Intentional injury among the indigenous and total populations in British Columbia, Canada: trends over time and ecological analyses of risk.

BACKGROUND: Our objective was to explore intentional injury disparity between Indigenous populations and the total population in the province of British Columbia (BC), Canada. We focus on hospitalizations, including both self-inflicted injuries and injuries inflicted by others. METHODS: We used data from BC's universal health care insurance plan, 1991 to 2010, linked to Vital Statistics databases. Indigenous people were identified through the insurance premium group, and birth and death records. Place of residence was identified through postal code. We calculated crude hospitalization incidence rates and the Standardized Relative Risk (SRR) of hospitalization, standardized by gender, 5-year age group, and Health Service Delivery Area (HSDA). With HSDA populations as the units of observation, linear regression was used to test hypothesized associations of Indigenous ethnicity, geographic, and socio-economic characteristics with SRR of injury. RESULTS: During the period 1991-2010, the crude rate of hospitalization for intentional injuries was 8.4 per 10,000 person-years (95% confidence interval (CI): 8.3 to 8.5) for the total BC population, compared to 45.3 per 10,000 (95% CI: 44.5 to 46.1) for the Indigenous population. For both populations, risk declined over the period for injuries self-inflicted and inflicted by others. The linear regression model predicts that the off-reserve Indigenous population will have SRR of intentional injury 3.98 greater, and the on-reserve Indigenous population 4.17, greater than the total population. The final model was an excellent fit (R2 = 0.912, F = 177.632, p < 0.001), and found that three variables - occupational risk, high school diploma, and university degree - each provide independent effects when interacting multiplicatively with Indigenous ethnicity. CONCLUSIONS: The observation of substantially declining rates of intentional injury for both the Indigenous and total BC populations is off-set by the high disparity in risk between the two populations, which will likely continue until Canada reduces disparity with respect to discriminatory practices, and physical, social, and economic conditions.

Injuries to Aboriginal populations living on- and off-reserve in metropolitan and non-metropolitan areas in British Columbia, Canada: Incidence and trends, 1986-2010.

BACKGROUND: Disparities in injury rates between Aboriginal and non-Aboriginal populations in British Columbia (BC) are well established. Information regarding the influence of residence on disparities is scarce. We sought to fill these gaps by examining hospitalization rates for all injuries, unintentional injuries and intentional injuries across 24 years among i) Aboriginal and total populations; ii) populations living in metropolitan and non-metropolitan areas; and iii) Aboriginal populations living on- and off-reserve. METHODS: We used data spanning 1986 through 2010 from BC's universal health care insurance plan, linked to vital statistics databases. Aboriginal people were identified by insurance premium group and birth and death record notations, and their residence was determined by postal code. "On-reserve" residence was established by postal code areas associated with an Indian reserve or settlement. Health Service Delivery Areas (HSDAs) were classified as "metropolitan" if they contained a population of at least 100,000 with a density of 400 or more people per square kilometre. We calculated the crude hospitalization incidence rate and the Standardized Relative Risk (SRR) of hospitalization due to injury standardizing by gender, 5-year age group, and HSDA. We assessed cumulative change in SRR over time as the relative change between the first and last years of the observation period. RESULTS: Aboriginal metropolitan populations living off-reserve had the lowest SRR of injury (2.0), but this was 2.3 times greater than the general British Columbia metropolitan population (0.86). For intentional injuries, Aboriginal populations living on-reserve in non-metropolitan areas were at 5.9 times greater risk than the total BC population. In general, the largest injury disparities were evident for Aboriginal non-metropolitan populations living on-reserve (SRR 3.0); 2.5 times greater than the general BC non-metropolitan population (1.2). Time trends indicated decreasing disparities, with Aboriginal non-metropolitan populations experiencing the largest declines in injury rates. CONCLUSIONS: Metropolitan/non-metropolitan residence appears to be a more important predictor than on/off-reserve residence for all injuries and unintentional injuries, and the relationship was even more pronounced for intentional injuries. The persistent disparities highlight the need for culturally sensitive and geographically relevant injury prevention approaches.

Primary care visits due to injuries among the Aboriginal off-reserve population of British Columbia, Canada, 1991-2010.

