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Admission to hospital for pneumonia and influenza attributable to 2009 pandemic A/H1N1 Influenza in First… Green, Michael E; Wong, Sabrina T; Lavoie, Josée G.; Kwong, Jeff; MacWilliam, Leonard; Peterson, Sandra; Liu, Guoyuan; Katz, Alan Oct 30, 2013

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RESEARCH ARTICLE Open AccessAdmission to hospital for pneumonia andinfluenza attributable to 2009 pandemic A/H1N1Influenza in First Nations communities in threeprovinces of CanadaMichael E Green1,2*, Sabrina T Wong3,4, Josée G Lavoie5, Jeff Kwong6,7,8,9, Leonard MacWilliam10, Sandra Peterson4,Guoyuan Liu2 and Alan Katz10,11AbstractBackground: Early reports of the 2009 A/H1N1 influenza pandemic (pH1N1) indicated that a disproportionateburden of illness fell on First Nations reserve communities. In addition, the impact of the pandemic on differentcommunities may have been influenced by differing provincial policies. We compared hospitalization rates forpneumonia and influenza (P&I) attributable to pH1N1 influenza between residents of First Nations reservecommunities and the general population in three Canadian provinces.Methods: Hospital admissions were geocoded using administrative claims data from three Canadian provincial datacentres to identify residents of First Nations communities. Hospitalizations for P&I during both waves of pH1N1were compared to the same time periods for the four previous years to establish pH1N1-attributable rates.Results: Residents of First Nations communities were more likely than other residents to have a pH1N1-attributableP&I hospitalization (rate ratio [RR] 2.8-9.1). Hospitalization rates for P&I were also elevated during the baseline period(RR 1.5-2.1) compared to the general population. There was an average increase of 45% over the baseline in P&I ad-missions for First Nations in all 3 provinces. In contrast, admissions overall increased by approximately 10% or less inBritish Columbia and Manitoba and by 33% in Ontario. Subgroup analysis showed no additional risk for remote orisolated First Nations compared to other First Nations communities in Ontario or Manitoba, with similar rates notedin Manitoba and a reduction in P&I admissions during the pandemic period in remote and isolated First Nationscommunities in Ontario.Conclusions: We found an increased risk for pH1N1-related hospital admissions for First Nations communities in all3 provinces. Interprovincial differences may be partly explained by differences in age structure and socioeconomicstatus. We were unable to confirm the assumption that remote communities were at higher risk for pH1N1-associated hospitalizations. The aggressive approach to influenza control in remote and isolated First Nations com-munities in Ontario may have played a role in limiting the impact of pH1N1 on residents of those communities.* Correspondence: michael.green@dfm.queensu.ca1Departments of Family Medicine and Public Health Sciences, Queen'sUniversity, Kingston, Ontario, Canada2Centre for Health Services and Policy Research and Institute for ClinicalEvaluative Sciences, Queen’s University, Kingston, Ontario, CanadaFull list of author information is available at the end of the article© 2013 Green et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.Green et al. BMC Public Health 2013, 13:1029http://www.biomedcentral.com/1471-2458/13/1029BackgroundThe 2009 A/H1N1 influenza pandemic (pH1N1) origi-nated in Mexico and quickly spread around the world.The first Canadian cases were reported in April of thatyear. Early descriptive studies focused on risk factors forsevere disease and identified key patterns such as the in-creased risk for children and pregnant women and youn-ger adults as well as those with chronic conditions [1-3].It was also assumed that Indigenousa communities inseveral countries including the United States, Australia,New Zealand and Canada were at increased risk: this as-sumption was confirmed in later studies [4-8]. As a con-sequence, public health officials in Canada began toconsider specific recommendations for Aboriginal Cana-dians, which includes First Nations, Inuit, and Métis.Prior studies in Canada have examined primarilylaboratory-confirmed cases [8-11] and have either exam-ined national or provincial rates, but did not comparethese across