PIECES of My RELATIONSHIPS: The Cultural Adaptation of a Biographical Assessment Tool for Indigenous Older Adults in Canada.

BACKGROUND AND OBJECTIVES: Healthcare services are rarely designed to meet the needs of Indigenous people, resulting in culturally unsafe care and assessment tools. This paper describes a collaboration between North East Behavioural Supports Ontario (NEBSO), university researchers, and Indigenous communities to adapt a biographical assessment tool used by NEBSO to be culturally appropriate and safe for Indigenous older adults (55+) in long-term care facilities in Ontario, Canada. RESEARCH DESIGN AND METHODS: Over 36 months, this project applied an Indigenized, community-based participatory research (CBPR) and cultural safety framework to the adaptation process. Qualitative data sources include the guidance of an Indigenous Elder, an Anishinaabe Language Expert Group, and focus groups conducted along the North Shore of Lake Huron, Sudbury, and Cochrane, Ontario. RESULTS: The adapted tool shifts the focus from personhood to relationships, includes culturally relevant domains, and supports trauma-informed approaches. Five themes were identified during the adaptation process: (1) practicing a relational approach to care, (2) valuing Indigenous language, (3) understanding Indigenous trauma, (4) respecting cultural values and understandings, and (5) addressing systemic barriers to culturally safe care. DISCUSSION AND IMPLICATIONS: Themes elucidated from this research process can inform future studies adapting mainstream practice tools and developing new tools for Indigenous populations. The collaboration and approach to this adaptation process demonstrated how cultural safety at systemic and practice levels can be addressed through CPBR partnerships between universities, organizations, and Indigenous communities. Findings support the need to evaluate the cultural safety of other assessments for older Indigenous adults in health care settings.

The MN RIDE pilot: feasibility of a synchronous, remotely delivered, aerobic exercise training program for rural-dwelling adults with subjective cognitive decline.

INTRODUCTION: Out of all the modifiable risk factors for Alzheimer's disease and related dementias (ADRD), physical inactivity is the strongest. Rural residents have an increased risk for dementia and face significant barriers to accessing ADRD information, caregiving support, and memory-related services, which contributes to substandard care. Rural communities have greater barriers to participating in physical activity, and in particular exercise, due to lack of social support, travel/weather problems, and lack of facilities/equipment. The purpose of this pilot study was to implement and evaluate the feasibility and safety of a synchronous, remotely delivered, aerobic exercise (AEx) telerehabilitation program in persons with subjective cognitive decline (SCD) living in rural areas. METHODS: The Minnesota Rehabilitation Intervention for Dementia Evasion for rural residents (MN RIDE) pilot study was one of five pilot studies conducted through the Center for Community Engaged Rural Dementia and Alzheimer's Research, conducted in collaboration with the Memory Keepers Medical Discovery Team. The Memory Keepers Medical Discovery Team employs a community-based participatory research model and uses a community advisory group, community-based researchers and a rural community engagement specialist to ensure research studies are aligned with rural community needs and to facilitate the recruitment of participants living in rural northern Minnesota. The MN RIDE study employed a single group, pretest-post-test design to test the feasibility and safety of an AEx-focused synchronous telerehabilitation program in rural-living middle-aged or older adults (>45 years) with SCD (indicated by answering yes to both, 'Do you perceive memory or cognitive difficulties?' and 'In the last two years, has your cognition or memory declined?'). All 36 AEx sessions (conducted over 12 weeks) were supervised remotely via smart devices and Zoom. The AEx program was classified as moderate intensity stationary cycling starting at a rating of perceived exertion (RPE) 11-12 or for 30-35 minutes in session 1, and was alternatively increased by 1-point RPE or 5-minute increments as tolerated up to RPE 12-14 for 50 minutes a session over time (by session 18). Secondarily, moderate intensity was defined as achieving an exercise heart rate of 64-76% of age-predicted maximum heart rate (HRmax). Feasibility and safety outcomes were assessed by session attendance, intensity adherence, presence of adverse events, and participant satisfaction. RESULTS: The average age of the study sample (n=9) was 57.44±7.16 years (average age of SCD onset 53.44±7.47 years) with 14.00±5.57 years of education and 88.9% female. All patients completed the study, resulting in a dropout rate of 0%. Out of the possible 324 sessions scheduled, 276 were attended (85% session adherence). Average intensity metrics achieved over the AEx sessions were RPE 13.2±0.5 and HRmax 72.0±7.9%, which both represent of moderate intensity AEx metrics. No adverse events were reported. CONCLUSION: This pilot study further provides the first evidence of preliminary feasibility of synchronous audiovisual, telerehabilitation programs delivered to rural residents at risk for ADRD. Thus, exercise telerehabilitation programs that focus on AEx could be viable and useful tools to overcome situations with limited access to healthcare services such as in rural communities. Further controlled studies with greater sample size could help further expand our results.

