The north is not all the same: comparing health system performance in 18 northern regions of Canada.

We investigated the availability of health system performance indicator data in Canada's 18 northern regions and the feasibility of using the performance framework developed by the Canadian Institute for Health Information [CIHI]. We examined the variation in 24 indicators across regions and factors that might explain such variation. The 18 regions vary in population size and various measures of socioeconomic status, health-care delivery, and health status. The worst performing health systems generally include Nunavut and the northern regions of Québec, Manitoba and Saskatchewan where indigenous people constitute the overwhelming majority of the population, ranging from 70% to 90%, and where they also fare worst in terms of adverse social determinants. All northern regions perform worse than Canada nationally in hospitalisations for ambulatory care sensitive conditions and potentially avoidable mortality. Population size, socioeconomic status, degree of urbanisation and proportion of Aboriginal people in the population are all associated with performance. The North is far from homogenous. Inter-regional variation demands further investigation. The more intermediate pathways, especially between health system inputs, outputs and outcomes, are largely unexplored. Improvement of health system performance for northern and remote regions will require the engagement of indigenous leadership, communities and patient representatives.

Assessing health care in Canada's North: what can we learn from national and regional surveys?

BACKGROUND: Health surveys are a rich source of information on a variety of health issues, including health care. OBJECTIVES: This article compares various national and regional surveys in terms of their geographical coverage with respect to the Canadian North, especially their Aboriginal population, and the comparability of the survey contents relating to health care. METHODS: Three surveys were selected as providing some information on health care, with separate estimates for the North and its Aboriginal populations. They are the Canadian Community Health Survey (CCHS), Aboriginal Peoples Survey (APS) and the First Nations Regional Health Survey (RHS). RESULTS: Different surveys focus on different categories of Aboriginal people, and no single survey has covered all categories of Aboriginal people in the North consistently. RHS is targeted at the on-reserve First Nations population only. APS and CCHS sample the off-reserve First Nations population as well as Métis and Inuit. To achieve adequate sample size for North-South comparisons and comparisons among Aboriginal groups within the North, several cycles of the biennial/annual CCHS can be merged, producing a large data set with consistent coverage of topics using comparable questions. The content areas of the 3 surveys can be broadly categorized as health status, health determinants and health care. Substantial variation exists across surveys in the domains covered. There are also changes over time in terms of definitions, questions and even basic concepts. The available health care content of the 3 surveys focus on access to different types of health services, contact with different categories of health professionals, unmet health needs and the use of preventive services. Many important dimensions of health care are not covered. Not all these basic indicators are available for the North or its Aboriginal populations. CONCLUSIONS: A comprehensive survey of health care in the North with sufficient sample size to provide reliable estimates for its subpopulations - urban and remote, Aboriginal and non-Aboriginal, and First Nations, Inuit and Métis - would provide useful information to decision-makers and service providers. Analytical studies can also be conducted to investigate the correlations and interactions among health status, health determinants and health care and assess whether such relationships differ among the different population groups.

Household Food Insecurity Is a Stronger Marker of Adequacy of Nutrient Intakes among Canadian Compared to American Youth and Adults.

BACKGROUND: The most recent statistics indicate that the prevalence of food insecurity in the United States is double that in Canada, but the extent to which the nutrition implications of this problem differ between the countries is not known. OBJECTIVE: This study was undertaken to compare adequacy of nutrient intakes in relation to household food insecurity among youth and adults in Canada and the United States. METHODS: Data from comparable nationally representative surveys, the 2004 Canadian Community Health Survey and the 2003-2006 NHANES, were used to estimate prevalences of inadequate intakes of vitamins A and C, folate, calcium, magnesium, and zinc among youth and adults in food-secure and food-insecure households. Potential differences in the composition of the populations between the 2 countries were addressed by using standardization, and analyses also accounted for participation in food and nutrition assistance programs in the United States. RESULTS: Larger gaps in the prevalences of inadequate intakes between those in food-secure and food-insecure households were observed in Canada than in the United States for calcium and magnesium. For calcium, the prevalences of inadequate intakes among those in food-secure and food-insecure households in Canada were 50% and 66%, respectively, compared with 50% and 51%, respectively, in the United States. For magnesium, the prevalences of inadequate intakes in Canada were 39% and 60% among those in food-secure and food-insecure households, respectively, compared with 60% and 61%, respectively, in the United States. These findings were largely unchanged after we accounted for participation in food and nutrition assistance programs in the United States. CONCLUSIONS: This study suggests that household food insecurity is a stronger marker of nutritional vulnerability in Canada than in the United States. The results highlight the need for research to elucidate the effects of domestic policies affecting factors such as food prices and fortification on the nutritional manifestations of food insecurity.

