The influence of community well-being on mortality among Registered First Nations people.

BACKGROUND: Living in a community with lower socioeconomic status is associated with higher mortality. However, few studies have examined associations between community socioeconomic characteristics and mortality among the First Nations population. DATA AND METHODS: The 1991-to-2006 Census Mortality and Cancer Cohort follow-up, which tracked a 15% sample of Canadians aged 25 or older, included 57,300 respondents who self-identified as Registered First Nations people or Indian band members. The Community Well-Being Index (CWB), a measure of the social and economic well-being of communities, consists of income, education, labour force participation, and housing components. A dichotomous variable was used to indicate residence in a community with a CWB score above or below the average for First Nations communities. Age-standardized mortality rates (ASMRs) were calculated for First Nations cohort members in communities with CWB scores above and below the First Nations average. Cox proportional hazards models examined the impact of CWB when controlling for individual characteristics. RESULTS: The ASMR for First Nations cohort members in communities with a below-average CWB was 1,057 per 100,000 person-years at risk, compared with 912 for those in communities with an above-average CWB score. For men, living in a community with below-average income and labour force participation CWB scores was associated with an increased hazard of death, even when individual socioeconomic characteristics were taken into account. Women in communities with below-average income scores had an increased hazard of death. INTERPRETATION: First Nations people in communities with below-average CWB scores tended to have higher mortality rates. For some components of the CWB, effects remained even when individual socioeconomic characteristics were taken into account.

Sexual risk and healthcare seeking behaviour in young Aboriginal and Torres Strait Islander people in North Queensland.

UNLABELLED: Background Compared with non-Indigenous Australians, Aboriginal and Torres Strait Islander people have higher rates of sexually transmissible infections (STI). The identification of the sexual risk and healthcare seeking behaviours of young Aboriginal and Torres Strait Islander people in a regional Australian setting was sought. METHODS: A cross-sectional survey of 155 young Aboriginal and Torres Strait Islander people (16-24 years) in Townsville was conducted. RESULTS: Most participants (83%) reported ever having had sex, with a median age of 15 years at first sex and a range from 9 to 22 years. While young men reported more sexual partners in the last 12 months than young women, they were also more likely to report condom use at the last casual sex encounter (92% vs 68%, P=0.006). Young women were significantly more likely than young men to report never carrying condoms (35% vs 16%); however, they were more likely to have had STI testing (53% vs 28%, P=0.004). Of those reporting previous STI testing, 29% reported ever being diagnosed with an STI. CONCLUSIONS: The sample of young Aboriginal and Torres Strait Islander people reported an early age at first sex, variable condom use and low uptake of STI testing. The high prevalence of self-reported STI diagnoses indicate a need for opportunistic sexual health education and efforts designed to promote the uptake of STI screening in this group.

Unintentional injury hospitalizations and socio-economic status in areas with a high percentage of First Nations identity residents.

BACKGROUND: Few national studies of hospitalizations due to injuries among the First Nations population have been conducted. DATA AND METHODS: Based on 2004/2005 to 2009/2010 data from the Discharge Abstract Database, this study examines associations between unintentional injury hospitalizations, socio-economic status and location relative to an urban core in Dissemination Areas (DAs) with a high percentage of First Nations identity residents versus a low percentage of Aboriginal identity residents. RESULTS: Unintentional injury hospitalization rates were higher in the less affluent and the most remote DAs. When DAs with the same socio-economic status and location were compared, the risk of hospitalizations was greater in high-percentage First Nations identity DAs relative to low-percentage Aboriginal identity DAs. INTERPRETATION: Socio-economic conditions and remote location accounted for some, but not all, of the differences in unintentional injury hospitalizations between high-percentage First Nations identity and low-percentage Aboriginal identity DAs. This suggests that characteristics not measured in this analysis--such as environmental, behavioural or other factors--play an additional role in DA-level unintentional injury hospitalization risk.

