Wîcohkamakew ("S/he Helps Someone"): A Qualitative Description of Experiences with a Community-derived Elders Mentoring Program for Indigenous Parents-to-be.

BACKGROUND: Responding to concerns about perinatal health risks and adverse outcomes, we established a community-based participatory research (CBPR) partnership between a Nêhiyawi (Cree) community and university-based researchers. We designed and implemented a community-derived Elders Mentoring Program (EMP) to provide additional support for pregnant women and their partners. Our objective was to understand the collective experiences of those involved in the Program. METHODS: We conducted a qualitative description with the principles of CBPR as an overarching framework. We carried out 14 qualitative interviews with parents, perinatal clinic staff, and mentor Elders involved in the Program. We also used detailed notes from Community Advisory Committee (CAC) meetings as data. All qualitative data were analyzed with content analysis. RESULTS: The Program helped pregnant women and their partners by fostering enhanced and multi-generational support networks. It also improved cultural security within the clinical environment and learning among health care staff. A sense of intergenerational fulfillment and enjoyment among those involved was common and was underpinned by genuine, collaborative relationships. CONCLUSIONS: A community-derived prenatal EMP, designed in partnership with those who have intimate knowledge of the community, is a major step toward ensuring multi-generational and culturally secure care in pregnancy for women and families.

Explaining the variability in cardiovascular risk factors among First Nations communities in Canada: a population-based study.

BACKGROUND: Historical, colonial, and racist policies continue to influence the health of Indigenous people, and they continue to have higher rates of chronic diseases and reduced life expectancy compared with non-Indigenous people. We determined factors accounting for variations in cardiovascular risk factors among First Nations communities in Canada. METHODS: Men and women (n=1302) aged 18 years or older from eight First Nations communities participated in a population-based study. Questionnaires, physical measures, blood samples, MRI of preclinical vascular disease, and community audits were collected. In this cross-sectional analysis, the main outcome was the INTERHEART risk score, a measure of cardiovascular risk factor burden. A multivariable model was developed to explain the variations in INTERHEART risk score among communities. The secondary outcome was MRI-detected carotid wall volume, a measure of subclinical atherosclerosis. FINDINGS: The mean INTERHEART risk score of all communities was 17·2 (SE 0·2), and more than 85% of individuals had a risk score in the moderate to high risk range. Subclinical atherosclerosis increased significantly across risk score categories (p<0·0001). Socioeconomic advantage (-1·4 score, 95% CI -2·5 to -0·3; p=0·01), trust between neighbours (-0·7, -1·2 to -0·3; p=0·003), higher education level (-1·9, -2·9 to -0·8, p<0·001), and higher social support (-1·1, -2·0 to -0·2; p=0·02) were independently associated with a lower INTERHEART risk score; difficulty accessing routine health care (2·2, 0·3 to 4·1, p=0·02), taking prescription medication (3·5, 2·8 to 4·3; p<0·001), and inability to afford prescription medications (1·5, 0·5 to 2·6; p=0·003) were associated with a higher INTERHEART risk score. Collectively, these factors explained 28% variation in the cardiac risk score among communities. Communities with higher socioeconomic advantage and greater trust, and individuals with higher education and social support, had a lower INTERHEART risk score. Communities with difficulty accessing health care, and individuals taking or unable to afford prescription medications, had a higher INTERHEART risk score. INTERPRETATION: Cardiac risk factors are lower in communities with high socioeconomic advantage, greater trust, social support and educational opportunities, and higher where it is difficult to access health care or afford prescription medications. Strategies to optimise the protective factors and reduce barriers to health care in First Nations communities might contribute to improved health and wellbeing. FUNDING: Heart and Stroke Foundation of Canada, Canadian Partnership Against Cancer, Canadian Institutes for Health Research.

Peyakohewamak-Needs of Involved Nehiyaw (Cree) Fathers Supporting Their Partners During Pregnancy: Findings From the ENRICH Study.

