Is geographical isolation associated with poorer outcomes for Northern Manitoba First Nation communities?

doi:10.21203/rs.2.15263/v1

Background: For First Nations, geographical isolation is often simultaneously presented as protective (less direct exposure racism, colonial encroachment on land, dispossession, and colonial imposition) and as a risk factor (lack of opportunities to participate in the formal economy, poorer access to services including healthcare). Our study sought to test the assumption that geographical isolation is associated with poorer population health outcomes among First Nations in Manitoba.

Methods: We conducted a population-based retrospective time-trend analysis using administrative data housed at the Manitoba Centre for Health Policy. The study included all Manitoba residents eligible under the Manitoba Health Services Plan (1984-2014). We measured premature mortality rates (PMR), and trends in hospitalization rates and length of stay (LOS) for Ambulatory Care Sensitive Conditions (ACSC) in northern and southern First Nations (FN) communities in Manitoba.

Results: The PMR was significantly higher in northern FN compared to southern FN. Hospitalization rates for mental health-related conditions were significantly higher in the northern First Nation communities compared to all Manitoba, and rising (southern, change=1.52%, P=0.015; northern, change=5.49%, P<0.0001), and significantly higher in northern compared to southern FN communities. The LOS for all ACSC increased significantly for all Manitoba (change=0.63%, P=0.0011) but not for FN communities. The LOS for mental health-related conditions increased only for the southern FN communities (% change=1.67, P=0.0032).

Conclusions: Our results show higher PMR in northern communities, declining slower than for any other Manitoba communities. Our results also show lower hospitalization rate for ACSC in the north, suggesting barriers to prevention and early diagnosis. There remains a large gap in ACSC hospitalization rates between FN and all Manitobans. Further research is warranted to understand the relationship between the changes in the rates of ACSC and the difference in the rates between northern and southern communities.

Health Policy

Health Economics & Outcomes Research

Primary care

primary health care

Aboriginal

Indigenous

avoidable hospitalizations

mental health

chronic conditions

geography

remoteness

The Truth and Reconciliation Commission of Canada (TRC) acknowledged that addressing jurisdictional disputes, sustainable funding and recognizing the value of “Aboriginal healing practices” are key measures to improving health and social outcomes of Indigenous peoples of Canada. It called upon all levels of government to acknowledge that the current state of Aboriginal health in Canada is a direct result of previous Canadian government policies and put forward 94 Calls to Action to address these issues (1).

Previous studies have reported higher rates of avoidable hospitalizations, poorer health outcomes and shorter life expectancy among First Nations (FN) peoples compared to other Canadians (2–6). Manitoba (MB) has 63 FN communities. Twenty-one of these FNs are isolated and most have no permanent road access. These 21 northern FNs have a Nursing Station model of primary healthcare delivery on-reserve, while most FNs in the south operate health centre and health office models, with funding from the federal government (3, 7). It is a common assumption that communities located at significant distances from provincial healthcare services have worse health outcomes compared to communities that are located closer to care. This assumption is largely based on an expectation that local services delivery, often managed by FN themselves, are likely substandard, and that geographical barriers to access healthcare and other services provided off-reserve is a major detriment to the health of FNs. Health policy and program implementation reflect this assumption, which remains empirically untested.

In Canada, it is important to understand the role of the federal government in the delivery of health services to FN communities and for status FN ‘Indians”, where constitutionally, healthcare is the responsibility of the provincial governments. Since the formation of a federal health department in 1919 and the decades following, the federal government assumed greater responsibility for the provision of health and curative services in FN communities (8) primarily to segregate FN peoples and protect settler populations from contagions carried by FN peoples (9). This resulted since the 1950’s in the development of federally-funded health services on-reserve. These include Nursing Stations delivering a limited scope of PHC services, and smaller health offices or health centres in communities that are considered by the federal government semi-isolated or non-isolated and can, at least theoretically, access health services off-reserve (10). On-reserve services are supplemented by visiting physician services in 22 remote and isolated communities. Elsewhere, physician care is accessed off-reserve.