Mortality among children and youth in high-percentage First Nations identity areas, 2000-2002 and 2005-2007.

INTRODUCTION: Many First Nations children live in communities that face diverse social and health challenges compared with their non-Aboriginal peers, including some of the most socio-economically challenging situations in Canada. These differences can be seen in broad indicators of the social determinants of health. Studies of mortality in Aboriginal populations across Canada are often restricted by the lack of Aboriginal identifiers on national death records. While some studies have utilised a record-linkage approach, this is often not possible for the entire country or for recent data. Some researchers have adopted a geographic approach and examined mortality and morbidity in areas that have a high percentage of Aboriginal identity residents, and have uniformly reported elevated rates of mortality and morbidity compared with other areas. The purpose of this article was to examine child and youth mortality (aged 1 to 19 years) in areas where a high percentage of the population identified as First Nations in comparison with areas where there is a low percentage of Aboriginal identity residents. METHODS: Using a geographic threshold table approach, areas with a high percentage of Aboriginal identity peoples were classified as either First Nations, Métis, or Inuit communities based on the predominant identity group. The upper one-third of the total Aboriginal population distribution was used as a cut-off for high percentage First Nations areas, where 97.7% of the population aged 1-19 were of First Nations identity in 2006 (N=140 779). Mortality rates were then calculated for high-percentage First Nations identity areas and compared with low-percentage Aboriginal identity areas, excluding high-percentage Métis or Inuit identity areas. Deaths were aggregated for the 3 years surrounding the 2001 and 2006 census periods, and a total of 473 deaths were recorded for 2000-2002 and 493 deaths for 2005-2007. Analysis was facilitated via the correspondence of six-digit residential postal codes on vital statistics records to census geographical areas using automated geo-coding software (Statistics Canada; PCCF+). RESULTS: Age-standardized mortality rates for children and youth in high-percentage First Nations identity areas were significantly higher than in low-percentage Aboriginal identity areas. The rate ratio for all-cause mortality for boys was 3.2 (CI: 2.9-3.6) for 2005-2007 and 3.6 (CI: 3.2-4.2) for girls. Mortality rates for injuries had the largest difference, with rate ratios of 4.7 (CI: 4.0-5.5) and 5.3 (CI:4.5-6.3) for boys in 2000-2002 and 2005-2007 and 5.5 (CI: 4.4-6.8) and 8.3 (CI: 6.8-10.1) for girls in the same period. CONCLUSION: A strength of this study is that it is the first to use national-level vital statistics registration data across two time periods to report mortality by cause for children and youth living in high-percentage First Nations areas. Vital events were geographically coded to high-percentage First Nations identity areas and compared with low-percentage Aboriginal identity areas at the Dissemination Areas level. This area-based methodology allows for mortality to be calculated for children and youth by sex and by detailed cause of death for multiple time periods. The results provide key evidence for the persistent differences in the causes of death for children and youth living in high-percentage First Nations identity areas.

The contribution of neighbourhood material and social deprivation to survival: a 22-year follow-up of more than 500,000 Canadians.