provinces. Internationally, most prior re-search has also focused on lab-confirmed hospitalizedcases. We are not aware of any other Canadian studiesexamining the population-based impacts across prov-inces or between Aboriginal communities and the gen-eral population. Yet, inequities between Aboriginal andother Canadians persist for virtually every measure ofhealth and social status.The potential for health and health care disparitiesamong those living on a reserve compared to residentsof other communities is higher. A reserve is a small por-tion of what might have previously been part of a na-tion’s traditional territory, which is protected bylegislation for the use and benefit of a First Nation [12].Although more than half (51%) of the First Nationspopulation in the provinces of British Columbia, Mani-toba, and Ontario live in urban areas [13-15], there con-tinues to be a significant portion of First Nationsindividuals who live on reserves that are consideredrural and remote geographic regions. Further, it has beendocumented that many First Nations people who liveoff-reserve travel back to their home reserve to accesshealthcare [16,17].This study was undertaken to assess whether therewere observed differences in the rates of hospitalizationsattributable to pH1N1 in British Columbia, Manitoba,and Ontario between residents of First Nations commu-nities and other residents, and between First Nations ineach province.MethodsWe used administrative data to examine rates of hospi-talizations attributed to pH1N1 for those living on FirstNations reserves and the rest of the population in BritishColumbia, Manitoba, and Ontario. Results were aggre-gated for all First Nations reserve communities in eachprovince. We did not merge the British Columbia, Mani-toba, or Ontario datasets because of documented datacoding variability.Sources of dataThe data included files held at Population Health DataBritish Columbia, the Manitoba Centre for Health Pol-icy, and the Institute for Clinical Evaluative Sciences(ICES) in Ontario. Standardized data, based on everyhospital contact, are submitted (including scrambledpersonal health identifiers, diagnoses, costs, hospital-ization, and institutionalization data) as part of a systemmaintained and controlled by all provincial ministries ofhealth. We used the hospitalization data availablethrough each province’s Discharge Abstract Database(DAD) files and the demographic data available throughprovince-specific datasets (Consolidation file in BritishColumbia, the Population Registry in Manitoba, and theRegistered Persons Database in Ontario) in order to de-termine sex, age, and location of residence. Socioeco-nomic quintiles were identified using standard protocolsin each province that utilize a combination of censusdata and location of residence. We also utilized the la-boratory influenza testing result files from each prov-ince to identify the time periods of interest for waves1 and 2 of pH1N1 in each province.FN identificationIn most provinces, current databases are unable to reli-ably report First Nations identification. Therefore, wecreated an ecological sample that was assumed to in-clude all British Columbia, Manitoba, and Ontario FirstNations living on a reserve. Our unit of interest was resi-dents of First Nations reserve communities. Based onprevious work by Lavoie and colleagues we used a com-bination of 6-digit postal code and First Nations reservenumbers (from Indians and Northern Affairs Canada) toidentify all BC, Manitoba, or Ontario residents living ona First Nations reserve [18]. In all three provinces Regis-tered First Nations represent over 90% of the overall on-reserve population [16]. The remainder of the on-reserve population will be the children of one Registeredparent and Métis or non-indigenous individuals, all ofwhom depend on the same services.Geographic mismatching can be a concern in any ruralarea, where many small communities may exist within asingle postal code. In British Columbia this is of particu-lar concern as postal codes tend to cover larger areas,and First Nations reserves are small. In the case of FirstNations, the payer of British Columbia provincial healthpremiums is the First Nation Inuit Health Branch ofHealth Canada. Therefore, we were able to use both aproxy for First Nations identification (premium payer)and postal codes where reserves are located