Prevalence and Incidence of Rheumatoid Arthritis in Canadian First Nations and Non-First Nations People: A Population-Based Study.

BACKGROUND: The aim of this study was to determine the prevalence, incidence, and onset age at rheumatoid arthritis (RA) diagnosis in First Nations (FN) and non-FN populations in Manitoba, Canada. METHODS: Population-based administrative health records from April 1, 1995, to March 31, 2010, were accessed for all Manitobans. The FN population was identified using the Federal Indian Registry File. Crude and adjusted RA prevalence and incidence rates (adjusted for age, sex, health region of residence) were compared using Poisson regression and reported as relative rates (RRs) with 95% confidence intervals (CIs). Mean (CI) diagnosis age and physician visits were compared with Student t tests. RESULTS: Rheumatoid arthritis crude prevalence increased between 2000 and 2010 to 0.65%; adjusted RA prevalence in females was 1.0% and in males was 0.53%. The 2009/2010 adjusted RA prevalence was higher in FN than non-FN (RR, 2.55; CI, 2.08-3.12) particularly for ages 29 to 48 years (RR, 4.52; CI, 2.71-7.56). Between 2000 and 2010, crude RA incidence decreased from 46.7/100,000 to 13.4/100,000. Adjusted RA incidence remained higher in FN than non-FN (2000-2010 RR, 2.1; CI, 1.7-2.6; p < 0.0001) particularly for ages 29 to 48 years (RR, 4.6; CI, 2.8-7.4; p < 0.0001). The FN population was younger at diagnosis than the non-FN population (mean age, 39.6 years [CI, 38.3-40.8 years] vs. 53.3 years [CI, 52.7-53.9 years]; p < 0.0001). The FN population had more physician visits but fewer rheumatology visits than the non-FN population. CONCLUSIONS: Rheumatoid arthritis prevalence is increasing, and RA incidence is decreasing in Manitoba. The FN population has a greater prevalence and incidence of RA and is younger at diagnosis than the non-FN population. When combined with fewer rheumatology visits, this significant care gap highlights the need to optimize rheumatology care delivery to the FN population.

Health, Social, Education, and Justice Outcomes of Manitoba First Nations Children Diagnosed with Fetal Alcohol Spectrum Disorder: A Population-Based Cohort Study of Linked Administrative Data.

OBJECTIVE: To examine health services, social services, education, and justice system outcomes among First Nations children and youth with fetal alcohol spectrum disorder (FASD). METHODS: In this retrospective cohort study, health and social services, education, and justice data were linked with clinical records on First Nations (FN) individuals aged 1 to 25 and diagnosed with FASD between 1999 and 2010 (n = 743). We compared the FN FASD group to non-FN individuals with FASD (non-FN FASD; n = 315) and to First Nations individuals (matched on age, sex, and income) not diagnosed with FASD (FN non-FASD; n = 2229). Rates and relative risks (RRs) were calculated using generalized linear models. RESULTS: FN FASD individuals had similar health services use to non-FN FASD individuals but had greater involvement with child welfare (RR, 1.20; 95% confidence interval [CI], 1.02 to 1.41) and the justice system (RR, 1.37; 95% CI, 1.07 to 1.74) and were more likely to be charged with a crime (RR, 1.40; 95% CI, 1.05 to 1.86). There were no suicides/suicide attempts among the non-FN FASD individuals during the study, but the crude rate/100 person-years of suicides among FN FASD individuals (0.22 for females; 1.06 for males) was substantially higher than for FN non-FASD individuals (0.08 for females; 0.32 for males). There were no significant differences between groups in the education outcomes we measured. CONCLUSIONS: Young people with FASD are at risk for poor health, education, and social outcomes, but First Nations young people with FASD face comparably higher risks, particularly with child welfare and justice system involvement. The study emphasizes a critical need for appropriate resources for First Nations children with FASD.

Translating to the Community (T2C): a protocol paper describing the development of Canada's first social epigenetic FASD biobank.

