Food insecurity as a mediator and moderator in the association between residential mobility and suicidal ideation among Indigenous adults in Canada

PURPOSE

Despite a growing body of literature on the link between residential mobility and suicidal ideation, research into potential mediating or moderating factors, especially among socioeconomically disadvantaged populations, is sparse. This study explores the mediating and moderating roles of food insecurity in the relationship between residential mobility and suicidal ideation in Indigenous Canadian adults.

METHODS

Data from the 2017 Aboriginal Peoples Survey, which represent a national sample of off-reserve First Nations peoples, Métis, and Inuit in Canada (N = 16,214), were analyzed using logistic regression models.

RESULTS

Food insecurity partially mediated the association between residential mobility in the past 5 years and increased suicidal ideation risk among Indigenous adults. Moreover, food insecurity intensified the adverse link between residential mobility during this same timeframe and suicidal ideation. Yet, while food insecurity did mediate the adverse relationship between residential mobility in the past year and suicidal ideation, it did not function as a moderator.

CONCLUSION

The results emphasize that food insecurity, as a systemic challenge, acts as both a partial mediator and, in some circumstances, an amplifier of the detrimental impacts of residential mobility on suicidal ideation.

The Mental Health of First Nations Children in Manitoba: A Population-Based Retrospective Cohort Study Using Linked Administrative Data: La santé mentale des enfants des Premières Nations au Manitoba : une étude de cohorte rétrospective dans la population, à l'aide de données administratives liées

OBJECTIVE

First Nations children face a greater risk of experiencing mental disorders than other children from the general population because of family and societal factors, yet there is little research examining their mental health. This study compares diagnosed mental disorders and suicidal behaviours of First Nations children living on-reserve and off-reserve to all other children living in Manitoba.

METHOD

The research team, which included First Nations and non-First Nations researchers, utilized population-based administrative data that linked de-identified individual-level records from the 2016 First Nations Research File to health and social information for children living in Manitoba. Adjusted rates and rate ratios of mental disorders and suicide behaviours were calculated using a generalized linear modelling approach to compare First Nations children (n = 40,574) and all other children (n = 197,109) and comparing First Nations children living on- and off-reserve.

RESULTS

Compared with all other children, First Nations children had a higher prevalence of schizophrenia (adjusted rate ratio (aRR): 4.42, 95% confidence interval (CI), 3.36 to 5.82), attention-deficit hyperactivity disorder (ADHD; aRR: 1.21, 95% CI, 1.09 to 1.33), substance use disorders (aRR: 5.19; 95% CI, 4.25 to 6.33), hospitalizations for suicide attempts (aRR: 6.96; 95% CI, 4.36 to 11.13) and suicide deaths (aRR: 10.63; 95% CI, 7.08 to 15.95). The prevalence of ADHD and mood/anxiety disorders was significantly higher for First Nations children living off-reserve compared with on-reserve; in contrast, hospitalization rates for suicide attempts were twice as high on-reserve than off-reserve. When the comparison cohort was restricted to only other children in low-income areas, a higher prevalence of almost all disorders remained for First Nations children.

CONCLUSION

Large disparities were found in mental health indicators between First Nations children and other children in Manitoba, demonstrating that considerable work is required to improve the mental well-being of First Nations children. Equitable access to culturally safe services is urgently needed and these services should be self-determined, planned, and implemented by First Nations people.

Effectiveness of RADAR on diabetes processes of care for First Nations communities in Alberta, Canada

The epidemic of type-2 diabetes in First Nations communities is tragic. Culturally-appropriate approaches addressing multiple components, focusing beyond glycemic control, are urgently needed. Using an intention-to-treat framework, 13 processes of care indicators were assessed to compare proportions of patients who received care at baseline relative to 2-year follow-up. Clinical improvements were demonstrated across major process of care indicators (e.g. screening, education, and vaccination activities). We found RADAR improved reporting for most diabetes processes of care across seven FN communities and was effective in supporting diabetes care for FN communities, in Alberta Canada.

Pregnant and early parenting Indigenous women who use substances in Canada: A scoping review of health and social issues, supports, and strategies

This study reviews and synthesizes the literature on Indigenous women who are pregnant/early parenting and using substances in Canada to understand the scope and state of knowledge to inform research with the Aboriginal Health and Wellness Centre of Winnipeg in Manitoba and the development of a pilot Indigenous doula program. A scoping review was performed searching ten relevant databases, including one for gray literature. We analyzed 56 articles/documents. Themes include: (1) cyclical repercussions of state removal of Indigenous children from their families; (2) compounding barriers and inequities; (3) prevalence and different types of substance use; and (4) intervention strategies. Recommendations for future research are identified and discussed.

COVID-19 in a remote First Nations community in British Columbia, Canada: an outbreak report

BACKGROUND

In April 2020, British Columbia experienced its first outbreak of COVID-19 in a remote First Nations community. The objective of this paper was to describe the outbreak, including epidemiological and laboratory findings, and the public health response.

METHODS

This report summarizes an outbreak of COVID-19 on Cormorant Island, British Columbia, in March and April 2020. Confirmed cases underwent investigation and contact tracing. Supports were provided to ensure successful isolation and quarantine for cases and contacts. Messaging to the community was circulated by trusted community members. Descriptive and social network analyses were conducted to describe the outbreak as it evolved. All case specimens underwent whole-genome sequencing.

