Design and implementation of the Our Health Counts (OHC) methodology for First Nations, Inuit, and Metis (FNIM) health assessment and response in urban and related homelands.

OBJECTIVES: Methods for enumeration and population-based health assessment for First Nations, Inuit, and Metis (FNIM) living in Canadian cities are underdeveloped, with resultant gaps in essential demographic, health, and health service access information. Our Health Counts (OHC) was designed to engage FNIM peoples in urban centres in "by community, for community" population health assessment and response. METHODS: The OHC methodology was designed to advance Indigenous self-determination and FNIM data sovereignty in urban contexts through deliberate application of Indigenous principles and linked implementation strategies. Three interwoven principles (good relationships are foundational; research as gift exchange; and research as a vehicle for Indigenous community resurgence) provide the framework for linked implementation strategies which include actively building and maintaining relationships; meaningful Indigenous community guidance, leadership, and participation in all aspects of the project; transparent and equitable sharing of project resources and benefits; and technical innovations, including respondent-driven sampling, customized comprehensive health assessment surveys, and linkage to ICES data holdings to generate measures of health service use. RESULTS: OHC has succeeded across six urban areas in Ontario to advance Indigenous data sovereignty and health assessment capacity; recruit and engage large population-representative cohorts of FNIM living in urban and related homelands; customize comprehensive health surveys and data linkages; generate previously unavailable population-based FNIM demographic, health, and social information; and translate results into enhanced policy, programming, and practice. CONCLUSION: The OHC methodology has been demonstrated as effective, culturally relevant, and scalable across diverse Ontario cities.

RéSUMé: OBJECTIFS: Les méthodes de dénombrement et d'évaluation populationnelle de la santé des personnes des Premières Nations, des Inuits et des Métis (PNIM) vivant dans les villes du Canada sont sous-développées, ce qui laisse des lacunes dans les informations essentielles sur le profil démographique, la santé et l'accès aux services de santé. Le projet Notre santé compte (NSC) vise à collaborer avec les personnes des PNIM dans les centres urbains au moyen d'une évaluation de la santé des populations et d'une intervention « pour nous-mêmes, par nous-mêmes ¼. MéTHODE: La méthode NSC est conçue pour renforcer l'autodétermination autochtone et la souveraineté des données des PNIM vivant en milieu urbain par l'application délibérée de principes autochtones et de stratégies de mise en œuvre connexes. Trois principes imbriqués (« les bonnes relations sont fondamentales ¼; « la recherche en tant qu'échange de cadeaux ¼; et « la recherche comme vecteur de résurgence des communautés autochtones ¼) constituent le cadre de stratégies de mise en œuvre connexes : l'établissement et le maintien actifs de relations; la guidance, la participation et le leadership significatifs des communautés autochtones dans tous les aspects du projet; le partage transparent et équitable des ressources et des avantages du projet; et les innovations techniques, dont l'échantillonnage en fonction des répondants, les enquêtes de santé exhaustives et personnalisées, et les couplages avec les fonds de données de l'Institut de recherche en services de santé (ICES), pour produire des indicateurs d'utilisation des services de santé. RéSULTATS: L'approche NSC a réussi dans six agglomérations urbaines de l'Ontario : à renforcer la souveraineté des données et la capacité d'évaluation de la santé des populations autochtones; à recruter et à mobiliser de vastes cohortes représentatives des PNIM vivant en milieu urbain et sur les territoires connexes; à personnaliser des enquêtes de santé exhaustives et des couplages de données; à générer des informations démographiques, sanitaires et sociales non disponibles auparavant sur les populations des PNIM; et à traduire ces résultats en politiques, en programmes et en pratiques améliorés. CONCLUSION: Il est démontré que la méthode NSC est efficace, culturellement appropriée et modulable dans différentes villes de l'Ontario.

Mental health and cultural continuity among an urban Indigenous population in Toronto, Canada.

OBJECTIVES: Mental health and psychiatric disorders significantly affect individuals on personal and social levels. Indigenous populations in Canada have disproportionately high rates of mental health diagnoses. Our Health Counts (OHC) Toronto assessed mental health, racism, family disruption, and cultural continuity among urban Indigenous people. The objectives of this study were to understand (1) the demographics and characteristics of Indigenous adults with a diagnosed psychological/mental health disorder and (2) potential associations of psychological/mental health diagnoses with experiences of colonization and cultural continuity among Indigenous adults in Toronto. METHODS: Using community-based participatory research methods, Indigenous adults in Toronto were recruited by respondent-driven sampling (RDS) to complete a comprehensive health assessment survey. RDS-II weights were applied to calculate population-based estimates, and adjusted odds ratios with 95% confidence intervals were produced using logistic regression, controlling for age and gender. RESULTS: Among Indigenous adults, nearly half (45%) reported receiving a mental health diagnosis. Participants reported lifetime anxiety disorders (53%), major depression (51%), and high rates of suicide ideation (78%). Of Indigenous adults with a diagnosed mental health disorder, 72.7% reported participating in ceremony. Attending residential schools (OR: 7.82) and experiencing discrimination (OR: 2.69) were associated with having a mental health disorder. CONCLUSION: OHC Toronto responded to the gaps in health assessment data for urban Indigenous people. Despite historic and ongoing trauma, Indigenous people have maintained cultural practices and a strong sense of identity. Efforts aimed at supporting Indigenous well-being must respond to the roots of trauma, racism, and existing Indigenous community knowledge and strengths.