In this study, the performance of the healthcare system serving FN peoples living in southern (non-isolated and semi-isolated) and northern (isolated and remote-isolated) First Nations communities was represented by the rates of episode of hospitalization for Ambulatory Care Sensitive Conditions (ACSC) and the length of hospital stay (LOS) for these conditions. We have expressed outcomes as hospitalization for ACSC. These are defined as diseases or conditions that are unlikely to lead to hospitalization if managed in a timely and effective manner through primary healthcare (PHC) services (11). Hospitalization for ACSC is a very well recognized tool to measure access to PHC services (3, 12–16). Several studies have reported that higher rates of ACSC indicate barriers to PHC services (3, 17–19). We have previously used these indicators to identify gaps in the delivery of PHC in previous studies, and provided recommendations to policy makers to transform the healthcare system within these communities (3, 17, 20, 21). We acknowledge that hospitalizations are linked to diagnoses and referrals: rates of hospitalization may decline as a result of barriers to PHC resulting in undiagnosed conditions and potentially premature mortality; or rates may decline as a result of early diagnosis and effective management in PHC. To discern between these two potential explanations, we have argued elsewhere that rates of hospitalization for ACSC should be used in tandem with rates of premature mortality (20).

Partnership: The Innovation in Community-based Primary Health Care (CBPHC) Supporting Transformation in the Health of First Nation and rural/remote communities in Manitoba (iPHIT) project is a five-year partnership between university-based researchers from the University of Manitoba, Nanaandawewigamig, the First Nation Health and Social Secretariat of Manitoba and eight First Nations communities in MB. The overall objective of this innovative, strength-based program of research is to expand our knowledge of various models of PHC in rural, remote and FN communities, and to learn from FN and rural and remote communities who have developed effective community based PHC.

Source of data: We used administrative health data (1984–2014) from the Manitoba Population Research Data Repository housed at the Manitoba Centre for Health Policy, University of Manitoba. The Repository is a comprehensive collection of administrative, registry, survey, and other data that includes the vast majority of residents of MB including residents of FN communities. The data used for this study included vital statistics files; the population health registry file for the provincial insured population; the hospital discharge abstract; and census data files. The study included all Manitoba residents eligible to receive health benefits under the Manitoba Health Services Insurance Plan. Six-digit postal codes were used to identify the population associated with each community. Registered members of FN represent 96.6 percent of the overall on-reserve population, others are non-status, (who may be FN children not eligible for registration as “Indians” under the Indian Act), Métis or non-indigenous individuals who depend on the same services (3).

Variables: Table 1 provides definitions of dependent variables. We used two dependent variables in this study: episodes of hospital care for ACSC (hACSC) and LOS. We used a previously created definition for ACSC, which is based on the Canadian Institute for Health information (2006) and the Victorian Government Department of Human Resources division (22), adapted for Manitoba First Nations (3). We then expanded this definition to add mental health-related ACSC, to align with Manitoba FN’s concept of PHC (23). The categories of ACSC explored in this study are shown in Table 2. Twenty-nine ACSC defined using 3, 4 and 5 digit International Statistical Classification of Disease codes, ICD–9-CM and ICD–10-CM) allowed cross-sectional and longitudinal comparison of hospitalization rates among communities.

[Table 1 here]

[Table 2 here]

Our main independent variable was isolation level as reflected by the location of the community (south or north of the 53^rd parallel). There is no single, universally accepted definition of concepts such as rural and remote. Most definitions generally focus on geography, population density or access to services such as healthcare (24, 25). The “right” definition is context dependent. For our analysis, the FN communities on the eastern side of Lake Winnipeg in Manitoba were grouped together with those above the 53^rd parallel due to their isolation from any major urban centre. This breakdown is based on our collective in-depth knowledge of these communities’ access to care, and on federal indexes of isolation which take into consideration federal services provided on-reserve (10). Other indexes often misrepresent FNs’ reality. For example, Statistics Canada’s recent set of remoteness and accessibility indices shows northern Manitoba FN communities as having no access to health services (26), where other resources which reflect our collective experience of these communities show them as having access to services delivered in Nursing Stations and generally better health outcomes than southern FN communities with access to provincial services within driving distance (3). For this paper, we defined FN communities as those recognized as Indian Reserves under the Indian Act.

