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Intentional injury among the indigenous and total populations in British Columbia, Canada: trends over… George, M. Anne; Jin, Andrew; Brussoni, Mariana; Lalonde, Christopher E; McCormick, Rod Aug 8, 2017

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RESEARCH Open AccessIntentional injury among the indigenousand total populations in British Columbia,Canada: trends over time and ecologicalreduces disparity with respect to discriminatory practices, and physical, social, and economic conditions.George et al. International Journal for Equity in Health  (2017) 16:141 DOI 10.1186/s12939-017-0629-4Vancouver, BC V6H 3V4, CanadaFull list of author information is available at the end of the article1Department of Pediatrics, Faculty of Medicine, University of British Columbia,Vancouver, BC, Canada2BC Children’s Hospital Research Institute, Room F508, 4480 Oak Street,Hospitalization, Canada, Inequities* Correspondence: ageorge@bccrhi.caKeywords: Wounds and injuries, American Indian, Aboriginal, Indigenous population, Suicide, attempted,populations is off-set by the high disparity in risk between tanalyses of riskM. Anne George1,2,3*, Andrew Jin4, Mariana Brussoni1,2,3, Christopher E. Lalonde5 and Rod McCormick6AbstractBackground: Our objective was to explore intentional injury disparity between Indigenous populations and the totalpopulation in the province of British Columbia (BC), Canada. We focus on hospitalizations, including both self-inflictedinjuries and injuries inflicted by others.Methods: We used data from BC’s universal health care insurance plan, 1991 to 2010, linked to Vital Statistics databases.Indigenous people were identified through the insurance premium group, and birth and death records. Placeof residence was identified through postal code. We calculated crude hospitalization incidence rates and theStandardized Relative Risk (SRR) of hospitalization, standardized by gender, 5-year age group, and Health Service DeliveryArea (HSDA). With HSDA populations as the units of observation, linear regression was used to test hypothesizedassociations of Indigenous ethnicity, geographic, and socio-economic characteristics with SRR of injury.Results: During the period 1991–2010, the crude rate of hospitalization for intentional injuries was 8.4 per 10,000person-years (95% confidence interval (CI): 8.3 to 8.5) for the total BC population, compared to 45.3 per 10,000(95% CI: 44.5 to 46.1) for the Indigenous population. For both populations, risk declined over the period forinjuries self-inflicted and inflicted by others. The linear regression model predicts that the off-reserve Indigenouspopulation will have SRR of intentional injury 3.98 greater, and the on-reserve Indigenous population 4.17, greaterthan the total population. The final model was an excellent fit (R2 = 0.912, F = 177.632, p < 0.001), and found thatthree variables - occupational risk, high school diploma, and university degree – each provide independent effects wheninteracting multiplicatively with Indigenous ethnicity.Conclusions: The observation of substantially declining rates of intentional injury for both the Indigenous and total BChe two populations, which will likely continue until Canada© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (, which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver( applies to the data made available in this article, unless otherwise stated.George et al. International Journal for Equity in Health  (2017) 16:141 Page 2 of 14BackgroundIntentional injuries are either assaults inflicted by othersor self-inflicted. With the aim to explore intentionalinjury risk among Indigenous populations in BritishColumbia (BC), Canada, we include both self-inflictedinjuries and injuries inflicted by another, and all sub-sumed external cause categories, such as poisoning,drowning, firearms, cutting, falls, and attempted suicide.Our previous work [1–12] has shown dramatic reductionin overall injury risk for both the total BC and Indigenouspopulations during the past two decades, including forchildren [6]. It has also shown decreasing, but persistent,disparity in risk between the two population groups, withmore rapid rates of decreased disparity for some categoriesof injury (e.g., unintentional falls) [5, 10], compared toothers (e.g., iatrogenic injuries) [11]. Our findings alsohighlight disparities in injury rates within Indigenouspopulations, with higher injury risk among rural and on-reserve communities [3, 8]. This report explores thecategory of intentional injury using the same population-based dataset with both total BC and Indigenous popula-tions, and discusses similarities with and differences fromrisk of other categories of injury.Canada recognizes three distinct Indigenous groups:First Nations, Inuit and Métis under the Constitution1982 and Indian Act 1876 Section 35. The three groupsare referred to as Indigenous for the purposes of thispaper. In our team’s previous papers [1–12], we used theterm Aboriginal peoples; however, this merely reflects achange in nomenclature. In BC, Indigenous peoplesaccount for approximately 5% of the population.Higher rates of intentional injuries have been reportedamongst Indigenous, compared to non-Indigenous, popu-lations in other colonized countries; for example, resultingfrom interpersonal violence in Australia [13] and for self-inflicted injuries in New Zealand [14]. In Canada, datahave shown that Indigenous peoples are at higher riskthan non-Indigenous populations of intentional injuriesthat result in either mortality [15–17] or hospitalization[18]. Oliver et al. [18] found that risk of self-inflicted in-jury was at least three times higher and assaults at leastfive times higher for those living in geographic areas withhigh, compared to low, concentrations of people whoidentify as Indigenous. In Alberta, Canada, self-inflictedinjury rates were found to be highest among people sup-ported by social assistance and for those with Indigenousstatus [19]. Thus, the epidemiological data represented byintentional injuries is important to comprehend becauseof the overall individual and societal burdens, and is par-ticularly relevant for overrepresented populations, such asIndigenous peoples.Considerable attention has been focused on the dispro-portionally higher rates of intentional injuries amongCanadian Indigenous peoples and, in particular on violenceagainst Indigenous women, in international reports[20, 21], national governmental [22–25] and non-governmental reports [26], and in the media [27]. AUnited Nations report noted that in Canada “Indigenouswomen and girls are also disproportionately victims of vio-lent crime” [21]. The topic became a political issue duringthe 2015 federal election [28], and subsequently the newlyelected government established a National Inquiry intoMissing and Murdered Indigenous Women and Girls [29].The present study extends and enhances our previousefforts to quantify the epidemiology of injuries amongIndigenous peoples living both on- and off-reserve andin urban and rural places [2–12]. We use hospitalizationdata rather than mortality data because this is a muchlarger dataset