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

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

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

Our Health Counts: Examining associations between colonialism and ever being incarcerated among First Nations, Inuit, and Métis people in London, Thunder Bay, and Toronto, Canada.

OBJECTIVES: Indigenous peoples have a disproportionately high prevalence of incarceration in the Canadian justice system. However, there is limited Indigenous-driven research examining colonialism and the justice system, specifically associations between racism, externally imposed family disruptions, and history of ever being incarcerated. Therefore, this study examined the association between the proportion of previous incarceration and family disruption, experiences of racism, and victimization for Indigenous adults in London, Thunder Bay, and Toronto, Ontario, Canada. The three communities expressed that they did not want comparison between the communities; rather, they wanted analysis of their community to understand where more supports were needed. METHODS: Indigenous community partners used respondent-driven sampling (RDS) to collect data from First Nations, Inuit, and Métis (FNIM) peoples in London, Thunder Bay, and Toronto. Prevalence estimates, 95% confidence intervals, and relative risk were reported using unweighted Poisson models and RDS-adjusted proportions. RESULTS: Proportions of ever being incarcerated ranged from 43.0% in London to 54.0% in Toronto and 72.0% in Thunder Bay. In all three cities, history of child protection involvement and experiencing racism was associated with an approximate 25.0% increase in risk for previous incarceration. In Toronto and London, victimization was associated with increased risk for incarceration. CONCLUSION: This research highlights disproportionately high prevalence of ever being incarcerated among FNIM living in three Ontario cities. Experiencing racism, family disruption, and victimization are associated with incarceration. Decreasing the rates of family disruption, experiences of racism, and victimization should inform future policy and services to reduce the disproportionately high prevalence of incarceration for FNIM people living in urban settings.

RéSUMé: OBJECTIFS: Les personnes autochtones présentent une prévalence démesurément élevée d'incarcération dans le système judiciaire canadien. Il y a cependant peu d'études dirigées par des Autochtones sur le colonialisme et le système judiciaire, en particulier sur les associations entre le racisme, les perturbations familiales imposées de l'extérieur et les antécédents d'incarcération. C'est pourquoi nous avons fait porter notre étude sur l'association entre la proportion d'incarcérations antérieures et de perturbations familiales, les expériences de racisme et la victimisation chez les adultes autochtones vivant à London, Thunder Bay et Toronto (Ontario), au Canada. Les trois villes ont dit ne pas vouloir que nous fassions de comparaisons entre elles; elles voulaient plutôt des analyses de leur ville pour savoir où des mesures de soutien supplémentaires étaient nécessaires. MéTHODE: Des partenaires associatifs autochtones ont utilisé l'échantillonnage en fonction des répondants (EFR) pour collecter des données auprès des personnes des Premières Nations, des Inuits et des Métis (PNIM) à London, Thunder Bay et Toronto. Les estimations de prévalence, les intervalles de confiance de 95 % et le risque relatif ont été présentés à l'aide de modèles de Poisson non pondérés et de proportions ajustées selon l'EFR. RéSULTATS: La proportion de répondantes et de répondants ayant déjà été incarcérés était de 43 % à London, de 54 % à Toronto et de 72 % à Thunder Bay. Dans les trois villes, la fréquentation des services de protection de l'enfance et l'expérience du racisme étaient associées à une hausse d'environ 25 % du risque d'incarcération antérieure. À Toronto et à London, la victimisation était associée à un risque accru d'incarcération. CONCLUSION: Cette étude souligne la prévalence démesurément élevée de l'incarcération antérieure chez les personnes PNIM vivant dans trois villes de l'Ontario. L'expérience du racisme, les perturbations familiales et la victimisation étaient associées à l'incarcération. La réduction des taux de perturbations familiales, d'expérience du racisme et de victimisation devrait éclairer les politiques et les services futurs afin de réduire la prévalence démesurément élevée de l'incarcération chez les personnes PNIM vivant en milieu urbain.

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

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

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

Relationships to land as a determinant of wellness for Indigenous women, two-spirit, trans, and gender diverse people of reproductive age in Toronto, Canada.