For the purpose of this study, we included under the variable “Non-FN rural communities” all Manitoba (MB) communities with a population of less than 8000 (n = 183), because all MB FN communities have fewer than 8000 residents. We then divided communities into southern and northern communities. Southern and northern labels were attached to communities where members normally reside, and not to the location of their care experience. Table 3 shows the population in each category.

[Table 3 here]

Data analysis Data was analyzed using generalized estimating equation (GEE) models, controlling for age, sex, and socioeconomic status (postal codes were used as an ecological measure using the census data, described above), to identify trends and differences in hospitalization rates for ACSC and LOS for ACSC. GEEs are used as a method for analyzing correlated longitudinal data. Trends in rates of ACSC hospitalization and LOS by residents living on FN reserves were identified from 1984 to 2014. Because of the relatively small sample size, we used a rolling five-year average to increase the number of episodes of care as a 5-year average is more stable than single year data for comparisons.

Premature mortality rates (PMR) Table 4 shows that between 2005–14, the average PMR was significantly higher for FN living in northern (7.27) or southern contexts (5.92), when compared to non-FN rural communities (2.95) and all of Manitoba (3.26). We note that the PMR for northern FN is slightly higher than for southern FN. We also note that the PMR has been declining in both northern (1.25 percent) and southern FN (1.40 percent), albeit at a much slower rate when compared to Manitoba non-FN rural communities (4.62 percent) and all of Manitoba (3.51 percent). All differences are statistically significant.

[Table 4]

Hospitalization rates for all (combined) ACSC: Table 5 andFigure 1a shows that, between 1984 and 2014, FN peoples living in southern communities had significantly higher hospitalization rates for all ACSC (313.69 in 1984–88; 105.23 in 2010–14) compared to northern FN communities (189.32 in 1984–88; 94.17 in 2010–14) and all Manitoba (85.90 in 1984–88; 36.24 in 2010–14). The hospitalization rates for these ACSC decreased by 2.29% during the same period in northern FN communities, by 4.41% in southern FN communities, by 3.08% in non-FN rural communities, and by 3.77% in all Manitoba. There results were statistically significant.

[Figure 1a here]

[Table 5 here]

Hospitalization rates for acute and chronic ACSC: The hospitalization rates for chronic (Table 5 and Figure 1b) and acute (Table 5 and Figure 1c) ACSC were higher in southern (chronic ACSC: 112.42 in 1984–88; 65.13 in 2010–14; acute ACSC 76.61 in 1984–88; 13.52 in 2010–14) and northern FN communities (chronic ACSC: 75.85 in 1984–88; 44.30 in 2010–14; acute ACSC 55.22 in 1984–88; 10.98 in 2010–14) compared to all Manitoba (P <0.0001). However, the hospitalization rates for these conditions (acute and chronic) were higher in southern FN communities compared to northern FNs. Between 1984 and 2014, the rate of decline for acute conditions was 6.41% in southern FN communities and 5.91% in northern FN communities. The rate of decline for chronic conditions was 2.84% in the southern FN communities and 2.37% in the northern FN communities.

[Figures 1b and 1c here]

Hospitalization rates for vaccine preventable ACSC: For vaccine preventable ACSC (Table 5 and Figure 1d), the rates were higher in northern (12.73 in 1984–88; 8.32 in 2010–14) compared to southern FN communities (14.38 in 1984–88; 1.87 in 2010–14; p<0.0001). Between 1984 and 2014, the hospitalization rates for these conditions did not decline in northern FN communities, whereas they declined by 8.08 (p<0.0001) in southern FN communities. We conducted a data sub-analysis (data not shown), and found the higher rates of hospitalization for these conditions are related to the higher rates of tuberculosis (TB) in the northern communities.