BACKGROUND: We examined the incremental influence on survival of neighbourhood material and social deprivation while accounting for individual level socioeconomic status in a large population-based cohort of Canadians. METHODS: More than 500,000 adults were followed for 22 years between 1982 and 2004. Tax records provided information on sex, income, marital status and postal code while a linkage was used to determine vital status. Cox models were used to estimate hazard ratios (HR) for quintiles of neighbourhood material and social deprivation. RESULTS: There were 180,000 deaths over the follow-up period. In unadjusted analyses, those living in the most materially deprived neighbourhoods had elevated risks of mortality (HR(males) 1.37, 95% CI: 1.33-1.41; HR(females) 1.20, 95% CI: 1.16-1.24) when compared with those living in the least deprived neighbourhoods. Mortality risk was also elevated for those living in socially deprived neighbourhoods (HR(males) 1.15, CI: 1.12-1.18; HR(females) 1.15, CI: 1.12-1.19). Mortality risk associated with material deprivation remained elevated in models that adjusted for individual factors (HR(males) 1.20, CI: 1.17-1.24; HR(females) 1.16, CI: 1.13-1.20) and this was also the case for social deprivation (HR(males) 1.12, CI: 1.09-1.15; HR(females) 1.09, CI: 1.05-1.12). Immigrant neighbourhoods were protective of mortality risk for both sexes. Being poor and living in the most socially advantageous neighbourhoods translated into a survival gap of 10% over those in the most socially deprived neighbourhoods. The gap for material neighbourhood deprivation was 7%. CONCLUSIONS: Living in socially and materially deprived Canadian neighbourhoods was associated with elevated mortality risk while we noted a "healthy immigrant neighbourhood effect". For those with low family incomes, living in socially and materially deprived areas negatively affected survival beyond their individual circumstances.

Mortality rates among children and teenagers living in Inuit Nunangat, 1994 to 2008.

BACKGROUND: Because Vital Statistics data do not include information on Inuit identity in all jurisdictions, mortality rates cannot be calculated specifically for Inuit. However, Inuit in Canada are geographically concentrated--78% live in Inuit Nunangat, and 82% of the area's total population identify as Inuit. While there are limitations, geographic approaches can be employed to calculate mortality for the population of that area. DATA AND METHODS: The Vital Statistics Database (1994 to 2008) and population estimates were used to calculate age-standardized mortality rates (ASMRs) in five-year intervals around the 1996 and 2006 Census years. Mortality rates were calculated for 1- to 19-year-olds living in Inuit Nunangat and those living elsewhere in Canada. RESULTS: The ASMR in 2004-2008 for 1- to 19-year-olds in Inuit Nunangat was 188.0 deaths per 100,000 person-years at risk, five times the rate (35.3) elsewhere in Canada. The disparity had not narrowed over the previous decade. In Inuit Nunangat, injuries were responsible for 64% of deaths of children and teenagers, compared with 36% in the rest of Canada. INTERPRETATION: The persistently high mortality rates for children and teenagers living in Inuit Nunangat, compared with the rest of Canada, are important in understanding the health and socio-economic situation of residents of this region.

Unintentional injury hospitalizations among children and youth in areas with a high percentage of Aboriginal identity residents: 2001/2002 to 2005/2006.

BACKGROUND: Because administrative data typically do not contain Aboriginal identifiers, national unintentional injury hospitalization rates among Aboriginal children have not been reported. This study examines rates of unintentional injury hospitalization for children in areas with a high-percentage Aboriginal identity population. DATA AND METHODS: Data are from the Hospital Morbidity Database (2001/2002 to 2005/2006). Rates of unintentional injury hospitalization were calculated for 0- to 19-year-olds in census Dissemination Areas (DAs) where at least 33% of residents reported an Aboriginal identity. DAs were classified as high-percentage First Nations, Métis or Inuit identity based on the predominant group. RESULTS: Unintentional injury hospitalization rates of children and youth in high-percentage Aboriginal identity areas were at least double the rate for their contemporaries in low-percentage Aboriginal identity areas. Falls and land transportation were the most common causes of unintentional injury hospitalization, regardless of Aboriginal identity status, but disparities between rates for high- and low-percentage Aboriginal identity areas were often greatest for less frequent causes, such as fire, natural/environmental, and drowning/ suffocation. INTERPRETATION: The geographic areas where children live were associated with hospitalization rates for injury.

Geozones: an area-based method for analysis of health outcomes.

