Birth Outcomes Among First Nations Birthing Parents Incarcerated While Pregnant: A Linked Administrative Data Study From Manitoba, Canada.

BACKGROUND: In Canada, colonial policies have resulted in health inequities between First Nations and other Canadians. These policies contribute to overrepresentation of First Nations in the criminal legal system, where incarcerated people and their infants face elevated health risks. We investigated the association between prenatal incarceration and adverse birth outcomes among First Nations and other birthing parents in Manitoba, Canada. METHODS: Using linked whole-population administrative data, we identified all live births (2004-2017) in which the birthing parent (First Nations n = 1,449; other Manitoban n = 278) was prenatally incarcerated and compared them to birthing parents who were postnatally incarcerated (First Nations n = 5,290; other Manitoban n = 790) or not incarcerated (First Nations n = 19,950; other Manitoban n = 3,203). We used generalized linear models adjusted for measured confounders with propensity score weighting to calculate risk differences and 95% confidence intervals for adverse birth outcomes among those prenatally versus postnatally incarcerated in each group. RESULTS: Low birthweight births were more likely among First Nations birthing parents who were prenatally (vs. postnatally) incarcerated (risk difference 1.59, 95% CI [.79, 2.38]) but less likely among other Manitoban birthing parents (risk difference -2.33, 95% CI [-4.50, -.16]) who were prenatally (vs. postnatally) incarcerated. Among First Nations, prenatal incarceration was also associated with large-for-gestational-age births, low Apgar scores, and no breastfeeding (vs. postnatal incarceration), as well as preterm births (vs. no incarceration). Among other Manitobans, prenatal incarceration was also associated with small-for-gestational-age births, low Apgar scores, and no breastfeeding (vs. postnatal incarceration), as well as preterm births (vs. no incarceration). CONCLUSIONS: The findings suggest that incarceration may contribute to intergenerational systems of oppression by compromising birth outcomes among First Nations and other birthing parents in Canada and underscore the need to both improve care for pregnant people who are incarcerated and invest in alternatives to incarceration.

Interprofessional Care Models for Pregnant and Early-Parenting Persons Who Use Substances: A Scoping Review.

Introduction: Use of substances during pregnancy is a global health concern. Interprofessional care teams can provide an optimal care approach to engage individuals who use substances during the perinatal period. The purpose of this scoping review is to provide a comprehensive summation of published literature reporting on interprofessional care models for perinatal individuals who use substances. Methods: We conducted a systematic search for articles from health-related databases. The Preferred Reporting Items for Systematic Reviews for Scoping Reviews (PRISMA-ScR) was followed. Data were extracted and synthesized to identify the interprofessional care team roles, program and/or provider characteristics, and care outcomes of these models. Results: We screened 645 publications for full text eligibility. Eleven articles met full inclusion criteria and were summarized. Programs were built on co-location of services, partnership with other agencies, available group/peer support and approaches inclusive of cultural care, trauma informed care, and harm reduction principles. Discussion: There is growing evidence supporting integrated care models that are inclusive of relational care providers from multiple health care professions to achieve wraparound care. Conclusions: Many of the interprofessional care models studied have successfully blended social, primary, pregnancy, and addictions care. The success and sustainability of programs varies, and more work is needed to evaluate program and patient outcomes.

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.

COVID-19 diagnostic testing and vaccinations among First Nations in Manitoba: A nations-based retrospective cohort study using linked administrative data, 2020-2021.

