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Objectives The overarching research objective was to examine, culturally adapt, and further evaluate a mental health promotion approach called the PAX within 8 First Nations communities. This presentation describes a research process whereby First Nations community members and researchers worked in collaborative and culturally safe ways to reach their research objectives. Approach Building on a strong existing relationship between Swampy Cree Tribal Council (SCTC) members from Northern Canada and academic researchers, a team was formed to prepare the research proposal. This team included community members, leaders from First Nations organizations, decision makers, program developers and researchers. This research was guided by two-eyed seeing, a principle developed by a Mi’kmaw Elder, that recognizes both Indigenous and Western ways of knowing, where one worldview does not dominate the other. The research process was compliant with Ownership, Control, Access, and Possession (OCAP) principles that ensure self-determination of First Nations communities over research involving their people. Results A First Nations community liaison was hired as a research team member ensuring that traditional and cultural protocols were adhered to and connections to community members facilitated and sustained. Over the course of the research, the team met monthly to oversee implementation and annually with SCTC community members for guidance and for sharing and interpreting results. All 8 communities were actively engaged and benefitted from their involvement. Seeing the value of examining PAX’s effectiveness through linkages to administrative datasets, community members supported engagement of an additional 16 First Nations communities thereby ensuring an adequate sample size for the study. Health and education databases were linked to program data from 20 First Nations communities. Infographics, lay summaries and presentations were prepared for meaningful knowledge exchange. Conclusion First Nations communities deemed it essential to understand what works and for whom regarding mental health promotion. Building relationships with First Nations community members based on trust and respect provided information that was relevant and beneficial to their communities. This relationship-building should be considered when developing research timelines and budgets.

Objectives PAX, a mental health promotion approach, has been shown to decrease negative mental health outcomes and improve academic achievement. These effects have yet to be shown among Indigenous children. We evaluated PAX for improving First Nations children’s outcomes following a research process wherein community members and researchers work more collaboratively. Approach Building on a long-term relationship with Swampy Cree Tribal Council, community members, First Nations leaders and researchers worked together through all phases of the project. This cluster randomized controlled trial used population-based health, social services, and education administrative data that allowed de-identified individual-level linkages across all databases through a scrambled health number. Our cohort of 725 children from 20 First Nations schools were randomized to PAX (n=469, 11 schools) or wait-list control (n=256, 9 schools). We used propensity score weighting and multi-level modeling to estimate the differences over time (2011 up to 2020) between children exposed to PAX and those who were not. Results Differences in baseline characteristics were found between the two groups of children, despite the cluster randomization. After applying propensity score weights, children in the PAX group had significantly greater decreases in conduct problems (β:-1.08, standard error(se):0.2505, p

Objectives Lack of consistent and relevant Indigenous identifiers in Canadian data sources leads to misclassification and under-recognition of the health and social issues impacting Indigenous Peoples, further perpetuating the harms of colonization. We are evaluating and optimizing our approach for identifying First Nations (FN) individuals in administrative data in Manitoba. Methods In partnership between the First Nations Health and Social Secretariat of Manitoba and the Manitoba Centre for Health Policy, we sought to evaluate to what extent four distinct Manitoba datasets derived from surveillance and social programs were able to identify FN individuals among a cohort of children in low-income Winnipeg neighbourhoods between 2005-2016. In choosing data sources to identify FNs, the population and research question were considered. We then compared the number of FNs identified in each dataset to the First Nations population research file, considered gold standard, but cognizant of its roots in colonial systems of registration. Results The total cohort comprised N=78,864; among these, n=27,347 children were identified as FN in either the FN registry or at least one of the datasets. The FN registry was the most sensitive dataset and identified 85.7% of these individuals. The two program datasets identified 58.2% and 46.2%, and the surveillance-based datasets each identified less than 10%. The First Nations Registry is critical to accurately identify FN individuals. Our analyses demonstrated that without it we would miss 23.5% of those identified as FN in at least one other dataset. However, using it alone could potentially cause us to miss 15% of FN individuals identified in other datasets. The proportions of FN individuals that would be missed by excluding any of the other datasets were smaller (

