Indigenous people's experiences of primary health care in Canada: a qualitative systematic review. / Expériences des Autochtones en matière de soins de santé primaires au Canada : revue systématique qualitative.

INTRODUCTION: Indigenous people in Canada encounter negative treatment when accessing primary health care (PHC). Despite several qualitative accounts of these experiences, there still has not been a qualitative review conducted on this topic. In this qualitative systematic review, we aimed to explore Indigenous people's experiences in Canada with PHC services, determine urban versus rural or remote differences and identify recommendations for quality improvement. METHODS: This review was guided by the Joanna Briggs Institute's methodology for systematic reviews of qualitative evidence. MEDLINE, CINAHL, PubMed, PsycInfo, Embase and Web of Science as well as grey literature and ancestry sources were used to identify relevant articles. Ancestry sources were obtained through reviewing the reference lists of all included articles and determining the ones that potentially met the eligibility criteria. Two independent reviewers conducted the initial and full text screening, data extraction and quality assessment. Once all data were gathered, they were synthesized following the meta-aggregation approach (PROSPERO CRD42020192353). RESULTS: The search yielded a total of 2503 articles from the academic databases and 12 articles from the grey literature and ancestry sources. Overall, 22 articles were included in this review. Three major synthesized findings were revealed-satisfactory experiences, discriminatory attitudes and systemic challenges faced by Indigenous patients-along with one synthesized finding on their specific recommendations. CONCLUSION: Indigenous people value safe, accessible and respectful care. The discrimination and racism they face negatively affect their overall health and well-being. Hence, it is crucial that changes in health care practice, structures and policy development as well as systemic transformation be implemented immediately.

Advancing health equity for Indigenous peoples in Canada: development of a patient complexity assessment framework.

BACKGROUND: Indigenous patients often present with complex health needs in clinical settings due to factors rooted in a legacy of colonization. Healthcare systems and providers are not equipped to identify the underlying causes nor enact solutions for this complexity. This study aimed to develop an Indigenous-centered patient complexity assessment framework for urban Indigenous patients in Canada. METHODS: A multi-phased approach was used which was initiated with a review of literature surrounding complexity, followed by interviews with Indigenous patients to embed their lived experiences of complexity, and concluded with a modified e-Delphi consensus building process with a panel of 14 healthcare experts within the field of Indigenous health to identify the domains and concepts contributing to health complexity for inclusion in an Indigenous-centered patient complexity assessment framework. This study details the final phase of the research. RESULTS: A total of 27 concepts spanning 9 domains, including those from biological, social, health literacy, psychological, functioning, healthcare access, adverse life experiences, resilience and culture, and healthcare violence domains were included in the final version of the Indigenous-centered patient complexity assessment framework. CONCLUSIONS: The proposed framework outlines critical components that indicate the presence of health complexity among Indigenous patients. The framework serves as a source of reference for healthcare providers to inform their delivery of care with Indigenous patients. This framework will advance scholarship in patient complexity assessment tools through the addition of domains not commonly seen, as well as extending the application of these tools to potentially mitigate racism experienced by underserved populations such as Indigenous peoples.

Incorporating First Nations, Inuit and Métis Traditional Healing Spaces within a Hospital Context: A Place-Based Study of Three Unique Spaces within Canada's Oldest and Largest Mental Health Hospital.

