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Background Ensuring high quality and equitable maternity services is important to promote positive pregnancy outcomes. Despite a universal health care system, previous research shows neighborhood-level inequities in utilization of prenatal care in Manitoba, Canada. The purpose of this population-based retrospective cohort study was to describe prenatal care utilization among women giving birth in Manitoba, and to determine individual-level factors associated with inadequate prenatal care. Methods We studied women giving birth in Manitoba from 2004/05–2008/09 using data from a repository of de-identified administrative databases at the Manitoba Centre for Health Policy. The proportion of women receiving inadequate prenatal care was calculated using a utilization index. Multivariable logistic regressions were used to identify factors associated with inadequate prenatal care for the population, and for a subset with more detailed risk information. Results Overall, 11.5% of women in Manitoba received inadequate, 51.0% intermediate, 33.3% adequate, and 4.1% intensive prenatal care (N = 68,132). Factors associated with inadequate prenatal care in the population-based model (N = 64,166) included northern or rural residence, young maternal age (at current and first birth), lone parent, parity 4 or more, short inter-pregnancy interval, receiving income assistance, and living in a low-income neighborhood. Medical conditions such as multiple birth, hypertensive disorders, antepartum hemorrhage, diabetes, and prenatal psychological distress were associated with lower odds of inadequate prenatal care. In the subset model (N = 55,048), the previous factors remained significant, with additional factors being maternal education less than high school, social isolation, and prenatal smoking, alcohol, and/or illicit drug use. Conclusion The rate of inadequate prenatal care in Manitoba ranged from 10.5–12.5%, and increased significantly over the study period. Factors associated with inadequate prenatal care included geographic, demographic, socioeconomic, and pregnancy-related factors. Rates of inadequate prenatal care varied across geographic regions, indicating persistent inequities in use of prenatal care. Inadequate prenatal care was associated with several individual indicators of social disadvantage, such as low income, education less than high school, and social isolation. These findings can inform policy makers and program planners about regions and populations most at-risk for inadequate prenatal care and assist with development of initiatives to reduce inequities in utilization of prenatal care.

OBJECTIVE Type 2 diabetes is increasing in children worldwide, with Canadian First Nations (FN) children disproportionally affected. The prevalence of gestational diabetes mellitus (GDM) also is increasing. The objective of this study was to evaluate the impact of GDM exposure in utero and FN status on the subsequent risk of type 2 diabetes in offspring in the first 30 years of life. RESEARCH DESIGN AND METHODS In this population-based historical prospective cohort study, we used administrative databases linked to a clinical database to explore the independent association and interaction between GDM and FN status on the subsequent development of type 2 diabetes in offspring. RESULTS Among 321,008 births with a median follow-up of 15.1 years, both maternal GDM and FN status were independently associated with subsequent risk of type 2 diabetes in offspring in the first 30 years of life (hazard ratio 3.03 [95% CI 2.44–3.76; P < 0.0001] vs. 4.86 [95% CI 4.08–5.79; P < 0.0001], respectively). No interaction between GDM and FN status on type 2 diabetes risk was observed. FN status had a stronger impact on the development of type 2 diabetes in offspring than GDM. CONCLUSIONS GDM is an important modifiable risk factor for type 2 diabetes, and its prevention may reduce the prevalence of subsequent type 2 diabetes in offspring. This study adds unique and rigorous evidence to the global public health debate about the impact of GDM on the long-term health of offspring.

Background Over the past 30 years, the prevalence of diabetes has steadily increased among Canadians, and is particularly evident among First Nations (FN) women. The interplay between FN ancestry, gestational diabetes and the development of subsequent diabetes among mothers remains unclear. Methods After excluding known pre-existing diabetes, we explored whether FN ancestry may modify the association between gestational diabetes and post-partum diabetes among women in Manitoba (1981–2011) via a historical prospective cohort database study. We analysed administrative data in the Population Health Research Data Repository using Kaplan–Meier survival analysis and Cox proportional hazards regression. Results Gestational diabetes was diagnosed in 11 906 of 404 736 deliveries (2.9%), 6.7% of FN and 2.2% of non-FN pregnant women (P < 0.0001). Post-partum diabetes during ≤ 30 years follow-up was more than three times higher among FN women than among non-FN women (P < 0.0001). Diabetes developed in 76.0% of FN and 56.2% of non-FN women with gestational diabetes within the follow-up period. The hazard ratio of gestational diabetes for post-partum diabetes was 10.6 among non-FN women and 5.4 among FN women. Other factors associated with a higher risk of diabetes included lower family income among FN and non-FN women and rural/remote residences among FN women. Among non-FN women, urban residence was associated with a higher risk of diabetes. Conclusion Gestational diabetes increases post-partum diabetes in FN and non-FN women. FN women had substantially more gestational diabetes or post-partum diabetes than non-FN women, partially due to socio-economic and environmental barriers. Reductions in gestational diabetes and socio-economic inequalities are required to prevent diabetes in women, particularly in FN population.

Objectives. We explored differences in health and education outcomes between children living in social housing and not, and effects of social housing’s neighborhood socioeconomic status. Methods. In this cohort study, we used the population-based repository of administrative data at the Manitoba Centre for Health Policy. We included children aged 0 to 19 years in Winnipeg, Manitoba, in fiscal years 2006–2007 to 2008–2009 (n = 13 238 social housing; n = 174 017 others). We examined 5 outcomes: age-2 complete immunization, a school-readiness measure, adolescent pregnancy (ages 15–19 years), grade-9 completion, and high-school completion. Logistic regression and generalized estimating equation modeling generated rates. We derived neighborhood income quintiles (Q1 lowest, Q5 highest) from average household income census data. Results. Children in social housing fared worse than comparative children within each neighborhood income quintile. When we compared children in social housing by quintile, preschool indicators (immunization and school readiness) were similar, but adolescent outcomes (grade-9 and high-school completion, adolescent pregnancy) were better in Q3 to Q5. Conclusions. Children in social housing had poorer health and education outcomes than all others, but living in social housing in wealthier areas was associated with better adolescent outcomes.

The PATHS Data Resource is a unique database comprising data that follow individuals from the prenatal period to adulthood. The PATHS Resource was developed for conducting longitudinal epidemiological research into child health and health equity. It contains individual-level data on health, socioeconomic status, social services and education. Individuals’ data are linkable across these domains, allowing researchers to follow children through childhood and across a variety of sectors. PATHS includes nearly all individuals that were born between 1984 and 2012 and registered with Manitoba’s universal health insurance programme at some point during childhood. All PATHS data are anonymized. Key concepts, definitions and algorithms necessary to work with the PATHS Resource are freely accessible online and an interactive forum is available to new researchers working with these data. The PATHS Resource is one of the richest and most complete databases assembled for conducting longitudinal epidemiological research, incorporating many variables that address the social determinants of health and health equity. Interested researchers are encouraged to contact [mchp_access@cpe.umanito ba.ca] to obtain access to PATHS to use in their own programmes of research.