We sought to understand the needs of involved Nehiyaw (Cree) fathers who supported their partners during pregnancy. We used qualitative description and a community-based participatory research approach. We carried out in-depth semi-structured interviews with six Nehiyaw fathers. Four also participated in photovoice and follow-up interviews. All data were content analyzed qualitatively. Fathers felt they had to support their partners and overcome challenges resulting from intergenerational colonial impacts (residential schools particularly) by reclaiming their roles and acknowledging the pregnancy as a positive change. Providing support was possible through their own strong support system stemming from family, faith, culture, and a stable upbringing with positive male role models and intact Nehiyaw kinships. Perinatal programming did little to include fathers. Attempts to improve perinatal care and outcomes should allow more inclusion of and support for Indigenous fathers through genuinely incorporating into care traditional culture and Elders, families, flexibility, cultural understanding, and reconciliation.

Canadian Alliance for Healthy Hearts and Minds: First Nations Cohort Study Rationale and Design.

BACKGROUND: This is the first national indigenous cohort study in which a common, in-depth protocol with a common set of objectives has been adopted by several indigenous communities across Canada. OBJECTIVES: The overarching objective of the Canadian Alliance for Healthy Hearts and Minds (CAHHM) cohort is to investigate how the community-level environment is associated with individual health behaviors and the presence and progression of chronic disease risk factors and chronic diseases such as cardiovascular disease (CVD) and cancer. METHODS: CAHHM aims to recruit approximately 2,000 First Nations indigenous individuals from up to nine communities across Canada and have participants complete questionnaires, blood collection, physical measurements, cognitive assessments, and magnetic resonance imaging (MRI). RESULTS: Through individual- and community-level data collection, we will develop an understanding of the specific role of the socioenvironmental, biological, and contextual factors have on the development of chronic disease risk factors and chronic diseases. CONCLUSIONS: Information collected in the indigenous cohort will be used to assist communities to develop local management strategies for chronic disease, and can be used collectively to understand the contextual, environmental, socioeconomic, and biological determinants of differences in health status in harmony with First Nations beliefs and reality.

Kikiskawâwasow - prenatal healthcare provider perceptions of effective care for First Nations women: an ethnographic community-based participatory research study.

BACKGROUND: Pregnant Indigenous women suffer a disproportionate burden of risk and adverse outcomes relative to non-Indigenous women. Although there has been a call for improved prenatal care, examples are scarce. Therefore, we explored the characteristics of effective care with First Nations women from the perspective of prenatal healthcare providers (HCPs). METHODS: We conducted an ethnographic community-based participatory research study in collaboration with a large Cree First Nations community in Alberta, Canada. We carried out semi-structured interviews with 12 prenatal healthcare providers (HCPs) that were recorded, transcribed, and subjected to qualitative content analysis. RESULTS: According to the participants, relationships and trust, cultural understanding, and context-specific care were key features of effective prenatal care and challenge the typical healthcare model. HCPs that are able to foster sincere, non-judgmental, and enjoyable interactions with patients may be more effective in treating pregnant First Nations women, and better able to express empathy and understanding. Ongoing HCP cultural understanding specific to the community served is crucial to trusting relationships, and arises from real experiences and learning from patients over and above relying only on formal cultural sensitivity training. Consequently, HCPs report being better able to adapt a more flexible, all-inclusive, and accessible approach that meets specific needs of patients. CONCLUSIONS: Aligned with the recommendations of the Truth and Reconciliation Commission of Canada, improving prenatal care for First Nations women needs to allow for genuine relationship building with patients, with enhanced and authentic cultural understanding by HCPs, and care approaches tailored to women's needs, culture, and context.

High Frequency of Pre-Existing Type 2 Diabetes in a Series of Pregnant Women Referred for "Gestational Diabetes" in a Large Canadian Indigenous Community.

We examined the referral processes and true diagnostic classifications for diabetes complicating pregnancy in a series of 62 pregnant women consecutively referred to a diabetes education and treatment centre in a large Indigenous community in Alberta, Canada. The referrals were made over a 5-year period (2010 to 2015). The main findings of this analysis were the high frequency (38.7%) of pre-existing type 2 diabetes and previously undiagnosed or unrecognized overt diabetes and the deficiencies in early testing and recognition.

Cultural continuity, traditional Indigenous language, and diabetes in Alberta First Nations: a mixed methods study.