BACKGROUND: Differential access to healthcare has contributed to a higher burden of illness and mortality among First Nations compared to other people in Canada. Throughout the Coronavirus Disease 2019 (COVID-19) pandemic, First Nations organizations in Manitoba partnered with public health and Manitoba government officials to ensure First Nations had early, equitable and culturally safe access to COVID-19 diagnostic testing and vaccination. In this study, we examined whether prioritizing First Nations for vaccination was associated with faster uptake of COVID-19 vaccines among First Nations versus All Other Manitobans (AOM). METHODS AND FINDINGS: In this retrospective cohort study, we used linked, whole-population administrative data from the Manitoba healthcare system (February 2020 to December 2021) to determine rates of COVID-19 diagnostic testing, infection, and vaccination, and used adjusted restricted mean survival time (RMST) models to test whether First Nations received their first and second vaccine doses more quickly than other Manitobans. The cohort comprised 114,816 First Nations (50.6% female) and 1,262,760 AOM (50.1% female). First Nations were younger (72.3% were age 0 to 39 years) compared to AOM (51% were age 0 to 39 years) and were overrepresented in the lowest 2 income quintiles (81.6% versus 35.6% for AOM). The 2 groups had a similar burden of comorbidities (65.8% of First Nations had none and 6.3% had 3 or more; 65.9% of AOM had none and 6.0% had 3 or more) and existing mental disorders (36.9% of First Nations were diagnosed with a mood/anxiety disorder, psychosis, personality disorder, or substance use disorder versus 35.2% of AOM). First Nations had crude infection rates of up to 17.20 (95% CI 17.15 to 17.24) COVID-19 infections/1,000 person-months compared with up to 6.24 (95% CI 6.16 to 6.32) infections/1,000 person-months among AOM. First Nations had crude diagnostic testing rates of up to 103.19 (95% CI 103.06 to 103.32) diagnostic COVID-19 tests/1,000 person-months compared with up to 61.52 (95% CI 61.47 to 61.57) tests/1,000 person-months among AOM. Prioritizing First Nations to receive vaccines was associated with faster vaccine uptake among First Nations versus other Manitobans. After adjusting for age, sex, income, region of residence, mental health conditions, and comorbidities, we found that First Nations residents received their first vaccine dose an average of 15.5 (95% CI 14.9 to 16.0) days sooner and their second dose 13.9 (95% CI 13.3 to 14.5) days sooner than other Manitobans in the same age group. The study was limited by the discontinuation of population-based COVID-19 testing and data collection in December 2021. As well, it would have been valuable to have contextual data on potential barriers to COVID-19 testing or vaccination, including, for example, information on social and structural barriers faced by Indigenous and other racialized people, or the distrust Indigenous people may have in governments due to historical harms. CONCLUSION: In this study, we observed that the partnered COVID-19 response between First Nations and the Manitoba government, which oversaw creation and enactment of policies prioritizing First Nations for vaccines, was associated with vaccine acceptance and quick uptake among First Nations. This approach may serve as a useful framework for future public health efforts in Manitoba and other jurisdictions across Canada.

Exploring Maternal and Infant Health App Development and Effectiveness Research: Scoping Review.

BACKGROUND: Globally, high rates of maternal and infant mortality call for interventions during the perinatal period to engage pregnant people as well as their loved ones in care. Mobile health technologies have become ubiquitous in our lives and in health care settings. However, there is a need to further explore their safety and effectiveness to support and improve health outcomes locally and globally. OBJECTIVE: The aim of this study was to review and synthesize published literature that described the development process or effectiveness evaluations of maternal and infant apps. METHODS: We applied a methodological framework for scoping reviews as well as the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines; in addition, the systematic review platform Covidence (Veritas Health Innovation Ltd) was used to facilitate the review of included studies. Search terms were developed collaboratively, and health sciences-associated databases were searched for studies conducted between January 1, 2000, and February 4, 2022. We excluded studies about apps that only gathered or tracked data or targeted care providers. RESULTS: A total of 1027 articles were included for title and abstract screening, of which 87 (8.47%) were chosen for full-text screening. Of these 87 articles, 74 (85%) were excluded with reasons, and 19 (22%) were included. Four articles were added at data extraction from hand searching and 2 others were excluded. Thus, we reviewed and synthesized data from 11 unique studies reported in 21 articles published between 2017 and 2021. The included studies represented 8 different countries. Most of the apps (8/11, 73%) were in English, although apps were also developed in Arabic, Bahasa Indonesia, and Nepali. The articles reviewed revealed the early stage of development of the field of maternal and infant health apps, with modest evidence of app use and achievement of study outcomes. Only 1 (9%) of the 11 apps was endorsed by an independent health care provider society. App development and evaluation processes emerged, and specific app features were identified as vital for well-functioning apps. End-user engagement occurred in some, but not all, parts of app research and development. CONCLUSIONS: Apps to improve maternal and infant health are being developed and launched in enormous numbers, with many of them not developed with mothers' needs in mind. There are concerns about privacy, safety, and the standardization of current apps as well as a need for professional or institution-specific guidelines or best practices. Despite challenges inherent in currently available apps and their design processes, maternal and infant app technology holds promise for achieving health equity goals and improving maternal and child health outcomes. Finally, we propose recommendations for advancing the knowledge base for maternal and infant apps.