OBJECTIVES: Breastfeeding is associated with improved health. Surveillance data show that breastfeeding initiation rates have increased; however, limited work has examined trends in socio-economic inequalities in initiation. The study’s research question was whether socio-economic inequalities in breastfeeding initiation have changed over the past 20 years. METHODS: This population-based study is a project within PATHS Equity for Children. Analyses used hospital discharge data for Manitoba mother–infant dyads with live births, 1988-2011 (n=316,027). Income quintiles were created, each with ~20% of dyads. Three-year, overall and by-quintile breastfeeding initiation rates were estimated for Manitoba and two hospitals. Age-adjusted rates were estimated for Manitoba. Rates were modelled using generalized linear models. Three measures, rate ratios (RRs), rate differences (RDs) and concentration indices, assessed inequality at each time point. We also compared concentration indices with Gini coefficients to assess breastfeeding inequality vis-a-vis income inequality. Trend analyses tested for changes over time. RESULTS: Manitoba and Hospital A initiation rates increased; Hospital B rates did not change. Significant inequalities existed in nearly every period, across all three measures: RRs, RDs and concentration indices. RRs and concentration indices suggested little to no change in inequality from 1988 to 2011. RDs for Manitoba (comparing initiation in the highest to lowest income quintiles) did not change significantly over time. RDs decreased for Hospital A, suggesting decreasing socio-economic inequalities in breastfeeding; RDs increased for Hospital B. Income inequality increased significantly in Manitoba during the study period. CONCLUSIONS: Overall breastfeeding initiation rates can improve while inequality persists or worsens.

Motor vehicle collisions (MVCs) are the leading cause of death in young people in North America. The effects of such deaths on parents have not been systematically studied. Administrative data sets were used to identify all parents (n = 1,458) who had an offspring die in a MVC between 1996 and 2008 in the province of Manitoba, Canada. They were matched to general population control parents who had not had offspring die from any sudden cause during the study period. Generalized estimating equations were used to compare the rates of physician-diagnosed mental and physical disorders, social factors, and treatment utilization in the 2 parent groups in the 2 years before and after offspring death, with adjustment for confounding factors. The risk of depression among bereaved parents almost tripled (adjusted prevalence ratio = 2.85, 95% confidence interval: 2.44, 3.33; P0.001) during the 2 years after death of an offspring. Significant increases in the risk of anxiety disorders (adjusted prevalence ratio = 1.45, 95% confidence interval: 1.26, 1.67; P0.001) were also observed. When compared with nonbereaved parents, bereaved parents had significant increases in the risks of depression (P0.001), anxiety disorders (P0.001), marital break-up (P = 0.015), and physician visits for mental illness (P0.001) in the post-death period. In conclusion, parents who lose an offspring in a MVC experience considerable mental illness and marital disruption.

The purpose of this study was to analyze population-based rates of surgical sterilization by sex, income, age group, and location of residence (urban, rural, or remote) among a universally insured population.The study included all 1.2 million residents of Manitoba. Data from comprehensive hospital and medical visit records were used to calculate rates of vasectomy and tubal ligation among the population aged 20 to 55 years. Analyses were carried out with generalized linear modelling, using administrative data housed at the Manitoba Centre for Health Policy.There were significant income-related gradients in sterilization rates for both sexes (P0.001), but the trends were in opposite directions for males and females. Tubal ligation rates were highest in low-income areas, and decreased with income, whereas vasectomy rates were lowest in low-income areas and increased with income. Rates also varied considerably by age and area of residence (urban, rural, or remote).These results are potentially worrying because tubal ligation is more invasive, associated with higher risks, and more costly than vasectomy. It would therefore be expected to be less common than vasectomy among all groups, not just those in higher income areas. The results contribute unique population-based procedure rates, which are not subject to biases that can affect survey-based studies. The findings may reflect underlying differences across income groups in decision-making regarding reproductive health issues.

The objective of this study was to examine mental disorders and treatment use among bereaved siblings in the general population. Siblings (N=7243) of all deceased children in the population of Manitoba, Canada who died between 1984 and 2009 were matched 1:3 to control siblings (N=21,729) who did not have a sibling die in the study period. Generalized estimating equations were used to compare the two sibling groups in the two years before and after the index child's death on physician-diagnosed mental disorders and treatment utilization, with adjustment for confounding factors including pre-existing mental illness. Analyses were stratified by age of the bereaved (

Background In Manitoba, Canada, school-based clinics providing sexual and reproductive health services for adolescents have been implemented to address high rates of sexually transmitted infections (STIs) and pregnancies. Methods The objectives of this population-based study were to compare pregnancy and STI rates between adolescents enrolled in schools with school-based clinics, those in schools without clinics, and those not enrolled in school. Data were from the PATHS Data Resource held in the Population Health Research Data Repository housed at the Manitoba Centre for Health Policy. Adolescents aged 14 to 19 between 2003 and 2009 were included in the study. Annualized rates of pregnancies and positive STI tests were estimated and Poisson regression models were used to test for differences in rates amongst the three groups. Results As a proportion, pregnancies among non-enrolled female adolescents accounted for 55 % of all pregnancies in this age group during the study period. Pregnancy rates were 2–3 times as high among non-enrolled female adolescents. Compared to adolescents enrolled in schools without school-based clinics, age-adjusted STI rates were 3.5 times (p

In Canada, suicide has transitioned from being a criminal activity with much associated stigma, to being a public health concern that needs to be managed by governments and clinicians in a culturally sensitive manner. In Canada and worldwide, the social attitudes toward and legal interpretation of suicide have been dynamic. Much has been proposed in the development of suicide policy in Canada, however Canada is unique in that it remains one of the only industrialized countries without a national suicide prevention strategy. The current article provides a critical review of the history of suicide in Canada, as well as an appraisal of Canadian suicide prevention policies and key government and political milestones that have impacted suicide policy. Current activity regarding a national suicide prevention strategy in Canada is discussed, as well as potential options for clinician involvement.

As health equity researchers, we need to produce research that is useful, policy-relevant, able to be understood and applied, and uses integrated knowledge translation (KT) approaches. The Manitoba Centre for Health Policy and its history of working with provincial government as well as regional health authorities is used as a case study of integrated KT. Whether or not health equity research "takes the day" around the decision-making table may be out of our realm, but as scientists, we need to ensure that it is around the table, and that it is understood and told in a narrative way. However, our conventional research metrics can sometimes get in the way of practicality and clear understanding. The use of relative rates, relative risks, or odds ratios can actually be detrimental to furthering political action. In the policy realm, showing the rates by socioeconomic group and trends in those rates, as well as incorporating information on absolute differences, may be better understood intuitively when discussing inequity. Health equity research matters, and it particularly matters to policy-makers and planners at the top levels of decision-making. We need to ensure that our messages are based on strong evidence, presented in ways that do not undermine the message itself, and incorporating integrated KT models to ensure rapid uptake and application in the real world.