INTRODUCTION: We used an exploratory sequential mixed methods approach to study the association between cultural continuity, self-determination, and diabetes prevalence in First Nations in Alberta, Canada. METHODS: We conducted a qualitative description where we interviewed 10 Cree and Blackfoot leaders (members of Chief and Council) from across the province to understand cultural continuity, self-determination, and their relationship to health and diabetes, in the Alberta First Nations context. Based on the qualitative findings, we then conducted a cross-sectional analysis using provincial administrative data and publically available data for 31 First Nations communities to quantitatively examine any relationship between cultural continuity and diabetes prevalence. RESULTS: Cultural continuity, or "being who we are", is foundational to health in successful First Nations. Self-determination, or "being a self-sufficient Nation", stems from cultural continuity and is seriously compromised in today's Alberta Cree and Blackfoot Nations. Unfortunately, First Nations are in a continuous struggle with government policy. The intergenerational effects of colonization continue to impact the culture, which undermines the sense of self-determination, and contributes to diabetes and ill health. Crude diabetes prevalence varied dramatically among First Nations with values as low as 1.2% and as high as 18.3%. Those First Nations that appeared to have more cultural continuity (measured by traditional Indigenous language knowledge) had significantly lower diabetes prevalence after adjustment for socio-economic factors (p =0.007). CONCLUSIONS: First Nations that have been better able to preserve their culture may be relatively protected from diabetes.

Diabetes in pregnancy among First Nations women.

We conducted a focused ethnography with 12 First Nations women who had had diabetes in pregnancy to understand their real-life experiences and find ways to improve care for those with diabetes in pregnancy. We carried out unstructured interviews that were recorded, transcribed, and subject to qualitative content analysis. The experience of diabetes in pregnancy is one wrought with difficulties but balanced to some degree by positive lifestyle changes. Having a strong support system (family, health care, cultural/community, and internal support) and the necessary resources (primarily awareness/education) allows women to take some control of their health. Efforts to improve pregnancy care for First Nations women should take a more patient-centered care approach and strive to enhance the support systems of these women, increase their sense of autonomy, and raise awareness of diabetes in pregnancy and its accompanying challenges.

Diabetes in pregnancy among First Nations women in Alberta, Canada: a retrospective analysis.

BACKGROUND: In addition to increasing the risk of adverse birth outcomes, diabetes in pregnancy is thought to be an important driver of the epidemic of type 2 diabetes affecting Canada's First Nations population. The relative contributions of gestational diabetes mellitus (GDM) and pre-existing diabetes are not well understood. We generated a comprehensive epidemiological profile of diabetes in pregnancy over a 10-year period among the First Nations population of Alberta, Canada. METHODS: De-identified administrative data for 427,058 delivery records were obtained for the years 2000-2009. Pregnancy risk factors and delivery outcomes were described and compared by ethnicity (First Nations vs. non-First Nations) and diabetes status. Age-adjusted prevalence values for GDM and pre-existing diabetes were calculated and were compared by ethnicity. Longitudinal changes over time were also examined. Predictors were explored using logistic regression analysis. RESULTS: First Nations women had more antenatal risk factors and adverse infant outcomes that were compounded by diabetes. First Nations descent was an independent predictor of diabetes in pregnancy (p < 0.001). GDM prevalence was significantly higher among First Nations (6.1%) compared to non-First Nations women (3.8%; p < 0.001), but prevalence values increased significantly over time only in non-First Nations women (4.5 average annual percent change; p < 0.05). The prevalence of pre-existing diabetes was stable over time in both groups, but First Nations women experienced a 2.5-fold higher overall prevalence compared with non-First Nations women (1.5% vs. 0.6%, respectively; p < 0.001). CONCLUSIONS: Although First Nations women experience a higher overall prevalence of diabetes in pregnancy, the lack of increase in the prevalence over time is encouraging. However, because high-risk pregnancies and poor outcomes are more common among First Nations women, particularly those with diabetes, strategies to improve perinatal care must be implemented.

Increasing rates of diabetes amongst status Aboriginal youth in Alberta, Canada.