Characterising methamphetamine use to inform health and social policies in Manitoba, Canada: a protocol for a retrospective cohort study using linked administrative data.

INTRODUCTION: Rising use of methamphetamine is causing significant public health concern in Canada. The biological and behavioural effects of methamphetamine range from wakefulness, vigour and euphoria to adverse physical health outcomes like myocardial infarction, haemorrhagic stroke, arrhythmia and seizure. It can also cause severe psychological complications such as psychosis. National survey data point to increasing rates of methamphetamine use, as well as increasing ease of access and serious methamphetamine-related harms. There is an urgent need for evidence to address knowledge gaps, provide direction to harm reduction and treatment efforts and inform health and social policies for people using methamphetamine. This protocol describes a study that aims to address this need for evidence. METHODS: The study will use linked, whole population, de-identified administrative data from the Manitoba Population Research Data Repository. The cohort will include individuals in the city of Winnipeg, Manitoba, who came into contact with the health system for reasons related to methamphetamine use from 2013 to 2021 and a comparison group matched on age, sex and geography. We will describe the cohort's sociodemographic characteristics, calculate incidence and prevalence of mental disorders associated with methamphetamine use and examine rates of health and social service use. We will evaluate the use of olanzapine pharmacotherapy in reducing adverse emergency department outcomes. In partnership with Indigenous co-investigators, outcomes will be stratified by First Nations and Métis identity. ETHICS AND DISSEMINATION: The study was approved by the University of Manitoba Health Research Ethics Board, and access datasets have been granted by all data providers. We also received approval from the First Nations Health and Social Secretariat of Manitoba's Health Information Research Governance Committee and the Manitoba Métis Federation. Dissemination will be guided by an 'Evidence 2 Action' group of public rightsholders, service providers and knowledge users who will ensure that the analyses address the critical issues.

Canada First Nations Strengths in Community-Based Primary Healthcare.

INTRODUCTION: First Nation (FN) peoples and communities in Canada are still grappling with the effects of colonization. Health and social inequities result in higher disease burden and significant disparities in healthcare access and responsiveness. For resilience, survival, and self-determination, FN are looking inwards for strengths. This paper reports on the cultural, community, and family strengths that have supported FN communities in developing community-based primary healthcare (CBPHC) strategies to support health and wellbeing. METHODS: The study was a partnership between university-based researchers; The First Nations Health and Social Secretariat of Manitoba; and eight First Nation communities in Manitoba. Community-based participatory research methods were used to engage the participating communities. One hundred and eighty-three in-depth, semi-structured key informant interviews were completed between 2014 and 2016 with key members of the First Nation communities, i.e., community-based health providers and users of primary healthcare services, representing all age and genders. Data-collection and analysis were conducted following iterative grounded theory analysis. RESULTS: Community-based healthcare models based on local strengths support easier access and shorter wait times for care and compassionate care delivery. Resources such as homecare and medical transportation are helpful. Community cooperation, youth power, responsive leadership, and economic development as well as a strong cultural and spiritual base are key strengths supporting health and social wellbeing. CONCLUSIONS: Locally led, self-determined care adds strength in FN communities, and is poised to create long-lasting primary healthcare transformation.

Decolonizing health in Canada: A Manitoba first nation perspective.