BACKGROUND: Aboriginal people in British Columbia (BC) have higher injury incidence than the general population. This report describes variability in visits to primary care due to injury, among injury categories, time periods, geographies, and demographic groups. METHODS: We used BC's universal health care insurance plan as a population registry, linked to practitioner payment and vital statistics databases. We identified Aboriginal people by insurance premium group and birth and death record notations. Within that population we identified those residing off-reserve according to postal code. We calculated crude incidence and Standardized Relative Risk (SRR) of primary care visit due to injury, standardized for age, gender and Health Service Delivery Area (HSDA), relative to the total population of BC. RESULTS: During 1991 through 2010, the crude rate of primary care visit due to injury in BC was 3172 per 10,000 person-years. The Aboriginal off-reserve rate was 4291 per 10,000 and SRR was 1.41 (95 % confidence interval: 1.41 to 1.42). Northern and non-metropolitan HSDAs had higher SRRs, within both total BC and Aboriginal off-reserve populations. In every age and gender category, the HSDA-standardized SRR was higher among the Aboriginal off-reserve than among the total population. For all injuries combined, and for the categories of trauma, poisoning, and burn, between 1991 and 2010, crude rates and SRRs declined substantially, but proportionally more rapidly among the Aboriginal off-reserve population, so the gap between the Aboriginal off-reserve and total populations is narrowing, particularly among metropolitan residents. CONCLUSIONS: These findings corroborate our previous reports regarding hospitalizations due to injury, suggesting that our observations reflect real disparities and changes in the underlying incidence of injury, and are not merely artefacts related to health care utilization.

Aboriginal community-level predictors of injury-related hospitalizations in British Columbia, Canada.

Population-level statistics indicating disparities in injury rates between Aboriginal and non-Aboriginal populations disguise considerable community-level heterogeneity. Using an ecological approach, we analyzed linked data from British Columbia's (BC) universal health care insurance plan, worker compensation, vital statistics, and census databases to identify community-level risk markers for hospitalization due to injury among the Aboriginal population of BC, Canada. Community standardized relative risks (SRR) of injury hospitalization relative to the total population of BC ranged from 0.24 to 9.35. Variables associated with increased SRRs included the following: higher proportions of crowded housing, housing in poor condition, participating in industries with greater risk of a work injury claim, being more remote, and at higher latitude. Higher income and more high school graduates were protective. In the best-fitting multivariable model, variables independently associated with SRR were proportion of the population with a high school certificate (RR = 0.89 per unit standard deviation change, 95 % confidence interval 0.83 to 0.94), and remoteness index (RR = 1.06, 95 % confidence interval (CI) 1.01 to 1.11). Results confirm profound diversity in Aboriginal communities across BC. SRRs of injury hospitalization increased as proportion of high school graduates dropped and remoteness increased. Promoting the educational attainment of community members should be an important focus of initiatives to improve health.

Is the injury gap closing between the Aboriginal and general populations of British Columbia?

BACKGROUND: Evidence from various jurisdictions has shown higher rates of injury for Aboriginal compared with non-Aboriginal populations. This study provides an overview of trends in hospitalization injury rates between the Aboriginal and total populations of one Canadian province, British Columbia. DATA AND METHODS: Hospital discharge records from 1986 through 2010 were obtained from linked health care databases maintained by Population Data BC. Crude rates and standardized relative risks of hospitalization due to injury among Aboriginal people, relative to the total population of British Columbia, were calculated. Changes over time among males and females were compared for various types and causes of injury. RESULTS: Throughout more than two decades, standardized risks of hospitalization for injury decreased among the Aboriginal and total populations of British Columbia. Larger decreases among the Aboriginal population than among the total population suggest that the gaps are closing. Downward trends in rates were found for most injury categories, and for males and females. INTERPRETATION: The findings indicate narrowing of the gap in injury rates between the total population of British Columbia and the province's Aboriginal population.

Worker compensation injuries among the Aboriginal population of British Columbia, Canada: incidence, annual trends, and ecological analysis of risk markers, 1987-2010.

