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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.

Objective Little is known about how prenatal care influences health outcomes in Canada. The objective of this study was to examine the association of prenatal care utilization with maternal, fetal, and infant outcomes in Manitoba. Methods This retrospective cohort study conducted at the Manitoba Centre for Health Policy investigated all deliveries of singleton births from 2004-2005 to 2008-2009 (N = 67 076). The proportion of women receiving inadequate, intermediate/adequate, and intensive prenatal care was calculated. Multivariable logistic regression was used to examine the association of inadequate and intensive prenatal care with maternal and fetal-infant health outcomes, health care use, and maternal health-related behaviours. Results The distribution of prenatal care utilization was 11.6% inadequate, 84.4% intermediate/adequate, and 4.0% intensive. After adjusting for sociodemographic factors and maternal health conditions, inadequate prenatal care was associated with increased odds of stillbirth, preterm birth, low birth weight, small for gestational age (SGA), admission to the NICU, postpartum depressive/anxiety disorders, and short interpregnancy interval to next birth. Women with inadequate prenatal care had reduced odds of initiating breastfeeding or having their infant immunized. Intensive prenatal care was associated with reduced odds of stillbirth, preterm birth, and low birth weight and increased odds of postpartum depressive/anxiety disorders, initiation of breastfeeding, and infant immunization. Conclusion Inadequate prenatal care was associated with increased odds of several adverse pregnancy outcomes and lower likelihood of health-related behaviours, whereas intensive prenatal care was associated with reduced odds of some adverse pregnancy outcomes and higher likelihood of health-related behaviours. Ensuring women receive adequate prenatal care may improve pregnancy outcomes.

The way state governments, worldwide, count or do not count Indigenous peoples has contributed to inconsistent reporting of Indigenous health statistics. To address unreliable reporting in Canada, we reviewed laws on Indian status and the development of a national Indian Registration System (IRS) to track Indian status and eligibility. With this information as a guide, we linked the IRS to the Manitoba provincial health registry systems and were able to identify individuals with Indian status for health reporting. To improve reporting, we identified individuals often missed in this type of linkage. For instance, we identified children and adult children who were eligible for Indian status but not yet registered. Equally as important, we identified individuals not eligible for Indian status but have Indian heritage and/or represent potential individual Indian status eligibility cases before the courts to right a historic form of identity sex discrimination that has made them invisible in Canadian society and health reporting. A familial kinship approach was used to identify Indian children and adult children typically missed when a strict legal entitlement criteria is used for data linkage. Our reflective socio-legal data linkage approach expanded the number of Indian peoples for health reporting purposes and demonstrated a feasible, inclusive way to report on the health of Indians in Canada.

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.

To examine associations between breastfeeding initiation and subsequent diabetes among First Nations (indigenous people in Canada who are not Métis or Inuit) and non-First Nations mothers and their offspring with and without gestational diabetes mellitus (GDM).This retrospective database study included 334,553 deliveries (1987-2011) in Manitoba with up to 24 years of follow-up for diabetes using population-based databases. Information of breastfeeding initiation before hospital discharge was obtained from hospital abstracts recorded by nurses in postpartum wards. Cox proportional hazard models were applied to examine the association between breastfeeding initiation and risk of diabetes in mothers and their offspring.Breastfeeding initiation was recorded in 83% of non-First Nations mothers and 56% of First Nations mothers (P.001). Breastfeeding initiation was associated with a reduced risk of incident (later developed) diabetes in non-First Nations mothers without GDM (hazard ratio [HR] 0.73 [or -27% of risk], 95% confidence interval [CI] 0.68-0.79), non-First Nations mothers with GDM (HR 0.78 or -22% of risk, CI 0.69-0.89), First Nations mothers without GDM (HR 0.89 or -11% of risk, CI 0.81-0.98), and First Nations mothers with GDM (HR 0.82 or -18% of risk, CI 0.73-0.92) with 24 years of follow-up or less. With 24 years of follow-up or less, breastfeeding initiation was associated with a 17% lower risk of youth-onset type 2 diabetes in offspring (HR 0.83, CI 0.69-0.99, P=.038). The association between breastfeeding initiation and subsequent diabetes in mothers and offspring was independent of family income, rural residence, First Nations status, GDM, parity, gestational hypertension, and age of the mother.Breastfeeding initiation is associated with a reduced risk of diabetes among women and their offspring in Manitoba. The results suggest that breastfeeding might be a potentially modifiable factor to reduce the risk of diabetes in both First Nations and non-First Nations women and children.

