Population-based birth cohort study on diabetes in pregnancy and infant hospitalisations in Cree, other First Nations and non-Indigenous communities in Quebec.

OBJECTIVES: Diabetes in pregnancy, whether pre-gestational (chronic) or gestational (de novo hyperglycaemia), increases the risk of adverse birth outcomes. It is unclear whether gestational diabetes increases the risk of postnatal morbidity in infants. Cree First Nations in Quebec are at high risk for diabetes in pregnancy. We assessed whether pre-gestational or gestational diabetes may increase infant hospitalisation (an infant morbidity indicator) incidence, and whether this may be related to more frequent infant hospitalisations in Cree and other First Nations in Quebec. DESIGN: Population-based birth cohort study through administrative health data linkage. SETTING AND PARTICIPANTS: Singleton infants (≤1 year) born to mothers in Cree (n=5070), other First Nations (9910) and non-Indigenous (48 200) communities in rural Quebec. RESULTS: Both diabetes in pregnancy and infant hospitalisation rates were much higher comparing Cree (23.7% and 29.0%) and other First Nations (12.4% and 34.1%) to non-Indigenous (5.9% and 15.5%) communities. Compared with non-diabetes, pre-gestational diabetes was associated with an increased risk of any infant hospitalisation to a greater extent in Cree and other First Nations (relative risk (RR) 1.56 (95% CI 1.28 to 1.91)) than non-Indigenous (RR 1.26 (1.15 to 1.39)) communities. Pre-gestational diabetes was associated with increased risks of infant hospitalisation due to diseases of multiple systems in all communities. There were no significant associations between gestational diabetes and risks of infant hospitalisation in all communities. The population attributable risk fraction of infant hospitalisations (overall) for pre-gestational diabetes was 6.2% in Cree, 1.6% in other First Nations and 0.3% in non-Indigenous communities. CONCLUSIONS: The study is the first to demonstrate that pre-gestational diabetes increases the risk of infant hospitalisation overall and due to diseases of multiple systems, but gestational diabetes does not. High prevalence of pre-gestational diabetes may partly account for the excess infant hospitalisations in Cree and other First Nations communities in Quebec.

Appreciative inquiry in evaluating integrated primary oral health services in Quebec Cree communities: a qualitative multiple case study.

OBJECTIVE: The Strategic Regional Plan of the Cree Board of Health and Social Services of James Bay (CBHSSJB), serving the Quebec Cree communities, mandates the objective of integrating oral health within primary healthcare. Emerging evidence suggests that the integration of oral health into primary healthcare can decrease oral health disparities. This research study aimed to answer the following research question: how and to what extent does the integration of oral health into primary healthcare address the oral health needs of the Cree communities? DESIGN: We used a multiple-case study design within a qualitative approach and developmental evaluation methodology. The Discovery, Dream, Design and Destiny model of appreciative inquiry was selected as a study framework among existing frameworks of the developmental evaluation. SETTING: Four purposefully selected Cree communities. PARTICIPANTS: Healthcare providers, administrators and patients at the community wellness centres and hospital. OUTCOME MEASURES: Integration of oral health into primary healthcare. RESULTS: A total of 36 interviews and 6 focus group discussions were conducted. We identified ten themes in discovery and dream phases. The Discovery phase identified the strengths of the organisation in facilitating enablers of integration including strategic planning, organisational structure, cultural integration, coordinated networks and colocation. In the Dream phase, participants' oral healthcare stories expressed various dimensions of integration and their wish for strengthening integration via extending public oral healthcare programmes, increasing resources and improving organisational management. In the Design phase, recommendations were formulated for a future action plan within the CBHSSJB. CONCLUSION: This study results suggested that the CBHSSJB has been successful in implementing oral health integration into primary care following its strategic planning. At present, the organisation could extend the level of integration into full integration by following study recommendations derived from the perspective of local stakeholders.

Preventing diabetes after pregnancy with gestational diabetes in a Cree community: an inductive thematic analysis.