Rural health disparities in health care utilization for dementia in Minnesota.

PURPOSE: We visualized rural-urban differences in inpatient hospitalization and emergency department (ED) health care utilization (HCU) for older adults with dementia to understand the HCU of rural versus urban older adults in Minnesota and to examine in greater detail the variability of HCU in rural areas. METHODS: For 3 older adult age groups, we utilized Healthcare Cost and Utilization Project (H-CUP) datasets from 2016 to 2018 to profile hospital admission rates, and ED visit rates related to dementia stratified by rurality and regions. Rates were visualized by spatial interpolation method. We then used logistic regression analysis adjusted by multiple covariates to evaluate rural-urban differences of the chance of having a dementia diagnosis in HCU. FINDINGS: Minnesota rural areas showed 17.6% lower age-adjusted rate (AAR) of dementia mortality than urban areas. AARs of ED visits for dementia were 12.4% higher in rural ZIP codes, whereas AARs of hospitalization were 24.7% lower. After controlling for neighborhood-level risk factors, such as income, education, health behaviors, and provider access, the odds ratios of having dementia diagnosis are 12% lower if an ED visit patient lives in rural as opposed to an urban area (OR = 0.88, P<.0001). CONCLUSIONS: In comparison to AAR, the fully adjusted data showed larger rural-urban predictors of having dementia diagnoses in hospitalizations and ED utilizations and demonstrated differences between AAR of ED visit and odds ratios of having dementia diagnosis. A regional comparison revealed that dementia ED visits were higher for Northeast MN compared to Minnesota's largest metropolitan region.

Training Indigenous Community Researchers for Community-Based Participatory Ethnographic Dementia Research: A Second-Generation Model.

Conducting community-based participatory research (CBPR) is a complex endeavor, particularly when training non-academic community members. Though examples of CBPR training programs and protocols have been published, they often address a limited set of concepts and are tailored for university or medical school students. Here, we describe the process of developing an online CBPR training program for American Indian (United States) and Indigenous (Canada) community members to conduct multi-sited ethnographic dementia research. This program is unique in its breadth and depth, as our program covers CBPR theory, methods, practical research, and administrative skills. Significantly, this program centers Indigenous methodology, pedagogy, and processes such as two-eyed seeing, storywork, and decolonization approaches. Key to this training program is a "second-generation" approach which incorporates experiential knowledge from prior community-based researchers and academic partners and is designed to develop CBPR capacity among community-based researchers and partnering communities. In this paper, we detail the experience of the first cohort of learners and subsequent improvement of the training materials. Unique challenges related to the specific research focus (dementia care pathway), population/setting (American Indian and Indigenous communities), and technology (rural digital infrastructure) are also discussed.

Wellness in the Face of Frailty Among Older Adults in First Nations Communities.