since injury resulting in hospitalization ismore common than injury resulting in death. We haveimproved methods for identification of the Indigenouspopulation compared to previous studies in Canada (e.g.,[18]) that use geography to identify the population,thereby making the assumption that all people living inspecific places (e.g., reserves) are Indigenous. Instead, wehave employed a method that identifies Indigenouspeople by record linkage to the provincial health insur-ance premium database and to Vital Statistics birth anddeath records.The purposes of the current report are threefold: tocompare intentional injury risk between the total andIndigenous populations of BC; to examine trends in riskby population group and sex over a 19-year time period;and to explore associations of risk with socioeconomicstatus, geographic place and ethnic identity. In addition,we discuss similarities with and differences from our re-sults [5, 10–12] exploring risk of other injury categories.MethodsThe University of British Columbia Behavioural ResearchEthics Board reviewed and approved our methods (BREBfile H06–80585). Data Stewards representing the BCMinistry of Health and the BC Vital Statistics Agencyapproved the data access requests. We used existingdatabases, permanently linked by British ColumbiaPersonal Health Number, maintained by Population DataBC [30–33]. Disclaimer: All inferences, opinions, andconclusions drawn in this journal article are those of theauthors, and do not reflect the opinions or policies of theData Stewards.We have published our methods in detail previously[2–11], including a discussion of the quality of the popula-tion registry, and validity and limitations of the Indigenousidentification [5, 6] and provide a summary below.Population and hospital countsAs in previous analyses pertaining to other categories ofinjury [2–12], we used the premium billing files [30] ofGeorge et al. International Journal for Equity in Health  (2017) 16:141 Page 3 of 14the province of BC’s universal health care insurance pro-gram, the Medical Services Plan of BC (MSP) as the popu-lation registry to calculate denominator populations forhospitalization rates. We classified persons as “Indigenous”according to method of insurance payment, which indi-cates the patient as having Indian Status, as defined by theIndian Act of Canada, or having Indian status noted onone’s own or on a parent’s linked Vital Statistics birthrecord [31] or death record [32]. This is an adaptation of amethod previously developed and used by the VitalStatistics Agency of BC [34]. Within the Indigenous popu-lation, we classified people residing on an Indian Reserveor in an Indian Settlement or in an Indian Self-GoverningDistrict recognized by the federal government of Canadaas “on-reserve”, and people not residing therein as “off-re-serve”, according to their postal code of residence.Hospital separations data [33] for residents of BC wereavailable from April 1, 1991 through March 31, 2010.We considered a hospitalization as “due to injury” if thelevel of care was “acute” or “rehabilitation,” and theMost Responsible Diagnosis on the discharge record wasan International Classification of Diseases Revision 9(“ICD-9”) numeric code in the range 800 through 999,or an International Classification of Diseases Revision 10(“ICD-10”) code in the range S00 through T98; and“intentional” if the first occurrence of the supplementalinjury diagnosis code (indicating intention and externalcause) was an ICD-9 E-code in the range E950-E958 oran ICD-10 code in the range X60-X84 (intentionally self-inflicted), or an ICD-9 E-code in the range E960-E968 oran ICD-10 code in the range X85-Y09 (purposely inflictedby another).Linking hospitalization records to the population regis-try, we tabulated counts of hospitalizations by calendaryear, gender, 5-year age group, Indigenous status, reserveresidence, and residence within BC’s 16 Health ServiceDelivery Areas (HSDA) [34].Incidence rates of hospitalizationWe calculated the crude rates of hospitalization per10,000 person-years. We treated the crude rate as a bino-mial proportion and calculated 95% confidence limits ac-cordingly. We calculated Standardized Relative Risk (SRR)of hospitalization, relative to the risk of hospitalization inthe total population of BC during the same time period,using the method of indirect standardization [35], stand-ardizing by gender, 5-year age group and HSDA in mostcases when comparing population groups during theperiod 1991–2010, but standardizing by gender and 5-year age group when comparing HSDAs during the pe-riods 1991–2010, 1999–2003 or 2004–2008. The SRRcould also be called the Standardized Incidence Ratio.We assessed cumulative change in SRR over time asthe proportional change between the first and last yearsof the observation period, i.e., (SRR2010/SRR1991) −1. Weconverted change over the entire period to an annual-ized change, using this formula. SRR2010SRR1991!1= 2010−1991ð Þ−1We compared the cumulative change (SRR2010/SRR1991) among Indigenous people to the cumulativechange among the total population of BC. We tested thestatistical significance of the disparity (SRR2010 /SRR1991Indigenous versus SRR2010 /SRR1991 BC) by calculatingthe probability (2-sided, z-test) that Ln((SRR2010)/(SRR1991)) Indigenous = Ln((SRR2010)/(SRR1991)) BC.Predictors of riskNeither the population registry, nor the hospital dis-charge database, nor any other database linkable to thesedatabases through Population Data BC, contained socio-economic descriptors of individual clients. Therefore, weused an ecological approach to our analysis to examinerisk markers, whereby the unit of observation was theHSDA (n = 16) subdivided into three population groups(total population, Indigenous off-reserve, and Indigenouson-reserve) and two time periods (1999–2003, and2004–2008). Since two HSDAs had no Indian reserves,the total number of observation units was(14 × 3 + 2 × 2) × 2 = 92. The population units are notmutually exclusive (because the total population includesthe two Indigenous subpopulations), therefore we didnot use the group classification as a variable in the sub-sequent analysis. We did include the proportion of thepopulation who are Indigenous as an analysis variable,because this an attribute of the observation unit, mea-sured on a noncategoric scale.Consistent with the ecological approach, we measuredboth outcome (i.e., injury risk) and predictors (i.e.,hypothesized risk markers) at the level of HSDAs andpopulation groups therein. Our hypothesized riskmarkers were socio-economic, housing, and geographicindicators previously developed by Statistics Canada andIndigenous and Northern Affairs Canada. From theCensuses of Canada, 2001 and 2006, we measured thefollowing indicators, for the three population groups ineach HSDA: (1) Total (annual) Income per capita, (2)the Income Score component (i.e., total annual incomeper capita, logarithmically scaled) of the CommunityWell-being Index [36], (3) proportion of population, age25+ years with at least a high school certificate, (4) pro-portion of population, age 25+ years with university de-gree, bachelors or higher, (5) average population perroom (an index