Translating to the Community (T2C) is a social biorepository designed to advance new diagnostic tools and realign community-clinical processes, with the aim to mitigate the short- and long-term impacts of fetal alcohol spectrum disorder (FASD) as well as prenatal alcohol exposure and its co-morbidities and behaviors. In this paper, we describe the evolution of this repository as a new translational partnership to advance a precision-medicine approach to FASD. Key to its evolution was a partnership between academic researchers, Indigenous communities, families, and a regional diagnostic clinic. We further describe the rationale for social biobanking, the type of banking, ethical engagement of families, communities, and clinics, their roles in repository design, governance, translation, and research activities, types of data collected from families, and how the study data are managed, reported, and accessed. The repository design includes biological samples, social-contextual health-survey data, and clinical data (which are linkable to administrative data) from community and clinical cohorts of diagnosed children, children prenatally exposed but not diagnosed, children suspected to have had a prenatal exposure, and related siblings, biological parents, and unrelated children and their parents. From these cohorts and families, potential studies drawing on this data will shed light on various risk factors, social and biological pathways, and service utilization issues, with the aim to implement primary and secondary prevention and intervention strategies.

Mammography rates for breast cancer screening: a comparison of First Nations women and all other women living in Manitoba, Canada, 1999-2008.

INTRODUCTION: First Nations (FN) women historically have low rates of preventive care, including breast cancer screening. We describe the frequency of breast cancer screening among FN women living in Manitoba and all other Manitoba (AOM) women after the introduction of a provincial, organized breast screening program and explore how age, area of residence, and time period influenced breast cancer screening participation. METHODS: The federal Indian Registry was linked to 2 population-based, provincial data sources. A negative binomial model was used to compare breast cancer screening for FN women with screening for AOM women. RESULTS: From 1999 through 2008, 37% of FN and 59% of AOM women had a mammogram in the previous 2 years. Regardless of area of residence, FN women were less likely to have had a mammogram than AOM women (relative rate [RR] = 0.69 in the north, RR = 0.55 in the rural south, and RR = 0.53 in urban areas). CONCLUSIONS: FN women living in Manitoba had lower mammography rates than AOM women. To ensure equity for all Manitoba women, strategies that encourage FN women to participate in breast cancer screening should be promoted.

Gatekeeper training for suicide prevention in First Nations community members: a randomized controlled trial.

BACKGROUND: Gatekeeper training aims to train people to recognize and identify those who are at risk for suicide and assist them in getting care. Applied Suicide Intervention Skills Training (ASIST), a form of gatekeeper training, has been implemented around the world without a controlled evaluation. We hypothesized that participants in 2 days of ASIST gatekeeper training would have increased knowledge and preparedness to help people with suicidal ideation in comparison to participants who received a 2-day Resilience Retreat that did not focus on suicide awareness and intervention skills (control condition). METHODS: First Nations on reserve people in Northwestern Manitoba, aged 16 years and older, were recruited and randomized to two arms of the study. Self-reported measures were collected at three time points-immediately pre-, immediately post-, and 6 months post intervention. The primary outcome was the Suicide Intervention Response Inventory, a validated scale that assesses the capacity for individuals to intervene with suicidal behavior. Secondary outcomes included self-reported preparedness measures and gatekeeper behaviors. RESULTS: In comparison with the Resilience Retreat (n = 24), ASIST training (n = 31) was not associated with a significant impact on all outcomes of the study based on intention-to-treat analysis. There was a trend toward an increase in suicidal ideation among those who participated in the ASIST in comparison to those who were in the Resilience Retreat. CONCLUSIONS: The lack of efficacy of ASIST in a First Nations on-reserve sample is concerning in the context of widespread policies in Canada on the use of gatekeeper training in suicide prevention.

Familial clustering of the serum cytokine profile in the relatives of rheumatoid arthritis patients.