Background The city of Winnipeg was the first among several jurisdictions in Manitoba, Canada, to introduce breed specific legislation (BSL) by banning pit-bull type dogs in 1990. The objective of the present work was to study the effectiveness of BSL in Manitoba. Methods Temporal differences in incidence of dog-bite injury hospitalisations (DBIH) within and across Manitoba jurisdictions with and without BSL were compared. Incidence was calculated as the number of unique cases of DBIH divided by the total person-years at risk and expressed as the number per 100 000 person-years. Year of implementation determined the pre-BSL and post-BSL period for jurisdictions with BSL; for jurisdictions without BSL to date, the entire study period (1984–2006) was considered as the preimplementation period. The annual number of DBIH, adjusted for total population at risk, was modelled in a negative binomial regression analysis with repeated measures. Year, jurisdiction and BSL implementation were independent variables. An interaction term between jurisdiction and BSL was introduced. Results A total of 16 urban and rural jurisdictions with pit-bull bans were identified. At the provincial level, there was a significant reduction in DBIH rates from the pre-BSL to post-BSL period (3.47 (95% CI 3.17 to 3.77) per 100 000 person-years to 2.84 (95% CI 2.53 to 3.15); p=0.005). In regression restricted to two urban jurisdictions, DBIH rate in Winnipeg relative to Brandon (a city without BSL) was significantly (p

OBJECTIVE To evaluate renal outcomes and survival in youth with type 2 diabetes (T2DM) versus type 1 diabetes (T1DM) versus nondiabetic control subjects. RESEARCH DESIGN AND METHODS In total, 342 prevalent youth (aged 1–18 years) with T2DM, 1,011 youth with T1DM, and 1,710 control subjects identified from 1986 to 2007 were anonymously linked to health care records housed at the Manitoba Centre for Health Policy to assess long-term outcomes using ICD codes. RESULTS Youth with T2DM were found to have a fourfold increased risk of renal failure versus youth with T1DM. Risk factors associated with renal failure were renin angiotensin aldosterone system inhibitor use and albuminuria in adolescence. Compared with control subjects (age, sex, and postal code matched), youth with T2DM had a 23-fold increased risk of renal failure and a 39-fold increased risk of dialysis. Kaplan-Meier survival at 10 years was 91.4% in the type 2 diabetic group versus 99.5% in the type 1 diabetic group (P < 0.0001). Renal survival was 100% at 10 years in both groups. It decreased to 92.0% at 15 years and 55.0% at 20 years in the type 2 diabetic group but remained stable in the type 1 diabetic group (P < 0.0001). CONCLUSIONS Youth with T2DM are at high risk of adverse renal outcomes and death. Albuminuria and angiotensin aldosterone system inhibitor use, which may be a marker of severity of disease, are associated with poor outcomes in early adulthood.

Background: Few population studies have examined the psychiatric outcomes of children and adolescents in the child welfare system, and no studies have compared outcomes before and after entry into care. Our objective was to assess the relative rate (RR) of suicide, attempted suicide, admission to hospital and visits to physicians’ offices among children and adolescents in care compared with those not in care. We also examined these outcomes within the child welfare population before and after entry into care. Methods: We used population-level data to identify children and adolescents 5 to 17 years of age who were in care in Manitoba for the first time between Apr. 1, 1997, and Mar. 31, 2006, and a comparison cohort not in care. We compared the two cohorts to obtain RRs for the specified outcomes. We also determined RRs within the child welfare population relative to the same population two years before entry into care. Results: We identified 8279 children and adolescents in care for the first time and a comparison cohort of 353 050 children and adolescents not in care. Outcome rates were higher among those in care than in the comparison cohort for suicide (adjusted RR 3.54, 95% confidence interval [CI] 2.11–5.95), attempted suicide (adjusted RR 2.11, 95% CI 1.84–2.43) and all other outcomes. However, adjusted RRs for attempted suicide (RR 0.27, 95% CI 0.21–0.34), admissions to hospital and physician visits decreased after entry into care. Interpretation: Children and adolescents in care were at greater risk of suicide and attempting suicide than those who were not in care. Rates of suicide attempts and hospital admissions within this population were highest before entry into care and decreased thereafter.

BACKGROUND Canadian First Nations, the largest of the Aboriginal groups in Canada, have had lower cancer incidence and mortality rates than non-Aboriginal populations in the past. This pattern is changing with increased life expectancy, a growing population, and a poor social environment that influences risk behaviors, metabolic conditions, and disparities in screening uptake. These factors alone do not fully explain differences in cancer risk between populations, as genetic susceptibility and environmental factors also have significant influence. However, genetics and environment are difficult to modify. This study compared modifiable behavioral risk factors and metabolic-associated conditions for men and women, and cancer screening practices of women, between First Nations living on-reserve and a non-First Nations Manitoba rural population (Canada). METHODS The study used data from the Canadian Community Health Survey and the Manitoba First Nations Regional Longitudinal Health Survey to examine smoking, binge drinking, metabolic conditions, physical activity, fruit/vegetable consumption, and cancer-screening practices. RESULTS First Nations on-reserve had significantly higher rates of smoking (P < 0.001), binge drinking (P < 0.001), obesity (P < 0.001) and diabetes (P < 0.001), and less leisure-time physical activity (P = 0.029), and consumption of fruits and vegetables (P < 0.001). Sex differences were also apparent. In addition, First Nations women reported significantly less uptake of mammography screening (P < 0.001) but similar rates for cervical cancer screening. CONCLUSIONS Based on the findings of this retrospective study, the future cancer burden is expected to be high in the First Nations on-reserve population. Interventions, utilizing existing and new health and social authorities, and long-term institutional partnerships, are required to combat cancer risk disparities, while governments address economic disparities.

The objective of this study was to estimate the impact of the First Nations and Inuit Home and Community Care Program (FNIHCCP) on the rates of hospitalization for ambulatory care sensitive conditions (ACSCs) in the province of Manitoba. A population-based time trend analysis was conducted using the de-identified administrative data housed at the Manitoba Centre for Health Policy, including data from 1984/85 to 2004/05. Findings show a significant decline in the rates of hospitalization (all conditions) following the introduction of the FNIHCCP in communities served by health offices (p

OBJECTIVE To validate a case definition for diabetes in the pediatric age-group using administrative health data. RESEARCH DESIGN AND METHODS Population-based administrative data from Manitoba, Canada for the years 2004–2006 were anonymously linked to a clinical registry to evaluate the validity of algorithms based on a combination of hospital claim, outpatient physician visit, and drug use data over 1–3 years in youth 1–18 years of age. Agreement between data sources, sensitivity, specificity, negative (NPV) and positive predictive value (PPV) were evaluated for each algorithm. In addition, ascertainment rate of each data source, prevalence, and differences between subtypes of diabetes were evaluated. RESULTS Agreement between data sources was very good. The diabetes definition including one or more hospitalizations or two or more outpatient claims over 2 years provided a sensitivity of 94.2%, specificity of 99.9%, PPV of 81.6% and NPV of 99.9%. The addition of one or more prescription claims to the same definition over 1 year provided similar results. Case ascertainment rates of both sources were very good to excellent and the ascertainment-corrected prevalence for youth-onset diabetes for the year 2006 was 2.4 per 1,000. It was not possible to distinguish between subtypes of diabetes within the administrative database; however, this limitation could be overcome with an anonymous linkage to the clinical registry. CONCLUSIONS Administrative data are a valid source for the determination of pediatric diabetes prevalence that can provide important information for health care planning and evaluation.