[Figure 1d here]

Mental health-related ACSC: Our data shows that between 1984 and 2014, the hospitalization rates for mental health-related conditions were significantly higher in northern FN communities (10.38 in 1984–88; 29.58 in 2010–14) compared to southern (14.95 in 1984–88; 21.22 in 2010–14) FN communities (p<0.0001). Further, the gaps in rates of hospitalization for mental-health related ACSC have continuously widened, when compared to all Manitoban and non-FN rural communities, increasing between 1984 to 2014 in southern and northern FN communities by 1.52% (P = 0.015) and 5.49% (P<0.0001), respectively. In comparison, the rates decreased in rural non-FN areas during the same period.

Length of stay (LOS): The LOS did not change significantly between 1984 and 2014 for acute, chronic and all ACSC. The exception was for mental health related conditions, where the LOS increased by 1.67% only for southern FN communities (p = 0.003). The LOS for mental health-related ACSC (Figure 2) was consistently significantly shorter for FN communities compared to all Manitoba. The LOS for all other ACSC increased significantly for all Manitoba (change 0.63%, P = 0.0011) but not for FN.

[Figure 2 here]

This study sheds light on differences in hospitalization rates for ACSC between southern and northern FN communities and compares it to all Manitoba. We show that the hospitalization rates for acute and chronic ACSC are higher in the southern FNs compared to the northern FN communities. The rates are significantly higher in northern and southern FN communities compared to all Manitoba. We note that rates are declining along with PMR, suggesting that rates of hospitalization are dropping at least in part due to decreased need for hospitalization. Despite the fact that the rates for acute and chronic conditions are decreasing over time in southern and northern FN communities, and in all other jurisdictions, it still clearly demonstrates the continuing inequities between all FN communities and all other Manitobans.

This study has many strengths. First, the use of administrative healthcare data to assess the performance of rural and remote healthcare systems is innovative, and is an effective method to measure the performance of healthcare systems at fairly low cost. The available data allowed us to run several GEE models and to run separate analyses on acute, chronic, vaccine preventable and mental health ACSCs and detect variations between different communities. Second, Indigenous scholars and proponents have advocated for many years for shifting the focus of research to be more responsive to local concerns and to reflect the voice and values of FN communities (27). This involves, first and foremost, developing a respectful ethical relationship with FN and determining what is important to them. The reported results are just one study from large collaborative project (the iPHIT as described above). The overall objective of this innovative, strength-based program of research is to learn about PHC in rural, remote and FN communities and learn from FN communities about their innovation in developing effective community based PHC. The iPHIT project involved FN in every aspect of the research process (23, 28, 29).

We acknowledge that this study has limitations. First, the hospitalization rates for ACSC do not reflect the quality of acute care and supportive services in the community, nor does it reflect delays in diagnosis, and medical transportation issues in FN communities (30). Also, the study does not control for many social determinants of health (e.g. lack of local infrastructure including clean water, inadequate housing, and limited access to services and opportunities). However, it is important to note that the southern and the northern FN communities we are comparing encounter very similar challenges. Second, the study does not report on community-based programs available in any of the FN communities, and whether there are more or less effective community-based programs in FN communities served with different models of care. However, even when considering these programs, it is clear that the objective of closing the healthcare equity gap is far from having been achieved.

Our results are consistent with a previous study which reported that Manitoban FN communities located close to an urban centre in southern Manitoba had worse health outcomes (defined as higher rates of hospitalization for ACSC (3) and premature mortality rates (31) compared to isolated communities. Lavoie and colleagues showed that on-reserve services provided primarily in nursing stations by nurse practitioners and/or nurses working with an expanded scope of practice are better able to address the needs of those living with chronic and acute conditions compared to the other models of on-reserve care (3). The nursing station model is the predominant model for providing PHC services in isolated northern FN communities. These results suggest that better access to PHC services provided in FN communities could be one of the reasons for the observed results.

PHC is an integral part of the healthcare system of any community, and that better access to quality PHC was associated with lower hospitalization for ACSC (32, 33). Nevertheless, PHC is not the only determinant of ACSC: the health status of the population, personal and collective resilience, overcrowded houses, coordination of care, geographical location, systematic racism, stigma, and socioeconomic opportunities are all important determinants of health that have been shown to be associated with higher hospitalization rates for ACSC (32, 34). Thus, it is extremely important not to ignore the role of social determinants of health in both southern and northern First Nations communities in relation to hospitalization for ACSC.