Globally and historically, Indigenous healthcare is efficacious, being rooted in Traditional Healing (TH) practices derived from cosmology and place-based knowledge and practiced on the land. Across Turtle Island, processes of environmental dispossession and colonial oppression have replaced TH practices with a colonial, hospital-based system found to cause added harm to Indigenous Peoples. Growing Indigenous health inequities are compounded by a mental health crisis, which begs reform of healthcare institutions. The implementation of Indigenous knowledge systems in hospital environments has been validated as a critical source of healing for Indigenous patients and communities, prompting many hospitals in Canada to create Traditional Healing Spaces (THSs). After ten years, however, there has been no evaluation of the effectiveness of THSs in Canadian hospitals in supporting healing among Indigenous Peoples. In this paper, our team describes THSs within the Center for Addiction and Mental Health (CAMH), Canada's oldest and largest mental health hospital. Analyses of 22 interviews with hospital staff and physicians describe CAMH's THSs, including what they look like, how they are used, and by whom. The results emphasize the importance of designating spaces with and for Indigenous patients, and they highlight the wholistic benefits of land-based treatment for both clients and staff alike. Transforming hospital spaces by implementing and valuing Indigenous knowledge sparks curiosity, increases education, affirms the efficacy of traditional healing treatments as a standard of care, and enhances the capacity of leaders to support reconciliation efforts.

A Systematic Scoping Review of Indigenous People's Experience of Healing and Recovery from Child Sexual Abuse.

Child sexual abuse is a form of violence that occurs across nations and cultures. Collective efforts are being made to address this issue within many Indigenous communities. In Australia, Aboriginal and Torres Strait Islander communities have expressed the need for cultural models of healing child sexual abuse. A preliminary exploration of the relevant literature shows a lack of synthesis with regard to the current evidence base. This protocol outlines the methods and background for a scoping review that aims to explore and collate the broad scope of literature related to healing from child sexual abuse within an Indigenous context. The proposed review utilises a 'population, concept, and context structure' from the Joanna Briggs Institute to explore the broad scope of the literature within a scoping review framework. The target population is Indigenous survivors of child sexual abuse, including Indigenous populations from six distinct regions: Aboriginal and Torres Strait Islander peoples from Australia; Maori peoples from Aotearoa (New Zealand); First Nations, Inuit and Métis peoples from Canada; Native American peoples from North America; Native peoples from Alaska; and the Sámi peoples of the Sápmi region in Northern Europe. The concept within the review is healing from an Indigenous perspective, which includes a broad range of processes related to both recovery and personal growth. The contexts explored within this review are any context in which healing from child sexual abuse can occur. This may include processes related to disclosure and accessing services, specific interventions or programs for survivors of child sexual abuse, as well as broader non-specific healing programs and personal experiences of healing without intervention. The scoping review will use search strings with broad inclusion and exclusion criteria to capture the potential breadth of perspectives. The search will be conducted across several academic databases and will also include an extensive search for grey literature. This protocol establishes the proposed benefits of this scoping review.

Relational Work Is the Work: Virtual Healthcare Transformation for Rural, Remote and First Nations Communities in British Columbia.

The healthcare crisis across unceded First Nations' territories in rural, remote and Indigenous communities in British Columbia (BC) is marked by persistent barriers to accessing care and support close to home. This commentary describes an exceptional story of how technology, trusted partnerships and relationships came together to create an innovative suite of virtual care programs called "Real-Time Virtual Support" (RTVS). We describe key approaches, learnings and future considerations to improve the equity of healthcare delivery for rural, remote and First Nations communities. The key lessons include the following: (1) moving beyond a biomedical model - the collaboration framework for health service design incorporated First Nations' perspective on health and wellness; (2) relational work is the work - the RTVS collaboration was grounded in building connections and relationships to prioritize cultivating trust in the partnership over specific outputs; and (3) aligning to the core values of co-creation - working from a commitment to do things differently and applying an inclusive approach of engagement to integrate perspectives across different sectors and interest groups.

Surveying the landscape: First Nations, Métis, and Inuit cancer resources in radiation therapy.