Objectives First Nations (FN) organizations worked with public health and governments to improve FN access to COVID-19 vaccines by prioritizing FN communities in vaccination initiatives. FN researchers and data scientists partnered to test whether these efforts were associated with increased access to COVID-19 vaccines among FN compared with all other Manitobans. Approach This retrospective cohort study linked whole-population administrative data from (i) the First Nations research file, (ii) COVID testing and vaccination data, and (iii) health and social services for sociodemographic data and information on potential confounders. Several public health policies were created to improve access to COVID vaccines among FN; we tested whether FN received their 1st and 2nd vaccines sooner than all other Manitobans (AOM) using restricted mean survival time models. We adjusted for sociodemographic characteristics, comorbidities, and whether FN lived on- or off-reserve. We conducted sex-specific and effect modification analyses to test whether associations differed by sex. Results Prioritizing FN to receive vaccines was associated with increased vaccine uptake compared with AOM. After adjusting for various confounders, FN received their first dose 15.5 (95% CI 14.9 – 16.0) days sooner than AOM and their second dose 13.9 (13.3 – 14.5) days sooner than AOM. Sex-stratified and subsequent effect modification analyses using interaction terms, found that differences were greater for males than for females: FN males received their first dose 18.1 (17.3 – 18.8) days sooner than AOM males and FN females received their first dose 12.9 (12.2 – 13.7) days sooner than AOM females. This pattern held for second doses as well. FN with comorbidities also received vaccines sooner than AOM with similar comorbidity levels 20.9 days (23.1 – 18.8) among those with 3+ comorbidities. Conclusion Partnerships between public health entities and FN organizations that respect FN community sovereignty were instrumental in supporting FN health and well-being during COVID-19. Policies and programs that prioritized FN people for vaccines improved uptake saving lives. This partnership-based COVID-19 response can provide a framework for future public health efforts.

Objectives Red River Métis are Indigenous people hailing from the Canadian Prairies who have historically experienced poor health outcomes due to colonial practices. Researchers from the Manitoba Métis Federation (MMF) partnered with health services researchers to test whether MMF-led COVID initiatives were associated with access to COVID-19 testing and vaccines. Approach We linked the Métis Population Data-Base from the MMF (to identify Red River Métis) with whole-population COVID testing and vaccination data and health and social services administrative data (for information on sociodemographics and confounders) to complete this retrospective cohort study. We used restricted mean survival time models to test whether COVID-19 vaccination differed between Métis and all other Manitobans (AOM); models adjusted for demographics, comorbidities, and other characteristics (age, socioeconomic status, urbanicity, and mental health status). Data were stratified by sex and subsequent effect modification analyses tested whether associations differed by sex and physical health comorbidities. Results COVID testing rates were lower during the first year of the pandemic among Métis than among AOM. During the second year of the pandemic, this finding was reversed - Métis accessed tests at higher rates. There was no difference between Métis and AOM in accessing first vaccine doses before implementation of MMF-led initiatives. After initiatives were put in place, Métis received their second COVID vaccine, on average, 1.3 (95% CI 1.9-0.6) days sooner than AOM, after adjusting for confounders. Effect modification analyses showed this relationship was concentrated among females – female Métis received their second vaccine 1.7 (2.6-0.8) days sooner than female AOM; differences were non-significant for males. Métis with 2+ comorbidities received their vaccine second 2.9 (5.3-0.5) days sooner than AOM with 2+ comorbidities. Conclusion Public health initiatives prioritizing Métis for vaccines improved uptake. Initiatives led by Métis to improve COVID outcomes were critical to supporting Métis during the course of the pandemic. Public health response efforts need to operate from a standpoint that honours Indigenous sovereignty in their design and implementation.

Objective A multi-disciplinary E2A group was established as part of a linked administrative data study examining methamphetamine use in Manitoba. In this presentation we will share our experiences of establishing an E2A, embedding stakeholders in the research process, and outline an iterative engagement plan for the remaining study years. Approach The E2A group is led by two researchers with expertise in patient and public engagement and guided by Pal’s (2014) work on policy analysis and activation. Pal emphasizes a multidisciplinary and iterative process as the basis of a more inclusive approach to policy development for complex problems, such as the prevalence of methamphetamine use in Manitoba. Our goal in engaging public rightsholders, service providers and knowledge users in the research is to ensure that their first-hand knowledge and perspectives are reflected in the interpretations of the findings and that analyses address identified complexities in a culturally sensitive and equity-focused way. Results In the fall of 2020 E2A members were recruited, including persons with lived experience using methamphetamines and their families/care-givers, academics, clinicians, government, and non-government stakeholders. Training was provided on the topics of trauma-informed care, public engagement, effects of colonial and racist institutions, and cultural safety. The first E2A meetings co-developed guiding principles, a vision and mission, as well as provided capacity building around administrative data research. This work was done as a foundation for the next two years, wherein the group will make decisions about key variables (ie: between methamphetamine use and mental health), interpretation of results, knowledge mobilization, and policy development using an iterative self-evaluation process. To date challenges addressed included public health restrictions related to Covid-19 and adapting the research flow to centre lived-experience decision making. Conclusion The E2A group is a key component of this study and could serve as a model for other administrative data studies. The group prioritizes stakeholder knowledge, interprets results, flags potential biases in the data research process, and ensures the findings are relevant to the people they are meant to support.