OBJECTIVES: To track and compare trends in diabetes rates from 1995 to 2007 for Status Aboriginal and general population youth. STUDY DESIGN: Longitudinal observational research study (quantitative) using provincial administrative data. METHODS: De-identified data was obtained from Alberta Health and Wellness administrative databases for Status Aboriginal (First Nations and Inuit people with Treaty status) and general population youth (<20 years). Diabetes cases were identified using the National Diabetes Surveillance System algorithm. Crude annual diabetes prevalence and incidence rates were calculated. The likelihood of being a prevalent case and incident case of diabetes for the 2 populations was compared for the year 2007. Average Annual Percent Changes (AAPC) in prevalence and incidence from 1995 to 2007 were determined and compared between the 2 groups to examine trends over time. RESULTS: While the prevalence of diabetes was higher in the general population in 1995, by 2007 there were no between group differences, reflected in the significantly higher AAPC of 6.98 for Status Aboriginal youth. Status Aboriginal males had a lower diabetes risk in 1995 compared with females, and experienced a greater increase in prevalence over the 13 years (AAPC 9.18) so that by 2007 their rates were equivalent to those of the females. Differences in diabetes incidence trends were only observed among male youth, where increases in incidence were greater for Status Aboriginal (AAPC 11.65) compared to general population males (AAPC 4.62) (p = 0.03). CONCLUSION: Youth-onset diabetes is an increasing problem in Alberta, especially among young Status Aboriginal males.

Recent epidemiologic trends of diabetes mellitus among status Aboriginal adults.

BACKGROUND: Little is known about longitudinal trends in diabetes mellitus among Aboriginal people in Canada. We compared the incidence and prevalence of diabetes, and its impact on mortality, among status Aboriginal adults and adults in the general population between 1995 and 2007. METHODS: We examined de-identified data from Alberta Health and Wellness administrative databases for status Aboriginal people (First Nations and Inuit people with treaty status) and members of the general public aged 20 years and older who received a diagnosis of diabetes mellitus from Apr. 1, 1995, to Mar. 31, 2007. We calculated the incidence and prevalence of diabetes and mortality rate ratios by sex and ethnicity in 2007. We examined the average relative changes per year for longitudinal trends. RESULTS: The average relative change per year in the prevalence of diabetes showed a smaller increase over time in the Aboriginal population than in the general population (2.39 v. 4.09, p < 0.001). A similar finding was observed for the incidence of diabetes. In the Aboriginal population, we found that the increase in the average relative change per year was greater among men than among women (3.13 v. 1.88 for prevalence, p < 0.001; 2.60 v. 0.02 for incidence, p = 0.001). Mortality among people with diabetes decreased over time to a similar extent in both populations. Among people without diabetes, mortality decreased in the general population but was unchanged in the Aboriginal population (-1.92 v. 0.11, p = 0.04). Overall, mortality was higher in the Aboriginal population than in the general population regardless of diabetes status. INTERPRETATION: The increases in the incidence and prevalence of diabetes over the study period appeared to be slower in the status Aboriginal population than in the general population in Alberta, although the overall rates were higher in the Aboriginal population. Mortality decreased among people with diabetes in both populations but was higher overall in the Aboriginal population regardless of diabetes status.

Emerging longitudinal trends in health indicators for rural residents participating in a diabetes and cardiovascular screening program in northern Alberta, Canada.

Background. Geographic isolation, poverty, and loss of culture/tradition contribute to "epidemic" rates of diabetes amongst indigenous Canadians. The Mobile Diabetes Screening Initiative travels to rural indigenous and other remote communities in Alberta to screen for diabetes and cardiovascular risk. We sought to examine risk factors longitudinally. Methods. Clinical and anthropometric measurements were undertaken for 809 adults (aged 20-91) between November 2003 and December 2009. For those who had more than one MDSi visit, trend estimates (actual changes) were calculated for body mass index (BMI), weight, waist circumference, hemoglobin A1c (A1c), total cholesterol, and blood pressure. Results. Among those without diabetes (N = 629), BMI and weight increased (P < .01) and blood pressure decreased (P < .05). For those with diabetes (N = 180), significant improvements (P < .05) were observed for all indicators except waist circumference. Conclusion. Improvements observed suggest that MDSi's model may effectively mediate some barriers and support subjects in managing their health.