INTRODUCTION/BACKGROUND: Alberta Health Services (AHS) is Canada's largest provincial integrated health care authority. AHS services over four million people with over 100,000 employees. In 2018, AHS introduced Indigenous training modules which were mandatory for all staff. These eight modules included topics detailing residential schools, Indian hospitals, The Indian Act, The 60's Scoop, Alberta's Indigenous populations, present day realities, including customs, practices and traditional medicines. Limited research exists in general in the field of radiation therapy with Canadian Indigenous populations. No formal research exists on the effectiveness of these AHS training modules. METHODS: A mixed methods survey was developed and distributed by the radiation therapy managers to practicing radiation therapists in the four cancer centers in Alberta. The survey contained both drop down and open text boxes. RESULTS: Survey respondents indicated that 90 % of radiation therapists completed the AHS Indigeneous training modules. However, 50 % of the respondents did not know what resources are available for their Indigenous patients. Furthermore, only 67 % felt that the information provided in the modules created enough comfort for them to have a conversation with Indigenous patients with cancer and their families. DISCUSSION: Respondents indicated that although they felt knowledgeable and educated from the training modules, this did not necessarily translate into daily clinical practice. This included a lack of confidence to lead a conversation, knowing what resources are available and how to document if patient education material was given. CONCLUSION: Creation of an Indigenous specific oncology module highlighting both resource availability and cultural customs that may be part of a person's cancer journey, may be of benefit to health care providers providing radiation treatment. Having Elders and Knowledge Keepers be part of the development of an oncology module may help create mutual understanding for both the cancer patient and their families and health care providers. This research suggests that the current cultural competency training for radiation therapists at AHS may not be enough for radiation therapists to feel comfortable with translating learnings from Indigenous online modules into their practice.

COVID-19 diagnostic testing and vaccinations among First Nations in Manitoba: A nations-based retrospective cohort study using linked administrative data, 2020-2021.

BACKGROUND: Differential access to healthcare has contributed to a higher burden of illness and mortality among First Nations compared to other people in Canada. Throughout the Coronavirus Disease 2019 (COVID-19) pandemic, First Nations organizations in Manitoba partnered with public health and Manitoba government officials to ensure First Nations had early, equitable and culturally safe access to COVID-19 diagnostic testing and vaccination. In this study, we examined whether prioritizing First Nations for vaccination was associated with faster uptake of COVID-19 vaccines among First Nations versus All Other Manitobans (AOM). METHODS AND FINDINGS: In this retrospective cohort study, we used linked, whole-population administrative data from the Manitoba healthcare system (February 2020 to December 2021) to determine rates of COVID-19 diagnostic testing, infection, and vaccination, and used adjusted restricted mean survival time (RMST) models to test whether First Nations received their first and second vaccine doses more quickly than other Manitobans. The cohort comprised 114,816 First Nations (50.6% female) and 1,262,760 AOM (50.1% female). First Nations were younger (72.3% were age 0 to 39 years) compared to AOM (51% were age 0 to 39 years) and were overrepresented in the lowest 2 income quintiles (81.6% versus 35.6% for AOM). The 2 groups had a similar burden of comorbidities (65.8% of First Nations had none and 6.3% had 3 or more; 65.9% of AOM had none and 6.0% had 3 or more) and existing mental disorders (36.9% of First Nations were diagnosed with a mood/anxiety disorder, psychosis, personality disorder, or substance use disorder versus 35.2% of AOM). First Nations had crude infection rates of up to 17.20 (95% CI 17.15 to 17.24) COVID-19 infections/1,000 person-months compared with up to 6.24 (95% CI 6.16 to 6.32) infections/1,000 person-months among AOM. First Nations had crude diagnostic testing rates of up to 103.19 (95% CI 103.06 to 103.32) diagnostic COVID-19 tests/1,000 person-months compared with up to 61.52 (95% CI 61.47 to 61.57) tests/1,000 person-months among AOM. Prioritizing First Nations to receive vaccines was associated with faster vaccine uptake among First Nations versus other Manitobans. After adjusting for age, sex, income, region of residence, mental health conditions, and comorbidities, we found that First Nations residents received their first vaccine dose an average of 15.5 (95% CI 14.9 to 16.0) days sooner and their second dose 13.9 (95% CI 13.3 to 14.5) days sooner than other Manitobans in the same age group. The study was limited by the discontinuation of population-based COVID-19 testing and data collection in December 2021. As well, it would have been valuable to have contextual data on potential barriers to COVID-19 testing or vaccination, including, for example, information on social and structural barriers faced by Indigenous and other racialized people, or the distrust Indigenous people may have in governments due to historical harms. CONCLUSION: In this study, we observed that the partnered COVID-19 response between First Nations and the Manitoba government, which oversaw creation and enactment of policies prioritizing First Nations for vaccines, was associated with vaccine acceptance and quick uptake among First Nations. This approach may serve as a useful framework for future public health efforts in Manitoba and other jurisdictions across Canada.