Divergent body mass index trajectories between Aboriginal and non-Aboriginal Canadians 1994-2009--an exploration of age, period, and cohort effects.

OBJECTIVES: Aboriginal Canadians have a high burden of obesity and obesity-related chronic conditions. Body mass index (BMI) trajectories from 1994 to 2009 were estimated for Aboriginal and non-Aboriginal Canadians using self-reported height and weight data from the National Population Health Survey to explore age, period, and cohort effects of BMI change. METHODS: Linear growth curve models were estimated for 311 Aboriginal and 10,967 non-Aboriginal respondents divided into five birth cohorts born in the 1940s, 50s, 60s, 70s, and 80s. RESULTS: Overall, Aboriginal Canadians experienced higher rates of BMI increase over the 14-year period. Rate of BMI increase was specifically higher for Aboriginal adults born in the 1960s and 1970s when compared with non-Aboriginal adults. At ages 25, 35, and 45, recent-born cohorts had consistently higher BMIs compared with earlier-born cohorts with magnitudes of differences typically larger in the Aboriginal population. Recent-born cohorts also exhibited steeper BMI trajectories. CONCLUSIONS: Cohort effects may be responsible for the divergent BMI trajectories between Aboriginal and non-Aboriginal Canadians born in the 1960s and 1970s. Aboriginal Canadians, particularly of more recent-born cohorts, experienced faster increases in BMI from 1994 to 2009 than non-Aboriginal Canadians, suggesting that prevalence of obesity will continue to rise in this population without intervention.

Socio-economic patterns of obesity among aboriginal and non-Aboriginal Canadians.

OBJECTIVES: Large disparities exist between Aboriginal and non-Aboriginal Canadians in both obesity and socio-economic status (SES). The purpose of this paper was to assess associations between obesity and three indicators of SES - employment, education and income - in conjunction with demographic and lifestyle factors. METHODS: Using the nationally-representative Canadian Community Health Survey (CCHS) cycle 2.2 (2004), among 334 off-reserve Aboriginal and 6,259 non-Aboriginal Canadians aged 25-64 years in the 10 provinces, obesity status was determined by body mass index derived from measured height and weight. Logistic regression was used to assess the relationships between socio-demographic variables and obesity status. RESULTS: Controlling for other socio-economic and lifestyle factors, odds for obesity were lower by 80% among Aboriginal men and 64% among Aboriginal women who were employed during the 12 months prior to the survey compared to Aboriginal men and women who were not employed. Employment was not significantly associated with obesity among non-Aboriginal adults. Probability for obesity increased as household income increased among Aboriginal men, but a negative association between income and obesity was observed among Aboriginal women. These associations persisted after adjustment for physical activity level, fruit and vegetable consumption, smoking, and marital status in the models. CONCLUSION: Unemployment among obese Aboriginal Canadians warrants attention. The knowledge that both high and low SES Aboriginal Canadians, of varying socio-demographic characteristics and lifestyle, experience high rates of obesity can lead to new hypotheses of how obesity develops in this population and influence how interventions are planned.

Associations of television viewing, physical activity and dietary behaviours with obesity in aboriginal and non-aboriginal Canadian youth.

OBJECTIVE: To determine associations of diet, physical activity and television (TV) viewing time with obesity among aboriginal and non-aboriginal youth in conjunction with socio-economic variables. DESIGN: Cross-sectional study of differences between aboriginal and non-aboriginal groups and associations between lifestyle and socio-economic factors with obesity were examined. SETTING: Population data from the Canadian Community Health Survey Cycle 2.2 conducted in 2004 in the ten provinces of Canada. SUBJECTS: A total of 198 aboriginal and 4448 non-aboriginal Canadian youth aged 12-17 years. RESULTS: Compared to non-aboriginal youth, physical activity participation among aboriginal youth was higher, but consumption of vegetables and dairy products was lower, and more aboriginal youth were 'high' TV watchers. Low income adequacy was associated with decreased odds for obesity among aboriginal youth in contrast to higher odds among non-aboriginal youth. Non-aboriginal 'high' TV watchers consumed more soft drinks and non-whole-grain products than did 'low' TV watchers. Physical activity participation did not differ between 'high' and 'low' TV watchers for both groups, and was associated with lowered odds for obesity only among aboriginal youth. CONCLUSIONS: Sociodemographic and lifestyle risk factors associated with obesity differ between aboriginal and non-aboriginal youth. These findings may be useful for guiding intervention efforts.

Central adiposity and associated lifestyle factors in Cree children.