OBJECTIVE: Rheumatoid arthritis (RA) is prevalent in North American Native populations, with a high frequency of multicase families and seropositivity in first-degree relatives. This study was undertaken to determine whether the serum cytokine profile of first-degree relatives of North American Native patients with RA differed from that of individuals with no family history of autoimmunity and whether there was an association with RA autoantibodies. METHODS: North American Native patients with RA (n = 105), their first-degree relatives (n = 273), healthy North American Native controls (n = 200), and Caucasian controls (n = 150) were studied. Serum levels of 42 cytokines were tested using a multiplex laser bead assay. Rheumatoid factor (RF), anti-cyclic citrullinated peptide 2 (anti-CCP-2), monocyte chemotactic protein 1 (MCP-l), and high-sensitivity C-reactive protein (hsCRP) were tested by enzyme-linked immunosorbent assay, and HLA-DRB1 alleles by specific primers. Discriminant analysis and logistic regression classified individuals based on their cytokine profile. RESULTS: The prevalence of RF (cutoff level predetermined to include 5% of Caucasian controls) and anti-CCP (cutoff level of ≥40 units) was, respectively, 88% and 81% in the RA patients, 34% and 9% in first-degree relatives, and 9% and 4% in North American Native controls; the prevalence of anti-CCP was 0% in Caucasian controls. Levels of most cytokines were highest in RA patients; 17 of 40 cytokines (43%) were significantly higher in first-degree relatives than in controls, including multiple proinflammatory cytokines. Discriminant analysis showed a notable distinction between the groups, with 85% classification accuracy. First-degree relatives had markedly higher MCP-1 and hsCRP levels than North American Native controls, but there was no consistent association with RA autoantibodies. CONCLUSION: Our findings indicate that levels of multiple cytokines and hsCRP are higher in first-degree relatives of North American Native patients with RA compared to individuals from a nonautoimmune background. These data suggest that elevated baseline cytokine levels may be part of the risk profile for developing RA.

Correlates of suicidality: investigation of a representative sample of Manitoba First Nations adolescents.

OBJECTIVES: We examined individual, friend or family, and community or tribe correlates of suicidality in a representative on-reserve sample of First Nations adolescents. METHODS: Data came from the 2002-2003 Manitoba First Nations Regional Longitudinal Health Survey of Youth. Interviews were conducted with adolescents aged 12 to 17 years (n=1125) from 23 First Nations communities in Manitoba. We used bivariate logistic regression analyses to examine the relationships between a range of factors and lifetime suicidality. We conducted sex-by-correlate interactions for each significant correlate at the bivariate level. A multivariate logistic regression analysis identified those correlates most strongly related to suicidality. RESULTS: We found several variables to be associated with an increased likelihood of suicidality in the multivariate model, including being female, depressed mood, abuse or fear of abuse, a hospital stay, and substance use (adjusted odds ratio range=2.43-11.73). Perceived community caring was protective against suicidality (adjusted odds ratio=0.93; 95% confidence interval=0.88, 0.97) in the same model. CONCLUSIONS: Results of this study may be important in informing First Nations and government policy related to the implementation of suicide prevention strategies in First Nations communities.

Prevalence of genetic variants associated with inflammatory bowel disease in a healthy First Nations cohort.

BACKGROUND: Inflammatory bowel disease is the result of both genes and environment. Canadian First Nations people, despite living in a region with a high prevalence of inflammatory bowel disease, are relatively protected from this disease. We aimed to compare the carriage of genetic variants associated with inflammatory bowel disease in healthy First Nations and white people. METHODS: DNA was extracted from the venous blood of healthy First Nations (n = 340) and white (n = 285) participants from Manitoba. Genotyping was performed for 69 single nucleotide polymorphisms (SNPs) with known or suspected associations with inflammatory bowel disease. We compared the genotypes between groups by logistic regression, adjusting for multiple testing. We calculated a risk score for the NOD2 gene by adding the number of risk alleles at three important NOD2 SNPs (G908R, R702W and 3020insC). RESULTS: We found genetic variation between white and First Nations participants at 45 of 69 SNPs. Notably, carriage of the ATG16L1 T300A mutation was lower in First Nations participants (p = 4.1 × 10(-30)). Cumulative carriage of important NOD2 variants was significantly lower among First Nations participants (3.9% v. 15.2%; p < 0.0001 for risk score) than among white participants. Risk variants in IL23R (p = 0.014) and IL12B (p = 1.2 × 10(-16)), among others, were more prevalent among First Nations participants than among white participants. INTERPRETATION: The low prevalence of variants associated with bacterial processing and handling in First Nations people may explain their relative protection from inflammatory bowel disease. Increased carriage of a number of risk variants, for example in the interleukin-23/Th17 pathway, is especially intriguing given their importance in other inflammatory diseases of high incidence in First Nations populations.