Background In circumpolar countries such as Canada, northern regions represent a unique geographical entity climatically, socioeconomically and environmentally. There is a lack of comparative data on birth outcomes among Indigenous and non-Indigenous subpopulations within northern regions and compared with southern regions. Methods A cohort study of all births by maternal mother tongue to residents of northern (2616 First Nations (North American Indians), 2388 Inuit and 5006 non-Indigenous) and southern (2563 First Nations, 810 643 non-Indigenous) Quebec, 1991–2000. Results Compared with births to southern non-Indigenous mother tongue women, births to northern women of all three mother tongue groups were at substantially elevated risks of infant death (adjusted OR (aOR) 1.7–2.9), especially postneonatal death (aOR 2.2–4.4) after controlling for maternal education, age, marital status and parity. The risk elevation in perinatal death was greater for southern First Nations (aOR 1.6) than for northern First Nations (aOR 1.2). Infant macrosomia was highly prevalent among First Nations in Quebec, especially in the north (31% vs 24% in the south). Within northern regions, Inuit births were at highest risk of preterm delivery (aOR 1.4) and infant death (aOR 1.6). Conclusion All northern infants (First Nations, Inuit or non-Indigenous) were at substantially elevated risk of infant death in Quebec, despite a universal health insurance system. Southern First Nations newborns have not benefited from the more advanced perinatal care facilities in southern regions. Environmental influences may partly account for the very high prevalence of macrosomia among First Nations in northern Quebec.

Objective: Little is known about the possible impacts of neighborhood socioeconomic status on birth outcomes and infant mortality among Aboriginal populations. We assessed birth outcomes and infant mortality by neighborhood so- cioeconomic status among First Nations and non-First Nations in Manitoba. Study Design: We conducted a retrospective birth cohort study of all live births (26,176 First Nations, 129,623 non-First Nations) to Manitoba residents, 1991-2000. Maternal residential postal codes were used to assign four measures of neigh- borhood socioeconomic status (concerning income, education, unemployment, and lone parenthood) obtained from 1996 census data. Results: First Nations women were much more likely to live in neighborhoods of low socioeconomic status. First Nations infants were much more likely to die during their first year of life (risk ratio (RR) =1.9) especially during the postneonatal period (RR=3.6). For both First Nations and non-First Nations, living in neighborhoods of low socioeconomic status was associated with an increased risk of infant death, especially postneonatal death. For non-First Nations, higher rates of pre- term and small-for-gestational-age birth were consistently observed in low socioeconomic status neighborhoods, but for First Nations the associations were less consistent across the four measures of socioeconomic status. Adjusting for neigh- borhood socioeconomic status, the disparities in infant and postneonatal mortality between First Nations and non-First Nations were attenuated. Conclusion: Low neighborhood socioeconomic status was associated with an elevated risk of infant death even among First Nations, and may partly account for their higher rates of infant mortality compared to non-First Nations in Manitoba.

Objective: There is limited and inconsistent evidence concerning rural versus urban differences in birth and in- fant outcomes for Indigenous peoples. We assessed birth and infant outcomes among Inuit, First Nations and French mother tongue groups by rural versus urban residence in Quebec, Canada. Study Deign: A retrospective birth cohort study of 5,184 First Nations, 2,527 Inuit and 652,940 French mother tongue (the majority reference) births in Quebec, 1991-2000. Results: In general, rural living was associated with slightly less favorable birth outcomes for French mother tongue women, but somewhat better outcomes for Indigenous women. For both Inuit and First Nations, rural births were half as likely to be small-for-gestational-age compared to urban births. Among First Nations, the difference in infant mortality rates comparing urban to rural areas was not statistically significant. Compared to infants of French mother tongue women, Inuit and First Nations infants were much less likely to be small-for-gestational-age in rural areas, while such an "advantage" diminished for First Nations and reversed for Inuit in urban areas. The disparities in infant mortality among First Nations versus French mother tongue births were greater in urban than in rural areas. These patterns of results re- mained after adjusting for maternal characteristics. Conclusion: Living in urban areas was not associated with better birth and infant outcomes for Inuit and First Nations in Quebec despite universal health insurance coverage, strongly indicating a need for improved socioeconomic conditions, perinatal and infant care for Indigenous people living in urban areas.

Objective: to determine the relationship of north-south place of residence to adverse birth outcomes among First Nations and non-First Nations in Manitoba, Canada, a setting with universal health insurance. Study Design: Live birth records (n=151,472) for the province of Manitoba, Canada 1991-2000 were analyzed, including 25,743 First Nations and 125,729 non-First Nations infants. North-south and rural-urban residence was determined for each birth through geocoding. Results: Comparing First Nations to non-First Nations, crude rates in North (and South) were: 7.0% versus 8.4% (9.3% versus 7.5%) for preterm birth; 6.1% versus 8.4% (8.7% versus 10.0%) for small-for-gestational-age birth, 4.2% versus 6.5% (6.2% versus 5.7%) for low birth weight, and 20.6% versus 13.7% (17.0% versus 11.0%) for large-for-gestational- age birth; and mortality per 1000 - neonatal 3.2 versus 6.2 (3.8 versus 3.3), post-neonatal 6.4 versus 6.4 (5.8 versus 1.5), and infant 9.5 versus 12.6 (9.6 versus 4.8). Adjusting for observed maternal and infant characteristics and rural versus ur- ban residence, the North was high risk for large-for-gestational-age birth for both First Nations and non-First Nations. First Nations' risk of preterm, small-for-gestational-age and low birth weight was lowest in the North, but for non-First Nations, the North was lower only for small-for-gestational-age. First Nations mortality indicators were similar North to South, but for non-First Nations, the North was high risk. Conclusion: North-South place of residence does matter for adverse birth outcomes, but the effects may differ by ethnicity and could require different intervention strategies.

Objective: We assessed individual- and community-level disparities and trends in birth outcomes and infant mortality among First Nations (North American Indians) and Inuit versus other populations in Quebec, Canada. Methods: A retrospective birth cohort study of all births to Quebec residents, 1991-2000. At the individual level, we ex- amined outcomes comparing births to First Nations and Inuit versus other mother tongue women. At the community level, we compared outcomes among First Nations and Inuit communities versus other communities. Results: First Nations and Inuit births were much less likely to be small-for-gestational-age but much more likely to be large-for-gestational-age compared to other births at the individual or community level, especially for First Nations. At both levels, Inuit births were 1.5 times as likely to be preterm. At the individual level, total fetal and infant mortality rates were 2 times as high for First Nations, and 3 times as high for Inuit. Infant mortality rates were 2 times as high for First Nations, and 4 times as high for Inuit. There were no reductions in these disparities between 1991-1995 and 1996-2000. Modestly smaller disparities in total fetal and infant mortality were observed for First Nations at the community level (risk ratio=1.6), but for Inuit there were similar disparities at both levels. These disparities remained substantial after adjusting for maternal characteristics. Conclusion: There were large and persistent disparities in fetal and infant mortality among First Nations and Inuit versus other populations in Quebec based on individual- or community-level assessments, indicating a need to improve socio- economic conditions as well as perinatal and infant care for Aboriginal peoples.