Objectives Perinatal risk factors can vary by immigration status. To advance knowledge on sociobehavioral health risks among pregnant and childbearing immigrant women, we compared perinatal health indicators between immigrant and non-immigrants, overall, and according to key immigrant characteristics (refugee status, secondary migration, birth region, and duration of residence). Approach We conducted a population-based cross-sectional study of 33,754 immigrant and 172,342 non-immigrant childbearing women in Manitoba, Canada, aged 15-55 years, who had newborn screening data completed by public health nurses within two weeks postpartum from 2000 to 2017. The screening data was linked to a Canadian national immigration database. Additional databases were linked to collect demographic and perinatal clinical information. Logistic regression models were used to examine the associations between immigration characteristics and perinatal health indicators, such as social isolation, relationship distress, partner violence, depression, alcohol, smoking, substance use and late prenatal care initiation. Results More immigrant women reported being socially isolated (12.3%) than non-immigrants (3.0%) (Adjusted Odds Ratio (aOR): 6.90, 95% Confidence Interval (CI): 6.53, 7.28) but exhibited lower odds of other outcomes. In the analysis restricted to immigrants, recent immigrants (< 5 years of stay) had higher odds of being socially isolated (aOR: 9.29, 95% CI: 7.80, 11.06) and late prenatal care (aOR: 1.73, 95% CI: 1.23, 2.42) compared to long-term immigrants, but lower odds relationship distress, depression, alcohol, smoking and substance use. Refugee status was positively associated with social isolation, relationship distress, depression, and late prenatal care whereas secondary migration was protective for social isolation, relationship distress, and smoking. Relationship distress and behavioral health indicators varied by maternal birth region. Conclusion The novel linkage of birth screening data with the immigration data advances knowledge on immigrant perinatal health by identifying risk patterns for multiple psychosocial and behavioral health indicators, highlighting subgroups at higher and lower risk of exposures that may contribute to adverse perinatal health outcomes.

Objectives Given the impact of colonization and responding to Canada’s Truth and Reconciliation Commission, we aimed to provide baseline measures of First Nations children’s health and social outcomes in Manitoba, Canada. We also aimed to create a research process where Indigenous and non-Indigenous researchers work collaboratively and in culturally safe ways. Approach We formed a team consisting of members of First Nation organizations and academic researchers. Knowledge Keepers from Anishinaabe, Cree, Anishininew, Dakota and Dene Nations guided the study, interpreted results and ensured meaningful knowledge translation. This retrospective cohort study utilized population-based health, social services, education and justice administrative data that allowed de-identified individual-level linkages across all databases through a scrambled health number. Adjusted rates and rate ratios were calculated using a generalized liner modeling approach to compare First Nations children (n=61,726) and all other Manitoba children (n=279,087) and comparing First Nations children living on and off-reserve. Results Large disparities between First Nations and other Manitoba children were found in birth outcomes, physical and mental health, health services, education, social services, justice system involvement and mortality. First Nations infants had higher rates of preterm births, large-for-gestational-age births, newborn readmissions to hospital and lower rates of breastfeeding initiation compared with other Manitoba infants. Suicide rates among First Nations adolescents were ten times higher than among other adolescents in Manitoba, yet we found few differences in diagnosis of mood and anxiety disorders between the groups. First Nations children were also seven times more likely to apprehended by child protection services and youth were ten times more likely to be criminally accused. Knowledge Keepers offered their perspectives on these findings. Conclusion These findings demonstrate that an enormous amount of work is required in virtually every area – health, social, education and justice – to improve First Nations children’s lives. There is an urgent need for equitable access to services, and these services should be self-determined, planned and implemented by First Nations people.

Objectives Over three decades ago, the Aboriginal Justice Inquiry identified structural racism in Canada’s justice system. Although rates of youth criminal charges and incarcerations have declined substantially since then, it is unclear whether First Nations youth are treated differently than non-First Nations youth for similar offences. Our study addressed this question. Approach This retrospective cohort study of youth born 1991-2001 and living in Manitoba between ages 12-17 used whole-population linked administrative data to identify youth charged with a crime (N=13,543). First Nations youth (n=7,081) were compared with all other Manitoba (AOM) youth (n=6,462) on whether their criminal charge proceeded or was dropped, deferred or diverted. The study applied an intersectionality theoretical framework. Individual (age, type and severity of charge, ever in child protection care, youth and/or mother diagnosed mental disorder, maternal incarceration, number of siblings, urban/rural residence) and social strata (First Nations identity, income, sex) factors were adjusted for using multi-level models. Results After accounting for other factors, First Nations youth had a higher risk of a charge proceeding than AOM (adjusted Relative Risk (aRR) 1.16, 95% CI 1.12-1.20). There was no difference in charges proceeding for male First Nations youth compared with male AOM, whereas among females, the risk was greater for First Nations (aRR 1.31, 95% CI 1.26-1.36). Low income and a history of being in the care of the child protection system increased the risk of charges proceeding for AOM only (aRR 1.16, 95% CI 1.13-1.18; aRR 1.13, 95% CI 1.07-1.20); for First Nations, there was no increased risk of charges proceeding associated with these intersecting factors. Conclusion These findings provide quantitative evidence of the intersecting structural racism in the youth criminal justice system previously identified by First Nations leaders. Future research will follow this cohort to determine whether more judicial sanctions are applied to First Nations youth throughout the justice process, including within criminal courts and corrections.