RéSUMé: OBJECTIFS: Les troubles psychiatriques et de santé mentale ont des effets considérables sur le plan personnel et social. Les populations autochtones du Canada ont des taux démesurément élevés de diagnostics en santé mentale. L'organisme Our Health Counts (OHC) Toronto a évalué la santé mentale, le racisme, les perturbations familiales et la continuité culturelle de personnes autochtones en milieu urbain. L'étude visait à comprendre 1) le profil démographique et les caractéristiques d'adultes autochtones ayant un trouble psychologique ou de santé mentale diagnostiqué et 2) les associations possibles entre les diagnostics psychologiques ou en santé mentale et les expériences de colonisation et de continuité culturelle chez les adultes autochtones de Toronto. MéTHODE: À l'aide de méthodes de recherche participative communautaire, des adultes autochtones de Toronto ont été recrutés par échantillonnage en fonction des répondants (EFR) pour répondre à une enquête d'évaluation globale de la santé. Des pondérations EFR-II ont été appliquées au calcul d'estimations populationnelles, et des rapports de cotes ajustés avec des intervalles de confiance de 95 % ont été produits par régression logistique, après avoir apporté des ajustements pour tenir compte des effets de l'âge et du sexe. RéSULTATS: Chez les adultes autochtones, près de la moitié (45 %) ont déclaré avoir reçu un diagnostic en santé mentale. Les participants ont déclaré avoir connu au cours de leur vie des troubles anxieux (53 %), une dépression majeure (51 %) et, dans une proportion élevée, des pensées suicidaires (78 %). Chez les adultes autochtones ayant un trouble mental diagnostiqué, 72,7 % ont déclaré participer à des cérémonies. La fréquentation des pensionnats (RC : 7,82) et l'expérience de la discrimination (RC: 2,69) étaient associées au fait d'avoir un trouble mental. CONCLUSION: OHC Toronto cherchait à combler les lacunes dans les données d'évaluation de la santé des populations autochtones en milieu urbain. Malgré leurs traumatismes présents et historiques, ces populations ont conservé leurs pratiques culturelles et un fort sentiment d'identité. Les démarches pour appuyer le bien-être des personnes autochtones doivent tenir compte des racines des traumatismes, du racisme, ainsi que des connaissances et des forces existantes des communautés autochtones.

Uncovering SARS-COV-2 vaccine uptake and COVID-19 impacts among First Nations, Inuit and Métis Peoples living in Toronto and London, Ontario.

BACKGROUND: First Nations, Inuit and Métis Peoples across geographies are at higher risk of SARS-CoV-2 infection and COVID-19 because of high rates of chronic disease, inadequate housing and barriers to accessing health services. Most Indigenous Peoples in Canada live in cities, where SARS-CoV-2 infection is concentrated. To address gaps in SARS-CoV-2 information for these urban populations, we partnered with Indigenous agencies and sought to generate rates of SARS-CoV-2 testing and vaccination, and incidence of infection for First Nations, Inuit and Métis living in 2 Ontario cities. METHODS: We drew on existing cohorts of First Nations, Inuit and Métis adults in Toronto (n = 723) and London (n = 364), Ontario, who were recruited using respondent-driven sampling. We linked to ICES SARS-CoV-2 databases and prospectively monitored rates of SARS-CoV-2 testing, diagnosis and vaccination for First Nations, Inuit and Métis, and comparator city and Ontario populations. RESULTS: We found that SARS-CoV-2 testing rates among First Nations, Inuit and Métis were higher in Toronto (54.7%, 95% confidence interval [CI] 48.1% to 61.3%) and similar in London (44.5%, 95% CI 36.0% to 53.1%) compared with local and provincial rates. We determined that cumulative incidence of SARS-CoV-2 infection was not significantly different among First Nations, Inuit and Métis in Toronto (7364/100 000, 95% CI 2882 to 11 847) or London (7707/100 000, 95% CI 2215 to 13 200) compared with city rates. We found that rates of vaccination among First Nations, Inuit and Métis in Toronto (58.2%, 95% CI 51.4% to 64.9%) and London (61.5%, 95% CI 52.9% to 70.0%) were lower than the rates for the 2 cities and Ontario. INTERPRETATION: Although Ontario government policies prioritized Indigenous populations for SARS-CoV-2 vaccination, vaccine uptake was lower than in the general population for First Nations, Inuit and Métis Peoples in Toronto and London. Ongoing access to culturally safe testing and vaccinations is urgently required to avoid disproportionate hospital admisson and mortality related to COVID-19 in these communities.