Objective: Little is known about community remoteness in relation to birth outcomes among Indigenous popu- lations. We assessed whether community remoteness matters for perinatal outcomes and infant mortality in Quebec First Nations communities. Study Design: A retrospective cohort study of all births (n=11,033) to residents of First Nations communities in Quebec 1991-2000, using linked vital statistics data. First Nations communities were grouped by community remoteness into four zones from the least to most remote. Results: Preterm birth rates declined progressively from the least remote (8.0%) to the most remote (5.7%) zones (p=0.002). In contrast, total fetal and infant mortality rose progressively from the least remote (10.4 per 1000) to the most remote (22.7 per 1000) zones (p

Birth outcomes are persistently worse among Aboriginal as compared to non-Aboriginal populations even in developed countries.1–10 The underlying causes remain incompletely understood. Several studies indicate that the place of residence may affect the disparities in birth outcomes and infant mortality when comparing Aboriginal versus non-Aboriginal populations. Among North American Indians (the Canadian equivalent term “First Nations”) and Alaskan Natives compared to whites in the United States, greater disparities in infant mortality have been reported in some urban areas than in rural areas.3,4 In British Columbia, the disparity in infant mortality when comparing First Nations to non-First Nations declined less substantially and less consistently in urban versus rural areas.2 A recent Australian study found that the disparity in infant mortality when comparing Aboriginal versus non-Aboriginal populations was larger in remote rural areas.6 However, it is unknown whether the degree of rural isolation per se may affect birth outcomes and infant mortality differentially among Aboriginal versus non-Aboriginal populations. The question may be of particular importance due to the increasing migration of Aboriginal people to less isolated areas over recent decades. Although many Aboriginal people have moved from rural to urban or near-urban areas, substantially higher proportions of the Aboriginal population remain living in rural and more isolated areas compared to the non-Aboriginal population. According to the 2001 census, 57% of the First Nations population of Canada lived in rural areas, compared to 20% of the non-Aboriginal population. We hypothesized that the degree of rural isolation may affect birth outcomes and infant mortality differentially among Aboriginal and non-Aboriginal populations, presumably because of the Aboriginal versus non-Aboriginal differences in access to and effective use of the better care facilities in urban centers, and the differences in socioeconomic conditions and other risk factors. The primary aim of this study was to evaluate whether the degree of rural isolation may differentially affect birth outcomes and infant mortality among First Nations and non-First Nations in Manitoba, Canada, a setting with universal health insurance.

Background: There is a lack of data on the safety of midwife-led maternity care in remote or Indigenous communities. In a de facto natural "experiment", we assessed birth outcomes by primary birthing attendant in two sets of remote Inuit communities. Methods: A geocoding-based retrospective birth cohort study in 14 Inuit communities of Nunavik, Canada, 1989-2000: primary birth attendants were Inuit midwives in the Hudson Bay (1,529 Inuit births) versus Western physicians in Ungava Bay communities (1,197 Inuit births). The primary outcome was perinatal death. Secondary outcomes included stillbirth, neonatal death, postneonatal death, preterm, small-for-gestational-age and low birth weight birth. Multi-level logistic regression was used to obtain the adjusted odds ratios (aOR) controlling for maternal age, marital status, parity, education, infant sex and plurality, community size and community-level random effects. Results: The aOR (95% confidence interval) for perinatal death comparing the Hudson Bay versus Ungava Bay communities were 1.29 (0.63, 2.64) for all Inuit births, and 1.13 (0.48, 2.47) for Inuit births at >=28 weeks of gestation. There were no statistically significant differences in the crude or adjusted risks of any of the outcomes examined. Conclusion: Risks of perinatal death were somewhat but not significantly higher in the Hudson Bay communities with midwife-led maternity care as compared to the Ungava Bay communities with physician-led maternity care. Our findings are inconclusive, although the results excluding extremely preterm births are more reassuring concerning the safety of midwife-led maternity care in remote Indigenous communities.

This study investigated the use of population-based administrative databases for stroke surveillance. First, a meta-analysis was conducted of four studies, identified via a PubMed search, which estimated the sensitivity and specificity of hospital data for ascertaining cases of stroke when clinical registries or medical charts were the gold standard. Subsequently, case-ascertainment algorithms based on hospital, physician and prescription drug records were developed and applied to Manitoba's administrative data, and prevalence estimates were obtained for fiscal years 1995/96 to 2003/04 by age group, sex, region of residence and income quintile. The meta-analysis results revealed some over-ascertainment of stroke cases from hospital data when the algorithm was based on diagnosis codes for any type of cerebrovascular disease (Mantel-Haenszel Odds-Ratio [OR] – 1.70 [95% confidence interval (CI): 1.53 – 1.88]). Analyses of Manitoba administrative data revealed that while the total number of stroke cases varied substantially across the algorithms, the trend in prevalence was stable regardless of the algorithm adopted.

Dans la présente étude, nous nous sommes penchés sur l'utilisation des bases de données administratives en matière de population dans la surveillance des accidents vasculaires cérébraux. Nous avons tout d'abord effectué une méta-analyse de quatre études, relevées au moyen d'une recherche dans PubMed, qui visaient à évaluer la sensibilité et la spécifi cité des données des hôpitaux dans la détermination des cas d'accident vasculaire cérébral lorsque les registres cliniques ou les dossiers médicaux étaient la méthode de référence. Nous avons ensuite mis au point des algorithmes de détermination des cas fondés sur les données des hôpitaux ainsi que les données relatives aux médecins et aux médicaments de prescription. Enfin, nous avons appliqué ces algorithmes aux données administratives du Manitoba, ce qui a permis d'obtenir des estimations de la prévalence pour les années fi nancières 1995-1996 à 2003-2004, par groupe d'âge, sexe, région de résidence et quintile de revenu. Les résultats de la méta-analyse ont fait ressortir une certaine surdétermination des cas d'accident vasculaire cérébral à partir des données des hôpitaux, lorsque l'algorithme était fondé sur les codes de diagnostic applicables à n'importe quel type de maladie vasculaire cérébrale (rapport de cotes de Mantel-Haenszel [RC] = 1,70 [intervalle de confiance (IC) à 95 % : 1,53-1,88]). Les analyses des données administratives du Manitoba ont révélé que même si le nombre total de cas d'accident vasculaire cérébral variait considérable ment selon l'algorithme, la tendance de la prévalence était stable indépendamment de l'algorithme utilisé.