INTRODUCTION & BACKGROUND: Global persistence of health inequities for Indigenous peoples is evident in ongoing discrepancies in health and standards of living. International literature suggests the key to transformation lies in Indigenous efforts to control Indigenous health and healthcare. Previous authors have focused upon participation, structural transformation, and culturally appropriate healthcare recognized as a political right as fundamental tenets of Indigenous control. Contextualizing Indigenous health and wellness falls within a growing discussion on decolonization - a resituating of expertise that privileges Indigenous voice and interests. METHODS: The study is a qualitative, grounded theory analysis, which is a constructivist approach to social research allowing for generation of theory in praxis, through interactions and conversations between researchers and participants. One hundred eighty-three interviews with additional focus groups were held between 2013-15 in eight Manitoba First Nation communities representing different models of health delivery, geographies, accessibilities, and Indigenous language groups. Community research assistants and respected Elders participated in data collection, analysis and interpretation. Line-by-line coding and constant comparative method led to the discovery of converging themes. FINDINGS: Ultimately four main themes arose: 1) First Nation control of healthcare; 2) traditional medicine and healing activities; 3) full and meaningful community participation; and 4) cleaning up impacts of colonization. Joint analyses and interpretation of findings revealed substantial evidence that communities were looking profoundly into problems of improperly delivered services and health inequities. Issues were consistent with those highlighted by international commissions on reconciliation, health, Indigenous rights and liberties. To those documents, these findings add ground upon which to build the transformative agenda. RESULTS & DISCUSSION: Communities discussed the need for creation of protocols, constitution and laws to ensure growth of a decolonizing agenda. Inclusive to the concept are holistic, preventative, traditional health perspectives, and Indigenous languages. Colonization impacts were of critical concern and in need of undoing. Sharing of social and political efforts is seen as pivotal to change and includes all members of communities.

Diagnostic testing and vaccination for COVID-19 among First Nations, Metis and Inuit in Manitoba, Canada: protocol for a nations-based cohort study using linked administrative data.

INTRODUCTION: Decades of research demonstrate that First Nations, Metis and Inuit (FN/M/I) populations have differential access to diagnostic and therapeutic healthcare. Emerging evidence shows that this continues to be the case during the SARS-CoV-2 pandemic. In an effort to rectify these differences in access to care, our team, which is co-led by FN/M/I partners, will generate and distribute evidence on COVID-19 diagnostic testing and vaccination in high-priority FN/M/I populations in Manitoba, with the goal of identifying system-level and individual-level factors that act as barriers to equitable care and thereby informing Indigenous-led public health responses. METHODS AND ANALYSIS: Our nations-based approach focuses on FN/M/I populations with separate study arms for each group. Linked administrative health data on COVID-19 diagnostic testing and vaccinations are available on a weekly basis. We will conduct surveillance to monitor trends in testing and vaccination among each FN/M/I population and all other Manitobans, map the geographic distribution of these outcomes by health region and tribal council, and identify barriers to testing and vaccination to inform public health strategies. We will follow the course of the pandemic starting from January 2020 and report findings quarterly. ETHICS AND DISSEMINATION: Ethics approvals have been granted by the University of Manitoba Research Ethics Board and from each of our FN/M/I partners' organisations. Our team is committed to engaging in authentic relationship-based research that follows First Nations, Metis and Inuit research ethics principles. Our FN/M/I partners will direct the dissemination of new information to leadership in their communities (health directors, community health organisations) and to decision-makers in the provincial Ministry of Health. We will also publish in open-access journals. The study will create ongoing capacity to monitor Manitoba's pandemic response and ensure potential health inequities are minimised, with learnings applicable to other jurisdictions where detailed administrative data may not be available.

The Two Great Healing Traditions: Issues, Opportunities, and Recommendations for an Integrated First Nations Healthcare System in Canada.

The First Nations in Manitoba, Canada, are calling for active recognition and incorporation of holistic traditional healing and medicine ways and approaches by the mainstream healthcare system that has hitherto tended to ignore all but biomedical approaches. This request for recognition requires elaboration on areas of opportunity for collaboration that could positively influence both Indigenous and allopathic medicine. We discuss pathways to an integrated healthcare system as community-based primary healthcare transformation. A community-based participatory research approach was used to engage eight Manitoba First Nations communities. One hundred and eighty-three (183) in-depth, semi-structured key informant interviews were completed in all communities. Grounded theory guided data analysis using NVivo 10 software. We learned that increased recognition and incorporation of traditional healing and medical methods would enhance a newly envisioned funded health system. Elders and healers will be meaningfully involved in the delivery of community-based primary health care. Funding for traditional healing and medicines are necessary components of primary health care. An overall respect for Indigenous health knowledge would aid transformation in community-based primary health care. Recognition of and respect for traditional healing, healers, medicines, therapies, and approaches is also recommended as part of addressing the legacy and intergenerational impact of assimilative policies including Indian residential schools as the Truth and Reconciliation Commission of Canada has stated in its Calls to Action.

