Health Service Delivery Area Research Articles

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

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

Homicide Among American Indians/Alaska Natives, 1999-2009: Implications for Public Health Interventions.

We determined estimates of homicide among American Indians/Alaska Natives (AI/ANs) compared with non-Hispanic white people to characterize disparities and improve AI/AN classification in incidence and mortality reporting. We linked 1999-2009 death certificate data with Indian Health Service (IHS) patient registration data to examine death rates from homicide among AI/AN and non-Hispanic white people. Our analysis focused primarily on residents of IHS Contract Health Service Delivery Area counties and excluded Hispanic people to avoid underestimation of incidence and mortality in AI/ANs and for consistency in our comparisons. We used age-adjusted death rates per 100,000 population and stratified our analyses by sex, age, and IHS region. Death rates per 100,000 population from homicide were four times higher among AI/ANs (rate = 12.1) than among white people (rate = 2.8). Homicide rates for AI/ANs were highest in the Southwest (25.6 and 6.9 for males and females, respectively) and in Alaska (17.7 and 10.3 for males and females, respectively). Disparities between AI/ANs and non-Hispanic white people were highest in the Northern Plains region among men (rate ratio [RR] = 9.8, 95% confidence interval [CI] 8.5, 11.3) and among those aged 25-44 years (RR59.0, 95% CI 7.5, 10.7) and 0-24 years (RR57.4, 95% CI 6.1, 8.9). Death rates from homicide among AI/ANs were higher than previously reported and varied by sex, age, and region. Violence prevention efforts involving a range of stakeholders are needed at the community level to address this important public health issue.

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

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

Regional Variations in General Practitioner Visits for Alcohol-Attributed Diseases in British Columbia, Canada

The purpose of this study was to examine geographic variations in primary health care utilization for diseases wholly attributed to alcohol consumption using physician billing data from British Columbia (BC), Canada. Data was modeled by Health Service Delivery Area (HSDA) (N = 16) and Health Authority (N = 5) to examine geographic variations in general practitioner (GP) consultations by persons with alcohol-attributed diseases from 2001 to 2011. Data was modeled by the count of cases per 10,000 residents per year by HSDA, and incidence rate ratios were calculated using negative binomial regression to determine the significance of yearly variations in cases by HSDA. The frequency of utilization was calculated to measure yearly changes in the intensity of primary health care service use by patient. From January 1, 2001 to December 31, 2011 there were 690,401 visits to GPs by 198,623 persons with an alcohol-attributed disease in BC. After the deletion of records with missing HSDA data, the final sample was comprised of 676,515 visits by 192,333 persons. Over the ten-year period, there was a significant increase in the number of alcohol-attributed disease cases per 10,000 seen by GPs at the provincial level, from 34.9 in 2001 to 48.2 per 10,000 in 2011. Urban areas of the province had the greatest crude number of visits to GPs for alcohol-attributed diseases; however, rural and northern HSDAs had the highest per capita consultations. A larger proportion of alcohol-attributed disease visits occurred in emergency room and inpatient hospital settings in rural and northern areas. Since 2001 there have been significant increases in the rates of alcohol-attributed disease cases in all Health Authorities. Rural and northern areas of BC had above average rates of GP utilization for alcohol-attributed diseases. The results of this study show that alcohol-related harms are both a regional and provincial issue for health care planning.

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

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

Ecological analyses of the associations between injury risk and socioeconomic status, geography and Aboriginal ethnicity in British Columbia, Canada.

BackgroundThe current study examines what factors contribute to higher injury risk among Aboriginal peoples, compared to the total British Columbia (BC) population. We explore socioeconomic, geographic, and cultural factors, and combinations of these factors, that contribute to increased injury risk for Aboriginal peoples. This follows from our previously reported findings of improvements in injury risk over time for both the total and Aboriginal populations.Data and methodsWe use provincial population-based linked health care databases of hospital discharge records. We identify three population groups: total BC population, and Aboriginal populations living off-reserve, or on-reserve. For each group we calculate age and gender-standardized relative risks (SRR) of injury-related hospitalization, relative to the total population of BC, for two 5-year time periods (1999–2003, and 2004–2008). We use custom data from the 2001 and 2006 long-form Censuses that described income, education, employment, housing conditions, proportion of urban dwellers, proportion of rural dwellers, and prevalence of Aboriginal ethnicity. We use multivariable linear regression to examine the associations between the census characteristics and SRR of injury.ResultsThe best-fitting model was an excellent fit (R2 = 0.905, p < 0.001) among the three population groups within Health Service Delivery Areas of BC. We find indicators in all three categories (socioeconomic, geographic, and cultural) are associated with disparity in injury risk. While the socioeconomic indicators (income, education, housing, employment) were shown to be highly correlated, only living in housing that needs major repair and occupational hazardousness, along with rural residence and Aboriginal ethnicity, remained in the final model. Our data show that cultural density is not associated with injury risk for Aboriginal peoples, and that living off-reserve is associated with reduced injury by improving socioeconomic and geographic conditions (compared to living on-reserve). Finally, our analyses show that Aboriginal status itself is associated with injury risk.ConclusionsOur findings confirm previous research indicating that geographical differences differentiate injury risk, including for Aboriginal populations, and that socioeconomic determinants are associated with health risks. Our analyses showing that Aboriginal status itself contributes to injury risk is new, but we can only speculate about pathway, and whether the causes are direct or indirect.