INTRODUCTION: Historical and political factors underpin the disproportional burden of type 2 diabetes mellitus (T2DM) and gestational diabetes mellitus (GDM) in women, a harbinger of future T2DM, in Indigenous populations. There is a need for T2DM prevention strategies driven by the voices of Indigenous women. In this study, we aimed to understand the perspectives of Cree women with prior GDM living in northern Quebec, where over a quarter of pregnancies are complicated by GDM. RESEARCH DESIGN AND METHODS: A local healthcare worker invited women with GDM in the prior 5 years to participate in semistructured interviews. A Cree-origin research partner and a researcher jointly conducted interviews in-person or by teleconference. Open-ended questions addressed GDM experience, maintaining a healthy lifestyle, and needs/preferences pertinent to designing a T2DM prevention program aimed at women affected by GDM. We adopted an inductive thematic analysis framework to categorize experiences and opinions. RESULTS: Among the 13 mothers interviewed, some success with health behavior changes during pregnancy was reported but there were difficulties postpartum resulting from time constraints, costs of healthy foods, discomfort at the gym related to not being perceived as athletic, and safety concerns. They acknowledged the existence of programs addressing T2DM prevention in their community but did not participate. They endorsed preferences for group sessions, with family collaboration and childcare, that addressed healthy cooking and physical activity and incorporated traditional elements. CONCLUSION: Cree mothers with a history of GDM highlighted several barriers to diabetes prevention. We are working to address these barriers through the creation of a Cree-facilitator-led community-based intervention.

Anthropological perspectives on Miyupimaatisiiun and the integration of oral health in primary care in the Cree communities of Northern Quebec.

The integration of primary oral health care has a pivotal role in improving oral health outcomes and providing accessible and affordable health care. This article contributes to the deep understanding of the cultural aspects of the integration of oral health into primary health care at an Indigenous health organization. Proceeding from a collaborative and interdisciplinary research project evaluating the integration of oral health care within primary care in Eeyou Istchee, this research is based on group discussions (6) and individual interviews (36) with 74 participants (care providers, administrators, and patients) held in four Eastern James Bay Cree communities. This study anthropologically explored participants' perceptions about primary health care conceptualizations, culturally based approaches, and experiences of oral care services at this organization using a "two-eyed seeing" Indigenous framework. The study identified three key factors related to the integration of primary oral health care: Cree perception of primary health and oral health care, cultural safety, and health provider-patient communication and the role of silence. Study findings reflected a dichotomy of perception of primary health care and the relevant units of care between the Cree structural and cultural perspective and the non-Cree professional perspective. The Cree people perceived "household" as a unit of care in comparison to non-Cree who viewed "health care services" as units of care. Our results also underline the role of cultural safety agents to address the needs for cultural competence and the role of silence as implicit cultural protocol. Our anthropological analysis illustrates the potential for increasing the level of appreciation for both users and workers in oral care in the future by ameliorating communication skills and intercultural knowledge.

Importance of Indigenous elders' contributions to individual and community wellness: results from a scoping review on social participation and intergenerational solidarity.

OBJECTIVE: Wellness is a challenge for Indigenous peoples, partly because Western services do not adopt a holistic approach. By devaluing traditional knowledge, Indigenous values and beliefs, these services lower Indigenous power and affect cultural identities. Indigenous elders participate in intergenerational solidarity by transmitting knowledge, values, and culture in a holistic approach. Despite widespread acceptance of the importance of Indigenous elders' contributions to wellness, a rigorous synthesis of knowledge has never been done. This study aimed to provide a comprehensive understanding of how Indigenous elders' social participation contributes to individual and community wellness. METHOD: A scoping review was conducted with Indigenous elders and stakeholders in Québec (Canada). Sixteen databases were searched with 57 keywords. Data from the documents retrieved were analyzed, organized, and synthesized based on the International Classification of Functioning, Disability and Health. SYNTHESIS: A total of 144 documents were examined, comprising 74 scientific papers and 70 sources from the gray literature. Indigenous elders contributed to wellness mainly through relationships and interactions with other community members and non-Indigenous people (72.2%); intergenerational oral and written communications (70.1%); community, social and civic life (45.8%); volunteering and jobs (35.4%); and family life (29.9%). Elders transmit traditional knowledge, strengthen social cohesion, and help to develop positive attitudes such as reciprocity. Their actions favour disease prevention and health promotion, as including traditional approaches increases the acceptability of health and social services. CONCLUSION: This scoping review highlights the need for longitudinal studies with mixed-method designs involving Indigenous communities at all stages of the research to deepen understanding of the contributions of Indigenous elders to individual and community wellness.

Relational continuity of oral health care in Indigenous communities: a qualitative study.

