Changes in health indicator gaps between First Nations and other residents of Manitoba.

BACKGROUND: The Truth and Reconciliation Commission of Canada has called for better reporting of health disparities between First Nations people and other Canadians to close gaps in health outcomes. We sought to evaluate changes in these disparities using indicators of health and health care use over the last 2 decades. METHODS: We used linked, whole-population, administrative claims data from the Manitoba Centre for Health Policy for fiscal years 1994/95 to 1998/99 and 2012/13 to 2016/17. We measured indicators of health and health care use among registered First Nations and all other Manitobans, and compared differences between these groups over the 2 time periods. RESULTS: Over time, the relative gap between First Nations and all other Manitobans widened by 51% (95% confidence interval [CI] 42% to 60%) for premature mortality rate. For potential years of life lost, the gap widened by 54% (95% CI 51% to 57%) among women and by 32% (95% CI 30% to 35%) among men. The absolute gap in life expectancy widened by 3.14 years (95% CI 2.92 to 3.36) among men and 3.61 years (95% CI 3.38 to 3.84) among women. Relative gaps widened by 20% (95% CI 12% to 27%) for ambulatory specialist visits, by 14% (95% CI 12% to 16%) for hospital separations and by 50% (95% CI 39% to 62%) for days spent in hospital, but narrowed by 33% (95% CI -36% to -30%) for ambulatory primary care visits, by 22% (95% CI -27% to -16%) for mammography and by 27% (95% CI -40% to -23%) for injury hospitalizations. INTERPRETATION: Disparities between First Nations and all other Manitobans in many key indicators of health and health care use have grown larger over time. New approaches are needed to address these disparities and promote better health with and for First Nations.

An Unconditional Prenatal Income Supplement Reduces Population Inequities In Birth Outcomes.

The Commission on Social Determinants of Health, sponsored by the World Health Organization, has identified measuring health inequities and evaluating interventions to reduce them as important priorities. We examined whether an unconditional prenatal income supplement for low-income women was associated with reduced population-level inequities in birth outcomes. We identified all mother-newborn pairs from the period 2003-10 in Manitoba, Canada, and divided them into the following three groups: low income exposed (received the supplement); low income unexposed (did not receive the supplement); and not low income unexposed (ineligible for the supplement). We measured inequities in low-birthweight births, preterm births, and breast-feeding initiation among these groups. The findings indicated that the socioeconomic gap in birth outcomes between low-income and other women was significantly smaller when the low-income women received the income supplement than when they did not. The prenatal income supplement may be an important driver in attaining population-level equity in birth outcomes; its success could inform strategies seeking to improve maternal and child health.

Families First Home Visiting programme reduces population-level child health and social inequities.

BACKGROUND: Home visiting has been shown to reduce child maltreatment and improve child health outcomes. In this observational study, we explored whether Families First, a home visiting programme in Manitoba, Canada, decreased population-level inequities in children being taken into care of child welfare and receiving complete childhood immunisations. METHODS: De-identified administrative health and social services data for children born 2003-2009 in Manitoba were linked to home visiting programme data. Programme eligibility was determined by screening for family risk factors. We compared probabilities of being taken into care and receiving immunisations among programme children (n=4575), eligible children who did not receive the programme (n=5186) and the general child population (n=87 897) and tested inequities using differences of risk differences (DRDs) and ratios of risk ratios (RRRs). RESULTS: Programme children were less likely to be taken into care (probability (95% CI) at age 1, programme 7.5 (7.0 to 8.0) vs non-programme 10.0 (10.0 to 10.1)) and more likely to receive complete immunisations (probability at age 1, programme 77.3 (76.5 to 78.0) vs non-programme 73.2 (72.1 to 74.3)). Inequities between programme children and the general population were reduced for both outcomes (being taken into care at age 1, DRD -2.5 (-3.7 to 1.2) and RRR 0.8 (0.7 to 0.9); complete immunisation at age 1, DRD 4.1 (2.2 to 6.0) and RRR 1.1 (1.0 to 1.1)); these inequities were also significantly reduced at age 2. CONCLUSION: Home visiting programmes should be recognised as effective strategies for improving child outcomes and reducing population-level health and social inequities.

Unconditional Prenatal Income Supplement and Birth Outcomes.