Impact of remote prenatal education on program participation and breastfeeding of women in rural and remote Indigenous communities.

BACKGROUND: First Nations (FN) women have a higher risk of diabetes than non-FN women in Canada. Prenatal education and breastfeeding may reduce the risk of diabetes in mothers and offspring. The rates of breastfeeding initiation and participation in the prenatal program are low in FN communities. METHODS: A prenatal educational website, social media-assisted prenatal chat groups and community support teams were developed in three rural or remote FN communities in Manitoba. The rates of participation of pregnant women in prenatal programs and breastfeeding initiation were compared before and after the start of the remote prenatal education program within 2014-2017. FINDINGS: The participation rate of FN pregnant women in rural or remote communities in the prenatal program and breastfeeding initiation during 1-year after the start of the community-based remote prenatal education program were significantly increased compared to that during 1-year before the start of the program (54% versus 36% for the participation rate, 50% versus 34% for breastfeeding initiation, p < 0·001). Availability of high-speed Wi-Fi and/or postpartum supporting team were associated with favorite study outcomes. Positive feedback on the remote prenatal education was received from participants. INTERPRETATION: The findings suggest that remote prenatal education is feasible and effective for improving the breastfeeding rate and engaging pregnant women to participate in the prenatal program in rural or remote FN communities. The remote prenatal education remained active during COVID-19 in the participating communities, which suggests an advantage to expand remote prenatal education in other Indigenous communities. FUNDING: Canadian Institutes of Health Research, the Lawson Foundation and University of Manitoba.

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.

Manitoba First Nation peoples' use of hospital-based mental health services: trends and solutions.

OBJECTIVES: The objective of this article is to document patterns and trends of in-hospital mental health service use by First Nations (FN) living in rural and remote communities in the province of Manitoba. METHODS: Our sample included all Manitoba residents eligible under the Manitoba Health Services Insurance Plan living on FN reserves and those living in rural and remote communities from 1986 to 2014. Using administrative claims data, we developed multi-level models that describe hospitalization for mental health conditions shown responsive to primary healthcare interventions. We aggregated the results by First Nation Tribal Councils and remoteness to derive rates of hospitalization episodes, length of stay and readmission rates. RESULTS: Rates of hospitalization for mental health are increasing for FN males and females. This is particularly evident for those affiliated with the Island Lake and Keewatin Tribal Councils. The length of stay has increased. Changes in rates of readmissions were not statistically significant. FNs are admitted for mental health conditions at a younger age when compared with other Manitobans, and trends show that the FNs' average age at admission is decreasing. CONCLUSIONS: Our results raise serious concerns about the responsiveness of community-based mental health services for FNs in Manitoba, because of both increasing rates of episodes of hospitalization and decreasing age of admission. Given the documented lack of mental health services accessible on-reserve, levels of social distress associated with a history of oppressive policies, and continued lack of infrastructure, current trends are alarming.