Healing journey: Experiences of First Nations individuals with recovery from opioid use.

OBJECTIVE: To understand experiences of recovery from opioid use among First Nations individuals living in a small remote community. DESIGN: Qualitative phenomenologic study. SETTING: Northwestern Ontario. PARTICIPANTS: Sixteen First Nations individuals living in a remote community who had participated in or completed the community opioid agonist therapy program. METHODS: Extensive community consultation took place to ensure local acceptance of the study and permission for publication. Semistructured telephone interviews with consenting participants were audiorecorded between November and December 2021 and transcribed. Transcripts were reviewed and discussed in meetings with Indigenous and non-Indigenous research team members who conducted thematic analysis using immersion and crystallization. MAIN FINDINGS: Participants described their opioid use as a form of self-management of trauma. Their recovery processes were multifaceted and included developing cultural and self-awareness. Motivation for change often arose from concerns about family well-being and finances. Traditional cultural practices and time spent on the land were identified as important wellness experiences. Barriers to healing included limited clinical and holistic addiction services, particularly around dose weaning and opioid agonist therapy discontinuation. CONCLUSION: Community-based addiction programming for First Nations patients needs to be robust. It requires resources for trauma-informed clinical and addiction care, culturally appropriate addictions education, aftercare support, and land-based activities.

Assessing Breast Cancer Screening and Outcomes Among First Nations Women in Alberta.

BACKGROUND: Breast cancer (BC) incidence rates for First Nations (FN) women in Canada have been steadily increasing and are often diagnosed at a later stage. Despite efforts to expand the reach of BC screening programs for FN populations in Alberta (AB), gaps in screening and outcomes exist. METHODS: Existing population-based administrative databases including the AB BC Screening Program, the AB Cancer Registry, and an AB-specific FN registry data were linked to evaluate BC screening participation, detection, and timeliness of outcomes in this retrospective study. Tests of proportions and trends compared the findings between FN and non-FN women, aged 50-74 years, beginning in 2008. Incorporation of FN principles of ownership, control, access, and possession (OCAP®) managed respectful sharing and utilization of FN data and findings. RESULTS: The average age-standardized participation (2013-8) and retention rates (2015-6) for FN women compared to non-FN women in AB were 23.8% (P < .0001) and 10.3% (P = .059) lower per year, respectively. FN women were diagnosed with an invasive cancer more often in Stage II (P-value = .02). Following 90% completion of diagnostic assessments, it took 2-4 weeks longer for FN women to receive their first diagnosis as well as definitive diagnoses than non-FN women. CONCLUSION: Collectively, these findings suggest that access to and provision of screening services for FN women may not be equitable and may contribute to higher BC incidence and mortality rates. Collaborations between FN groups and screening programs are needed to eliminate these inequities to prevent more cancers in FN women.

First Nations and Inuit mental health and the Non-Insured Health Benefits program: Urgent priorities for evaluation.