RESULTS

Thirty cases of SARS-CoV-2 infection were identified. Those infected had a median age of 34 years (range 15-77), and the majority identified as female (19, 63%) and as First Nations (27, 90%). The most common symptoms included chills, cough, diarrhea, headache and fever. Five people were hospitalized (17%) and 1 died (3%). Percent positivity in the community was 18%. Transmission occurred primarily during evening social gatherings and within households. Two weeks after control measures were initiated, no further cases were identified. All cases were genetically related by 2 single nucleotide polymorphisms or fewer, and they belonged to the most dominant SARS-CoV-2 lineage present in British Columbia in April 2020.

INTERPRETATION

A community-led response was essential for the effective containment of this outbreak that included 30 cases, preventing onward transmission of the virus. Lessons learned from the management of this outbreak can inform response to other similar outbreaks in First Nations communities across Canada.

Geographical variation and factors associated with gastric cancer in Manitoba

Objectives

We investigated the spatial disparities and factors associated with gastric cancer (GC) Incidence in Manitoba.

Methods

We combined information from Manitoba Cancer registry and Census data to obtain an age-sex adjusted relative risk (IRR) of GC incidence. We geocoded the IRR to the 96 regional health authority districts (RHADs) using the postal code conversion file (PCCF). Bayesian spatial and spatio-temporal Poisson regression models were used for the analysis.

Results

Adjusting for the effect of socio-economic score index (SESI), Indigenous, and immigrant population, 25 districts with high overall GC risk were identified. One unit increase in SESI was associated with reduced risk of cardia GC (CGC) by 14% (IRR = 0.859; 95% CI: 0.780–0.947) and the risk of non-cardia GC (NCGC) by approximately 10% (IRR = 0.898; 95% CI: 0.812–0.995); 1% increase in regional Indigenous population proportion reduced the risk of CGC by 1.4% (IRR = 0.986; 95% CI: 0.978–0.994). In the analysis stratified by sex, one unit increase in SESI reduced the risk of CGC among women by 26.2% (IRR = 0.738; 95% CI: 0.618–0.879), and a 1% increase in Indigenous population proportion reduced the risk of CGC among women by 1.9% (IRR = 0.981; 95% CI: 0.966–0.996).

Conclusion

Our results support a significant association between SESI and NCGC. We report regional variation of GC IRR and a varying temporal pattern across the RHADs. These results could be used to prioritize interventions for regions with high and progressive risk of GC.

Health care costs associated with hepatitis C virus infection in First Nations populations in Ontario: a retrospective matched cohort study

BACKGROUND

Colonization and marginalization have affected the risk for and experience of hepatitis C virus (HCV) infection for First Nations people in Canada. In partnership with the Ontario First Nations HIV/AIDS Education Circle, we estimated the publicly borne health care costs associated with HCV infection among Status First Nations people in Ontario.

METHODS

In this retrospective matched cohort study, we used linked health administrative databases to identify Status First Nations people in Ontario who tested positive for HCV antibodies or RNA between 2004 and 2014, and Status First Nations people who had no HCV testing records or only a negative test result (control group, matched 2:1 to case participants). We estimated total and net costs (difference between case and control participants) for 4 phases of care: prediagnosis (6 mo before HCV infection diagnosis), initial (after diagnosis), late (liver disease) and terminal (6 mo before death), until death or Dec. 31, 2017, whichever occurred first. We stratified costs by sex and residence within or outside of First Nations communities. All costs were measured in 2018 Canadian dollars.

RESULTS

From 2004 to 2014, 2197 people were diagnosed with HCV infection. The mean net total costs per 30 days of HCV infection were $348 (95% confidence interval [CI] $277 to $427) for the prediagnosis phase, $377 (95% CI $288 to $470) for the initial phase, $1768 (95% CI $1153 to $2427) for the late phase and $893 (95% CI -$1114 to $3149) for the terminal phase. After diagnosis of HCV infection, net costs varied considerably among those who resided within compared to outside of First Nations communities. Net costs were higher for females than for males except in the terminal phase.

INTERPRETATION

The costs per 30 days of HCV infection among Status First Nations people in Ontario increased substantially with progression to advanced liver disease and finally to death. These estimates will allow for planning and evaluation of provincial and territorial population-specific hepatitis C control efforts.

Regionally representative hair mercury levels in Canadian First Nations adults living on reserves

OBJECTIVE

The primary objective of this participatory study was to assess the current body burden of mercury among First Nations adults.

METHODS

The First Nations Food, Nutrition and Environment Study (2008-2018) collected regionally representative data from First Nations adults living on reserves south of the 60th parallel. Mercury was analyzed in hair as a preferred biomarker for prolonged exposure. Hair samples, a 5 mm bundle cut from the occipital region, were collected from the participants who gave consent and measured for total mercury concentrations using cold vapor atomic fluorescence spectrophotometry.

RESULTS

In total, 3404 First Nations adults living in 92 communities provided hair samples. This represents 52.5% of the respondents to the household surveys. The mean hair mercury concentrations were 0.56 μg/g among all participants and 0.34 μg/g among women of childbearing age (WCBA). There were 64 exceedances of Health Canada's mercury biomonitoring guidelines (44 WCBA, 8 women aged 51+ years, 3 men aged 19-50 years, and 9 men aged 51+ years).