OBJECTIVES: First Nations people report high levels of wellness despite high rates of chronic illness. Our goal was to understand the factors associated with wellness among First Nations adults in Ontario who were considered frail. METHODS: Using the First Nations Regional Health Survey, we created a profile of First Nations adults (aged 45+) who were categorized as "frail" (weighted sample size = 8121). We used multivariate logistic regression to determine associations between wellness (as measured by self-reported physical, emotional, mental, and spiritual balance) and determinants of health. RESULTS: Rates of reported wellness were high among those who were frail, ranging from 56.7% reporting physical balance to 71.6% reporting mental balance. Three key elements were associated with wellness: the availability of resources, individual lifestyle factors, and cultural connection and identity. DISCUSSION: Our findings provide a profile of strength and wellness among older First Nations adults living with frailty.

Practitioner Experience With Mistreated Older Adults Who Have Dementia: Understanding Contextual Influences and Consequences.

Studies of mistreatment of older adults have revealed alarmingly higher prevalence rates of mistreatment of those who have dementia. When the mistreatment occurs within the context of the home and is perpetrated by a family caregiver, it may remain hidden and only be discovered by the health and social service practitioners who have access to the home. Understanding the contexts within which this mistreatment occurs, and the influence of these contexts on the experience of these practitioners as well as on the resulting outcomes for mistreated older adults, has received little attention in the literature. This qualitative study, framed by critical social theory, aimed to answer the following research question: What are the contextual influences on practitioner experience with mistreatment of older adults with dementia by a caregiver within the home? Specifically, this study explored contextual influences within a Canadian province, where there is neither specific adult protective legislation nor infrastructure when mistreatment occurs within the home. Data were collected via semi-structured interviews, journals, and focus groups with 51 practitioners from various disciplines providing services to mistreated older adults with dementia in their homes. Theoretical thematic analysis led to the discovery of five contextual themes influencing the experience: the privileged burden of seeing behind closed doors; a domestic problem within a societal context; interprofessional challenges; a history of stagnation, losses, and systems failure; and a legislative complexity and oppression. Understanding these contextual influences is crucial to supporting practitioners, who, although entrusted to protect mistreated older adults, describe powerlessness within current contexts. This understanding is needed to improve outcomes for mistreated older adults with dementia.

Canadian Indigenous Cognitive Assessment (CICA): Inter-rater reliability and criterion validity in Anishinaabe communities on Manitoulin Island, Canada.

INTRODUCTION: Despite increasing dementia rates, few culturally informed cognitive assessment tools exist for Indigenous populations. The Canadian Indigenous Cognitive Assessment (CICA) was adapted with First Nations on Manitoulin Island, Canada, and provides a brief, multi-domain cognitive assessment in English and Anishinaabemowin. METHODS: Using community-based participatory research (CBPR) methods, we assessed the CICA for inter-rater and test-retest reliability in 15 individuals. We subsequently evaluated validity and established meaningful CICA cut-off scores in 55 individuals assessed by a geriatrician. RESULTS: The CICA demonstrated strong reliability (intra-class coefficient = 0.95 [0.85,0.98]). The area under the curve (AUC) was 0.98 (0.94, 1.00), and the ideal cut-point to identify likely cases of dementia was a score of less than or equal to 34 with sensitivity of 100% and specificity of 85%. DISCUSSION: When used with older First Nations men and women living in First Nations communities, the CICA offers a culturally safe, reliable, and valid assessment to support dementia case-finding.

Understanding Aging, Frailty, and Resilience in Ontario First Nations.

Following Canadian estimates of frailty, academic researchers and the Chiefs of Ontario came together to create the first Ontario-wide profile of aging in First Nations people in Ontario. Using self-reported data from First Nations adults who participated in the Ontario First Nations Regional Health Survey Phase 2, we found that First Nations people in Ontario experience higher rates of frailty than the general Canadian population and early onset frailty appears to affect First Nations communities. This is important to consider as communities plan for health care needs of an aging population and is particularly relevant in the face of Covid-19, as we know severity is exacerbated by underlying health conditions.

Practitioner Empowerment, Older Adult Mistreatment, and Dementia.