BACKGROUND: Aboriginal people in British Columbia (BC) have higher injury incidence than the general population, but information is scarce regarding variability among injury categories, time periods, and geographic, demographic and socio-economic groups. Our project helps fill these gaps. This report focuses on workplace injuries. METHODS: We used BC's universal health care insurance plan as a population registry, linked to worker compensation and vital statistics databases. We identified Aboriginal people by insurance premium group and birth and death record notations. We identified residents of specific Aboriginal communities by postal code. We calculated crude incidence rate and Standardized Relative Risk (SRR) of worker compensation injury, adjusted for age, gender and Health Service Delivery Area (HSDA), relative to the total population of BC. We assessed annual trend by regressing SRR as a linear function of year. We tested hypothesized associations of geographic, socio-economic, and employment-related characteristics of Aboriginal communities with community SRR of injury by multivariable linear regression. RESULTS: During the period 1987-2010, the crude rate of worker compensation injury in BC was 146.6 per 10,000 person-years (95% confidence interval: 146.4 to 146.9 per 10,000). The Aboriginal rate was 115.6 per 10,000 (95% CI: 114.4 to 116.8 per 10,000) and SRR was 0.88 (95% CI: 0.87 to 0.89). Among those living on reserves SRR was 0.79 (95% CI: 0.78 to 0.80). HSDA SRRs were highly variable, within both total and Aboriginal populations. Aboriginal males under 35 and females under 40 years of age had lower SRRs, but older Aboriginal females had higher SRRs. SRRs are declining, but more slowly for the Aboriginal population. The Aboriginal population was initially at lower risk than the total population, but parity was reached in 2006. These community characteristics independently predicted injury risk: crowded housing, proportion of population who identified as Aboriginal, and interactions between employment rate and income, occupational risk, proportion of university-educated persons, and year. CONCLUSIONS: As employment rates rise, so has risk of workplace injury among the Aboriginal population. We need culturally sensitive prevention programs, targeting regions and industries where Aboriginal workers are concentrated and demographic groups that are at higher risk.

Influence of Perceived Racial Discrimination on the Health of Immigrant Children in Canada.

Racial discrimination and racism are recognized as determinants of health for adults. Less is understood regarding the influence of discrimination targeted towards parents, the family, or the cultural and children's health. Data from the New Canadian Children and Youth Study (NCCYS) are used in this paper. The NCCYS is a national, longitudinal study of children whose families settled in urban centers of Canada. We analyzed data from individuals who settled in the metropolitan Vancouver area from six ethnic communities: Mainland China, Hong Kong, the Philippines, Iran, Afghanistan, and the Punjab who were interviewed at two times, approximately 2 years apart. Data were collected on perceived parental, family, and cultural discrimination. Our dependent variable was parent-reported child health status. Over time, perceived parental discrimination and perceived family discrimination decreased; and both forms of discrimination had a positive effect on child health. In contrast, perceived cultural discrimination increased over time and had a negative effect on child health at both times. Different forms of discrimination have different effects on child health. Racial discrimination is complex. Its influence on either increasing family cohesion, and thereby leading to improved health, or increasing stress, thereby leading to poorer health needs to be explored further.

Correction: Hospitalizations due to unintentional transport injuries among Aboriginal population of British Columbia, Canada: Incidence, changes over time and ecological analysis of risk markers.

[This corrects the article DOI: 10.1371/journal.pone.0191384.].

Hospitalizations due to unintentional transport injuries among Aboriginal population of British Columbia, Canada: Incidence, changes over time and ecological analysis of risk markers.

BACKGROUND: Worldwide, Indigenous people have disproportionately higher rates of transport injuries. We examined disparities in injury-related hospitalizations resulting from transport incidents for three population groups in British Columbia (BC): total population, Aboriginal off-reserve, and Aboriginal on-reserve populations. We also examined sociodemographic, geographic and ethnic risk markers for disparities. METHODS: We identified Aboriginal people through BC's universal health care insurance plan insurance premium group and birth and death record notations. We calculated crude incidence rate and Standardized Relative Risk (SRR) of hospitalization for unintentional transport injury, standardized for age, gender and Health Service Delivery Area (HSDA), relative to the total population of BC. We tested hypothesized associations of geographic, socio-economic, and employment-related characteristics of Aboriginal communities with SRR of transport injury by multivariable linear regression. RESULTS: During the period 1991-2010, the SRR for the off-reserve Aboriginal population was 1.77 (95% CI: 1.71 to 1.83); and 2.00 (95% CI: 1.93 to 2.07) among those living on-reserve. Decline in crude rate and SRRs was observed over this period among both the Aboriginal and total populations of BC, but was proportionally greater among the Aboriginal population. The best-fitting multivariable risk marker model was an excellent fit (R2 = 0.912, p<0.001), predicted SRRs very close to observed values, and retained the following terms: urban residence, population per room, proportion of the population with a high school certificate, proportion of the population employed; and multiplicative interactions of Aboriginal ethnicity with population per room and proportion of the population employed. CONCLUSIONS: Disparities in risk of hospitalization due to unintentional transport injury have narrowed. Aboriginal ethnicity modifies the effects of socioeconomic risk factors. Continued improvement of socioeconomic conditions and implementation of culturally relevant injury prevention interventions are needed.