BACKGROUND AND OBJECTIVES: Perinatal outcomes have improved in developed countries but remain poor for disadvantaged populations. We examined whether an unconditional income supplement to low-income pregnant women was associated with improved birth outcomes. METHODS: This study included all mother-newborn pairs (2003-2010) in Manitoba, Canada, where the mother received prenatal social assistance, the infant was born in the hospital, and the pair had a risk screen (N = 14 591). Low-income women who received the income supplement (Healthy Baby Prenatal Benefit [HBPB], n = 10 738) were compared with low-income women who did not receive HBPB (n = 3853) on the following factors: low birth weight, preterm, small and large for gestational age, Apgar score, breastfeeding initiation, neonatal readmission, and newborn hospital length of stay (LOS). Covariates from risk screens were used to develop propensity scores and to balance differences between groups in regression models; γ sensitivity analyses were conducted to assess sensitivity to unmeasured confounding. Population-attributable and preventable fractions were calculated. RESULTS: HBPB was associated with reductions in low birth weight (aRR, 0.71 [95% CI, 0.63-0.81]), preterm births (aRR, 0.76 [95% CI, 0.69-0.84]) and small for gestational age births (aRR, 0.90 [95% CI, 0.81-0.99]) and increases in breastfeeding (aRR, 1.06 [95% CI, 1.03-1.09]) and large for gestational age births (aRR, 1.13 [95% CI, 1.05-1.23]). For vaginal births, HBPB was associated with shortened LOS (weighted mean, 2.86; P < .0001). Results for breastfeeding, low birth weight, preterm birth, and LOS were robust to unmeasured confounding. Reductions of 21% (95% CI, 13.6-28.3) for low birth weight births and 17.5% (95% CI, 11.2-23.8) for preterm births were associated with HBPB. CONCLUSIONS: Receipt of an unconditional prenatal income supplement was associated with positive outcomes. Placing conditions on income supplements may not be necessary to promote prenatal and perinatal health.

Does a pay-for-performance program for primary care physicians alleviate health inequity in childhood vaccination rates?

INTRODUCTION: Childhood vaccination rates in Manitoba populations with low socioeconomic status (SES) fall significantly below the provincial average. This study examined the impact of a pay-for-performance (P4P) program called the Physician Integrated Network (PIN) on health inequity in childhood vaccination rates. METHODS: The study used administrative data housed at the Manitoba Centre for Health Policy. We included all children born in Manitoba between 2003 and 2010 who were patients at PIN clinics receiving P4P funding matched with controls at non-participating clinics. We examined the rate of completion of the childhood primary vaccination series by age 2 across income quintiles (Q1-Q5). We estimated the distribution of income using the Gini coefficient, and calculated concentration indices for vaccination to determine whether the P4P program altered SES-related differences in vaccination completion. We compared these measures between study cohorts before and after implementation of the P4P program, and over the course of the P4P program in each cohort. RESULTS: The PIN cohort included 6,185 children. Rates of vaccination completion at baseline were between 0.53 (Q1) and 0.69 (Q5). Inequality in income distribution was present at baseline and at study end in PIN and control cohorts. SES-related inequity in vaccination completion worsened in non-PIN clinics (difference in concentration index 0.037; 95 % CI 0.013, 0.060), but remained constant in P4P-funded clinics (difference in concentration index 0.006; 95 % CI 0.008, 0.021). CONCLUSIONS: The P4P program had a limited impact on vaccination rates and did not address health inequity.

Can opportunities be enhanced for vaccinating children in home visiting programs? A population-based cohort study.

BACKGROUND: Home visiting programs focused on improving early childhood environments are commonplace in North America. A goal of many of these programs is to improve the overall health of children, including promotion of age appropriate vaccination. In this study, population-based data are used to examine the effect of a home visiting program on vaccination rates in children. METHODS: Home visiting program data from Manitoba, Canada were linked to several databases, including a provincial vaccination registry to examine vaccination rates in a cohort of children born between 2003 and 2009. Propensity score weights were used to balance potential confounders between a group of children enrolled in the program (n = 4,562) and those who were eligible but not enrolled (n = 5,184). Complete and partial vaccination rates for one and two year old children were compared between groups, including stratification into area-level income quintiles. RESULTS: Complete vaccination rates from birth to age 1 and 2 were higher for those enrolled in the Families First program [Average Treatment Effect Risk Ratio (ATE RR) 1.06 (95 % CI 1.03-1.08) and 1.10 (95 % CI 1.05-1.15) respectively]. No significant differences were found between groups having at least one vaccination at age 1 or 2 [ATE RR 1.01 (95 % CI 1.00-1.02) and 1.00 (95 % CI 1.00-1.01) respectively). The interaction between program and income quintiles was not statistically significant suggesting that the program effect did not differ by income quintile. CONCLUSIONS: Home visiting programs have the potential to increase vaccination rates for children enrolled, despite limited program content directed towards this end. Evidence-based program enhancements have the potential to increase these rates further, however more research is needed to inform policy makers of optimal approaches in this regard, especially with respect to cost-effectiveness.