Background Home visiting programs focused on improving early childhood environments are commonplace in North America. A goal of many of these programs is to improve the overall health of children, including promotion of age appropriate vaccination. In this study, population-based data are used to examine the effect of a home visiting program on vaccination rates in children. Methods Home visiting program data from Manitoba, Canada were linked to several databases, including a provincial vaccination registry to examine vaccination rates in a cohort of children born between 2003 and 2009. Propensity score weights were used to balance potential confounders between a group of children enrolled in the program (n = 4,562) and those who were eligible but not enrolled (n = 5,184). Complete and partial vaccination rates for one and two year old children were compared between groups, including stratification into area-level income quintiles. Results Complete vaccination rates from birth to age 1 and 2 were higher for those enrolled in the Families First program [Average Treatment Effect Risk Ratio (ATE RR) 1.06 (95 % CI 1.03–1.08) and 1.10 (95 % CI 1.05–1.15) respectively]. No significant differences were found between groups having at least one vaccination at age 1 or 2 [ATE RR 1.01 (95 % CI 1.00–1.02) and 1.00 (95 % CI 1.00–1.01) respectively). The interaction between program and income quintiles was not statistically significant suggesting that the program effect did not differ by income quintile. Conclusions Home visiting programs have the potential to increase vaccination rates for children enrolled, despite limited program content directed towards this end. Evidence-based program enhancements have the potential to increase these rates further, however more research is needed to inform policy makers of optimal approaches in this regard, especially with respect to cost-effectiveness.

Objectives To review and synthesize the currently available research on whether early intervention for psychosis programs reduce the use of inpatient services. Methods A systematic review was conducted using keywords searches on PubMed, Embase (Ovid), PsycINFO (ProQuest), Scopus, CINAHL (EBSCO), Social Work Abstracts (EBSCO), Social Science Citations Index (Web of Science), Sociological Abstracts (ProQuest), and Child Development & Adolescent Studies (EBSCO). To be included, studies had to be peer-reviewed publications in English, examining early intervention programs using a variant of assertive community treatment, with a control/comparison group, and reporting inpatient service use outcomes. The primary outcome extracted number hospitalized and total N. Secondary outcome extracted means and standard deviations. Data were pooled using random effects models. Primary outcome was the occurrence of any hospitalization during treatment. A secondary outcome was the average bed-days used during treatment period. Results Fifteen projects were identified and included in the study. Results of meta-analysis supported the occurrence of a positive effect for intervention for both outcome measures (any hospitalization OR: 0.33; 95% CI 0.18-0.63, bed-days usage SMD: -0.38, 95% CI -0.53 to -0.24). There was significant heterogeneity of effect across the studies. This heterogeneity is due to a handful of studies with unusually positive responses. Conclusion These results suggest that early intervention programs are superior to standard of care, with respect to reducing inpatient service usage. Wider use of these programs may prevent the occurrence of admission for patients experiencing the onset of psychotic symptoms.

Contexte : Nous avons etudie les inegalites sur le plan de la sante chez les membres inscrits des Premieres nations manitobaines par rapport au reste de la population du Manitoba. Methode : Nous avons compare trois indices de mortalite - le taux de mortalite prematuree (TMP), defini comme etant le taux de deces avant 75 ans ajuste selon l'âge et le sexe; l'esperance de vie a la naissance; et les annees potentielles de vie perdues (APVP) - pour les membres inscrits des Premieres nations et le reste de la population du Manitoba selon les zones geographiques de la province. Les donnees ont ete derivees d'un registre, le Population Health Research Data Repository, lie au Systeme de verification du statut (SVS) federal, pour la periode de 1995 a 1999. Resultats : Chez les membres des Premieres nations, le TMP etait le double de celui du reste de la population du Manitoba (6,6 c. 3,3 deces p. 1 000, p

OBJECTIVE: The Manitoba Centre for Health Policy was commissioned by Manitoba’s provincial health department to examine the health of newborns born 1994 through 1998, using three indicators: preterm birth (37 weeks gestation), birthweight, and type of infant feeding. METHODS: Data were derived from the Population Health Research Data Repository and the National longitudinal Survey of Children and Youth 1996. Variation by 12 Regional Health Authorities (RHAs) and by 12 Winnipeg Community Areas (CAs) was examined, as well as associations with the population’s health and socioeconomic well-being. RESULTS: Manitoba’s preterm birth rate was 6.7% of live births, from 5.3% to 7.4% by RHA, and 5.7% to 8.0% by Winnipeg CA. Manitoba’s low birthweight rate (

Objectif : Donner un apercu des indicateurs de la sante des enfants et des modes d'utilisation des soins de sante au Manitoba en comparant les resultats de sante d'enfants pour differentes categories de revenu : a) les enfants de deux communautes de la region de Winnipeg (Fort Garry et Point Douglas) et b) les adolescents de deux regions du Manitoba (le Nord et Winnipeg). Methode : Divers indicateurs de sante des enfants, derives de donnees administratives et d'enquetes nationales representatives, sont decrits dans les articles du present supplement. La morbidite et la mortalite des enfants, les modes d'utilisation des soins de sante, la consommation de produits pharmaceutiques et les donnees demographiques regionales dont il est question dans le supplement sont resumes ici en comparant les resultats obtenus dans des « classes virtuelles » de 100 enfants. Resultats: De hauts gradients ont ete observes en comparant les classes virtuelles de 100 eleves du secondaire, notamment dans le nombre d'adolescentes prenant la pilule anticonceptionnelle (Winnipeg 11, Nord 18) et le nombre annuel d'eleves hospitalises en raison de blessures (Winnipeg 1; Nord 4). Dans les classes virtuelles de 100 enfants, on a observe des gradients pour certains resultats, mais pas pour d'autres. Par exemple: nombre d'enfants nes avant terme (FG 7, PD 7); enfants allaites a la naissance (FG 90, PD 66); enfants hospitalises pour des infections des voies respiratoires inferieures avant l'âge d'un an (FG 3, PD 8); et enfants dont les parents n'ont pas termine leurs etudes secondaires (FG 11; PD 41). Conclusion: Partout au Manitoba, les indicateurs et les determinants de la sante des enfants et des adolescents montrent des gradients selon le revenu et la zone geographique.

Despite a reported socioeconomic gradient in health, little is known about relationship between socioeconomic status (SES) and frequency of dog-bite injuries. The primary objective of this study was to compare the frequency of dog-bite injuries, using data on dog-bite injury hospitalizations (DBIH), across different SES areas in Manitoba, Canada. The secondary objective of the study was to assess if frequency and pattern of DBIHs are similar to those of non-canine bite injury hospitalizations (NCBIH) and rabies post-exposure prophylaxis (PEP). SES grouping in this study was defined through rurality and area-wide income quintile groups.Rural and urban Manitoba neighbourhoods were ranked according to average area-level incomes into five levels (quintiles) with equal numbers of people in each income level. Prevalence was defined as the number of cases of hospitalizations (whether dog-bite injury or non-canine bite injury) or PEP reported in the years 1984-2006, divided by the total population during the same time period and expressed as the number of cases per 100 000 population per SES grouping. The 95% confidence intervals (CI) were calculated using the approach for Poisson distribution.During 1984-2006, Manitoba's prevalence (CI) of DBIH (3.19 (2.97, 3.41) per 100 000 population) was lower than prevalence of NCBIH (4.08 (3.84, 4.32)) and PEP (7.24 (6.92, 7.57)). Prevalence of DBIH was higher in rural than in urban areas (DBIH: 3.58 (3.24, 3.92) vs 2.87 (2.59, 3.15), p0.01) and higher in the lowest income quintile areas than in the highest, whether rural (5.18 (4.24, 6.26) vs 3.29 (2.55, 4.17), p0.0001) or urban (3.65 (2.97, 4.44) vs 2.24 (1.73, 2.87), p0.01). The patterns of relationship between SES (rurality and income levels) and prevalence of NCBIH and PEP were similar to those between SES and DBIH.Although only a descriptive study, the results suggest that policies for control of dog-bite injuries should be area-specific. Prevention efforts could perhaps be improved by focussing not only on families, but also on neighbourhood regions.