Risk of Hospitalization Due to Unintentional Fall Injury in British Columbia, Canada, 1999-2008: Ecological Associations with Socioeconomic Status, Geographic Place, and Aboriginal Ethnicity.

BACKGROUND: Aboriginal people in British Columbia (BC), especially those residing on Indian reserves, have higher risk of unintentional fall injury than the general population. We test the hypothesis that the disparities are attributable to a combination of socioeconomic status, geographic place, and Aboriginal ethnicity. METHODS: Within each of 16 Health Service Delivery Areas in BC, we identified three population groups: total population, Aboriginal off-reserve, and Aboriginal on-reserve. We calculated age and gender-standardized relative risks (SRR) of hospitalization due to unintentional fall injury (relative to the total population of BC), during time periods 1999-2003 and 2004-2008, and we obtained custom data from the 2001 and 2006 censuses (long form), describing income, education, employment, housing, proportions of urban and rural dwellers, and prevalence of Aboriginal ethnicity. We studied association of census characteristics with SRR of fall injury, by multivariable linear regression. RESULTS: The best-fitting model was an excellent fit (R 2 = 0.854, p < 0.001) and predicted SRRs very close to observed values for the total, Aboriginal off-reserve, and Aboriginal on-reserve populations of BC. After stepwise regression, the following terms remained: population per room, urban residence, labor force participation, income per capita, and multiplicative interactions of Aboriginal ethnicity with population per room and labor force participation. CONCLUSIONS: The disparities are predictable by the hypothesized risk markers. Aboriginal ethnicity is not an independent risk marker: it modifies the effects of socioeconomic factors. Closing the gap in fall injury risk between the general and Aboriginal populations is likely achievable by closing the gaps in socioeconomic conditions.

Iatrogenic Injury among the Aboriginal and Total Populations of British Columbia, Canada, 1991-2010: Inequities Associated with Ethnicity and Socioeconomic Status.

PURPOSE: Measure population health impact, and socioeconomic, geographic, and ethnic predictors of iatrogenic injury. METHODS: Within three groups (total population, Aboriginal off-reserve, and Aboriginal on-reserve) in each of 16 Health Service Delivery Areas (HSDAs) of British Columbia, Canada we calculated crude incidence and Standardized Relative Risk (SRR) of hospitalization for iatrogenic injury. We tested hypothesized associations between HSDA census characteristics and SRR, by multivariable regression. RESULTS: Among hospitalizations due to any injury, 22.2% were iatrogenic. Crude rate of iatrogenic injury hospitalization was 20.4 per 10,000 person-years. Aboriginal rate was 24.4 per 10,000 and SRR was 1.57 (1.76 among females, 1.38 among males). Non-metropolitan HSDAs had higher SRRs. The best-fitting regression model was an excellent fit (R=0.836, p<.001) and included education, income, house needs major repairs, population per room, and Aboriginal ethnicity. CONCLUSIONS: Iatrogenic injury has significant population health impact. Aboriginal people, especially females, have higher risk. Ethnicity and socioeconomic factors explain regional disparities.

Injury risk in British Columbia, Canada, 1986 to 2009: are Aboriginal children and youth over-represented?