to trackGreen et al. BMC Public Health 2013, 13:1029 Page 2 of 8http://www.biomedcentral.com/1471-2458/13/1029British Columbia First Nations individuals living onreserve.Outcome measuresSince influenza is infrequently confirmed by laboratorytests and the criteria for testing for pH1N1 varied overthe study period, and between provinces, we estimatedpH1N1-attributable outcomes by applying statisticalmethods to administrative data. Pneumonia and influ-enza (P&I) hospitalization (International Classification ofDiseases, Tenth Revision [ICD-10] J10-J18) in any diag-nostic field was the primary outcome. We examined assecondary outcomes: i) hospitalizations due to pneumo-nia and influenza as the primary diagnosis; and ii) any re-spiratory condition (ICD-10 J00-J99) in any diagnosticfield. To confirm the specificity of any observed differ-ences, we examined motor vehicle collisions (ICD-10V01-V79) as a condition where pH1N1 was not expectedto have an impact.Data analysisData analyses were conducted within each province. Fre-quent communication during the analysis stage ensuredconsistency in analyses despite slight variations inherentin the health administrative data. To estimate pH1N1-attributable outcomes, we first defined periods of pH1N1activity (i.e., pandemic waves 1 and 2, which were ap-proximately April-June and October-November 2009)using provincial laboratory data. We then determinedevent rates during these periods in 2009 and comparedthem to event rates during the same periods in the previ-ous five years (2004 to 2008). The rate during the previ-ous years served as the expected baseline for theseoutcomes, controlling for inherent differences betweenprovinces and between First Nations communities andthe general population in terms of health servicesutilization, public health prevention and control strat-egies, and influenza disease rates. pH1N1-attributableevent rates were calculated as the difference between thepH1N1 waves in 2009 and the baseline periods in previ-ous years.We conducted analyses that included crude and agestandardized rates and rate ratios. Rates of admissionwere first determined for each week then aggregated togenerate average weekly rates for the time periods ofinterest. For Ontario and Manitoba we also used theFirst Nations and Inuit Health rurality designation to de-termine if there were differences between Remote andIsolated First Nations reserve communities and thoserated as Semi-Isolated and Non-Isolated. In Ontario, thelocations and categories of each community in our data-set were compared to the information in the First Na-tions Community Profiles on the Aboriginal Affairs andNorthern Development Canada website to ensure theywere accurate. One of the investigators (MG) has con-tent expertise in this area and was able to resolve anyconflicts identified during this processes. In Manitobathis information was already available and verified fromprevious work by one of the investigators(JL). This wasnot possible in British Columbia due to the nature of thedataset obtained from Population Health Data BritishColumbia, where aggregation beyond the communitylevel had already been completed prior to release of thedata set, making it impossible to use this approach. Weused a rate ratio approach as the relatively low eventcounts in the First Nations communities precluded themeaningful use of regression models to adjust for con-founding variables. We used SAS 8.0/9.2 for data analysisdepending on the version in use at each data centre [19].Ethics and partnershipsThis project was conducted in keeping with the Tri-Council Policy Statement on Research involving AboriginalPeoples [20]. As we were using provincial-level datasets,guidance and input into the study was provided byprovincial-level First Nations organizations. Research agree-ments were implemented between the research team andChiefs of Ontario, the Assembly of Manitoba Chiefs, andthe British Columbia First Nations Health Council. Theroles of the partners included review and approval of theapplication for funding, the methodology used for identify-ing First Nations communities, review of preliminary re-sults and review, and approval of the final manuscript.All procedures were approved by ethics boards at theUniveristy of British Columbia, University of Manitoba, andQueen’s University. Data access requests were approved