BACKGROUND AND OBJECTIVES:Perinatal outcomes have improved in developed countries but remain poor for disadvantaged populations. We examined whether an unconditional income supplement to low-income pregnant women was associated with improved birth outcomes.METHODS:This study included all mother–newborn pairs (2003–2010) in Manitoba, Canada, where the mother received prenatal social assistance, the infant was born in the hospital, and the pair had a risk screen (N = 14 591). Low-income women who received the income supplement (Healthy Baby Prenatal Benefit [HBPB], n = 10 738) were compared with low-income women who did not receive HBPB (n = 3853) on the following factors: low birth weight, preterm, small and large for gestational age, Apgar score, breastfeeding initiation, neonatal readmission, and newborn hospital length of stay (LOS). Covariates from risk screens were used to develop propensity scores and to balance differences between groups in regression models; γ sensitivity analyses were conducted to assess sensitivity to unmeasured confounding. Population-attributable and preventable fractions were calculated.RESULTS:HBPB was associated with reductions in low birth weight (aRR, 0.71 [95% CI, 0.63–0.81]), preterm births (aRR, 0.76 [95% CI, 0.69–0.84]) and small for gestational age births (aRR, 0.90 [95% CI, 0.81–0.99]) and increases in breastfeeding (aRR, 1.06 [95% CI, 1.03–1.09]) and large for gestational age births (aRR, 1.13 [95% CI, 1.05–1.23]). For vaginal births, HBPB was associated with shortened LOS (weighted mean, 2.86; P < .0001). Results for breastfeeding, low birth weight, preterm birth, and LOS were robust to unmeasured confounding. Reductions of 21% (95% CI, 13.6–28.3) for low birth weight births and 17.5% (95% CI, 11.2–23.8) for preterm births were associated with HBPB.CONCLUSIONS:Receipt of an unconditional prenatal income supplement was associated with positive outcomes. Placing conditions on income supplements may not be necessary to promote prenatal and perinatal health.

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.

Introduction Although the physician's role with patients is crucial in encouraging FOBT screening, the nature and content of physician-patient discussions about FOBT screening is unclear. As part of a larger study, this paper reports on our analyses of physician beliefs about fecal occult blood testing (FOBT) and strategies they employed to enhance patient adherence. The second aim of this paper is to report on the perceptions of individuals at average risk for colorectal cancer (CRC) in regard to their awareness of the FOBT and their responses to physician recommendations about FOBT screening. Methods The larger study was conducted in urban and rural Manitoba, Canada between 2008 and 2010. We used a qualitative design and conducted semi-structured, audio-recorded interviews with 15 physicians and 27 individuals at average risk for CRC. We included data from 11 family members or friends on their perspectives of FOBT instructions as individuals who were also at average risk for CRC and had their own experiences with CRC screening recommendations. Results Despite widespread knowledge of The Canadian Task Force on Preventive Health Care CRC screening guidelines, physician attitudes, behaviors, and instructions were not uniform in promoting patient adherence to FOBT screening. Individuals at average-risk for CRC identified that FOBT instructions were confusing and burdensome, which in turn served as a barrier in their adherence to FOBT screening. Conclusions Variation in FOBT instruction counseling in relation to the recommended age of individuals at average risk for CRC, as well as adequate patient preparation affected patient adherence. We recommend uniform or standardized instructions and counseling by health care providers who administer the FOBT kit to patients to promote adherence to recommended CRC screening.