BACKGROUND: Children and youth worldwide are at high risk of injury resulting in morbidity, disability or mortality. Disparities in risk exist between and within countries, and by sex and ethnicity. Our aim is to contribute data on disparities of injury rates for Aboriginal children and youth compared with those of the general population in British Columbia (BC), Canada, by examining risks for the two populations, utilizing provincial administrative data over a 24-year period. METHODS: Hospital discharge records from the provincial health care database for children and youth were used to identify injury for the years 1986 to 2009. Within the total BC population, the Aboriginal population was identified. Crude rates and standardized relative risks (SRR) of hospitalization were calculated, by year and category of injury type and external cause, and compared to the total BC population for males and females under age 25 years. RESULTS: Over the 24-year period, substantive decreases were found in hospitalization injury risks for children and youth in both Aboriginal and total populations, for both sexes, and for most categories and types of injuries. Risk in overall injury dropped by 69% for the Aboriginal population and by 66% for the total BC population, yet in every year, the Aboriginal population had a higher risk than the total BC population. There were over 70% declines in risks among females of intentionally inflicted injury by another, among both the Aboriginal and total BC populations. Risk of injury caused by transport vehicles has decreased by an overwhelming 83% and 72% for the Aboriginal male population and for the total BC male population, respectively. CONCLUSIONS: The over 70% declines in risks for females of intentionally inflicted injury by another, among both the Aboriginal and total BC populations is excellent news. Risk of injury caused by transport vehicles for males decreased overwhelmingly for both populations. Disparities in rates between the Aboriginal population and total BC population remain because of similarity in the proportional reductions among the two populations. Since the Aboriginal population started at a much higher risk, in absolute terms, the gap between the two populations is shrinking.

Injury hospitalizations due to unintentional falls among the Aboriginal population of British Columbia, Canada: incidence, changes over time, and ecological analysis of risk markers, 1991-2010.

BACKGROUND: Aboriginal people in British Columbia (BC) have higher injury incidence than the general population. Our project describes variability among injury categories, time periods, and geographic, demographic and socio-economic groups. This report focuses on unintentional falls. METHODS: We used BC's universal health care insurance plan as a population registry, linked to hospital separation and vital statistics databases. We identified Aboriginal people by insurance premium group and birth and death record notations. We identified residents of specific Aboriginal communities by postal code. We calculated crude incidence and Standardized Relative Risk (SRR) of hospitalization for unintentional fall injury, standardized for age, gender and Health Service Delivery Area (HSDA), relative to the total population of BC. We tested hypothesized associations of geographic, socio-economic, and employment-related characteristics with community SRR of injury by linear regression. RESULTS: During 1991 through 2010, the crude rate of hospitalization for unintentional fall injury in BC was 33.6 per 10,000 person-years. The Aboriginal rate was 49.9 per 10,000 and SRR was 1.89 (95% confidence interval 1.85-1.94). Among those living on reserves SRR was 2.00 (95% CI 1.93-2.07). Northern and non-urban HSDAs had higher SRRs, within both total and Aboriginal populations. In every age and gender category, the HSDA-standardized SRR was higher among the Aboriginal than among the total population. Between 1991 and 2010, crude rates and SRRs declined substantially, but proportionally more among the Aboriginal population, so the gap between the Aboriginal and total population is narrowing, particularly among females and older adults. These community characteristics were associated with higher risk: lower income, lower educational level, worse housing conditions, and more hazardous types of employment. CONCLUSIONS: Over the years, as socio-economic conditions improve, risk of hospitalization due to unintentional fall injury has declined among the Aboriginal population. Women and older adults have benefited more.

Country of birth and language spoken at home in relation to illicit substance use.

BACKGROUND: This study examines the association between country of birth, language spoken at home, and lifetime illicit substance use in a Canadian national sample. METHOD: Secondary analysis of data was conducted using a sample of 8,656 persons who were between 15 and 54 years of age in 1994 and who participated in Canada's Alcohol and Other Drugs Survey. RESULTS: Rates of substance use differed among the four groups (42.6% for Canadian-born who spoke official languages, 33.8% for Canadian-born who spoke non-official languages, 35.2% for foreign-born who spoke official languages, and 11.1% for foreign-born who spoke non-official languages). The rate differences persisted after adjustment for sociodemographic factors, religiousness, friends' use of substances, and participation in social activities. INTERPRETATION: More in-depth studies that include culture-specific information are required to explain the rate differences. In addition, alternative preventive strategies may be required to reduce substance use among foreign-born persons.