OBJECTIVE: Disparities in Indigenous reproductive health reflect Canada's historic and ongoing colonial relationship with Indigenous peoples, which includes persistent inequities in health and social services. Reproductive justice scholars and activists advocate for intersectional approaches to enhancing Indigenous health equity that recognize land as a central determinant of wellness. The purpose of this study is to examine the association between relationships to land and wellness in a study of urban Indigenous women, two-spirit, trans, and gender diverse people of reproductive age in Canada's largest city, Toronto. METHODS: Data were obtained from the cross-sectional Our Health Counts (OHC) Toronto study, which employed respondent-driven sampling methods (n = 323) and a community-directed comprehensive health assessment survey. In an exploratory analysis, we took an Indigenous reproductive justice theoretical approach to multivariable logistic regression. RESULTS: After adjusting for covariates, there was a statistically significant positive association between relationships to the land and wellness that was estimated with good precision (OR 3.7, 95% CI 2.5-5.3). CONCLUSION: Our findings indicate that among urban Indigenous women, two-spirit, trans, and gender diverse people of reproductive age there is a positive association between feeling strong in their relationships to land and feeling balanced in the four domains of health (physical, spiritual, mental, and emotional). The community-based, community-directed design of OHC Toronto was congruent with a reproductive justice approach to research. Reproductive justice theories are adaptable to quantitative research on Indigenous reproductive health and can yield novel insights for supporting Indigenous wellness.

RéSUMé: OBJECTIF: Les disparités que connaissent les peuples autochtones sur le plan de la santé reproductive sont le reflet des relations coloniales historiques et continues du Canada avec ces peuples, encore entachées d'iniquités dans les domaines de la santé et des services sociaux. Théoricien·nes et militant·es de la justice reproductive préconisent des approches intersectionnelles pour améliorer l'équité en santé chez les peuples autochtones, approches qui reconnaissent le territoire comme un déterminant central du bien-être. Nous avons voulu examiner l'association entre les relations avec le territoire et le bien-être dans une étude menée auprès de femmes et de personnes autochtones bispirituelles, trans et de diverses identités de genre en âge de procréer vivant à Toronto, la plus grande ville du Canada. MéTHODE: Nos données proviennent de l'étude transversale Our Health Counts (OHC) Toronto, qui a employé des méthodes d'échantillonnage en fonction des répondant·es (n = 323) et une enquête d'évaluation globale de la santé dirigée par la communauté. Dans une analyse exploratoire, nous avons employé la régression logistique multivariée selon une approche théorique de justice reproductive autochtone. RéSULTATS: Après l'apport d'ajustements pour tenir compte des covariables, nous avons observé une association positive significative entre les relations avec le territoire et le bien-être, que nous avons estimée avec une bonne précision (RC 3,7, IC de 95 % 2,5­5,3). CONCLUSION: D'après nos constatations, il y a chez les femmes et les personnes autochtones bispirituelles, trans et de diverses identités de genre en âge de procréer vivant en milieu urbain une association positive entre un fort sentiment d'appartenance au territoire et un sentiment d'équilibre entre les quatre domaines de la santé (physique, spirituel, mental et émotionnel). L'étude OHC Toronto ayant été conçue par et pour la communauté, elle est conforme à une approche de recherche axée sur la justice reproductive. Les théories de la justice reproductive peuvent être adaptées à la recherche quantitative sur la santé reproductive autochtone, et elles peuvent jeter un nouvel éclairage sur les moyens d'appuyer le bien-être des personnes autochtones.

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

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

Modelling prevalent cardiovascular disease in an urban Indigenous population.

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

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

Long-distance travel for birthing among Indigenous and non-Indigenous pregnant people in Canada.

BACKGROUND: For Indigenous Peoples in Canada, birthing on or near traditional territories in the presence of family and community is of foundational cultural and social importance. We aimed to evaluate the association between Indigenous identity and distance travelled for birth in Canada. METHODS: We obtained data from the Maternity Experiences Survey, a national population-based sample of new Canadian people aged 15 years or older who gave birth (defined as mothers) and were interviewed in 2006-2007. We compared Indigenous with non-Indigenous Canadian-born mothers and adjusted for geographic and sociodemographic factors and medical complications of pregnancy using multivariable logistic regression. We categorized the primary outcome, distance travelled for birth, as 0 to 49, 50 to 199 or 200 km or more. RESULTS: We included 3100 mothers living in rural or small urban areas, weighted to represent 31 100 (1800 Indigenous and 29 300 non-Indigenous Canadian-born mothers). We found that travelling 200 km or more for birth was more common among Indigenous compared with non-Indigenous mothers (9.8% v. 2.0%, odds ratio [OR] 5.45, 95% confidence interval [CI] 3.52-8.48). In adjusted analyses, the association between Indigenous identity and travelling more than 200 km for birth was even stronger (adjusted OR 16.44, 95% CI 8.07-33.50) in rural regions; however, this was not observed in small urban regions (adjusted OR 1.04, 95% CI 0.37-2.91). INTERPRETATION: Indigenous people in Canada experience striking inequities in access to birth close to home compared with non-Indigenous people, primarily in rural areas and independently of medical complications of pregnancy. This suggests inequities are rooted in the geographic distribution of and proximal access to birthing facilities and providers for Indigenous people.