byPopulation Data British Columbia, The Health InformationPrivacy Committee in Manitoba, and the Institute for Clin-ical Evaluative Sciences.ResultsThere were key demographic differences between FirstNations reserve communities and other residents in eachof the three provinces (Table 1). Residents of First Na-tions reserves were more likely to be younger, havelower socioeconomic status and less likely to reside inan urban area (as would be expected given the locationof most reserves). The age and SES differences weregreatest in Manitoba and smallest in British Columbia.Ontario had several reserve communities located inurban census metropolitan areas, while there were nonein Manitoba. British Columbia data were not availablefor this particular analysis.Figure 1 presents the weekly hospitalization rates for P&Iin one province (Ontario) from April 2004 to April 2010.Hospitalization rates for P&I were higher in First Nationsreserves than in other communities throughout this period.The influence of seasonal influenza on admission rates isGreen et al. BMC Public Health 2013, 13:1029 Page 3 of 8http://www.biomedcentral.com/1471-2458/13/1029clearly evident, as is the spike in admissions due to wave 2of pH1N1.The remainder of the results are limited to the pandemicperiods noted in Figure 1 and the corresponding control pe-riods (same weeks) in each of the prior five years. Table 2presents the results for our primary outcome. The differ-ences between age-adjusted and crude rates did not signifi-cantly influence the results of our primary outcome so wehave presented only the crude rates. For both the baselineperiod and during pH1N1 waves, the rates of admissionwere highest in Manitoba. All provinces had higher rates ofadmission for First Nations reserve communities duringthe baseline period (RR 1.5-2.1). pH1N1-attributable ad-missions were higher for First Nations reserve communities(RR 2.8-9.1). In all three provinces there was a similar in-crease (44-46%) in P&I admissions among First Nations re-serve communities. In contrast, there was little change inthe admission rates for the general population in eitherBritish Columbia (8%) or Manitoba (11%), but a 33% in-crease in Ontario. The “ratio of ratios” indicates the degreeby which the proportional increase in P&I related hospitali-zations for residents of First Nations Reserve communitieswas greater than that experienced by the general populationafter taking into account expected differences based on his-torical data. This showed the increase in hospitalizationrates for residents of First Nations Reserve communities tobe 35% higher in BC, 31% higher in Manitoba and 8%higher inOntario.Table 1 Sociodemographic characteristics of First Nations Reserves and Other Residents in British Columbia, Manitoba,and Ontario, 2009.British Columbia Manitoba OntarioFirst Nations Reserves Other residents First Nations Reserves Other residents First Nations Reserves Other residentsAge <16 years 26.9% 17.2% 35.2% 19.6% 32.4% 18.4%Age >65 years 6.1% 13.6% 5.5% 13.6% 7.06% 13.05%% Female 48.8% 50.6% 49.1% 50.8% 50.4% 50.1%% Urban NA NA 0.02% 65.1% 12.2% 76.8%SES Quintiles1 45.1% 20.1% 61.9% 16.8% 49.1% 20.8%2 16.5% 20.1% 17.1% 19.9% 11.8% 20.1%3 14.5% 20.2% 16.2% 20.2% 7.2% 19.6%4 13.6% 20.0% 2.7% 21.0% 14.0% 19.8%5 10.3% 19.6% 1.9% 21.0% 17.9% 19.7%Urban = Census Metropolitan Area (>100,000).SES Quintiles excluding missing results.NA = Not available.Figure 1 Weekly hospitalizations rates for pneumonia and influenza in Ontario. Ontario – standardized rates per 100,000 population perweek, April 2004-April 2012. Vertical bars represent waves 1 and 2 of H1N1 and corresponding control periods in earlier years.Green et al. BMC Public Health 2013, 13:1029 Page 4 of 8http://www.biomedcentral.com/1471-2458/13/1029Our additional sensitivity analyses showed that whenP&I was used as the primary diagnosis, we found similarresults to our primary outcome (data not shown). For allrespiratory hospitalizations an increase was also noted,but with the degree of this somewhat tempered (increasesof approximately 15% rather than 44% in Ontario for ex-ample) as would be expected by the inclusion of othernon-infectious respiratory admissions in this outcome(data not shown). Sensitivity analyses also showed thatthere was no temporal relationship noted between motorvehicle collision rates and pH1N1, although