Assessing inflammatory bowel disease-associated antibodies in Caucasian and First Nations cohorts.

BACKGROUND: First Nation populations in Canada have a very low incidence of inflammatory bowel disease (IBD). Based on typical infections in this population, it is plausible that the First Nations react differently to microbial antigens with a different antibody response pattern, which may shed some light as to why they experience a low rate of IBD. OBJECTIVE: To compare the positivity rates of antibodies known to be associated with IBD in Canadian First Nations compared with a Canadian Caucasian population. METHODS: Subjects with Crohn's disease, ulcerative colitis (UC), rheumatoid arthritis (RA) (as an immune disease control) and healthy controls without a personal or family history of chronic immune diseases, were enrolled in a cohort study aimed to determine differences between First Nations and Caucasians with IBD or RA. Serum from a random sample of these subjects (n=50 for each of First Nations with RA, First Nations controls, Caucasians with RA, Caucasians with Crohn's disease, Caucasians with UC and Caucasians controls, and as many First Nations with either Crohn's disease or UC as could be enrolled) was analyzed in the laboratory for the following antibodies: perinuclear antineutrophil cytoplasmic antibody (pANCA), and four Crohn's disease-associated antibodies including anti-Saccharomyces cerevisiae, the outer membrane porin C of Escherichia coli, I2 - a fragment of bacterial DNA associated with Pseudomonas fluorescens, and the bacterial flagellin CBir-1. The rates of positive antibody responses and mean titres among positive results were compared. RESULTS: For pANCA, First Nations had a positivity rate of 55% in those with UC, 32% in healthy controls and 48% in those with RA. The pANCA positivity rate was 32% among Caucasians with RA. The rates of the Crohn's disease-associated antibodies for the First Nations and Caucasians were comparable. Among First Nations, up to one in four healthy controls were positive for any one of the Crohn's disease-associated antibodies. First Nations had significantly higher pANCA titres in both the UC and RA groups than Caucasians. DISCUSSION: Although First Nation populations experience a low rate of IBD, they are relatively responsive to this particular antibody panel. CONCLUSIONS: The positivity rates of these antibodies in First Nations, despite the low incidence of IBD in this population, suggest that these antibodies are unlikely to be of pathogenetic significance.

Spouses bereaved by suicide: A population-based longitudinal cohort comparison of physician-diagnosed mental disorders and hospitalized suicide attempts.

BACKGROUND: This study compares a longitudinal population-based sample of spouses bereaved by suicide and those bereaved by other sudden deaths to determine if suicide-bereaved spouses (SBS) experience greater rates of physician-diagnosed mental disorders. METHODS: First, married individuals whose spouse died by suicide, sudden natural death (SND) and unintentional injury (UI) were compared to non-bereaved matched cohorts to determine if there were differences in mental disorder rates between bereavement groups and non-bereaved matches. Second, SBS (n = 365), spouses bereaved by SND (n = 1000), and spouses bereaved by UI (n = 270), were compared using inverse probability treatment weighting and generalized estimating equations to calculate relative rates of mental disorders 5 years before/after death. OUTCOMES: All bereaved cohorts had higher rates of mental disorders compared to non-bereaved cohorts. SBS had the greatest rate of depression post-bereavement (50·96%), followed by UI (38·52%) and SND (33·70%) spouses. When comparing bereavement cohorts, a significant group-by-time interaction (P = 0·047) revealed the rate change for depression was significantly different between suicide and UI-bereaved spouses, with SBS having higher rates of depression before bereavement. SBS had increased rates of any mental disorder both pre (ARR = 1·35, 95% CI = 1·03-1·18, P<·05) and post spousal death (ARR = 1·24, 95% CI = 1·03-1·45, P<·05) when compared to UI spouses signifying pre-existing mental disorders. Post-bereavement, SBS had greater rates of depression only when compared to SND-bereaved spouses (ARR = 1·31, 95% CI = 1·10-1·55, P<·01). INTERPRETATION: SBS have the greatest rates of depression and any mental disorder before the death of their spouse, suggesting suicide bereavement may be unique. Sudden spousal bereavement is a vulnerable time for mental disorders.