Introduction Early education outcomes influence children’s educational trajectories with long-term effects extending into adulthood. Aboriginal peoples face numerous systemic barriers to academic success. It remains unknown if full-day kindergarten (FDK) is associated with improved academic outcomes among Metis children – a distinct Aboriginal people recognized by the Canadian Constitution. Objectives and Approach The Manitoba Metis Federation and the Manitoba Centre for Health Policy partnered to identify whether FDK was associated with improved short- and long-term outcomes among Metis children. We created a cohort of Metis children by linking several provincial databases held in the Manitoba Population Research Data Repository (1998-2011). Education data were used to identify all Metis children who attended FDK (n=247) vs half day kindergarten (HDK; n=547). FDK children were matched by age and sex to children in HDK. We used a step-wedged design and applied propensity scores to adjust for measured confounding. We tested for differences in grades 3, 7, 8 outcomes and high school graduation using generalized linear models. Results FDK children were more likely to live in a low-income neighbourhood. 72% FDK and 74% HDK students met or approached numeracy expectations in grade 3; and 55% FDK and 48% HDK met or approached numeracy expectations in grade 7. For reading expectations, 77% FDK and 75% HDK met or approached grade 3 reading expectations; in grade 8, 62% in each group met or approached expectations for reading and writing. High school graduation rate for FDK children was 84% and for HDK children was 64%. After adjusting for confounding we found FDK children were more likely to graduate high school than HDK children; other outcomes were non-significant. Conclusion / Implications Kindergarten programs may be insufficient to overcome structural barriers that Metis children face. Culturally appropriate education strategies are needed to support improved outcomes amongst this population.

Introduction Administrative data studies routinely report that First Nations mothers and children experience a disproportionate burden of poor health. Due to the nature of administrative data, research often takes a deficits-oriented approach. First Nations health research needs to consider the role that community- and individual-level strengths play in promoting wellbeing and examine how these interact with the delivery and outcomes of health programs. Objectives and Approach The First Nations Health and Social Secretariat of Manitoba (FNHSSM) and the University of Manitoba partnered to construct measures of community-level strengths that can be linked with administrative data to examine the delivery and outcomes associated with population health programs delivered in First Nations communities. We linked data from the FNHSSM-administered Regional Health Survey (RHS) with administrative data housed in the Manitoba Population Research Data Repository. We identified 60 questions from the child, youth, and adult versions of the RHS to measure community strengths. We used principal component analysis to identify strength-based constructs. We used Eigen values and percent of variance explained to determine the final number of factors. We used random group resampling and bootstrap methods to test for community-level homogeneity. Community-level factor scores were calculated as the scaled combination of RHS questions within each factor and averaged to the community. Results We identified 12 constructs of community strength: 5 from child responses, 4 from youth, and 3 from adult responses. Strength-based constructs common to all age groups included knowledge of traditional language, involvement in cultural events, and connection with community. Conclusion / Implications Colonial approaches to health research perpetuate deficit-based dialogues and negative portrayal of First Nations peoples. First Nations health research should consider how community strengths promote health and interact with program delivery. Including measures of community strength leads to richer understandings of factors that promote wellness among First Nations peoples.

Introduction In Manitoba, low-income pregnant women are eligible for the Healthy Baby Prenatal Benefit (HBPB), a prenatal income supplement. Research has demonstrated positive outcomes associated with HBPB, but it remains unknown if Metis women and children – who are of mixed European and Aboriginal descent and one of the most marginalized populations in Canada -- benefit from the program. Objectives and Approach The Manitoba Metis Federation and the Manitoba Centre for Health Policy partnered to determine the impact of HBPB on Metis newborn and early childhood outcomes. We included all Metis women giving birth in Manitoba 2003-2011 who received income assistance during pregnancy (n=4,852), adjusting for differences between those receiving (n=3,681) and not receiving (n=1,171) HBPB with propensity score weighting. We used multi-variable regressions to compare outcomes between groups: breastfeeding initiation, low birth weight, preterm birth, small- and large-for-gestational age, Apgar scores, birth hospitalization length of stay (LOS), neonatal readmissions, infant hospitalizations, vaccinations at age 1 and 2, and child development scores at kindergarten. Results HBPB receipt was associated with reductions in low birth weight (adjusted Relative Risk (aRR): 0.74 (95% CI: 0.58-0.94)) and preterm births (aRR: 0.78 (0.65-0.94)), and increases large-for-gestational age births (aRR: 1.21 (1.06-1.39)) and neonatal readmissions (aRR: 1.58 (1.05-2.37)). Birth hospitalization LOS was lower for newborns whose mothers received HBPB (Mean Difference 0.29 days). HBPB was associated with increases in vaccinations for children aged 1 (aRR: 1.08 (1.00-1.15)) and 2 (aRR: 1.12 (1.05-1.18)). No significant associations were found for small-for-gestational age births, Apgar scores, breastfeeding initiation, infant hospitalizations or child development scores. Conclusion / Implications A modest unconditional prenatal income supplement to low-income Metis women was associated with improved birth outcomes and child vaccinations; however, an association with increased neonatal readmissions warrants further exploration. Lack of significant associations between HBPB and child development measures suggests more sustained support may be necessary to improve longer-term outcomes.