Modelling prevalent cardiovascular disease in an urban Indigenous population.

OBJECTIVE: Studies have highlighted the inequities between the Indigenous and non-Indigenous populations with respect to the burden of cardiovascular disease and prevalence of predisposing risks resulting from historical and ongoing impacts of colonization. The objective of this study was to investigate factors associated with cardiovascular disease (CVD) within and specific to the Indigenous peoples living in Toronto, Ontario, and to evaluate the reliability and validity of the resulting model in a similar population. METHODS: The Our Health Counts Toronto study measured the baseline health of Indigenous community members living in Toronto, Canada, using respondent-driven sampling. An iterative approach, valuing information from the literature, clinical insight and Indigenous lived experiences, as well as statistical measures was used to evaluate candidate predictors of CVD (self-reported experience of discrimination, ethnic identity, health conditions, income, education, age, gender and body size) prior to multivariable modelling. The resulting model was then validated using a distinct, geographically similar sample of Indigenous people living in Hamilton, Ontario, Canada. RESULTS: The multivariable model of risk factors associated with prevalent CVD included age, diabetes, hypertension, body mass index and exposure to discrimination. The combined presence of diabetes and hypertension was associated with a greater risk of CVD relative to those with either condition and was the strongest predictor of CVD. Those who reported previous experiences of discrimination were also more likely to have CVD. Further study is needed to determine the effect of body size on risk of CVD in the urban Indigenous population. The final model had good discriminative ability and adequate calibration when applied to the Hamilton sample. CONCLUSION: Our modelling identified hypertension, diabetes and exposure to discrimination as factors associated with cardiovascular disease. Discrimination is a modifiable exposure that must be addressed to improve cardiovascular health among Indigenous populations.

RéSUMé: OBJECTIF: Des études ont souligné les iniquités entre les populations autochtones et non autochtones en ce qui a trait au fardeau des maladies cardiovasculaires et à la prévalence des risques prédisposants qui résultent des impacts historiques et continus de la colonisation. Nous avons voulu étudier les facteurs associés aux maladies cardiovasculaires (MCV) au sein des populations autochtones vivant à Toronto (Ontario) et spécifiques à ces populations, puis évaluer la fiabilité et la validité du modèle ainsi obtenu dans une population semblable. MéTHODE: L'étude Our Health Counts Toronto a mesuré l'état de santé de départ de membres de communautés autochtones vivant à Toronto, au Canada, à l'aide d'un échantillonnage en fonction des répondants. Une approche itérative, valorisant à la fois les données d'études scientifiques, l'expérience clinique, le vécu de personnes autochtones et les mesures statistiques, a été employée pour évaluer les candidats prédicteurs des MCV (expérience autodéclarée de discrimination, identité ethnique, affections médicales, revenu, instruction, âge, genre et taille) avant la modélisation multivariée. Le modèle ainsi obtenu a ensuite été validé à l'aide d'un échantillon distinct, mais géographiquement similaire, de personnes autochtones vivant à Hamilton (Ontario), au Canada. RéSULTATS: Le modèle multivarié des facteurs de risque associés aux MCV prévalentes incluait l'âge, le diabète, l'hypertension artérielle, l'indice de masse corporelle et l'exposition à la discrimination. La présence combinée du diabète et de l'hypertension artérielle était associée à un risque accru de MCV comparativement à l'une ou l'autre de ces deux affections médicales; c'était aussi la plus forte variable prédictive des MCV. Les personnes ayant déclaré des expériences passées de discrimination étaient aussi plus susceptibles d'être atteintes de MCV. D'autres études sont nécessaires pour déterminer l'effet de la taille sur le risque de MCV dans la population autochtone urbaine. Le modèle final avait un bon pouvoir discriminant et une calibration adéquate lorsqu'il a été appliqué à l'échantillon de Hamilton. CONCLUSION: Notre modélisation a cerné l'hypertension artérielle, le diabète et l'exposition à la discrimination comme facteurs associés aux maladies cardiovasculaires. La discrimination est un risque modifiable qui doit être abordé pour améliorer la santé cardiovasculaire au sein des populations autochtones.