RéSUMé: OBJECTIFS: L'objectif de cet article est de documenter les caractéristiques et les tendances de l'utilisation des services de santé mentale en milieu hospitalier par les Premières nations (PN) vivant dans les collectivités rurales et éloignées de la province du Manitoba. MéTHODES: Notre échantillon inclus tous les résidents du Manitoba admissibles au Régime d'assurance-maladie du Manitoba vivant dans les réserves des PN et ceux vivant dans des collectivités rurales et éloignées de 1986 à 2014. À partir de données de réclamations administratives, nous avons mis au point des modèles à plusieurs niveaux décrivant l'hospitalisation pour des problèmes de santé mentale qui se sont montrés sensibles aux interventions en soins de santé primaires. Nous avons agrégé les résultats par Conseil de Tribu pour obtenir les taux d'épisodes d'hospitalisation, la durée du séjour et les taux de réadmission. RéSULTATS: Les taux d'hospitalisation liée à la santé mentale augmentent pour les hommes et femmes PN. Cela est particulièrement évident pour les membres des conseils tribaux d'Island Lake et de Keewatin. La durée du séjour a aussi augmenté. Les changements dans les taux de réadmission n'étaient pas statistiquement significatifs. Les PNs sont admis pour des problèmes de santé mentale plus jeunes que les autres Manitobains, et les tendances montrent que l'âge moyen des PNs continue de décroître. CONCLUSIONS: Nos résultats soulèvent des inquiétudes quant à la réactivité des services de santé mentale communautaires pour les PNs au Manitoba, à la fois en raison de la fréquence croissante des épisodes d'hospitalisation et de la diminution de l'âge d'admission. Étant donné le manque documenté de services de santé mentale accessibles dans les réserves, le niveau de détresse sociale associé à des antécédents de politiques oppressives et le manque continu d'infrastructure, les tendances actuelles sont alarmantes.

First Nations' hospital readmission ending in death: a potential sentinel indicator of inequity?

In this study, we focused on readmissions for Ambulatory Care Sensitive Conditions (ACSC) ending in death, to capture those admissions and readmissions that might have been prevented if responsive primary healthcare was accessible. We propose this as a sentinel indicator of equity. We conducted analyses of Manitoba-based 30-day hospital readmission rates for ACSC which resulted in death, using data from 1986-2016 adjusted for age, sex, and socio-economic status. Our findings show that, across Manitoba, overall rates of readmissions ending in death are slowly increasing, and increasing more dramatically among northern First Nations, larger First Nations not affiliated with Tribal Councils, and in the western region of the province. These regions have continuously been highlighted as disadvantaged in terms of access to care, suggesting that the time for action is overdue. Rising rates of readmissions for ACSC ending in death suggest that greater attention should be placed on access to responsive primary healthcare. These findings have broader implications for territorial healthcare systems which purchase acute care services from provinces south of them. As an indicator of quality, monitoring readmissions ending in death could provide territorial governments insights into the quality of care provided to their constituents by provincial authorities.

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.

RéSUMé: OBJECTIFS: L'objectif de cette étude était d'évaluer le rendement des modèles de soins de santé primaires (SSP) dispensés dans les Premières Nations et les communautés adjacentes du Manitoba, en utilisant les taux d'hospitalisation pour les conditions propices aux soins ambulatoires (CPSA) comme résultat principal. MéTHODES: Nous avons utilisé une régression logistique par équation d'estimation généralisée sur les données de réclamations administratives pour 63 communautés des Premières Nations du Manitoba (1986-2016) comprenant 140 111 personnes, hébergées au Manitoba Centre for Health Policy. Nous avons contrôlé l'âge, le sexe et le statut socioéconomique afin de décrire la relation entre les taux d'hospitalisation pour les CPSA et les modèles de soins de santé primaires dans les communautés des Premières Nations. RéSULTATS: Les taux d'hospitalisation pour les CPSA aigus, chroniques, évitables par la vaccination et liés à la santé mentale ont diminué au fil du temps dans les communautés des Premières Nations, mais demeurent considérablement plus élevés dans les communautés des Premières Nations et éloignées non des Premières Nations par rapport aux autres Manitobains. Lorsque l'on compare différents modèles de soins, les taux d'hospitalisation étaient historiquement plus élevés dans les communautés desservies par les centres/bureaux de santé, qu'ils soient ou non complétés par des services médicaux itinérants. Ces taux ont considérablement diminué au cours des deux dernières décennies. CONCLUSION: L'accès local à un éventail plus large de services de SSP est associé à des taux plus faibles d'hospitalisation évitable dans les collectivités des Premières Nations. Le manque de ces services dans de nombreuses collectivités des Premières nations démontre l'incapacité du système de santé canadien actuel à répondre aux besoins des peuples des Premières nations. On peut s'attendre à ce que l'amélioration de l'accès aux soins de santé primaires dans les 63 collectivités des Premières nations se traduise par une réduction des taux d'hospitalisation et des coûts des soins de santé.