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

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

Cancer incidence in indigenous people in Australia, New Zealand, Canada, and the USA: a comparative population-based study

Indigenous people have disproportionally worse health and lower life expectancy than their non-indigenous counterparts in high-income countries. Cancer data for indigenous people are scarce and incidence has not previously been collectively reported in Australia, New Zealand, Canada, and the USA. We aimed to investigate and compare, for the first time, the cancer burden in indigenous populations in these countries. We derived incidence data from population-based cancer registries in three states of Australia (Queensland, Western Australia, and the Northern Territory), New Zealand, the province of Alberta in Canada, and the Contract Health Service Delivery Areas of the USA. Summary rates for First Nations and Inuit in Alberta, Canada, were provided directly by Alberta Health Services. We compared age-standardised rates by registry, sex, cancer site, and ethnicity for all incident cancer cases, excluding non-melanoma skin cancers, diagnosed between 2002 and 2006. Standardised rate ratios (SRRs) and 95% CIs were computed to compare the indigenous and non-indigenous populations of each jurisdiction, except for the Alaska Native population, which was compared with the white population from the USA. We included 24 815 cases of cancer in indigenous people and 5 685 264 in non-indigenous people from all jurisdictions, not including Alberta, Canada. The overall cancer burden in indigenous populations was substantially lower in the USA except in Alaska, similar or slightly lower in Australia and Canada, and higher in New Zealand compared with their non-indigenous counterparts. Among the most commonly occurring cancers in indigenous men were lung, prostate, and colorectal cancer. In most jurisdictions, breast cancer was the most common cancer in women followed by lung and colorectal cancer. The incidence of lung cancer was higher in indigenous men in all Australian regions, in Alberta, and in US Alaska Natives than in their non-indigenous counterparts. For breast cancer, rates in women were lower in all indigenous populations except in New Zealand (SRR 1·23, CI 95% 1·16-1·32) and Alaska (1·14, 1·01-1·30). Incidence of cervical cancer was higher in indigenous women than in non-indigenous women in most jurisdictions, although the difference was not always statistically significant. There are clear differences in the scale and profile of cancer in indigenous and non-indigenous populations in Australia, New Zealand, Canada, and the USA. Our findings highlight the need for much-improved, targeted programmes of screening, vaccination, and smoking cessation, among other prevention strategies. Governments and researchers need to work in partnership with indigenous communities to improve cancer surveillance in all jurisdictions and facilitate access to cancer data. International Agency for Research on Cancer-Australia Fellowship.

American-Indian diabetes mortality in the Great Plains Region 2002–2010

ObjectiveTo compare American-Indian and Caucasian mortality rates from diabetes among tribal Contract Health Service Delivery Areas (CHSDAs) in the Great Plains Region (GPR) and describe the disparities observed.Research design and...

Preparedness of County Referral Health Facilities in Implementing Adolescent Friendly Health Services: A Case Study of Mama Lucy Kibaki Hospital.