BACKGROUND: The relational continuity of care is an essential function of primary health care. This study reports on the perspectives of Cree communities and their primary health care providers regarding the barriers and enablers of relational continuity of oral health care integrated at a primary health care organization. METHODS: A multiple case study design within a qualitative approach and developmental evaluation methodology were used to conduct this research study in Cree communities of Northern Québec. Maximum variation sampling and snowball techniques were used to recruit the participants. Data collection consisted of individual interviews and focus group discussions. Thematic analysis was conducted which included transcription, debriefing, codification, data display, and interpretation. The consolidated criteria for reporting qualitative studies (COREQ) were used to guide the reporting of study findings. RESULTS: A total of six focus group discussions and 36 individual interviews were conducted. Five major themes emerged from the thematic analyses for barriers (two) and enablers (three). Themes for barriers included impermanence and lack of effective communication, whereas themes for enablers included culturally competent professionals, working across professional boundaries, and proactive organizational engagement. CONCLUSIONS: Based on these findings, relational continuity can be empowered by effective strategies for overcoming barriers and encouraging enablers, such as recruitment of permanent professionals, organizing cultural competency training, development of a Cree language dental glossary, encouraging inter-professional collaboration, and promoting the organization's efforts.

A minimum evaluation protocol and stepped-wedge cluster randomized trial of ACCESS Open Minds, a large Canadian youth mental health services transformation project.

BACKGROUND: Many Canadian adolescents and young adults with mental health problems face delayed detection, long waiting lists, poorly accessible services, care of inconsistent quality and abrupt or absent inter-service transitions. To address these issues, ACCESS Open Minds, a multi-stakeholder network, is implementing and systematically evaluating a transformation of mental health services for youth aged 11 to 25 at 14 sites across Canada. The transformation plan has five key foci: early identification, rapid access, appropriate care, the elimination of age-based transitions between services, and the engagement of youth and families. METHODS: The ACCESS Open Minds Research Protocol has multiple components including a minimum evaluation protocol and a stepped-wedge cluster randomized trial, that are detailed in this paper. Additional components include qualitative methods and cost-effectiveness analyses. The services transformation is being evaluated at all sites via a minimum evaluation protocol. Six sites are participating in the stepped-wedge trial whereby the intervention (a service transformation along the key foci) was rolled out in three waves, each commencing six months apart. Two sites, one high-population and one low-population, were randomly assigned to each of the three waves, i.e., randomization was stratified by population size. Our primary hypotheses pertain to increased referral numbers, and reduced wait times to initial assessment and to the commencement of appropriate care. Secondary hypotheses pertain to simplified pathways to care; improved clinical, functional and subjective outcomes; and increased satisfaction among youth and families. Quantitative measures addressing these hypotheses are being used to determine the effectiveness of the intervention. DISCUSSION: Data from our overall research strategy will help test the effectiveness of the ACCESS Open Minds transformation, refine it further, and inform its scale-up. The process by which our research strategy was developed has implications for the practice of research itself in that it highlights the need to actively engage all stakeholder groups and address unique considerations in designing evaluations of complex healthcare interventions in multiple, diverse contexts. Our approach will generate both concrete evidence and nuanced insights, including about the challenges of conducting research in real-world settings. More such innovative approaches are needed to advance youth mental health services research. TRIAL REGISTRATION NUMBER: Clinicaltrials.gov, ISRCTN23349893 (Retrospectively registered: 16/02/2017).

Patients' perspectives on integrated oral healthcare in a northern Quebec Indigenous primary health care organisation: a qualitative study.

OBJECTIVE: Patient-centred care is considered to be an important element in the evaluation of integrated healthcare and has been effective in addressing oral health disparities. This study explored the patients' perspectives of patient-centred integrated care in oral health services integrated into a primary healthcare organisation serving a northern Quebec Cree population. DESIGN: This study used a multiple case study design within a qualitative approach and developmental evaluation methodology. Two theoretical models, Picker's Principles of Patient-Centred Care and Valentijn's Rainbow Model of Integrated Care, guided data collection and data analysis. The thematic analysis included transcription, debriefing, codification, data display and interpretation. SETTING: This study was conducted in purposefully selected four Cree communities of Northern Quebec. PARTICIPANTS: Adult patients in need of oral healthcare and who attended the local dental clinic were identified and recruited by maximum variation sampling and snowball techniques. OUTCOME MEASURES: Patients' perspectives of patient-centred integrated oral healthcare. RESULTS: Data analysis generated six major themes: enhanced accessibility, creating supportive environment, building trust through shared decision making, appreciation of public health programmes, raising oral health awareness and growing cultural humility among healthcare providers. Patients identified the integration of dental care into primary healthcare with respect to co-location, provision of free oral healthcare services, care coordination and continuity of care, referral services, developing supportive environment, shared decision making, oral health promotion and culturally competent care. CONCLUSION: These results confirmed that patient-centred care is an important element of integrated care. Patients valued the use of this concept in all domains and levels of integration. They recommended to further strengthen the clinical integration by involving parents in oral health promotion as well as optimising care coordination and empowering a supportive environment in organisational integration.