The mental health needs and disparities facing First Nations and Inuit in Canada far exceed those of the general population and yet accessing culturally safe care remains a serious challenge. One means for accessing mental health care is through the Non-Insured Health Benefits (NIHB) mental health counselling program run by Indigenous Services Canada. However, evaluations of the efficacy of the NIHB's mental health counselling program remain entirely absent in the academic literature and this is startling given that this program receives significant federal funding to care for a population that experiences extreme marginalization. The following commentary will present three challenges observed with the present state of the program in the areas of service accessibility, the need for an Indigenous mental health workforce, and culturally safe care. For each challenge presented, we make recommendations on how to improve the program in its current state. The conclusion of this article advocates for a broader evaluation of the NIHB mental health counselling program from the perspective of its service users and its registered mental health professionals. This type of evaluation is commensurate with the Calls to Action outlined by the Truth and Reconciliation Commission of Canada.

RéSUMé: Les besoins en santé mentale et les disparités rencontrés par les Premières Nations et les Inuits au Canada dépassent de loin ceux de la population générale, et pourtant, l'accès à des soins culturellement sécuritaires demeure un sérieux défi. Une des manières d'accéder aux soins de santé mentale est par le biais du programme de counselling en santé mentale des Services de santé non assurés (SSNA), géré par Services aux Autochtones Canada. Cependant, les évaluations de l'efficacité du programme de counselling en santé mentale des SSNA sont entièrement absentes de la littérature académique, ce qui est surprenant compte tenu que ce programme reçoit un financement fédéral important pour prendre en charge une population qui vit une marginalisation extrême. Le commentaire suivant présentera trois défis observés avec l'état actuel du programme dans les domaines de l'accessibilité des services, la nécessité d'une main-d'œuvre en santé mentale autochtone, et des soins culturellement sécuritaires. Pour chaque défi présenté, nous faisons des recommandations sur la manière d'améliorer le programme dans son état actuel. La conclusion de cet article plaide pour une évaluation plus large du programme de counselling en santé mentale des SSNA du point de vue de ses utilisateurs de services et des professionnels de la santé mentale inscrits. Ce type d'évaluation est conforme aux Appels à l'action décrits par la Commission de vérité et réconciliation du Canada.

Effectiveness of RADAR on diabetes processes of care for First Nations communities in Alberta, Canada.

The epidemic of type-2 diabetes in First Nations communities is tragic. Culturally-appropriate approaches addressing multiple components, focusing beyond glycemic control, are urgently needed. Using an intention-to-treat framework, 13 processes of care indicators were assessed to compare proportions of patients who received care at baseline relative to 2-year follow-up. Clinical improvements were demonstrated across major process of care indicators (e.g. screening, education, and vaccination activities). We found RADAR improved reporting for most diabetes processes of care across seven FN communities and was effective in supporting diabetes care for FN communities, in Alberta Canada.

Recurrent child protection post-investigation services for First Nations children in the province of Quebec.

BACKGROUND: The longitudinal trajectory of Indigenous children within child protection (CP) services, including their recurrent involvement, has yet to be documented. OBJECTIVES: 1) To document whether First Nations children were at increased risk of a first recurrence of post-investigation CP services compared to children from the majority group. 2) To identify the characteristics associated with recurrence for First Nations children, and to compare these results to those for children from the majority group. METHOD: Anonymized CP administrative data (2002-2014; n = 1150) of a region in the province of Quebec were used to conduct Cox proportional hazards modeling, in partnership with an advisory committee. RESULTS: The risk of recurrence of First Nations children did not significantly differ from the risk for children from the majority group (HR: 0.980, n.s.) while controlling for covariates. Among First Nations children (n = 459), being under two at the case closure (HR: 2.718, p < .05), having received short-term intervention (HR: 5.027, p < .001) and coming from a family already known to the CP agency (HR: 2.023, p < .001) were associated with an increased risk of recurrence. CONCLUSIONS: The findings highlight the importance of studying First Nations children's trajectories within CP services as a group deserving full attention and for First Nations to be able to design or demand appropriate services responding to their population's needs. A family-based research perspective is recommended to understand better the full family history leading to and in relation to CP services, which could provide more sound practice recommendations.