motor ve-hicle collision rates for residents of First Nations reservecommunities were also noted to be twice that of the gen-eral population (data not shown).For Manitoba and Ontario, we were also able to com-pare remote and isolated First Nations reserve communi-ties to those that are not remote or isolated (Table 3). InManitoba the rates of admission overall and the pH1N1-attributable rates were similar for both groups. In On-tario, there were fewer P&I admissions in remote andTable 2 Pneumonia and Influenza Hospitalizations (Crude Rate per 100,000 per week)2009 2004-08 H1N1 Attributable Rate Ratio: 2009:2004-08British ColumbiaFirst Nations Reserves 13.77 9.48 4.29 1.45Other Residents 6.65 6.18 0.47 1.08Rate Ratio: 2.07 1.53 9.13 1.35*First Nations:OtherManitobaFirst Nations Reserves 26.84 18.44 8.40 1.46Other Residents 11.21 10.07 1.14 1.11Rate Ratio: 2.39 1.83 7.36 1.31*First Nations:OtherOntarioFirst Nations Reserves 16.84 11.74 5.10 1.44Other Residents 7.35 5.54 1.81 1.33Rate Ratio: 2.29 2.12 2.81 1.08*First Nations:OtherCrude rates of hospitalization for pneumonia or influenza (any diagnostic field) per 100,000 population per week. 2009 represents the average combined rate ofboth waves of H1N1 and 2004-08 the average rate during the same weeks in each of the prior 5 years. *Indicates the “ratio of ratios” which represents the degreeto which the rate of P&I admissions increased relative to the general population after taking into account expected differences in rates based on the rates ofhospitalization for P&I in 2004-2009.Table 3 Pneumonia and Influenza Hospitalizations by Geographic Location – First Nations Communities in Manitobaand Ontario only (Crude rates per 100,000 per week)2009 2004-08 H1N1 Attributable Rate Ratio: 2009:2004-08Manitoba First Nations CommunitiesRemote/Isolated 27.69 18.29 9.40 1.51Other 25.71 18.64 7.07 1.38Rate Ratio 1.077 0.98 1.32 1.10*RI:OtherOntario First Nations CommunitiesRemote/Isolated 7.05 7.91 −0.88 0.89Other 21.47 13.56 7.91 1.58Rate Ratio 0.33 0.58 −0.11 0.56*RI:OtherCrude rates of hospitalization for pneumonia or influenza (any diagnostic field) per 100,000 population per week. 2009 represents the average combined rate ofboth waves of H1N1 and 2004-08 the average rate during the same weeks in each of the prior 5 years. *Indicates the “ratio of ratios” which represents the degreeto which the rate of P&I admissions in remote or isolated FN communities increased (or decreased) relative to the rates in other FN communities after taking intoaccount expected differences in rates based on rates of hospitalization of P&I in 2004-2009.British Columbia data was not included as the nature of the data set did not permit this particular subgroup analysis.Green et al. BMC Public Health 2013, 13:1029 Page 5 of 8http://www.biomedcentral.com/1471-2458/13/1029isolated communities and there was actually a decreasein admissions between the baseline period and 2009for these communities. In contrast, there was a 58%increase in admissions for other First Nations reservecommunities.DiscussionThis study confirms that at a population level, therewas a greater risk of pH1N1-attributable hospitalization(RR = 2.8-9.1) for First Nations reserve communitiesthan the remainder of the population. These health dispa-rities are consistent across BC, Manitoba, and Ontario,and consistent with other studies of hospitalized orlaboratory-confirmed cases in North America, Australia,and New Zealand [3-11,21]. For example, Campbell et al.found that the likelihood of hospital admissions for labconfirmed pH1N1 in Canada was 5-7 times greater forthose with Aboriginal status compared to the generalpopulation [10]. LaRuche et al. compared hospitalizationrates for pH1N1 across several countries and found thatthe relative risk for Indigenous populuations to be be-tween 3.0-7.7 times higher than the general population[4]. They also noted elevated mortality (RR 3.4-5.3) [4], asdid Castrodale et al. (RR2.9-5.6) in the United States [5].Wilson et al. also reported increased mortality for theMaori in New Zealand (RR 2.0-7.2), and further note thatthis pattern has been consistently observed in all themajor pandemics documented since 1918 [21].We also found elevated baseline risks of P&I hospi-talization (RR = 1.5-2.1) variability in both the baselineand pH1N1-attributable hospitalization rates