A call for action that cannot go to voicemail: Research activism to urgently improve Indigenous perinatal health and wellbeing.

In this call to action, a coalition of Indigenous and non-Indigenous researchers from Australia, Aotearoa New Zealand, United States and Canada argue for the urgent need for adequately funded Indigenous-led solutions to perinatal health inequities for Indigenous families in well-resourced settler-colonial countries. Authors describe examples of successful community-driven programs making a difference and call on all peoples to support and resource Indigenous-led perinatal health services by providing practical actions for individuals and different groups.

Conceptualising cultural safety at an Indigenous-focused midwifery practice in Toronto, Canada: qualitative interviews with Indigenous and non-Indigenous clients.

OBJECTIVE: Cultural safety is an Indigenous concept that can improve how healthcare services are delivered to both Indigenous and non-Indigenous peoples in Canada. This study explored how Indigenous and non-Indigenous clients at an urban, Indigenous-focused midwifery practice in Toronto, Canada (Seventh Generation Midwives Toronto, SGMT) conceptualised and experienced culturally safe care. DESIGN AND SETTING: Interviews were conducted with former clients of SGMT as a part of a larger evaluation of the practice. Participants were purposefully recruited. Interviews were transcribed and analysed thematically using an iterative, consensus-based approach and a critical, naturalistic, and decolonising lens. PARTICIPANTS: Saturation was reached after 20 interviews (n=9 Indigenous participants, n=11 non-Indigenous participants). RESULTS: Three domains of cultural safety emerged. Each domain included several themes: Relationships and Communication (respect and support for choices; personalised and continuous relationships with midwives; and being different from past experiences); Sharing Knowledge and Practice (feeling informed about the basics of pregnancy, birth, and the postpartum period; and having access to Indigenous knowledge and protocols), and Culturally Safe Spaces (feeling at home in practice; and having relationships interconnected with the physical space). While some ideas were shared across groups, the distinctions between the Indigenous and non-Indigenous participants were prominent. CONCLUSION: The Indigenous participants conceptualised cultural safety in ways that highlight the survival and resurgence of Indigenous values, understandings, and approaches in cities like Toronto, and affirm the need for Indigenous midwives. The non-Indigenous participants conceptualised cultural safety with both congruence, illuminating Black-Indigenous community solidarities in cultural safety, and divergence, demonstrating the potential of Indigenous spaces and Indigenous-focused midwifery care to also benefit midwifery clients of white European descent. We hope that the positive impacts documented here motivate evaluators and healthcare providers to work towards a future where 'cultural safety' becomes a standard of care.

Unmet health needs and discrimination by healthcare providers among an Indigenous population in Toronto, Canada.

OBJECTIVES: Inequalities between Indigenous and non-Indigenous peoples in Canada persist. Despite the growth of Indigenous populations in urban settings, information on their health is scarce. The objective of this study is to assess the association between experience of discrimination by healthcare providers and having unmet health needs within the Indigenous population of Toronto. METHODS: The Our Health Counts Toronto (OHCT) database was generated using respondent-driven sampling (RDS) to recruit 917 self-identified Indigenous adults within Toronto for a comprehensive health assessment survey. This cross-sectional study draws on information from 836 OHCT participants with responses to all study variables. Odds ratios and 95% confidence intervals were estimated to examine the relationship between lifetime experience of discrimination by a healthcare provider and having an unmet health need in the 12 months prior to the study. Stratified analysis was conducted to understand how information on access to primary care and socio-demographic factors influenced this relationship. RESULTS: The RDS-adjusted prevalence of discrimination by a healthcare provider was 28.5% (95% CI 20.4-36.5) and of unmet health needs was 27.3% (95% CI 19.1-35.5). Discrimination by a healthcare provider was positively associated with unmet health needs (OR 3.1, 95% CI 1.3-7.3). CONCLUSION: This analysis provides new evidence linking discrimination in healthcare settings to disparities in healthcare access among urban Indigenous people, reinforcing existing recommendations regarding Indigenous cultural safety training for healthcare providers. Our study further demonstrates Our Health Counts methodologies, which employ robust community partnerships and RDS to address gaps in health information for urban Indigenous populations.