Although some studies have revealed practitioner disempowerment in cases of older adult mistreatment, this experience is poorly understood. In addition, dementia and contextual influences further complicate cases; yet,  little is known about the experience of practitioners with this complexity. This critical inquiry, based on Critical social theory, critical consciousness, and professional agency, aimed to address these gaps. Fifty-one practitioners from diverse health care and social service disciplines from rural and urban communities in Northeastern Ontario participated in interviews, journals, and focus groups. Analysis of data revealed the need for empowerment within a perpetual cycle of non-resolution, to refocus on legal clarity and intervention versus the current legal complexity and education focus, and to develop adequate infrastructure to support interprofessional efforts. The infusion of this knowledge into policy, practice, and research has great potential to improve outcomes for older adults with dementia who are mistreated in their homes.

Alzheimer's Disease and Related Dementia in Indigenous Populations: A Systematic Review of Risk Factors.

BACKGROUND: There remains a lack of information and understanding of the prevalence and incidence of Alzheimer's disease and related dementia in Indigenous populations. Little evidence available suggests that Indigenous peoples may have disproportionately high rates of Alzheimer's disease and related dementia (ADRD). OBJECTIVE: Given this information, this study systematically explores what risk factors may be associated with ADRD in Indigenous populations. METHODS: A search of all published literature was conducted in October 2016, March 2018, and July 2019 using Medline, Embase, and PsychINFO. Subject headings explored were inclusive of all terms related to Indigenous persons, dementia, and risk. All relevant words, phrases, and combinations were used. To be included in this systematic review, articles had to display an association of a risk factor and ADRD. Only studies that reported a quantifiable measure of risk, involved human subjects, and were published in English were included. RESULTS: Of 237 articles originally identified through database searches, 45 were duplicates and 179 did not meet a priori inclusion criteria, resulting in 13 studies eligible for inclusion in this systematic review. CONCLUSION: The large number of potentially modifiable risk factors reported relative to non-modifiable risk factors illustrates the importance of socioeconomic context in the pathogenesis of ADRD in Indigenous populations. The tendency to prioritize genetic over social explanations when encountering disproportionately high disease rates in Indigenous populations can distract from modifiable proximal, intermediate, and distal determinants of health.

Peace of mind: A community-industry-academic partnership to adapt dementia technology for Anishinaabe communities on Manitoulin Island.

INTRODUCTION: Aging Technologies for Indigenous Communities in Ontario (ATICON) explores the technology needs of Anishinaabe older adults in the Manitoulin region of Northern Ontario. Our program of research addresses inequitable access to supportive technologies that may allow Indigenous older adults to successfully age in place. METHODS: Using Indigenous research methodologies (IRM) and community-based participatory research (CBPR) we explored the acceptability of CareBand - a wearable location and activity monitoring device for people living with dementia using a LoRaWAN, a low-power wide-area network technology. We conducted key informant consultations and focus groups with Anishinaabe Elders, formal and informal caregivers, and health care providers (n = 29) in four geographically distinct regions. RESULTS: Overall, participants agreed that CareBand would improve caregivers' peace of mind. Our results suggest refinement of the technology is necessary to address the challenges of the rural geography and winter weather; to reconsider aesthetics; address privacy and access; and to consider the unique characteristics of Anishinaabe culture and reserve life. CONCLUSION: All three partners in this research, including the Indigenous communities, industry partner, and academic researchers, benefited from the use of CBPR and IRM. As CareBand is further developed, community input will be crucial for shaping a useful and valued device.

Developing the Canadian Indigenous Cognitive Assessment for Use With Indigenous Older Anishinaabe Adults in Ontario, Canada.