Health service delivery is a key pillar of the health system management .The World Health Organization recently emphasized the need to develop adolescent -friendly health services to improve the care provided to young people throughout the world. However, there is limited peer reviewed literature on this subject therefore necessitating assessment of whether the existing health facilities are prepared to implement the adolescent friendly health services. Adolescent friendly health services remains a relatively new and sensitive area mainly due to restrictive norms and policies guiding the services. After International Conference on Population and Development in 1994, countries started implementing adolescent friendly health services. The Government of Kenya together with partners in an attempt to address the health challenges came up with the Adolescent package of care (APOC) in 2013 whose guidelines were finalized in November 2014 and released for use by service providers . Despite this package of care, there is still ineffective staff capacity in relation to skills and knowledge gap of health professionals, training needs, health resources as well as health system factors that can affect implementation of AFHS. The study explored ways of mitigating or addressing the barriers to implementation of these services. The study used both quantitative and qualitative approaches to collect data. The study utilized survey research adapting descriptive cross sectional design and semi-structured questionnaire to interview 348 health care providers and 472 adolescents in Mam Lucy Kibaki Hospital from 3rd May 2014 to 16 June 2014 .The key informants were mainly nurses, clinical officers and Medical doctors who were working at the health service delivery area at the time of study and were interviewed using an interview guide. The managers at the hospital were interviewed using an in-depth interview guide while the adolescents were interviewed through interview guide and focused group discussion. Quantitative data was analyzed using Statistical Package for Social Sciences (SPSS) Version 18.0. Descriptive statistics and chi-square tests were performed to determine significant associations. The study established that sex, age, level of education and adolescent awareness about existence of friendly health services offered were significantly associated with utilization at p<0.05. Long queues, unfavorable working hours and lack of money negatively affected consumption of AFHS.The study concluded that the utilization of health services among the adolescents was low largely due to unfriendliness of the health care providers at health facilities and lack of awareness of AFHS services. In view of the findings, this study recommends need for the Government through the Ministry of Health and partners in health service provision to increase the number of AFHS and ensure that the recommendations of Adolescent Package of care is implemented fully with good evaluation strategies in place. Laborious awareness drives to sensitize the adolescents about the available services through rigorous health education and increased involvement of both parents/guardians and teachers to scale up implementation are also recommended.

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

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

Abstract B55: Cervical cancer incidence and mortality disparities among American Indians and Alaska Natives, 1999-2009

Abstract Objectives. Previous studies have reported higher rates of cervical cancer incidence and mortality in American Indian and Alaska Native (AI/AN) women compared to women of other races. However, race misclassification hampers accurate determinations of rates among AI/AN women. Observed disparities in incidence rates of cervical cancer between AI/AN and white populations increased after efforts were made to ensure that members of AI/AN populations were properly identified, which increased the number of AI/AN cases and corresponding rates. The purpose of this analysis is to describe the incidence and mortality of cervical cancer among AI/AN women from 1999-2009, using techniques to minimize the effect of race misclassification in surveillance data, and to compare rates of cervical cancer among these women to rates among white women living in the same areas. Methods. Data on cervical cancer deaths and incidence were linked with Indian Health Service records in order to improve identification of AI/AN populations. Analyses focused on deaths of AI/AN residents in IHS Contract Health Service Delivery Area (CHSDA) counties in 35 states. Linked data were used to produce age-adjusted incidence and death rates for 1999 to 2009. Data for both white and AI/AN populations were limited to non-Hispanics only. Results: Mortality. AI/AN women had a cervical cancer death rate of 3.3 per 100,000, which was higher than the rate of 2.2 for white women (RR 1.54). For CHSDA areas only, the death rate from cervical cancer for AI/AN women was 4.2 per 100,000, which was nearly twice the corresponding rate among white women in CHSDA areas (rate 2.0 per 100,000; RR 2.11). Cervical cancer mortality among AI/AN women in CHSDA areas was highest in the Northern Plains region and correspondingly higher than white women in Northern Plains (RR 4.15), Southern Plains (RR 1.58), and the Southwest (RR 2.05). Cervical cancer mortality in CHSDA areas declined during 1990-2009 among both AI/AN women and white women. Major declines for AI/AN women occurred primarily during 1990-1993 (APC -25.8, p&amp;lt;0.05); but death rates remained relatively steady from 1993-2009 (APC -1.3). Declines among white women were more level, and statistically significant (APC -2.4 for 1990-2009) Results: Incidence. AI/AN women had an incidence rate of cervical cancer of 8.7 per 100,000, compared to a rate of 7.5 for white women. However, when limiting to CHSDA areas, the rate for AI/AN women was 11.0 per 100,000, which was higher than for white women in CHSDA areas (rate 7.1 per 100,000). Cervical cancer incidence among AI/AN women in CHSDA areas was highest in the Southern Plains region (rate 15.1 per 100,000) and was higher than incidence for White women in Northern Plains (RR 1.97), Alaska (RR 1.94), Southern Plains (RR 1.64), Southwest (RR 1.19), and Pacific Coast (RR 1.36). Conclusions. Our results demonstrate that AI/AN women suffer disproportionately from cervical cancer incidence and mortality, compared to white women in the same areas. However, both incidence and mortality have decreased over time, documenting improvements in identifying and treating cervical cancer and precancerous lesions. Most cervical cancers can be avoided or diagnosed early through screening and treatment. We noted steep declines in cervical cancer deaths among AI/AN women in the early 1990's. We believe that these are likely due to screening and treatment programs aimed specifically at AI/AN women. However, our data also underscore the need for further efforts as noted in CHSDA areas, where identification of AI/AN women is likely to be highest, because AI/AN women still die from cervical cancer at twice the rate of white women. Citation Format: Meg Watson, Vicki Benard, Cheryll Thomas, Annie Brayboy, Roberta Paisano, Thomas Becker. Cervical cancer incidence and mortality disparities among American Indians and Alaska Natives, 1999-2009. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr B55. doi:10.1158/1538-7755.DISP13-B55