BACKGROUND: Administrative datasets often lack information about individual characteristics such as Aboriginal identity and income. However, these datasets frequently contain individual-level geographic information (such as postal codes). This paper explains the methodology for creating Geozones, which are area-based thresholds of population characteristics derived from census data, which can be used in the analysis of social or economic differences in health and health service utilization. DATA AND METHODS: With aggregate 2006 Census information at the Dissemination Area level, population concentration and exposure for characteristics of interest are analysed using threshold tables and concentration curves. Examples are presented for the Aboriginal population and for income gradients. RESULTS: The patterns of concentration of First Nations people, Métis, and Inuit differ from those of non-Aboriginal people and between urban and rural areas. The spatial patterns of concentration and exposure by income gradients also differ. INTERPRETATION: The Geozones method is a relatively easy way of identifying areas with lower and higher concentrations of subgroups. Because it is ecological-based, Geozones has the inherent strengths and weaknesses of this approach.

Neighbourhood variation in hospitalization for unintentional injury among children and teenagers.

BACKGROUND: Research suggests that living in more affluent neighbourhoods positively influences children's health. Relationships with injury are less clear. This study examines variations in rates of unintentional injury hospitalization by neighbourhood income for the population aged 0 to 19 in urban Canada. DATA AND METHODS: Acute-care inpatient hospitalization discharge records from 2001/2002 through 2004/2005 for 0-to 19-year-olds were examined. Injuries were classified using the International Classification of Diseases. Census Dissemination Areas were used as neighbourhood proxies; income quintiles were calculated from the 2001 Census. Age-standardized rates of hospitalization per 10,000 person-years at risk were calculated for each type of injury, by sex, age group and neighbourhood income quintile. RESULTS: Children and teenagers in the lowest neighbourhood income quintile generally had a higher rate of unintentional injury hospitalization than did those in the highest. The pattern was particularly evident among children aged 0 to 9 in lower-income neighbourhoods for injuries due to land transportation, poisoning, fire, drowning/ suffocation, being cut or pierced, and the natural environment. INTERPRETATION: Canadian children in lower-income neighbourhoods generally have higher rates of hospitalization due to unintentional injuries, compared with children in higher-income neighbourhoods.

Are obesity and physical activity clustered? A spatial analysis linked to residential density.

The aim of this study was to examine spatial clustering of obesity and/or moderate physical activity and their relationship to a neighborhood's built environment. Data on levels of obesity and moderate physical activity were derived from the results of a telephone survey conducted in 2006, with 1,863 survey respondents in the study sample. This sample was spread across eight suburban neighborhoods in Metro Vancouver. These areas were selected to contrast residential density and income and do not constitute a random sample, but within each area, respondents were selected randomly. Obesity and moderate physical activity were mapped to determine levels of global and local spatial autocorrelation within the neighborhoods. Clustering was measured using Moran's I at the global level, Anselin's Local Moran's I at the local level, and geographically weighted regression (GWR). The global-level spatial analysis reveals no significant clustering for the attributes of obesity or moderate physical activity. Within individual neighborhoods, there is moderate clustering of obesity and/or physical activity but these clusters do not achieve statistical significance. In some neighborhoods, local clustering is restricted to a single pair of respondents with moderate physical activity. In other neighborhoods, any moderate local clustering is offset by negative local spatial autocorrelation. Importantly, there is no evidence of significant clustering for the attribute of obesity at either the global or local level of analysis. The GWR analysis fails to improve significantly upon the global model-thus reinforcing the negative results. Overall, the study indicates that the relationship between the urban environment and obesity is not direct.

Neighbourhood quality and self-rated health: a survey of eight suburban neighbourhoods in the Vancouver Census Metropolitan Area.

We investigated the relationship between perceptions of neighbourhood quality and self-rated health for residents of eight suburban neighbourhoods with modestly contrasting income profiles in the Vancouver Census Metropolitan Area. Survey respondents from lower income neighbourhoods more often rated their health as fair/poor, and perceived their neighbourhood to be of poor quality. The strongest predictors for fair/poor health status were employment status, body mass index, neighbourhood satisfaction, and age, while modest predictors were annual household income, neighbourhood median income profile, and perceptions of neighbourhood safety. The unique contribution of this study is its demonstration that social gradients in self-rated health are observable between neighbourhoods of even modestly contrasting income profiles.