Confronting Racism within the Canadian Healthcare System: Systemic Exclusion of First Nations from Quality and Consistent Care.

The study is on racism against First Nation peoples in the Canadian healthcare system. The study design incorporates principles of grounded theory, participant and Indigenous (decolonizing) research. Four questions are addressed: (1) What is the root cause of racism against First Nation peoples in the healthcare system? (2) What factors perpetuate racisms existence? (3) What are the impacts of racism on First Nation health? (4) What needs to be done to eradicate racism and to create an equitable healthcare system that sufficiently represents the needs, interests and values of First Nation peoples?

Elevating the uses of storytelling approaches within Indigenous health research: a critical and participatory scoping review protocol involving Indigenous people and settlers.

BACKGROUND: There is a complicated and exploitative history of research with Indigenous peoples and accompanying calls to meaningfully and respectfully include Indigenous knowledge in healthcare. Storytelling approaches that privilege Indigenous voices can be a useful tool to break the hold that Western worldviews have within the research. Our collaborative team of Indigenous and non-Indigenous researchers, and Indigenous patients, Elders, healthcare providers, and administrators, will conduct a critical participatory, scoping review to identify and examine how storytelling has been used as a method in Indigenous health research. METHODS: Guided by two-eyed seeing, we will use Bassett and McGibbon's adaption of Arksey and O'Malley's scoping review methodology. Relevant articles will be identified through a systematic search of the gray literature, core Indigenous health journals, and online databases including Scopus, MEDLINE, Embase, CINAHL, AgeLine, Academic Search Complete, Bibliography of Native North Americans, Canadian Reference Centre, and PsycINFO. Qualitative and mixed-methods research articles will be included if the researchers involved Indigenous participants or their healthcare professionals living in Turtle Island (i.e., Canada and the USA), Australia, or Aotearoa (New Zealand); use storytelling as a research method; focus on healthcare phenomena; and are written in English. Two reviewers will independently screen titles/abstracts and full-text articles. We will extract data, identify the array of storytelling approaches, and critically examine how storytelling was valued and used. An intensive collaboration will be woven throughout all review stages as academic researchers co-create this work with Indigenous patients, Elders, healthcare professionals, and administrators. Participatory strategies will include four relational gatherings throughout the project. Based on our findings, we will co-create a framework to guide the respectful use of storytelling as a method in Indigenous health research involving Indigenous and non-Indigenous peoples. DISCUSSION: This work will enable us to elucidate the extent, range, and nature of storytelling within Indigenous health research, to critically reflect on how it has been and could be used, and to develop guidance for the respectful use of this method within research that involves Indigenous peoples and settlers. Our findings will enable the advancement of storytelling methods which meaningfully include Indigenous perspectives, practices, and priorities to benefit the health and wellbeing of Indigenous communities. SYSTEMATIC REVIEW PROTOCOL REGISTRATION: Open Science Framework ( https://osf.io/rvf7q ).

Virtual Reality Analgesia for Children With Large Severe Burn Wounds During Burn Wound Debridement.

The objective of this study was to compare the effect of adjunctive virtual reality vs. standard analgesic pain medications during burn wound cleaning/debridement. Participants were predominantly Hispanic children aged 6-17 years of age, with large severe burn injuries (TBSA = 44%) reporting moderate or higher baseline pain during burn wound care. Using a randomized between-groups design, participants were randomly assigned to one of two groups, (a) the Control Group = pain medications only or (b) the VR Group = pain medications + virtual reality. A total of 50 children (88% Hispanic) with large severe burns (mean TBSA > 10%) received severe burn wound cleaning sessions. For the primary outcome measure of worst pain (intensity) on Study Day 1, using a between groups ANOVA, burn injured children in the group that received virtual reality during wound care showed significantly less pain intensity than the No VR control group, [mean worst pain ratings for the No VR group = 7.46 (SD = 2.93) vs. 5.54 (SD = 3.56), F (1,48) = 4.29, <0.05, MSE = 46.00]. Similarly, one of the secondary pain measures, "lowest pain during wound care" was significantly lower in the VR group, No VR = 4.29 (SD = 3.75) vs. 1.68 (2.04) for the VR group, F(147) = 9.29, < 0.005, MSE = 83.52 for Study Day 1. The other secondary pain measures showed the predicted pattern on Study Day 1, but were non-significant. Regarding whether VR reduced pain beyond Study Day 1, absolute change in pain intensity (analgesia = baseline pain minus the mean of the worst pain scores on Study days 1-10) was significantly greater for the VR group, F (148) = 4.88, p < 0.05, MSE = 34.26, partial eta squared = 0.09, but contrary to predictions, absolute change scores were non-significant for all secondary measures.