Addressing FASD in British Columbia, Canada: analysis of funding proposals.

BACKGROUND: Fetal Alcohol Spectrum Disorder is a preventable health issue affecting about 10% of the population. This research examined proposals submitted to a call for funding for projects to improve outcomes for people with fetal alcohol spectrum disorder (FASD). OBJECTIVES: The aim was to use the proposals as proxy for perceptions of needs held by practitioners in British Columbia, Canada, where considerable FASD-related education and awareness exists. METHODS: Content analyses were conducted and Chi-square tests were used to test the relationship between proposal foci, community size and the submitting agency's experience with FASD. RESULTS: Nine foci were found: Skill Development, Care, Training, Resource Development, Education, Transition, Peer Support, Research and Other. No statistically significant difference was found in proposal foci according to size of community, and only one focus, Research, was associated with agency experience. Proposals varied in intensity, timing, participants, and focus of change (people or environments). CONCLUSIONS: Analysis of the proposals provides a unique view into perceptions regarding ways to improve outcomes for people with FASD.

Does living in a neighbourhood with others of the same ethnic background contribute to health of Canada's immigrant children?

OBJECTIVES: To understand how neighbourhood characteristics affect the health of immigrant children in Canadian cities. We question whether the health of children is influenced by immigrants living in enclaves of people with similar ethnic and socio-economic backgrounds. METHODS: Two datasets were used: the New Canadian Children and Youth Study (NCCYS) and Statistics Canada census data. The NCCYS comprises children from Hong Kong, the Philippines and Mainland China living in Canada's largest cities. Logistic regression was used to examine the influence of neighbourhood ethnic concentrations and mean income on health. RESULTS: Girls were more likely to be reported to have excellent health compared to boys, as were children living in neighbourhoods with lower mean parental education. Children from Hong Kong were less likely to have excellent health compared to the reference group. For the Mainland Chinese group only, there was an inverse relationship between reported health status and the concentration of people from the same ethnic background in the neighbourhood. CONCLUSION: The health of children from different ethnic backgrounds is influenced by different social and economic factors. In practice and in research, "immigrants" and even broadly defined cultural groupings, such as "Asian immigrants", should be considered as heterogeneous.

The RISC research project: injury in First Nations communities in British Columbia, Canada.

BACKGROUND: The project, Injury in British Columbia's Aboriginal Communities: Building Capacity while Developing Knowledge, funded by the Canadian Institutes of Health Research (CIHR), aims to expand knowledge on injury rates among First Nations communities in British Columbia (BC), Canada. OBJECTIVE: The purpose is to improve understanding of community differences and to identify community-level risk and protective factors. Generally, injury incidence rates in the Aboriginal population in Canada greatly exceed those found in the non-Aboriginal population; however, variability exists between Aboriginal communities, which have important implications for prevention. DESIGN: This study uses administrative records of deaths, hospitalizations, ambulatory care episodes, and workers' compensation claims due to injuries to identify communities that have been especially successful in maintaining low rates of injury. RESULTS: The analysis of risk and protective factors extends the work of Chandler and Lalonde who observed that community efforts to preserve and promote Aboriginal culture and to maintain local control over community life are strongly associated with lower suicide rates. CONCLUSION: The discussion on psychological and cultural considerations on healing and reducing the rates of injury expands the work of McCormick on substance use in Aboriginal communities.

Review of procedures for approval of health studies in northern Canada.

OBJECTIVES: This article describes the review processes required for research being conducted in Canada's 3 northern territories. When conducting research involving human subjects in northern Canada, researchers must go through a 2-step process by submitting protocols to both their university or hospital ethics review boards as well as to northern research institutions. Canada's northern territorial governments have requirements for attaining licensure before any research can be conducted. METHODS: A document review was the method used to gather data, and an Internet search of the literature and documents was conducted to gather information. RESULTS: Generally, university and hospital-based ethics review boards have been concerned with the rights of individuals in research. Northern Canadian research protocols require review by territorial government institutions and communities with respect to community rights. CONCLUSIONS: The 3 territorial governments of northern Canada take the concept of community and individual participation in research seriously and have enacted processes so that opportunities for such approaches to research are ensured.