Postpartum depression prevalence and risk factors among Indigenous, non-Indigenous and immigrant women in Canada.

OBJECTIVES: The social position of different minority groups in contemporary societies suggests different risk factors for postpartum depression (PPD). In this study, we used two cut-offs of the Edinburgh Postpartum Depression Scale (EPDS) to examine prevalence and risk factors for PPD among mothers participating in the Canadian Maternity Experiences Survey (MES), and to compare Indigenous, Canadian-born non-Indigenous and immigrant mothers. METHODS: We used cross-sectional nationwide data from the 2006 MES (unweighted N = 6237, weighted N = 74,231) and conducted multivariate logistic regression models for EPDS ≥ 10 and EPDS ≥ 13 to explore risk factors for the total sample of mothers and in each study group. RESULTS: Prevalence (%, 95 % CI) of EPDS ≥ 10 and EPDS ≥ 13 was significantly higher among immigrant (12.2 %, 10.2-14.2 and 24.1 %, 21.5-26.7) and Indigenous (11.1 %, 7.5-14.7 and 21.2 %, 16.5-25.9) compared to Canadian-born non-Indigenous mothers (5.6 %, 4.9-6.3 and 12.9 %, 11.9-13.9). Multivariate analysis of the total sample showed similar risk factors for EPDS ≥ 10 and EPDS ≥ 13 (ethnicity, low education, ≥ low income cut-off, taking antidepressants, experiencing abuse, low social support). Stratification by study group revealed differing risk factors in each group for EPDS ≥ 10 and EPDS ≥ 13. Indigenous mothers had the most distinct risk factors, followed by immigrant mothers. Non-indigenous Canadian-born mothers had risk factors most similar to the total sample. CONCLUSION: Differing prevalence and risk factors for PPD within and across study groups suggest that instead of a universal approach, tailored programs and services to prevent PPD in Indigenous, immigrant and non-Indigenous Canadian-born groups could better protect the mental health of Canadian mothers.

Our Health Counts Toronto: using respondent-driven sampling to unmask census undercounts of an urban indigenous population in Toronto, Canada.

OBJECTIVES: To provide evidence of the magnitude of census undercounts of 'hard-to-reach' subpopulations and to improve estimation of the size of the urban indigenous population in Toronto, Canada, using respondent-driven sampling (RDS). DESIGN: Respondent-driven sampling. SETTING: The study took place in the urban indigenous community in Toronto, Canada. Three locations within the city were used to recruit study participants. PARTICIPANTS: 908 adult participants (15+) who self-identified as indigenous (First Nation, Inuit or Métis) and lived in the city of Toronto. Study participants were generally young with over 60% of indigenous adults under the age of 45 years. Household income was low with approximately two-thirds of the sample living in households which earned less than $C20 000 last year. PRIMARY AND SECONDARY OUTCOME MEASURES: We collected baseline data on demographic characteristics, including indigenous identity, age, gender, income, household type and household size. Our primary outcome asked: 'Did you complete the 2011 Census Canada questionnaire?' RESULTS: Using RDS and our large-scale survey of the urban indigenous population in Toronto, Canada, we have shown that the most recent Canadian census underestimated the size of the indigenous population in Toronto by a factor of 2 to 4. Specifically, under conservative assumptions, there are approximately 55 000 (95% CI 45 000 to 73 000) indigenous people living in Toronto, at least double the current estimate of 19 270. CONCLUSIONS: Our indigenous enumeration methods, including RDS and census completion information will have broad impacts across governmental and health policy, potentially improving healthcare access for this community. These novel applications of RDS may be relevant for the enumeration of other 'hard-to-reach' populations, such as illegal immigrants or homeless individuals in Canada and beyond.