While this study looked at differences in hospitalization rates based on geographical location, it did not control for all the previously listed determinants of ACSC and all the programs available to residents. There are important variations in the distribution of these social determinants of health across southern and northern FN communities (31). Crowded houses, poverty, malnutrition, lack of access to responsive PHC services, stigma and lack of culturally appropriate practices are all important factors contributing to the higher rates of hospitalizations (35). Equitable and culturally appropriate healthcare services in all FN communities is only one, albeit important action, to reduce health disparities.

In the current study, the hospitalization rates for mental health-related conditions were higher in FN communities compared to the rest of Manitoba. Reports show that FN peoples continue to bear a disproportionate burden of physical and emotional illness (2, 3, 31, 36). In MB, the delivery of mental health services in FN communities is fragmented; services are not comprehensive, less accessible and rarely available on a 24/7 basis (37, 38). This study also shows that the LOS for mental health-related conditions is shorter for FN peoples compared to other Manitobans. It is important to note that the results of all MB over-represent urban-based population, who are more likely to be hospitalized at higher levels of acuity only. We therefore expect urban-centric data to show longer LOS. Still, our results could indicate that FN people are discharged from hospitals before receiving the care they need and this could result in a revolving door of admission and re-admission for mental health care. While a growing impetus to integrate comprehensive mental health care into PHC services is occurring globally, integration has been fraught with challenges (39, 40). Challenges vary but are commonly characterized by fiscal constraints, organizational issues, availability of medical technologies and public health surveillance systems, the cultural and technical competence of health professionals working with marginalized groups and urban rural bias (39, 41, 42). Nevertheless, integrating mental health services into PHC, could reduce stigma, improve access to mental health care services and improve social integration (39). The communities involved in the IPHiT program of research have clearly indicated that from their perspective, mental health is an integral component of all care, including PHC (23).

The results presented in this paper have important implications for health services policy planning and the incorporation of equity prospective to the objectives of health research in FN communities. There is a large gap in hospitalization rates for ACSC between FN and other Manitobans, and the hospitalization rates for chronic and acute ACSC are higher in the southern rather than the northern (isolated) FN communities. However, the hospitalization rates for mental health-related conditions have increasing since 1984, and are higher in northern compared to southern FN communities. Urgent action is needed to address the mental health challenges faced by northern FN communities. Organizational-level interventions to promote the provision of more equitable, responsive, and respectful PHC services for FN people living on reserves in Manitoba are needed to close the equity gap within this population (43). Also, critical actions are required to address the distribution of resources and the needs of Indigenous peoples, supporting the TRC Calls to Action, which begins with recognizing and implementing health-care rights of FN peoples as identified in international law, constitutional law, and under the Treaties. Systematic social and health inequities in southern and northern First Nations communities will only be addressed through equitable rights-based funding, equitable access to primary health care in each FN community, and through active involvement of Indigenous people in Canada in developing long term structural changes. The FN inherent right to self-determination also requires moving their research knowledge into action. Data from this research is important for future program planning to deliver health care services in FN communities in Manitoba.

The 2015 Truth and Reconciliation Commission report (1) urged the federal government to implement TRC Calls to Action #18 & 19, which involves expanding the scope and mandate of health facilities in southern communities to include essential PHC services in all FN communities. Access to PHC services is only one measure, improving the living conditions for all FN living on reserve, reducing systemic and jurisdictional barriers, and addressing racism within the health care system and a coordinated effort by all levels of government will all be necessary to close the gap between FN and all other Manitobans (and Canadians).

ACSC - Ambulatory Care Sensitive Conditions

FN - First Nations

FNHSSM - First Nations Health and Social Secretariat

GEE - Generalized estimating equation

hACSC - Hospitalization for Ambulatory Care Sensitive Conditions

iPHIT - Innovation in Community-based Primary Health Care Supporting Transformation in the Health of First Nation and rural/remote communities in Manitoba

LOS - Length of stay

MB - Manitoba

PHC - Primary healthcare

PMR - Premature mortality rate

SES - Socio-economic status

TRC - Truth and Reconciliation Commission of Canada

Ethics approval and consent to participate Ethical approvals for this study were received from the University of Manitoba Health Research Ethics Board and data access approval from the Government of Manitoba Health Information Privacy Committee, and both ethical approval and data access from the Manitoba FNs Health Information Research Governance Committee (HIRGC).