Background Adults with chronic disease are the most frequent users of the primary healthcare system. In Manitoba, patients are allowed to seek ambulatory (outpatient) care from the provider of their choosing (primary care physician or specialist), with referrals to specialists preferred but not always required. Some patients receive their routine care from specialists. We conducted this study to determine the patterns by which adults with chronic disease access ambulatory care as a prelude to exploring the impact these patterns may have on the quality of care received. Methods Physician claims for all visits between 2007/8-2009/10 were extracted from the Data Repository at the Manitoba Centre for Health Policy. Patients included in the analysis made at least four ambulatory visits to a primary care physician or specialist within the study period, and met the definition criteria for at least one of six chronic diseases: diabetes mellitus; congestive heart failure; mood disorders; ischemic heart disease; total respiratory morbidity; and/or hypertension. Patients were “assigned” to the physician they visited most regularly. Physician visit patterns were assessed by dividing visits into nine visit types based on the type of physician patients visited (assigned primary care physician, other primary care physician, or specialist) and whether or not they received a referral. Results 347,606 patients with 7,662,411 physician visits were included in the analysis. Most visits were to the patients’ assigned primary care physician. About 50% of the visits to specialists were by referral from the assigned primary care physician. However, 26-29% of all visits to a primary care physician were not to the assigned primary care physician, and non-assigned physicians were more likely to refer patients to specialists than assigned primary care physicians. Conclusion The findings suggest that the current primary care system in Manitoba may not adequately support coordination of ambulatory care. Ambulatory visits to a primary care provider who is not the patient’s regular provider may represent a lost opportunity for coordination and continuity of care, and may affect the quality of care patients receive. Primary care renewal initiatives in this province should address this challenge to service provision. Electronic supplementary material The online version of this article (doi:10.1186/1471-2296-15-148) contains supplementary material, which is available to authorized users.

What lessons have we learned at the Manitoba Centre for Health Policy (MCHP) about knowledge translation (KT) over the past 20 years, and what is our vision for the future? How does that KT interrelate with our other activities – research and the Population Health Data Repository? Who first noticed that “there's gold in them thar hills,” and what did they do about it? How did we weave administrative database “straw” into gold, how have we panned for gold and how do we look for the pot of gold in the future? This paper describes how MCHP began with an integrated KT research relationship with government, and through The Need to Know Team, extended KT to regional health authority planners. It describes the various push–pull KT mechanisms that MCHP has used, including dissemination of research to planners through interactive workshops, and to other researchers through Web-based resources.

Evaluation of the effectiveness of a patient decision aid (nurse-managed telephone support line and/or colorectal cancer screening website), distributed to patients by their family physician, in improving fecal occult blood test (FOBT) colorectal cancer screening rates. A pragmatic, two arm, cluster randomized controlled trial in Winnipeg, Manitoba, Canada (39 medical clinic clusters; 79 fee-for-service family physicians; 2,395 average risk patients). All physicians followed their standard clinical screening practice. Intervention group physicians provided a fridge magnet to patients that facilitated patient decision aid access. Primary endpoint was FOBT screening rate within four months. Multi-level logistic regression to determine effect of cluster, physician, and patient level factors on patient FOBT completion rate. ICC determined. Family physicians were randomized to control (n = 39) and intervention (n = 40) groups. Compared to controls (56.9%; n = 663/1165), patients receiving the intervention had a higher FOBT completion rate (66.6%; n = 805/1209; OR of 1.47; 95% confidence interval 1.06 to 2.03; p < 0.02). Patient aid utilization was low (1.1%; 13/1,221) and neither internet nor telephone access affected screening rates for the intervention group. FOBT screening rates differed among clinics and physicians (p < 0.0001). Patients whose physician promoted the FOBT were more likely to complete it (65%; n = 1140/1755) compared to those whose physician did not (51.1%; n = 242/470; p < 0.0001; OR of 1.54 and 95% CI of 1.23 to 1.92). Patients reporting they had done an FOBT in the past were more likely to complete the test (70.6%; n = 1141/1616; p < 0.0001; 95% CI 2.51 to 3.73) than those who had not (43%; n = 303/705). Patients 50–59 years old had lower screening rates compared to those over 60 (p < 0.0001). 75% of patients completing the test did so in 34 days. Despite minimal use of the patient aid, intervention group patients were more likely to complete the FOBT. Powerful strategies to increase colorectal cancer screening rates include a recommendation to do the test from the family physician and focusing efforts on patients age 50–59 years to ensure they complete their first FOBT. Trial registration number: clinicaltrials.gov identifier NCT01026753 .

In the first longitudinal, population-based study of full-day kindergarten (FDK) outcomes beyond primary school in Canada, we used linked administrative data to follow 15 kindergarten cohorts (n ranging from 112 to 736) up to grade 9. Provincial assessments conducted in grades 3, 7, and 8 and course marks and credits earned in grade 9 were compared between FDK and half-day kindergarten (HDK) students in both targeted and universal FDK programmes. Propensity score matched cohort and stepped-wedge designs allowed for stronger causal inferences than previous research on FDK. We found limited long-term benefits of FDK, specific to the type of programme, outcomes examined, and subpopulations. FDK programmes targeted at low-income areas showed long-term improvements in numeracy for lower income girls. Our results suggest that expectations for wide-ranging long-term academic benefits of FDK are unwarranted.

Background National health surveys are sometimes used to provide estimates on risk factors for policy and program development at the regional/local level. However, as regional/local needs may differ from national ones, an important question is how to also enhance capacity for risk factor surveillance regionally/locally. Methods A Think Tank Forum was convened in Canada to discuss the needs, characteristics, coordination, tools and next steps to build capacity for regional/local risk factor surveillance. A series of follow up activities to review the relevant issues pertaining to needs, characteristics and capacity of risk factor surveillance were conducted. Results Results confirmed the need for a regional/local risk factor surveillance system that is flexible, timely, of good quality, having a communication plan, and responsive to local needs. It is important to conduct an environmental scan and a gap analysis, to develop a common vision, to build central and local coordination and leadership, to build on existing tools and resources, and to use innovation. Conclusions Findings of the Think Tank Forum are important for building surveillance capacity at the local/county level, both in Canada and globally. This paper provides a follow-up review of the findings based on progress over the last 4 years.

The Breastfeeding Promotion Steering Committee of Manitoba conducted the cross-sectional Provincial Infant Feeding Study in 1996 to examine: correlation between breastfeeding policies and actual practices in Manitoba hospitals; compliance with Baby-Friendly Hospital Initiative (BFHI) criteria; and associations between hospital practices and two-week breastfeeding duration. Three separate surveys obtained information from: administrators concerning hospital policy; nursing staff concerning hospital practices; and all women giving birth in a five-week period, concerning breastfeeding rates and maternal perceptions of hospital practices. The results highlighted the need for policy and practice changes to comply with BFHI criteria. 92% initiated breastfeeding, and 84% were breastfeeding at two weeks postpartum. Independent predictors of weaning included: in-hospital supplementation (adjusted RR = 2.1, 95% CI 1.02-4.36, p = 0.04); temporarily interrupting breastfeeding while in hospital (adjusted RR = 4.9, 95% CI 2.7-8.9, p = 0.0001); no previous breastfeeding experience (adjusted RR = 2.5, 95% CI 1.4-4.4, p = 0.002); and Grade 12 or less maternal education.