betweenprovinces. Some of this variability may be explained bydemographic differences between FNs reserve communi-ties in each province. Manitoba, which had the highestrates, also has the youngest and poorest First Nations re-serve population. This would be in keeping with other stud-ies, which have shown a convincing association betweenlower SES and increased risk of adverse outcomes fromH1N1 influenza [22,23]. Once baseline differences areaccounted for, the relative increase in risk of hospitalizationfor pH1N1 for those living on a First Nations reserve wassimilar across provinces at about 45% (44-46%) comparedto prior years. In Ontario, where pH1N1-related hospitali-zations mostly occurred during the second wave, there wasalso a significant impact in the general population, while inBC andManitoba the impact on the general population wasminimal. This would be consistent with a prior study oflaboratory-confirmed pH1N1 hospitalizations that foundthe second wave to havemuch higher admission rates [11].Guidelines identified remote or isolated First Nations asbeing at particularly increased potential risk and in someprovinces such as Ontario, more aggressive pandemic con-trol strategies (such as more liberal use of antiviral medica-tion, expanded indications for mask usage and increasedconsideration of cancellation of mass gatherings) were im-plemented [24-27]. Our data did not show increased riskfor these communities compared to other First Nations re-serve communities at baseline, with admission rates beingessential identical in Manitoba and actually lower in On-tario. This may be due in part to the types of facilities andhealthcare services available locally in these communitiesas more isolated communities often receive higher levels ofservices on site. During pH1N1 inManitoba there was onlya slightly higher rate of pH1N1-attributable admission inremote/isolated vs. other First Nations community types(RR = 1.51 vs. RR = 1.38). In Ontario, there was actually adecrease in hospitalizations in remote/isolated First Na-tions reserve communities during pH1N1, with all of the in-crease in admissions coming from the other communitytypes. This could be related to the more aggressive ap-proach taken to control and treatment of pH1N1 in thesecommunities or other factors. It should be noted that aspH1N1 was primarily a second wave event in Ontario, theexperience of other jurisdictions with the first wave ofpH1N1 was taken into consideration during the develop-ment and implementation of clinical and public healthguidelines in that province. Future guidelines should con-sider all First Nations communities to be at elevated riskand also address the needs of those less isolated communi-ties that have limited access to on reserve healthcareservices.LimitationsA number of limitations to the study should be takeninto consideration. The first is that we are using pH1N1-attributable rather than laboratory-confirmed hospitali-zations as an outcome. We feel this is reasonable be-cause not all patients would necessarily have beentested, but this does potentially lead to incorrect attribu-tion of cases. We did not adjust for a number of knownrisk factors such chronic diseases, pregnancy, or agegroup. Moreover, there are other risk factors that are notmeasurable in administrative data (e.g., access to safedrinking water or overcrowding) [28]. However, our ana-lyses included close to the entire population in eachprovince and age standardization did not have a majorimpact on our conclusions. The time periods for obser-vation were based on provincial level laboratory data,which could be confounding if the waves of H1N1 onFirst Nations reserves occurred at different times fromthe general population. Finally, it is likely that there wassome misattribution due to imperfect matching of FirstNation reserve boundaries with postal code boundaries.In BC, using a combination of postal code and premiumpayer to identify First Nations may result in the inclu-sion of a small number of First Nations living outsidebut close to the reserve. We believe their access toGreen et al. BMC Public Health 2013, 13:1029 Page 6 of 8http://www.biomedcentral.com/1471-2458/13/1029health services compares to that of the First Nations on-reserve population living adjacent to them.ConclusionsThe findings reported here are unique in that analyses werecarried