Calls to the British Columbia Drug and Poison Information Centre: A summary of differences by health service areas.

ObjectivesPoison control centres provide information on the management of poisoning incidents. The British Columbia (BC) Drug and Poison Information Centre recently implemented an electronic database system for recording case information, making it easier to use case data as a potential source of population-based information on health services usage and health status. This descriptive analysis maps poisoning case rates in BC, highlighting differences in patient age, substance type, medical outcome, and caller location.MethodsThere were 50,621 human exposure cases recorded during 2012 and 2013. Postal code or city name was used to assign each case to a Health Service Delivery Area (HSDA). Case rates per 1,000 person-years were calculated, including crude rates, age-standardized rates, age-specific rates, and rates by substance type, medical outcome, and caller location.ResultsThe lowest case rate was observed in Richmond, a city where many residents do not speak English as a first language. The highest rate was observed in the Northwest region, where the economy is driven by resource extraction. Pharmaceutical exposures were elevated in the sparsely populated northern and eastern areas. Calls from health care facilities were highest in the Northwest region, where there are many remote Aboriginal communities.ConclusionsCase rates were generally highest in the primarily rural northern and eastern areas of the province. Considering these results alongside contextual factors informs further investigation and action: addressing cultural and language barriers to accessing poison centre services, and developing a public health surveillance system for severe poisoning events in rural and remote communities.

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

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

The Role of Health Systems and Policy in Producing Behavior and Social Change to Enhance Child Survival and Development in Low- and Middle-Income Countries: An Examination of the Evidence

Evidence-based behavior change interventions addressing health systems must be identified and disseminated to improve child health outcomes. Studies of the efficacy of such interventions were identified from systematic searches of the published literature. Two hundred twenty-nine of the initially identified references were judged to be relevant and were further reviewed for the quality and strength of the evidence. Studies were eligible if an intervention addressed policy or health systems interventions, measured relevant behavioral or health outcomes (e.g., nutrition, childhood immunization, malaria prevention and treatment), used at least a moderate quality research design, and were implemented in low- or middle-income countries. Policy or systems interventions able to produce behavior change reviewed included media (e.g., mass media, social media), community mobilization, educational programs (for caregivers, communities, or providers), social marketing, opinion leadership, economic incentives (for both caregiver and provider), health systems strengthening/policy/legislation, and others. Recommendations for policy, practice, and research are given based on fairly strong data across the areas of health service delivery, health workforce, health financing, governance and leadership, and research.

Alcohol-attributable mortality among American Indians and Alaska Natives in the United States, 1999-2009.

We describe the relative burden of alcohol-attributable death among American Indians/Alaska Natives (AI/ANs) in the United States. National Death Index records were linked with Indian Health Service (IHS) registration records to identify AI/AN deaths misclassified as non-AI/AN. We calculated age-adjusted alcohol-attributable death rates from 1999 to 2009 for AI/AN and White persons by sex, age, geographic region, and leading causes; individuals of Hispanic origin were excluded. AI/AN persons had a substantially higher rate of alcohol-attributable death than Whites from 2005 to 2009 in IHS Contract Health Service Delivery Area counties (rate ratio = 3.3). The Northern Plains had the highest rate of AI/AN deaths (123.8/100,000), and the East had the lowest (48.9/100,000). For acute causes, the largest relative risks for AI/AN persons compared with Whites were for hypothermia (14.2) and alcohol poisoning (7.6). For chronic causes, the largest relative risks were for alcoholic psychosis (5.0) and alcoholic liver disease (4.9). Proven strategies that reduce alcohol consumption and make the environment safer for excessive drinkers should be further implemented in AI/AN communities.