Dismantling "Race" in Health Research.

In this era of confronting racism in public space, it is critical to keep addressing the covert systemic racism in the healthcare system. We want to bring attention to the continued unscientific practice of race-based medicine and the absurdity of treating race as a biological indicator in the 21st century. We believe race is a social construct that does not qualify as a scientific biological indicator for predicting health outcomes. In this paper, we first present arguments for inappropriate use of race in health research and then discuss alternative explanations for health disparity findings that use race as a predictor. Our main concern centers on two specific aspects of the concept of "race": (1) its fundamental lack of scientific basis as a predictor for health outcomes, (2) the misguided narrative that the term creates, placing the onus of racial discrimination on the victim, instead of highlighting the act of discrimination and the role researchers play in actively reinforcing racism when using "race" as a variable. We conclude by proposing that "race" be replaced by the variable "racism" in health.

Addressing the need for indigenous and decolonized quantitative research methods in Canada.

Though qualitative methods are often an appropriate Indigenous methodology and have dominated the literature on Indigenous research methods, they are not the only methods available for health research. There is a need for decolonizing and Indigenizing quantitative research methods, particularly in the discipline of epidemiology, to better address the public health needs of Indigenous populations who continue to face health inequities because of colonial systems, as well as inaccurate and incomplete data collection about themselves. For the last two decades, researchers in colonized countries have been calling for a specifically Indigenous approach to epidemiology that recognizes the limits of Western epidemiological methods, incorporates more Indigenous research methodologies and community-based participatory research methods, builds capacity by training more Indigenous epidemiologists, and supports Indigenous self-determination. Indigenous epidemiology can include a variety of approaches, including: shifting standards, such as age standardization, according to Indigenous populations to give appropriate weight to their experiences; carefully setting recruitment targets and using appropriate recruitment methods to fulfill statistical standards for stratification; acting as a bridge between Indigenous and Western technoscientific perspectives; developing culturally appropriate data collection tools; and developing distinct epidemiological methods based on Indigenous knowledge systems. This paper explores how decolonization and Indigenization of epidemiology has been operationalized in recent Canadian studies and projects, including the First Nations Regional Longitudinal Health Survey and how this decolonization and Indigenization might be augmented with the capacity-building of the future Our Health Counts Applied Indigenous Epidemiology, Health Information, and Health Services and Program Evaluation Training and Mentorship Program in Canada.

A systematic review of electronic mental health interventions for Indigenous youth: Results and recommendations.

Electronic health interventions involve health services delivered using the Internet and related communication technologies. These services can be particularly relevant for Indigenous populations who often have differential access to health-care services compared to general populations, especially within rural and remote areas. As the popularity of electronic health interventions grows, there is an increased need for evidence-based recommendations for the effective use of these technologies. The current study is a systematic review of peer-reviewed and available grey literature with the aim of understanding outcomes of electronic health interventions for mental health concerns among Indigenous people. Studies used electronic health technologies for substance use treatment or prevention, suicide prevention, parenting supports, goal setting and behaviour change and consultation services. Various technological platforms were used across interventions, with both novel and adapted intervention development. Most studies provided qualitative results, with fewer studies focusing on quantitative outcomes. Some preliminary results from the engagement of Indigenous individuals with electronic health services has been demonstrated, but further research is needed to confirm these results. Identified barriers and facilitators are identified from the reviewed literature. Recommendations for future development of electronic health interventions for Indigenous youth are provided.

Insiders' Insight: Discrimination against Indigenous Peoples through the Eyes of Health Care Professionals.

Discrimination in the health care system has a direct negative impact on health and wellbeing. Experiences of discrimination are considered a root cause for the health inequalities that exist among Indigenous peoples. Experiences of discrimination are commonplace, with patients noting abusive treatment, stereotyping, and a lack of quality in the care provided, which discourage Indigenous people from accessing care. This research project examined the perspectives of health care providers and decision-makers to identify what challenges they see facing Indigenous patients and families when accessing health services in a large city in southern Ontario. Discrimination against Indigenous people was identified as major challenges by respondents, noting that it is widespread. This paper discusses the three key discrimination subthemes that were identified, including an unwelcoming environment, stereotyping and stigma, and practice informed by racism. These findings point to the conclusion that in order to improve health care access for Indigenous peoples, we need to go beyond simply making health services more welcoming and inclusive. Practice norms shaped by biases informed by discrimination against Indigenous people are widespread and compromise standards of care. Therefore, the problem needs to be addressed throughout the health care system as part of a quality improvement strategy. This will require not only a significant shift in the attitudes, knowledge, and skills of health care providers, but also the establishment of accountabilities for health care organizations to ensure equitable health services for Indigenous peoples.