CONCLUSION

Current mercury exposure no longer presents a significant clinical health risk in most of the First Nations population south of the 60th parallel across Canada. However, mercury exposure continues to be an ongoing environmental public health concern that requires continued monitoring and assessment. Women of childbearing age (19-50 years) and older individuals living in northern ecozones and Quebec have higher mercury exposures, often exceeding Health Canada's guidelines. Careful risk communication and risk management programs need to focus on northern ecozones and Quebec.

The relationship between dietary exposure to persistent organic pollutants from fish consumption and type 2 diabetes among First Nations in Canada

OBJECTIVE

We previously examined the associations between dietary dichlorodiphenyldichloroethylene (DDE) and polychlorinated biphenyls (PCBs) intake from fish consumption and type 2 diabetes (T2D) prevalence in Ontario and Manitoba. This study aims to further explore the relationship in a regionally representative sample of First Nations adults living on-reserve across Canada.

METHODS

Dietary, health and lifestyle data collected by the cross-sectional First Nations Food, Nutrition and Environment Study (2008-2018) were analyzed. This participatory study included 6091 First Nations adult participants who answered questions on T2D. The consumption of locally caught fish was estimated with a food frequency questionnaire. A total of 551 samples from 96 fish species were collected and analyzed for the presence of DDE and PCBs. The associations between fish and dietary DDE/PCBs intake with self-reported T2D were investigated using multiple logistic regression models adjusted for confounders.

RESULTS

Dietary exposure to DDE (>2.11 ng/kg/bw) and PCBs (>1.47 ng/kg/bw) vs no exposure was positively associated with T2D with ORs of 2.33 (95% CI: 1.24-4.35) for DDE and 1.43 (95% CI: 1.01-3.59) for PCBs. The associations were stronger among females (DDE OR = 3.11 (1.41-6.88); PCBs OR = 1.76 (1.10-3.65)) and older individuals (DDE OR = 2.64 (1.12-6.20); PCBs OR = 1.44 (1.01-3.91)) as compared with males and younger participants. Also, significant dose-response relationships were found for fish consumption in females only.

CONCLUSION

This study confirms our previous findings that dietary DDE/PCBs exposure may increase the risk of T2D. The effect of DDE/PCBs from fish consumption is driven by geographical differences in DDE/PCBs concentrations in fish and by the amount of fish consumed, and is more prominent in females than in males.

Nutrient adequacy and nutrient sources of adults among ninety-two First Nations communities across Canada

OBJECTIVES

To identify food sources of nutrients in First Nations adults in Canada and to establish whether these populations are meeting their nutrient requirements and whether traditional foods (TF) contribute to better nutrient intake.

METHODS

The First Nations Food, Nutrition and Environment Study is a cross-Canada participatory study of First Nations adults living south of the 60th parallel. Twenty-four-hour recalls were conducted in 92 First Nations communities from 2008 to 2016. Repeat recalls were attempted with 20% of participants to adjust for within-person variation and estimate the proportion of individuals below recommendations according to Institute of Medicine guidelines. Nutrients from days with and without TF were compared. The main food sources of select nutrients were identified, including TF.

RESULTS

Mean energy intakes among women and men ranged from 1664 to 1864 and from 1761 to 2298 kcal/day respectively. Most macronutrients were within the acceptable macronutrient diet range except for fat in most age groups and carbohydrates in men 71 years of age and older. Saturated fat was above recommendations for all ages. Only niacin was identified as above recommendations in all age and sex categories. Days where TF were eaten showed greater intakes of key nutrients.

CONCLUSION

It is imperative that we find culturally appropriate ways to improve the quality and nutritional value of First Nations Peoples food intake by improving TF access and use on the one hand and conversely providing better quality store-bought foods. For success in this, we must empower First Nations communities and health practitioners to collaboratively overcome these challenges.

Associations of health status and diabetes among First Nations Peoples living on-reserve in Canada

OBJECTIVE

Our objective is to describe self-reported health status, prevalence of diabetes and obesity and their associations in participants from the First Nations Food, Nutrition and Environment Study (FNFNES) in order to identify possible correlates of health in First Nations adults.

METHODS

FNFNES is a participatory study with First Nations Peoples living on reserve lands south of the 60th parallel. Health and diabetes were self-reported, and prevalence of obesity was evaluated. Socio-demographic and lifestyle factors and traditional food (TF) activities were investigated for associations with health parameters.

RESULTS

High prevalence rates of overweight/obesity (78-91%) and diabetes (19% age-standardized prevalence) were found. Smoking rates were high and physical activity was low. In multivariable analyses, obesity was associated with region, income source, age, gender, smoking and self-reported health; diabetes and lesser self-reported health were associated with obesity and lower education. Diabetes was strongly associated with lesser self-reported health and weakly associated with being a smoker.

CONCLUSION

We have identified possible correlates of health in this population that can help to better understand the underlying concerns and identify solutions for First Nations and their partners. We urge governments and First Nations to address the systemic problems identified with a holistic ecosystem approach that takes into consideration the financial and physical access to food, particularly TF, and the facilitation of improved health behaviour. New mechanisms co-developed with First Nations leadership should focus on supporting sustainable, culturally safe and healthy lifestyles and closing the gaps in nutrition and food insecurity.