Diabetes in pregnancy in associations with perinatal and postneonatal mortality in First Nations and non-Indigenous populations in Quebec, Canada: population-based linked birth cohort study.

OBJECTIVE: Both pregestational and gestational diabetes mellitus (PGDM, GDM) occur more frequently in First Nations (North American Indians) pregnant women than their non-Indigenous counterparts in Canada. We assessed whether the impacts of PGDM and GDM on perinatal and postneonatal mortality may differ in First Nations versus non-Indigenous populations. DESIGN: A population-based linked birth cohort study. SETTING AND PARTICIPANTS: 17 090 First Nations and 217 760 non-Indigenous singleton births in 1996-2010, Quebec, Canada. MAIN OUTCOME MEASURES: Relative risks (RR) of perinatal and postneonatal death. Perinatal deaths included stillbirths and neonatal (0-27 days of postnatal life) deaths; postneonatal deaths included infant deaths during 28-364 days of life. RESULTS: PGDM and GDM occurred much more frequently in First Nations (3.9% and 10.7%, respectively) versus non-Indigenous (1.1% and 4.8%, respectively) pregnant women. PGDM was associated with an increased risk of perinatal death to a much greater extent in First Nations (RR=5.08[95% CI 2.99 to 8.62], p<0.001; absolute risk (AR)=21.6 [8.6-34.6] per 1000) than in non-Indigenous populations (RR=1.76[1.17, 2.66], p=0.003; AR=4.2[0.2, 8.1] per 1000). PGDM was associated with an increased risk of postneonatal death in non-Indigenous (RR=3.46[1.71, 6.99], p<0.001; AR=2.4[0.1, 4.8] per 1000) but not First Nations (RR=1.16[0.28, 4.77], p=0.35) infants. Adjusting for maternal and pregnancy characteristics, the associations were similar. GDM was not associated with perinatal or postneonatal death in both groups. CONCLUSIONS: The study is the first to reveal that PGDM may increase the risk of perinatal death to a much greater extent in First Nations versus non-Indigenous populations, but may substantially increase the risk of postneonatal death in non-Indigenous infants only. The underlying causes are unclear and deserve further studies. We speculate that population differences in the quality of glycaemic control in diabetic pregnancies and/or genetic vulnerability to hyperglycaemia's fetal toxicity may be contributing factors.

Mental Health in the Cree Peoples of Northern Quebec: Relationships Among Trauma, Familial Psychological Distress, and Mood or Anxiety Disorders.

OBJECTIVE: This study examined the physical and mental health of Cree adults, as well as the personal, clinical, and environmental factors associated with the presence of lifetime anxiety and mood disorders. METHODS: Mental health was assessed using the computerised version of the Diagnostic Interview Schedule (CDIS-IV), and standardised instruments were used to assess physical health, addiction severity, and psychological distress in 506 randomly selected participants from 4 Northern Cree communities in Quebec. RESULTS: Overall, 46.1% of participants reported chronic medical problems, 42.1% were current smokers and 34.5% met the DSM-IV criteria for an anxiety or mood disorder. Individuals with an anxiety or mood disorder were younger, predominantly female, and with higher educational levels, and a large proportion (47.7%) met the lifetime criteria for substance dependence. Hierarchical regression determined that anxiety or mood disorders were associated with serious problems getting along with parents, a history of physical and sexual abuse, and a lifetime diagnosis of substance dependence. Overall, 29.7% of Cree adults reported sexual abuse, 47.1% physical abuse, and 52.9% emotional abuse. CONCLUSIONS: This study highlights the high rates of physical and mental health problems in Cree communities and the association among parental history of psychological problems, history of abuse, and psychological distress. Participants expressed a desire for additional medical and psychological treatments to address the patterns of abuse, trauma, and mental disorders that are burdening the Cree communities in Northern Quebec.

Canadian response to need for transformation of youth mental health services: ACCESS Open Minds (Esprits ouverts).