BACKGROUND AND OBJECTIVES: Dementia is a growing public health issue for aging Indigenous populations. Current cognitive assessments present varying degrees of cultural, educational, and language bias, impairing their application in Indigenous communities. Our goal is to provide Anishinaabe communities in Canada with a brief cognitive test that can be administered within the community setting by community health workers or professionals. The purpose of this study was to adapt the Kimberly Indigenous Cognitive Assessment (KICA) for use as a brief cognitive test with Anishinaabe populations in Canada. RESEARCH DESIGN AND METHODS: We used a community-based participatory research approach coupled with two-eyed seeing to provide an equitable space for Indigenous knowledge. Adaptation of the KICA was accomplished over 22 months using an iterative cycle of monthly consultations between an 11-member expert Anishinaabe language group (EALG) and the investigators, with ad hoc consultations with an Indigenous Elder, a community advisory council, and the KICA authors. Face validity was established with two pilot studies using cognitive interviewing with Indigenous older adults (n = 15) and a focus group consultation with local health professionals (n = 7). RESULTS: Each question of the KICA was scrutinized by the EALG for cultural appropriateness, language and translation, and cultural safety. Every domain required adaptation to reflect cultural values, specificity of language, tone, and a culturally safe approach. Orientation, verbal comprehension and fluency, praxis, and naming domains required the most adaptations. The first pilot for face validity resulted in additional changes; the second confirmed satisfactory adaptation of all changes. DISCUSSION AND IMPLICATIONS: The research resulted in the new Canadian Indigenous Cognitive Assessment. The findings reveal important cultural and linguistic considerations for cross-cultural cognitive assessment in Indigenous contexts. This new culturally appropriate and safe brief cognitive test may improve case finding accuracy and lead to earlier diagnosis and improved dementia care for Indigenous peoples.

Obesity in adults: a clinical practice guideline

Obesity is a complex chronic disease in which abnormal or excess body fat (adiposity) impairs health, increases the risk of long-term medical complications and reduces lifespan.1 Epidemiologic studies define obesity using the body mass index (BMI; weight/height2), which can stratify obesity-related health risks at the population level. Obesity is operationally defined as a BMI exceeding 30 kg/m2 and is subclassified into class 1 (30­34.9), class 2 (35­39.9) and class 3 (≥ 40). At the population level, health complications from excess body fat increase as BMI increases.2 At the individual level, complications occur because of excess adiposity, location and distribution of adiposity and many other factors, including environmental, genetic, biologic and socioeconomic factors.

Obesity management and indigenous peoples

Exploring obesity within the context of multiple co-occurring health, socioeconomic, environmental and cultural factors, and situating these within policy/jurisdictional structures specific to Indigenous populations (e.g., federal versus provincial health funding), can facilitate emerging opportunities for obesity management. These contexts highlight a tension that providers must navigate, between drivers of obesity embedded in social- and system-level inequities and protective factors that promote healing through relationships and culturally contextualized approaches to care. Healthcare professionals should consider the following contextual factors when providing obesity care for Indigenous peoples: Structural inequities (i.e., social and systemic in origin) are embedded in health, education, social services and other systems, and they maintain social disadvantage for a large segment of the Indigenous population. These inequities influence food security, for example, through lower wages perpetuated by inaccessible education and high food costs in urban and remote areas, or through limited access to activity-based resources at individual and community levels. Indigenous people have experienced systemic disadvantage throughout their lifespan and those of their family members, producing a cumulative effect on obesity. In Indigenous contexts, obesity is therefore deeply affected by responses to pervasive stressors, as individuals navigate social and systemic barriers to meeting their goals. Overwhelming stress from social (e.g., discrimination) and systemic exclusion (e.g., poor or absent primary healthcare) can disempower Indigenous people in maintaining healthy behaviours. Patients may appear to be resistant to healthcare recommendations, where together with healthcare providers they may come to feel fatalistic toward their capacity to address obesity. Healthcare professionals often interpret such patient incongruity with recommendations in a deficit lens, labeling it as patient non-compliance or non-adherence. This non-concordance, or seeming apathy, may actually be a sense of paralysis in the face of overwhelming stress. Exploration of the patient's social reality can open opportunities for contextualized approaches to obesity management. Reflection on assumptions about seeming apathy may contextualize patient motivations, where deep exploration of one's own perceptions, attitudes and behaviours toward Indigenous patients may uncover anti-Indigenous sentiment implicit in healthcare practices or systems. Validation of a patient's experiences of inequity can empower both patients and providers to identify steps to address social factors that influence health behaviours. Culture and relationships facilitate learning of complex knowledge. The interaction of obesity with co-occurring structural factors represents complex knowledge that is critical for patients to gain deep understanding of their health. Non-Indigenous healthcare providers may have ways of knowing and doing that are inconsistent with Indigenous patient perspectives on health knowledge and how it should be exchanged. Obesity management in this context requires a longitudinal, relationship-centred approach that engages and explores interactions with co-existing factors to build both knowledge and trust, in a manner aligned with Indigenous principles for communication. Connection: When patients connect with healthcare providers around their co-occurring health needs, there are complex linkages between wider structures and their health. The therapeutic relationship may be critically supportive when knowledge is delivered in a relevant way and makes sense to the patient. Trust-building: Healing of the therapeutic relationship is itself fundamental to engaging and supporting patients within contexts of multi-generational trauma to explore complex intersections in relation to health and health behaviour change. Differing worldviews: Western concepts of healthy behaviours related to obesity management, including preferences for body size, activity and food, may be dis­cordant with Indigenous perspectives. Patients may not identify with provider perspectives, and providers must not assume that patients share provider worldviews or principles around how to communicate health knowl­edge. Discordant perspectives may involve a distinct sense of locus of control, self-efficacy and modes for speaking about the pathways into and out of obesity. An Indigenous approach to knowledge exchange in­cludes contextualizing knowledge within the world of the patient and employing a narrative-based and indi­rect approach to sharing knowledge.