out across three provinces using their health admin-istrative data to shed light on the impact of pH1N1 amongFirst Nations reserve communities. Findings provide empir-ical population level evidence of both an absolute and rela-tive increase in risk for pH1N1-attributable hospitalizationsfor First Nations reserves relative to the general population.The increased baseline risk suggests that this risk is ele-vated in general and not specific to pH1N1.The interprovincial variations could indicate that SES,age, and other differences for which we do not haveregular sources of data (e.g., housing status) are import-ant mediators of these differences. Unlike what is gener-ally assumed, increasing remoteness of the communitywas not an important risk factor. Outcomes were not re-lated to where the communities are situated, but ratherto the care provided. Future studies should examinemore closely the influence of the types of health servicesdelivered locally. Still, the aggressive use of antiviralmedications in remote and isolated communities in On-tario may have contributed to the reduced impact of thepandemic in those areas.EndnoteaThroughout this paper, the term Aboriginal will beused when statements apply to First Nations living on-and off-reserve, Inuit, and Métis. Elsewhere, the termsFirst Nations, Inuit, and Métis will be used when specificto each of these populations. Finally, the term Indigenouswill only be used when speaking in international terms.Competing interestsMG serves as a medical officer for First Nations and Inuit Health Branch,Ontario Region and participated in the management of the H1N1 pandemicon First Nations reserves in Ontario.Author’s contributionsMG, SW, AK, JL and JK designed the study and contributed to all aspectsincluding the development of partnerships, acquisition of data, analysis andinterpretation of results. LM, SP and GL worked directly on the analysis of theadministrative data. All authors contributed to the discussion and review ofthe manuscript. All authors read and approved the final manuscript.AcknowledgementsThis project was funded by the Canadian Institutes of Health Researchthough the Applied Health Services Research on H1N1 program grant H1N-104058. We would like to thank Marlo Whitehead, senior analyst at ICES@Queen’s for her assistance with specific aspects of the study. Most importantly,we would like to recognize the essential contributions of our partner organi-zations, the BC First Nations Health Council, the Assembly of Manitoba Chiefsand the Chiefs of Ontario, without whom this project would not have beenpossible. The administrative data centres (ICES, Manitoba Centre for HealthPolicy, Population Health Data BC) receive support from provincial ministriesof health. The opinions, results and conclusions presented here are those ofthe authors and are independent of these funding sources. No endorsementby these sources of support is intended or should be inferred.Author details1Departments of Family Medicine and Public Health Sciences, Queen'sUniversity, Kingston, Ontario, Canada. 2Centre for Health Services and PolicyResearch and Institute for Clinical Evaluative Sciences, Queen’s University,Kingston, Ontario, Canada. 3School of Nursing and Centre, University ofBritish Columbia, Vancouver, BC, Canada. 4Centre for Health Services andPolicy Research, University of British Columbia, Vancouver, BC, Canada.5School of Health Sciences, University of Northern British Columbia, PrinceGeorge, BC, Canada. 6Department of Family and Community Medicine andDalla Lana School of Public Health, University of Toronto, Toronto, Ontario,Canada. 7Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.8University Health Network, Toronto, Ontario, Canada. 9Public Health Ontario,Toronto, Ontario, Canada. 10Manitoba Centre for Health Policy, University ofManitoba, Winnipeg, Manitoba, Canada. 11Departments of Family Medicineand Community Health Sciences, Manitoba Centre for Health Policy,University of Manitoba, Winnipeg, Manitoba, Canada.Received: 19 July 2013 Accepted: 28 October 2013Published: 30 October 2013References1. 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Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitGreen et al. BMC Public Health 2013, 13:1029 Page 8 of 8http://www.biomedcentral.com/1471-2458/13/1029

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