Comparison of measures of diet quality using 24-hour recall data of First Nations adults living on reserves in Canada

OBJECTIVE

Assess the diet quality of First Nations adults in Canada using percentage energy from traditional foods (TF) and ultra-processed products (UPP), food portions from the 2007 Eating Well with Canada's Food Guide - First Nations, Inuit and Métis (EWCFG-FNIM) and a Healthy Eating Index (HEI).

METHODS

Data collection for this participatory research occurred in 92 First Nations reserves across Canada from 2008 to 2016. Percent daily energy intakes were estimated from 24-hour recalls for TF and NOVA food categories. Portions of food groups from the 2007 EWCFG-FNIM were compared to recommendations. A Canadian-adapted HEI was calculated for each participant.

RESULTS

The percent energy from TF was 3% for all participants and 18% for consumers. Meat and alternatives were above the EWCFG-FNIM recommendations and all other food groups were below these. HEI was "low" with only older individuals attaining "average" scores. HEI was above "average" in 4 regions. UPP represented 55% of energy, the largest proportion from a NOVA category.

CONCLUSION

The diet quality of First Nations adults in Canada is nutritionally poor. The nutrition, food security and health of First Nations would be improved by better access to TF and healthy store-bought food. However, poor diet is only one aspect of the difficulties facing First Nations in Canada. Researchers and policy makers must strive to better understand the multiple challenges facing First Nations Peoples in order to foster empowerment and self-determination to develop First Nations living conditions and lifestyles that are more culturally sound and more conducive to health.

Importance of the traditional food systems for First Nations adults living on reserves in Canada

OBJECTIVE

To describe the traditional food (TF) systems of First Nations in Canada, including intake, barriers and promoters.

METHODS

The First Nations Food, Nutrition and Environment Study is a cross-Canada participatory study of First Nations adults below the 60th parallel that obtained data for communities excluded from other national studies. A food frequency questionnaire was used to establish frequency of TF intake (number of days in a year) to allow comparisons across ecozones/regions in Canada. Grams of TF intake were also calculated using frequency multiplied by average portions from 24-h recalls. Closed- and open-ended questions attempted to identify some of the key barriers and concerns regarding TF access and use. Multivariable analyses were run to determine what factors are associated with increased TF consumption.

RESULTS

Across communities, there is a strong preference by adults to have TF in the diet more often. Consumption of land animals was most frequently reported in most ecozones except for the Pacific Maritime and Mixedwood Plains, where fish and plants, respectively, were more frequently consumed. First Nations identified structural and environmental challenges such as development, government regulations and climate change, along with household barriers such as insufficient capital for equipment and transportation, lack of time and absence of a hunter in the household. Multivariable analyses revealed that the highest intake of TF occurred in the Taiga Plains ecozone, and for older individuals and men.

CONCLUSION

Identifying solutions that empower First Nations at all levels is required to overcome the multiple challenges to the inclusion of TF in the diet.

First Nations households living on-reserve experience food insecurity: prevalence and predictors among ninety-two First Nations communities across Canada

OBJECTIVE

To describe the prevalence of food insecurity in First Nations households across Canada while identifying barriers and enablers to traditional food (TF) consumption.

METHODS

The First Nations Food, Nutrition and Environment Study is a cross-Canada participatory study of on-reserve First Nations from 2008 to 2018. The Household Food Security Survey Module was used to capture income-related challenges experienced by First Nations households. Households were classified as food secure, or marginally, moderately, or severely food insecure. Barriers and enablers to TF access and use were identified describing the Indigenous experience.

RESULTS

Almost half of on-reserve First Nations households were food insecure and the prevalence was higher than that for non-Indigenous households in Canada. On-reserve food insecurity prevalence was higher in western regions of Canada. First Nations households with children experienced greater food insecurity than those without children. More adults experienced severe food insecurity than children. Most adults would like to have more TF in their diet but state that factors such as financial and household constraints, industrial activities, government regulations, climate change, and fear of contamination impede greater access. Food costs were substantially higher in remote First Nations communities, but remoteness was not associated with food security in multivariable analysis.

CONCLUSION

Existing systems have been unsuccessful in curbing the food insecurity in First Nations households. Improving food security hinges on achieving Indigenous Food Sovereignty, the key to long-term conservation and stewardship of the land and the co-management of these by Indigenous Peoples. Studies investigating the feasibility of increasing TF from an Indigenous perspective are required.

The First Nations Food, Nutrition and Environment Study (2008-2018)-rationale, design, methods and lessons learned

OBJECTIVE

To describe the rationale, the participatory nature of the methodology, and the lessons learned during the First Nations Food, Nutrition and Environment Study (FNFNES), a community-based participatory research project implemented in eight Assembly of First Nations regions, which includes the entirety of Canada south of the 60th parallel.