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

Background: Although the number of Canadians being screened for colon cancer is rising, only 40% of Canadians aged 50 years or older reported they had engaged in faecal occult blood test (FOBT) screening as recommended. The notion of ‘partnerships’ that is inclusive of physicians, individuals at average-risk for colorectal cancer, and influential family members is receiving more attention in primary health care literature and policy on promoting health maintenance behaviours. To the best of our knowledge there are no studies that have taken a tripartite approach in describing perspectives of these three key stakeholders on the role of family in promoting adherence to FOBT. The aim of this study was to address the gap in understanding the perspectives of primary care physicians, individuals at average-risk for colorectal cancer, and family on family role in promoting adherence to FOBT screening. Method: We employed a qualitative design and conducted semi-structured interviews with 15 physicians, 27 patients at average-risk for colorectal cancer, and 19 family members or friends from urban and rural Manitoba, Canada between October 2008 and March 2010. Interviews were audio-recorded, transcribed verbatim, and analysed using content analysis and constant comparative techniques. Results: While physicians described a clear role for family in managing chronic disease or dealing with acute or serious illness, they identified barriers in working with family to promote FOBT screening: lack of time, privacy and confidentiality concerns, and family dynamics. Conversely, patients and family described instrumental, emotional, informational, and appraisal roles that family play in promoting FOBT outside medical encounters. Conclusion: Adherence to colorectal cancer screening is based on supportive ‘patient–physician’ dialogue that is separate from assistive ‘patient–family member’ relations. Further research is required to explore social support mechanisms involving family members outside medical encounters that hold promise in boosting self-efficacy, overcoming barriers, and gaining positive reinforcement for individuals at average-risk when making the decision to engage in FOBT.

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 lion's tail and knowledge boundaries are two analogies referred to in the lead essay by Lindstrom, MacLeod and Levy. These may be helpful but require slight readjustment. Grabbing onto the lion's tail implies one reality and one intersection point, whereas the old analogy of the blind men and the elephant shows that various perspectives are required. Integrated knowledge translation refers to user involvement throughout the research process. Participatory models are one form of integrated knowledge translation, but caution is required to help maintain the knowledge boundaries. There is the real danger of one group becoming "pickled," or having unbalanced osmotic pressure from another group, resulting in destroyed "cell wall" boundaries. Neither researchers nor users should morph into each other but should, rather, fulfill unique roles within a respectful, trusted research relationship. Lessons learned at the Manitoba Centre for Health Policy teach us that collaborative health services research takes time, money, mutual understanding and respect (including respect from academic institutions for this paradigm of research). This requires a dedicated centre of core group scientists willing to devote the necessary time. Diffused networks may not be stable enough to maintain the long-term relationship building required for the intersection of researchers and decision-makers.

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.

The objective of this study was to document the relationship between First Nation's community characteristics and the rates of hospitalization for Ambulatory Care Sensitive Conditions (ACSC) in the province of Manitoba, Canada. A population-based time trend analysis of selected ACSC was conducted using the de-identified administrative data housed at the Manitoba Centre for Health Policy, including vital statistics and health information. The study population included all Manitoba residents eligible under the universal Manitoba Health Services Insurance Plan and living on First Nation reserves between 1984/85 and 2004/05. Twenty-nine ACSC defined using 3, 4 and 5 digit ICD-9-CM and ICD-10-CM codes permitted cross-sectional and longitudinal comparison of hospitalization rates. The analysis used Generalized Estimated Equation (GEE) modeling. Two variables were significant in our model: level of access to primary health care on-reserve; and level of local autonomy. Communities with local access to a broader complement of primary health care services showed a lower rate of hospitalization for ACSC. We also examined whether there was a significant trend in the rates of hospitalization for ACSC over time following the signature of an agreement increasing local autonomy over resource allocation. We found the rates of hospitalization for ACSC decreased with each year following the signature of such an agreement. This article demonstrates that communities with better local access to primary health care consistently show lower rates of ACSC. Secondly, the longer community health services have been under community control, the lower its ACSC rate.

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.