What happens after community-based screening for diabetes in rural and Indigenous individuals?

Rural individuals (mostly Indigenous) were screened for undiagnosed diabetes and cardiovascular risk. A subsequent survey showed roughly half engaged in timely follow-up with the health care system. The Mobile Diabetes Screening Initiative identifies a substantial number of people needing medical attention, who may otherwise be "missed" through conventional healthcare delivery.

Improvements in indicators of diabetes-related health status among first nations individuals enrolled in a community-driven diabetes complications mobile screening program in Alberta, Canada.

OBJECTIVE: The goal of Screening for Limb, I-Eye, Cardiovascular, and Kidney complications of diabetes (SLICK) is to reduce the burden of diabetes among Alberta First Nations individuals. By analyzing the longitudinal results of SLICK over a six-year time span, our purpose was to examine both baseline diabetes-related health status and whether subsequent improvements occurred. METHODS: Diabetes complications screening, diabetes education, and community-based care were provided by mobile clinics which traveled to 43 Alberta First Nations communities biannually. Body mass index (BMI), waist circumference, hemoglobin A1c (HbA1c), total cholesterol and blood pressure, as well as the presence of foot and kidney abnormalities were assessed among 2102 unique subjects with diabetes. Mean values of diabetes health indicators at baseline and subsequent visits for returning subjects were compared. Secular trends were sought by examining trends in mean baseline health indicators per year. RESULTS: High baseline rates of obesity, poor HbAlc concentrations, hypercholesterolemia, hypertension, foot abnormalities and kidney damage were observed. Significant improvements in BMI, blood pressure, total cholesterol and HbA1c concentrations were identified (p < 0.01) in returning subjects. Similarly, significant decreasing secular trends in total cholesterol and HbA1c concentrations were observed (p < 0.01). At baseline, females had a higher prevalence of obesity and abnormal waist circumference (p < 0.05); however, males had more inadequate HbA1c concentrations (>8.4%), hypercholesterolemia, hypertension, foot abnormalities and kidney damage (p < 0.05). DISCUSSION: Despite worrisome baseline clinical characteristics, diabetes-related health appears to be improving modestly in Alberta First Nations individuals.

Increasing incidence and prevalence of diabetes among the Status Aboriginal population in urban and rural Alberta, 1995-2006.

OBJECTIVE: To compare changes in diagnosed diabetes prevalence and incidence among Status Aboriginal men and women living in urban and rural areas of Alberta. METHODS: We compared trends in diabetes prevalence and incidence from 1995 to 2006 based on diagnostic codes from Alberta Health and Wellness (AHW) administrative records for adults aged 20 years and older. The AHW Registry file was used to determine registered Aboriginal status, as well as rural and urban residence (based on postal code). Multivariable logistic regression was used to compare diabetes rates over time, by sex and location of residence. RESULTS: Age- and sex-adjusted diabetes prevalence increased 35% in rural Status Aboriginals, from 10.9 (10.4-11.5) per 100 in 1995 to 14.7 (14.2-15.2) per 100 in 2006. Rates in urban Status Aboriginals increased 22% in the same time period from 9.4 (8.5-10.3) per 100 in 1995 to 11.5 (10.9-12.1) per 100 in 2006. The increases in prevalence were greater (p < 0.001) for men (43% and 40%) compared to women (30% and 12%) in rural and urban settings, respectively. Diabetes incidence increased 45% in Status Aboriginal men, from 7.4 (4.9-10.6) per 1000 in 1995 to 10.7 (8.3-13.5) per 1000 in 2006 in urban locations, compared to a 35% increase among Status Aboriginal men living in rural locations (p = 0.628). Among Status Aboriginal women, incidence increased by 25% for those living in urban locations, but did not change for those in rural locations (p = 0.109). CONCLUSIONS: Prevalence and incidence of diagnosed diabetes were highest in Status Aboriginal women, but these rates have increased faster in men over the past decade, regardless of their location of residence.

Differences in the prevalence of diabetes risk-factors among First Nation, Métis and non-Aboriginal adults attending screening clinics in rural Alberta, Canada.