METHODS

FNFNES respected the First Nations principles of Ownership, Control, Access and Possession (OCAP®) ( https://fnigc.ca/ocap ). A random sampling strategy based on an ecosystem framework comprising 11 ecozones was adopted to collect representative nutritional and environmental health results for all First Nations adults living on-reserve south of the 60th parallel. Data collection occurred during the fall months from 2008 to 2016. Respective First Nations were involved in the planning and implementation of data collection for the five principal components: household interviews, tap water sampling for metals, surface water sampling for pharmaceuticals, hair sampling for mercury, and traditional food sampling for contaminants.

RESULTS

A total of 6487 adults from 92 First Nations participated in the Study (participation rate 78%). A higher percentage of females (66%) participated than males (34%). The average age of males and females was similar (44 and 45 years, respectively). This study offers a novel body of coherent and regionally representative evidence on the human dimension of the ongoing environmental degradation affecting First Nations.

CONCLUSION

FNFNES serves as a good example of participatory research. We encourage public health professionals to develop policy and programs building on the participatory dimension of the research as well as on its results. The information collected by the FNFNES is also important for community empowerment, environmental stewardship and the general promotion of good health by and for First Nations peoples in Canada.

Importance of fish for food and nutrition security among First Nations in Canada

OBJECTIVE

To investigate the relationships between fish/seafood consumption patterns and food security status among First Nations (FN) communities in Canada. We estimated the contribution of fish/seafood to daily nutrient requirements. Barriers to traditional food (TF) access including fish were summarized.

METHODS

Data were collected by the First Nations Food, Nutrition and Environment Study (2008-2018). The sample of this participatory study comprised 6258 randomly selected FN adults. Fish/seafood consumption was estimated with a food frequency questionnaire. Food security status was assessed with the Household Food Security Survey Module. The contribution of fish/seafood to protein, n-3 fatty acid, vitamin (A, B12, D, niacin) and mineral (selenium, zinc) requirements was assessed by comparison to Dietary Reference Intakes.

RESULTS

Regional differences were observed in fish/seafood consumption patterns and their relationship with food security status. In the eastern regions (Ontario, Quebec/Labrador and the Atlantic region), consumption of fish/seafood and other TF was significantly higher among food insecure compared with food secure FN participants. Severely food insecure men (particularly in British Columbia, Alberta, Quebec/Labrador and the Atlantic region) tended to eat a higher amount of TF, including fish/seafood, compared with food secure and moderately food insecure men, while no difference was observed in women. Fish/seafood provided good sources of selected nutrients. However, the high cost of harvesting equipment, industry-related activities and climate change reduce access to fish/seafood and other wildlife.

CONCLUSION

Fish/seafood continues to be vital to the diet of FN communities. Focusing on policies that support FN increased access to fish/seafood has the potential to decrease food insecurity and support sustainable livelihoods. Future policies should focus on socio-economic determinants of food insecurity and support traditional harvesting and sustainable fisheries among FN communities.

An unconditional prenatal income supplement is associated with improved birth and early childhood outcomes among First Nations children in Manitoba, Canada: a population-based cohort study

BACKGROUND

In Manitoba, Canada, low-income pregnant women are eligible for the Healthy Baby Prenatal Benefit, an unconditional income supplement of up to CAD $81/month, during their latter two trimesters. Our objective was to determine the impact of the Healthy Baby Prenatal Benefit on birth and early childhood outcomes among Manitoba First Nations women and their children.

METHODS

We used administrative data to identify low-income First Nations women who gave birth 2003-2011 (n = 8209), adjusting for differences between women who received (n = 6103) and did not receive the Healthy Baby Prenatal Benefit (n = 2106) with using propensity score weighting. Using multi-variable regressions, we compared rates of low birth weight, preterm, and small- and large-for-gestational-age births, 5-min Apgar scores, breastfeeding initiation, birth hospitalization length of stay, hospital readmissions, complete vaccination at age one and two, and developmental vulnerability in Kindergarten.

RESULTS

Women who received the benefit had lower risk of low birth weight (adjusted relative risk [aRR] 0.74; 95% CI 0.62-0.88) and preterm (aRR 0.77; 0.68-0.88) births, and were more likely to initiate breastfeeding (aRR 1.05; 1.01-1.09). Receipt of the Healthy Baby Prenatal Benefit was also associated with higher rates of child vaccination at age one (aRR 1.10; 1.06-1.14) and two (aRR 1.19; 1.13-1.25), and a lower risk that children would be vulnerable in the developmental domains of language and cognitive development (aRR 0.88; 0.79-0.98) and general knowledge/communication skills (aRR 0.87; 0.77-0.98) in Kindergarten.

CONCLUSIONS

A modest unconditional income supplement of CAD $81/month during pregnancy was associated with improved birth outcomes, increased vaccination rates, and better developmental health outcomes for First Nations children from low-income families.

The relationship between rates of hospitalization for ambulatory care sensitive conditions and local access to primary healthcare in Manitoba First Nations communities : Results from the Innovation in Community-based Primary Healthcare Supporting Transformation in the Health of First Nations in Manitoba (iPHIT) study

OBJECTIVES

The objective of this study was to assess the performance of models of primary healthcare (PHC) delivered in First Nation and adjacent communities in Manitoba, using hospitalization rates for ambulatory care sensitive conditions (ACSC) as the primary outcome.