Consent for publication N/A

Availability of data and materials All data used for this analysis are protected under the privacy policies of the Manitoba Centre for Health Policy, and within the terms of the institutional review board approval for this study and are not publicly available. The datasets generated and/or analyzed during the current study are not publicly available due privacy and confidentiality issues.

Competing interests The authors declare that they have no competing interests.

Funding This study was funded by the Canada Institutes of Health Research, Grant # TT1–128267. The funder played no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.

Authors’ contributions Each author meets the authorship requirements as established by the International Committee of Medical Journal Editors in the Uniform Requirements for Manuscripts Submitted to Biomedical Journals. JL, AK and KAK conceived of the study. JL, WPB, KAK, GKA, SS and AK interpreted the analyses. JL created the first draft of the manuscript. JL, WPB, KAK, SS, GKA and AK contributed to critical revisions of the manuscript.

All authors have read and approved the manuscript.

Acknowledgements

We would like to acknowledge the unique and invaluable contribution of our community partners: Birdtail Sioux Dakota Nation, Berens River First Nation, Cross Lake Band of Indians Pimicikamak Cree Nation, Ebb and Flow First Nation, Northlands Denesuline First Nation, Pinaymootang First Nation and Fisher River Cree Nation. Authors’ contributions JL wrote the first draft. JL, AK, KK, WP, GA and SS analyzed and interpreted data; JL, AK, WP and KK conceptualized and designed the work. All authors contributed into drafting the articles and approved the final version for publications. Also, we thank Mr. Matthew Dahl, data analyst at the Manitoba Centre for Health policy, for running the analysis and the Canadian Institutes of Health Research for funding this project.

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Table 1, Definition of dependent variables
Measure of Hospitalization	Definition of Hospitalization Measure
Rates of episodes of hospital care	The discrete number of hospitalization episodes from admission to discharge. Hospitalizations were treated as a single episode when readmission to another hospital occurred within one day, to account for transfers from one hospital to another.
Rates of length of stay per admission	An average of the number of days in hospital for each episode of care.

Table 2, Categories of ACSC explored in this study
Categories of ACSC	Conditions
Chronic conditions	Diabetes; Diabetes with complications; Hypertension; Asthma; acute Bronchitis; Chronic Obstructive Pulmonary Disease, Pneumonia; Epilepsy; Angina, Heart Failure and Pulmonary Edema; Iron Deficiency Anemia
Acute conditions	Dental Conditions; Cellulitis; sever Ear, Nose, and Throat infections
Mental health	Schizophrenia and mood disorder
Vaccine preventable conditions	Hepatitis A and B; Influenza; Hemophilic Influenza; Measles; Mumps; Rubella; Meningitis; Tuberculosis; Tetanus; Rubella; Poliomyelitis; Pertussis
All ACSC	All conditions combined

Table 3, Population per category of community
Average, 1984-88	Average, 2010-14
FN Northern MB	27,051	41,418
FN Southern MB	27,948	32,425
Non-FN Rural MB	365,727	393,061
All Manitoba	1,055,061	1,186,947

Table 4, Comparison of premature mortality rate (PMR), 2005-14
Adjusted PMR rate	Probability that PMR is different from All Manitoba (P value)	Direction	Percentage change	P value
FN North	7.27 (6.92-7.62)	0.00*	Decreasing	1.25	0.0494*
FN South	5.92 (5.62-6.23)	0.00*	Decreasing	1.40	0.0177*
Non-FN Rural	2.95 (2.89-3.01)	0.00*	Decreasing	4.62	<.0001*
All Manitoba	3.26 (3.23-3.29)	Decreasing	3.51	<.0001*