Use of the health care system by Ontario First Nations people with diabetes: a population-based study.

BACKGROUND: First Nations people in Ontario have an increased prevalence of diabetes compared to other people in the province. This study examined use of health care services by First Nations people with diabetes and other people with diabetes in Ontario. METHODS: Using linked health administrative databases, we identified all people in Ontario with diabetes as of Apr. 1, 2014. We identified First Nations people using the Indian Register. We looked at outcomes from Apr. 1, 2014, to Mar. 31, 2015. We determined the proportion of people with a regular family physician and their continuity of care with that physician. We also examined visits with specialists for diabetes care, hospital admissions for ambulatory-care-sensitive conditions, and emergency department visits for hypo- or hyperglycemia. RESULTS: There were 1 380 529 people diagnosed with diabetes in Ontario as of Apr. 1, 2014, of whom 22 952 (1.7%) were First Nations people. First Nations people were less likely to have a regular family physician (85.3% v. 97.7%) and had lower continuity of care with that physician (mean score for continuity of care 74.6 v. 77.7) than other people in Ontario. They were also less likely to see specialists. First Nations people were more likely to be admitted to hospital for ambulatory-care-sensitive conditions (2.4% v. 1.2%) and to have an emergency department visit for hypo- or hyperglycemia (1.5% v. 0.8%). Disparities were particularly marked for those living in First Nations communities. INTERPRETATION: First Nations people with diabetes in Ontario had poorer access to and use of primary care than other people with diabetes in the province. These findings may help explain continued disparities in the rates of complications related to diabetes.

Nurturing Meaningful Intergenerational Social Engagements to Support Healthy Brain Aging for Anishinaabe Older Adults.

The emergence of Alzheimer's disease and related dementias (ADRD) in Indigenous populations across Canada is of rising concern, as prevalence rates continue to exceed those of non-Indigenous populations. The Intergenerativity Model, guided by Indigenous Ways of Knowing, nurtures a psychosocial approach to promoting healthy brain aging and quality of life. Community-based participatory action methods led by interviews, focus groups, and program observations aid in identifying the barriers to and facilitators of success for intergenerational social engagements in the Anishinaabe community of Wiikwemkoong in northwestern Ontario. A qualitative thematic analysis guides future recommendations for programming opportunities that foster traditional roles of older First Nation adults and support intergenerational relationships. The results of this project elicit culturally appropriate recommendations for community-driven supports that address healthy brain aging. These outcomes are relevant to other Indigenous communities as the framework for determining that culturally appropriate health supports can be adapted to the unique context of many communities.