OBJECTIVE To evaluate the risk of complications in youth with type 2 diabetes. RESEARCH DESIGN AND METHODS Population-based cohorts of 342 youth (1–18 years of age) with prevalent type 2 diabetes, 1,011 youth with type 1 diabetes, and 1,710 nondiabetic control youth were identified between 1986 and 2007 from a clinical registry and linked to health care records to assess long-term outcomes using ICD-9CM and ICD-10CA codes. RESULTS Youth with type 2 diabetes had an increased risk of any complication (hazard ratio 1.47 [95% CI 1.02–2.12]). Significant adverse clinical factors included age at diagnosis (1.08 [1.02–2.12]), HbA1c (1.06 [1.01–1.12]), and, surprisingly, renin-angiotensin-aldosterone system (RAAS) inhibitor use (1.75 [1.27–2.41]). HNF-1α G319S polymorphism was protective in the type 2 diabetes cohort (0.58 [0.34–0.99]). Kaplan-Meier statistics revealed an earlier diagnosis of renal and neurologic complications in the type 2 diabetes cohort, manifesting within 5 years of diagnosis. No difference in retinopathy was seen. Cardiovascular and cerebrovascular diseases were rare; however, major complications (dialysis, blindness, or amputation) started to manifest 10 years after diagnosis in the type 2 diabetes cohort. Youth with type 2 diabetes had higher rates of all outcomes than nondiabetic control youth and an overall 6.15-fold increased risk of any vascular disease. CONCLUSIONS Youth with type 2 diabetes exhibit complications sooner than youth with type 1 diabetes. Younger age at diagnosis is potentially protective, and glycemic control is an important modifiable risk factor. The unexpected adverse association between RAAS inhibitor use and outcome is likely a confounder by indication; however, further evaluation in young people is warranted.

The objective of this study was to evaluate the effectiveness of an invitation letter on cervical screening participation among unscreened women 30 to 69 years of age.A cluster randomized trial design was used in which unscreened women (n=31,452) were randomized by the forward sortation area (FSA) of their postal code to an intervention group that was sent an invitation letter (n=17,068) or a group that was not sent an invitation letter (n=14,384).Six months after the letters were mailed, 1,010 women in the intervention group (5.92%) and 441 women in the control group (3.06%) had a Pap test. After adjusting for variables that have previously shown to influence screening participation, women who were sent an invitation letter were significantly more likely to have had a Pap test in the next 6 months compared with women who were not sent an invitation letter (odds ratio [OR]=2.60, 95% confidence interval [CI] 2.09-3.35, p0.001). Overall, the effectiveness of the invitation letter improved with increasing age (p=0.02).Sending invitation letters increased cervical screening participation but because the overall effect was small, additional strategies that remove barriers to screening for unscreened women are also necessary.

In the midst of frequent reports about "the asthma epidemic," results from a number of studies by the manitoba centre for health policy have shown stable or decreasing prevalence of an overall indicator of respiratory diseases which includes asthma. To resolve these apparently contrary findings, we conducted a time trend analysis using administrative data. results revealed significant potential for diagnostic exchange: asthma prevalence increased, but that of bronchitis decreased.

Purpose of the Study:This study evaluates a nursing home Fall Management program to see if residents' mobility increased and injurious falls decreased. DESIGN AND METHODS: Administrative health care use and fall occurrence report data were analyzed from 2 rural health regions in Manitoba, Canada, from June 1, 2003 to March 31, 2008. A quasiexperimental, pre-post, comparison group design was used to compare rates of three outcomes, falls, injurious falls, and falls resulting in hospitalization, by RHA (program vs nonprogram nursing homes) and period (preprogram vs postprogram). Data collectors entered occurrence report information into spreadsheets. This was supplemented with administrative health care use data. RESULTS: The program appears to have benefitted residents-falls trended upward, injurious falls remained stable, and hospitalized falls decreased significantly (0.036-0.021 per person-year [ppy]; p = .043). Compared with nonprogram residents in the postperiod, both groups had the same fall rate, but program residents had significantly fewer injurious falls (0.596-0.746 ppy; p = .02) and hospitalized falls (0.02-0.041 ppy; p = .023). IMPLICATIONS: These results are among a small body of literature showing that Fall Management was associated with improved outcomes in program nursing homes from pre- to postperiod and compared with nonprogram nursing homes. This research provides some support for the benefits of being proactive and implementing injury prevention strategies universally and pre-emptively before a resident falls, helping to minimize injuries while keeping residents mobile and active. Larger scale research is needed to identify the true effectiveness of the Fall Management program and generalizability of results. Language: en

CONTEXT Suicide bereavement remains understudied and poorly understood. OBJECTIVES To examine outcomes of parents bereaved by the suicide death of their offspring and to compare these with both nonbereaved parent controls and parents who had offspring die in a motor vehicle crash (MVC). DESIGN Population-based case-control study. Suicide-bereaved parents were compared with nonbereaved matched control parents in the general population (n = 1415) and with MVC-bereaved parents (n = 1132) on the rates of physician-diagnosed mental and physical disorders, social factors, and treatment use in the 2 years after death of the offspring. Adjusted relative rates (ARRs) were generated by generalized estimating equation models and adjusted for confounding factors. SETTING Manitoba, Canada. PARTICIPANTS All identifiable parents who had an offspring die by suicide between 1996 and 2007 (n = 1415). MAIN OUTCOME MEASURES Mental and physical disorders, social factors, and treatment use. RESULTS Suicide bereavement was associated with an increased rate of depression (ARR, 2.14; 95% CI, 1.88-2.43), anxiety disorders (ARR, 1.41; 95% CI, 1.24-1.60), and marital breakup (ARR, 1.18; 95% CI, 1.13-1.23) in the 2 years after the suicide of an offspring, as compared with the 2 years prior to the death. Suicide-bereaved and MVC-bereaved parents had very few differences on predeath to postdeath outcomes. Depression rate increases were greater for MVC-bereaved parents (19.9%) compared with suicide-bereaved parents (15.9%; P = .005), whereas suicide-bereaved parents had higher rate increases of hospitalization for mental illness (P = .049). Suicide-bereaved parents were more likely than their MVC-bereaved counterparts to have depression (ARR, 1.30; 95% CI, 1.06-1.61), physical disorders (ARR, 1.32; 95% CI, 1.19-1.45), and low income (ARR, 1.34; 95% CI, 1.18-1.51) before their offspring's death. CONCLUSIONS Suicide bereavement is associated with adverse mental health and social outcomes. These consequences appear similar to those associated with MVC bereavement. Parents who lose offspring to suicide appear to be a vulnerable group even prior to their offspring's death.