Conceptualizations of help-seeking for mental health concerns in First Nations communities in Canada: A comparison of fit with the Andersen Behavioral Model.

This qualitative study explored the fit between on-reserve First Nations community members' conceptualizations of help-seeking for mental health concerns and the Andersen Behavioral Model of Health Services Use. Youth, adults and elders (N = 115) living and or working in eight distinct First Nations communities within a tribal council area in Canada participated in focus groups or individual interviews that were transcribed, coded and then analyzed using a thematic analysis approach informed by grounded theory methodology. Resulting themes were then mapped onto the Andersen Behavioral Model of Health Services Use. Participants' conceptualizations of predisposing characteristics including social structures, health beliefs and mental illness, enabling and impeding resources had a high degree of fit with the model. While perspectives on perceived need for mental health care, and spirituality as a health and lifestyle practice had only moderate fit with the model, these domains could be modified to fit First Nations' interpretations of help-seeking. Participants' perceptions of avoidant strategies and non-use of mental health services, however did not map onto the model. These findings suggest conceptualizations of help-seeking for mental health issues in these First Nations communities are only partially characterized by the Andersen Behavioral Model, suggesting there are a number of considerations to Indigenize the model. Findings also highlight potential explanations for why some members of this population may not access or receive appropriate mental health treatment. Multi-pronged efforts are warranted to link culturally normed pathways of help-seeking with effective mental health supports for First Nations community members in Canada.

Examining the Impact of First Nations Status on the Relationship Between Diabetes and Cancer.

Purpose: This population-based study examined the relationship between diabetes and cancer and determined if this relationship was influenced by First Nations (FN) status. Methods: In a matched case-cohort study, individuals 30-74 years of age diagnosed with diabetes during 1984-2008 in the province of Manitoba, Canada, with no cancer diagnosis before their diabetes diagnosis were matched to one diabetes-free control by age, sex, FN status, and residence. Flexible competing risk and Royston-Parmar regression models were used to compare cancer rates. Results: Overall, 72,715 individuals diagnosed with diabetes were matched to controls. In all age groups, diabetes was related to an increased risk of cancer. The relationship between diabetes and any type of cancer was not influenced by FN status (i.e., there was no interaction between the diagnosis of diabetes and people's FN status for any age group). The only significant interaction between diabetes and FN status was for kidney cancer for individuals 60-74 years of age; diabetes increased the risk of kidney cancer for all other Manitobans (AOMs) but not for FN. Conclusions: Diabetes increased the risk of cancer. The association was not modified by FN status except for kidney cancer where diabetes increased the risk for AOMs but not for FN.

Creating a Canadian Indigenous Research Network Against Cancer to Address Indigenous Cancer Disparities.

PURPOSE: In Canada, indigenous peoples' cancer rates have increased, but cancer screening rates tend to be lower. When coupled with poor cancer prognosis, treatment barriers, and inaccessible health care, indigenous patients with cancer experience many unmet needs. Further complicating their journey is a multijurisdictional system that complicates cancer control services, treatments, patient supports, and cancer surveillance. To address these issues, the Canadian Indigenous Research Network Against Cancer (CIRNAC) was developed. This article describes the forerunners and consultative process that created the network and the consensus model developed to ground this network with, by, and for indigenous peoples. METHODS: A consultative workshop was held to (1) establish and increase network membership, (2) enhance partnerships with indigenous communities and other researchers, and (3) develop an indigenous-led research program, new funding, and related initiatives. RESULTS: Participants viewed the CIRNAC as a reflective parallel network led by indigenous peoples that would identify research priorities within Canada, assess how these priorities align with indigenous patients' cancer care and research needs, and cross-check to see if these priorities align with each other. The network would also advocate for indigenous elders/knowledge holders and community grassroot processes to drive research and training, thus demonstrating the power of the community voice and lived experience in research. In addition, the network would foster research partnerships to investigate alternative indigenous models for cancer prevention, care, treatment, and support. CONCLUSION: The CIRNAC evolved as a viable vehicle to address cancer with, for, and by indigenous peoples. The network is guided by a preamble, a set of aims, and an inclusion engagement circle model. It is evolving through major world initiatives, with the aim of formally becoming an internationally linked national network.