Immersive Virtual Reality as an Adjunctive Non-opioid Analgesic for Pre-dominantly Latin American Children With Large Severe Burn Wounds During Burn Wound Cleaning in the Intensive Care Unit: A Pilot Study.

Background/Aim: Using a within-subjects, within-wound care design, this pilot study tested for the first time, whether immersive virtual reality (VR) can serve as an adjunctive non-opioid analgesic for children with large severe burn wounds during burn wound cleaning in the ICU, in a regional burn center in the United States, between 2014-2016. Methods: Participants included 48 children from 6 years old to 17 years of age with >10% TBSA burn injuries reporting moderate or higher worst pain during no VR on Day 1. Forty-four of the 48 children were from developing Latin American countries. Patients played adjunctive SnowWorld, an interactive 3D snowy canyon in virtual reality during some portions of wound care, vs. No VR during comparable portions of the same wound care session (initial treatment condition randomized). Using Graphic Rating scales, children's worst pain ratings during "No VR" (treatment as usual pain medications) vs. their worst pain during "Yes VR" was measured during at least 1 day of wound care, and was measured for up to 10 study days the patient used VR. Results: VR significantly reduced children's "worst pain" ratings during burn wound cleaning procedures in the ICU on Day 1. Worst pain during No VR = 8.52 (SD = 1.75) vs. during Yes VR = 5.10 (SD = 3.27), t (47) = 7.11, p < 0.001, SD = 3.33, CI = 2.45-4.38, Cohen's d = 1.03 (indicating large effect size). Patients continued to report the predicted pattern of lower pain and more fun during VR, during multiple sessions. Conclusion: Immersive virtual reality can help reduce the pain of children with large severe burn wounds during burn wound cleaning in the Intensive Care Unit. Additional research and development is recommended.

Association between participation in the Families First Home Visiting programme and First Nations families' public health outcomes in Manitoba, Canada: a retrospective cohort study using linked administrative data.

OBJECTIVE: To determine whether the Families First Home Visiting (FFHV) programme, which provides home visiting services to families across Manitoba, is associated with improved public health outcomes among First Nations families facing multiple parenting challenges. DESIGN: Retrospective cohort study using population-based administrative data. SETTING: Manitoba, Canada. PARTICIPANTS: First Nations children born in Manitoba in 2003-2009 (n=4010) and their parents enrolled in FFHV compared with non-enrolled families with a similar risk profile. INTERVENTION: FFHV supports public health in Manitoba by providing home visiting services to First Nations and non-First Nations families with preschool children and connecting them with resources in their communities. OUTCOMES: Predicted probability (PP) and relative risk (RR) of childhood vaccination, parental involvement in community support programmes and children's development at school entry. RESULTS: FFHV participation was associated with higher rates of complete childhood vaccination at age 1 (PP: FFHV 0.715, no FFHV 0.661, RR 1.08, 95% CI 1.03 to 1.14) and age 2 (PP: FFHV 0.465, no FFHV 0.401, RR 1.16, 95% CI 1.08 to 1.25), and with parental involvement in community support groups (PP: FFHV 0.149, no FFHV 0.097, RR 1.54, 95% CI 1.27 to 1.86). However, there was no difference between FFHV participants and non-participants in rates of children being vulnerable in at least one developmental domain at age 5 (PP: FFHV 0.551, no FFHV 0.557, RR 1.00, 95% CI 0.91 to 1.11). CONCLUSIONS: FFHV supports First Nations families in Manitoba by promoting childhood vaccination and connecting families to parenting resources in their communities, thus playing an important role in fulfilling the mandate of public health practice.