METHODS

We used generalized estimating equation logistic regression on administrative claims data for 63 First Nations communities from Manitoba (1986-2016) comprising 140,111 people, housed at the Manitoba Centre for Health Policy. We controlled for age, sex, and socio-economic status to describe the relationship between hospitalization rates for ACSC and models of PHC in First Nation communities.

RESULTS

Hospitalization rates for acute, chronic, vaccine-preventable, and mental health-related ACSCs have decreased over time in First Nation communities, yet remain significantly higher in First Nations and remote non-First Nations communities as compared with other Manitobans. When comparing different models of care, hospitalization rates were historically higher in communities served by health centres/offices, whether or not supplemented by itinerant medical services. These rates have significantly declined over the past two decades.

CONCLUSION

Local access to a broader complement of PHC services is associated with lower rates of avoidable hospitalization in First Nation communities. The lack of these services in many First Nation communities demonstrates the failure of the current Canadian healthcare system to meet the need of First Nation peoples. Improving access to PHC in all 63 First Nation communities can be expected to result in a reduction in ACSC hospitalization rates and reduce healthcare cost.

Exploring Métis health, spirituality and well-being: a patient-oriented community-based qualitative study with the Métis Nation of Alberta - Region 3

BACKGROUND

There is a lack of Métis-guided participatory research on factors that contribute to individual, family and community well-being, such as developing social support and engaging in cultural, social and historical processes for healing and health. The purpose of this study was to explore links among health, spirituality and well-being within the Métis Nation of Alberta (MNA) - Region 3.

METHODS

In the largest of 12 MNA - Region 3 communities, together with a working group of 9 community members, informal and elected leaders, and an Elder, we codeveloped a qualitative structured survey exploring health, spirituality and well-being. Following face-to-face distribution of the paper survey to community members (February to March 2019), we engaged with 7 working group members in coding and theme development. Results were shared with the community.

RESULTS

Thirty-one community members requested surveys, with 29 participants aged 28-80 years (mean 54.77 yr, standard deviation 15.31 yr) completing the surveys (94% completion rate). Six participants were in the working group that codeveloped the survey. An overarching theme of connection and 4 corresponding subthemes were identified; central to well-being was maintaining connection and balance in mental, emotional, spiritual and physical aspects of health. Connection to Métis ancestry required understanding identity; connection to community involved feeling at home; connection to land included belonging; and connection to tradition encompassed blending of cultures.

INTERPRETATION

Connection among ancestry, land, community and tradition contributed to well-being in our sample. Under the direction of each MNA region, exploration of health, spirituality and well-being with the use of our survey could be considered in community-specific Métis-guided ways across the remaining 5 MNA regions; the survey may also be of use to other provincial bodies in the Métis Nation.

Pregnancy and development of diabetes in First Nations and non-First Nations women in Alberta, Canada

AIM

To conduct a retrospective population-based study to examine the risk of developing diabetes after delivery in First Nations and non-First Nations women in Alberta.

METHODS

Delivery records (1999-2014) were linked to provincial administrative data, which allowed for a maximum follow-up of 16 years after delivery. Prevalence of pregnancy risk factors were compared by First Nations status. Hazard ratios for diabetes after delivery by First Nations status, high pre-pregnancy body weight (≥91 kg) and gestational diabetes status were estimated using the Cox proportional hazards model.

RESULTS

Age-adjusted prevalence of gestational diabetes (7.9% vs 4.6%; P<0.0001), high pre-pregnancy body weight (18.8% vs 10.2%; P<0.0001) and diabetes after delivery (3.9% vs 1.1%; P<0.0001) were higher in First Nations women than in non-First Nations women. Development of diabetes after delivery was higher with First Nations status (hazard ratio 3.0, 95% CI 2.6-3.4), high pre-pregnancy body weight (hazard ratio 3.6, 95% CI 3.3-4.0) and gestational diabetes status (hazard ratio 19.2, 95% CI 17.9-20.6). The highest risk was within First Nations women with high pre-pregnancy body weight and gestational diabetes (hazard ratio 54.8, 95% CI 45.2-66.5) compared to women without these three risk factors. Reduced prenatal visits per pregnancy (8.4 vs 10.7; P<0.0001) and delayed first prenatal visit (time to delivery 23.7 vs 26.7 weeks; P<0.0001) were observed in First Nations women compared to non-First Nations women.

CONCLUSION

First Nations women are at greater risk of developing diabetes after pregnancy, with gestational diabetes being the strongest predictor. Strategies that target the specific needs of First Nations women before, during and after pregnancy are required.

Valuing Cultural Activities Moderating the Association Between Alcohol Expectancies and Alcohol Use Among First Nation Adolescents

OBJECTIVE

Indigenous youth often exhibit high rates of alcohol use and experience disproportionate alcohol-related harm. We examined the moderating role that valuing cultural activities has on the relationship between positive alcohol expectancies and alcohol use and heavy drinking in a sample of Indigenous youth.

METHOD

First Nation adolescents between ages 11 and 18 living on a reserve in eastern Canada (N = 106; mean age = 14.6; 50.0% female) completed a pencil-and-paper survey regarding their positive alcohol expectancies, alcohol use, and beliefs about the importance of cultural activities.