of the degree of crowding in the popula-tion’s housing [37], (6) proportion of the population liv-ing in a dwelling in need of major repair, (7) proportionGeorge et al. International Journal for Equity in Health  (2017) 16:141 Page 4 of 14of population, age 25+ years, in the labour force, (8) pro-portion of population, age 25+ years, employed (for pay),(9) proportion of population who identified themselvesas “an Aboriginal person, that is, North American Indian,Métis or Inuit (Eskimo)”, (10) proportion of populationwho gave only one response to the ethnic origin question,and it was a group that could be classified as NorthAmerican Indian, (11) proportion of the HSDA’s popula-tion classified as “urban” (residing in a population centrewith 100,000 or more persons), and (12) proportion of theHSDA’s population classified as “rural” (residing in a popu-lation centre with fewer than 1000 persons, or in an areawith population density less than 400 persons per km2).For each population group in each HSDA, we cal-culated the following work-related statistics of injuryrisk, relative to the population of BC: (13) relativerisk of work injury compensation claim, expectedfrom occupational categories, and (14) relative risk ofwork injury compensation claim, expected from in-dustry categories. These two markers, defined in aprevious report focusing on work-related injuries [2],describe the hazardousness of the distribution of thelabour force among occupational and industrial cat-egories. We also created four interaction terms, calcu-lated as each of the employment-related risk markersmultiplied by the proportion of the population whowere employed, and by the proportion who were inthe labour force. In regression analysis, the inter-action terms model the effects of the hypothesizedrisk markers on risk of injury, with the effect varyingaccording to the proportion of the population whoare in the labour force, or who are employed. Thesemay be interpreted as representing effects occurringspecifically to the fraction of the population who arein the labour force, or who are employed.Assuming that the effects of socioeconomic and geo-graphic risk markers might be different for Indigenouspeoples than for the general population, we created eth-nicity interaction terms, calculated as each of the socio-economic or geographic risk markers multiplied by theproportion of the population who were Indigenous.These interactions may be interpreted as representingeffects occurring to the portion of the population whoare Indigenous.Ecological analysisFor each HSDA sub-population, we calculated the ageand gender standardized SRR of hospitalization due tointentional injury for two time periods, 1999 through2003 (a 5-year period centred about the Census year2001) and 2004 through 2008 (centred about the Censusyear 2006), relative to the total population of BC duringthe same time period. We used SRR as the dependent(Y) variable for regression analysis.We tested hypotheses of association by performingleast-squares linear regressions, weighted by person-years to diminish the impact of extreme values of SRRoccurring in smaller population units. We tested censusyear, hypothesized socio-economic, work-related, geo-graphic, and ethnicity markers, and interaction terms inturn as the single independent variable. Variables thathad statistically significant association (p < 0.05) withSRR in univariate analysis were included in subsequentmultivariable regression analysis. Beginning with thevariable most strongly correlated with SRR (largest coef-ficient of determination R2 in the univariate analysis), weused stepwise forwards addition of variables to arrive atthe best-fitting multivariable model. At each step, thevariable with the largest p-value greater than 0.05 waseliminated. Addition and elimination stopped when allindependent variables had regression coefficients signifi-cantly different from zero (p < 0.05) and the list of can-didate variables was exhausted. In the final model, wetested the normality of the distribution of the standard-ized residuals by the Kolmogorov-Smirnov and Shapiro-Wilk statistics, and we verified homoscedasticity byscatter-plotting the standardized residuals against theregression-predicted values of SRR.The regression coefficient (“B”) of each independentvariable represents the mean change in the dependentvariable SRR that is associated with unit change in theindependent variable. The absolute change in SRR (i.e.,SRR2 − SRR1) associated with a change of one standarddeviation (SD) in the independent variable is calculatedasB × SD.We verified that the step-wise regression procedure(weighted by population) had indeed produced a modelrepresentative of the experience of the total populationof BC and the much smaller Indigenous populations aswell. We used the final regression model as a riskprediction calculator, then we compared the predicteddisparities of injury SRR among the three populationgroups (total population, Indigenous off-reserve, andIndigenous on-reserve) to the observed disparitiesamong the three groups; i.e., all HSDAs combined.ResultsTable 1 shows observed and expected numbers ofintentional injuries for the total BC population andIndigenous populations over the study period, 1991 to2010. It also shows rates, SRR and their 95% confidenceintervals (CI). Compared to the total BC population,the Indigenous population had more than threefoldSRR for self-inflicted injuries and more than fourfoldSRR for injuries inflicted by another person. Within theIndigenous population, the difference between thoseliving on-reserve and those living off-reserve in SRR ofself-inflicted injuries was not statistically significantbate.–9anachGeorge et al. International Journal for Equity in Health  (2017) 16:141 Page 5 of 14Table 1 Hospital separations for intentional injuriesa, British ColumP-yearsc Obsd Expe RBC, total populationIntentional 78,256,306 65,802 65,802 8Self-inflicted 78,256,306 38,590 38,590 4Inflicted by another 78,256,306 27,212 27,212 3BC, IndigenousIntentional 2,541,060 11,506 2990 4Self-inflicted 2,541,060 6036 1738 2Inflicted by another 2,541,060 5470 1252 2BC, Indigenous, off-reserveIntentional 1,403,813 6009 1531 4Self-inflicted 1,403,813 3029 889 2Inflicted by another 1,403,813 2980 642 2BC, Indigenous, on-reserveIntentional 1,131,862 5468 1457 4Self-inflicted 1,131,862 2997 848 2Inflicted by another 1,131,862 2471 610 2a“Intentional injury” defined as Most Responsible Diagnosis in the range ICD9:80or ICD10:X60-X84 (self-inflicted) or ICD9:E960-E968 or ICD10:X85-Y09 (inflicted bybInjuries occurring during the observation period 1991-Apr-01 to 2010-Mar-31cPerson-years is the sum of the annual population counts times the fraction of e(p = 0.284, two-sided). However, the SRR of injuriesinflicted by another was higher among those living off-reserve (p = 0.001, two-sided).Table 2 shows gender and age-specific crude ratesand SRRs for intentional injuries, among the totaland Indigenous populations of BC during the period1991–2010. Crude rates were highest in the 10–49 yearsage range, lower among children aged under 10 years andadults aged 50 years or older. Crude rates were higheramong males than among