AIM: Youth mental health is of paramount significance to society globally. Given early onset of mental disorders and the inadequate access to appropriate services, a meaningful service transformation, based on globally recognized principles, is necessary. The aim of this paper is to describe a national Canadian project designed to achieve transformation of mental health services and to evaluate the impact of such transformation on individual and system related outcomes. METHOD: We describe a model for transformation of services for youth with mental health and substance abuse problems across 14 geographically, linguistically and culturally diverse sites, including large and small urban, rural, First Nations and Inuit communities as well as homeless youth and a post-secondary educational setting. The principles guiding service transformation and objectives are identical across all sites but the method to achieve them varies depending on prevailing resources, culture, geography and the population to be served and how each community can best utilize the extra resources for transformation. RESULTS: Each site is engaged in community mapping of services followed by training, active stakeholder engagement with youth and families, early case identification initiatives, providing rapid access (within 72 hours) to an assessment of the presenting problems, facilitating connection to an appropriate service within 30 days (if required) with no transition based on age within the 11 to 25 age group and a structured evaluation to track outcomes over the period of the study. CONCLUSIONS: Service transformation that is likely to achieve substantial change involves very detailed and carefully orchestrated processes guided by a set of values, principles, clear objectives, training and evaluation. The evidence gathered from this project can form the basis for scaling up youth mental health services in Canada across a variety of environments.

Determinants of tuberculosis trends in six Indigenous populations of the USA, Canada, and Greenland from 1960 to 2014: a population-based study.

BACKGROUND: Tuberculosis continues to disproportionately affect many Indigenous populations in the USA, Canada, and Greenland. We aimed to investigate whether population-based tuberculosis-specific interventions or changes in general health and socioeconomic indicators, or a combination of these factors, were associated with changes in tuberculosis incidence in these Indigenous populations. METHODS: For this population-based study we examined annual tuberculosis notification rates between 1960 and 2014 in six Indigenous populations of the USA, Canada, and Greenland (Inuit [Greenland], American Indian and Alaska Native [Alaska, USA], First Nations [Alberta, Canada], Cree of Eeyou Istchee [Quebec, Canada], Inuit of Nunavik [Quebec, Canada], and Inuit of Nunavut [Canada]), as well as the general population of Canada. We used mixed-model linear regression to estimate the association of these rates with population-wide interventions of bacillus Calmette-Guérin (BCG) vaccination of infants, radiographic screening, or testing and treatment for latent tuberculosis infection (LTBI), and with other health and socioeconomic indicators including life expectancy, infant mortality, diabetes, obesity, smoking, alcohol use, crowded housing, employment, education, and health expenditures. FINDINGS: Tuberculosis notification rates declined rapidly in all six Indigenous populations between 1960 and 1980, with continued decline in Indigenous populations in Alberta, Alaska, and Eeyou Istchee thereafter but recrudescence in Inuit populations of Nunavut, Nunavik, and Greenland. Annual percentage reductions in tuberculosis incidence were significantly associated with two tuberculosis control interventions, relative to no intervention, and after adjustment for infant mortality and smoking: BCG vaccination (-11%, 95% CI -6 to -17) and LTBI screening and treatment (-10%, -3 to -18). Adjusted associations were not significant for chest radiographic screening (-1%, 95% CI -7 to 5). Declining tuberculosis notification rates were significantly associated with increased life expectancy (-37·8 [95% CI -41·7 to -33·9] fewer cases per 100 000 for each 1-year increase) and decreased infant mortality (-9·0 [-9·5 to -8·6] fewer cases per 100 000 for each death averted per 1000 livebirths) in all six Indigenous populations, but no significant associations were observed for other health and socioeconomic indicators examined. INTERPRETATION: Population-based BCG vaccination of infants and LTBI screening and treatment were associated with significant decreases in tuberculosis notification rates in these Indigenous populations. These interventions should be reinforced in populations still affected by tuberculosis, while also addressing the persistent health and socioeconomic disparities. FUNDING: Public Health Department of the Cree Board of Health and Social Services of James Bay.

Estimating the incidence of interstitial lung diseases in the Cree of Eeyou Istchee, northern Québec.