Have we left some behind? Trends in socio-economic inequalities in breastfeeding initiation: a population-based epidemiological surveillance study.

OBJECTIVES: Breastfeeding is associated with improved health. Surveillance data show that breastfeeding initiation rates have increased; however, limited work has examined trends in socio-economic inequalities in initiation. The study's research question was whether socio-economic inequalities in breastfeeding initiation have changed over the past 20 years. METHODS: This population-based study is a project within PATHS Equity for Children. Analyses used hospital discharge data for Manitoba mother-infant dyads with live births, 1988-2011 (n=316,027). Income quintiles were created, each with ~20% of dyads. Three-year, overall and by-quintile breastfeeding initiation rates were estimated for Manitoba and two hospitals. Age-adjusted rates were estimated for Manitoba. Rates were modelled using generalized linear models. Three measures, rate ratios (RRs), rate differences (RDs) and concentration indices, assessed inequality at each time point. We also compared concentration indices with Gini coefficients to assess breastfeeding inequality vis-à-vis income inequality. Trend analyses tested for changes over time. RESULTS: Manitoba and Hospital A initiation rates increased; Hospital B rates did not change. Significant inequalities existed in nearly every period, across all three measures: RRs, RDs and concentration indices. RRs and concentration indices suggested little to no change in inequality from 1988 to 2011. RDs for Manitoba (comparing initiation in the highest to lowest income quintiles) did not change significantly over time. RDs decreased for Hospital A, suggesting decreasing socio-economic inequalities in breastfeeding; RDs increased for Hospital B. Income inequality increased significantly in Manitoba during the study period. CONCLUSIONS: Overall breastfeeding initiation rates can improve while inequality persists or worsens.

The effect of neighborhood socioeconomic status on education and health outcomes for children living in social housing.

OBJECTIVES: We explored differences in health and education outcomes between children living in social housing and not, and effects of social housing's neighborhood socioeconomic status. METHODS: In this cohort study, we used the population-based repository of administrative data at the Manitoba Centre for Health Policy. We included children aged 0 to 19 years in Winnipeg, Manitoba, in fiscal years 2006-2007 to 2008-2009 (n = 13,238 social housing; n = 174,017 others). We examined 5 outcomes: age-2 complete immunization, a school-readiness measure, adolescent pregnancy (ages 15-19 years), grade-9 completion, and high-school completion. Logistic regression and generalized estimating equation modeling generated rates. We derived neighborhood income quintiles (Q1 lowest, Q5 highest) from average household income census data. RESULTS: Children in social housing fared worse than comparative children within each neighborhood income quintile. When we compared children in social housing by quintile, preschool indicators (immunization and school readiness) were similar, but adolescent outcomes (grade-9 and high-school completion, adolescent pregnancy) were better in Q3 to Q5. CONCLUSIONS: Children in social housing had poorer health and education outcomes than all others, but living in social housing in wealthier areas was associated with better adolescent outcomes.

Data resource profile: Pathways to Health and Social Equity for Children (PATHS Equity for Children).

The PATHS Data Resource is a unique database comprising data that follow individuals from the prenatal period to adulthood. The PATHS Resource was developed for conducting longitudinal epidemiological research into child health and health equity. It contains individual-level data on health, socioeconomic status, social services and education. Individuals' data are linkable across these domains, allowing researchers to follow children through childhood and across a variety of sectors. PATHS includes nearly all individuals that were born between 1984 and 2012 and registered with Manitoba's universal health insurance programme at some point during childhood. All PATHS data are anonymized. Key concepts, definitions and algorithms necessary to work with the PATHS Resource are freely accessible online and an interactive forum is available to new researchers working with these data. The PATHS Resource is one of the richest and most complete databases assembled for conducting longitudinal epidemiological research, incorporating many variables that address the social determinants of health and health equity. Interested researchers are encouraged to contact [mchp_access@cpe.umanitoba.ca] to obtain access to PATHS to use in their own programmes of research.