females, in every age groupexcept 10–19 years, where the rate was higher amongfemales. These patterns are seen among both the total andIndigenous populations. Compared to the others of thesame gender in the total population, and combining allage groups, intentional injury among Indigenous females(SRR = 3.98) was higher than among Indigenous males(SRR = 3.73, p = 0.019, two-sided).Over the study period, risk decreased for self-inflictedinjuries for both the Indigenous population and the totalBC population, and for both sexes, as shown in Fig. 1.For the Indigenous population, SRR of self-inflicted in-juries decreased from 3.87 to 1.83 for males (52.7% de-crease), and from 5.15 to 1.79 for females (65.2%decrease). For the total BC population, SRR of self-inflicted injuries decreased for males from 1.37 to 0.60(56.4% decrease), and for females from 1.37 to 0.68dObserved number of injurieseExpected number, indirectly standardized, based on age, gender and HSDA-specififCrude Rate per 10,000 person-yearsgStandardized Relative Risk (compared to the total population of BC) = Observed/Exia, 1991–2010bf 95% CI for Rate SRRg 95% CI for SRR8.3 to 8.5 1 [reference]4.9 to 5.0 1 [reference]3.4 to 3.5 1 [reference]44.5 to 46.1 3.85 3.71 to 3.9923.2 to 24.4 3.47 3.31 to 3.6421.0 to 22.1 4.37 4.13 to 4.6241.7 to 43.9 3.92 3.74 to 4.1320.8 to 22.4 3.41 3.19 to 3.6420.5 to 22.0 4.64 4.30 to 5.0247.0 to 49.6 3.75 3.57 to 3.9625.5 to 27.4 3.54 3.31 to 3.7821.0 to 22.7 4.05 3.74 to 4.3999 or ICD10:S00-T98, and supplemental diagnosis in the range ICD9:E950-E958other)year included in the observation period(50.0% decrease). The decreases over time were not sig-nificantly different comparing Indigenous males to totalBC males (p = 0.844), or comparing Indigenous femalesto total BC females (p = 0.224). Thus, considerable dis-parity remains between the total Indigenous and totalBC populations.For injuries inflicted by another person, similar down-ward trends for SRR were found, as shown in Fig. 2. Forthe Indigenous population, SRR decreased from 5.50 to2.64 (51.9% decrease) for males, and from 10.86 to 5.76(47.0% decrease) for females. For the total BC popula-tion, SRR for males decreased from 1.25 to 0.79 (36.5%decrease), and for females from 1.85 to 0.84 (54.5%decrease). Risk for Indigenous populations was consider-ably higher than risk for the total BC population in everyyear. As with self-inflicted injuries, the decreases werenot significantly different comparing males in the twopopulations or females in the two populations, and con-siderable disparity remains between the total Indigenousand total BC populations.Having established a consistently higher, although de-clining, risk for intentional injury for Indigenous peoplescompared to the total BC population, we conducted eco-logical analyses to understand factors contributing to thedisparity. Table 3 describes the three population groups(total BC population, Indigenous off-reserve population,c rates in the total population of BCpectedTable 2 Hospital separations for intentional injuriesa, British Columbia, 1991–2010b, by gender and ageTotal population Indigenous populationGender Age Obsc Rated 95% CI for Rate SRR [ref] Obsc Rated 95% CI for Rate SRRe 95% CI for SRRF 0–9 267 0.6 0.5 - 0.7 1 70 2.5 1.9 to 3.1 3.48 2.42 - 6.19F 10–19 6427 13.0 12.7 - 13.4 1 1183 53.0 49.9 to 56.0 3.00 2.73 - 3.33F 20–29 6536 12.2 11.9 - 12.5 1 1529 75.6 71.8 to 79.4 4.08 3.70 - 4.54F 30–39 6706 10.9 10.7 - 11.2 1 1583 75.7 72.0 to 79.5 4.69 4.24 - 5.26F 40–49 5223 8.4 8.2 - 8.6 1 839 49.6 46.3 to 53.0 4.33 3.80 - 5.04F 50–59 2083 4.4 4.2 - 4.6 1 255 25.1 22.0 to 28.2 4.49 3.57 - 6.07F 60–69 696 2.1 2.0 - 2.3 1 71 12.7 9.7 to 15.6 5.11 3.35 - 10.78F 70–79 465 1.8 1.7 - 2.0 1 30 10.8 7.0 to 14.7 5.36 2.93 - 31.16F 80+ 348 2.0 1.8 - 2.2 1 6 4.2 0.8 to 7.5 2.20 1.01 - NAF Total 28,751 7.3 7.2 - 7.4 1 5566 43.4 42.2 to 44.5 3.98 3.78 - 4.20M 0–9 325 0.7 0.6 - 0.7 1 59 2.0 1.5 to 2.5 2.29 1.65 - 3.72M 10–19 5223 10.0 9.8 - 10.3 1 809 34.8 32.4 to 37.2 2.86 2.56 - 3.24M 20–29 10,994 20.8 20.4 - 21.1 1 2078 105.3 100.8 to 109.8 3.63 3.36 - 3.96M 30–39 9146 15.2 14.9 - 15.5 1 1616 81.5 77.5 to 85.4 4.09 3.72 - 4.53M 40–49 6753 10.9 10.7 - 11.2 1 930 59.9 56.1 to 63.7 4.29 3.78 - 4.95M 50–59 2779 5.9 5.6 - 6.1 1 294 32.4 28.7 to 36.1 4.35 3.51 - 5.71M 60–69 1024 3.1 2.9 - 3.3 1 112 23.0 18.8 to 27.3 5.69 3.94 - 10.18M 70–79 523 2.4 2.2 - 2.6 1 33 14.7 9.7 to 19.8 4.62 2.67 - 17.33M 80+ 270 2.6 2.3 - 2.9 1 6 6.1 1.2 to 10.9 2.42 1.08 - NAM Total 37,037 9.6 9.5 - 9.7 1 5937 47.5 46.3 to 48.7 3.73 3.56 - 3.93a“Unintentional transportation injury” defined as hospital separation with Most Responsible Diagnosis in the rangeICD9:800–999 or ICD10:S00-T98, and supplemental diagnosis in the range ICD9:E800-E807, E810-E829, E831, E833-E838, E840-E848or ICD10:V01-V89, V91, V93-V99bInjuries occurring during the observation period 1991-Apr-01 to 2010-Mar-31cObserved number of injuriesdCrude Rate per 10,000 person-yearseStandardized Relative Risk (indirectly standardized by age, gender and HSDA, compared to the total population of BC) = Observed/Expected0.,egarofdet sujd a(Indigenous, Separations, FBC, Separations. FIndigenous, Separations, MBC, Separations, MFig. 1 Injury hospitalizations in British Columbia, 1991–2010, relative risk by gender and year. Intentional Injury, Self-inflictedGeorge et al. International Journal for Equity in Health  (2017) 16:141 Page 6 of 14byGeorge et al. International Journal for Equity in Health  (2017) 16:141 Page 7 of 14and Indigenous on-reserve population), and their studiedcharacteristics (intentional injury SRR, and socioeco-nomic, geographic, and ethnicity markers). In general,Indigenous populations have higher intentional injuryrisk, and are more socioeconomically disadvantaged andless urban than the total population. Similar tendenciesare seen when comparing the on-reserve to the off-reserve Indigenous populations. However, the off-reserveIndigenous population has the highest labour force par-ticipation (higher than the total population), and the0. aleRdezidradnatS)ADSHdnaredneg,eg arofdetsujda(Fig. 2 Injury hospitalizations in British Columbia, 1991–2010, relative riskmost hazardous employment (more than the on-reservepopulation).Table 4 shows regression statistics from the preliminaryregression models with one independent (X) variable, i.e.,SRR = Bx + Constant. The regression coefficient (B) andthe “SRR change per SD” describe the association betweenthe specified variable (x) and intentional injury risk (SRR).The coefficient of Determination (R2) measures the pro-portion of the variance in SRR explained by x. “P” is theprobability of the null hypotheses that R2 = 0 and B = 0(i.e., no association between SRR and x).Table 5 shows statistics from bivariate regressionmodels where the independent term is a multiplicativeinteraction of Indigenous ethnicity with another variable(x), i.e., SRR = Bx•Ind + Constant, where Ind is the pro-portion of the population who are Indigenous (i.e.,0 ≤ Ind ≤ 1). One may interpret this table as describingassociations between each of the listed variables and fallsinjury risk in the Indigenous portion of the population(for whom Ind = 1).Tables 