Barriers to cervical cancer screening (Pap tests) may exist for women experiencing schizophrenia.This study analyzed healthcare records of all women in the province of Manitoba, Canada to: (a) compare cervical cancer screening rates of women with and without schizophrenia; and (b) determine factors associated with screening uptake.This study took place in Manitoba, Canada, utilizing anonymized universal administrative data in the Population Health Research Data Repository at the Manitoba Centre for Health Policy.All females aged 18-69 living in Manitoba December 31, 2002, excluding those diagnosed with invasive or in situ cervical cancer in the study period or previous 5 years.To determine factors associated with Papanicolaou (Pap) test uptake (1+ Pap test in 3 years, 2001/02-2003/04), logistic regression modeling included: diagnosis of schizophrenia, age, region, average household income, continuity of care (COC), presence of major physical comorbidity. Good COC was defined as at least 50% of ambulatory physician visits from the same general/family practitioner within two years.Women with schizophrenia (n=3220) were less likely to have a Pap test (58.8% vs. 67.8%, p.0001) compared to all other women (n=335 294). In the logistic regression, a diagnosis of schizophrenia (aOR=0.70, 95% CI 0.65-0.75); aged 50+, and living in a low-income area or the North decreased likelihood; good continuity of care (aOR 1.88, 95% CI 1.85-1.91) and greater physical comorbidity (1.21, 95% CI 1.04-1.41) increased likelihood.Women with schizophrenia are less likely to receive appropriate cervical cancer screening. Since good continuity of care by primary care physicians may mitigate this, psychiatrists should consider assisting in ensuring screening uptake.

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.

Background/Purpose Significant socioeconomic disparities have been observed in the rates of perforated appendicitis among children in private health care. We seek to explore if, in the Canadian system of public, universal health care access, pediatric appendicitis rupture rates are an indicator of health disparities. Methods Using the Population Health Research Data Repository housed at Manitoba Centre for Health Policy, a retrospective analysis over a 20-year period (1983-2003) examined all patients aged less than 18 years with International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic and procedural codes for appendicitis (N = 7475). Multivariate logistic regression analysis was used to calculate odds ratios in the association between appendiceal rupture rates and the patient's socioeconomic status (SES) based upon average household income of the census area adjusted for age, sex, area of residence, and treating hospital. Results The overall appendiceal rupture rate was 28.8%. Significant positive predictors of appendiceal rupture were lower rural SES, lower urban SES, younger age, northern area of residence, and receiving treatment at the province's only pediatric tertiary care hospital. Conclusion Despite free, universal access health care, children from lower SES areas have increased appendiceal rupture rates. Seeking and accessing medical attention can be complicated by social, behavioral, and geographical problems.

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.

Full-term newborn normative weight loss and factors influencing this were determined through chart audits (n = 812) at 6 hospitals in Manitoba, Canada. The effects of parity, gestational age, birth weight, sex, length of stay, type of delivery (cesarean vs vaginal), epidural use, and type of infant feeding (exclusively breastfed, partially breastfed, exclusively formula-fed) on percentage weight loss in hospital were analyzed using multiple regression analysis. In-hospital weight loss was 5.09% ± 2.89% (95% CI, 4.89-5.29), varying by feeding category: exclusively breastfed 5.49% ± 2.60% (95% CI, 5.23-5.74), partially breastfed 5.52% ± 3.02% (95% CI, 5.16-5.88), and formula-fed 2.43% ± 2.12% (95% CI, 2.02-2.85). Factors significantly increasing the percentage weight loss included higher birth weight, female sex, epidural use, and longer hospital stay. Lower percentage weight loss was associated with greater gestational age and exclusive formula feeding. Parity and type of delivery were not significant. Controlling for demographic and delivery-related variables, exclusive formula feeding had the largest impact, with 3.1% less weight loss than exclusive breastfeeding. J Hum Lact. 23(3):233-241.

OBJECTIVE For Aboriginal on-reserve First Nations populations of Manitoba, Canada, this study explores (i) diabetes and amputation patterns; and (ii) their ecologic associations with geography, income and access to healthcare. RESEARCH DESIGN AND METHODS De-identified administrative claims data in the Population Health Research Data Repository were linked to federal Status Verification System files for 1995 to 1999 (n=48 036 First Nations; 1 054 422 other Manitobans). Directly standardized rates were determined for ages 20 to 79 using International Classification of Diseases, 9th Revision, Clinical Modification codings: (i) treatment prevalence of diabetes, using physician and hospital billing claims with diagnosis 250; (ii) lower limb amputation with diabetes comorbidity (diagnosis 250) using hospitalization procedure codes 84.40 and 84.45 to 84.48. Ecologic correlations at the tribal council level, consisting of 9 First Nations on-reserve groupings, examined associations of diabetes indicators, average household income (1996 Statistics Canada census), ambulatory consult rates and geography (north vs. south). RESULTS Comparing First Nations with other Manitobans, rates of diabetes (203 vs. 45 per thousand) and amputation (3.39 vs. 0.19 per thousand) were higher. For on-reserve First Nations, diabetes varied by tribal council (149 to 249 per thousand) and was associated with income (r=—0.82, p=0.007) and geography (north 186.8, south 227.9, p CONCLUSION Among First Nations, diabetes prevalence is associated with socioeconomic (income) and geographic gradients, whereas the adverse outcome of amputation is associated with healthcare access (consult rates). Even within universally insured industrialized countries, First Nations barriers to healthcare must be addressed.