Introduction The Boys & Girls Clubs of Winnipeg (BGCW) provide out-of-school programs to children and youth living in low-income neighbourhoods in Winnipeg, Canada. These programs aim to set participants on a path to success by supporting healthy behaviours, academic achievement and social skills. Metis children and youth make up a substantial proportion of BGCW participants, but there are few empirical data available on how the programs influence health, social and education outcomes in this population. Objectives and Approach We linked BGCW attendance records for all Manitoba children born 1987-2010 to the individual-level administrative health, social and education data in the population-based Data Repository at the Manitoba Centre for Health Policy in Winnipeg. The comparison group of non-participants was matched on age and neighbourhood of residence. We narrowed the cohort to Metis participants by linking to datasets containing Metis identifiers. Education outcomes were examined using a generalized additive model, and health and justice system outcomes with a time-to-event model, adjusted for socioeconomic status, mother's mental health and age at first birth, and involvement in the child welfare system. Results 1,664 Metis children and youth participated in BGCW from 2005-2016. The comparison group comprised 9,248 Metis children and youth. Greater BGCW participation was associated with higher likelihood of performing well in grade 3 numeracy (boys and girls) and grade 7 student engagement (boys only), but not other education outcomes (grade 3 reading, grade 7 mathematics, grade 7/8 reading/writing, or graduating high school). Greater BGCW participation was also associated with lower risk of becoming involved with the justice system (i.e., lower risk of being charged with a crime) and with lower risk of teen pregnancy. Conclusion / Implications Participation in BGCW programs may contribute to improved health, justice and education outcomes for Metis children and youth in Winnipeg.

Introduction The Boys & Girls Clubs of Winnipeg (BGCW) provide out-of-school programs to children and youth living in low-income neighbourhoods in Winnipeg, Canada. These programs aim to set participants on a path to success by supporting healthy behaviours, academic achievement and social skills. First Nation children and youth make up a substantial proportion of BGCW participants, but there are few empirical data available on how the programs influence health, social and education outcomes in this population. Objectives and Approach We linked BGCW attendance records for all Manitoba children born 1987-2010 to the individual-level administrative health, social and education data in the population-based Data Repository at the Manitoba Centre for Health Policy in Winnipeg. The comparison group of non-participants was matched on age and neighbourhood of residence. We narrowed the cohort to First Nation participants by linking to datasets containing First Nation identifiers. Education outcomes were examined using a generalized additive model, and health and justice system outcomes with a time-to-event model, adjusted for socioeconomic status, mother's mental health and age at first birth, and involvement in the child welfare system. Results 3,754 First Nation children and youth participated in BGCW from 2005-2016. The comparison group comprised 23,593 First Nation children and youth. Greater BGCW participation was associated with higher likelihood of performing well in grade 3 numeracy, but not other education outcomes (grade 3 reading, grade 7 student engagement or mathematics, grade 7/8 reading/writing, or graduating high school). Greater BGCW participation was also associated with lower risk of becoming involved with the justice system among youth aged 12-17 (i.e., lower risk of being charged with a crime) and with lower risk of teen pregnancy. Conclusion / Implications Participation in BGCW programs may contribute to improved health, justice and education outcomes for First Nation children and youth in Winnipeg.

Introduction The quality of early education children receive influences their developmental trajectories, with long-term effects extending into adulthood. First Nations children face many structural barriers to academic success. Few studies have examined the impact of education programs on removing these barriers to support better outcomes amongst First Nations children. Objectives and Approach We examined educational outcomes associated with full-day (FDK) versus half-day (HDK) kindergarten among First Nations children using data from the Manitoba Population Research Data Repository. We linked children’s education records with the Manitoba Health Registry and the First Nations Registry to identify all First Nations children who attended kindergarten in a Winnipeg school division (1998-2011). Children enrolled FDK were age- and sex- matched to children enrolled in HDK. Propensity scores used to adjust for confounding. Outcomes included academic achievements in grades 3, 7, and 8 and high school graduation. We used generalized linear models to test for differences in education. Results We identified 324 First Nations children enrolled in FDK and 595 matches in HDK in the study period. Among these, 37% FDK and 31% HDK students met or approached numeracy expectations in grade 3; and 30% FDK and 33% HDK met or approached numeracy expectations in grade 7. For reading expectations, 37% FDK and 33% HDK met or approached grade 3 reading expectations; in grade 8, roughly half of each group met or approached expectations for reading and writing. High school graduation rate for First Nations children in both FDK and HDK children was 60%. We found no differences in education outcomes when we tested for differences between HDK and FDK children. Conclusion/Implications Education outcomes did not differ between First Nations children enrolled in FDK vs. HDK programs. Kindergarten programs may be insufficient to overcome structural barriers to academic success that these children face. Culturally appropriate education strategies may be needed to support improved outcomes amongst this population.