Effects of neighbourhood income on reported body mass index: an eight year longitudinal study of Canadian children.

BACKGROUND: This study investigates the effects of neighbourhood income on children's Body Mass Index (BMI) from childhood (ages 2-3) to early adolescence (ages 10-11) using longitudinal data. METHODS: Five cycles of data from the Canadian National Longitudinal Survey of Children and Youth are analyzed for a sub-sample of children (n = 2152) aged 2-3 at baseline (1994) and assessed at two year intervals to 2002. Body mass index percentiles are based on height/weight estimates reported by proxy respondents (child's person most knowledgeable). Family and neighbourhood factors were assessed at baseline. The prevalence of neighbourhood low income was obtained from the 1996 Census and divided into three categories from 'most poor' to 'least poor'. Longitudinal modelling techniques were applied to the data. RESULTS: After controlling for individual/family factors (age, sex, income, education, family structure) living in the 'most poor' neighbourhood was associated with increasing BMI percentile (1.46, 95% CI 0.16 to 2.75) over time compared to a 'middle' income neighbourhood. Living in an urban (vs. rural) neighbourhood was associated with a decreased BMI percentile (-3.57, 95% CI -6.38 to -0.76) across all time periods. CONCLUSION: These findings provide evidence that effects of neighbourhood disadvantage on children's BMI occur between childhood and early adolescence and suggest that policies should target the conditions of childhood, including the neighbourhood environment.

A meta-analysis of randomised controlled trials assessing drug-eluting stents and vascular brachytherapy in the treatment of coronary artery in-stent restenosis.

OBJECTIVE: We undertook a meta-analysis of randomised trials assessing the outcome of vascular brachytherapy (VBT) or DES for the treatment of coronary artery ISR. METHODS AND RESULTS: Studies utilising DES or VBT for ISR were identified by a systematic search. Data was pooled and combined overall effect measures were calculated for a random effect model in terms of deaths, myocardial infarctions, revascularisation, binary restenosis, mean late luminal loss and major adverse cardiac events (MACE). Fourteen eligible studies (3103 patients) were included. Neither therapy had any effect on mortality or myocardial infarction rate. VBT reduced the rate of revascularisation (RR 0.59, 95%CI 0.50-0.68), MACE (RR 0.58, 95%CI 0.51-0.67), binary restenosis (RR 0.51, 95%CI 0.44-0.59) and late loss (-0.73 mm, 95%CI -0.91 to -0.55 mm) compared to balloon angioplasty and selective bare metal stents (BMS) alone at intermediate follow-up and MACE (RR 0.72, 95%CI 0.61-0.85) at long-term follow-up. DES reduced the rate of revascularisation (OR 0.51, 95% CI 0.36-0.71), MACE (OR 0.55, 95% CI 0.39-0.79) and binary restenosis (OR 0.57, 95% CI 0.40-0.81) compared to VBT but follow-up was limited to 9 months. CONCLUSIONS: VBT improves the long-term outcome of angioplasty compared with BMS alone in the treatment of ISR. DES appears to provide similar results to that of VBT during short-term follow-up.

Does choice of spatial unit matter for estimating small-area disparities in health and place effects in the Vancouver Census Metropolitan Area?