RESULTS

A significant interaction was identified between positive alcohol expectancies and valuing cultural activities on past-3-month alcohol use (b = -0.01, SE = 0.001, p < .001) and past-3-month heavy drinking (b = -0.01, SE = 0.001, p < .001). Simple slopes analysis revealed that the association between positive alcohol expectancies and past-3-month alcohol use and heavy drinking was significant for those with low (b = 0.06, SE = 0.007, p < .001; b = 0.07, SE = 0.008, p < .001; respectively) but not high levels of valuing cultural activities (b = 0.01, SE = 0.008, p = .12; b = 0.01, SE = 0.009, p = .08; respectively).

CONCLUSIONS

Highly valuing cultural activities may interrupt the relationship between positive alcohol expectancies and alcohol use. This suggests that community interventions and treatment programs targeting alcohol use among Indigenous adolescents should prioritize increasing the value of cultural activities by perhaps making them more available.

Explaining the gaps in psychological distress and suicidal behaviours between non-Indigenous and Indigenous adults living off-reserve in Canada: a cross-sectional study

BACKGROUND

Indigenous people are disproportionately affected by mental health issues in Canada. We investigated factors underlying the difference in psychological distress and suicidal behaviours between non-Indigenous and Indigenous populations living off-reserve in Canada.

METHODS

We conducted a cross-sectional study using data from the 2012 Canadian Community Health Survey - Mental Health. Respondents were aged 18 years and older. We measured the variation in psychological distress (10-item Kessler Psychological Distress Scale scores, ranging from 10 [no distress] to 50 [severe distress]) and the prevalence of lifetime suicidal ideation and suicide plan between the Indigenous and non-Indigenous populations and explained these differences using the Blinder-Oaxaca approach.

RESULTS

The overall response rate for the survey was 68.9%, comprising 18 300 respondents (933 Indigenous and 17 367 non-Indigenous adults). We found lower mean psychological distress scores among non-Indigenous people than among Indigenous people (15.1 v. 16.1, p < 0.001) and a lower prevalence of lifetime suicidal ideation (9.2% v. 16.8%, p < 0.001) and plan (2.3% v. 6.8%, p < 0.001). We found that if socioeconomic status among Indigenous people were made to be similar to that of the non-Indigenous population, the differences in mean psychological distress scores and prevalence of lifetime suicidal ideation and suicide plan would have been reduced by 25.7% (women 20.8%, men 36.9%), 10.2% (women 11.2%, men 11.9%) and 5.8% (women 7.8%, men 8.1%), respectively.

INTERPRETATION

Socioeconomic factors account for a considerable proportion of the variation in mental health outcomes between non-Indigenous and Indigenous populations in Canada. Improving socioeconomic status among Indigenous people through plans like income equalization may reduce the gap in mental health outcomes between the 2 populations in Canada.

Valuing Cultural Activities Moderating the Association Between Alcohol Expectancies and Alcohol Use Among First Nation Adolescents

OBJECTIVE

Indigenous youth often exhibit high rates of alcohol use and experience disproportionate alcohol-related harm. We examined the moderating role that valuing cultural activities has on the relationship between positive alcohol expectancies and alcohol use and heavy drinking in a sample of Indigenous youth.

METHOD

First Nation adolescents between ages 11 and 18 living on a reserve in eastern Canada (N = 106; mean age = 14.6; 50.0% female) completed a pencil-and-paper survey regarding their positive alcohol expectancies, alcohol use, and beliefs about the importance of cultural activities.

RESULTS

A significant interaction was identified between positive alcohol expectancies and valuing cultural activities on past-3-month alcohol use (b = -0.01, SE = 0.001, p < .001) and past-3-month heavy drinking (b = -0.01, SE = 0.001, p < .001). Simple slopes analysis revealed that the association between positive alcohol expectancies and past-3-month alcohol use and heavy drinking was significant for those with low (b = 0.06, SE = 0.007, p < .001; b = 0.07, SE = 0.008, p < .001; respectively) but not high levels of valuing cultural activities (b = 0.01, SE = 0.008, p = .12; b = 0.01, SE = 0.009, p = .08; respectively).

CONCLUSIONS

Highly valuing cultural activities may interrupt the relationship between positive alcohol expectancies and alcohol use. This suggests that community interventions and treatment programs targeting alcohol use among Indigenous adolescents should prioritize increasing the value of cultural activities by perhaps making them more available.

Indigenous and non-Indigenous parents separated from their children and experiencing homelessness and mental illness in Canada

The purpose of this study is to examine the parent-child experiences of Indigenous and non-Indigenous mothers and fathers experiencing homelessness, mental illness, and separation from their children. A qualitative thematic analysis of baseline and 18-month follow-up narrative interviews was used to compare 12 mothers (n = 8 Indigenous and n = 4 nonindigenous) with 24 fathers (n = 13 Indigenous and n = 11 non-Indigenous). First, it was found that children are more central in the lives of mothers than fathers. Second, Indigenous parents' narratives were characterized by interpersonal and systemic violence, racism and trauma, and cultural disconnection, but also more cultural healing resources. Third, an intersectional analysis showed that children were peripheral in the lives of non-Indigenous fathers, and most central to the identities of Indigenous mothers. Gender identity, Indigenous, and intersectional theories are used to interpret the findings. Implications for future theory, research, and culturally relevant intervention are discussed.