Introduction Manitoba Public Health Nurses (PHNs) attempt to visit all families with newborns shortly after discharge from birth hospitalizations. Since 2000, PHNs have completed the Families First Screen (FFS) at these visits, to identify families at risk for child maltreatment. The information captured in FFS is a valuable tool for research. Objectives and Approach Our objective was to clean and validate FFS data and link to health data in the Manitoba repository in order to determine the percent of births in Manitoba hospitals that had FFS. We identified all babies born in Manitoba hospitals 2000-2015 using ICD-9-CM /ICD-10-CA codes. Mothers were identified through the Health Registry (Mom_Baby Link File) using scrambled Personal Health Identification Numbers (sPHINs). FFS data were linked to births via baby’s sPHIN. Determining which FFS records linked to babies required several steps of cleaning and validating the data to account for differences in birthdates between files, missing sPHINs, and multiple records. Results For example, in 2014 there were 16,079 births and 14,002 FFS records; 13,524 FFS had mother and/or baby sPHIN. For those missing baby sPHIN (9,295), 99.8% were retrieved via the Mom_Baby Link File. Linking the FFS to the hospital births we found: 3,043 births didn’t have an FFS; 12,762 had a single FFS, and 274 births had multiple FFS (i.e., baby associated with more than one mother, FFS and/or form date). To ensure that the baby was only associated with one mother and one FFS the most current FFS was kept. We found that in 2014, 81.07% (13,036/16,079) of the births had an FFS. In the longitudinal analysis, the percent of births with an FFS ranged from 74.6% in 2000 to 81.1% in 2014. Conclusion/Implications We were able to achieve good linkage between FFS and health registry data, allowing this rich data source to be used for research on maternal and child health. Information on percent of births with FFS has been shared with policy-makers over the years and changes to screening practices implemented.

Introduction The relationship between childhood/adolescent mental disorders and adult outcomes has been studied using surveys and clinical samples. These studies are prone to selection, recall and self-reporting biases. No previous studies have used population-based administrative databases linking individual-level data that could address these biases and further elucidate this relationship. Objectives and Approach Using de-identified administrative databases housed at the Manitoba Centre for Health Policy, we aimed to determine whether people diagnosed with mental disorders in childhood/adolescence, compared to those without, were at higher risk of early adverse adult outcomes. We created a birth cohort of 60,838 residents of Manitoba, Canada, born from fiscal years 1980/81 to 1984/85 and followed them to the end of study period in 2014/15. Through a scrambled health identifier, health, education, social services and justice system data were linked at an individual level. Survival analysis was used to test for differences controlling for key childhood covariates. Results We found that 16.5% of the cohort had a diagnosed mental disorder at some point in their childhood/adolescence. Having a diagnosed mental disorder in childhood/adolescence increased the risk of being diagnosed with the same disorder in early adulthood (at age 30 to 34 years old). It also increased the risk of suicidal death (hazard ratio (HR): 2.41), suicide attempts (HR: 3.05), public housing use (HR: 1.44), income assistance use (HR: 2.07), criminal accusation (HR:1.53), and criminal victimization (HR:1.54) in adulthood. Similarly, but to a greater extent, suicide attempts in adolescence increased the risk of suicidal death (HR: 3.65), suicide attempts (HR: 5.68), public housing use (HR: 1.64), income assistance use (HR: 1.68), criminal accusation (HR: 2.18), or criminal victimization (HR: 2.43) in adulthood. Conclusion/Implications Young people’s mental health has significant influence on their health and well-being trajectories into adulthood. This knowledge could directly inform policy and practice to provide better population-based mental health promotion, prevention and early interventions for children/adolescents with mental disorders and subsequently prevent adverse adult outcomes in the future.

Introduction In Manitoba, low-income pregnant women are eligible for the Healthy Baby Prenatal Benefit (HBPB), an unconditional income supplement provided during the second and third trimester of pregnancy. HBPB is associated with improved birth outcomes for Manitoba women; its association with birth outcomes for First Nations (Indigenous) women is unknown. Objectives and Approach To determine the association between HBPB and First Nations’ (FN) newborn and early childhood outcomes, we linked whole-population data from health, public health, family services and education. We included only FN women receiving income assistance during pregnancy (n=7074) to develop comparable treatment (received HBPB; n=5283) and comparison (no HBPB; n=1791) groups. Propensity score weighting adjusted for differences in maternal characteristics between groups. Multi-variable regressions compared groups on breastfeeding initiation, low birth weight, preterm birth, small- and large-for-gestational age, Apgar scores, complete immunizations at 1 and 2 years, and developmental vulnerability in kindergarten measured with the Early Development Instrument (EDI). Results Receipt of the HBPB was associated with reductions in low birth weight births (adjusted Relative Risk (aRR): 0.77; 95% CI: 0.63, 0.93) and preterm births (aRR: 0.78 (0.68, 0.90)), and increases in breastfeeding initiation (aRR: 1.05 (1.00, 1.09)) and large-for-gestational age births (aRR: 1.11 (1.01, 1.23)). HBPB receipt during pregnancy was also associated with increases in 1- and 2-year immunizations for FN children (aRR: 1.14 (1.09, 1.19), and aRR: 1.28 (1.19, 1.36), respectively). Reductions in the risk of being developmentally vulnerable in the language and cognitive domain of the EDI were also found for FN children whose mothers had received the HBPB during pregnancy (aRR: 0.85 (0.74, 0.97). Conclusion/Implications A modest unconditional income supplement during pregnancy was associated with improved birth outcomes, increased immunization rates, and improved language and cognitive development at kindergarten for children born to low-income First Nations women. Long-term strategies to address structural inequities and the ongoing effects of colonization are also needed.