Hospital admission for stroke or transient ischemic attack among First Nations people with diabetes in Ontario: a population-based cohort study.

BACKGROUND: First Nations people have high rates of diabetes mellitus, which is a risk factor for stroke. We studied the rates of hospital admission, processes of care and outcomes of stroke and transient ischemic attack (TIA) in First Nations people in Ontario. METHODS: Using linked administrative databases, we identified annual cohorts of people aged 20-105 years in Ontario with prevalent diabetes between Apr. 1, 1995, and Mar. 31, 2015. We identified Status First Nations people in Ontario from the Indian Register. We compared age- and sex-standardized rates of hospital admission for stroke or TIA, processes of care and case fatality among First Nations versus other people in Ontario with diabetes. RESULTS: Overall, 28 874 people with diabetes (of whom 536 were First Nations people) were admitted to hospital with a stroke or TIA between Apr. 1, 2011, and Mar. 31, 2016. Admission rates for stroke or TIA declined over the study period but were higher among First Nations people than other Ontarians in most years after 2005/06. First Nations people admitted with stroke or TIA were as likely as other Ontarians to undergo neuroimaging within 24 hours (94.6% v. 96.0%), be discharged to inpatient rehabilitation (31.8% v. 34.8%) and receive carotid revascularization (1.4% v. 2.7%), but were less likely to receive thrombolysis (6.3% v. 11.0%). Age- and sex-standardized stroke case fatality was similar in First Nations people and other Ontarians at 7 days (12.0% v. 8.5%), 30 days (19.2% v. 16.0%) and 1 year (33.8% v. 28.1%). INTERPRETATION: Rates of hospital admission for stroke or TIA were higher among First Nations people than other people with diabetes in Ontario. Future work should focus on determining Indigenous-specific determinants of health related to this disparity and implementing appropriate interventions to mitigate the risks and sequelae of stroke in First Nations people.

Diabetes during pregnancy and perinatal outcomes among First Nations women in Ontario, 2002/03-2014/15: a population-based cohort study.

BACKGROUND: In Canada, increasing numbers of women, especially First Nations women, are affected by diabetes during pregnancy, which is a major risk factor for adverse maternal and neonatal outcomes. The aim of this study was to examine temporal trends in pregnancy outcomes and use of health care services in a population-based cohort of First Nations women compared to other women in Ontario according to diabetes status during pregnancy. METHODS: Using health administrative databases, we created annual cohorts of pregnant women from 2002/03 to 2014/15 and identified those with preexisting diabetes and gestational diabetes. We used the Indian Register to identify First Nations women. We estimated rates of adverse maternal and infant outcomes, and measures of use of health care services in each population. RESULTS: There were 1 671 337 deliveries among 1 065 950 women during the study period; of these deliveries, 31 417 (1.9%) were in First Nations women, and 1 639 920 (98.1%) were in other women. First Nations women had a higher prevalence of preexisting diabetes and gestational diabetes than other women in Ontario. First Nations women with preexisting diabetes had higher rates of preeclampsia (3.2%-5.6%), labour induction (33.4%-42.9%) and cesarean delivery (47.8%-53.7%) than other women in Ontario, as did First Nations women with gestational diabetes (3.2%-4.7%, 38.5%-46.9% and 41.4%-43.4%, respectively). The rate of preterm birth was similar between First Nations women and other women in Ontario. Although First Nations women had a higher rate of babies who were large for gestational age than other women, regardless of diabetes status, obstructed labour rates were similar for the 2 cohorts. Almost all First Nations women, regardless of diabetes status, were seen by a primary care provider during their pregnancy, but rates of use of specialty care were lower for First Nations women than for other women. Fifteen percent of all pregnant women with preexisting diabetes visited an ophthalmologist during their pregnancy. INTERPRETATION: Our results confirm disparities in maternal and neonatal outcomes between First Nations women and other women in Ontario. Access to primary care for pregnant women seemed adequate, but access to specialized care, especially for women with preexisting diabetes, needs to improve.