BACKGROUND: Little is known about the epidemiology of interstitial lung disease (ILD) amongst Canada's Indigenous populations. Clinicians working in Eeyou Istchee (the Cree territory of the James Bay region of Québec, population 17, 956) suspected that ILD was more common in this area. We sought to identify all prevalent and incident cases of ILD in Eeyou Istchee between 2006 and 2013, to describe characteristics of affected patients, distribution of subtypes, and estimate disease incidence. METHODS: Potential ILD cases amongst Eeyou Istchee residents were identified by searching hospitalization databases and lists of patients on long term home oxygen in the region's nine communities, and surveying physicians and nurses. Clinical, radiological and pathological data were reviewed. Potential cases were classified as 'Definite ILD' if an open lung biopsy demonstrated ILD or, in the absence of histopathologic confirmation, if their thoracic CT imaging was deemed consistent with ILD by a panel of two respirologists and a chest radiologist. Potential cases for whom CT images could not be retrieved for our review were not eligible for classification as Definite ILD, unless they had undergone open lung biopsy. The Definite ILD group was further categorized by subtype of ILD. For usual interstitial pneumonia and non-specific interstitial pneumonitis patterns, we assumed cases were idiopathic in the absence of documentation of connective tissue disease or occupational exposures in the medical chart. For Definite ILD and the most common subtype, we calculated the average annual incidence rates, age-standardized to the province of Quebec, for 2006 to 2013, using a gamma distribution to calculate 95% confidence intervals. RESULTS: Of 167 potential cases, 52 were categorized as Definite ILD: 14 on the basis of histopathology and 38 on the basis of CT imaging alone. Six patients had a prior history of connective tissue disease. Information on occupation was recorded in the charts of 18/52 (35%) cases, and missing in the remainder. We found the most common subtype was idiopathic pulmonary fibrosis (27/52, 52%), followed by idiopathic non-specific interstitial pneumonia (13/52, 25%), and secondary usual interstitial pneumonia associated with connective tissue diseases (5/52, 10%). The age-standardized annual incidence between 2006-2013 was 80 per 100,000 person-years observed (PYO) for ILD, and 46 per 100,000 PYO for idiopathic pulmonary fibrosis. INTERPRETATION: The incidence of ILD and of idiopathic pulmonary fibrosis in Eeyou Istchee may be higher than rates reported in other populations; however, cautious interpretation is required due to the lack of histopathological confirmation in the majority of cases, and our reliance on chart review to exclude secondary causes. A prospective study of incident cases with standardized assessments to establish the types of ILD and to assess for potential causes could overcome some of the limitations of the present analysis. Studies evaluating ILD incidence and subtype distribution in other Indigenous populations would also be of interest.

Disparities in infant hospitalizations in Indigenous and non-Indigenous populations in Quebec, Canada.

BACKGROUND: Infant mortality is higher in Indigenous than non-Indigenous populations, but comparable data on infant morbidity are lacking in Canada. We evaluated disparities in infant morbidities experienced by Indigenous populations in Canada. METHODS: We used linked population-based birth and health administrative data from Quebec, Canada, to compare hospitalization rates, an indicator of severe morbidity, in First Nations, Inuit and non-Indigenous singleton infants (< 1 year) born between 1996 and 2010. RESULTS: Our cohort included 19 770 First Nations, 3930 Inuit and 225 380 non-Indigenous infants. Compared with non-Indigenous infants, all-cause hospitalization rates were higher in First Nations infants (unadjusted risk ratio [RR] 2.05, 95% confidence interval [CI] 1.99-2.11; fully adjusted RR 1.43, 95% CI 1.37-1.50) and in Inuit infants (unadjusted RR 1.96, 95% CI 1.87-2.05; fully adjusted RR 1.37, 95% CI 1.24-1.52). Higher risks of hospitalization (accounting for multiple comparisons) were observed for First Nations infants in 12 of 16 disease categories and for Inuit infants in 7 of 16 disease categories. Maternal characteristics (age, education, marital status, parity, rural residence and Northern residence) partly explained the risk elevations, but maternal chronic illnesses and gestational complications had negligible influence overall. Acute bronchiolitis (risk difference v. non-Indigenous infants, First Nations 37.0 per 1000, Inuit 39.6 per 1000) and pneumonia (risk difference v. non-Indigenous infants, First Nations 41.2 per 1000, Inuit 61.3 per 1000) were the 2 leading causes of excess hospitalizations in Indigenous infants. INTERPRETATION: First Nations and Inuit infants had substantially elevated burdens of hospitalizations as a result of diseases of multiple systems. The findings identify substantial unmet needs in disease prevention and medical care for Indigenous infants.

A scoping review protocol on social participation of indigenous elders, intergenerational solidarity and their influence on individual and community wellness.