Introduction The province-wide Families First Home Visiting Program (FFHV) provides home visiting to families with children living in conditions of risk. It remains unknown if First Nations families are benefiting from the program. Using existing administrative and population-wide data is an innovative practice to evaluate programs that have been scaled up. Objectives and Approach The objective is to determine FFHV’s effectiveness at improving outcomes for First Nations children and parents. The partnership with First Nations Health and Social Secretariat of Manitoba facilitated access to First Nations identifiers and provided guidance in conducting the study. Program data from 4,010 First Nations children and parents were linked at an individual-level to administrative data housed at the Manitoba Centre for Health Policy. We compared the predictive probability of outcomes of program and non-program families. Inverse probability of treatment weights were used to adjust for confounders related to both entry into FFHV and the outcomes under study. Results The cohort of First Nations children and parents was successfully linked through an individual scrambled health identifier. FFHV was associated with higher rates of child immunization at age one (71% versus 66%) and age two (47% versus 41%) and parental involvement in community support groups (21% versus 17%). It was also associated with lower rates of being in care of child welfare at age one (10% versus 14%) and age two (15% versus 19%); maltreatment-related hospitalizations at age three (0.4% versus 1.0%); and child victimization as measured by justice system records (1.7% versus 3.0%). However, there were no differences in being “not ready for school” between the two groups of children, nor between the groups of mothers in physician visits for mental health reasons. Conclusion/Implications Home visiting services can play a role in supporting healthy development of First Nations children by providing support to parents and connecting children to health and social services, however, there also remains an urgent need for long term strategies to address structural inequality and the ongoing effects of colonization.

ABSTRACT Objectives Manitoba has one of the highest rates of children in out-of-home care in the world. Our aims were to: 1) describe characteristics of children in care; 2) determine differences in educational outcomes for children in care, children receiving in-home protection services and children not involved with child welfare; and, 3) identify factors contributing to educational success for children in care. Approach Population-level administrative data from the Population Health Research Data Repository at the Manitoba Centre for Health Policy, were used. Several data sources were linked together at an individual level: child welfare services (e.g., in care, in-home services; hospital birth records (e.g., birth weight, gestational age); health status (e.g., from hospitalizations, physician visits); family risk factors (e.g., maternal prenatal smoking and/or drinking, maternal education); family characteristics (e.g., number of children in family, receipt of income assistance); education assessments at kindergarten, grades 3, 7, 8, 9 and 12. Children in care from 1998 onward were included. Number of children analyzed differed depending on the educational outcome examined: e.g., analyses at kindergarten include 1,893 children in care, 4,229 children receiving in-home services, and 32,280 children not involved with child welfare services; for high school completion these numbers were 11,234, 40,671, and 162,265 respectively. Multivariate regressions identified characteristics associated with educational outcomes for children in care. Results Over one-third of children in care first entered care as infants, and of those, close to half were apprehended at birth. 5.5% of children in Manitoba spent some time in care before their 15th birthday, with an almost tenfold difference for Indigenous (16.6%) and non-Indigenous (1.7%) children. Across the range of educational outcomes, children in care did more poorly than children receiving in-home services, who in turn did more poorly than children with no child welfare involvement. For example, only 33.4% of children in care completed high school compared to 66.8% of children receiving in-home services and 89.3% of children with no child welfare involvement. Adjusting covariates reduced differences but all remained statistically significant. Factors associated with positive outcomes for children in care differed depending on the outcome and included measures like poverty (at Kindergarten, p