Table 5, Age, Sex and SES Adjusted hACSC rates (per 1000 population), 1986-2014
1984-88		2010-14		1984-2014
	Rate	P value (compared to All MB)	Rate	P value (compared to All MB)	Direction	% change	P value
All ACSC
FN Northern MB	189.32 (158.56-226.05)	0.0000*	94.17 (70.77-125.32)	0.00*	Decreasing¹	2.29	<.0001*
FN Southern MB	313.69 (259.07-379.84)	0.0000*	105.23 (79.20-139.79)	0.00*	Decreasing²	4.41	<.0001*
Non-FN Rural MB	111.29 (96.23-128.71)	0.0005*	39.58 (30.47-51.42)	0.51	Decreasing³	3.77	<.0001*
All Manitoba	85.90 (61.35-120.27)		36.24 (35.90-36.58)		Decreasing⁴	3.08	<.0001*
Chronic ACSC
FN Northern MB	75.85 (59.50-96.70)	0.0000*	44.30 (34.90-56.24)	0.00*	Decreasing¹	2.37	<.0001*
FN Southern MB	112.42 (88.30-143.13)	0.0000*	65.13 (52.92-80.15)	0.00*	Decreasing²	2.84	<.0001*
Non-FN Rural MB	49.77 (41.05-60.35)	0.0871	20.56 (17.542-24.27)	0.10	Decreasing³	3.60	<.0001*
All Manitoba	42.07 (32.50-54.44)	17.85 (17.61-18.09)		Decreasing⁴	3.56	<.0001*
Acute ACSC
FN Northern MB	55.22 (45.85-66.50)	0.0000*	10.98 (7.19-16.76)	0.00*	Decreasing¹	5.91	<.0001*
FN Southern MB	76.61 (61.87-94.86)	0.0000*	13.52 (8.72-20.97)	0.00*	Decreasing²	6.41	<.0001*
Non-FN Rural MB	24.69 (21.22-28.73)	0.0010*	6.09 (4.10-9.03)	0.50	Decreasing³	4.42	<.0001*
All Manitoba	19.13 (12.60-29.04)	5.31 (5.18-5.44)		Decreasing⁴	4.62	<.0001*
Mental health ACSC
FN Northern MB	10.38 (7.39-14.57)	0.2210	29.58 (18.97-46.11)	0.00*	Increasing¹	5.49	<.0001*
FN Southern MB	14.95 (11.23-19.91)	0.2933	21.22 (13.66-32.96)	0.01*	Increasing²	1.52	0.0153*
Non-FN Rural MB	14.10 (11.16-17.82)	0.4277	9.87 (6.67-14.61)	0.30	Decreasing³	0.72	0.0007*
All Manitoba	12.83 (7.82-21.03)	12.14 (11.94-12.33)		Increasing⁴	0.07	0.9533
Vaccine preventable ACSC
FN Northern MB	12.73 (10.47-15.47)	0.0000*	8.32 (5.58-12.39)	0.00*	Decreasing¹	1.00	0.1317
FN Southern MB	14.38 (11.56-17.88)	0.0000*	1.87 (1.87-1.18)	0.01*	Decreasing²	8.08	<.0001*
Non-FN Rural MB	5.91 (5.10-6.85)	0.0000*	0.81 (0.60-1.11)	0.23	Decreasing³	7.57	<.0001*
All Manitoba	4.36 (3.06-6.21)	0.98 (0.98-1.04)		Decreasing⁴	6.27	<.0001*
¹FN Northern MB Slope Diff from 0
²FN Southern MB Slope Diff from 0
³Non-FN Rural MB Slope Diff from 0
⁴ALL MB 0 Slope Diff from 0

Is geographical isolation associated with poorer outcomes for Northern Manitoba First Nation communities?

Status:

Journal Publication

Version 1

Abstract

Figures

Introduction

Methods

[Table 1 here]

[Table 2 here]

[Table 3 here]

Results

[Table 4]

[Figure 1a here]

[Table 5 here]

[Figures 1b and 1c here]

[Figure 1d here]

[Figure 2 here]

Discussion

Conclusion

List of abbreviations

Declarations

References

Tables

Status:

Journal Publication

Version 1