Tuberculosis among northern Manitoba First Nations, 2008-2012: program performance on- and off-reserve.

OBJECTIVES: The objectives of this study were to: (1) report tuberculosis (TB) program performance for northern First Nations in the province of Manitoba; (2) present methods for TB program performance measurement using routinely collected surveillance data; and (3) advance dialogue on performance measurement of Canadian TB programs. METHODS: Data on a retrospective cohort of people diagnosed with TB in Manitoba between January 1, 2008 and December 31, 2010, and their contacts, were extracted from the Manitoba TB Registry. Performance measures based on US-CDC were analyzed. Adjusted probability ratios (aPR) and 95% confidence intervals (CIs) were reported with comparisons between on-/off-reserve First Nations, adjusted for age, sex, and treatment history. RESULTS: A cohort of n = 149 people diagnosed with TB and n = 3560 contacts were identified. Comparisons off-/on-reserve: Treatment completion (aPR = 1.03; 95% CI 0.995-1.07); early detection (aPR = 0.87; 95% CI 0.57-1.33); HIV testing and reporting (aPR = 0.42; 95% CI 0.21-0.83); pediatric TB (age < 15 years) (aPR = 1.20; 95% CI 0.47-3.06); retreatment for TB (aPR = 0.93; 95% CI 0.89-0.97); contact elicitation (aPR = 0.94; 95% CI 0.84-1.05); contact assessment (aPR = 0.69; 95% CI 0.50-0.94). Pediatric (ages < 15 years) TB incidence in northern Manitoba was 37.1 per 100,000/year. CONCLUSION: TB program performance varies depending on residence in a reserve or non-reserve community. Action is urgently needed to address TB program performance in terms of contact investigation and HIV testing/reporting for First Nations off-reserve and to address high rates of pediatric TB in northern Manitoba. First Nations collaboration and models of care should be considered both on- and off-reserve to improve TB program performance.

The Swampy Cree Tribal Council and Aboriginal governance: a case study of nursing education in Northern Manitoba.

This case study provides a historical account of the development of the Northern Bachelor of Nursing Program in the Canadian province of Manitoba through the lens of self-determination (governance) efforts in the fields of health and education by the Swampy Cree Tribal Council. Using records from the Faculty of Nursing archives at the University of Manitoba, the authors outline the chronology of the Northern Bachelor of Nursing Program in 4 phases: initiation (1982-86), development (1986-88), management (1986-90), and implementation and closure (1990-94). Contemporary implications of full partnership between universities and Aboriginal organizations are discussed.

Adapting and enhancing PAX Good Behavior Game for First Nations communities: a mixed-methods study protocol developed with Swampy Cree Tribal Council communities in Manitoba.

INTRODUCTION: High rates of mental health problems, such as suicidal behaviours, among First Nations youth in Canada are a major public health concern. The Good Behavior Game (GBG) is a school-based intervention that provides a nurturing environment for children and has been shown to promote positive outcomes. PAX Good Behavior Game (PAX GBG) is an adaptation and enhancement of the GBG. While PAX GBG has been implemented in Indigenous communities, little research exists examining the cultural and contextual appropriateness and effectiveness of the intervention in First Nations communities. METHODS AND ANALYSIS: The present paper describes a protocol of the mixed-methods approach guided by an Indigenous ethical engagement model adopted to implement, adapt and evaluate PAX GBG in First Nations communities in Manitoba, Canada. First, implementation outcomes (eg, acceptability, adoption) of PAX GBG will be evaluated using qualitative interviews with teachers, principals and community members from Swampy Cree Tribal Council (SCTC) communities. Second, by linking administrative databases to programme data from schools in 38 First Nations communities, we will compare PAX GBG and control groups to evaluate whether PAX GBG is associated with improved mental health and academic outcomes. Third, the qualitative results will help inform a cultural and contextual adaptation of PAX GBG called First Nations PAX (FN PAX). Fourth, FN PAX will be implemented in a few SCTC communities and evaluated using surveys and qualitative interviews followed by the remaining communities the subsequent year. ETHICS AND DISSEMINATION: Ethical approval was obtained from the University of Manitoba Health Research Ethics Board and will be obtained from the Health Information Privacy Committee and respective data providers for the administrative database linkages. Dissemination and knowledge translation will include community and stakeholder engagement throughout the research process, reports and presentations for policymakers and community members, presentations at scientific conferences and journal publications.