ABSTRACT Objective The objective of this population health intervention research was to determine the effectiveness in improving children’s outcomes of a provincial home visiting program for at-risk families in Manitoba, Canada. Home visiting programs have been evaluated in highly structured and supervised conditions which may provide different results than those evaluated in real-world delivery systems. Approach In this retrospective cohort study, data for 4,562 children from home visiting program families and 5,184 comparison children were linked to de-identified administrative health, social services, and education data held securely at the Manitoba Centre for Health Policy. Inverse probability of treatment weights were used to address the selection bias inherent in delivering a voluntary program. We used generalized linear modelling to calculate program effects among those exposed to the program, those unexposed and the average effect. Child outcomes examined included being taken into care of child welfare, hospitalizations for maltreatment-related injuries, and child development scores at school entry. Results The home visiting program was associated with lower rates of children being taken into care and lower rates of hospitalization for maltreatment-related injuries. For being taken into care by child’s first birthday, the adjusted Risk Ratio (aRR) was 0.75 (95% Confidence Interval [CI]: 0.66, 0.86); for being taken into care by second birthday, aRR=0.79, (95% CI: 0.70, 0.88); and for hospitalizations for maltreatment-related injuries by third birthday, aRR=0.59 (95% CI: 0.35, 0.99). Similar program effects would be expected among comparison children if they had received the program (i.e., average treatment effect for the untreated). No differences between groups were found across five domains of child development at school entry. Conclusion Home visiting programs can be an effective strategy for decreasing child maltreatment at a population level. Home visiting program enhancements are necessary to improve child development scores when children enter school. Use of population-based linkable data systems provides an opportunity to evaluate interventions using large, real-world samples, adjusting for a wide range of risk factors, and examining a variety of outcomes.

ABSTRACT Objective Perinatal outcomes have improved overall in developed countries over the last several decades but remain poor for disadvantaged populations. In Manitoba, Canada, the Healthy Baby Prenatal Benefit (HBPB), a cash transfer to low-income pregnant women, was introduced with the goal of improving perinatal outcomes. The objective of this study was to use linked administrative and program datasets to determine whether this unconditional income supplement was associated with improved birth outcomes for a low-income population. Approach This study used data from the PATHS Data Resource, which contains population-level health and social service records as well as program data for approximately 600,000 children in Manitoba, Canada, over a 30-year period, linkable at the individual level. All mother-newborn pairs, from 2003-2010, who met the following criteria were included for analyses: i) the mother was on social assistance (i.e., low income); ii) the infant was born in hospital; and, iii) the pair had a newborn risk screen (n=14,591), documenting factors such as prenatal alcohol and tobacco exposure and maternal and family characteristics. Low-income women who received HBPB (exposed, 10,738) were compared with low-income women who did not receive HBPB (unexposed, 3,853) on several outcomes: low birth weight, preterm, small- and large-for-gestational age, 5-minutes Apgar scores, breastfeeding initiation, neonatal readmission, and newborn hospital length of stay (LOS). Covariates from the risk screens were used to develop propensity scores to construct Inverse Probability of Treatment Weights, to balance differences between exposed and unexposed groups in regression models. Gamma sensitivity analyses assessed sensitivity to unmeasured confounding. Population attributable and preventable fractions were calculated. Results HBPB exposure was associated with reductions in low birth weight (adjusted risk ratio, aRR=0.71, 95% CI=0.63, 0.81), preterm (aRR=0.76 (0.69, 0.84)) and small-for-gestational age (aRR=0.90 (0.81, 0.99)) births and increases in breastfeeding (aRR=1.06 (1.03, 1.09)) and large-for-gestational age births (aRR=1.13 (1.05, 1.23)). For vaginal births, HBPB was associated with shortened LOS (mean=2.86, p

ABSTRACT Objectives Roots of Empathy is a school-based mental health program with demonstrated effectiveness in reducing bullying and aggression, and raising children’s social/emotional competence and empathy. This study examines the program’s impact on several longer-term health and social outcomes that are related to the program’s goals, but not specifically targeted by the program’s design or objectives. Approach This study used linked, de-identified administrative records of health, education, social service use and justice system involvement for children and youth in Manitoba who participated in the ROE program, along with a carefully matched comparison group. Propensity scores were used along with hard matching on key variables to ensure comparability of groups. Outcome measures encompass a broad array of health, educational, and social indicators including hospitalization for injury, teen pregnancy, high school graduation, involvement with the criminal justice system, and suicide attempts. Analyses were performed at the Manitoba Centre for Health Policy (MCHP), using SAS 9.4. Results Findings from analyses of data from the pilot study (N=688) reveal several ‘collateral benefits’ that may be related to the program, though most differences did not reach statistical significance in this initial sample. (Results from the full sample will be available May 2016; N ~ 8000.) Compared to matched counterparts who did not receive the program, ROE participants had lower rates of teen pregnancy (6.6% vs 9.6%; p=0.19), and school grade repetition (2.4% vs 3.8%, p=0.09), and higher rates of high school graduation (77.7% vs 73.5%, p=.36). However, they also had higher rates of injury-related hospitalization (6.4% vs 5.0%, p=0.14). Even in this small pilot, sub-group analyses for some outcomes showed significant differences for some strata but not others. Analyses of the full study group (underway) will provide more robust results. Conclusion These findings provide intriguing evidence suggesting beneficial impacts in several longer-term health and social outcomes that could feasibly be related to participation in the Roots of Empathy program. The multi-variable propensity scores and hard-matching algorithms used on this large group provide considerable confidence in attributing group differences to program participation. Results from the full sample will provide more conclusive results, and allow sub-group analyses. The linkage of databases from health, education, social service and justice systems provides a unique opportunity to examine the truly multi-dimensional long-term impacts of a program already proven to provide dramatic improvements in short and medium-term outcomes.