were performed with daily smoking, suicidal thoughts and obesity as health outcomes. Daily smoking was most prevalent among participants with low social position whereas obesity was most prevalent among participants with high social position. With household assets as indicator of social position, the results showed high and increasing social inequality for both daily smoking and obesity. Social inequality for daily smoking increased over time also for urbanization and the sociocultural index. The hypothesis that social inequality increased over time was thus confirmed for daily smoking and obesity but not for suicidal thoughts. With the results from the present study there is solid evidence to guide prevention and health care towards social equality in health.

Developing the ACEIG-scale: An adverse childhood experience scale for Inuit youth in Greenland

BACKGROUND

Adverse Childhood Experiences (ACEs) have been identified as a major public health challenge in Greenland. No previous studies have created a multi-item ACE- scale among an Arctic Indigenous population.

OBJECTIVE

To develop a multi-item ACE-scale among Inuit youth in Greenland (the ACEIG scale).

METHODS

The ACEIG scale was created with data from the 'Wellbeing among Inuit youth in Greenland'-survey. Scale items were based on a recognised ACE-scale and further adapted to the context of Inuit youth in Greenland by adding items relevant for the population. The scale was validated through item response theory (IRT) and reliability was assessed by Cronbach's alpha.

RESULTS

Four items relevant for Inuit youth in Greenland were added to the recognised ACE scale (bullying, death of parent, gambling problems in close family, and suicide in close relations). The scale was reduced by IRT, as three items (bullying, divorce of parents and parents passing away) exceeded the difficulty index threshold. The ACEIG scale therefore consists of 10 items: alcohol problems in close family, marijuana use in close family, domestic violence, being victim of physical violence, being victim of psychological violence, any type of sexual abuse, sexual abuse (intercourse), sexual abuse (more than once), suicide in close relations, and gambling problems in close family. Cronbach's alpha was 0.7.

CONCLUSION

The ACEIG scale includes 10 items with acceptable reliability. The scale can inform future screening tools to identify vulnerable youth and target interventions. Future studies should investigate the association between the ACEIG scale and health outcomes.