INTRODUCTION: Indigenous elders have traditionally played an important role in maintaining social cohesion within their communities. Today, part of this role has been taken over by government social and healthcare services, but they are having limited success in addressing social challenges. Increasing elders' social participation and intergenerational solidarity might foster community development and benefit young people, families, communities and the elders themselves. However, knowledge of the contribution of elders' social participation and intergenerational solidarity to wellness is scattered and needs to be synthesised. This protocol presents a scoping review on the social participation of indigenous elders, intergenerational solidarity and their influence on individual and community wellness. METHODS AND ANALYSIS: This scoping review protocol is based on an innovative methodological framework designed to gather information from the scientific and grey literature and from indigenous sources. It was developed by an interdisciplinary team including indigenous scholars/researchers, knowledge users and key informants. In addition to searching information databases in fields such as public health and indigenous studies, an advisory committee will ensure that information is gathered from grey literature and indigenous sources. ETHICS: The protocol was approved by the Ethics Review Board of the Université du Québec en Abitibi-Témiscamingue and the First Nations of Quebec and Labrador Health and Social Services Commission. DISCUSSION: The comprehensive synthesis of the scientific and grey literature and indigenous sources proposed in this protocol will not only raise awareness within indigenous communities and among healthcare professionals and community organisations, but will also enable decision-makers to better meet the needs of indigenous people. CONCLUSION: The innovative methodological framework proposed in this scoping review protocol will yield richer information on the contribution of elders to community wellness. This work is an essential preliminary step towards developing research involving indigenous communities, drawing on the social participation of elders and intergenerational solidarity.

Macrosomia, Perinatal and Infant Mortality in Cree Communities in Quebec, 1996-2010.

BACKGROUND: Cree births in Quebec are characterized by the highest reported prevalence of macrosomia (~35%) in the world. It is unclear whether Cree births are at greater elevated risk of perinatal and infant mortality than other First Nations relative to non-Aboriginal births in Quebec, and if macrosomia may be related. METHODS: This was a population-based retrospective birth cohort study using the linked birth-infant death database for singleton births to mothers from Cree (n = 5,340), other First Nations (n = 10,810) and non-Aboriginal (n = 229,960) communities in Quebec, 1996-2010. Community type was ascertained by residential postal code and municipality name. The primary outcomes were perinatal and infant mortality. RESULTS: Macrosomia (birth weight for gestational age >90th percentile) was substantially more frequent in Cree (38.0%) and other First Nations (21.9%) vs non-Aboriginal (9.4%) communities. Comparing Cree and other First Nations vs non-Aboriginal communities, perinatal mortality rates were 1.52 (95% confidence intervals 1.17, 1.98) and 1.34 (1.10, 1.64) times higher, and infant mortality rates 2.27 (1.71, 3.02) and 1.49 (1.16, 1.91) times higher, respectively. The risk elevations in perinatal and infant death in Cree communities attenuated after adjusting for maternal characteristics (age, education, marital status, parity), but became greater after further adjustment for birth weight (small, appropriate, or large for gestational age). CONCLUSIONS: Cree communities had greater risk elevations in perinatal and infant mortality than other First Nations relative to non-Aboriginal communities in Quebec. High prevalence of macrosomia did not explain the elevated risk of perinatal and infant mortality in Cree communities.

Traumatic brain injury in a rural indigenous population in Canada: a community-based approach to surveillance.

BACKGROUND: Indigenous populations are disproportionately affected by traumatic brain injury. These populations rely on large jurisdiction surveillance efforts to inform their prevention strategies, which may not address their needs. We examined the incidence and determinants of traumatic brain injury in an indigenous population in the Terres-Cries-de-la-Baie-James health region of the province of Quebec and compared them with the incidence and determinants in 2 neighbouring health regions and in the province overall. METHODS: We conducted a retrospective population-based cohort study of patients in Quebec admitted to hospital with incident traumatic brain injury, stratified by health region (Terres-Cries-de-la-Baie-James, Nunavik and Nord-du-Québec), from 2000 to 2012. We used MED-ÉCHO administrative data for case-finding. A subgroup analysis of adults in the Terres-Cries-de-la-Baie-James health region was completed to assess determinants of the severity of traumatic brain injury and patient outcomes. RESULTS: A total of 172 hospital admissions for incident traumatic brain injury occurred in the Terres-Cries-de-la-Baie-James region during the study period. The incidence was 92.1 per 100 000 person-years, and the adjusted incidence rate ratio was 1.84 (95% confidence interval 1.56-2.17) compared with the entire province. The incidence was higher than in the neighbouring nonindigenous population (Nord-du-Québec) but significantly lower than in the neighbouring indigenous population (Nunavik). Determinants of traumatic brain injury in the Terres-Cries-de-la-Baie-James region differed from those in the neighbouring populations and in the entire province. INTERPRETATION: We found that the incidence rates and determinants of traumatic brain injury requiring hospital admission varied greatly between the three regions studied. Community-based surveillance efforts should be encouraged to inform the development of relevant prevention strategies.