4 and 5 show that almost all of the hypothe-sized predictors (both individually and as interactionswith Indigenous ethnicity) are statistically significantlyassociated with injury risk (p < 0.05). However, becauseeach model contains only one independent variable orterm, the association may be due to confounding byanother variable. We explored this further using multi-variable models.Table 6 shows the best-fitting multivariable regressionmodel remaining after step-wise regression:SRR ¼ B1x1•Indþ B2x2•x3 þ B4x4 þ B5x5•Indþ B6x6•Indþ Constant;YearIndigenous, Separations, FBC, Separations. FIndigenous, Separations, M BC, Separations, Mgender & year. Intentional Injury, Inflicted by anotherWhere:Ind ¼ proportion of population who are Indigenous;1 ¼ hazardousness of occupational category;2 ¼ hazardousness of industry category;3 ¼ proportion of population; age 25þ years; in labour force;4 ¼ proportion of population; age 25þ years; employed;5 ¼ proportion of population; age 25þ years;with high school diploma;6 ¼ proportion of population; age 25þ years;with university degree:The final model was an excellent fit (R2 = 0.912,F = 177.632, p < 0.001). Standardized residuals were ap-proximately normally distributed: Kolmogorov-Smirnovstatistic was 0.101 (p = 0.022) and Shapiro-Wilk statisticwas 0.971 (p = 0.039). Scatter-plotting of standardizedolgrGeorge et al. International Journal for Equity in Health  (2017) 16:141 Page 8 of 14Table 3 Descriptive profile of three population groups in British CVariable PopulationYearAge and gender-SRR of hospital separation due 1999–2003residuals against the predicted values of SRR showedsymmetrical distribution above and below, all along thehorizontal baseline.Two employment-related terms had no interaction withIndigenous identity; that is, these applied to Indigenousand non-Indigenous people alike. These were: beingemployed decreased the risk of intentional injuries, and theto intentional injury2004–2008Person-years of observation 1999–20032004–2008Mean annual person count 1999–20032004–2008Census total population 20012006Total Income per capita 20012006Community Well-being Index Score 20012006Proportion of population, age 25+ years with at leasta high school certificate20012006Proportion of population, age 25+ years withuniversity degree, bachelors or higher20012006Average number of persons per room 20012006Proportion of population residing indwelling requiring major repairs20012006Proportion of population, age 25+ years,labour force participation20012006Proportion of population, age 25+ years, employed 20012006Risk of work injury claim, relative to BC pop 2006,expected from occupation, labour force age 15+ years20012006Risk of work injury claim, relative to BC pop 2006,expected from industry, labour force age 15+ years20012006Proportion of population, Indigenous identity 20012006Proportion of population, North AmericanIndian single response20012006Proportion of HSDA population residing inlarge urban population centre20012006Proportion of HSDA population residing in rural area 20012006umbiaoupTotal Population Indigenous livingoff-reserveIndigenous livingon-reserve1 5.18 5.39interaction between industry risk and labour force partici-pation had a small increased effect on intentional injuries.Three different variables – occupational risk, high schooldiploma, and university degree – each provide independenteffects when interacting multiplicatively with Indigenousethnicity; that is, these variables affect only the Indigenouspopulation. Indigenous ethnicity times occupation risk1 4.94 5.2820,663,214 363,704 301,52921,916,203 431,968 308,3714,132,643 72,741 60,3064,383,241 86,394 61,6743,868,875 123,640 46,3854,074,380 145,020 51,060$22,890 $13,357 $9994$27,370 $16,619 $10,79781.4 63.4 53.787.3 70.7 56.30.720 0.590 0.4960.834 0.716 0.5300.161 0.049 0.0200.217 0.079 0.0350.478 0.547 0.6830.471 0.522 0.6770.083 0.159 0.3430.074 0.149 0.3900.658 0.677 0.6410.658 0.701 0.6160.611 0.549 0.4700.624 0.626 0.4760.992 1.161 1.1271.000 1.191 1.1431.008 1.094 1.0771.000 1.107 1.0860.044 1.000 1.0000.048 1.000 1.0000.031 0.600 0.9500.032 0.554 0.9650.608 0.375 0.2160.616 0.371 0.2160.145 0.231 0.2920.142 0.232 0.290nas wGeorge et al. International Journal for Equity in Health  (2017) 16:141 Page 9 of 14Table 4 Ecologic analysis of risk of hospitalization due to intentioin British Columbia, 1999-2008a. Regressionb statistics from modelX Variable min max meanc SDc NCensus 2001 2006 2003.5 2.5 92Income Per Capita 1000 7.7 36.0 17.1 6.4 92Income Score 45.1 96.5 69.5 12.4 92High School 0.315 0.907 0.650 0.132 92University Degree 0.000 0.364 0.084 0.076 92Population Per Room 0.403 0.812 0.549 0.097 92Need Major Repairs 0.050 0.478 0.186 0.116 92Labour Force 0.515 0.771 0.664 0.053 92Employed 0.380 0.734 0.572 0.083 92Occupation Risk 0.805 1.446 1.111 0.146 92Industry Risk 0.687 1.258 1.064 0.108 92Occupation Risk Employed 0.350 0.934 0.635 0.126 92increases risk of intentional injury, and that effect is huge,with a change in SRR of 3.96 for each SD increase.Indigenous ethnicity times high school diploma decreasesrisk of intentional injury, and the protective effect is huge,reducing the SRR by 3.19 for each SD increase. Indigenousethnicity times university degree increases risk ofintentional injury somewhat, adding 1.246 to SRR for eachSD increase.As shown in Table 7, the best-fitting model predictsthat the off-reserve Indigenous population will have SRRof intentional injury 3.98 greater than the total popula-tion. That is very close to the observed disparitiesbetween the total BC population and the off-reserveIndigenous population (5.18–1 in 1999–2003, and 4.94–1in 2004–2008) shown in Table 3. The model predicts thatthe on-reserve Indigenous population will have SRR ofintentional injury 4.17 greater than the total BC popula-tion. Similarly, that is very close to the observed disparities(5.39–1 in 1999–2003, and 5.28–1 in 2004–2008),reported in Table 3.Industry Risk Employed 0.299 0.826 0.609 0.113 92Occupation Risk Labour Force 0.510 1.055 0.739 0.124 92Industry Risk Labour Force 0.448 0.900 0.708 0.102 92Urban 0.000 1.000 0.386 0.416 92Rural 0.000 0.446 0.228 0.153 92Indigenous 0.007 1.010 0.676 0.447 92North American Indian 0.004 0.992 0.501 0.377 92aThree population groups (total, Indigenous on-reserve and Indigenous off-reserve)bThe dependent (Y) variable is SRR of hospitalization due to intentional injury, andcUnweighted mean and standard deviation (SD) of the independent (X) variabledB = regression coefficienteSE = standard error of the regression coefficientfp = probability that B = 0gSRR change per SD = BxSD. One SD change in the independent variable is associaamount. E.g., one SD change in Income Per Capita ($6400) is associated with changhLower limit of the 95% confidence interval for the SRR change per SDiUpper limit of the 95% confidence interval for the SRR change per SDl injury among Health Service Delivery Area population groupsith one independent (X) variableR2 Bd SEe pf SRR changeper SDgL95CLh U95CLi0.000 0.000 0.036 0.999 0.000 −0.181 0.1810.296 −0.111 0.018 0.000 −0.706 −0.934 −0.4780.421 −0.090 0.011 0.000 −1.110 −1.383 −0.8370.277 −5.558 0.946 0.000 −0.736 −0.985 −0.4870.211 −4.539 0.926 0.000 −0.344 −0.483 −0.2040.058 4.035 1.709 0.020 0.392 0.062 0.7220.616 16.377 1.364 0.000 1.901 1.586 2.2160.001 −0.841 2.363 0.723 −0.045 −0.295 0.2050.209 −9.191 1.888 0.000 −0.765 −1.077 −0.4530.175 2.481 0.568 0.000 0.363 0.198 0.5290.134 2.911 0.780 0.000 0.315 0.147 0.4820.029 1.598 0.976 0.105 0.201 −0.043 0.444Table 7 also shows differences between Indigenouspeoples living on- and of-reserve. Those living off-reserveare more likely to complete high school and be employed,both of which are protective against intentional injury,although this is offset by factors that increase risk; that isuniversity education and working in more hazardousoccupations.DiscussionIntentional injuries resulting in hospitalization are im-portant because of the considerable number, and subse-quent individual and societal burdens. The high risk ofself-inflicted and inter-personal assaults for Indigenouspeoples in Canada has been long recognized [15, 20–26]and is of major concern. The downward trend in risk,and the reduced disparity between populations, shownin our results are both good news. Still, both the overallrisk and the disparities remain high, with the risk beingapproximately three times higher for the Indigenouspopulation for self-inflicted injuries, and four times0.003 0.610 1.256 0.628 0.069 −0.212 0.3500.144 3.145 0.809 0.000 0.389 0.190 0.5880.098 3.324 1.062 0.002 0.339 0.124 0.5530.189 −0.949 0.207 0.000 −0.394 −0.566 −0.2230.191 2.642 0.574 0.000 0.404 0.230 0.5780.832 4.521 0.214 0.000 2.022 1.832 2.2130.810 5.655 0.289 0.000 2.132 1.916 2.348divided by 16 HSDAs and 2 time periods (1998–2003 and 2004–2008)regression is weighted by person-yearsted with absolute change in the Standardized Relative Risk of injury by thise in SRR of −0.706 (decrease of 0.706)Table 5 Ecologic analysis of risk of hospitalization due to intentional injury among Health Service Delivery Area population groups inBritish Columbia, 1999-2008a. Regressionb statistics from models with one independent (X) variable interacting with Indigenous ethnicityX Variable min max meanc SDc N R2 Bd SEe pf SRR changeper SDgL95CLh U95CLiCensus Indigenous 14 2026 1355 896 92 0.832 0.002 0.000 0.000 2.022 1.831 2.212Income Per Capita 1000 Indigenous 0.2 22.0 9.2 6.2 92 0.758 0.313 0.019 0.000 1.942 1.712 2.172Income Score Indigenous 0.6 80.1 42.5 28.0 92 0.811 0.071 0.004 0.000 1.992 1.791 2.193High School Indigenous 0.005 0.871 0.405 0.279 92 0.748 7.119 0.435 0.000 1.985 1.744 2.226University Degree Indigenous 0.000 0.149 0.032 0.032 92 0.458 54.398 6.234 0.000 1.747 1.350 2.145Population Per Room Indigenous 0.004 0.812 0.398 0.279 92 0.822 7.402 0.363 0.000 2.063 1.862 2.264Need Major Repairs Indigenous 0.000 0.478 0.158 0.143 92 0.713 15.093 1.008 0.000 2.155 1.869 2.440Labour Force Indigenous 0.005 0.758 0.451 0.301 92 0.817 6.737 0.336 0.000 2.029 1.827 2.230Employed Indigenous 0.004 0.714 0.373 0.254 92 0.772 8.021 0.459 0.000 2.039 1.807 2.271Occupation Risk Indigenous 0.006 1.446 0.770 0.521 92 0.848 3.901 0.174 0.000 2.034 1.854 2.215Industry Risk Indigenous 0.007 1.258 0.726 0.487 92 0.846 4.149 0.187 0.000 2.020 1.839 2.200Occupation Risk Employed Indigenous 0.004 0.934 0.426 0.298 92 0.783 6.882 0.382 0.000 2.053 1.827 2.279Industry Risk Employed Indigenous 0.004 0.826 0.402 0.280 92 0.782 7.314 0.407 0.000 2.049 1.822 2.276Occupation Risk Labour Force Indigenous 0.004 1.055 0.514 0.353 92 0.828 5.771 0.277 0.000 2.038 1.843 2.232Industry Risk Labour Force Indigenous 0.004 0.859 0.485 0.331 92 0.827 6.137 0.296 0.000 2.029 1.834 2.223Urban Indigenous 0.000 1.004 0.253 0.378 92 0.122 3.408 0.963 0.001 1.289 0.565 2.012Rural Indigenous 0.000 0.447 0.157 0.158 92 0.765 14.012 0.819 0.000 2.209 1.952 2.465aThree population groups (total, Indigenous on-reserve and Indigenous off-reserve) divided by 16 HSDAs and 2 time periods (1998–2003 and 2004–2008)bThe dependent (Y) variable is SRR of hospitalization due to intentional injury, and regression is weighted by person-yearscUnweighted mean and standard deviation (SD) of the independent (X) variabledB = regression coefficienteSE = standard error of the regression coefficientfp = probability that B = 0gSRR change per SD = BxSD. One SD change in the independent variable is associated with absolute change in the Standardized Relative Risk of injury bythis amounthLower limit of the 95% confidence interval for the SRR change per SDiUpper limit of the 95% confidence interval for the SRR change per SDTable 6 Ecologic analysis of risk of hospitalization due to intentional injury among Health Service Delivery Area population groupsin British Columbia, 1999-2008a. Regressionb statistics from best-fitting model with multiple independent (X) variablesX Variable min max meanc SDc N Bd SEe pf SRR changeper SDgL95CLh U95CLh(Constant) 92 2.160 0.444 0.000Occupation Risk Indigenous 0.006 1.446 0.770 0.521 92 7.598 0.780 0.000 3.962 3.154 4.770Industry Risk LabourForce 0.448 0.900 0.708 0.102 92 1.436 0.390 0.000 0.146 0.067 0.225Employed 0.380 0.734 0.572 0.083 92 −3.796 0.765 0.000 −0.316 −0.442 −0.189High School Indigenous 0.005 0.871 0.405 0.279 92 −11.362 1.949 0.000 −3.168 −4.249 −2.087University Degree Indigenous 0.000 0.149 0.032 0.032 92 38.779 7.082 0.000 1.246 0.793 1.698Multivariable model statistics: R2 = 0.912, F = 177.632, p <0.001aThree population groups (total, Indigenous on-reserve and Indigenous off-reserve) divided by 16 HSDAs and 2 time periods (1998–2003 and 2004–2008)bThe dependent (Y) variable is SRR of hospitalization due to intentional injury, and regression is weighted by person-yearscUnweighted mean and standard deviation (SD) of the independent (X) variabledB = regression coefficienteSE = standard error of the regression coefficientfp = probability that B = 0gSRR change per SD = BxSD. One SD change in the independent variable is associated with absolute change in the Standardized Relative Risk of injury by this amounth95% confidence limits of the SRR change per SDGeorge et al. International Journal for Equity in Health  (2017) 16:141 Page 10 of 14egccifotace)George et al. International Journal for Equity in Health  (2017) 16:141 Page 11 of 14higher for inter-personal assaults, compared to the totalpopulation of BC.In spite of differing methods to identify the Indigenouspopulations, our data showing disparity for self-inflictedinjuries are consistent with those of Oliver et al. [18], al-though they found even greater disparity for assaults byanother person than did our data. These consistent find-ings regarding disparity indicate that national and inter-national concern remains warranted [15–24].Limitations to our data focus on our measurement forinjury. We counted hospitalizations due to intentionalinjury, both for self-inflicted and assaults by another per-son, but this does not represent the total burden ofintentional injuries. Not included in our dataset areintentional injuries that result in mortality, and lesssevere injuries that do not warrant hospitalization. How-ever, our findings are consistent with previous studies ofmortality [34] and primary care utilization [7] due to in-Table 7 Relative risks predicted by the best-fitting