Aboriginal children are prone to central adiposity (CA), a component of the metabolic syndrome. The objective of this study was to determine if lifestyle factors were associated with CA in Canadian Cree children. Children aged 9-12 years were classified as having CA if their waist circumference met or exceeded the 85th percentile of the NHANES III reference. Weight status was determined using the CDC growth reference, dietary intake using three 24 h dietary recalls, physical activity using pedometers, and fitness by completion of the 20 m shuttle run test. Of the 178 children (79% participation rate), 32.6% were normal weight, 23.6% were overweight, and 43.8% were obese. Half (52.2%) of the children had CA (97.4% of obese children, 35.7% of overweight children, and 2.2% of normal weight children). Waist circumference was negatively correlated with pedometer step counts (r = -0.187, p = 0.012) and shuttle run time (r = -0.508, p < 0.001). In children with CA, waist circumference was positively correlated with sweetened beverage intake (r = 0.250, p = 0.016). The odds ratio (adjusted for age and sex) for CA for children consuming 3 or more fruits and vegetables per day was 0.43 (95% CI 0.18 - 0.98), for meeting step recommendations for a healthy body weight was 0.45 (95% CI 0.24 - 0.84), and for relative fitness was 0.12 (95% CI 0.04 - 0.33). CA was prevalent in children who were overweight and obese. Preventive strategies might include promoting a healthy diet, physical activity, and fitness.

Cancer among the circumpolar Inuit, 1989-2003. I. Background and methods.

OBJECTIVES: This is first of 2 papers on the Circumpolar Inuit Cancer Review, an international collaborative effort involving researchers and health officials from Alaska, Canada and Greenland. It covers the period 1989-2003, updating the last review (1969-1988) and together provides an overview of the trends and patterns of cancer among the Inuit in 3 countries and over a 35-year period. METHODS: Inuit cancer cases by age-sex group and anatomic site were obtained from the regional cancer registries. The sources of the age-sex distribution of various Inuit populations include the population registry (Greenland), and annual estimates and periodic censuses (Alaska and Canada). Incidence rates were age-standardization by the direct method to the standard world population of the International Agency for Research on Cancer. CONCLUSIONS: This project demonstrates the feasibility of international partnerships in cancer surveillance, and when these partnerships are extended to other diseases and health conditions, they can contribute to the development of a Circumpolar Health Observatory.

Cancer among the circumpolar Inuit, 1989-2003. II. Patterns and trends.

OBJECTIVES: This is the second of 2 papers reporting on the result of the Circumpolar Inuit Cancer Review, an international collaborative effort involving researchers and health officials from Alaska, Canada and Greenland. METHODS: Inuit cancer cases by age-sex group and anatomic site were obtained from the regional cancer registries. RESULTS: Cancer in general is increasing among Inuit, in all regions, and among both men and women. Inuit continue to be at extreme high risk, relative to non-Inuit and to comparisons of global populations, for the historically recognized so-called traditional cancers (such as cancer of the nasopharynx and salivary glands). Among the so-called modern cancers prevalent in developed societies, lung cancer is rapidly increasing in incidence (especially in Canada), such that the rate in both Inuit men and women is the highest in the world; other cancers, such as colorectal cancer, are also on the rise (especially in Alaska), while breast and prostate cancer remain low relative to the non-Inuit population. The decline in cervical cancer is a positive development; in the 3 regions, the rate in Greenland is the highest. CONCLUSIONS: Data such as these can form the basis of interventions directed towards known risk factors such as smoking, diet, obesity, viral and bacterial infections, and low screening prevalence. Cancer surveillance is a basic task of the public health system; in the Arctic, it is particularly important as Inuit continue to undergo further changes in their life-styles and social environments.

Obesity, adiposity, physical fitness and activity levels in Cree children.

OBJECTIVES: To describe the levels of obesity, adiposity measures, physical activity and fitness in Cree children aged 9-12 years. STUDY DESIGN: Cross-sectional survey. METHODS: The study took place in northern Quebec, Canada. Height, body mass, waist circumference and five skinfold thicknesses were measured. Physical activity was assessed by having children wear a pedometer for two days. Children performed the 20-metre shuttle run test (SRT) to determine their physical fitness level. RESULTS: Of 82 participating children, 33% were overweight (but not obese) and 38% were obese according to an international reference. The mean sum of five skinfold measures exceeded the 95th percentile of Canadian children. Compared with the Third National Health and Nutrition Examination Survey, the majority of children exceeded the 85th percentile for waist circumference (62%) and at the suprailiac (80%), subscapular (72%), and triceps (54%) skinfold sites. 90% of children scored below the 20th percentile in the SRT compared with normative data from Quebec children. Based on pedometer scores, only 49% of children were sufficiently active. CONCLUSIONS: There is a high prevalence of overweight and central adiposity in this population, with low physical activity and fitness levels. This profile may result in adverse health outcomes.