Building a health research relationship between First Nations and the University in Manitoba.

This paper describes the emergence of a formal partnership between Manitoba First Nations and researchers in the Department of Community Health Sciences at the University of Manitoba. This partnership reflects two decades of a working relationship in Manitoba involving university researchers and First Nations communities, as well as new and innovative approaches to developing organizations, training initiatives and projects that strengthen First Nations principles of governance. The emerging trust that has developed between the Manitoba First Nations and the University has made it possible to extend this partnership into building further research capacity and evidence-based decision-making among First Nations. Discussions between the Assembly of Manitoba Chiefs and the Northern Health Research Unit resulted in the development of a Manitoba First Nations Centre for Aboriginal Health Research. Its mission is to initiate, coordinate and support research activities designed to assist First Nations and Aboriginal communities and organizations in their efforts to promote healing, wellness and improved health services in their communities. Much of the health research described in this journal was facilitated through this partnership, which demonstrated the value of partnerships and new funding opportunities to better address the health information needs of First Nations communities, particularly at a time when Aboriginal communities were highly skeptical of the value of academic research.

One little, too little: Counting Canada's indigenous people for improved health reporting.

The way state governments, worldwide, count or do not count Indigenous peoples has contributed to inconsistent reporting of Indigenous health statistics. To address unreliable reporting in Canada, we reviewed laws on Indian status and the development of a national Indian Registration System (IRS) to track Indian status and eligibility. With this information as a guide, we linked the IRS to the Manitoba provincial health registry systems and were able to identify individuals with Indian status for health reporting. To improve reporting, we identified individuals often missed in this type of linkage. For instance, we identified children and adult children who were eligible for Indian status but not yet registered. Equally as important, we identified individuals not eligible for Indian status but have Indian heritage and/or represent potential individual Indian status eligibility cases before the courts to right a historic form of identity sex discrimination that has made them invisible in Canadian society and health reporting. A familial kinship approach was used to identify Indian children and adult children typically missed when a strict legal entitlement criteria is used for data linkage. Our reflective socio-legal data linkage approach expanded the number of Indian peoples for health reporting purposes and demonstrated a feasible, inclusive way to report on the health of Indians in Canada.

Pap test use and cervical cancer incidence in First Nations women living in Manitoba.

This study examined Papanicolaou (Pap) test utilization, Pap test results, and cervical cancer incidence among First Nations (FN) women living in Manitoba, Canada taking into account age group, time period, and area of residence. Six population-based data sources were linked at an individual level. Negative binomial regression was used to compare Pap test utilization and results between FN and all other Manitoba (AOM) women. Poisson regression was used to compare cervical cancer incidence. Among women younger than 25 years, FN were more likely than AOM women to have had a Pap test [rate ratio (RR) = 1.37, 95% confidence intervals (CI), 1.22-1.53, 18-19 year olds; RR = 1.17, 95% CI, 1.05-1.31, 20-24 year olds]. There was no difference in Pap test use for women 25 to 29 or 30 to 39 years. FN 40 years and older were less likely to have a Pap test than AOM women (RR = 0.84, 95% CI, 0.75-0.93, 40-49 years old; RR = 0.71, 95% CI, 0.63-0.79, 50-59 years old; RR = 0.59, 95% CI, 0.52-0.66, 60-69 years old). FN were more likely than AOM women to have a high (RR = 1.88, 95% CI, 1.65-2.13) or low-grade Pap test result (RR = 1.60, 95% CI, 1.48-1.73). The invasive cervical cancer incidence rate was double for FN women 25 to 39 years of age (21.9 per 100,000, FN; 10.2 per 100,000, AOM, P = 0.006) and 40 to 69 years of age (24.3 per 100,000, FN; 12.3 per 100,000, AOM, P = 0.007). In conclusion, cervical cancer screening among FN women over 40 years of age must be increased to address the higher cervical cancer incidence.