multivariable rX Variable TotalPopulationOff-Reserve IndigenousMeana Meana Differenceb SRRchangeOccupation RiskIndigenous0.046 1.178 1.132 8.60Industry Risk Labour Force 0.660 0.760 0.100 0.14Employed 0.618 0.590 −0.027 0.10High School Indigenous 0.036 0.658 0.622 −7.07University DegreeIndigenous0.009 0.066 0.057 2.20Total (sum) 3.98apopulation-weighted mean of the x-variable, 2001 and 2006 Census, for the spebdifference between mean of the specified population group and mean of the tcpredicted SRR change associated with the difference, calculated as (B x differenjuries among the Indigenous population of BC. As well,we included only the “most responsible diagnosis” onthe discharge record so that a person who is hospitalizedmainly for another diagnosis or an unintentional injurywould not be included.The insurance registry counts about 7% more popula-tion than the Census. As a result, the denominators ofcalculated rates may thus be inflated (resulting in under-estimation of the rates), but since this applies to therates in all population groups, this should not bias thecalculated SRRs, which are ratios of two rates. Regardingthe off-reserve Indigenous population, the Censuscounts more than the insurance registry, but regardingthe on-reserve Indigenous population, the Censuscounts less than the insurance registry. These disparitiesresult from different definitions of “Indigenous”, and in-accuracies of postal codes as a way of identifying Indianreserves. Indigenous population groups within HSDAsamong whom we calculated injury risks were not exactlythe same as the population groups among whom weascertained the ecological predictors of risk; however,this mismatch amounts to a bias toward the null hypoth-esis. Nevertheless, we found strong associations, suggest-ing that the representativeness of the population groupswas not materially affected.Given the disparity by ethnicity found in this and in ourprevious work [3, 8], we hypothesized that disparities be-tween the total BC population and the Indigenous popula-tions living off- or on-reserve would be attributable tosocioeconomic status, geographic place, and Indigenousethnicity, or a combination of these factors. Our final mul-tivariable regression model was an excellent fit, but ouroverall findings were only partially consistent with ourhypotheses. The model did not include geographic place,income variables or housing variables.Intentional injuries were associated with occupationaland educational factors. Employment was protectiveression modelOn-Reserve IndigenousL95CLc U95CLc Meana Differenceb SRR changec L95CLc U95CLc6.84 10.35 1.135 1.089 8.28 6.59 9.960.07 0.22 0.679 0.019 0.03 0.01 0.040.06 0.15 0.473 −0.145 0.55 0.33 0.77−9.48 −4.66 0.513 0.477 −5.42 −7.27 −3.571.40 3.00 0.028 0.019 0.74 0.47 1.014.17ied population groupl population, where B is the regression coefficent in the best-fitting multivariable modelagainst intentional injury for everyone. Independently ofemployment, industry risk was associated with increasedrisk of intentional injury for everyone, and occupationalrisk was highly influential for both Indigenous popula-tion groups. It is possible that industries with high riskfor injury are stressful, resulting in self-inflicted injuriesor assaults. Further interpretation of these occupationalrelated findings warrants exploration.Our data show associations between educational at-tainment and injury risk. Completing high school educa-tion provides a buffer for intentional injury for theIndigenous population, while this is not the case for thetotal BC population. Possibly, this relates to high schoolcompletion being the norm for the total BC population(83.4% achievement rate) but less so for Indigenouspopulations (71.6% for Indigenous off-reserve and 53.0%on-reserve achievement rates). The effect of universityeducation completion increasing the risk of intentionalinjury for the Indigenous population is paradoxical. It isGeorge et al. International Journal for Equity in Health  (2017) 16:141 Page 12 of 14possible that having a university education sets oneapart, leading to both alienation from one’s own cultureand racial discrimination in workplaces and elsewhere inwhich Indigenous peoples are a minority.Our findings regarding geographic place of residenceand specific socioeconomic factors differ across our pre-vious reports on specific categories of injury. We havereported that increased risk corresponded with living inmore remote areas for all injuries combined [10], andfor the specific categories of unintentional falls [7, 12]and unintentional transportation injuries [14]. The ex-clusion of geography from our best fitting model forintentional injuries is consistent with the finding on an-other specific category of injury – iatrogenic injuries[13]. The explanation may relate to the differing mecha-nisms of injury: in the two latter categories, geography isinsignificant when one controls for socioeconomic fac-tors and ethnicity.When examining differences in injury risk betweenIndigenous populations living off- and on-reserve, wefound large differences for total injuries [8]. Exploringthe Indigenous off- and on-reserve population differ-ences for specific categories of injury showed differingpatterns and suggests different mechanisms are at play.Both intentional injuries and iatrogenic injuries [11]showed little difference between the Indigenous popula-tions living on-reserve and off-reserve. In contrast, largedifferences were shown between those two groups forunintentional falls [5, 10] and for unintentional transpor-tation injuries [12]. It is plausible that the risk for unin-tentional falls and transportation injuries is influencedby the environment, both physical (natural geography,climate) and social (poverty); whereas the risks forintentional injuries and iatrogenic injuries [11] are psy-chosocial, and involve Indigenous identity.A question arising from these results is why the timetrends of some categories of injury (e.g., unintentionalfalls, transportation) differ from other categories (e.g.,intentional, iatrogenic). The ecological analyses resultssuggest that it is due to the effect of Indigenous ethni-city. The best-fitting multivariable regression modelswith unintentional falls injury [10] or unintentionaltransportation injury [12] as the outcome have Indigen-ous ethnicity as a multiplicative interaction with socio-economic factors. If Indigenous ethnicity remainsconstant and the socioeconomic disparity diminishes,then the models predict that the injury disparity betweenthe Indigenous and total populations will diminish too.That happened during the period 1991–2010. Therefore,if the goal is to fully close the injury gap in these cat-egories, it would seem prudent to focus efforts on clos-ing the socioeconomic gap.The best-fitting multivariable regression model withintentional injury as the outcome also has Indigenousethnicity as a multiplicative interaction with socioeco-nomic factors. However, the benefits of increased highschool education (decreased risk of intentional injury)were countered by the effects of increased occupationalhazards and increased university education (increasedrisk of intentional injury). For Indigenous