The Social and Psychological Impacts of Gambling in the Cree Communities of Northern Québec.

A detailed survey of gambling, addiction and mental health was conducted with randomly selected respondents (n = 506) from four Cree communities of Northern Quebec. The study examined the current patterns of gambling in relation to demographic, social, and psychological factors. Instruments included the Canadian Problem Gambling Index, Addiction Severity Index, Beck Depression Inventory and the computerized Diagnostic Interview Schedule for psychiatric diagnoses. Overall, 69.2 % of the total sample participated in any gambling/gaming activities over the past year; 20.6 % of this group were classified as moderate/high risk gamblers, and 3.2 % were classified in the highest "problem gambling" category. Considering the entire sample, the overall prevalence of problem gambling was 2.2 %. Women were significantly more likely to play bingo (56.6 %) compared to men (35.1 %) and they played more frequently; 20.8 % of women versus 3.8 % of men played once/week or more often. Compared to the no/low risk gamblers, a greater proportion of moderate/high risk gamblers were cigarette smokers (44.8 vs. 56.3 %), they were more likely to meet DSM-IV diagnostic criteria for alcohol dependence (21.2 vs. 46.2 %), and they were more likely to report moderate to severe depressive symptoms in the past month. Risk factors for problem gambling included traumatic life events (physical and emotional abuse), anxiety and depression, as well as drug/alcohol abuse. The high rates of comorbidity between problem gambling, tobacco dependence, substance abuse and other psychological problems demonstrate that gambling among some Cree adults is part of a pattern of high-risk factors for negative long-term health consequences. The results also have implications for treatment, suggesting that interventions for gambling disorders should not focus on gambling alone but rather the constellation of high-risk behaviours that pose a risk to recovery and well-being.

Disparities and Trends in Birth Outcomes, Perinatal and Infant Mortality in Aboriginal vs. Non-Aboriginal Populations: A Population-Based Study in Quebec, Canada 1996-2010.

BACKGROUND: Aboriginal populations are at substantially higher risks of adverse birth outcomes, perinatal and infant mortality than their non-Aboriginal counterparts even in developed countries including Australia, U.S. and Canada. There is a lack of data on recent trends in Canada. METHODS: We conducted a population-based retrospective cohort study (n = 254,410) using the linked vital events registry databases for singleton births in Quebec 1996-2010. Aboriginal (First Nations, Inuit) births were identified by mother tongue, place of residence and Indian Registration System membership. Outcomes included preterm birth, small-for-gestational-age, large-for-gestational-age, low birth weight, high birth weight, stillbirth, neonatal death, postneonatal death, perinatal death and infant death. RESULTS: Perinatal and infant mortality rates were 1.47 and 1.80 times higher in First Nations (10.1 and 7.3 per 1000, respectively), and 2.37 and 4.46 times higher in Inuit (16.3 and 18.1 per 1000, respectively) relative to non-Aboriginal (6.9 and 4.1 per 1000, respectively) births (all p<0.001). Compared to non-Aboriginal births, preterm birth rates were persistently (1.7-1.8 times) higher in Inuit, large-for-gestational-age birth rates were persistently (2.7-3.0 times) higher in First Nations births over the study period. Between 1996-2000 and 2006-2010, as compared to non-Aboriginal infants, the relative risk disparities increased for infant mortality (from 4.10 to 5.19 times) in Inuit, and for postneonatal mortality in Inuit (from 6.97 to 12.33 times) or First Nations (from 3.76 to 4.25 times) infants. Adjusting for maternal characteristics (age, marital status, parity, education and rural vs. urban residence) attenuated the risk differences, but significantly elevated risks remained in both Inuit and First Nations births for the risks of perinatal mortality (1.70 and 1.28 times, respectively), infant mortality (3.66 and 1.47 times, respectively) and postneonatal mortality (6.01 and 2.28 times, respectively) in Inuit and First Nations infants (all p<0.001). CONCLUSIONS: Aboriginal vs. non-Aboriginal disparities in adverse birth outcomes, perinatal and infant mortality are persistent or worsening over the recent decade in Quebec, strongly suggesting the needs for interventions to improve perinatal and infant health in Aboriginal populations, and for monitoring the trends in other regions in Canada.