Canine Support Program: Student perceptions and preferences at a regional university and implications for health, well-being, and student support enhancements.

ISSUE ADDRESSED: Canine Support Programs (CSPs) are a potential solution to growing university student support demands. While current studies focus on the impacts of CSPs, there is limited understanding of the views and expectations of tertiary students about CSPs. This study explored the perceptions and preferences of students in an Australian regional university about CSPs. METHODS: A questionnaire with multiple choice and open-ended questions surveyed residential students' perspectives about CSP. Data were analysed using descriptive statistical tests and thematic analysis for open responses. RESULTS: Majority (98%) of participants (sample n = 48) would support a CSP on campus. Frequent, small-group interactions of ≥15 min involving physical contact were preferred. Dog disposition, welfare-trained handlers, and veterinary certification were important aspects of program safety. Participants strongly agreed a CSP would improve mental health and well-being, relieve stress, reduce feelings of homesickness, provide support, comfort, and enable social interactions. CONCLUSION: There is strong support among the study population for CSP to be established on campus. This study supports earlier research that CSP has benefit potential for new, stressed, and/or students who love dogs. The preferences of students should inform program design to enhance utility and impact. This aligns with Health Promoting Universities and College's Okanagan Charter principle of 'engaging student voices'. More institutional awareness and support for CSPs will be necessary for integration. SO WHAT?: This study reveals the need for tailored and creative student support beyond traditional offerings including those that focus on student well-being and social initiatives. CSPs can be utilised as an advocate, enabler, and medium for mental health promotion action and well-being support for tertiary students; thereby, contributing to the 'Health Promoting University' agenda in Australia. It also reinforces the need for a Health in All Policies approach to be incorporated into our tertiary education sector. Future actions should focus on improving institutional awareness, support, and sector implementation.

Knowledge Gaps Regarding Indigenous Health in Occupational Therapy: A National Survey.

Background. There is a need for the occupational therapy profession to respond to the Truth and Reconciliation Commission of Canada Calls to Action and work towards supporting the health and well-being of Indigenous Peoples. Purpose. (1) To determine the knowledge gaps of occupational therapists about Indigenous health and (2) to create recommendations to address identified gaps and inform responses from the profession. Method. A national needs survey was created and distributed to occupational therapists across Canada to determine the knowledge of occupational therapists about Indigenous health. Survey results were analyzed using thematic analysis and descriptive statistics. Findings. Data collected from 364 survey responses informed six distinct themes representing knowledge gaps of occupational therapists related to Indigenous health as follows: lack of foundational knowledge, power relations, lifelong learner, need for appropriate tools/approaches, respectful collaboration, and environmental influences. Implications. The project offers insight into the role of the occupational therapy profession in the process of reconciliation. Insights are focused on decolonizing occupational therapy practice, building trusting relationships with Indigenous Peoples, and the provision of appropriate training for occupational therapists to engage in culturally safer practices.

Perceptions of Beverages With Non-nutritive Sweeteners Among Indigenous Adults Living in Manitoba and Implications for Type 2 Diabetes.