BACKGROUND: The purposes of this study were to determine (i) the extent to which small-area estimates of self-rated health are dependent upon the choice of areal unit and measure of socio-economic (SES) status, and (ii) the extent to which place effects on self-rated health are dependent upon the choice of areal unit and measure of SES. METHODS: The data were obtained from a subset of respondents in the Canadian Community Health Survey 2.1 (2003) aged 18 to 74 residing in the Vancouver Census Metropolitan Area. General health status was estimated using an item assessing respondents' self-rated health. Small-area data were obtained from the Statistics Canada 2001 Census at two spatial levels: larger Census Tract (CT) (average population 2,500-8,000) and smaller Dissemination Area (DA) (average population 400-700). SES quintiles were constructed using median family income and two indices. Hierarchical non-linear modelling was used to test for place effects. RESULTS: A gradient was found of increasing prevalence of "fair or poor" self-rated health by decreasing SES quintile at both the DA and CT level. With age category, sex, family income and education controlled for, hierarchical analysis showed that compared with living in a high SES CT or DA the odds of reporting fair or poor self-rated health increased for respondents living in the lowest quintile CT or DA. INTERPRETATION: Aggregation using DAs or CTs produces only small differences in estimates of fair or poor self-rated health by quintiles of SES. Gradients are somewhat stronger for DAs. Place effects are somewhat stronger for deprivation indices than the measure of median income.

Comparing circular and network buffers to examine the influence of land use on walking for leisure and errands.

BACKGROUND: There is increasing interest in examining the influence of the built environment on physical activity. High-resolution data in a geographic information system is increasingly being used to measure salient aspects of the built environment and studies often use circular or road network buffers to measure land use around an individual's home address. However, little research has examined the extent to which the selection of circular or road network buffers influences the results of analysis. The objective of this study is to examine the influence of land use type (residential, commercial, recreational and park land and institutional land) on 'walking for leisure' and 'walking for errands' using 1 km circular and line-based road network buffers. Data on individual walking patterns is obtained from a survey of 1311 respondents in greater Vancouver and respondent's postal code centroids were used to construct the individual buffers. Logistic regression was used for statistical analysis. RESULTS: Using line-based road network buffers, increasing proportion of institutional land significantly reduced the odds of 'walking for leisure 15 minutes or less per day' no significant results were found for circular buffers. A greater proportion of residential land significantly increased the odds of 'walking for errands less than 1 hour per week' for line-based road network buffer while no significant results for circular buffers. An increased proportion of commercial land significantly decreased the odds of 'walking for errands less than 1 hour per week' for both circular and line-based road network buffers. CONCLUSION: The selection of network or circular buffers has a considerable influence on the results of analysis. Land use characteristics generally show greater associations with walking using line-based road network buffers than circular buffers. These results show that researchers need to carefully consider the most appropriate buffer with which to calculate land use characteristics.

Neighbourhood socio-economic status and the prevalence of overweight Canadian children and youth.

BACKGROUND: The purposes of this study are to determine (i) if neighbourhood socioeconomic status (SES) is systematically related to the prevalence of overweight children and youth in Canada, (ii) if the factors accounting for the apparent relationship have face validity, and (iii) if neighbourhood SES has an independent influence on this distribution. METHODS: Cross-sectional data from Cycle 4 (2000/2001) of the National Longitudinal Survey of Children and Youth were used. Children and youth aged 5 to 17 were included. Overweight was established using age and sex cut-off points. Neighbourhood socioeconomic data were obtained from the Statistics Canada 2001 Dissemination Area databases and SES quartiles constructed using a composite of socio-economic variables. Hierarchical non-linear modelling was used to test for independent neighbourhood effects. RESULTS: A gradient of increasing overweight prevalence by decreasing neighbourhood SES quartiles was observed (24% high SES, 30% mid-high SES, 33% mid-low SES, 35% low SES). Controlling for individual age, gender, family income and education hierarchical analysis found that a child's odds of being overweight increases if living in a low versus a high SES neighbourhood (OR=1.29, 95% CI=1.14-1.46). INTERPRETATION: The prevalence of child and youth overweight in Canada is inversely and statistically significantly related to neighbourhood SES. Independent effects indicate that neighbourhood characteristics directly influence the odds of being overweight. This research suggests that consideration of opportunity structures that exist in different types of neighbourhoods is fundamentally important to health promotion and disease prevention strategies.