peoples, thetrend of socioeconomic improvement had mixed effectson intentional injury risk, therefore the disparity be-tween the Indigenous and total populations did notdiminish.The best-fitting multivariable regression model withiatrogenic injuries as the outcome has Indigenous ethni-city and socioeconomic descriptors as independent fac-tors. If Indigenous ethnicity remains constant and thesocioeconomic disparities diminish, the model predictsthat the injury disparity between the Indigenous andtotal populations will diminish somewhat, but there willremain a persistent gap due to the independent effect ofIndigenous ethnicity. Again, that is consistent with thehistorical record. Therefore, in order to close the injurygap completely in the future, it would not be sufficientto close the socioeconomic gap. The nature and effect ofIndigenous ethnicity in terms of health has to change.ConclusionsWhat does the continuing influence of Indigenous ethni-city on health outcomes actually mean? The history ofCanada contains many examples of misguided attemptsto modify or eliminate Indigenous ethnicity itself.Numerous reports, including from the United Nations[20, 21], Amnesty International [26] and the Truth andReconciliation Commission of Canada [25] expressmajor concern for enduring health (including intentionalinjury) disparities. As the latter report [25] notes, gapswill persist until Canadians address the deeply rooted in-tense racism, marginalization and poverty endured byIndigenous peoples. We look forward to the day whengovernments stop fighting against Indigenous peoples[38] and instead, the history, cultural richness and con-tributions of Indigenous peoples are acknowledged bygovernments and by the general public so that the phys-ical, psychosocial, and economic conditions for Indigenouspeoples can equal those of non-Indigenous Canadians.AcknowledgmentsThis research was funded by the Canadian Institutes of Health Research,Institute of Aboriginal People’s Health (funding reference: AHR # 81043).Salary support for authors was provided by the Child & Family ResearchInstitute of BC Children’s Hospital (MAG), by the British Columbia Children’sHospital Research Institute (MB), by a Michael Smith Foundation for HealthResearch Scholar Award (MB) and by the British Columbia Region, FirstNations and Inuit Health Program, Health Canada (AJ). The funders had norole in study design, data collection and analysis, decision to publish, orpreparation of the manuscript. The authors thank Anna Low, SherylynArabsky and Kelly Sanderson of Population Data BC for assistance with dataaccess and linkage, and Stewart Deyell of Statistics Canada for assistance inobtaining custom tabulations of Census data.Arabsky and Kelly Sanderson of Population Data BC for assistance with dataAvailability of data and materialsUnit Lead, email:; specifications in project fileVital Statistics Agency [creator], 2011: Vital Statistics Births. Population DataCompeting interestsRep. 2009;20:31–51.George et al. International Journal for Equity in Health  (2017) 16:141 Page 13 of 14The authors declare that they have no competing interests.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims in publishedmaps and institutional affiliations.Author details1Department of Pediatrics, Faculty of Medicine, University of British Columbia,Vancouver, BC, Canada. 2BC Children’s Hospital Research Institute, RoomF508, 4480 Oak Street, Vancouver, BC V6H 3V4, Canada. 3School ofPopulation and Public Health, University of British Columbia, Vancouver, BC,Canada. 4Epidemiology consultant, Surrey, Vancouver, BC, Canada.Authors’ contributionsMAG participated in the conception and design of the study and drafted themanuscript. AJ participated in the conception and design of the study,performed the statistical analysis and edited the manuscript. MB, CEL and RBeach participated in the conception and design of the study and edited themanuscript. All authors read and approved the final manuscript.Ethics approval and consent to participateThe University of British Columbia Behavioural Research Ethics Board reviewedand approved our methods (BREB file H06–80585). Data Stewards representingthe BC Ministry of Health and the BC Vital Statistics Agency approved the dataaccess requests. We used existing databases, permanently linked by BritishColumbia Personal Health Number, maintained by Population Data BC.Consent for publicationNot applicable.BC [publisher]. Data extract. BC Vital Statistics Agency (2011). BC VitalStatistics Agency [creator], 2011: Vital Statistics Deaths. Population Data BC[publisher]. Data extract. BC Vital Statistics Agency (2011). Canadian Institutefor Health Information [creator] (2011): Discharge Abstract Database (HospitalSeparations). British Columbia Ministry of Health [publisher]. Data Extract.MOH (2012). 11–012) subject to approval by the Data Stewards representing theBritish Columbia Ministry of Health Services, and the Vital Statistics Agency ofBritish Columbia, for ethical and privacy reasons, because the data pertain toindividuals. The data may be accessed and statistically analyzed only onPopulation Data BC’s Secure Research Environment cloud server. BC Ministryof Health [creator], 2012: Consolidation File (MSP Registration & PremiumBilling). V2012. Population Data BC [publisher]. Data extract. MOH (2012). BCThe data that we studied are available on request, from Population Data BC(, contact: Kelly Sanderson, Researcher Liaisonaccess and linkage, and Stewart Deyell of Statistics Canada for assistance inobtaining custom tabulations of Census data.FundingThis research was funded by the Canadian Institutes of Health Research,Institute of Aboriginal People’s Health (funding reference: AHR # 81043).Salary support for authors was provided by the Child & Family ResearchInstitute of BC Children’s Hospital (MAG), by the British Columbia Children’sHospital Research Institute (MB), by a Michael Smith Foundation for HealthResearch Scholar Award (MB) and by the British Columbia Region, FirstNations and Inuit Health Program, Health Canada (AJ). The funders had norole in study design, data collection and analysis, decision to publish, orpreparation of the manuscript. The authors thank Anna Low, Sherylyn5Department of Psychology, Faculty of Social Sciences, University of Victoria,Victoria, BC, Canada. 6Faculty of Human, Social and EducationalDevelopment, Thompson Rivers University, Kamloops, BC, Canada.18. Oliver LN, Fines P, Bougie E, Kohen D. Intentional injury hospitalizations ingeographical areas with a higher percentage of aboriginal-identity residents,2004/2005 to 2009/10. Chronic Dis Inj Can. 2014;134:82–94.Received: 13 February 2017 Accepted: 14 July 2017References1. George MA, McCormick R, Jin A, Lalonde CE, Brussoni M. The RISC researchproject: injury in first nations communities in British Columbia. Canada.Int J Circumpolar Health. 2013;72:21182. doi:10.3402/ijch.v72i0.21182.2. Jin A, George MA, Brussoni B, Lalonde CE. Worker compensation injuriesamong the aboriginal population of British Columbia, Canada: incidence,annual trends, and ecological analysis of risk markers, 1987-2010. 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