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.

Background This paper reviews what is currently known about mortality among Canadians with intellectual and developmental disabilities and describes opportunities for ongoing monitoring. Methods In-hospital mortality among adults with intellectual and developmental disabilities in Ontario was examined using hospital data. Mortality was compared between age-, sex- and residence area-matched groups of Manitobans with and without intellectual and developmental disabilities using linked administrative data. A retrospective cohort study of mortality among individuals with intellectual and developmental disabilities in a region of Ontario focused on measuring excess mortality and risk factors. Findings There is evidence of excess mortality in persons with intellectual and developmental disabilities in Canada. Some of the excess is attributable to comorbidities that are more common in this population. Women may have a greater risk of death than men. Excess mortality occurs at all ages but is more pronounced in early life. Discussion High-quality ongoing monitoring of mortality among individuals with intellectual and developmental disabilities is possible in Canada. Examination of sex differences should be a priority.

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.

This study addressed a key question for assessing breastfeeding duration: at what point is an infant considered no longer exclusively breastfed or no longer breastfed at all? Mothers provided longitudinal infant feeding data via daily checklists. Transitions between exclusive to partial breastfeeding and partial to no breastfeeding were compared across 11 time periods for 10 age groups of infants. Daily transitions between exclusive and partial breastfeeding were common, especially for infants 6 months of age and younger, and transitions from partial to no breastfeeding occurred much more quickly than transitions from exclusive to partial breast-feeding. Ages at supplementation and weaning calculated in 1-day or 7-day spans correlated highly (intraclass correlation = .99). These results support the Breastfeeding Definitions and Data Collection Periods guideline recently developed by the Breastfeeding Committee for Canada and may bring the breastfeeding research and clinical communities closer to a consensus on the definition of breastfeeding over time.

Caries is the most common chronic disease of childhood, and severe forms may necessitate rehabilitative dental surgery. In this study, administrative data related to pediatric dental surgery performed under general anesthesia to treat severe early childhood caries in Manitoba, Canada, were reviewed to determine trends in pediatric dental surgery, as well as geographic, regional and socio-economic variations in surgical rates.The total number of dental surgery cases performed under general anesthesia was obtained from provincial administrative databases for fiscal years from 1997-98 to 2006-07. Codes from the International Classification of Diseases and Related Health Problems (9th or 10th revision, as appropriate) were used to identify children who underwent extractions under general anesthesia for a slightly earlier fiscal year period (1996-97 to 2005-06). Each 10-year period was divided into two 5-year periods for comparisons over time. Analyses included descriptive and bivariate statistics, with the data being disaggregated by regional health authority (RHA) or by community area (for Winnipeg). Comparisons for which p ≤ 0.05 were defined as statistically significant.A total of 18,544 children had dental surgery under general anesthesia between 1997-98 and 2006-07 (mean age ± standard deviation 3.28 ± 1.02 years). Many of the children requiring surgery resided in one northern RHA (26.8%) or the Winnipeg RHA (23.8%). More than half of the RHAs (7/11) displayed significant increases in the rate of surgery, with northern RHAs having the highest rates. Within Winnipeg, 3 of the 12 community areas had significant increases in the rate of surgery. Two inner-city neighborhoods accounted for nearly 50% of surgical cases. The rate of extractions under general anesthesia increased significantly in 6 of the 11 RHAs, with northern RHAs having the highest rates. Four Winnipeg communities experienced significant increases in the extraction rate over time.Pediatric dental surgery under general anesthesia for treatment of severe early childhood caries is common in Manitoba, and the demand increased in several communities over the study period. These results are being shared with decision-makers and communities to identify regions where oral health promotion is needed.