OBJECTIVES: The purpose of this study was to explore the perspectives of Indigenous adults on consuming beverages with non-nutritive sweeteners. METHODS: In this work, we used a community-based, participatory design in partnership with National Indigenous Diabetes Association, Four Arrows Regional Health Authority, and Fearless R2W. We conducted 74 qualitative interviews with Indigenous adults living in Manitoba, including Island Lake First Nations (n=39), Flin Flon (n=15), and the North End neighbourhood of Winnipeg (n=20). Data were indexed in NVivo, and transcripts were analyzed thematically. RESULTS: Participants exclusively discussed beverages with non-nutritive sweeteners (BNNSs) as an alternative to regular pop or sugary drinks, which were widely available, accessible, and consumed. Why or how BNNSs were viewed as an alternative comprised 3 subthemes: an alternative for health reasons; divergent taste preferences; and an alternative with mysterious but negative health effects. Participants who reported regular consumption of BNNSs largely described consuming them to manage type 2 diabetes. Fewer participants discussed BNNS as a means of weight management or as a preventive health behaviour. Participants who did not report regular BNNS consumption described not liking the taste of BNNSs. Finally, many participants described negative health impacts of consuming BNNSs, and specifically aspartame, although few articulated what those negative impacts were. CONCLUSIONS: Divergent perspectives among Indigenous adults regarding the health implications of consuming BNNSs may reflect ongoing scholarly debates. These findings have implications for the prevention and dietary management of type 2 diabetes in Indigenous communities.

Screen Time and Socioemotional and Behavioural Difficulties Among Indigenous Children in Canada: Temps d'écran et difficultés socio-émotionnelles et comportementales chez les enfants autochtones du Canada.

OBJECTIVES: To describe screen time levels and determine their association with socioemotional and behavioural difficulties among preschool-aged First Nations, Métis, and Inuit children. METHOD: Data were taken from the Aboriginal Children's Survey, a nationally representative survey of 2-5-year-old Indigenous children in Canada. Socioemotional and behavioural difficulties were defined using parent/guardian reports on the Strengths and Difficulties Questionnaire. Multiple linear regression analyses were conducted separately for First Nations, Métis, and Inuit participants, and statistically adjusted for child age, child sex, and parent/guardian education. Statistical significance was set at P < 0.002 to adjust for multiple comparisons. RESULTS: Of these 2-5-year-old children (mean [M] = 3.57 years) 3,085 were First Nations (53.5%), 2,430 Métis (39.2%), and 990 Inuit (7.3%). Screen time exposure was high among First Nations (M = 2 h and 58 min/day, standard deviation [SD] = 1.89), Métis (M = 2 h and 50 min [SD = 1.83]), and Inuit children (M = 3 h and 25 min [SD = 2.20]), with 79.7% exceeding recommended guidelines (>1 h/day). After adjusting for confounders, screen time was associated with more socioemotional and behavioural difficulties among First Nations (total difficulties ß = 0.15 [95% CI, 0.12 to 0.19]) and Métis (ß = 0.16 [95% CI, 0.12 to 0.20]) but not Inuit children (ß = 0.12 [95% CI, 0.01 to 0.23]). CONCLUSIONS: Screen time exposure is high among Indigenous children in Canada, and is associated with more socioemotional and behavioural difficulties among First Nations and Métis children. Contributing factors could include enduring colonialism that resulted in family dissolution, lack of positive parental role models, and disproportionate socioeconomic disadvantage. Predictors of poor well-being should continue to be identified to develop targets for intervention to optimize the health and development of Indigenous children.

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.

Oshkibiimaates Wiidoogakewin: A Partnership between Matawa First Nations Management and St. Joseph's Care Group.

Many Indigenous young people who live in remote northern communities are required to relocate to larger urban centres to pursue their secondary education. These youth have often experienced significant hardships that are exacerbated by the stresses of relocation. When seeking help for these struggles, it can be complicated to navigate complex systems in an unfamiliar city and difficult to engage with services that may not be designed to address these unique needs. The question then becomes: what would happen if those specialized supports were easily accessible and provided in a space where the youth felt safe and valued? A unique program providing holistic and culturally sensitive mental health and substance use services has been developed through a partnership between the Matawa First Nations Management and St. Joseph's Care Group in Thunder Bay, ON. The Oshkibiimaates Wiidoogakewin program has eliminated barriers to accessing service, reduced stigma and met the individual wellness needs of hundreds of students since its inception, with continuous improvements to serve students better. Creativity, flexibility and collaboration are at the heart of this program's success, as well as a shared vision of building a community that helps youth thrive.