Anemia, iron status, and associated protective and risk factors among children and adolescents aged 3 to 19 years old from four First Nations communities in Quebec

OBJECTIVES

Anemia and iron deficiency (ID) are frequent among Indigenous children of Canada, but few data are available in Quebec. The present study aimed to characterize anemia and ID prevalence and associated protective and risk factors among First Nations youth in Quebec.

METHODS

The 2015 First Nations (JES!-YEH!) pilot study was conducted among children and adolescents (3 to 19 years; n = 198) from four First Nations communities in Quebec. Blood and urine samples and anthropometric measurements were collected. Hemoglobin (Hb), serum ferritin (SF), plasma hs-CRP, and urinary cotinine levels were measured. Factors associated with anemia and ID (including traditional and market food consumption) were assessed using an interview-administered food frequency questionnaire, based on which nutritional intakes were calculated. Structural equation models were used to test associations.

RESULTS

The prevalence of anemia and ID was elevated (16.8% and 20.5% respectively). Traditional meat, fruit, and fruit juice (natural and powdered)-via their positive association with vitamin C intake-were the only food variables positively associated with SF (coefficient [95% CI] 0.017 [0.000, 0.114]; 0.090 [0.027, 0.161]; and 0.237 [0.060, 0.411]). Male sex was also associated with higher SF (0.295 [0.093, 0.502]). Inflammation status (hs-CRP > 5 mg/L) was inversely associated with Hb (- 0.015 [- 0.025, - 0.005]), whereas SF was positively associated with Hb (0.066 [0.040, 0.096]). Fruit and juice consumption was also positively associated with Hb, via vitamin C intake and SF (0.004 [0.001, 0.010]; 0.008 [0.003, 0.017]).

CONCLUSIONS

Interventions fostering healthier food environments as well as higher consumption of traditional meats and foods naturally rich in vitamin C, which is known to enhance iron absorption, and fighting inflammation could contribute to decrease the high prevalence of anemia and ID in this young Indigenous population.

Improving the response of primary care providers to rural First Nation women who experience intimate partner violence: a qualitative study

BACKGROUND

Some legacies of colonialism are that Indigenous women living in Canada experience higher rates of intimate partner violence (IPV) and that violence is often more severe relative to non-Indigenous women. This results in avoidable physical, psychological, emotional, financial, sexual and spiritual harm in the lives of Indigenous women, families, and communities. Trusted primary care providers are well positioned to provide brief interventions and referrals to treatment and services, but little is known about the providers' preparedness to support Indigenous women. Information on what enables or prevents providers to respond to Indigenous patients who experience IPV is needed in order to ensure this potential lifeline for support is realized.

METHODS

The purpose of this community-based participatory study was to elucidate the barriers and facilitators to care for rural Indigenous women who experience IPV from the perspectives of primary care providers and to recommend strategies to improve their preparedness. Using a Grounded Theory approach, we conducted qualitative research with 31 providers to discuss their experiences with patients affected by IPV.

RESULTS

The results showed providers often feel a degree of unpreparedness to deal with IPV in a clinical setting. Underlying the feelings of unpreparedness were: Recognition of patients' under disclosure of IPV due to stigma, shame and fear Lack of formal provider training on appropriate approaches to IPV Lack of referral network due to fragmented, scarce services for IPV Lack of understanding of jurisdictional complexity of First Nations and non-First Nations specific services for IPV Uncertainty how to negotiate cultural safety around IPV Multiple-role relationship & confidentiality dilemmas characteristic of small communities Risk of jeopardizing patient-provider relationship CONCLUSIONS: Our recommendations to improve provider preparedness to address IPV include reducing the stigma of IPV; creating effective referral pathways; improving cultural safety within the referral network; developing services for perpetrators; engaging natural helpers in the community, and; developing policies, procedures and continuing education related to patients who experience IPV in the clinical and community setting. We suggest that increasing providers' comfort to respond to IPV for rural and Indigenous women will ultimately lead to improved safety and health outcomes.

Traditional Food, Health, and Diet Quality in Syilx Okanagan Adults in British Columbia, Canada

In Canada, store-bought food constitutes the majority of First Nations (FN) people’s diets; however, their traditional foods (TF; wild fish, game, fowl, and plants) remains vital for their health. This study compares health indicators and diet quality among 265 Syilx Okanagan adults according to whether or not they reported eating TF during a 24-h dietary recall. Three methods assessed diet quality: nutrient intakes and adequacy, Healthy Eating Index (HEI-C), and contributions of ultra-processed products (UPP) to %energy using the NOVA classification. Fifty-nine participants (22%) reported eating TF during the dietary recall; TF contributed to 13% of their energy intake. There were no significant differences in weight status or prevalence of chronic disease between TF eaters and non-eaters. TF eaters had significantly higher intakes of protein; omega-3 fatty acids; dietary fibre; copper; magnesium; manganese; phosphorus; potassium; zinc; niacin; riboflavin; and vitamins B6, B12, D, and E than non-eaters. TF eaters also had significantly better diet quality based on the HEI-C and the %energy from UPP. Findings support that TF are critical contributors to the diet quality of FN individuals. Strength-based FN-led interventions, such as Indigenous food sovereignty initiatives, should be promoted to improve access to TF and to foster TF consumption.