Suicide mortality among American Indians and Alaska Natives, 1999-2009.

We assessed national and regional suicide mortality for American Indian and Alaska Native (AI/AN) persons. We used 1999 to 2009 death certificate data linked with Indian Health Service (IHS) patient registration data to examine death rates from suicide in AI/AN and White persons. Analysis focused primarily on residents of IHS Contract Health Service Delivery Area counties; Hispanics were excluded. We used age-adjusted death rates per 100,000 population and stratified our analyses by age and IHS region. Death rates from suicide were approximately 50% higher among AI/AN persons (21.2) than Whites (14.2). By region, rates for AI/AN people were highest in Alaska (rates = 65.4 and 19.3, for males and females, respectively) and in the Northern Plains (rates = 41.6 and 11.9 for males and females, respectively). Disparities between AI/AN and White rates were also highest in these regions. A coordinated, multidisciplinary effort involving federal, state, local, and tribal health officials is needed to address this important public health issue.

Trends and Disparities in Heart Disease Mortality Among American Indians/Alaska Natives, 1990–2009

We evaluated heart disease death rates among American Indians and Alaska Natives (AI/ANs) and Whites after improving identification of AI/AN populations. Indian Health Service (IHS) registration data were linked to the National Death Index for 1990 to 2009 to identify deaths among AI/AN persons aged 35 years and older with heart disease listed as the underlying cause of death (UCOD) or 1 of multiple causes of death (MCOD). We restricted analyses to IHS Contract Health Service Delivery Areas and to non-Hispanic populations. Heart disease death rates were higher among AI/AN persons than Whites from 1999 to 2009 (1.21 times for UCOD, 1.30 times for MCOD). Disparities were highest in younger age groups and in the Northern Plains, but lowest in the East and Southwest. In AI/AN persons, MCOD rates were 84% higher than UCOD rates. From 1990 to 2009, UCOD rates declined among Whites, but only declined significantly among AI/AN persons after 2003. Analysis with improved race identification indicated that AI/AN populations experienced higher heart disease death rates than Whites. Better prevention and more effective care of heart disease is needed for AI/AN populations.

Period life tables for the non-Hispanic American Indian and Alaska Native population, 2007-2009.

We estimated complete period life tables for the non-Hispanic American Indian and Alaska Native (AI/AN) population residing in Contract Health Service Delivery Area (CHSDA) counties for the period 2007-2009. We used National Vital Statistics System mortality data files for years 2007-2009 corrected for AI/AN misclassification on death certificates, midyear 2008 revised census bridged race intercensal population estimates, and National Vital Statistics System birth data for years 2006-2009. We used the same methodology as that used to estimate official US annual life tables, with some minor modifications. For the period 2007-2009, the non-Hispanic AI/AN population in CHSDA counties had the lowest life expectancy at birth (71.1 years) of any racial/ethnic group for which official US life tables are estimated. By comparison, in 2008, life expectancy at birth was 73.9 years for the non-Hispanic Black population, 78.4 years for the non-Hispanic White population, and 80.8 years for the Hispanic population. The life tables showed a clear mortality disadvantage for the non-Hispanic AI/AN population in CHSDA counties relative to other national populations. The findings suggested that further research is necessary to explore the causes behind these disadvantages.

Diabetes-Related Mortality Among American Indians and Alaska Natives, 1990–2009

We assessed diabetes-related mortality for American Indians and Alaska Natives (AI/ANs) and Whites. Study populations were non-Hispanic AI/AN and White persons in Indian Health Service (IHS) Contract Health Service Delivery Area counties; Hispanics were excluded. We used 1990 to 2009 death certificate data linked to IHS patient registration records to identify AI/AN decedents aged 20 years or older. We examined disparities and trends in mortality related to diabetes as an underlying cause of death (COD) and as a multiple COD. After increasing between 1990 and 1999, rates of diabetes as an underlying COD and a multiple COD subsequently decreased in both groups. However, between 2000 and 2009, age-adjusted rates of diabetes as an underlying COD and a multiple COD remained 2.5 to 3.5 times higher among AI/AN persons than among Whites for all age groups (20-44, 45-54, 55-64, 65-74, and ≥ 75 years), both sexes, and every IHS region except Alaska. Declining trends in diabetes-related mortality in both AI/AN and White populations are consistent with recent improvements in their health status. Reducing persistent disparities in diabetes mortality will require developing effective approaches to not only control but also prevent diabetes among AI/AN populations.