INTRODUCTION: Populations that are developing (westernizing) are suffering the highest rates of increases in diabetes incidence and prevalence worldwide, with the most notable and documented increases in Canada seen among the First Nations. Less is known about the Métis (mixed blood) or the rural populations in general. To date, no studies have assessed the contributions of ethnicity to diabetes risk-factors. Our objective was to examine diabetes risk factors in First Nations, Métis and non-Aboriginal individuals residing in rural or remote locations, investigating whether ethnicity contributed to any differences. METHODS: From the databases of three separate community-based diabetes screening projects in Alberta we created a unique subject pool of 3148 adults without diabetes (1790 First Nation, 867 Métis, and 491 non-Aboriginals). Age, body mass index (BMI), waist circumference, reported history of gestational diabetes (GDM) or babies over nine pounds (females only), hemoglobin A1c (A1c) fasting plasma glucose (FPG) or random plasma glucose (RPG) were assessed. Chi-square tests and logistic regression analysis were used to identify between-group differences. RESULTS: The highest mean values for waist circumference (104.7 cm) and BMI (31.2) were found in First Nations subjects (p<0.01). First Nations individuals had the highest prevalence of overweight/obesity (84.4%), abnormal waist circumference (76.8%) and history of GDM (9.0%) (p<0.01). The RPG was also higher in First Nations, but there were no differences between groups with respect to mean FPG and A1c levels, and there were no differences with respect to the prevalence of pre-diabetes or undiagnosed diabetes. Métis (OR 0.80; p = 0.01) and non-Aboriginal individuals (OR 0.62; p< 0.01) were less likely to be obese after age/gender adjustment, compared with First Nations. Métis (OR 0.70; p<0.01) and non-Aboriginals (OR 0.35; p<0.01) were also less likely than the First Nations group to have abnormal waist circumferences. Individuals in the non-Aboriginal group had a lower prevalence of pre-diabetes (OR 0.50; p = 0.01) compared with both the Métis and First Nations groups. CONCLUSIONS: First Nations individuals had more risk factors for diabetes than Métis and non-Aboriginal individuals, although Métis rates appeared intermediate. While these risk-factor differences did not translate to more undiagnosed diabetes or pre-diabetes, they are consistent with known rates of diagnosed diabetes in Alberta.

Diabetes care and health status of First Nations individuals with type 2 diabetes in Alberta.

OBJECTIVE: To describe the state of diabetes care among Alberta First Nations individuals with diabetes living on reserves. DESIGN: Survey and screening for diabetes-related complications. SETTING: Forty-three Alberta First Nations communities. PARTICIPANTS: A total of 743 self-referred First Nations individuals with known diabetes. MAIN OUTCOME MEASURES: Clinical measurements (glycated hemoglobin A(1c) levels, body mass index, waist circumference, total cholesterol, blood pressure, and the presence of kidney complications or proteinuria, retinopathy, and foot abnormalities), self-reported health services utilization, clinical history, and knowledge of and satisfaction with diabetes services. RESULTS: Female participants tended to be more obese (P < .05) and to have abnormal waist circumferences more often than men (P < .05). Male participants, however, had a higher proportion of proteinuria (P < .05), hypertension (P < .05), limb complications (P < .05), and retinopathy (P < .05). Family physicians were the main diabetes care providers for most participants. Nearly half the participants felt they did not have care from a diabetes team. A total of 38% had never seen dietitians. Diabetes-related concerns were responsible for 24% of all hospitalizations and emergency department visits. Approximately 46% and 21% of participants had recommended hemoglobin A(1c) testing and foot examinations, respectively. Only 24% of participants with kidney complications were receiving treatment. A considerable proportion of participants had undiagnosed complications of diabetes: kidney damage or proteinuria (23%), high cholesterol (22%), foot complications (11%), hypertension (9%), and retinopathy (7%). CONCLUSION: Diabetes care is suboptimal in Alberta First Nations communities. Rural physicians caring for First Nations individuals on reserves should be involved, along with other members of diabetes health care teams, in strategies to improve diabetes care. Our results justify the need for community-based screening for diabetes control and complications in First Nation communities.